Theoretical Framework - TBI

Behavioral and Social Interventions for Individuals with Traumatic Brain Injury: A Summary of the Research with Clinical Implications

Mark Ylvisaker, Ph.D.,1Lyn S.Turkstra, Ph.D.,2 and Carl Coelho, Ph.D.3

ABSTRACT

Specialists in communication disorders who work with individuals who have traumatic brain injury (TBI) often focus their rehabilitative efforts on the cognitive, social, and behavioral dimensions of disability. These domains of functioning are included in the scope of practice of the American Speech-Language and Hearing Association because of their close associa- tions with communication effectiveness. This article summarizes relevant research findings and clinical perspectives in the areas of intervention for disorders of behavioral self-regulation and social-interactive competence after TBI. This clinical summary is associated with a systematic evidence review sponsored by the TBI Practice Guidelines Group of the Academy of Neurologic Communication Disorders and Sciences (ANCDS).

KEYWORDS: Acquired brain injury, social skills training, positive

behavior supports, evidence-based practice

Learning Outcomes: Upon completion of this article, the reader will be able to (1) summarize the current evidence for social and behavioral intervention after traumatic brain injury; (2) describe relevant evidence from

related populations, such as individuals with developmental disabilities; and (3) differentiate between the two

main approaches to behavioral intervention, applied behavior analysis and positive behavior supports.

Personality changes, including increases in challenging behavior, are common after severe traumatic brain injury (TBI) in both children and adults (see the review by Ylvisaker

et al1). Estimates of new persisting behavior disorders (i.e., those not predating the injury) among children and adolescents with severe TBI range from about 35%2 to a high of

Evidence-Based Practice for Cognitive-Communication Disorders after Traumatic Brain Injury; Editors in Chief, Audrey L. Holland, Ph.D., and Nan Bernstein. Ratner, Ed.D.; Guest Editor, Lyn S. Turkstra, Ph.D. Seminars in Speech and Language, volume 26, number 4, 2005. Address for correspondence and reprint requests: Mark Ylvisaker, Ph.D., 1171 Van Antwerp Road, Schenectady, NY 12309. E-mail: [email protected]. 1College of Saint Rose, Albany, New York; 2Department of Communicative Disorders, University of Wisconsin-Madison, Madison, Wisconsin; 3Communi- cation Sciences, University of Connecticut, Storrs, Connecticut. Copyright # 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 0734-0478,p;2005,26,04,256,267,ftx,en; ssl00252x.

256

70%.3 This sobering picture is worsened by the frequent finding that preexisting behavior prob- lems are common among both children and adults with TBI, predisposing them to injury,1

although not all outcome studies have con- firmed this.4,5 The intensity of behavior disor- ders has been associated in some studies with the severity of injury.6

Behavioral and social changes are often judged by family members, teachers, employers, friends, and others to be the most problematic consequences of the injury.7,8 Poorly controlled behavior and problematic social interaction have been linked to difficulty in family reinte- gration and educational, vocational, social, and avocational pursuits.9–11

Factors that may contribute to ineffective social reintegration include preinjury behavioral and communication problems, impairments tied directly and indirectly to the injury, the hard-to-predict evolution of postinjury reac- tions, and the effectiveness of ongoing manage- ment and support.12 Preinjury contributors have been highlighted since the early studies of Lishman,13 a theme captured in the often- repeated generalization, ‘‘It is not only the kind of injury that matters, but the kind of head.’’4 Frequently linked directly to the injury are the two classical frontolimbic behavior syndromes: the so-called pseudopsychopathic and pseudodepressed personalities or variations on these.14 These syndromes are of special concern following closed head injury because of the relatively high frequency of prefrontal lesions.15 Often associated with ventral frontal lesions or frontal-limbic disconnection is some combination of transient or persistent disinhibition, impulsiveness, lability, reduced anger control, aggressiveness, sexual acting out, perseveration, inefficient learning from consequences, and generally poor social judg- ment. The pseudodepressed personality, asso- ciated with dorsal prefrontal lesions, may be characterized by some combination of re- duced initiation, apathy, lack of drive, loss of interest, lethargy, slowness, inattentiveness, re- duced spontaneity, unconcern, lack of emo- tional reactivity, dullness, poor grooming, and perseveration.

