Positive behaviour support for challenging behaviour after acquired brain injury: An introduction to PBS + PLUS and three case studies

Kate Rachel Gould, Jennie Louise Ponsford, Amelia J. Hicks, Malcolm Hopwood, Belinda Renison and Timothy J. Feeney

Neuropsychological Rehabilitation

https://doi.org/10.1080/09602011.2019.1656647

What the study is about

Challenging behaviours, such as aggression, inappropriate social behaviours and lack of initiation are common following acquired brain injury (ABI). These behaviours may place the person and others at risk of harm, interfere with community participation and cause distress to family members. There are no evidence-based guidelines for managing challenging behaviours after ABI, leaving clinicians with few resources to guide practice. Over the last few decades, findings from case studies and single subject experimental designs have supported the use of positive behaviour support (PBS) interventions for challenging behaviour post-ABI. The key approach of PBS, which evolved from applied behaviour analysis, is that by proactively preventing challenging behaviours –

making them inefficient and ineffective – and systematically facilitating desired behaviours, challenging behaviours become unnecessary (Carr et al., 2002).

What we did

This paper introduces PBS + PLUS: a multi-component and flexible PBS intervention using a person-driven collaborative approach to build a meaningful life and self-regulate behaviour after ABI. This approach reflects  on the body of knowledge developed by Mark Ylvisaker and Tim Feeney. The efficaciousness of PBS + PLUS is currently being examined in a randomised controlled trial (RCT) conducted by our team, which will help to strengthen evidence-based practice. In the meantime, we have prepared three detailed pilot case studies from our trial to illustrate the highly individualised implementation of the program, delivered to the individuals with ABI and carers over 12 months by a transdisciplinary team including neuropsychologists, occupational therapists, and psychiatrists. These case studies will assist clinicians and service providers to implement PBS + PLUS in anticipation of the results of the RCT. Objective behavioural outcomes are reported for participants using the Overt Behaviour Scale (OBS) at baseline and four-monthly intervals for two years. Goal attainment scaling was used to measure personally meaningful goals.

What we found

The three participants presented with diverse behaviours, living situations, cognitive profiles, functioning levels, support networks and desired outcomes. Reese, Ethan and Ollie, along with their support networks, received 12 months of individualised intervention from transdisciplinary PBS + PLUS therapists. Through these varied cases, we demonstrate different aspects of the flexible and individualised PBS + PLUS approach. Visual analysis of the primary outcome measure, the OBS, indicated that whilst Ethan and Ollie made substantial improvements

in self-regulation of behaviour, which were maintained over time, Reese’s improvements in behaviour were not sustained beyond 8 months. The qualitative appraisals of the intervention by participants, families and carers, and 12-month follow-up outcomes are described in the article along with a discussion of the advantages and challenges of program delivery. The detailed description of the intervention and expansive case studies should assist clinicians in understanding how the PBS + PLUS principles, framework and strategies may be applied.

Acknowledgements

The authors would like to acknowledge and gratefully thank the generosity, time and effort of the participants, therapists (Dr Kate Gould, Dr Belinda Renison, Dr Kim Trezise, Dr Diane Parcell, Nadine Holgate, Cathy Bucolo, Sally Peterson, and Dr Clare Kempnich), research staff at the Monash-Epworth Rehabilitation Research Centre; our independent expert for integrity monitoring Melissa Capo, Albany, NY, USA; and Kat Orgallo, Teaching Resource Support Unit. This research was funded by the Transport Accident Commission (through the Institute for Safety Compensation and Recovery Research).