Clinical perspectives on delivering a Positive Behaviour Support intervention for challenging behaviours following acquired brain injury.

Challenging behaviours are distressing sequelae for people with acquired brain injury (ABI) and their families. Positive Behaviour Support (PBS) is a collaborative approach focussing on improving quality of life for individuals with ABI presenting with challenging behaviours. This qualitative study explored clinicians' experiences of a 12-month intervention (PBS+PLUS) for adults with ABI and their family/carers. Semi-structured interviews were conducted with eight clinicians trained in neuropsychology (n = 5), occupational therapy (n = 3), speech pathology (n = 2), with two clinicians trained in two of these disciplines. Interviews were analysed through reflexive thematic analysis. Three themes were identified: Shifting clinical identity; Working as equals; Adapting to the environment. Participants experienced PBS+PLUS as a difficult approach to learn but one which enhanced overt client communication and comfort with their clinical fallibility. PBS+PLUS involved giving clients equal status in the clinician-client relationship which for some clients and families was challenging. Finally, PBS+PLUS was perceived as problematic to implement in some work settings (e.g., involving high staff turnover). Clinicians' recommendations for future implementation included thorough training and supervision and early setting of client expectations. With increasing interest in PBS to address challenging behaviours after ABI, these findings will guide PBS+PLUS translation for community clinicians.

"I've never been positive I am now": Participant perspectives of a Positive Behaviour Support intervention (PBS + PLUS) for community-living individuals with ABI and their close others.

Challenging behaviours are common following moderate to severe acquired brain injury (ABI). These behaviours cause relationship and community participation difficulties and are a significant source of stress for many individuals with ABI and their close others (COs). A Positive Behaviour Support intervention, PBS + PLUS, was implemented to assist individuals with ABI to collaboratively build meaningful lives and self-regulate their behaviour. This study explored the perspectives of individuals with ABI and COs (family members, friends, and carers) who had completed an individualized 12-month PBS + PLUS intervention. Fifty-two individuals participated in semi-structured interviews, and a thematic analysis of interview transcripts identified the interrelated themes of Openness to Change, Embeddedness, Clinician Connection, and Preparedness for the Future. Participant perceptions of, and engagement with, PBS + PLUS were influenced by an attitude of openness to new ideas and by the intervention itself. Achieving contextual relevance allowed the intervention to become embedded in participants' lives, and the client-clinician relationship was central to participants' positive experiences. While most participants felt better equipped to cope with the future, some experienced difficulties transitioning to post-intervention life. These results suggest PBS + PLUS may assist individuals with ABI to lead meaningful lives and more confidently overcome behavioural challenges, while encouraging supportive and empowered COs.

Positive behaviour support for challenging behaviour after acquired brain injury: An introduction to PBS + PLUS and three case studies.

Challenging behaviours are a common and distressing consequence of acquired brain injury (ABI). There are no evidence-based guidelines for managing challenging behaviours after ABI, leaving clinicians with few resources to guide practice. Findings from case studies and single-subject experimental designs support the use of positive behaviour support (PBS) interventions for challenging behaviour post-ABI. This paper introduces PBS + PLUS: a multi-component and flexible PBS intervention using a person-driven collaborative approach to build a meaningful life and self-regulate behaviour after ABI. PBS + PLUS is currently being examined in a randomized controlled trial (RCT). Three detailed pilot case studies illustrate the highly individualized implementation of the programme, delivered to the individuals with ABI and carers over 12 months by a transdisciplinary team including neuropsychologists, occupational therapists, and psychiatrists. Objective behavioural outcomes are reported for participants using the Overt Behaviour Scale at baseline and four-monthly intervals for two years. Goal attainment scaling was used to measure personally meaningful goals. The qualitative appraisals of the intervention by participants, families and carers, and 12-month follow-up outcomes are described. The advantages and challenges of programme delivery are discussed. These case studies will assist clinicians and service providers to implement PBS + PLUS in anticipation of the results of the RCT.

Structured flexibility: the use of context-sensitive self-regulatory scripts to support young persons with acquired brain injury and behavioral difficulties.

OBJECTIVE: This study investigated the effects of a cognitive-behavioral intervention on the escalating behavior problems observed in 2 children with severe traumatic brain injury. DESIGN: Multiple baseline designs were used to document the effects of an intervention package that integrated cognitive and executive function interventions to address severe challenging behaviors in public school settings. MAIN OUTCOMES AND RESULTS: The results suggested that the intervention reduced the frequency and intensity of challenging behaviors and increased the quantity of work completed. CONCLUSIONS: These 2 successful single-subject experiments expand the findings of previous studies on the use of a support-oriented intervention that uses context-sensitive, flexible cognitive/behavioral scripts combined with positive behavior interventions and supports to reduce challenging behaviors.

There's always something that works: principles and practices of positive support for individuals with traumatic brain injury and problem behaviors.

Behavioral and cognitive problems are among the most common and troubling consequences of traumatic brain injury Furthermore, behavioral and cognitive challenges typically develop in complex ways, necessitating an integrated approach to intervention and supports. This article summarizes literature on interventions positively affecting the behavioral outcomes for individuals with brain injury. This literature extends many of the traditional approaches to behavioral intervention and cognitive rehabilitation to include positive behavioral support and the development of personally meaningful activities for program development. In addition, the article provides a framework for intervention based on the decades-long work of Mark Ylvisaker, which is founded on positive principles of assessment and treatment and is implemented in a context-sensitive manner that integrates cognitive and behavioral intervention themes and focuses on the development of self-regulation.

Structured flexibility and context-sensitive behavioral support for the chronically cranky.

BACKGROUND: A significant number of individuals with brain injury demonstrate behavioral challenges that negatively affect their ability to live successfully in community settings. While there are a number of treatment approaches that have demonstrable effects in well controlled clinical settings, it is very difficult to implement these approaches in natural settings. OBJECTIVES: The goal of this study was to report the results of an investigation of the effects of a multicomponent behavioral intervention on the challenging behavior of an adolescent and young adult with growing behavioral concerns after acquired brain injury (TBI). METHODS: The participants were an 16 year old adolescent male and a 24 year old female, with escalating behavior problems after severe TBI. Multiple baseline designs were used to document the effects of an intervention package that integrated cognitive and executive function intervention to address severe challenging behaviors in natural settings. The following dependent variables were used to establish the effectiveness of the interventions: frequency and intensity of aggressive behaviors and participation in scheduled activities. The intervention included integrated components of positive behavior supports, cognitive supports and specific executive function scripts. RESULTS: These single subject experiments demonstrated the effectiveness of a multicomponent intervention on the reduction of the frequency of problem behaviors and the increase of pro-social behaviors. CONCLUSION: These two successful interventions extended the findings of previously published data for the successful treatment of behavioral challenges using a flexible support-oriented intervention that combines behavioral, cognitive, and executive function components.

Context-sensitive behavioral supports for young children with TBI: short-term effects and long-term outcome.

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.