Programmatic emphasis on context-sensitive supports for people with disability has a long history and has gained considerable momentum over the past 40 years. Clinicians have increasingly organized their interventions around supported living in the community, supported employment in integrated work settings, and supported education in inclusive schools. These support movements mirror the increasing emphasis of the World Health Organization on participation in chosen life activities and settings, with the context supports needed to make participation possible.
In recent years, rehabilitation programming for individuals with cognitive impairment and behavioral challenges after traumatic brain injury (TBI) has evolved from (1) a primary emphasis on impairment-oriented cognitive retraining and behavioral services delivered in clinical settings and designed to reduce aberrant behaviors to (2) an increasing emphasis on teaching functional skills and organizing supports for successful participation in natural environments. Positive behavior support (PBS) is a movement within the field of applied behavior analysis that focuses on long-term, flexible supports that are sensitive to the demands of unique contexts and to the culture, goals, and choices of the individual being served. Behavior change is understood to be largely a result of organizing environmental and personal antecedents so that functional skills are developed even as the need for negative behavior decreases.
Similarly, supported cognition, or an apprenticeship approach to serving individuals with cognitive impairment, shifts the emphasis from direct clinical retraining in areas of cognitive impairment to support for successful performance of meaningful tasks in natural environments. As with normal cognitive development in children, improvement of cognitive functioning is seen as a result of supported and coached participation in valued activities, not as a prerequisite for such participation.
These perspective shifts in behavioral and cognitive services have required cultural changes in some service delivery systems. The articles in this issue are designed to explain the support orientation to serving individuals with challenging behavior and cognitive impairment after TBI. Single-subject research designs and case study material are provided as illustrations of and support for the approach. Because the approach is conceptually quite simple, but at times procedurally difficult, readers are invited to attend to the details of the interventions described in the articles.
In their review article, Ylvisaker, Jacobs, and Feeney describe the recent history of services for individuals with cognitive impairment and challenging behavior. Drawing from a variety of theoretical and clinical literatures, they present and offer a rationale for an integrated framework for behavioral and cognitive intervention that highlights antecedent supports and apprenticeship teaching. They also demonstrate parallels between the practice of functional assessment in behavioral psychology and dynamic assessment in cognitive rehabilitation.
Feeney and Ylvisaker apply this integrated, antecedent-focused, cognitive/behavioral approach to two young children whose behavioral difficulties had escalated following their return to school. The multicomponent intervention contains elements of both PBS and supported cognition, all delivered within a general executive function "goal-plan-do-review" format. The authors use single-subject methods to document the effectiveness of the intervention and qualitative data to demonstrate positive long-term outcome.
Gardner and colleagues illustrate the application of antecedent-focused behavioral interventions, combined with training in choice making and self-determination, to extreme challenging behavior of two adolescents whose brain injuries occurred early in childhood. Their case studies underscore the long-term dangers of poorly conceived management strategies for children with brain injury. However, the positive outcomes of their intensive, long-term, community-based treatments offer optimism for individuals whose behavioral difficulties have spiraled out of control.
Willis and LaVigna describe how positive and nonconsequential behavioral strategies helped a young man, injured as an adolescent, remain in the community for more than 10 years, despite a long history of physical aggression and elopement. The authors compare the financial and clinical cost of such supports to the costs of reactive or emergency treatment for disruptive behavior, often the only options for such people.
Finally, Ducharme sheds valuable light on a behavioral issue infrequently discussed in the literature, namely the training and support needed by parents with TBI in managing the behavior of their children. After reviewing relevant literature, Ducharme describes and illustrates an intervention designed to develop positive parenting skills for a father with brain injury, with the secondary goal of positive change in the behavior of his child.
We anticipate that this issue of JHTR will contribute to an understanding of a positive, context-sensitive, support orientation to serving individuals with cognitive and behavioral difficulties after brain injury in community settings. We hope that the articles will also stimulate clinical research in this area.