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Neuropsychological Rehabilitation

ISSN: 0960-2011 (Print) 1464-0694 (Online) Journal homepage:

A comparison of treatment methods for behaviour

disorder following herpes simplex encephalitis

Nick Alderman & Paul Burgess

To cite this article: Nick Alderman & Paul Burgess (1994) A comparison of treatment
methods for behaviour disorder following herpes simplex encephalitis, Neuropsychological
Rehabilitation, 4:1, 31-48, DOI: 10.1080/09602019408401454

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Published online: 14 May 2010.

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A Comparison of Treatment Methods for Behaviour

Disorder Following Herpes Simplex Encephalitis
Nick Alderman
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The Kemsley Unit, Northampton, U.K.

Paul Burgess
Department of Psychology, University College London, U. K.

This study describes the response to treatment of a survivor of herpes simplex

encephalitis (HSE) who presented with a dense amnesia, dysexecutive syn-
drome, and very severe behaviour disturbance that prevented rehabilitation
from taking place. Three interventions were used: (1) a behaviour manage-
ment approach that used a token economy together with “time-out”; (2) an
individually designed positive reinforcement programme; and (3) response
cost. Only response cost was found to bring about a significant improvement
in behaviour. The differing effectiveness of the three interventions are dis-
cussed in relation to the load on memory they made, the patient’s under-
standing of the reward contingencies operating, and the degree to which the
patient himself was involved in his own treatment.

A residual amnesic syndrome is commonly observed in survivors of herpes
simplex encephalitis (HSE). This is frequently accompanied by severe
behaviour disturbance, and survivors may be aggressive, disruptive, emo-
tionally labile, and sexually disinhibited (Greenwood, Bhalla, Gordon, &
Roberts, 1983). The impact of such behaviour disturbance is often severe.
For example, studies examining the long-term effects of head injury con-
clude that disturbance of psychosocial functioning constitutes the chief
Requests for reprints should be sent to Nick Alderman, Clinical Neuropsychologist , The
Kemsley Unit, St. Andrew’s Hospital, Billing Road, Northampton, NNl 5DG, U.K.
Many thanks to the staff of the Kemsley Unit, without whose enthusiasm and support
the interventions described in this paper could not have been carried out. Thanks to Dr
Rodger Wood for his involvement in the early management of this case. Finally, many thanks
to Dr Barbara Wilson and Dr Martyn Rose for their helpful comments on an earlier draft
of this paper, and to Dr Rose for permission to report details of a patient under his care,

01994 Lawrence Erlbaum Associates Limited


handicapping factor that prevents successful reintegration into family,

community, and vocational life (Brooks et al., 1986; Thomsen, 1987).
Behaviour disturbance secondary to neuropathological changes is also
likely to interfere with attempts at rehabilitation and reduce the probability
that individuals will achieve their optimal recovery potential (Wood, 1987).
In recent years there has been a growth in the use of behaviour modi-
fication techniques in the remediation of psychosocial disturbance follow-
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ing neurological damage. The results have been very encouraging, although
reported studies have been chiefly limited to survivors of traumatic brain
injury (Alderman, 1991; Eames & Wood, 1985; Giles, Fussey, & Burgess,
1988; Harlow, Clontz, & Thomas, 1993; Wilson, 1991).
The response of individuals with amnesia to conditioning methods is not
well documented. Weiskrantz and Warrington (1979) demonstrated class-
ical conditioning in two amnesic patients. The frequently cited case first
reported by Claparede (191111951) can be construed as an example of
operant conditioning in the case of an amnesic (Korsakoff) patient. The
experimenter concealed a pin in his hand and shook hands with the patient,
an action that resulted in a painful response for the latter. The following
day the experimenter went to shake hands again but the patient refused,
and could not explain why she was reluctant to do so. This change in
behaviour could be accounted for through the operation of a punishment
contingency the previous day. Similarly, in the cases cited by Weiskrantz
and Warrington, none of the amnesic individuals had episodic recall of the
conditioning events themselves.
The presence of amnesia may severely limit response to applied condi-
tioning methods in the rehabilitation setting. For example, Wood and his
colleagues (Wood & Eames, 1981; Wood & Burgess, 1988) have advocated
the use of the token economy in the management of behaviour disturbance
with survivors of traumatic brain injury. Under this scheme desirable
behaviour is reinforced with social praise and a token every 15 minutes;
undesirable behaviour is not rewarded but specific feedback is given
regarding which aspects of conduct were inappropriate. At given times
during the day, tokens are exchanged for a variety of back-up reinforcers;
the more tokens an individual has earned, the greater the choice and form
these rewards take. At an intuitive level, it is difficult to see how individuals
with amnesia could benefit from a 15-minute fixed reinforcement schedule;
this appears to rely upon retention of verbal feedback from staff to facilitate
behavioural change. However, densely amnesic patients will be extremely
limited in their ability to remember this information.
Recent case studies by Alderman and Ward (1991) and McMillan,
Papadopoulos, Cornall, and Greenwood (1990) have described the treat-
ment of behaviour disturbance in HSE survivors. Both used behaviour
modification as part (McMillan et al., 1990) or all (Alderman & Ward,

