International Journal of Adolescence and Youth

ISSN: 0267-3843 (Print) 2164-4527 (Online) Journal homepage: http://www.tandfonline.com/loi/rady20

The Use of the Johnson Behavioral System

Model to Measure Changes During Adolescent
Hospitalization

Elizabeth C. Poster & Linda Beliz

To cite this article: Elizabeth C. Poster & Linda Beliz (1992) The Use of the Johnson Behavioral
System Model to Measure Changes During Adolescent Hospitalization, International Journal of
Adolescence and Youth, 4:1, 73-84, DOI: 10.1080/02673843.1992.9747724

To link to this article: https://doi.org/10.1080/02673843.1992.9747724

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International journal of Adolescence and Youth, 1992, Volume 4, pp. 73-84
0267-3843/92 $10
© 1992 AB Academic Publishers
Printed in Great Britain

The Use of the Johnson Behavioral

System Model to Measure Changes
During Adolescent Hospitalization*

Elizabeth C. Poster 1 and Linda Beliz 2

!Director of Nursing Research & Education, 2Administralive nurse 1, Adolescent Unit,

Neuropsychiatric Institute & Hospital, University of California, Los Angeles, 760 Westwood
Plaza, Los Angeles, California 90024, USA

ABSTRACT

This study utilized a patient categorization instrument based upon the Johnson
Behavioral System Model (JBSM) to assess 38 patients hospitalized on an
adolescent psychiatry inpatient unit. The results indicated that the model was
effective in targeting specific behavioral subsystems requiring nursing in-
tervention and evaluating behavioral changes during the hospitalization.
Eight behavioral subsystems and an overall behavioral category were ranked
according to four levels of behavioral efficiency reflecting severity of symptoms
and patient care requirements.
Assessment of the levels of behavioral efficiency among the 8 behavioral
subsystems revealed that the aggressive-protective subsystem of 60% of the
patients became more efficient within the first week of hospitalization. While
overall improvement was found in adolescents with diagnoses of conduct
disorder, borderline personality disorder and eating disorder, there was
considerable variability in improvement in specific behavioral subsystems related
to all 3 phases of hospitalization. Specific subsystem efficiency scores provided
not only an indicator of effectiveness of the interventions, but also pointed to the
need to target specific areas for intervention post-discharge.
The use of the JBSM, a behavioral system model which focuses on measurable
behavior change, provides clinicians with valuable information on which to
target specific interventions, monitor behavioral change, and evaluate the impact
of interventions.

*The authors wish to acknowledge the assistance of Joann Rigali and Roberta
Freeman in the implementation of this study.

73
74

INTRODUCTION

Accurate assessment of adolescents' behavior and level of

behavioral efficiency is essential to the development of therapeutic
nursing care plans and to the determination of the need for
frequency and intensity of nurse patient contact. Observations,
interviews and rating scales all have the goal of contributing
specific types of information which can be utilized by clinicians to
focus on specific problematic behaviors requiring modification. In
fact, there are literally hundreds of rating scales and checklists
available for use in the evaluation process (Eyberg, 1985). Yet,
most of these are so specific that a single tool does not provide
adequate information on which a comprehensive plan of nursing
care can be formulated.
A patient classification system based upon the Johnson
Behavioral System Model of nursing has been shown to be a valid
and reliable assessment tool with psychiatric patients (Auger and
Dee, 1983; Dee, 1986). A method of assessment based upon a
behavioral system model allows nurses to evaluate not only
specific behaviors but also the patient's love of behavioral
efficiency through each phase of hospitalization. This critical
component of the evaluation promotes effective planning of
nursing interventions which target specific behavioral sub-
systems. Information from a variety of sources, such as
parent/child interviews, direct observation and rating scales can
also be incorporated into the behavioral system assessment.
The Johnson Behavioral System Model (Johnson, 1980)
addresses eight subsystems of behavior which include: ingestive,
eliminative, sexual, dependency, affiliative, achievement, ag-
gressive-protective, and restorative. Observed patient behaviors
associated with each subsystem are the product of a complex
interaction between bio-psycho-socio-cultural regulators specific
to the individual, as well as the influence of immediate
situational/environmental factors. In an inpatient setting a major
influence on changes in patient behaviors is the care provided by
the health care team.
This model has been utilized and found effective in various
health care settings (Derdiarian, 1983; Holaday, 1980; McCauley,
Choromanski, Wallinger and Liu, 1984; Rawls, 1980). In a
previous study by Poster and Beliz (1988) the model was shown to
be effective in evaluating initial behavioral changes in adolescent
patients with a wide variety of psychiatric diagnoses. The purpose
of this study was to identify behavioral changes in adolescents
during three phases of inpatient psychiatric care, Phase I the first
week of hospitalization, Phase II, the inhospitallength of stay and
Phase II, the week of discharge.
 75

