Brain Injury and Behavior

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Nov 9, 2013 (3 years and 9 months ago)

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Brain Injury and Behavior


Wendy

Adams
Ed.S
., NCSP


Dr. 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


Observe


A=antecedent


B=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 Behavior


Time Out Procedures


Punishment 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
assignment








LEARNet


Behavioral Impairments with
Traumatic Brain Injuries



Irritability/Agitation (overstimulation)


Frustration


Aggressive Behavior


Anger Outbursts


Short 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



“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.

cokidswithbraininjury.com

BrainSTARS 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.

Memory

Traumatic 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

Visual
-
Spatial

Traumatic Brain Injury Matrix


Behavioral Impacts


Difficulty organizing materials


Can experience behavior difficulties due to
frustration of not understanding visual
materials and expectations


Organization

Traumatic 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

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.


Re
peat 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 LEAR
Net
)


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