Indirectly linked to success in social inte- gration are commonly occurring cognitive16

and executive function impairments (in do- mains of attention, memory, organization, planning, flexible problem solving, self-aware- ness, and the like).17 Weakness in these areas negatively affects performance in nonroutine social interaction and indirectly reduces social effectiveness and behavioral self-regulation by contributing to failure and resulting frustration that may increase over time. Theory of mind deficits (i.e., generally impaired ability to inter- pret others’ behavior as motivated by unobserv- able thoughts, desires, and feelings that can be inferred from their behavior) have been linked to frontal lobe damage18 and have been identi- fied as a potential source of social impairments in TBI.19 Impaired social perception, including weak recognition of emotional signals from others, can interfere with social reintegration as the individual misinterprets the behavior of others and responds accordingly.20,21 These impairments have been linked to right hemi- sphere frontal lobe and limbic lesions,22,23

specifically a ventral system that includes the amygdala, ventral prefrontal structures, and anterior cingulate gyrus, commonly injured in closed head injury.21

The long-term evolution of psychosocial adjustment is difficult to predict in individual cases. Many people with TBI enjoy a successful social reintegration, often resulting in part from their effort and natural resilience and in part from the understanding and accommodations of everyday people in their social environments. In contrast, those referred for behavioral services may have experienced a systematic downward social spiral, as social, academic, and vocational failures create negative reac- tions, which in turn exacerbate the challenges tied directly to the injury and intensify their social, academic, and vocational failures (see review by Kendall and Terry12). Iatrogenic behavior problems are also common, particu- larly those caused by overly restrictive or puni- tive environments that encourage a downward behavioral spiral caused by power battles.1

Children and adolescents with TBI face future developmental challenges with disrupted neural systems and associated deficits in learning and self-regulation. Therefore, delayed onset or exacerbation of symptoms, including behavioral symptoms, is common in this group, especially

BEHAVIORAL AND SOCIAL INTERVENTION/YLVISAKER ET AL 257

in the presence of frontal lobe injury (see review in Feeney and Ylvisaker24).

BEHAVIORAL INTERVENTIONS Over the past 20 years, the field of applied behavior analysis (ABA) has evolved into two overlapping but distinguishable approaches to assessment and intervention. These are referred to here as traditional ABA and positive behav- ior supports (PBS). Traditional ABA has a much longer history of theory construction, procedure development, and efficacy research than PBS. It is supported by an extensive research literature with a variety of clinical populations and emphasizes the management of behavior by deliberately manipulating consequences (i.e., contingency management). This approach is based on the fundamental principle that behaviors increase or decrease in frequency as a result of positive or negative consequences. By contrast, the PBS approach is based on the principle that behavior is best managed and modified by organizing immedi- ate and remote antecedent supports so that individuals are likely to behave successfully and, with practice, acquire repertoires of be- havior that enable them to succeed in their social contexts. Table 1 outlines the major themes and critical differences between tradi- tional ABA and PBS approaches. The table lists specific procedures within both frame- works that have been studied as interventions for individuals with TBI.

The potential success of the traditional ABA framework with adults with TBI has been demonstrated by several single-subject studies conducted in England25,26 and else- where. Similarly, PBS procedures have been shown to be effective in managing behavior problems in children and adults with TBI. In a series of single-subject experiments, Feeney and Ylvisaker described PBS procedures and showed them to be effective.24,27–29 Two class I randomized controlled examinations of behavior management procedures have appeared in the TBI literature, both using PBS procedures (see later). Although specific behavior management procedures are often studied in isolation to measure their individual contribution to outcome, combinations of

intervention strategies (whether traditional ABA or PBS) have been shown to in- crease the effect size in studies of many clinical populations.30

Support-oriented behavioral procedures have often been combined with support- oriented cognitive, communication, and execu- tive function procedures. For example, Feeney and Ylvisaker24 combined the following proce- dures in a multicomponent intervention that proved to be successful in two pediatric TBI single-subject experiments, with positive results at an 8-year follow-up:

* Daily Routine: Negotiation and choice. Daily routines were analyzed collaboratively by the instructional staff and students, followed by modifications in the support provided, amount of work to be accomplished, and plans for achieving the goals.

* Positive Momentum. Staff ensured that the plan included relatively easy tasks with a guaranteed high level of success before diffi- cult work was introduced, and, if possible, a student-preferred activity preceded every mandated activity.

