Context-sensitive cognitive-behavioral supports for young children with TBI: a second replication study.(traumatic brain injury)(Report)

This study produced a second replication of an investigation of the effects of a multicomponent cognitive-behavioral intervention on the challenging behavior of young children with growing behavioral concerns after traumatic brain injury (TBI). The participants were two young elementary-age children with escalating behavior problems after severe TBI. Single-subject reversal designs were used to document the effects of the combined behavioral, cognitive, and executive function intervention on the following: frequency and intensity of aggressive behaviors and amount of work accomplished. The intervention included integrated components of positive behavior supports, cognitive supports (e.g., graphic organizers), and an executive function routine (goal-plan-do-review). Results included reduced frequency and intensity of challenging behaviors and increased quantity of work completed. These two successful single-subject experiments replicated four previously published single-subject experiments demonstrating the potential for successfully treating behavior disorders in young children with TBI using a support-oriented intervention that combines behavioral, cognitive, and executive function components.

Keywords: behavior disorders; pediatric rehabilitation; traumatic brain injury; positive behavior support; cognitive-behavioral intervention; functional assessment; school-based treatment; multicomponent intervention; ecological validity

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Traumatic brain injury (TBI) is a leading cause of death and disability in childhood (Kraus, 1995). New and persisting behavior disorders among children with severe TBI are common (Andrews, Rose, & Johnson, 1998; Bloom et al., 2001; Brown, Chadwick, Shaffer, Rutter, & Traub, 1981; Fletcher et al., 1996; Kinsella, Ong, Murtagh, Prior, & Sawyer, 1999), with estimates ranging from approximately 35% (Max et al., 1997) to 70% (Costeff, Grosswasser, Landman, & Brenner, 1985). The prevalence of behavior problems among children with TBI is increased by the finding that preinjury behavioral adjustment difficulties are themselves a predictor of TBI (Asarnow et al., 1995; Bloom et al., 2001; Light et al., 1998; Schwartz et al., 2003; Yeates et al., 1997). Reported behavior problems include both externalizing symptoms (e.g., disinhibition, aggression, immature behavior relative to age expectations, rigidity, awkward social interaction) and internalizing symptoms (e.g., depression, social withdrawal). Aggression has been highlighted in the TBI follow-up literature as particularly common (Baguley, Cooper, & Felmingham, 2006).

The participants for the current study were injured at an early age and the interventions took place in first-grade classrooms in their community schools. Persisting behavior disorders following TBI tend to be more common and more severe in children injured at a younger age (V. Anderson & Moore, 1995; Hebb, 1947; Levin et al., 1993; Michaud, Rivara, Grady, & Reay, 1992; H. G. Taylor & Alden, 1997; Woodward et al., 1999). Animal studies have similarly shown that many functions related to the frontal lobes, vulnerable in closed head injury (Levin et al., 1993; Scheibel & Levin, 1997), are more severely affected if the injury occurs in early childhood (Kolb, 1995). For these reasons, the escalating behavior problems of the children in these studies were cause for great concern.

Furthermore, cognitive and behavioral functioning often worsens over the years after pediatric TBI rather than improving, as parents, teachers, and others understandably expect (Costeff et al., 1985; Koskiniemi, Kyykka, Nybo, & Jarho, 1995). Long-term follow-up studies of children with relatively "pure" prefrontal injuries have, with few exceptions, documented an evolution of increasing behavior and social self-regulation problems over the years after their injuries, with new problems continuing to emerge through adolescence (S. W. Anderson, Damasio, Tranel, & Damasio, 2000; Eslinger, Biddle, & Grattan, 1997: Marlowe, 1992; Mateer Williams, 1991; Max et al., 1997: Williams & Mateer, 1992). Thus, a primary goal of intervention and support for these children is to prevent the predicted behavioral deterioration from occurring (Feeney & Ylvisaker, 1995; Ylvisaker & Feeney, 1995, 1998).

The current study combined behavioral with cognitive, executive function, and communication-focused interventions. In this article, we use the term cognitive to stand for mental processes involved in the acquisition and use of knowledge (e.g., attention, memory, organization, reasoning, and problem solving). Executive functions include the self-regulatory functions used to guide thinking, emotions, and behavior in the pursuit of goals. Cognitive problems have been positively associated with behavior problems in some pediatric TBI studies (Max et al., 1999) but not others (V. A. Anderson et al., 2001; Yeates et al., 1997). Our experience along with that of many other clinicians suggests a complex interaction among the behavioral, cognitive, and executive function domains of outcome. A possible explanation for the discrepancies in the research literature is that the cognitive impairments commonly associated with frontal lobe injury (e.g., difficulty with complex organizational and planning tasks; Biddle, McCabe, & Bliss, 1996; Chapman, 1997), difficulty processing abstract and indirect language (Dennis & Barnes, 2001), and impaired strategic behavior under novel or stressful circumstances (Burgess & Shallice, 1996) are often not assessed by follow-up test batteries but are required for successful school performance. Indeed, a hallmark of prefrontal injury is reasonable performance during office-bound testing and apparently good overall recovery despite reduced effectiveness in demanding educational, social, and vocational contexts (S. W. Anderson et al., 2000; Eslinger, Grattan, Damasio, & Damasio, 1992; Hanten, Bartha, & Levin, 2000; Koelfen et al., 1997; Varney & Menefee, 1993; Wilson, 1993). The children in the current study were judged to have cognitive and executive function deficits in the classroom, particularly in the areas of organizing and planning. These difficulties exceeded expectations based on psychoeducational testing and substantially contributed to the children's behavioral difficulties. Cognitive difficulties in an increasingly demanding school context predictably lead to frustration and behavior problems, particularly for children with relatively significant inhibition impairment.