Dr. Paul Dores reviews the types of challenging behaviors that can arise as a result of traumatic brain injury.
Next talk on managing challenging patient behaviors without drugs. We have dr paul Dorries, who is a licensed psychologist and board certified behavior analyst, doctoral in private practice in SAn Diego. Doctor Dorries practice specializes in behavioral consultation, evaluation and training and autism spectrum disorders, developmental disabilities and traumatic brain injury. With an emphasis on the assessment and treatment of significant behavior problems. Dr Doris has worked with individuals with severe behavior problems in home, institutional residential, educational and psychiatric settings in new york, massachusetts and California. Beginning at the U. C. L. A. Autism project project under Dr Ivor Lovas in the early 19 seventies. Additionally, Dr Doris is a consulting psychologist, behavior analyst to several organizations. Please have included residential facilities serving individuals with T. B. I. And behavioral challenges. Several southern California school districts and non public agencies providing providing abia services. Thank you very much Doctor Dorries. Thank you. Dr jennifer mm. Good morning everyone. Uh well today we're going to talk about the types of behavioral challenges. Excuse me. There you go. That we see in individuals who have suffered traumatic brain injury. Uh We're going to talk about the reasons why traumatic brain injury uh uh causes challenging behaviors. Uh We're gonna discuss briefly strategies to understand the challenging behaviors that people with traumatic brain injuries exhibit. We're going to discuss non drug strategies for preventing and managing challenging behaviors. This is not an anti drug talk. It is really just talking about an alternative uh that may be available to individuals working in rehabilitation. Uh Working with traumatic brain injury. Now for several decades, I have seen a variety of different challenging behaviors uh including physical aggression, property destruction, self injury, verbal abuse, non compliance, elopement, stealing, hoarding, a variety of inappropriate sexual behaviors, refusal to eat. And this is on top of the skill deficits that are the focus often of rehabilitation, toilet ng feeding, dressing and such. Uh There is a cost to these challenging behaviors and the rehabilitation process. Uh The more challenging behaviors and individual exhibits the greater the need for more restrictive environments, both for rehabilitation and for living. Uh, There is a need for increased intensities of staffing. Uh When medications are used, the long term costs of medications need to be calculated uh challenging behaviours which interfere with rehabilitation, caused delays in delivering services due to resistance and non compliance and these all create barriers to transitioning to less expensive services. Some of the sources of behavior problems seen after traumatic brain injury are the direct result of the injury to the brain itself. Uh Obviously, when the brain is injured, the brain's ability to moderate uh and manage behavior is, is damaged. But we have in addition to that the emotional response to having been in the traumatic event which caused the injury, along with contributory pre injury history, who you were before your injury, certainly can contribute a significant amount to the kinds of challenging behaviors you may see after injury. And then the behaviors that occur after a brain injury occur within environments. And those environments can modify behaviors uh, in their own unique ways. The things that happened before challenging behavior and the things that happen after behavior can influence the future probability that those behaviors will occur. And what is important to consider is that even those challenging behaviors, which we believe arise directly from the injury to the brain can come under the control of environmental factors, meaning that behaviors we think we do not have environmental control over, we may have more environmental control than we realize. Uh So what can we do about uh this, There is a possible roadmap for working with challenging behaviors. A methodology to teach skills efficiently adaptive rehabilitative skills and skills to teach caregivers to teach and manage behavior. Uh This same methodology is used to reduce and replace challenging behaviors, which as we indicated, can increase the cost of rehabilitation by creating safer rehabilitation environments, increasing functional independence and reducing rehabilitative costs. Uh Generally, this goes by the name of applied behavior analysis. The current current jargon is A. B. A. Uh which is uh more popular and well known, but applied behavior analysis is a methodology based on the learning principles of B. F. Skinner. Uh it is a methodology that has been demonstrated to achieve behavior change in people since the 1940s and before that, certainly in laboratory experiments and it has been successfully applied to multiple populations in multiple settings. Some people believe that Abba is an autism intervention. Uh but it is really much more. There is a substantial literature for the use of applied behavior analysis in autism behavior disorders, mental illness, brain