* Reduction of Errors. In addition to eliminat- ing time demands and negotiating the amount of work to be completed, instruc- tional staff were trained to provide sufficient modeling and assistance so that the students would experience few errors (which histori- cally evoked negative behavior and interfered with learning).

* Escape Communication. Because the func- tional behavior assessment indicated that most occurrences of challenging behavior served to communicate a need to escape a task or place, the students were taught pos- itive communication alternatives (e.g., ‘‘I need a break’’ or ‘‘I’m finished’’). Staff mem- bers were trained to encourage these alter- natives at natural transition times and when the students began to appear anxious or upset and to reward the students’ use of positive escape communication.

* Adult Communication Style. Instructional assistants were trained to (1) increase their frequency of supportive and reinforcing in- teractions with the students, (2) anticipate students’ difficulties and offer assistance or

258 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER 4 2005

Table 1 Contrasting Themes: Traditional Applied Behavior Analysis and Positive Behavior Supports

Traditional Applied Behavior Analysis Positive Behavior Supports

Focus and Goals

Focus on specific behaviors, with the goal of increasing the

frequency of positive and decreasing the frequency of

negative behaviors. Focus on external control of

behavior via systematic manipulation of consequences.

Primary focus on lifestyle change satisfactory to

the individual and important others in that life.

Secondary focus on specific behaviors. Focus

on internal control of behavior and behavior

change via manipulation of antecedents,

including both remote and internal

antecedents to behavior. Often combined

with cognitive, communication, and executive

system intervention.

Assessment

Functional behavior assessment (correlational and

experimental), ideally conducted by behavior

specialists in analogue (i.e., experimentally

controllable) environments.

Functional behavior assessment, ideally

conducted in natural environments and

involving collaboration among staff, family,

and the individual. Assessment includes

exploration of background setting events

(including general lifestyle, internal states of

the person, remote antecedents, and

environmental facilitators and barriers).

Intervention Modalities and Methods

Primary use of contingency management (i.e., systematic

and planned manipulation of consequences), designed

to increase (positive and negative reinforcement)

or decrease (extinction or punishment) specific

behaviors. Procedures include differential

reinforcement of targeted positive behaviors or

of alternative behaviors or of low rates of targeted

negative behaviors, token economy procedures

(e.g., receiving a token for positive behavior that

can be traded for a reward later), extinction

procedures (e.g., ignoring negative behaviors,

time-out from reinforcement), response-cost

procedures (e.g., losing points for negative

behavior), redirection, contingent restraint,

behavioral contracts, prompting, and cuing. Less

focus on antecedents, typically immediate

antecedents (e.g., specific provocation,

environmental conditions, instructions, demands).

Often primary use of extrinsic reinforcers (e.g.,

food, stickers, tokens) not logically and naturally

related to the targeted behavior.

Primary focus on control of antecedents,

including both remote (e.g., negative events

at an earlier time) and internal (e.g., sense of

loneliness, perceived failure, physical pain)

setting events, with the goal of making

background setting events as positive as

possible. Procedures include assurance of

adequate amount of choice and control,

engagement in personally meaningful

activities, building positive momentum before

difficult tasks (e.g., with preferred activities or

guaranteed success), positive communication

from communication partners, teaching

positive communication alternatives to

negative behavior, provision of positive roles

and scripts, and natural and logical rewards

for positive behavior.

Organization of Intervention

Specific behaviors often taught in a sequential

manner: acquisition then stabilization/fluency,

then transfer to novel contexts.

Specific behaviors often targeted in natural

settings and in the context of natural

activities from the outset (with support);

thus, generalization is facilitated from the

outset.

BEHAVIORAL AND SOCIAL INTERVENTION/YLVISAKER ET AL 259

model escape utterances, and (3) avoid ‘‘nag- ging’’ (as perceived by the students).

* Graphic Advance Organizers. Because of significant organizational impairment, the students were provided with photograph cues as a support for organizationally de- manding tasks.

* Goal-Plan-Do-Review Routine. The stu- dents were given a graphic ‘‘map’’ that repre- sented the general sequence of activities from an executive function perspective: Goal (i.e., ‘‘What are you trying to accomplish?’’); Iden- tification of difficulty level (i.e., ‘‘Is this going to be hard or easy?’’); Plan: (i.e., ‘‘How do you plan to get this done? What do you need? What are the steps? How long will this take?); and Review (i.e., ‘‘What were you trying to accomplish? How’d it work out? What worked for you? What didn’t work? What was easy? Difficult?’’). These interac- tions with staff were brief and collaborative (versus a performance-oriented quiz).

