Positive behavior supports

Behavior disorders and associated social communication problems are not only common but also the most difficult to treat. Feeney and Ylvisaker have described several successful single-subject experiments and case studies in which children and adolescents with challenging behavior associated with executive function impairment after brain injury were taught to regulate their behavior sufficiently to meet standards in community schools. Although the need for intervention in these cases was based on “behavioral” concerns, the impairments and interventions/supports clustered within that domain in which cognitive, executive function/self-regulatory (EF/SR), communication, social, academic, and behavioral concerns overlap and dynamically interact. Because the intervention/support plans had several components, it was impossible to identify the specific contributions of individual components to the positive outcomes. The approach is organized around several components. (See Ref. for a discussion of the theoretical and empirical supports for this approach.)

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  Cognitive/EF/SR Focus: Daily Routine, Negotiation and Choice. Daily routines in school (and often at home as well) are analyzed collaboratively, and decisions about the minimum amount of work to be accomplished and support plans for achieving the goals (within limits set by general classroom routines) are made collaboratively with the student. Specific time demands (eg, “You must finish these 10 problems in 5 minutes.”) are often eliminated from the routine because they frequently evoke oppositional behavior.

  
  
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  EF/SR Focus: Goal-Obstacle-Plan-Do-Review Routine. Students are given a graphic “map” that represents the general sequence of activities from an EF/SR perspective, that is, negotiation of the goal (ie, “What are you trying to accomplish?”); the identification of a difficulty level and obstacles (ie, “Is this going to be hard or easy? What might stand in the way?”); the creation of a plan (ie, “How do you plan to get this done? What do you need? What are the steps? How long will this take?”); and a review following task completion (ie, “What were you trying to accomplish? How did it work out? What worked for you? What did not work? What was easy? What was difficult? What adjustments need to be made?”). These interactions with staff are brief and collaborative (versus a performance-oriented quiz).

  
  
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  Cognitive/EF Focus: Graphic Advance Organizers. Because of significant organizational impairment, students are generally provided with photographs or other graphic cues. In some cases, one photograph or drawing is sufficient to orient the student to the task; in others, a sequence of photographs or drawings is used to guide the student through organizationally demanding tasks. Staff work with the students to choose the content of the photographs/drawings, which could include the student engaged in the activity with or without staff, critical materials, important places, and so on. The photographs or drawings are placed in small binders that could be hidden in a fanny pack or pocket.

  
  
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  Behavioral Focus: Positive Momentum. Staff ensure that the plan includes relatively easy tasks with a guaranteed high level of success and reinforcement before difficult or stressful work is introduced, and, if possible, a student-preferred activity precedes every mandated activity. In this way, “positive momentum” is created before potentially stressful tasks.

  
  
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  Cognitive/Behavioral Focus: Reduction of Errors. In addition to eliminating time demands and negotiating the amount of work to be completed, instructional staff are trained to provide sufficient modeling and assistance so that students experience few errors (which tend to evoke negative behavior and interfere with learning). Instruction is consistent with the principles of “errorless learning,” which has been shown to be important for individuals with significant memory impairment .

  
  
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  Behavioral/Communication Focus: Escape Communication. Because the functional behavior assessment often indicates that many occurrences of challenging behavior serve to communicate a need to escape a task or place, students are taught positive communication alternatives (eg, “I’m done” or “I need a break”). Staff are trained to encourage these alternatives at natural transition times and when students begin to appear anxious or upset, and to reward the students’ use of positive escape communication.

  
  
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  Communication Focus: Adult Communication Style. Instructional assistants are trained to (1) increase their frequency of supportive and reinforcing interactions with students, (2) anticipate students’ difficulties and offer assistance or model escape utterances, and (3) avoid “nagging” (as perceived by the students).

The emphasis on cognitive, EF/SR, and behavioral antecedent supports is based in part on the repeated finding that individuals with ventral prefrontal damage (common in TBI and other EF/SR diagnoses) learn at best inefficiently from the consequences of their behavior . This finding is especially important in light of the fact that most school-based behavior management programs are organized almost exclusively around the consequences of behavior (ie, contingency management). Similarly, classroom instruction tends to be organized around demands for performance followed by feedback. Students with EF/SR impairment may routinely receive interventions that are incompatible with their primary neuropsychologic impairment.

Wade and colleagues reported the results of a randomized controlled clinical trial comparing usual care (N=16, procedures not described) in pediatric rehabilitation units with a fairly intensive family-centered, problem-solving intervention (N=16) that included many of the components used by Feeney and Ylvisaker in their intervention studies. The results suggested that the program was well received by parents and children alike. Both parents and children noted increased knowledge and skills and improved relationships in a comparison with the usual care group. Parents in the family problem-solving group reported greater improvements in child behavior. Standardized assessment demonstrated significant reduction in internalizing behavioral symptoms in the family problem-solving versus usual care group, with large effect sizes. This study offers preliminary randomized controlled clinical support for a context-sensitive, EF/SR-oriented, positive, proactive, and family-centered approach to serving children with cognitive and behavior problems after moderate or severe TBI.