injury dementia, substance abuse geriatrics, as well as a variety of other kinds of populations. And it has been applied in homes, schools, residential settings, hospitals, nursing homes, rehab centers, and even in in large businesses. Uh It is it is surrounding us all the time. Uh The model is basically a very simple one, and it says that behaviours, both good and bad behaviors, adaptive and challenging behaviors occur for reasons. Uh and those reasons are found in the environments in which individuals live and where those behaviors occur her. Uh And and quite simply, uh, the behavioral model says that the antioxidants to behavior, the things that occur before behavior and the events that occur after behavior influence the future probability of that behavior. Uh And that is a that is a model we call the three term contingency. It is a model of operate conditioning. Uh uh The most important thing to think about when we think about behavioral model is whether you believe it's happening or not, whether you're a believer in behavioral theory or a user of behavior modification, uh behavioral modification of behavior is happening all the time it is occurring, whether we believe it's occurring, uh antioxidants are influencing behaviors that occur, the consequences of behavior are increasing or decreasing that behavior, it is happening in your life, not only in your work. And so we either manage behavior by intent by understanding these principles and getting ahead of them, or we managed by mistake, meaning that we don't take these kinds of environmental factors into consideration. And as a result we can make behavior worse uh and uh we can uh lose significant opportunities for behavior change in our work. So the kinds of behavioral interventions that are described in a pretty substantial tv literature include using what we call task analysis to break down complex skills into smaller pieces to be taught. The use of differential reinforcement to uh rewards successful acquisition, uh to prompt behaviors to model and to shape new learning, uh modifying environments to prevent challenging behaviors from occurring. Because the best behavior plan in any situation is a plan that we don't ever have to use. So anything that we can do to prevent behavior is a good thing uh and the manipulation of consequences both to improve new behavior and to reduce uh and replace challenging behaviors. Ah The data based model uh is uh is uh an important component of brain injury rehabilitation, but if you only do one thing behaviorally uh then um I would suggest that the focus be on reinforcement uh reinforcement is uh the simplest behavioral concept to discuss and the most difficult and least well implemented behavioral intervention in any environment. And for most of us as human beings we're not great reinforce ear's. Uh it is a reinforcement is any event which follows a behavior and then increases the future probability of that behavior. So reinforcement is defined by its action on behavior. Uh and if we reinforce a behavior it is more likely to happen in the future. Uh The individual being reinforced is the one who decides whether it's reinforcing. The fact that we think it's reinforcing is not in itself sufficient and all sorts of things reinforce individuals and many times the things we think should be punishing or things like reprimands and and such are actually quite reinforcing for people. Uh When we reinforce behavior we like and want to see more, That's great, that's exactly what should happen. But when we reinforce the behavior we don't want to see by reacting in a way which creates reinforcement that we're not paying attention to. Uh then we become the cause of the long term continuation of that problem behavior because we're actually reinforcing that behavior and increasing the future probability that it will occur. So it's critically important that we be aware of how to use reinforcement and at the same time that we are aware that we are inadvertently at times reinforcing exactly the behaviors we do not want to uh Seymour. Mhm. Go back. Uh in the rehabilitative setting, it is really essential to train caregivers to reinforce behaviors that we want to see more of. Uh We want to make sure that reinforcement occurs immediately after the behaviors that we want to see more of that occurs consistently and that the reinforces are actually things that are of interest and value to the individual being reinforced. Uh We want to train people, we want to teach people to look for every opportunity. When a behavior occurs that we want to see more of in every setting, that we provide some feedback that says this is a good behavior in this setting. Use it again ah more significantly often with our caregivers and with paraprofessional staff is that we need to teach people how to reinforce less the behaviors that we don't want to see more of. Ah oftentimes uh in a busy environment, it is very difficult to reinforce individuals to provide the level of attention that we need that they need. But one thing that almost consistently and reliably brings staff attention to an individual is challenging behaviour, which means that oftentimes an individual can learn very quickly that the best way to get people's attention is to act in an inappropriate