Abstract
Objective: To investigate the effects of a multicomponent cognitive-behavioral intervention on the challenging behavior of two young children with growing behavioral concerns after traumatic brain injury.
Design: Single-subject reversal designs were used to document the effects of the intervention on the specific dependent variables. In addition, qualitative data were collected to determine the children's long-term outcome and staff evaluations of the intervention.
Participants: Both children were normally developing before injury at age 5 years. Both experienced increasing behavior problems as expectations in school escalated.
Main Outcome Measures: Quantitative data included frequency and intensity of aggression and amount of work completed. Qualitative data included children's general engagement in school work and peer interaction and staff evaluations of the intervention.
Intervention: The intervention included components of positive behavior supports, cognitive supports, and an executive function routine.
Results: The targeted challenging behaviors were reduced to near zero with decreased intensity. Long-term outcome was positive.
Conclusions: These results illustrate the potential for successfully treating behavior disorders in young children with traumatic brain injury using a support-oriented intervention that combines behavioral and cognitive components.
WITH AN ESTIMATED incidence of 180 per 100,000 in children under age 15, traumatic brain injury (TBI) is a leading cause of death and disability in childhood. 1 Estimates of new persisting behavior disorders (i.e., those not predating the injury) among children with severe TBI range from approximately 35% 2 to an alarming 70%, 3 with most studies suggesting that a large percentage of this population experience new persisting behavior problems after the injury. 4-8 Furthermore, the frequency of behavioral difficulties after TBI, including disinhibition, aggression, immature behavior (relative to age expectations), rigidity, social awkwardness, depression, and social withdrawal, is increased by the frequent finding that behavioral adjustment difficulties are themselves a predictor of TBI in children. 6,10-13 That is, children with adjustment problems or a propensity toward risk-taking behavior are more likely than others to incur TBI, and the injury in turn increases the likelihood of or the severity of behavior disorders.
The purpose of the current study was to evaluate the effectiveness of a support-oriented, context-sensitive, multicomponent behavioral and cognitive intervention for reducing challenging behavior and increasing the behavioral adjustment of two young children with frontal-lobe impairment and severe challenging behavior associated with TBI. The intervention was initially delivered in the children's community schools, with maintenance procedures applied at school and in their family homes.
Unlike those functions (e.g., language) associated with greater neural plasticity in early childhood, persisting behavior disorders after TBI tend to be more common and more severe in children injured at a younger age. Several studies have found that general outcome is worse in younger children than comparably injured older children. 14-18 Specifically, with respect to behavioral adjustment, Woodward and colleagues 19 found that the younger children in their study were more impaired than the older children. Similarly, Michaud and colleagues 20 identified a dramatically increased likelihood of special education placement for behavior disorders if the child had a head injury as a preschooler. Pediatric TBI that occurred beyond the preschool years was less predictive of a subsequent behavioral diagnosis. Consistent with these findings in children, animal studies have shown that many functions related to the frontal lobes are more severely affected if the injury occurs at a young age. 21 Frontal lobe involvement has been discovered in a majority of children with closed head injury, and the frequency of documented frontal lobe injury appears to increase with each improvement in neuroimaging technology. 16,22 For these reasons, the escalating behavior problems of the two children described in the current study were cause for great concern.
