Addressing Challenging Behaviors in Young Children with TBI

There is limited literature on evidence-based practices for behavior intervention with young in children (ages 0-5) with TBI. The following are some strategies shown to work with older children, which may translate well to younger ages.

Conduct a Functional Behavior Assessment (FBA)

Use information gathered to define target behaviors and gather baseline data to determine:

• Frequency of target behaviors:
  • Number of tasks completed.
  • Number of explosive episodes.
• Duration of target behaviors:
  
  • Length of time off task.
  • Length of explosive episodes.
• Intensity of target behaviors:
  
  • Loudness of explosive episode.
• Time of day target behaviors occur.

Gather information through:

• Interviews with staff.
• Behavioral checklists.
• Observation of student.
• Interviews with student.

Identify possible interventions to address problems identified in the FBA

• Daily routines:
  • Make decisions about routines collaboratively with the child as much as possible.
  • Collaboration helps the student to learn decision-making and feel a greater sense of ownership.
• Increase positive behavioral momentum:
  • In order to build positive momentum, allow the child to complete a preferred activity before doing a difficult activity.
  • Provide high levels of reinforcement.
• Reduce the number of errors the student makes:
  • Teach staff to provide modeling of the desired behavior.
  • Teach staff to provide enough structure to decrease errors.
• When it is possible, reduce the structure to decrease the student’s dependency.
• Teach the student appropriate verbal and non-verbal escape communication, for example, “I need a break.” This communication must be honored immediately by the staff.
• Staff can model escape communication for the student when the student begins to get upset.
• Teach staff to increase frequency of supportive communications, predict the student’s behavior and avoid repeated reminders.
• Use graphic organizers, schedules, pictures or objects to help the student know what is coming.
• Teach the Goal Plan Predict Do Review routine:
  • Ask the student what she needs to do
    • What is your goal?
    • What do you need to do here?
    • Ask the student to identify level of difficulty.
      • Hard or easy?
      • Scary or not scary?
  • Ask the student what her plan is for finishing the task, and to predict how she thinks it will work.
    • What do you need to start the task?
    • What steps do you need to take to complete the task?
  • After task completion, follow up by asking the student to consider what went well and what worked.
    • This conversation should be conversational — not a checklist.
• Consequence procedure:
  • Note: Most of an intervention is focused on preventing undesirable target behaviors, as well as teaching students to manage their own behavior. Use the following procedure for behaviors targeted in the FBA.
    1. Teacher makes a statement, “You are showing me you are not ready to do X, because…”
    2. Remove materials.
    3. Tell the student what he needs to do to show that he is ready to do the task.
    4. Remind the student of supports he needs to use (e.g., appropriate escape communication, etc.).

Implement plan and measure behaviors

To track how well the plan is working for the child and enable necessary modifications.  Alter the plan until you see changes in frequency, duration, and intensity of target behaviors, or until you see an increase in the number of tasks successfully completed.

Compare results to baseline data and adapt the intervention plan as needed

This process combines cognitive (information acquisition) and executive (self regulatory) functions to address behavior difficulties in students with TBI. It has been validated in four studies of students with TBI.

Important Note: The Functional Behavioral Assessment process is not delivered in a clinical setting; it is done in the setting where the student needs to use the behaviors being learned (e.g., study skills in the classroom or cooperative play on the playground).

Plan to adapt the intervention regularly and over the long-term

Teaching any child to use and maintain appropriate behavior takes years of training and practice. Children with TBI need even more support and structure, which makes it necessary to plan for the long term while still working to build independence into the child’s plan.

Adapted from:

Feeney T.J. & Ylvisaker, M. (2008). Context sensitive cognitive-behavioral supports for young children with TBI: A second replication study. Journal of Positive Behavioral Interventions, 10 (2), 115–128.