manner, and we need to make sure that we are delivering attention under all other circumstances and working our hardest uh to limit the kind and the amount of attention that is delivered when challenging behaviors occur. That means responding as neutrally as possible with Oftentimes as few words as possible as we all learn and working with individuals with brain injury. An agitated person with brain injury does not want to hear a lot of words from us a lot of the time. It only makes things worse. Uh, so we want to make sure that we're focusing our attention on teaching caregivers how to use reinforcement, both to build behaviors, but also to ensure that they are not making that the worst behaviors even worse. before we can intervene, though, we need to assess the question that we need to ask about challenging behaviors in all populations, including brain injury, is why does it happen? Uh and uh we can assess uh to the extent possible those aspects of the environment that we may have some control over so that we can work to build a behavior plan that modifies those aspects of the environment. We can't control all aspects of brain injury and y brain injury causes challenging behaviour. What we can strive to do is to control those variables that we can control and to make sure that by our actions we do not make behavior worse. And we use a form of assessment that is called functional analysis Assessment, which is essentially asking the question, why does behavior happen? Uh and since challenging behaviors don't generally happen all the time, even in our worst acting out clients, the question we have to ask ourselves when challenging behaviors occur are why did it happen now as opposed to 10 minutes ago or during this activity? Or why did it happen in this location? Why did it happen with this individual? Ah, By asking the question why the behavior happens in the moment, we are trying to get to. The ultimate question is what purpose does that behavior serve right now for individuals, the model that we are working from says the behavior occurs in the moments that it does oftentimes because there's an environmental need that that must be served and the individual does not have another effective, efficient way to communicate that need to you. So they may have established a repertoire of behaviors that worked very effectively uh to get environmental change to occur. So our job is to ask the question, what do you need, What can I do for you now that will help change the environment. We use simple amines such as abc recording or what is here called? The scatter plot which is recording behavior by time of day and day of the week. Uh We ask a lot of questions we interview. We observe where we can experimentally uh we create environmental conditions to look to see which conditions actually cause more behavior to happen. We are looking for the functions we are looking for the environmental changes people are interested in and they include things like escape which is get me out of here. Stop asking me to do that. Go away. I don't want to. It's too hot in here, it's too crowded, it's too loud. Any of a variety of things from which an individual may want to remove themselves, but they do not have another effective way. They may create a behavior which they have learned in the past causes people to stop placing demands on them or uh ah removes them from an environment. Uh And so often the behavior serves a very efficient uh means of ending rehabilitative sessions or modifying them in a way that says to the individual, this is neat, This is good. I think I'll try that again. Uh And it may have started with physical therapy hurts a lot, so I am going to engage in behaviors to get you away from me because you're hurting me. But once I see that punching you in the nose makes you stop asking me to do things. I may learn that punching you in the nose is a very effective behavior to stop you from doing other things. We need to constantly be aware of the fact that the environment is working to teach individuals what behaviors were attention is another significant function of challenging behavior. Uh, you're not spending enough time with me, you're talking to that guy over there and you're not talking to me. Uh, you were working with me, but then you went to work with the other guy in the therapy room and I want you to come back. And so I I may find a behavior which is as consistent as anything else I do or more at getting you to come back to calm me down to ask me what's wrong, uh, to reassure me. Uh, and so attention seeking behavior, even in individuals, traumatic brain injury can be a significant source of challenging behaviour. Uh, there is the desire to access things. I want that thing. I want something to eat. I want something to drink. I want that uh item that book that the other guy over across the room has. Uh and so when I cannot get it or get it as quickly as I would like, then I may find ways to engage in behaviors that get that thing to me quickly. Uh There is also the possibility for what are called automatically reinforced behaviours. And those are behaviors which um uh are not socially mediated but are mediated by internal stimulation or sensory stimulation. And those could be things like yelling or banging one's