1991) of the intervention. Alderman and Ward described the effective use
of two operant conditioning methods, but whilst their case performed cer-
tain memory tests poorly, she was not densely amnesic in everyday life.
The case described by McMillan et al. was amnesic and her behaviour was
shown to respond to their intervention. However, whilst behaviour modi-
fication was incorporated as part of treatment, medication was used con-
temporaneously. Consequently, as acknowledged by McMillan et al., the
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relative contribution of the different approaches remains unclear.

This study investigates the response of an amnesic HSE survivor to three
behaviour modification techniques in the treatment of severe psychosocial
disturbance. The first stage of treatment made use of a token economy
system combined with extinction methods. The second used an individually
designed positive reinforcement programme, and in the final stage the
efficacy of another operant technique, response cost (Burchard & Barnera,
1972; Siegal, Lenski, & Broen, 1969), is evaluated.

GAS was a 39-year-old male who was admitted to the Kemsley Unit,
St Andrew’s Hospital, Northampton, UK, for a period of rehabilitation.
He had contracted HSE 32 months previously and as a consequence he
had two main problems. The first of these was a severe cognitive impair-
ment characterised by a dense, global amnesia. The second was a chronic
behavioural disturbance characterised by a general lack of inhibitory con-
trol and a severe dysexecutive syndrome (Baddeley & Wilson, 1988). No
appropriate resources in the form of either day or residential rehabilitation
services were available in his area. Consequently, he remained at home in
the care of his wife. This situation proved far from satisfactory. He was
poorly oriented and frequently threatened his wife and visitors who came
to the house; on at least one occasion he was physically aggressive towards
his wife.

Radiological Investigation
An MRI brain scan was carried out; balanced and T2 weighted axial images
were supplemented by Tl weighted coronal images. The third and lateral
ventricles were dilated. Both temporal horns were large, the right being
larger than the left. The right sylvian fissure was very large and displaced
downwards. High signal on the T2 weighted images was reported from
most of the right temporal lobe; similar abnormality was evident in the
left temporal lobe but was not so extensive. Abnormalities of the cortex
and white matter of the medial and upper part of the right frontal lobe
were reported. There was extensive white matter abnormality extending

to the lateral ventricles in both hemispheres, especially the right. The

posterior fossa appeared normal. These findings were reported as being
consistent with the history of HSE with the high signal in the cortex and
white matter representing gliosis and cyst formation. The right hemisphere,
particularly its temporal lobe, was the most affected.

