Brain Injury and Behavior: Strategies and Interventions

1. Brain Injury and Behavior Wendy Adams Ed.S., NCSP Dr. Karen McAvoy Strategies and Interventions

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

3. 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)

4. 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

5. 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”.

6. 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?

7. Understanding the Behavior and its Function • Description versus Interpretation of Behavior • Function of Behavior • Behavior related to antecedents and consequences • Observe • A=antecedent • B=behavior • C=consequence LEARNet

8. 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

9. Behavior • Behavior refers to something specific, observable, and measurable, an event or action that can be seen and measured.

10. 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 Behavior • Time Out Procedures • Punishment Procedures • Response-Cost Procedures

11. 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 assignment LEARNet

12. Behavioral Impairments with Traumatic Brain Injuries • Irritability/Agitation (overstimulation) • Frustration • Aggressive Behavior • Anger Outbursts • Short Temper • Apathy • Withdrawal

13. Behavioral Impairments with Traumatic Brain Injuries • Emotional Lability • Impulsivity • Hyperactivity • Social Disinhibition/Inappropriate Behavior • Lack of Awareness of Deficits

14. SOS Model: Structure, Organization and Strategies NASP, 2004

15. 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.

16. 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

17. Organization • Utilize tactics of effective instruction: Students must use planning skills and strategies; “learn how to learn”. • Organize assignments

18. 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

19. “Oregon Model” ‘07-’08 TBI Team Manual Research-Based Intervention Strategies Related to Common Characteristics of Individuals with Brain Injury

20. Characteristic: Memory Impairment • 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).

21. 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”.

22. 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.

23. Characteristic: Decreased Self-Awareness/ Denial of Deficits • Strategy: Self-awareness/attribution training • Facilitation of individual’s understanding of his/her role in learning.

24. 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.

25. cokidswithbraininjury.com BrainSTARS Manual RESOURCES AND INTERVENTION

26. 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.

27. MemoryTraumatic Brain Injury Matrix • Behavioral Impacts • Can’t remember more than one thing at a time • Doesn’t remember recent events • Disorganized • Gets lost frequently and easily • Looks spacey • Appears to have attitude issues • Appears manipulative • Learned Helplessness • BrainSTARS Chapter 3 and Blue Tabbed sections: #9 Memory

28. Visual-SpatialTraumatic Brain Injury Matrix • Behavioral Impacts • Difficulty organizing materials • Can experience behavior difficulties due to frustration of not understanding visual materials and expectations

29. OrganizationTraumatic Brain Injury Matrix • Behavioral Impacts • Difficulties with transisitions • Follower • Loses things easily • Is disorganized • Copies behaviors of others • Spacey • Easily frustrated • BrainSTARS Chapter 3 and Blue tabbed section: #14 and #15

30. Jeanne E. Dise-Lewis, Ph.D. Margaret Lohr Calvery, Ph.D Hal C. Lewis, Ph.D. BrainSTARS Manual

31. 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 changingbehavior problems (At least one manual of BrainSTARS is in each school in District 20)

32. 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)

33. 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)

34. 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)

35. 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)

36. 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)

37. 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.

38. 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.

39. 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

40. 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

41. 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

42. 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.

43. Top 10 Things to Remember When Working With Kids With Challenging Behaviors Tim Feeney

44. 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.

45. 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.

46. 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

47. 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