head, uh or uh physical contact sexual behaviors and such. So uh there are going to be some challenging behaviors that have a an internal function as well. Uh So what do we do with that information? Uh We use the information from a functional analysis to formulate behavior plants. Uh and the goals of our behavior plans are to make challenging behaviors irrelevant or unnecessary if we learn that a behavior is escape motivated. Uh The goal of our behavior plan is to is to evaluate what is it about what we're doing or the environments we're creating. That would be so aversive to an individual that they may want to engage in physical aggression to not do them. Uh So we want to look at the reasons why behaviors occurring and modify environments to the extent possible to make activities less aversive, shortening lengths of time changing locations, looking for another modality to teach the same skill that is less aversive. If the attention, if the behaviors attention seeking, then we may want to look at ways to dramatically enhance the amount of attention in the environment overall so that the need to attract attention in challenging ways disappears uh and so on. So we wanna behavior plan that says, we know why behavior is happening. We're going to try to make that an unnecessary uh factor and you won't have to use your challenging behaviors. We want to replace challenging behaviors with socially appropriate, functionally equivalent behaviors so that if an individual wants to tell you to stop, we need to teach them away that as efficiently as punching you in the nose gets you to stop what you're doing. And a client who reliably says please no more or I'm all done instead of punching you in the nose is something probably we would take any day. So our plan needs to make the behavior irrelevant when it still occurs. We want to try to teach alternative behaviors like excuse me, can you come and talk to me or it hurts? Please stop that. Uh Or uh I would really like it if I could get a snack right now, teach them a socially appropriate way to change the environment. And if that replacement behavior is as efficient as they're challenging behavior, they will use it. Uh The goal of challenging behavior is usually not to hurt people, It is usually to achieve a goal. And if we can provide another way to teach that goal, then we can remove the need for dangerous and harmful behaviors. Uh huh. Part of a behavior plan is always to increase other functional skills because of behavioural repertoire which grows in adaptive skills is usually one in which challenging behaviors take a secondary role uh And the more uh pivotal behaviors like communication and problem solving that we can teach. The more likely people are then to prop themselves out of situations that they might have previously used challenging behaviours to resolve. And we want to do our best to alter the consequences within the environment that maintain challenging behaviors. Uh If we are, if we are inadvertently reinforcing behavior by ending every session in which a challenging behavior occurs or by having four people rushed to a location where an individual is engaging in attention seeking behavior. If we can do those things to alter the consequences, then we stopped the reinforcement process and we reduce the future probability that that behavior occurred ethically and responsibly. We can only do that if we are working simultaneously to teach people an alternative way to communicate. Because a behavioral model that is based on our belief that behavior is communication uh cannot say to an individual, thank you for letting me know what you're communicating and then ignore them. We have to respect communication and therefore we cannot remove the consequences of challenging behaviour without acknowledging that we know what you're trying to communicate to us, to ignore an individual who is trying to communicate, even if that communication is in an inappropriate or a dangerous manner uh removed from them, the ability to self advocate. So the altering of consequences is only effective if it is done with the altering of antecedent environmental factors and the replacement of challenging behaviors as part of a comprehensive behavior plant. Uh So we want to uh prevent by removing the triggers that cause challenging behaviors to occur. Look at the environment to consider those things that maybe aversive and make those changes to the extent possible, based upon our observations, interviews and data collection that make the environment more amenable to the individual. And those changes may be different for every individual as we indicated, respect the communicative function of challenging behaviors but offer a socially appropriate means. This is a technology called functional communication training, Which has a 30 or 40 year history within the field of Abia. It is extraordinarily effective as an intervention developed by uh two gentlemen Ted Car and Marc Durand at the State University of new york at stony brook. Uh uh and it has has functioned in uh in traumatic brain injury as well. Uh We can reduce the sources of reinforcement that are maintaining challenging behavior. We can use things like extinction where we know a behavior is attention seeking and we provide an enormous