NeuropsychologicaI Investigation
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Premorbid level of intellectual functioning fell within the “average” range

(NART). Whilst verbal IQ, as assessed by the WAIS, was commensurate
with premorbid abilities, non-verbal intellectual functioning fell within the
“borderline” range. Perceptual, visuomotor, and language abilities were
grossly intact. However, GAS was severely dysexecutive; this was con-
firmed by his poor performance on a number of tests reported to be
sensitive to frontal lobe dysfunction (Table 1). Additionally, he presented
with a severe amnesic syndrome. Immediate auditory attention span, as
measured by the number of digits forward recalled (9) was above average.
In contrast, his performance on all tests which examined long-term memory
was grossly impaired. Results of psychometric testing are summarised in
Table 1.

GAS: Results of Psychometric Testing

Psychometric Test Result Percentile

Intellectual functioning
VIQ 101
PI0 14
Verbal subtests
Information 10
Comprehension 8
Arithmetic 12
Similarities 11
Vocabulary 10
Digit Span 9
Performance subtests
Digit Symbol
Picture Completion
Block Design
Picture Arrangement
Object assembly
Note: subtest results age-scaled
NART’ FSIQ equivalent 101

~~~~ ~ ~

Psychometric Test Result Percentile

Memory functioning
Digits forward' 9
Logical memory'
immediate 4.5120 15
delayed 0120 <10
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Recognition memory4:
words <5
Paired associate learning (easy, hard)' 1
Rey auditory verbal learning test6 <1
Visual reproduction' 1
Rey figure':
COPY 25/36 <10
immediate 9136 <5
delayed 0136 <5
Recognition memory4:
faces 28/50 <5
standard profile score 0124 <1
Tests of executive functions
Cognitive estimates"' 11 <1
Card sorting":
categories achieved 0 <1
total errors 34/48 <1
perseverative errors 11 <1
Verbal fluency (FAS, 60 seconds each)'' 32 25-50
Alternation faskI3 10 errors <5
Money's road-map testI4 0 50
Personal orientation test'' 10 errors <5

FAS, words beginning with these letters.

FSIQ, Full Scale IQ.
PIQ, Performance IQ.
VIQ, Verbal IQ.
' Wechsler Adult Intelligence Scale (Wechsler, 1955); 'National Adult Reading
Test (Nelson & O'Connell, 1978); 'the "Anna Thompson" story taken from the
British adaptation of the Wechsler Memory Scale (Wechsler, 1945); 4Recognition
Memory Test (Warrington, 1984); 'Wechsler Memory Scale (Wechsler, 1945);
'Rey (1964); '7Wechsler Memory Scale (Wechsler, 1945); 'Osterrieth & Rey
(1944); "Rivermead Behavioural Memory Test (Wilson, Cockburn, & Baddeley,
1985); "'Shallice & Evans (1978); "Modified Wisconsin Card Sorting Test (Nelson,
1976); I2Miller (1984); ''Chorover & Cole (1966); ''Semmes, Weinstein, Ghent,
& Teuber (1963); "Butters, Soeldner, & Fedio (1973).

GAS’s degree of cognitive impairment did not fluctuate significantly

over the several occasions he was retested during his 24-month admission.
GAS was poorly oriented for time and place. When questioned, his
immediate response was that he was still working in his previous occupation
(engineer) and that he was at home. He was never able to spontaneously
recall names of either staff or other patients throughout his 2-year admis-
sion. However, recall of some names was noted to improve with the pro-
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vision of verbal and/or visual cues.

Medication and Behaviour

Medication on admission included haloperidol (10 mg three times a day),
which had a significant sedating effect; this was discontinued after 3 weeks,
and GAS’s verbal and physical aggression increased. GAS was observed
to spend most of his time pacing about the ward, stopping periodically to
rub his hands together vigorously, after which he would burst into loud
repetitive song or rhyme, which frequently had an obscene content. He
would wander amongst staff and patients making demands for cigarettes;
refusal would result in him becoming verbally abusive, making threatening
gestures (for example, raising his fist) and on occasion he would physically
assault others. On other occasions he threatened and hit others for no
apparent reason.
The top six items resulting from a behaviour rating scale (Wood, 1987)
completed routinely by staff to identify principle problem areas were (in
descending order): (1) swears excessively; (2) uses inappropriate speech
volume; (3) interrupts or joins in conversations unreasonably; (4)makes
inappropriate social approaches and greetings; ( 5 ) abuses others verbally;
(6) shouts at others. The degree of behavioural disturbance was so great
that he was completely unmanageable within an environment that operated
few behavioural constraints.