METHODOLOGY

Setting
The Neuropsychiatric Hospital is an University teaching facility
providing child, adolescent, adult and geropsychiatric patient
services. Many of the patients present with unusual signs and
symptoms and many are referred from facilities in the United
States as well as other countries. The adolescent inpatient service
is composed of 2 units. The setting for this study was one of these
units, a 19-bed inpatient psychiatric unit, which provides
evaluation and therapy for boys and girls between 12 and 18 years
of age with a wide variety of problems and psychiatric diagnoses.
Treatment is eclectic, multi-disciplinary and consisting of in-
dividual and group therapy, psychodynamic milieu, pharmacologic
and behavioral interventions, occupational and recreational
therapy and a school to deal with special academic needs.

Sample

Thirty-eight patients admitted to the unit during the 12 month

study period were included in the sample. The mean age of the 18
males and 20 females was 14.62 years and the mean length of stay
was 81 days with a range of 10 to 180 days (see Table 1).
Psychiatric diagnoses at discharge included: Conduct Disorder
(N = 11), Borderline Personality Disorder (N = 8), Eating Disorder
(N = 6), Affective Disorder (N = 6), Schizophrenic Disorder (N = 4)
Adjustment Reaction (N = 2) and Organic Disorder (N = 1).

TABLE 1

Rank order of mean length of stay by discharge diagnosis N = 38

Mean LOS Range LOS

Discharge Diagnoses N (Days) (Days) N=38
Eating Disorder 6 105 38-160 46
Affective Disorder 6 93 58-176 63
Conduct Disorder 11 89 14-167 55
Schizophrenic Disorder 4 77 31-180 101
Borderline Personality
Disorder 8 68 21-155 43
Adjustment Reaction 2 65 27-103 53
Organic Disorder 1 10 10 1
76

Data Collection Instrument

A patient classification instrument used in this study was

developed at the UCLA Neuropsychiatric Hospital (UCLA-NPH)
to monitor patient care requirements as well as establish a
framework for clinical practice (Auger and Dee, 1985). It has
established validity and reliability. Patient behavioral indices and
related interventions have been operationalized for each of the
seven subsystems of behavior developed by Dorothy Johnson
(1968) and the eighth subsystem added by Auger (1976). This
instrument provides the basis for the clinical application of the
model in terms of patient assessment, planning, intervention, and
evaluation of patient progress. It is comprehensive and flexible,
allowing for the description of behaviors related to a variety of
psychiatric diagnoses in child, adolescent and adult patient
populations.
Each subsystem of behavior is operationalized in terms of
critical efficient/effective, and inefficient behaviors. Behavioral
statements meet the following four criteria: measurable, relevant
to the clinical setting, observable, and specific to the subsystem.
The behaviors are scored in four categories according to their level
of efficiency:

1. developmentally appropriate efficient behavior; physical status

is stable;
2. behavior in the process of being learned, minimally maladaptive
to the situation; chronic or acute health problem of minor
significance (e.g. cold);
3. moderately maladaptive and age inappropriate; chronic and/or
acute health problem of major significance (e.g. uncontrolled
seizures);
4. severely maladaptive behavior of high intensity and frequency;
acute episode of life threatening physical condition.

Data Collection Procedures

Within 24 hours of admission to the unit, each patient was

assessed and a score was given to each of the eight subsystems of
patient behavior and an overall category by both the admitting
nurse and the Administrative Nurse I (shift coordinator). These
ratings were based on initial observations and the history given by
the patient, parents and/or significant others. The initial
psychiatric diagnoses of the patients were also noted in addition to
using the classification system based upon the JBSM. Weekly
 77

throughout each patient's hospitalization the Administrative

Nurse I recorded the behavioral ratings on the same check list. The
Administrative Nurse I based the ratings on her own as well as on
primary nurse's and other team members' observations. Weekly
changes in behavioral category ratings were recorded for each
patient. Each discharge diagnosis was also recorded.
Based on a pilot study of 20 patients, inter-rater reliabilities of
the behavioral ratings between the admitting nurse and adminis-
trative nurse were 100% in relationship to 8 patients. Inter-rater
reliabilities ranged from .33 to .95 related to the remaining 12
ptients. Low inter-rater reliabilities were evident for patients with
bipolar disorder and bulimia and were over 70% for patients
exhibiting depression, conduct disorder and schizophrenia. Inter-
rater reliability between the Administrative Nurse I and other
staff were found to vary considerably in both subsystem and
overall category scores. Based on the preliminary data it was
decided that only the Administrative Nurse I scores would be
utilized throughout the study since they were a more valid
indicator of patient behavioral status based upon her level of skill
and knowledge of the JBSM applied to this patient population.