An equally ominous finding for young children is that their profile of cognitive and behavioral abilities often worsens over the years after the injury, rather than improving, as parents, teachers, and others predictably expect. Long-term outcome studies of children with TBI have suggested that behavioral outcome later in childhood and into the adult years tends to be worse than predicted shortly after the injury. 3,23 Taylor and Alden 18 similarly identified worsening cognitive and academic skills in some of the children with severe TBI. Furthermore, the few children with relatively "pure" prefrontal injuries have, with few exceptions (notably one child described by Eslinger and Biddle 24), developed increasing behavior problems over the years after their injuries. 2,25-29 Eslinger and colleagues 30 reviewed the nine available long-term case studies of children with isolated prefrontal injury and concluded that impairment of "social executors" is the most consistent and critical theme with this population, and that delayed social difficulties may continue to emerge through adolescence. Anderson and colleagues concluded that:
The magnitude and intractability of the defects incurred by injury at an early age suggest that there may be limited neuronal plasticity in the sectors of the prefrontal circuitry which contribute to emotional modulation and the linkage of emotion and decision making. 25(p.290)
With these findings as background, a primary goal of intervention for these children is to prevent the predicted behavioral deterioration from occurring. 31-33
The relation between cognitive and behavioral outcomes after pediatric TBI is unclear. Max and colleagues 34 found a positive correlation, whereas other investigators have found at most a weak correlation. 35,36 Brown and coworkers 6 found a correlation early in recovery, but not later. A possible explanation for the discrepancies is that the cognitive impairments commonly associated with frontal lobe injury, including difficulty with complex organizational and planning tasks, 37,38 difficulty processing abstract and indirect language, 39 and impaired strategic behavior under novel or stressful circumstances, 40 are often not assessed by follow-up test batteries, but are required for successful school performance. Indeed, a hallmark of prefrontal injury is reasonable performance during office-bound testing and apparently good overall recovery, despite reduced effectiveness in demanding educational, social, and vocational contexts, 25,41-45 The children in the current study were judged to have cognitive and executive function deficits in the classroom, particularly in the areas of organizing and planning. These difficulties exceeded expectations based on psychoeducational testing and substantially contributed to the children's behavioral difficulties.
Several studies have associated children's behavioral outcome after TBI with family variables. Preinjury family problems or psychosocial disadvantage have been shown to increase the likelihood of postinjury behavior problems in the child. 6,46-50 Similarly, postinjury family adjustment difficulties have been shown to have a bidirectional relationship with behavior problems in the child with TBI. 51-53 Viewed positively, these findings indicate that behavioral dysfunction is not an inevitable biological consequence of the injury, but rather a result of complex interactions between the child with the injury, the evolving profile of impairments and abilities, and the supports available in the environment over the years after the injury. This strong environmental influence may explain the superiority of parent-delivered rehabilitation services over direct clinician delivered services, assuming effective education, training, and support for the parents. 54,55 Teachers, therapists, and others should receive these findings as cause for optimism regarding the potential effectiveness of well-conceived interventions. In the current study, well-oriented and trained parents were a critical component of the supports for generalization and maintenance of school-based treatment gains.
The purpose of the current study was to evaluate the effectiveness of a support-oriented behavioral and cognitive intervention for improving the behavioral self-regulation of two children with severe challenging behavior after TBI and in facilitating long-term maintenance of treatment gains and life satisfaction in the children and important stake holders in their lives. The behavioral excesses were largely addressed with a combination of remote and immediate antecedent supports, based on functional analysis of the challenging behavior. Cognitive and executive system impairments were similarly addressed with antecedent supports, and all of the interventions were organized within the children's daily school routines and delivered by education staff supported by a TBI consultant. Rationale and summary of experimental evidence for the behavioral interventions (consistent with positive behavior supports applications of applied behavior analysis 56) and related cognitive interventions (consistent with the theory of supported cognition 33) are presented by Ylvisaker, Jacobs, and Feeney. 57
After successful implementation of the experimental intervention, maintenance of treatment gains was facilitated through training of parents and education staff, including the following school year's teachers and assistants. Outcome was measured by counting and rating the severity of episodes of aggression and by judging the amount of work completed per school day. Generalization and maintenance were measured qualitatively, using structured interviews and rating scales designed for the study.
The hypotheses were as follows. The multicomponent, context-sensitive, antecedent-focused intervention would result in:
1. A decrease in frequency of the students' challenging behaviors
2. A decrease in intensity of the students' challenging behaviors
3. An increase in school work accomplished
In addition, it was hypothesized that classroom staff would find the interventions reasonably easy to implement and useful in improving the children's behavior and social interaction, and that the children's behavioral and social gains would be maintained at intermediate (1-year) and long-term (8-year) follow-ups.