Intervention 1
Procedure. An initial attempt at treatment was made using the token
economy system, which remains in continual operation on the unit. Appro-
priate behaviour was rewarded with the payment of tokens at 15-minute
intervals; these were subsequently exchanged for a variety of back-up re-
inforcers at several times during the day. When possible, inappropriate
behaviours were “timed-out-on-the-spot” (Wood, 1987) to reduce the
likelihood of reinforcement through staff attention.
Unfortunately, it quickly became apparent that use of the token system
and “time-out-on-the-spot” had no impact on GAS’s behaviour; the token
economy was consequently withdrawn. Physical aggression continued to
be managed through GAS being placed in a time-out room for a 5-minute
period contingent on this behaviour.

Threatening behaviour (as distinct from physical aggression) was treated

using a discriminatory time-out programme (Wood, 1987); immediately
after observation of a threatening gesture by GAS he was placed in the
time-out room for a 2-minute period. As he went into the time-out room
the verbal prompt “threatening” was given by a member of staff to facil-
itate learning. After 2 weeks, due to the severity of GAS’s verbal abuse,
all swearing was included within the discriminatory time-out programme.
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It continued to be implemented in this form for a further 7 days.

During the first week of the programme GAS was placed in the time-out
room 59 times, either for threatening behaviour or for physical aggression;
this increased to 78 in the second week. During the next 7 days GAS was
placed in the time-out room 687 times; 48% of these were consecutive-as
soon as the door of the time-out room was opened GAS would threaten,
be verbally abusive, and as a consequence be immediately timed-out again.
The highest number of time-outs occurring on any one day during this
period was 330; of these 82% were consecutive.

Despite the fact that time-out methods have often been shown to be effect-
ive in the treatment of severe psychosocial disturbance, the programme
was spectacularly unsuccessful in managing GAS’s behaviour, and indeed
appeared to exacerbate it. Staff were understandably concerned and it
appeared that GAS was completely confused by the programme. Despite
the discriminatory cue being given, he seemed to have no awareness as to
why he had been placed in the time-out room. Due to his amnesia he had
no recall of the behaviour that had led to time-out just a few minutes
previously. The programme was therefore discontinued.
Consequently, a special individual programme was designed and imple-
mented. The possibility of using a positive reinforcement schedule was
explored. Given the severity of GAS’s amnesia the reinforcement intervals
clearly needed to be shorter than 15 minutes. A method was required
where memory load was minimal. This was addressed in the second inter-

Intervention 2
Procedure. Treatment was carried out during sessions held once per
day immediately after GAS had completed a morning hygiene programme;
up to two additional sessions were conducted at other times during the
day. His task was to engage a member of staff in conversation without
swearing or being verbally abusive. This programme relied upon the

operant principle of “differential reinforcement of incompatible behavi-

our” (DRI) and took the following form (for a general overview of the
theory and application of differential reinforcement see Yule & Carr,
An explanation of the procedure was given to GAS. It was explained
to him that if he did not engage in either of the target behaviours for 30
seconds he would be immediately rewarded with social praise and a token.
He was then informed that when he had collected ten tokens he could
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exchange them for a cigarette. As soon as the explanation had been given
staff started timing with a stop watch. If he swore or was verbally abusive
timing was stopped and staff told GAS that he had just engaged in one of
the target behaviours. The stopwatch was reset to zero and timing
restarted. The session continued until GAS had earned all ten tokens.
Whilst this ensured he would always obtain his reward, the more frequently
he engaged in the target behaviours, the longer it would take to receive.
Staff recorded the total time taken to earn all ten tokens at the end of the
session. GAS was reminded of the aims of the programme and the min-
imum time it would take to earn a cigarette at the beginning of each session.
In addition, he was also reminded that it would take longer to obtain his