amount of attention at other times. What we also have to do is reduce or remove the attention that occurs right at the time the challenging behaviour is occurring uh and that is called extinction. It is the non delivery of a reinforcing consequence. Again, you do not do extinction unless you deliver massive amounts of of reinforcement at other times in that individuals day. Uh And the last thing you want to do with an attention seeking individual is remove all of the attention they get. They will demonstrate to you pretty dramatically and pretty quickly that they have other levels of behavior. They are willing to access to make sure you do pay attention to them. Uh And you will shape them to use those behaviors so that they will simply get worse and worse and worse and worse as you ignore their challenging behaviour. You can only ignore challenging behavior if you are paying so much attention to everything else that the individual does not really note that they are losing a reinforcement. They simply note that reinforcement seems to be coming after they do different things. Uh So how can uh uh how can apply behavior analysis have the most impact in brain injury rehabilitation. Uh It can first and foremost help reduce challenging behaviors that serve as barriers to rehabilitation and require costly treatment settings and staffing. I happen to work as a consultant in a residential behavior uh behavior neuro behavioural uh brain injury setting here in Ramona California called Hidden Valley Ranch. Uh And neuro behavioural settings in general are very expensive. They are the places where the most restrictive kinds of environmental modifications have to be made, where staffing levels are often one on one, and we've had staffing levels of more than one on one where the cost of training is increased, the cost of injury to staff is increased. Uh And so uh the most effective thing that that a behavioral approach can take as a component of your rehabilitation is that it can reduce the costs uh and complications that that challenging behaviors bring to your environment. Ah It can also work to improve compliance to rehabilitative efforts by understanding uh maybe ways to modify your rehabilitative efforts or modify your rehabilitation environments, uh to break down your rehabilitation tasks uh and uh to uh use reinforcement in an effective way, all of which make your skill training activities potentially more efficient. Uh And those uh uh are particularly relevant in things like toilet training, incontinence, uh work in in feeding programs uh and uh and such uh ah I noted here uh elopement protocols and uh uh we developed something at Hidden Valley Ranch called the guided elopement. And I'm not sure we invented in anything I think Shakespeare is right when he said there's nothing new under the sun. So I'm sure other people are using exactly the same thing. But we have found it to be a very effective means for us because uh people eloped for a lot of different reasons. They eloped in part because they are confused and disoriented. They eloped because they're angry and agitated uh develop because they don't want to do the things you want them to do. As you know, many individuals with brain injuries are in significant denial of their brain injury and thus they don't understand why they may need to be in rehabilitative settings. Uh And part of the challenge is how to safely uh keep people who elop from from leaving the environment. But when they do leave the environment, how to safely bring them back uh to to the environment without causing a significant harm to yourself, to others in the community and to your client. Uh and a guided elopement. It basically involves uh walking with an individual uh with a walkie talkie in hand, uh discussing everything other than why they left the environment, discussing where they plan to go and how they plan to get there, uh inserting as appropriate, how hot it's getting and how nice a glass of cold water would be right now. Ah and uh waiting for the individual to make their own decision to come back. Uh And uh with the help of the walkie talkie often you're then able to have a program vehicle uh show up pretty quickly and the elopement is over with uh in our environments. Uh The issue of elopement is complicated by the fact that an individual who is their own conservator is not eloping there, simply choosing to leave and therefore bringing them back is a complicated and ethically fraught issue because bringing someone back to a program when they are their own conservator is against their will uh is a little like kidnapping. Uh And so uh these are some of the ways in developing, you know, uh behaviorally based model. We can address a complex behavior such as elopement. Ah fortunately there is a substantial literature uh in the use of behavioral interventions in the treatment of brain injury and dementia. Uh further uh is now not just at the edges of brain injury treatment. The there are conference presentations and special interest groups and uh uh the uh acceptability of a behavioral approach for a brain injury is now widely accepted. And there are dozens and dozens and dozens and dozens of articles uh that exists now that address uh the behavioral treatment of depression in brain injury, physical