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Mark and Katie

The following stories were summarized from a research article by Timothy J. Feeney and Mark Ylvisaker published in the Journal of Head Trauma Rehabilitation. Click here for the full citation or go to the bottom of this page .

Feeney and Ylvisaker (2003) looked at two students who had sustained severe traumatic brain injury (TBI) with frontal lobe involvement. The authors completed a longitudinal study of the two students using one-year and eight-year follow-ups. Both students were in danger of being removed from their classroom placements because of behavioral concerns. According to the authors, anecdotal records indicated that for a period of time, both children had progressed adequately after their discharge from inpatient rehabilitation. At some point, however, both students began to exhibit severe behavioral challenges, including physical aggression. As academic and interpersonal demands increased, school behaviors deteriorated.

One of the two students was Mark. He was a 7-year-old male who had been involved in an auto-bike accident. There was no prior record of behavior, learning, neurological, or developmental problems. Mark came from a supportive family and had many friends. Upon beginning first grade he was having difficulty in the areas of speech, memory, processing efficiency, following complex directions, organization and memory. Mark had one-to-one paraprofessional support during the school day. Even with this one-to-one assistance, Mark found it very difficult to meet the academic needs of first grade. When presented with tasks that were cognitively or physically challenging, Mark became physically aggressive.

The other student was Katie. She was a 6-year-old female and had been hit by a car at age 5. Prior to the accident, parents reported that Katie was bright, active and strong- willed. She was very well liked by most of her peers in her day care program. Parents also reported no previous instances of motor, developmental, academic, behavioral or emotional problems prior to her injury. According to the authors, upon return to school, Katie had no common signs of serious brain injury. The school staff had received training, prior to her return, from the rehabilitation center and had developed an individualized educational program in order to support her during re-entry into a school setting. Shortly after school started, Katie became more disinhibited, aggressive and began challenging school staff. Academic and social skills began to decline as well. In an effort to manage her behaviors, the school had placed her on a positive token system with little success.

Before an intervention plan was created, an extensive assessment was completed for both students. The assessment utilized both quantitative and qualitative measures to establish baseline behavior rates for each student. The quantitative measures used were the Motivational Assessment Scale and the Antecendent-Behavior-Consequence Assessment. While these measures were being given, the examiners were corroborating these findings with direct observation of no less than three separate school days. The findings from these measures were then shown to the classroom staff in order to see if staff was in agreement with what had been assessed and observed. Specifically, aggression and work completion were measured as the dependent variables. The qualitative measures used in this study were administered the staff involved. The instruments were a 10-item 5-point Likert rating scale measuring the effectiveness of the intervention and an extensive two- hour exit interview. The interview consisted of six open-ended questions asked directly of staff by the consultants.

A multi-component intervention was developed and implemented by the authors of this study. The seven components addressed were daily routine, positive momentum, reduction of errors, escape communication, adult communication style, graphic advance organizers and goal-plan-do-review routine. (see article for further explanation of components) An ABAB experimental design was used and confirmed the effectiveness of the multi- component intervention. In an ABAB experimental design, researchers collect data during a baseline when no changes have been introduced (the “A” condition) and then compared to data collected after the intervention is introduced (the “B” condition). The next step is to take away the intervention to see if there is a change in the frequency of challenging behaviors. Then the interventions are re-introduced one last time. This ABAB design provides evidence that the interventions were responsible for changes in behavior and not due to other variables.

At the time of the 8-year follow up, both students continued to show a decrease in aggressive behaviors. This allowed them to be maintained in the school setting. Work completion, however, showed little to no significant improvement. The amount of work completed did not seem to be critical in that both students were making passing grades. Qualitative data would suggest that the staff felt positive about the implementation of the interventions.

Key elements for successful behavior management plans include thorough assessment prior to the development of the plan, adequate data collection, inclusion of the individual in all planning phases, a positive behavior support plan developed , and open communication and feedback between staff, family and the individual.

Feeney, T. J., & Ylvisaker, M. (2003). Context-sensitive behavioral supports for young children with TBI. Journal of Head Trauma Rehabilitation, 18(1), 33-51

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