reward every time it was necessary to reset the stopwatch to zero contingent
on swearingherbal abuse.
DRI was initially attempted by setting a time limit of 30 seconds. After
10 weeks some improvement was evident (see below) and the target was
increased to 60 seconds. This new target was maintained for a further
17-week period.

Treatment was carried out one to three times per day over a 27-week
period. The results of the DRI intervention are presented graphically in
Figure 1, which represents the mean difference (in minutes per week from
criteria) taken by GAS to earn all ten of his tokens (that is, mean time
actually taken minus maximum time possible).
When DRI was attempted using a 30-second period, the minimum time
possible to earn all ten tokens was 5 minutes; when changed to 60 seconds
this increased to 10 minutes. If learning was to occur then the difference
between actual time taken and criteria should approach zero over time.
Analysis of the data when the DRI target was 30 seconds using time-
series analysis procedures (Tyron, 1982) confirmed the visual impression
from Figure 1 of a trend downwards (C = 0.762, 2 = 2.681, P < 0.01)
during this stage of the intervention. However, when the DRI target was
increased to 60 seconds no such trend in the data was evident (C = 0.141,
2 = 0.618, ns).
Target = 30 secs Target = 60 secs
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' 1 10 19 27
FIG. 1. Effect of differential reinforcement on the frequency of swearing and verbal abuse.
The horizontal axis represents the minimum time taken to earn all ten tokens. During the
initial phase of the intervention one token was earned at the end of any 30-second period
during which GAS had not sworn or been verbally abusive. During the next 10 weeks there
was a significant reduction in the time taken by GAS to earn his reinforcer. The target was
then increased from 30 to 60 seconds. Despite implementing the intervention one to three
times per day for the next 17 weeks, there was no reduction in the time taken by GAS to
earn reward.

The results suggested that it was possible to use a positive reinforcement
strategy, in the form of DRI, to teach GAS some control over aspects of
his verbal behaviour when the period of reinforcement was very short (30
seconds). However, attempts at increasing the period of reinforcement to
60 seconds were not effective, despite the intervention running on a daily
basis for 17 weeks. It would appear that although GAS could respond to
positive reinforcement, and was strongly motivated by the prospect of
earning cigarettes, use of DRI was constrained either by the limits of his
memory, or his lack of inhibitory control at this stage.
Whilst DRI using a 30-second interval was successful it was not practic-
able to generalise its use throughout the day. Giving reinforcement every
30 seconds would have seriously intruded with and disrupted any ongoing
rehabilitation activity in which GAS was involved.
What was required was a programme that could be implemented with
minimum disruption to other activities. A third intervention, which fulfilled
these criteria, was therefore designed around the principle of negative
punishment through response cost.

Intervention 3
Design. Treatment was conducted within individual sessions imple-
mented for 1-hour per day, 5 days per week. An “A-B-A-B” reversal
design was used (Wilson, 1987) so that the effects of treatment could be
assessed reliably: each “A” phase consisted of a baseline only condition
from which the intervention described below was absent, whilst in each
“B” phase it was present.
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Each 1-hour session was split into two 30-minute trials, during which a
variety of background tasks were conducted, including orientation exer-
cises, psychometric testing, and card and board games; these tasks were
changed every 15 minutes. Two experimenters were present. A frequency
count of the following target behaviours was made during each daily 1-hour
trial across the design:

1. Verbal abuse. This consisted of all swearing and derogatory comments

about others and was recorded as being either directed (that is, verbal
abuse directed at either of the experimenters) or non-directed (that is,
all non-specific swearing in conversation). Verbal abuse could be either
spoken or shouted.
2. Rhyming. This included all spontaneous singing and repetition of verse.
The duration of each rhyming outburst was also timed and recorded
across the design. Rhyming could be shouted.

Procedure. During the first 5 days, GAS’ baseline was recorded over
five 1-hour sessions. The mean number of target behaviours observed per
session was 61.6 (range 36-96), just over one episode per minute. Sub-