aggression and agitation in brain injury, destructive vocalizations in brain injury, wandering an exit seeking inappropriate sexual behavior, feeding difficulties, incontinence, uh even self injury. Uh uh interestingly, even impulsivity and disinhibition, which are behaviors or uh uh approaches to behavior you might call them that we often consider to be out of our control, have been demonstrated within the literature to come under behavioral control and thus under behavioral control, they can be managed uh additionally, improving participation in rehabilitation activities, uh increasing social interaction, increasing independent ambulance asian, uh and improving the acquisition of independent self care skills. So the uh efficacy, the value of of applied behavior analysis uh in traumatic brain injury rehabilitation is now widely validated by controlled research, readily available to all clinicians. Uh uh and I would argue that behavioral approach would be a reasonable to incorporate into any aspect of tv I care. Uh and the best way is to do that are to uh in my opinion, include a board certified behavior analyst as part of your clinical team. Board certification in behavior analysis is now many, many, many years old. Uh and uh it is reasonable as an assumption that if someone is a board certified behavior analysts are going to be skilled in the use of behavioral procedures. Now I would caution you if this is something you were considering, that board certification in behavior analysis, although the board that certifies us would not like to hear, it is still heavily focused on certifying behavior analysts who work in the autism field. And that is because applied behavior analysis is primarily as a business in the, in the autism business. Ah That means that if you're looking for a board certified behavior analyst, you really need to find one who not only has they're sort of occasion but has experience uh in brain injury, has worked in a rehabilitative setting or is willing to work under the tutelage of a supervisor with that kind of experience. The technologies are similar, but the nuances that a brain injured client brings to the table are significantly different than developmental disabilities or autism. Uh And most people who have tried in residential environments to mix autistic and brain injured individuals together have found that they do not mix well as a population. Uh they are not the same and you cannot work with them the same. Uh It is best to have methodology to train your caregivers on basic behavioral strategies. And if you are a clinician who is doing uh your own ot pt speech, uh and such and finding that you're facing an extraordinary amount of resistance or or agitation or physical aggression, educating yourself on those strategies you may use uh to make sure you're not making those behaviors worse and that you can uh modify your work environments to reduce the danger to yourself and increase your efficiency. Uh Mostly what we want to train caregivers on is reinforcement. Almost all of the research articles that I just indicated to you exist. Not surprisingly utilize fundamentally the redistribution of reinforcement to change behavior in brain injury, which is exactly what you would expect. Uh We want to teach our caregivers. Clinicians are paraprofessionals to understand that behavior may occur for multiple reasons and that are ethical responsibility to our clients is to understand what they are using their behavior to communicate to us uh and how to break down rehabilitation tasks for instruction. Uh equally important is that we want to make sure we develop data collection systems to track challenging behaviour to track acquisition because without data applied behavior analysis does not exist. It is a data based methodology in which clinical decision making is solely made upon uh data. And so we want to make sure that we use uh good data collection systems to understand whether the things we are doing our working. Uh If we are using a behavioral intervention or some other type of intervention to change challenging behaviors, then uh we need to know whether that's working because we do not want to continue an intervention for a behavior when all of our data tells us it is either not working at all or even worse, it's making the behavior worse by our actions. Uh And I would argue that one of the most significant places that we want to use data is in how and when we use medications for behavior change, uh We want to be able to feed back to the prescribing doctors exactly how effective or ineffective the medications they're prescribing have been. And that requires a good data collection system. Our memories for data are not great. Uh And so when we go in to talk to the doctor about behavior since the last medication change, if we don't have a good data system, uh then we are likely to be uh inaccurate and incomplete. Uh And by using good data to monitor medication use, we have the ability hopefully to reduce the amount of medications used and therefore reduce the the physiological neurological impact of those medications uh and the long term cost. Uh So key takeaways. There is a strong research literature that informs us that behavioral interventions have a clear role in tv rehabilitation, both