Findings

Data were analyzed using descriptive statistics with regard with

regard to four major aspects of the study: 1) levels of behavioral
efficiency one week following admission; 2) levels of behavioral
efficiency during the in-hospital phase; 3) levels of behavioral
efficiency at the discharge phase; and 4) changes in psychiatric
diagnoses between admission and discharge. T-test was used to
determine the significance of the changes in scores during the
various phases of hospitalization.
During Phase I, the first week of hospitalization, ninety percent
of the adolescents had an increase in behavioral efficiency in at
least one behavioral category, while 5% had no change and 5% had
a decrease in behavioral efficiency. Although increases in
efficiency were seen in all subsystems, the primary change
occurred in 60% of the patients' agressive/protective and ingestive
subsystem scores. Significant positive behavioral changes
(p > .001) occurred in the patients' overall behavioral category
scores and in aggressive/protective and ingestive subsystems
scores. The most frequent psychiatric diagnoses at the time of
admission were conduct disorder (N = 10), after disorder (N = 8),
eating disorder (N = 6), and schizophrenic disorder (N = 3).
During the inhospital phase, mean behavioral category ratings
 ~
())

riJ

>o
J
Ill:
0

~
~

Ingestive Dependence Affiliation Sexual Overall

Eliminative Achievement Aggressive/ Restorative
Protective

BEHAVIORAL SUBSYSTEMS

Figure 1. A comparison of mean behavioral category ratings at admission, inhospital stay and discharge by discharge
diagnosis: conduct disorder (N =11)
 fl)

~
~;..
CIC

~
u
~
~

Ingestive DependP.nce Affiliation Suual Overall

Eliminative Achievement Aggressive/ Restorative
Protective

BEHAVIORAL SUBSYSTEMS

Figure 2. A comparison of mean behavioral category ratings at admission, inhospital stay and discharge by discharge 'I
\()
diagnosis: eating disorder (N =6)
80

varied greatly depending upon psychiatric diagnosis. While an

overall trend of increased levels of behavioral efficiency during the
inhospital phase was found among patients in all psychiatric
diagnostic categories, specific subsystem changes were evident in
subgroups. Focusing on the largest subgroups as defined by
psychiatric discharge diagnosis (Conduct Disorder N = 11, Eating
Disorder N =6, Affective Disorder N =6, and Borderline Per-
sonality Disorder N = 8) overall behavioral category scores
decreased during the inhospitalstay in each of these subgroups. A
Lower score was evident, not only in overall scores but more
importantly in scores which reflected problematic behaviors in
specific subsystems. For example, patients with an eating disorder
exhibited the most inefficient behavior in the ingestive sub-
systems at admission, patients with a conduct disorder exhibited
the most inefficient behavior in the aggressive protective
subsystem. Patients with an affective disorder exhibited in-
efficient behavior in the affiliative, aggressive/protective, and
dependency subsystems. Patients with a diagnosis of Borderline
Personality Disorder had the most inefficient behavior in the
aggressive/protective and dependency subsystems.

TABLE 2

Rank order of percent change in diagnosis from admission to

discharge N = 38

Discharge Diagnosis Admitting Diagnosis Change

Klein-Levin Syndrome (N =I)
Borderline Personality
Disorder (N = 8)
Adjustment Reaction (N =2)
Affective Disorder (N = 6)
Schizophrenic Disorder (N = 4)
Conduct Disorder (N = 11)
Eating Disorder (N =6)
Organic Syndrome (N =I) IOOo/o
Identity Disorder (N =I) 88%
Affective Disorder (N = 3)
Adjustment Reaction (N =I)
Conduct Disorder (N =I)
Personality Disorder (N =I)
Missing Ox (N =I)
Affective Disorder (N =I) 50%
Adjustment Reaction (N =)
Schizophrenic Disorder (N =I) 33%
Affective Disorder (N = 4)
Missing Ox (N =I)
Schizophrenic Disorder (N = 3) 25%
ADHD (N=I)
Conduct Disorder (N =IO) 9%
ADHD (N=I)
Eating Disorder (N = 6) Oo/o
 81

The mean overall rating as well as the mean scores for each of
the 8 subsystems showed significant improvement in the
discharge phase of hospitalization. When viewing the results
according to specific subsystems by discharge diagnoses, it was
evident that the most improvement in subsystem scores occurred
in those which were most inefficient at admission (See Figures 1
and 2).
Thirty-four percent of the patients' psychiatric diagnoses
changed from admission to discharge. While the diagnoses of
conduct disorder and eating disorder had similar frequencies at
admission and discharge, the diagnosis of borderline personality
disorder was made for eight patients at discharge who were
admitted with a variety of other diagnoses (see Table 2).