sequently, the response cost intervention was introduced as follows.
At the beginning of each trial GAS was given 50 one-pence pieces: these
were placed directly on the table in front of him in five piles each containing
10 pence. It was explained to him that at the end of a 30-minute trial he
could exchange this money for a cigarette, a commodity that GAS found
highly reinforcing and one for which he made frequent requests. He was
also told that he would lose money by singing, shouting, or swearing: every
time one of the target behaviours occurred one of the experimenters would
intervene and prompt him to state what he had just done. If GAS was
unable to verbalise that he had just engaged in singing, swearing, or
shouting the experimenter informed him that he had just done so and
prompted him to hand over one of the coins. At the end of any 30-minute
trial GAS was given the opportunity to exchange any remaining coins he
had left for a cigarette. Access to this powerful reinforcer was determined
by the number of pence in his possession. The “cost” of a cigarette was
initially fixed at eighteen pence: this was calculated from the data collected
during the first baseline stage of the design and was low enough to ensure

that GAS would have sufficient coins left to exchange for a cigarette at
the end of the first 30-minute trial. If he retained enough one pence pieces
equal to or more than this target he could exchange the money for a
reinforcer. However, the target was increased by 2 pence following any
one trial in which GAS achieved his target.
Because of GAS’Sseverely impaired memory functioning a short written
cue was kept on the table, which briefly described the programme and the
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number of pence necessary to exchange for a cigarette at the end of the

trial. He was directed to this by one of the experimenters as and when it
was necessary to orientate him.
The first “B”, or intervention, phase was implemented over 54 1-hour
sessions. Re-baselining then took place over five sessions, followed by a
further 26 sessions during which the response cost intervention was again

A total of 90 1-hour sessions were carried out over the equivalent number
of days. The results of the intervention are presented in Figure 2 and Tables
2 to 4.

Overall Frequency Target Behaviours. Inspection of Figure 2 suggests

that, whilst variable, no trend was evident during the first “A”, or baseline,


IA 41

1 5

FIG. 2. Effect of response cost on the frequency of swearing, rhyming, and verbal abuse.
“A” represents a stage in the intervention in which response cost was not implemented and
these behaviours were “timed-out-on-the-spot”. “B” represents a stage in which response
cost was in operation. Each data point represents the total number of target behaviours
recorded across the two 30-minute trials comprising each session.
Summary of the Frequency of All Target Behaviours Within
1-Hour Sessions

Condition Stage Mean (SD) Range

Baseline A 61.6 (26.9) 36-96

Response cost B 5.1 (0.9) 0-7
Baseline A 11.4 (3.5) 8-17
Response cost B 2.2 (1.8) 0-6
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Summary of Frequency of Verbal Abuse Within 1-Hour Sessions

Target Behaviour Condition Stage Mean (SD) Range

Total verbal abuse Baseline A 35.2 (21.8) 13-59

Response cost B 1.8 (2.3) 0-7
Baseline A 3.8 (4.3) 0-9
Response cost B 0.3 (0.6) 0-2
Directed verbal abuse Baseline A 15.0 (9.9) a22
Response cost B 2.3 (3.3) 0-20
Baseline A 1.4 (3.1) 0-7
Response cost B 0.1 (0.3) 0-1
Non-directed verbal abuse Baseline A 28.0 (12.7) 19-37
Response cost B 0.3 (0.5) 0-1
Baseline A 2.4 (3.2) 0-8
Response cost B 0.2 (0.5) 0-2

Summary of Frequency and Duration of Rhyming Within 1-Hour Sessions

Target Behaviour Condition Stage Mean (SD) Range

Total rhyming Baseline A 26.4 (6.7) 21-38

Response cost B 4.4 (1.3) 2-6
Baseline A 7.6 (2.2) 4-10
Response cost B 1.3 (1.5) 0-6
Duration (seconds) Baseline A 7.2 (3.2) 4.3-12.5
Response cost B 2.9 (0.9) 0-6
Baseline A 3.2 (0.2) 2.9-3.3
Response cost B 3.3 (2.1) 0-8.7


phase. However, the visual impression conveyed in the figure-f a trend

downwards in the overall frequency of target behaviours following the
implementation of the response cost intervention-was confirmed by
application of time-series analysis procedures (C = 0.51, Z = 3.82,
P < 0.01).
Time-series analysis was also used to determine at what point within
each phase there was no trend in the data: these stable portions of the
data were used to calculate the summary statistics in Table 2 and con-
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sequently to determine the significance of any changes in level between