Multicomponent interventions of this sort confound research by making it difficult to identify the relative contributions of each com- ponent to the outcome. They are, however, respectful of dynamic interactions among the behavioral, cognitive, communication, and ex- ecutive function dimensions of human activity.

SUMMARY OF THE EVIDENCE: INTERVENTIONS FOR BEHAVIORAL DISORDERS In an evidence review sponsored by Academy of Neurologic Communication Disorders and Sciences (ANCDS), Ylvisaker and colleagues

(article in preparation) identified 59 studies in which behavioral (nonpharmacologic) inter- ventions were provided to individuals with problematic behavior after TBI. These studies included 194 participants. Two studies were classified as class I (randomized controlled trials [RCTs]), 2 as class II (uncontrolled group studies), 34 as class III (single-subject experi- ments or series of experiments), and 20 as class IV (uncontrolled case studies or series of case studies).

All but one of the reports documented improvement in the participants who received the intervention. The exception was a series of single-subject designs in which stress inocula- tion training procedures (relaxation, self- instruction, coping skills) were used in a resi- dential setting.31 The documented success in the remaining 58 reports, including two RCTs, supports the conclusion that behavioral inter- ventions have a reasonably strong evidence base in their application to individuals with TBI. Because a wide variety of intervention proce- dures were used, specific standards or guidelines for clinical practice cannot be derived from this body of evidence. However, the strength of the evidence supports a conservative conclusion that behavioral interventions, understood ge- nerically, should be considered at least a prac- tice guideline for clinicians.

Both RCTs used PBS procedures. Wade and colleagues32 trained parents of children with TBI to use antecedent support-oriented procedures to manage challenging behavior. Children in the experimental group (n ¼ 16) showed greater improvements in internalizing symptoms (anxiety, depression, withdrawal of child) than those in the control group (n ¼ 16).

Table 1 (continued)

Traditional Applied Behavior Analysis Positive Behavior Supports

Setting, Providers

Intervention often provided in ‘‘behavior management’’

settings (e.g., segregated classroom, clinic,

residential center). Intervention largely delivered,

at least in the acquisition stage, by behavior

specialists.

Intervention ideally provided in natural (home, work,

school) community settings, with primary

providers being the people who are natural

communication partners in those settings

(e.g., family members, work or school staff,

peers), supported by specialists.

260 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER 4 2005

Children and parents in the experimental group reportedly liked the program and im- proved on measures of knowledge, skills, and relationships within the family. Relatively greater behavioral improvements were noted in the older and less severely impaired children with better-educated parents. Medd and Tate33

used TBI education, self-awareness training, and anger management strategies with an ex- perimental group of adults with TBI (n ¼ 8) while a control group (n ¼ 8) received only anger monitoring training. Both groups im- proved on measures of anger, with the exper- imental group showing greater improvement.

In addition to the fact that only two of the studies yielded class I evidence, the literature is fraught with methodological problems. Nota- bly, relatively few of the studies provide com- pelling evidence that the intervention resulted in improvements that transferred to personally meaningful functional contexts and were main- tained over extended periods of time.

INTERVENTION TRENDS OVER THE PAST 30 YEARS As an organized intervention approach sup- ported by a coherent theory, PBS is relatively new and, compared with ABA, is therefore associated with a smaller research base across clinical populations. However, a review of the literature suggests a marked evolution from consistent reliance on traditional ABA proce- dures in the 1980s to a striking dominance of PBS approaches since 2000, as shown in Table 2.

Several possible reasons can be identified for the increasing use of PBS procedures in TBI rehabilitation:

1. Ventral frontal lobe injury, common in closed head injury, is associated with inhibi- tion impairment.34 It is well understood that the behavior of markedly disinhibited indi- viduals (e.g., toddlers) is best managed by thoughtfully organizing the antecedents of behavior in an attempt to facilitate positive routines rather than simply reacting to the impulsive behaviors.

2. Ventral frontal lobe injury has also been associated with a dramatic inefficiency in learning from consequences.35 Damasio’s somatic marker theory offers one possible explanation for this inefficiency.36 Damasio hypothesized that lack of connection be- tween somatic (feeling) states and memories (conscious or unconscious) of past behavior is a critical factor in this failure to learn from consequences.

