STRATEGIES AND INTERVENTIONS

Brain Injury and Behavior Wendy Adams Ed.S., NCSPDr. Karen McAvoy

Behavior can be defined simply as: the interaction of a person with their environment, or daily situation

Why Are Behavioral Issues Important For Many Students With TBI? Studies show up to 50% or more of

students with TBI have some behavioral challenges

Most often have externalizing behavior problems (e.g. hitting, yelling, making rude comments)

Sometimes have internalizing problems (social withdrawal, inactivity)

Why Are Behavioral Issues Important For Many Students With TBI? Directly related to injury itself (e.g.

aggression related to frontal lobe injury causing inhibition impairment

Some responses are related to the restrictions in life after the injury or are consequence of distress or disability

What is a Behavior Problem? A problem behavior is a behavior that

someone (the person or others) find to be a problem!!

The absence of a behavior can count as a behavior.

“Behavior” is not a synonym for “bad behavior”.

There is Always a Reason For Our Behavior Behavior is a barometer or gauge of

how a person is doing. The way a person acts can be a good

measure of what is going on within or around him.Is the person angry or aggressive?Is the person not paying attention?Is the person refusing to do what they have

been asked?

Understanding the Behavior and its Function Description versus Interpretation of

Behavior Function of Behavior

Behavior related to antecedents and consequences

ObserveA=antecedentB=behavior C=consequence

LEARNet

Antecedents Physical environment Visual cues Schedules and mini-schedules Physical prompts Modeling of skills and positive behavior Language used Instructions and directions Learning materials Child’s physical and emotional state

Behavior Behavior refers to something specific,

observable, and measurable, an event or action that can be seen and measured.

Consequences for Students with TBI Difficulty Learning from Consequences Emphasis on Positive Consequences: Reinforcement Strengthening Positive Behaviors Teaching Alternative Behaviors Procedures Not Recommended for Students with TBI’s

Natural versus Artificial Rewards Systematically Reducing Negative BehaviorTime Out ProceduresPunishment Procedures Response-Cost Procedures

Modifying Behavior Behavior management/behavior modification

used to increase or decrease the likelihood of a specific behavior (antecedent management).Procedures used before student engages in a

specific behavior with goal of increasing or decreasing frequency of that behavior.○ Increasing: teacher shows student an organizer with

goal to increase the chance student will stay with task○ Decreasing: teacher does first 2-3 math problems with

goal of preventing negative reaction to math assignmentLEARNet

Behavioral Impairments with Traumatic Brain Injuries

Irritability/Agitation (overstimulation) Frustration Aggressive Behavior

Anger OutburstsShort Temper

Apathy Withdrawal

Behavioral Impairments with Traumatic Brain Injuries Emotional Lability Impulsivity Hyperactivity Social Disinhibition/Inappropriate

Behavior Lack of Awareness of Deficits

SOS Model: Structure, Organization and Strategies

NASP, 2004

Structure Augment behavioral consistency: Brief and clear

rules that are understandable, reasonable, and obtainable, with consequences enforced across the educational experience.

Consider endurance and stamina: Modify assignments or length of school day and/or increased rest time.

Structure (continued) Control environmental stimulation:

Avoid distractions and disruptions. Utilize a life skills curriculum: Activities

relevant to everyday living. Support and validate feelings: Need to

be encouraged Forge a home-school partnership:

Strong link to home

Organization Utilize tactics of effective instruction:

Students must use planning skills and strategies; “learn how to learn”.

Organize assignments

Strategies Consider method and process: Single

learning or multi-modal learning style may be required.

Utilize compensatory methods: i.e. calculator

Offer remediation when appropriate: Direct instruction in content areas.

Teach Social Skills: Social skills training to address loss of friends.

NASP, 2004

RESEARCH-BASED INTERVENTION STRATEGIES RELATED TO COMMON CHARACTERISTICS OF INDIVIDUALS WITH BRAIN INJURY “Oregon Model”

‘07-’08 TBI Team Manual

Strategy: Errorless learning and high rates of success in interactions

Acquisition and retention of new information tends to increase with high rates of success (and error frequency increases with frequent errors and error correction).