different stages of the design.
Serial dependency effects in the stable portions of the data were not
evident (Kazdin, 1984). Analysis using the Kruskal-Wallis method indic-
ated significant differences between stages of the design (H = 23.49;
df = 3, P < 0.001). Table 2 shows that the overall frequency of target
behaviours was lowest during the two treatment phases when response cost
was implemented compared to baseline conditions. It will be noted that
there was a modest increase during the second baseline period. However,
when response cost was reintroduced there were further decreases in fre-
quency over time (C = 0.33, Z = 1.73, P < 0.05).
These changes in trend and level in the data are associated with the
introduction and withdrawal of response cost; they are also consistent with
the rationale behind using a reversal design in the evaluation of any inter-
vention, which suggests that reductions in the frequency of target behavi-
ours were due to the intervention and not other uncontrollable variables,
including spontaneous recovery.

Verbal Abuse. Following the implementation of the response cost

intervention in the first “B” phase there were significant decreases over
time in both the total frequency of verbal abuse (C = 0.47, Z = 3.53,
P < 0.01) and non-directed abuse (C = 0.62, Z = 4.66, P < 0.01). Whilst
there was no evidence of such a trend in the frequency of directed verbal
abuse (C = 0.16, Z = 1.22, P > 0.05) inspection of Table 3 suggests that
there was an immediate change in level compared to baseline.
Analysis of variance by ranks indicated that there were significant differ-
ences in measures of central tendency between the different stages of the
design for total verbal abuse (H = 23.5, df = 3, P < 0.001), directed
verbal abuse (H = 33.1, df = 3, P < 0.001) and non-directed verbal abuse
(H = 15.74, df = 3, P < 0.005). As before, inspection of Table 3 suggests
that the frequency of all categories of verbal abuse was lowest in those
stages of the design in which response cost was implemented.

Rhyming. There was a significant decrease over time in the frequency

of rhyming following implementation of response cost (C = 0.45,

Z = 3.36, P < 0.01). Analysis of variance by ranks also indicated

significant differences in measures of central tendency between different
stages (H = 29.57, df = 3, P < 0.001). Inspection of Table 4 suggests, as
above, that lower frequencies of rhyming were associated with implementa-
tion of the response cost intervention.
Whilst there was no significant trend down in the mean duration of
rhyming per session over time (C = -0.01,Z = -0.06, P > 0.05) analysis
of variance by ranks (H = 13.09, df = 3, P < 0.005) suggested that the
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mean duration of each rhyming outburst decreased significantly following

treatment implementation.

This paper details three behaviour modification interventions in the treat-
ment of severe behavioural disturbance in a densely amnesic survivor of
HSE. The first intervention used a combination of positive reinforcement
(token economy) and extinction (“time-out-on-the-spot” and discrimin-
atory time-out) techniques; the second employed an individually designed
positive reinforcement programme. Neither intervention resulted in the
patient exerting clinically significant control over his abusive, threatening,
and inappropriate verbalisations. Implementation of a negative reinforce-
ment procedure-response cost-in the third intervention did, however,
result in significant modification of these aspects of his behaviour. Reasons
for the success of one method where two others failed will now be dis-
First, why in the case of this patient was a system of behaviour manage-
ment based on the token economy and time-out ineffective, when it has
been shown to be effective for other cases? One explanation is it would
appear that in the case of the token economy a fixed interval (15 minutes)
reinforcement schedule was inappropriate given GAS’S severe memory
impairment. When feedback giving reasons as to why tokens had not been
earned at these times was given to him by staff, GAS had no recall of the
events they described and simply denied them. H e was also unable to
remember such feedback and use it to modify his behaviour.
Extinction methods were similarly ineffective. The use of “time-out-on-
the-spot’’ did not appear to have any influence over his behaviour. This
may have been because the reinforcement gained from engaging in the
behaviour at the time was greater than overt withdrawal of staff attention.
Clinically it appeared that one consequence of GAS’S memory impairment