In addition to the randomized controlled study of Wade and colleagues , Ylvisaker and coworkers identified 16 reports of studies (11 single-subject experiments, five case studies) in which positive behavior support procedures were used, possibly in conjunction with traditional contingency management. The 30 participants were all children or adolescents at the time of the intervention. In most cases, explicit training in self-monitoring and self-direction was a component of the intervention. All of the studies reported a positive outcome, indicating that this approach can be said to be evidence based according to criteria established for the evaluation of single-subject designs in evidence-based practice .

Social skills intervention

Many reviews of outcome following pediatric and adult TBI have highlighted the important role of social competence for successful reintegration into school, family, and social networks, and the frequency with which these competencies are impaired . Even if followed by good neurologic outcome, severe TBI is known to threaten social relationships and increase social isolation over time . To date, no studies have specifically documented the rate at which genuine friendships are maintained after pediatric TBI, although experienced clinicians have documented a decrease in meaningful friendship . Even animal studies have shown that bilateral frontal and temporal lobe lesions (common in TBI) reduce social perception and result in group exclusion .

Social skills include general competencies and specific goal-directed, situationally appropriate, verbal and nonverbal behaviors. Individuals use such skills to affect the responses of others, to achieve acceptance by peers, family members, and teachers, and to meet the demands of school and community. Socially skilled individuals are capable of affecting others positively and with the intended effect, and of being affected positively by others as they intend. Adequate social skills increase the likelihood of reciprocal friendships and a satisfying social life.

The relationship among social skills, peer acceptance (enabling the child to have adequate opportunities for satisfying interaction), and friendship (ie, symmetrical, emotionally committed relationships) is reciprocal. Children who are rejected by their peers often exhibit depression, loneliness, a negative self-concept, anxiety, low academic achievement, and higher truancy and drop-out rates . Students with acquired brain injury predictably attempt to reconnect with their pre-injury friends and peers; however, physical, cognitive, and personality changes often result in a gradual loss of friends and increasing isolation. Reduced social opportunities may then further jeopardize social interactive success, leading to a downward social spiral.

Traditionally, social skills interventions have focused on the acquisition of declarative knowledge (“This is what I should do in this situation.”) and procedural knowledge (“This is how I do it.”) of specific social behaviors or competencies. Typically, the skills are taught in a social skills training setting using coached role-playing procedures (eg, scripting, modeling, prompting, cuing, reinforcing). Several training programs have been developed within this traditional paradigm, generally for students with developmental disabilities or emotional/behavioral disorders. Ylvisaker and colleagues have described procedures used in many of these training programs.

Students who lack declarative and procedural knowledge of relevant social skills or competencies need explicit instruction. Nevertheless, even when applied to students with congenital disability who presumably need such instruction, the traditional model of social skills training has not been supported by evidence reviews. Gresham and colleagues reviewed narrative reviews and meta-analyses of the extensive social skills intervention research literature and concluded that “SST [social skills training] has not produced large, socially important, long-term, or generalized changes in the social competence of students with high-incidence disabilities.” Specifically, they described two meta-analyses. The first included 99 studies of social skills training applied to students with emotional and behavioral disturbance, with a small mean effect size of 0.20. The second included 53 studies of social skills training applied to students with learning disabilities, with a similarly small mean effect size of 0.21. Barkley’s review of the literature on decontextualized social skills training similarly concludes that this approach has minimal demonstrated effectiveness with students who are impulsive as a result of ADHD . In general, meta-analyses and narrative reviews of experiments with several populations using decontextualized social skills training suggest minimal effect on real-world behavior, peer social skills ratings, and maintenance of new social behaviors over extended periods of time.

It is reasonable to conclude that traditional decontextualized social skills training would be even less effective for students who retain pretraumatically acquired declarative and procedural knowledge of social rules, roles, and routines but have difficulty applying that knowledge without support in social situations. The authors’ experience with many children and adolescents with social interaction difficulties after brain injury, seen through the filter of neuropsychologic findings and recent evidence reviews, suggests that the following components of intervention/support are particularly important:

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  Knowledgeable, understanding, and competent communication partners who do not misinterpret and react punitively to neurologically based awkward behaviors that result from impulsiveness, failure to initiate, misreading of social cues, anxiety, and so on

  
  
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  Selection of highly specific and personally important skills for context-sensitive training

  
  
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  Extensive practice of social behaviors in the situations in which they are required, with satisfying natural and logical consequences for successful performance

  
  
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  Situational coaching that includes advance cues (presetting) before potentially problematic interactions

  
  
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  Situational training specifically designed to improve social perception and the ability to interpret the behavior of others

  
  
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  Situational training specifically designed to improve self-monitoring of stress levels so that students can remove themselves from stressful situations as needed

  
  
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  Application of the Goal-Obstacle-Plan-Do-Review format to social interaction so that students understand that the goal is their social success, not “social appropriateness” understood abstractly as some authority figure’s goal

  
  
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  Counseling specifically designed to help students develop a personally compelling sense of self that includes positive social interaction as a component