3. Dorsal frontal lobe injury, less common in closed head injury, can result in initiation impairment, which also reduces the effi- ciency of contingency management. That is, even if a connection is made between behavior and its consequences, initiation impairment may result in failure to engage in the learned behavior.

4. Impaired social perception, mentioned ear- lier and also a common consequence of TBI, jeopardizes contingency management insofar as that approach assumes accurate perception and interpretation of social situa- tions and social cues. Several investigators have linked social perception impairments to vulnerable frontolimbic structures.21,37–39

5. A history of failure and frustration, possibly combined with oppositionality (common among individuals with TBI), also reduces the effectiveness of contingency management.

Table 2 Relative Emphasis of Traditional ABA and PBS Behavioral Intervention Studies in TBI Rehabilitation over the Past 25 Years, Demonstrating Systematically Increasing Use of PBS Procedures (N ¼ 59)

Intervention Type 1980–1989 1990–1999 2000–2005

Traditional ABA 6 15 1

Combined 2 12 5

Positive behavior supports 0 6 11

Unclassifiable 0 0 1

ABA, applied behavior analysis; PBS, positive behavior supports; TBI, traumatic brain injury.

BEHAVIORAL AND SOCIAL INTERVENTION/YLVISAKER ET AL 261

6. Finally, studies of effectiveness of intervention have increasingly demonstrated the merits of PBS procedures.24,27

SOCIAL INTERACTIVE COMPETENCE: OUTCOME AND INTERVENTION Social skills include both general competencies and specific goal-directed, situationally appro- priate, verbal and nonverbal behaviors. Individ- uals use such skills to affect the behavior of others, gain acceptance by peers and family members, establish friendships, and meet the demands of school, work, and community. Adequate social skills increase the likelihood of reciprocal friendships and a satisfying social life.

Although theoretically distinguishable, so- cial skills and behavioral self-regulation overlap in practice. Individuals diagnosed with chal- lenging behavior are often also described as socially unskilled. Generally, the diagnostic and rehabilitative focus is on the behavior disorder if the difficulty has little to do with reduced knowledge of the relevant social rules, roles, and routines and more to do with diffi- culty regulating behavior with that knowledge, possibly combined with oppositionality. Out- come literature, including studies supporting pathophysiological associations with specific deficits in social behavior, was cited earlier.

The relationships among social skills, peer acceptance (enabling the individual to have adequate opportunities for satisfying in- teraction), and friendship (i.e., symmetrical, emotionally committed relationships) are recip- rocal. Individuals who behave awkwardly in social situations are likely to be rejected by peers and, in turn, often exhibit depression, loneliness, negative self-concept, anxiety, low academic achievement, and higher dropout rates, further reducing social interactive com- petence.40 Children and adults with TBI pre- dictably attempt to reconnect with their preinjury friends and peers. However, physical, cognitive, and personality changes often result in a gradual loss of friends and increasing isolation.41,42 Reduced social opportunities may then further jeopardize social interactive success, leading to a downward social spiral.

Loneliness is often reported to be the dominant concern of individuals with TBI.43

INTERVENTION FOR IMPAIRED SOCIAL-INTERACTIVE COMPETENCE The tradition of social skills intervention, based on work with children and adults with devel- opmental disabilities or psychiatric diagnoses, is based on the assumption that their social inter- action problems are largely due to inadequately developed knowledge of relevant social rules, roles, and routines. Many training programs have been developed and organized around training groups within which the participants practice social behaviors considered relevant to their social success. Such training programs differ with respect to the degree to which they emphasize discrete trial training or social prob- lem solving. However, the common thread is repeated practice in a socially decontextualized training setting.

The success of traditional social skills training (SST) groups (including pragmatics groups typically led by speech-language pathol- ogists) assumes that the individuals (1) lack knowledge of relevant social rules, roles, and routines; (2) are motivated to change their social behavior; (3) possess the capacity to transfer skills acquired in a training setting to varied real-world application settings; and (4) are reasonably self-regulated. Unfortunately, the profile of many individuals with TBI is opposite to that suggested by these assump- tions. With relatively damaged anterior brain structures and relatively preserved posterior structures, individuals with a common profile after TBI typically possess relevant declarative social knowledge44 but are poorly regulated, have difficulty transferring social knowledge to daily living, or may lack the motivation to change, particularly if the injury has reduced their awareness of their interactive social com- petence and the effects of their behavior on others.