and consequent disorientation was increased anxiety. At these times, his
abusive behaviour increased concomitantly. It may have been the case that
singing and swearing served to ameliorate this anxiety-a kind of
“whistling in the dark” phenomenon-and this reduction in anxiety was

more reinforcing than the rewards offered by the programme. Addition-

ally, his behaviour frequently resulted in attention from other patients.
Discriminatory time-out was probably also ineffective due to his gross
memory impairment. Despite the discriminatory cue being given, GAS
remained unaware as to why the programme had been implemented. The
resultant confusion led to an increase in agitation, which led to verbal
abuse and threats being made towards staff as soon as the door of the
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time-out room was opened.

The second intervention was only partially successful. The punitive
aspects of the previous programme were reduced by ensuring that re-
inforcement would be available within GAS’s effective memory span and
by ensuring that he would always receive reinforcement whenever he
engaged in the programme. Whilst success was obtained when the re-
inforcement schedule was fixed at 30 seconds, this was not the case when
it was subsequently increased to 60 seconds. However, generalising a 30-
second reinforcement schedule throughout the day in the general rehabil-
itation environment was clearly impracticable. As before, the presence of
amnesia appeared to place constraints on learning when positive reinforce-
ment was used.
In contrast, the third intervention (response cost) was very successful,
and enabled GAS to exert control over his disruptive behaviour. Alderman
and Burgess (1990) and Alderman and Ward (1991) have discussed some
reasons why response cost can be effective when other behavioural pro-
cedures are not. These can be summarised as follows.
First, GAS’s dysexecutive syndrome and consequent problems with
abstract reasoning may have impaired his ability to understand the re-
inforcement contingencies operating in more traditional behavioural
methods. Response cost places less reliance on the ability to understand
these contingencies because feedback is immediate and is verbalised by
staff and patient on each occasion.
Second, the method decreases the memory load incurred in remem-
bering the treatment contingencies, which may be a particularly significant
factor with severely amnesic patients.
Third, in GAS’s case it appeared to decrease his levels of anxiety, which
were a consequence of his disorientation, by giving him the opportunity
to be involved in meaningful interaction with staff.
Last, it might be speculated that response cost programmes minimise
the “overjustification effect” (Ogilvie & Prior, 1982; see also Alderman
and Burgess, 1990) by increasing the patient’s participation in the pro-
gramme. This “active” role of the patient in response cost contrasts with
the more “passive” role assigned to individuals participating within some
positive reinforcement programmes. Increased participation (through
physically handing over tokens and stating reasons as to why they have

been lost) may emphasise a procedural learning component whilst decreas-

ing the involvement of declarative processes.
In summary, we would like to argue that there are three key components
at work in the programmes we have described in the treatment of GAS:
(1) the memory load; (2) the patient’s understanding of reward contingen-
cies; and (3) the degree of patient involvement. Whereas the use of the
token economy and extinction procedures placed a heavy load on the
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memory component and ability to understand reward contingencies,

patient involvement was low. The opposite pattern was shown in the very
successful response cost programme, which had a small memory load,
required little understanding of the reward contingencies, and where the
involvement of the patient in his own programme was high. The second
intervention, which was only moderately successful, falls midway between
the other two along these dimensions. This may provide an explanation as
to the differing success of these programmes.
Whether all patients will show similar patterns of response to the behavi-
oural techniques described here is a matter for further investigation. How-
ever, after rehabilitation GAS was eventually able to return home into the
care of his wife and has since been managed successfully in the community.

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Manuscript received 21 June 1993

Revised manuscript received 24 September 1993