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Brief Description of PBS Related to Traumatic Brain Injury

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Brain injuries that occur after the developmental and birth processes are classified as an acquired brain injury (ABI); a smaller subgroup of ABI is traumatic brain injury (TBI). For a brain injury to be classified as traumatic, it has to be caused by an external force to the brain that impairs physical, emotional or cognitive abilities. These types of injuries are most commonly caused by motor vehicle accidents, but can also be caused by falls, assaults, gunshot wounds or abuse. Traumatic brain injury can result in either an open head injury (OHI) or a closed head injury (CHI) depending on whether or not the skull remained unbroken. According to reports from the Center for Disease Control and the Brain Injury Association of America, an estimated 5.3 million Americans currently live with disability from TBI.

While the force related trauma is occurring in the brain, there are often many other serious medical complications for which the patient might need treatment. Since motor vehicle accidents, violence, and falls are the leading causes of traumatic brain injury, there can be other medical and orthopedic injuries simultaneously occurring. Depending on the cause and location of the brain injury, speech, memory and cognition may also be greatly affected. Most TBI survivors require some therapies once they are medically stable, while many will need extensive therapy to regain skills.

Children and adults who have a traumatic brain injury, as well as those who love and care for them, have experienced a life changing event causing many emotionally challenging experiences. The child or adult with TBI may feel frustrated and sad that they have lost important skills or mobility. In some cases, these individuals must relearn how to communicate if speech and language abilities have been compromised. In other cases, physiological changes are also associated with TBI, including depression or other psychiatric disorders. Both the individual child or adult and his or her family learn to adapt and overcome challenges related to TBI that are at times daunting. A person with TBI may engage in problem behaviors that are related to the challenges that come with learning new communication skills or adapting to an environment that may no longer meet that person's needs. According to the Brain Injury Association of America, approximately 90% of people who sustain a severe brain injury experience some emotional, behavioral, or psychiatric difficulties.

Positive behavior support strategies are one way to support an individual with TBI who is engaging in problem behavior. Positive behavior support emphasizes the importance of using both the science of behavior and biomedical information to create a plan of support that builds upon an individual's strengths, reorganizes the environment to remove or change the situations or settings that trigger problem behavior, and to emphasize the importance of prompting, teaching, and supporting communication skills.

Positive behavior support begins with person-centered or wraparound planning. Both person-centered planning and wraparound are team-based strategies that involve placing the child or adult with TBI and his family in control of his life. Teams accomplish this by scheduling planning sessions that focus on building upon an individual's strengths to create a better life, and ensuring services are integrated and effective. Outcomes of person-centered planning and wraparound include lifestyle improvements such as participation in community life, gaining and maintaining satisfying relationships, expressing personal preferences and making choices, and developing personal competencies. Such improvements in quality of life are facilitated by establishing a positive long-range vision with the individual and his/her family (e.g., through person-centered planning) and establishing natural supports through effective teamwork

To address problem behaviors, the child or adult and his or her team will focus on creating a positive behavior support plan, starting with a process called Functional Behavioral Assessment.

Functional Behavioral Assessment (FBA)

The functional behavioral assessment (FBA) process involves gathering information about what reliably predicts and maintains a child or adult's problem behavior. A variety of assessment tools are used to conduct a FBA. Interviews with people who know the person well are usually a first step for gathering information. Observing the individual in his/her natural environment provides further evidence regarding the function of a problem behavior. The team working with the individual systematically observes the person in different settings to see if there are certain environmental variables triggering problem behavior. A FBA is considered complete when the following outcomes are accomplished:

  • there is a clear description of the problem behavior,
  • the events, times, and situations that predict both the occurrence and nonoccurrence of problem behavior are identified,
  • events immediately following problem behaviors are identified,
  • one or more educated guesses (hypotheses) about the function maintaining problem behavior are developed, and
  • direct observation data identifying and confirming the function of the problem behavior is complete.

Individualized Multi-component Interventions

The team that forms to support the individual in order to create a PBS plan should include the people who are actively present in the situations and settings that are part of the person's life. Information gathered from a functional behavioral assessment helps this team develop and implement a behavior support plan that is positive, proactive, educative, and functional. PBS plans include a number of interventions that can be implemented across situations and settings. These interventions include: 1) proactive strategies for changing the environment so triggering events are removed, 2) teaching new skills that replace problem behaviors, 3) eliminating or minimizing natural reinforcement for problem behavior, and 4) maximizing clear reinforcement for appropriate behavior. A hallmark of PBS planning is emphasis on improving overall lifestyle quality (relationships, activities, health) as an integrated part of behavior support.