To be sure, individuals who lack declara- tive and procedural knowledge of relevant social skills or competencies need explicit in- struction. However, even applied to those with congenital disability who presumably need such

262 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER 4 2005

instruction, the traditional model of SST has not been supported by evidence reviews. Gre- sham, Sugai, and Horner45 reviewed narrative reviews and meta-analyses of the extensive social skills intervention research literature and concluded that ‘‘SST (social skills training) has not produced large, socially important, long-term, or generalized changes in the social competence of students with high-incidence disabilities’’ (p. 331). Specifically, they de- scribed two meta-analyses. The first included 99 studies of SST applied to students with emotional and behavioral disturbance, with a small mean effect size of 0.20. The second included 53 studies of SST applied to students with learning disabilities, with a similarly small mean effect size of 0.21. Barkley’s review of the literature on decontextualized SST similarly concluded that this approach has minimal dem- onstrated effectiveness with students who are impulsive as a result of attention deficit hyper- activity disorder.46 In general, meta-analyses and narrative reviews of experiments with sev- eral populations using decontextualized social skills (or ‘‘pragmatics’’) training suggest mini- mal effects on real-world behavior, peer social skills ratings, and maintenance of new social behaviors over extended periods of time.

SUMMARY OF THE EVIDENCE FOR INTERVENTIONS FOR DISORDERS OF SOCIAL INTERACTIVE COMPETENCE AFTER TRAUMATIC BRAIN INJURY Struchen’s recent review yielded 19 peer-re- viewed studies that evaluated the effectiveness of social communication interventions for in- dividuals with acquired brain injury.47 Thirteen of these were case studies or case series, includ- ing single-subject experiments (a total of 19 participants with TBI); the remaining six were group studies (56 participants with acquired brain injury, mostly TBI). Commonly used intervention procedures included modeling, role-playing, feedback, self-monitoring, behav- ioral rehearsal, and social reinforcement.

Only 1 of the 19 studies was classified as providing class I evidence (i.e., from a random- ized, controlled, clinical trial). In that study, Helffenstein and Wechsler48 demonstrated the

effectiveness of 20 hours of interpersonal proc- ess recall (IPR) compared with 20 hours of nontherapeutic attention. IPR includes indi- vidualized videotaped interactions; structured review of the taped interactions with feedback provided by the conversation partner, a thera- pist, and the individual with TBI; development of alternative skills as needed; modeling; and guided rehearsal. Participants receiving the IPR treatment reported significantly reduced anxi- ety and improved self-concept. Furthermore, they were rated as having significantly greater improvement in specific interpersonal skills by both professional staff and independent observ- ers, both of whom were unaware of group placement. Maintenance of improved interac- tion was confirmed at a 1-month follow-up. The obvious strengths of this study are tem- pered by the small sample size (eight partic- ipants per group) and study setting (inpatient rehabilitation).

Struchen cited the evidence review by Cicerone and colleagues49 in which those au- thors conclude from the same body of evidence that social interaction intervention for individ- uals with TBI should be considered a practice standard. However, the many serious methodo- logical weaknesses in the available studies, de- scribed in detail by Struchen, should caution against drawing such strong conclusions. Inter- vention in this domain can be considered evi- dence based; however, the state of the evidence is far from offering clinicians guidance in con- necting specific intervention approaches or in- tensities with specific profiles of need or in supporting confident predictions of functional outcome following the intervention. It is worth noting that the only available class I study employed an intervention that is highly indi- vidualized, employs extensive video feedback, and is labor intensive. These features are often absent in standard social skills or pragmatics training groups.