DISCUSSION

The impact of initial hospitalization on severely inefficient

behaviors is striking. 26% of the adolescents received level 4
ratings in at least one subsystem at admission, of the patients who
continued to manifest this level of behavioral inefficiency one
week later. The increases in behavioral efficiency in 80% of
patients occurred in each of the 8 subsystems as well as in overall
ratings. The overall category rating is especially important as it
reflects the patients' overall functioning. This finding can be
accounted for by a number of possible explanations. One factor
may be that a 'honeymoon' period exists during the early stages of
hospitalization during which time more positive behaviors are
manifest (LaBarbara and Dozier, 1985). This is seen as a period of
transition with few lasting changes in behavior taking place.
Another factor to account for these positive changes is that,
most child and adolescent patients do well in a structured
environment especially as it applies to the aggressive/protective
subsystem (Frankel and Simmons, 1985). The behaviors in the
aggressive/protective subsystem became more efficient in 60% of
the patients during this time period. The frequency and intensity
of nurse-patient contact during this time is proposed to be a major
contributor to this change. The nursing staff established controls
to protect patients, teach identification of feelings and promote
verbal rather than physical expressions of anger and frustration
and closely monitor the patient and environment for potentially
hazardous situations. In addition, techniques are utilized to foster
internal control in the patients. Another possible explanation for
this dramatic change may be that the initial behaviors were
reported by parents to be more negative than they actually were in
order to assure inpatient hospitalization.
82

Of the 38 patients, only two exhibited an increase in inefficient

behaviors following one week of inpatient hospitalization. One
patient with a diagnosis of bipolar disorder was manifesting
delusions, became confused, agitated, depressed and had sleep
difficulties. The behavioral ratings showed ratings of moderate
inefficiency and age inappropriate behaviors in the subsystems of
dependency and achievement. One patient with the diagnosis of
conduct disorder also began to report hearing voices and became
overtly psychotic within the week following admission. The
dependency and ingestive subsystems were rated as moderately
inefficient. (At the time of this study, the Ingestive system
reflected sensory input, perceptions as well as food/fluid intake.)
Two of the 6 anorexic patients showed no changes in either
direction (efficient/inefficient) one week following admission.
This finding is consistent with the literature (Garfinkle and
Gamer, 1988) which shows that patients with eating disorders are
resistant to change and this resistance would be primarily
reflected in the ingestive subsystem scores.
The average length of stay in this institution's child/adolescent
service at the time of this study was 86 days (Essock-Vitale, 1987).
During each patient's hospitalization ongoing assessments were
made which either substantiated the initial psychiatric diagnosis
or provided data for a more accurate psychiatric diagnosis. The
fact that 34% of the admitting diagnoses changed during the
course of hospitalization may be attributed to a variety of factors.
Lack of information at the time of admission, particularly related
to the patient's psychodynamics and thought processes is one
factor. Another may reflect the mental health professionals'
reluctance to give young patients a stigmatizing, life long label,
such as schizophrenia or personality disorder. Clearly the
inaccuracy of the admitting diagnoses in 34% of the cases has
implications for reimbursement as for nursing care planning.
Appropriateness and effectiveness can only occur if an accurate
behavioral assessment provides the data base for the plan of care.
This finding supports the work of Halloran (1987) who found that
medical diagnoses change from admission to discharge in 50% of
all patients and therefore suggested that length of stay criteria and
care requirements can not be determined by medical diagnoses
alone. This finding is also consistent with previous research in this
institution which demonstrated a 25% change in the adolescent
patients' psychiatric diagnoses (Poster and Beliz, 1988).
 83

CONCLUSION
The Johnson Behavioral System Model provides nurses with a
systematic method to assess patients' behavior and level of
behavioral efficiency at admission and throughout the patient's
length of stay. The use of a behavioral model which focuses on
measurable behavior change provides clinicians with valuable
information on which to target specific interventions, monitor
behavioral change and evaluate the impact of interventions.
Behavioral category scores at discharge provide an indicator of
continuing need for targeted interventions specific to each
patient's primary problem area and therefore can be used to
develop a specific behavioral discharge plan. The next important
step is to more clearly connect. patient outcomes with specific
nursing interventions.

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