in acquisition of new behaviors and managing and replacement of old behaviors that are challenging. Even though many of the impacts of Tv are a direct result of the injury to the brain environments can act to modify and often worsen those behavioral impacts. And knowing how to manage those environments effectively ensures that even when we can't improve behavior we won't buy our responses. Make it worse. Save some time here for questions if there are any otherwise. Thank you all very much for uh for listening. Well thank you very much. Uh dr Doris it was uh a lot of helpful information. Um uh you mentioned the data collection system and I think it's really important to know in order to find a pattern. And no if our intervention is changing the pattern of behavior, we need to get the data. We do have a question that that's asking. If you could uh says can you share the files for the behavior observation record and scattered platforms. Are those easily down downloadable or are they they are they are my forms and I have them digitally and anyone that wants to email me. Uh and I understand that you have the capacity to provide my email or I'm happy to give my email. I will send a digital copy of the data systems that I have. Yeah. Thank you. Um And uh there's another question about uh there's a question about medications. I mean, I think one of the things we think about the cost of medications and the actual economic cost of medications itself, but especially in the hospital, there's a cost of the whole supply chain, but then there's also the cost of side effects as well. The medications, you know, they're making him sleepy, They can't participate in therapy, things like that. Um But what I have a question that's asking, what are your thoughts on using circle or other medications similar to it to control T. B. I. Patient behavior? Well, first and foremost my disclosure, I am I am a PhD doctor and not an MD doctor and thus uh those kinds of prescribing questions specifically are out of my realm. I would say this though. Um I believe that uh you always want to try to behaviorally understand why behavior is occurring uh and not rely on medication because one of the things that medication does as a side effect, which is not always considered, is that it allows people to stop thinking about their role and the role of the environment and why behavior happens if I have a medication I can give someone, then I, to an extent absolve myself of the responsibility for perhaps being part of the reason why behavior is occurring. And so I am not, again, I am not against medications, medications are sometimes critical for sleep to reduce high levels of anxiety. Uh but it is also important to know that most of the time those medications were not developed for the use they are being used for, and therefore we want to be careful and oftentimes the side effects for an individual with brain injury is that we're clouding their cognition is even more with medication, which then makes it even harder to problem solve and live in the environments that we're trying to get them to live in. Uh, I have seen the very successful use of medication and I uh, I think it is as unethical to not medicate when it is required, as it is unethical to medicate when it is not required. Um, and I think that uh if you have done everything in your power to evaluate the extent to which the environment is contributing to challenging behaviors and those behaviors are still significantly challenging dangerous disruptive interfering with effective rehabilitation, then it is certainly reasonable to consider medication. Uh but, you know, don't stop doing your behavioral interventions. Medication is oftentimes simply the methodology to open other people, open people up to then having good effective behavioral interventions applied. Uh We're running short on time, but I have another question. Any recommendations for A. B. A. Organizations in southern California which have experienced with T. B. I. Patients star butterfly effects are focused on autism. Yeah, there there are very few, the most of the non public behavioral uh agencies are autism based, and that is, unfortunately because that's where they get paid insurance mandates and such require the payment for behavioral services for autism. They do not for brain injury. Uh And so, uh there are a few programs, you know, in southern California that our neuro behavioural to an extent, and you probably know them. Uh Hidden Valley Ranch here is one learning services in escondido castle Kalina in pomona, the center for Euro Skills in Los Angeles and in Bakersfield and a few other cities. But there are also special interest groups. Now there is a brain injury special interest group in the A. B. A. International organization. Uh And uh and I would start, they're looking at the special interest groups to see who the people are, who may have the same interests that you do uh in behavior and brain injury. Uh Again, I want to thank you for your time um and uh the valuable information um If there are additional questions, please keep posting them and we'll send them along to dr Dorries. But thank you very much, Doctor Doris. I appreciate it. Thank you for inviting me and uh please all enjoy the rest of your day. Thank you.