AN EMERGING THEME: FOCUSING INTERVENTION EFFORTS ON COMMUNICATION PARTNERS Traditional SST assumes that the problem and its solution are located ‘‘in’’ the person with disability. In contrast, recently developed

BEHAVIORAL AND SOCIAL INTERVENTION/YLVISAKER ET AL 263

intervention programs are sensitive to the im- pact of the understanding and competencies of communication partners on the success of social interaction. These developments are consistent with the current World Health Organization50

emphasis on context (environmental and attitu- dinal) as a determinant in health and disability outcomes. Furthermore, specialists in commu- nication and its disorders have long recognized the dynamic interactive effects of partner com- petencies in explaining communication effec- tiveness. Training of communication partners has been shown to have a positive effect on communication effectiveness and (re)acquisi- tion of communication skills in toddlers and preschoolers with language disorders and de- velopmental disabilities,51 adults with apha- sia,52 adults with dementia,53 and adults with TBI.54

CLINICAL THEMES EMERGING FROM THE AVAILABLE EVIDENCE AND CLINICAL PRACTICE The limited research evidence in the field of social skills intervention in TBI rehabilitation, combined with a wealth of evidence from related disability fields and the authors’ experi- ence with many children and adults with social interaction difficulties after brain injury, suggests that the following components of intervention and support may be particularly important:

* The facilitation of knowledge, understand- ing, and communication competence in everyday communication partners so that they can interact supportively and do not misinterpret or react punitively to awkward behaviors that result from the individual’s impulsiveness, failure to initiate, misreading of social cues, anxiety, and the like.

* The selection of highly specific and person- ally important social interactive competencies for context-sensitive training.

* Extensive practice of social behaviors in the situations in which they are required, with satisfying natural and logical consequences for successful performance. This practice may be supplemented by video self-modeling for additional learning trials.

* Situational coaching that includes advance cues prior to potentially problematic interactions.

* Situational training that is specifically de- signed to improve social perception and the ability to interpret the behavior of others.

* Situational training that is specifically de- signed to improve self-monitoring of stress levels, so that individuals can remove them- selves from stressful situations as needed.

* The application of a person-centered goal formulation framework, so that the individ- uals understand that the goal is their social success, not ‘‘social appropriateness’’ under- stood abstractly as an authority figure’s goal.

* Counseling specifically designed to help the individual develop a personally compelling sense of self that includes positive social interaction strategies as a component.55

Applied to TBI, research on the effective- ness of social skills intervention is in its infancy. Considerable work needs to be done to identify the specific profiles of ability and impairment that lend themselves to specific intervention approaches. However, these investigations should be informed by the impressive bodies of evidence available in related disability fields. That evidence, combined with common char- acteristics of brain injury, such as difficulty transferring learned behaviors to untrained contexts, should caution against reliance on currently popular intervention options, such as social skills or pragmatics training groups. Rather, the available evidence seems to support approaches that are sensitive to the specific realities of the individual’s communication con- text, integrate communication with cognitive and executive function interventions, and in- clude situational coaching and training of com- munication partners.

SUMMARY Community reintegration after severe TBI is strongly influenced by social competence and behavioral self-regulation. These related do- mains of functioning are commonly impaired by TBI and constitute a primary rehabilitative focus for specialists in communication disor- ders. In both domains there is an evidence

264 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER 4 2005

base that supports intervention. However, guidelines linking specific profiles of ability, need, and available supports with specific in- tervention and support strategies await future investigations.

ACKNOWLEDGMENTS

This work was supported by funding from the American Speech-Language-Hearing Associa- tion (ASHA), ASHA Division 2: Neurophysi- ology and Neurogenic Speech and Language Disorders, and the Department of Veterans Affairs. Support also was provided by the Col- lege of Saint Rose, the University of Minne- sota, and Case Western Reserve University.

REFERENCES

1. Ylvisaker M, Jacobs HE, Feeney T. Positive supports for people who experience behavioral and cognitive disability after brain injury: a review. J Head Trauma Rehabil 2003;18:7–32

2. Max JE, Robin DA, Lindgren SD, et al. Traumatic brain injury in children and adolescents: psychiatric disorders at two years. J Am Acad Child Adolesc Psychiatry 1997;36:1278–1285

3. Costeff H, Grosswasser Z, Landman Y, Brenner T. Survivors of severe traumatic brain injury in childhood: I, late residual disability. Scand J Rehabil Med 1985;12(suppl):10–15

4. Tate RL. ‘‘It is not only the kind of injury that matters, but the kind of head’’: the contribution of premorbid psychosocial factors to rehabilitation outcomes after severe traumatic brain injury. Neuropsychol Rehabil 1998;8:1–18

5. Tate RL, Broe GA. Psychosocial adjustment after traumatic brain injury: what are the important variables? Psychol Med 1999;29:713–725