Characteristic: Memory Impairment

Characteristic: Unpredictable Recovery, Unusual Profiles, and Inconsistency in Behavior Strategy: Ongoing assessment and

flexibility in curricular modification.

Adjustment of interaction based on ongoing assessment of the individual’s progress facilitates learning and allows for curricular modifications “on the fly”.

Characteristic: Unpredictable Recovery, Unusual Profiles, and Inconsistency in Behavior Strategy: Strategy-based intervention

Organized intervention designed to facilitate a strategic approach to difficult tasks, including organizational strategies.

Characteristic: Decreased Self-Awareness/ Denial of Deficits

Strategy: Self-awareness/attribution training

Facilitation of individual’s understanding of his/her role in learning.

Characteristic: Behavioral Difficulties Strategy: Positive behavior supports

Using an approach to behavior intervention that focuses primarily on the antecedents of behavior in the broadest sense (including setting events and establishing operations), environmental management, and role improvement.

RESOURCES AND INTERVENTION

cokidswithbraininjury.comBrainSTARS Manual

www.cokidswithbraininjury.com Traumatic Brain Injury Matrix (3 areas commonly

affected)Memory

○ The mental ability to store and retrieve words, facts, procedures, skills, concepts, and experiences.

Visual-spatial○ The ability to generate, retain, retrieve and transform

well- structured visual images.Organization

○ The ability to create and maintain orderliness in thoughts, activities, materials and the physical environment.

MemoryTraumatic Brain Injury Matrix Behavioral Impacts

Can’t remember more than one thing at a timeDoesn’t remember recent eventsDisorganizedGets lost frequently and easilyLooks spaceyAppears to have attitude issuesAppears manipulativeLearned Helplessness

○ BrainSTARS Chapter 3 and Blue Tabbed sections: #9 Memory

Visual-SpatialTraumatic Brain Injury Matrix Behavioral Impacts

Difficulty organizing materialsCan experience behavior difficulties due to

frustration of not understanding visual materials and expectations

OrganizationTraumatic Brain Injury Matrix Behavioral Impacts

Difficulties with transisitionsFollowerLoses things easilyIs disorganizedCopies behaviors of othersSpaceyEasily frustrated

○ BrainSTARS Chapter 3 and Blue tabbed section: #14 and #15

BRAINSTARS MANUAL

Jeanne E. Dise-Lewis, Ph.D.Margaret Lohr Calvery, Ph.D

Hal C. Lewis, Ph.D.

BrainSTARS Manual Brain Injury: Strategies for Teams And Re-

education for Students Provides education about brain injury and

clarifies the many after-effects of brain injury on development

Teaches a systematic approach for analyzing and changing behavior problems(At least one manual of BrainSTARS is in each school in District 20)

Memory Teach your child how to pay careful attention

and how to engage actively in thinking about what he is learning.Use everyday activities

○ Establish regular location for essential items. Key, wallet, shoes, backpack, etc. should always be stored in the same location. Practice a daily routine for putting items away. Initially, provide supportive supervision or post visual cues and reminders.

BrainSTARS (Blue tab # 9)

Memory○ To help your child remember recent events,

have her repeat out loud what just happened.○ When you ask the student to recall

information, remind him of the situation in which the information was first learned.

BrainSTARS (Blue tab # 9)

Memory○ The following strategies may help your child

remember important information.Repeat out loud the main points.Make up rhymes, acronyms, or letter associations.Relate the new information to something familiar.Relate the information to a personal experience.

BrainSTARS (Blue tab # 9)

Organization She will probably be unable to organize her

workspaces, her learning process, and her daily life independently. Teachers need to set up and maintain organizational systems. Use everyday activities

○ Make a daily schedule for the child, using pictures or words, ad tape it inside her notebook or folder. The daily schedule helps the student to understand the organization of her day and allows her to anticipate special event and other changes in the routine.

