Abstract
Background: Based on the technologies of applied behavior analysis and person-centered planning, positive behavior support is a process for designing and implementing proactive behavioral interventions with the goal of positive lifestyle changes.
Participants: The two adolescents who received the intensive, longitudinal, multicomponent intervention had experienced escalating behavior challenges over several years after brain injury in early childhood.
Main Outcome Measures: Quantitative data included episodes of aggression and property destruction. Qualitative data included intensity of supports, family involvement, peer relationships, medication regime, vocational status, educational status, community access, and self-help skills.
Research Design: A long-term, natural-environment, case-study method was used.
Results: The targeted challenging behaviors were reduced to zero. In addition, the participants' domains of activity increased and self-management improved even as supports were systematically withdrawn.
Conclusions: These results illustrate the potential for successfully treating extreme chronic behavior disorders after childhood brain injury.
ONE OF THE frequent sequelae of brain injury in children is an increase in challenging behavior, 1-6 possibly including aggression, property destruction, verbal disinhibition, noncompliance, and sexual inappropriateness. When these behaviors occur frequently, they can have serious effects on the individual's community integration, result in a loss of instructional time and educational services, and lead to social and educational exclusion. 7-9 Behavioral disorders can also have devastating consequences for the individual's family and friends, and social isolation may result. In response to these challenges, behavioral programming can be a valuable strategy in an array of rehabilitative services necessary to successfully reintegrate children and adolescents with brain injury into school and other community activities. 6
Applied behavior analysis (ABA) is based on a set of principles, developed through empirical research, that enable clinicians to explain and change behavior. ABA provides a useful technology for building skills that enable individuals with brain injury to achieve their goals. Unfortunately, procedures are often too narrowly defined, primarily emphasizing contingency management and often using intrusive treatments delivered in segregated settings, therefore producing only short-term changes in student behavior.
In response to these concerns, a broader approach to helping individuals acquire socially meaningful skills has been increasingly emphasized over the last several years. Positive behavior support (PBS) is an applied science, which initially evolved within the field of developmental disabilities. It uses educational methods and environmental redesign strategies to expand an individual's behavior repertoire, thereby enhancing quality of life and minimizing challenging behaviors. 10-12 PBS integrates the technology of ABA with person-centered values. It incorporates functional behavior assessment and leads to behavioral intervention strategies that are educational, proactive and functional in design.
Carr and colleagues 10 summarized the published research that has documented the effectiveness of PBS in improving the lives of people with developmental disabilities. Recent studies have expanded the approach to other populations, including children with emotional and behavioral disorders, 12 typically developing children with discipline problems, 14 and individuals with traumatic brain injury (TBI). 15-17 The development of PBS across populations suggests a movement toward "a science of positive subjective experience, positive individual traits, and positive institutions." 18(p.5)
Functional behavior assessment (FBA) includes a range of strategies used to identify antecedent variables that occasion challenging behaviors, and consequential variables or reinforcers that maintain these behaviors. FBA strategies include descriptive or correlational assessment, based on structured interviews and observations of the individual in natural environments, and functional analysis, which involves direct manipulation of variables to empirically validate hypothesized functions of challenging behaviors. These assessment results are necessary to identify intervention strategies most likely to have the greatest impact in reducing negative and increasing positive behaviors. When behavioral intervention is matched to the function of the challenging behavior, positive clinical outcomes result. 19 Studies have shown that behavioral interventions based on the results of functional assessments are more effective than those that are not. 20,21 Dunlap and Kern 22 demonstrated that descriptive and experimental FBA can be conducted effectively in natural settings. Effective applications of FBA have been reported in the brain injury literature by several clinicians and researchers. 6,23-25
After the functions of target behaviors have been identified, treatment strategies can be developed to decrease challenging behaviors and to teach prosocial behaviors. Behavioral strategies within the PBS framework emphasize prevention, addressing behavior challenges proactively. The primary methods are antecedent management (or environmental design) and behavior skills training. Strategies addressing antecedent variables seek to prevent challenging behaviors by providing opportunities for choice-making, 26 creating routines and consistent structure, 24 modifying the setting events that affect the value of reinforcers for significant behaviors, 27 restructuring curricula, 28 creating behavioral momentum, 6 and embedding preferred activities within an existing curriculum. 29 These antecedent control strategies emphasize modifying the environment to reduce the probability of challenging behaviors (i.e., making the challenging behavior unnecessary or irrelevant), while also manipulating variables to elicit adaptive behavior and appropriate response fluency.
Behavior skills training includes teaching adaptive behaviors that are functionally equivalent to the challenging behaviors. Because challenging behaviors often serve an adaptive purpose for the individual, the primary goal for intervention is to teach new skills for influencing people so that the challenging behaviors are no longer necessary. Specifically, challenging behaviors often function as a form of communication for individuals who have difficultly using appropriate interaction to access desirable outcomes. 30-32 Service providers often report that individuals with brain injury use challenging behaviors because they do not have an appropriate means to express themselves. The hypothesis that there is a relationship between challenging behavior and communication deficits has also been confirmed in the research literature, 33 which suggests that behaviors such as aggression and self-injury represent nonverbal forms of functional communication. 34-36
Teaching alternative communicative responses has been successful in reducing severe behaviors, including aggression, 37-40 because the new adaptive communicative responses replaced the challenging behaviors by providing the individual with a more effective means of accessing desirable outcomes. Although functional communication training has been successfully implemented across a spectrum of diagnoses, including mental retardation, autism, deaf-blindness, Down syndrome, pervasive developmental disorder, and attention deficit disorder, 40-44 limited research is available regarding its effectiveness with individuals with traumatic brain injury. 6,17,24,45
The case studies reported here illustrate successful application of PBS procedures as a component of community-based service, and are based on Carr and colleagues' recommended intervention principles: 10 (1) basing behavioral interventions on ongoing functional assessments of environmental and behavioral deficiencies; (2) directly linking results of functional assessment to the design of the interventions; (3) implementing the intervention in all relevant natural contexts through the use of multicomponent designs; (4) providing interventions that have ecological validity, thereby enabling staff to implement the strategies in typical community environments; (5) changing interventions as changes in life circumstances occur as a means of providing a long-term perspective; (6) making students an integral part of the approach to developing interventions that are practical; and (7) producing socially valid outcomes in terms of lifestyle change.
In this study, a multicomponent treatment plan, including functional assessment, antecedent control procedures, functional communication training, and positive reinforcement strategies, was implemented to effect positive lifestyle changes for two students with severe chronic behavior disorders associated with brain injury. Both individuals had been exposed to aversive treatments in previous settings, including mechanical and physical restraint, seclusion for extended periods, and physical punishers. They had failed in community placements and in secured settings, and were considered at significant risk. Over 42 months, behavior support plans were developed and refined to address the students' severe aggression, property destruction, and self-injurious behavior. The study used a longitudinal case study design, with construction and systematic modification of behavior supports based on ongoing functional analysis of the challenging behaviors. In addition, functionally equivalent strategies and skills were taught to assist these individuals in improving their quality of life. Evaluation of outcome included documentation of (1) systematic reduction of challenging behaviors, even as task demands and range of environmental contexts increased, and (2) acquisition of skills and strategies to use as alternatives to the challenging behavior. It was hypothesized that the multicomponent intervention would reduce the frequency of challenging behaviors and that subsequent phases of treatment would be characterized by systematic reduction of supports combined with systematic increases in the participants' domains of functional activity.