BrainSTARS (Blue tab # 14)

Organization (continued)○ Create routines and schedules for everyday events (lunch,

music, art) as much as possible, stick with them. Prepare the child for a change in the routine, and give her a visual reminder about the change.

○ Prepare the child in advance if there is something you need to do. Remember to focus on the positive: tell the child what to do and avoid telling her what she should not do.

○ Provide visual reminder and teach their use. Break down multistep activities and sequence them, using pictures or phrases.

BrainSTARS (Blue tab # 14)

Strategies for Interventions(For All Ages) Assign a paraprofessional or another adult as

a behavior coach. Set up a time-out or cool down procedure for

acting-out behaviors. Post classroom rules for appropriate behavior. Repeat classroom rules aloud. Use a quiet voice when reinforcing classroom

rules. Teach and encourage the use of relaxation

procedures.

Strategies for Interventions(For All Ages) Correct inappropriate behaviors by providing

verbal feedback to the student regarding the behaviors exhibited and the correct behaviors expected.

Coach other students in the classroom about how to the treat the student by using problem solving techniques and scenarios.

Develop and implement a behavior intervention plan (BIP).

Teach awareness of all disabilities including TBI’s.

Strategies for Interventions(For Younger Students)

Give clear and simple directions Avoid time outs (the student is not likely

to independently regroup or calm down Label the emotion and direct the student

to show the acceptable behavior

Strategies for Intervention(For Older Students) Teach strategies and how to use them

rather than offering assistance Discuss and practice age-appropriate

behaviors in real life situations Create structured social activities (e.g. a

school friendship group focused on the student)

Assume limited ability to generalize from one setting to another

School-based Intervention Identify Strengths Identify several people who are willing

Natural helpers (prior relationship is best)○ Peers○ Counselors○ Parents○ Teachers○ Mentors

Student Strengths + strength of natural helpers + strategies in natural context

Further considerations Expect impulsive and poorly regulated

behavior at times. Anticipate and prevent. For example, if

student arrives at school anxious or angry as a result of events before school, early in the day give them an opportunity to do some job that defines them as positive contributors to the classroom.

Top 10 Things to Remember When Working With Kids With Challenging Behaviors

Tim Feeney

10. Best behavior intervention is prevention.

9. Successful behavior programs focus on ANTECEDENTS.

8. Behavior problems and cognitive problems are inseparable after brain injury; successful behavior interventions must include cognitive supports.

7. Always look like you feel like you know what you’re doing.

6. Always make your expectations clear; make sure the student knows where you’re going to take them, how much work you want done, etc.

5. Make a plan prior to beginning an activity. Clearly identifying when the tasks begins and ends.

4. All behaviors communicate something. The key to successful intervention is figuring out what the student’s behavior is telling you, and then giving them another more positive way to say it.

3. BE PATIENT – BE PATIENT – BE PATIENT.

2. Keep your sense of humor, sometimes that’s all you’ve got.

1. Remember the cardinal rule in behavior management…we may really want our kids to succeed but we can’t make them do what we want!!

Tim Feeney

References BrainSTARS, Brain Injury: Strategies for Teams and Re-education for

Students. Jeanne E. Dise-Lewis, Ph.D.; Margaret Lohr Calvery, Ph.D; Hal C. Lewis, Ph.D.

Colorado Department of Education. Brain Injury: A Manual for Educators Feeney, Tim, Ph.D., Project Director, New York State Neurobehavioral

Resource Project (Contributor to LEARNet) Florida Department of Education, Bureau of Exceptional Education and

Student Services, 2005; Understanding and Teaching Students with Traumatic Brain Injury: What Families and Teachers Need to Know

http://www.bianys.org/learnet http://cokidswithbraininjury.com National Association of School Psychologists (NASP) 2004. Traumatic Brain

Injury (TBI): Strategies for Educators. Oregon ‘07-’08 TBI Team Manual