6. Schwartz L, Taylor HG, Drotar D, Yeates KO, Wade SL, Stancin T. Long-term behavior prob- lems following pediatric traumatic brain injury: prevalence, predictors, and correlates. J Pediatr Psychol 2003;28:251–263

7. Brooks DN, Campsie L, Symington C, Beattie A, Bryden J, McKinley W. The effects of severe head injury upon patient and relative within seven years of injury. J Head Trauma Rehabil 1987;2:1–13

8. Lezak M. Psychological implications of traumatic brain damage for the patient’s family. Rehabil Psychol 1986;31:241–250

9. Morton MV, Wehman P. Psychosocial and emo- tional sequelae of individuals with traumatic brain

injury: a literature review and recommendations. Brain Inj 1995;9:81–92

10. Perlesz A, Kinsella G, Crowe S. Psychological distress and family satisfaction following traumatic brain injury: injured individuals and their primary, secondary, and tertiary carers. J Head Trauma Rehabil 2000;15:909–929

11. Taylor HG, Yeates KO, Wade SL, Drotar D, Stancin T, Minich N. A prospective study of short- and long-term outcomes after traumatic brain injury in children: behavior and achievement. Neuropsychology 2002;16:15–27

12. Kendall E, Terry DJ. Psychosocial adjustment following closed head injury: a model for under- standing individual differences and predicting outcome. Neuropsychol Rehabil 1996;6:101–132

13. Lishman WA. The psychiatric sequelae of head injury: a review. Psychol Med 1973;3:304–318

14. Stuss DT, Benson DF. The Frontal Lobes. New York: Raven Press; 1986

15. Scheibel RS, Levin HS.Frontal lobe dysfunction following closed head injury in children and adults. In: Krasnegor NA, Lyon GR, Goldman-Rakic PS, eds. Development of the Prefrontal Cortex: Evolution, Neurobiology, and Behavior. Baltimore, MD: Paul Brookes Publishing; 1997:241–263

16. Max JE, Roberts MA, Koele SL, et al. Cognitive outcome in children and adolescents following severe traumatic brain injury: influence of psycho- social, psychiatric, and injury-related variables. J Int Neuropsychol Soc 1999;5:58–68

17. Levin HS, Goldstein FC, Williams DH, Eisenberg HM. The contribution of frontal lobe lesions to the neurobehavioral outcome of closed head injury. In: Levin HS, Eisenberg HM, Benton AI, eds. Frontal Lobe Function and Dysfunction. New York: Oxford University Press; 1991:318–338

18. Stuss DT, Gallup GG, Alexander MP. The frontal lobes are necessary for ‘theory of mind’. Brain 2001; 124:279–286

19. Turkstra LS, McDonald S, DePompei R. Social information processing in adolescents: data from normally developing adolescents and preliminary data from their peers with traumatic brain injury. J Head Trauma Rehabil 2001;16:469–483

20. Turkstra L. Should my shirt be tucked in or left out? The communication context of adolescence. Aphasiology 2000;14:349–364

21. McDonald S. Are you crying or laughing? Emotion recognition deficits after severe traumatic brain injury. Brain Impairment 2005;6:56–67

22. Shammi P, Stuss DT. Humour appreciation: a role of the right frontal lobe. Brain 1999;122:657–666

23. Stuss DT, Alexander MP.Affectively burnt in: a proposed role of the right frontal lobe. In: Tulving E, ed. Memory, Consciousness and the Brain. Philadelphia, PA: Psychology Press; 1999:215–227

BEHAVIORAL AND SOCIAL INTERVENTION/YLVISAKER ET AL 265

24. Feeney TJ, Ylvisaker M. Context-sensitive behav- ioral supports for young children with TBI: short- term effects and long-term outcome. J Head Trauma Rehabil 2003;18:33–51

25. Alderman N. Contemporary approaches to the management of irritability and aggression follow- ing traumatic brain injury. Neuropsychol Rehabil 2003;13:211–240

26. Wood RL, Eames P. Application of behavior modification in the rehabilitation of traumatically brain-injured patients. In: Davey G, ed. Applica- tions of Conditioning Theory. London: Methuen; 1981:81–101

27. Feeney T, Ylvisaker M. Choice and routine: antecedent behavioral interventions for adolescents with severe traumatic brain injury. J Head Trauma Rehabil 1995;10:67–82

28. Feeney TJ, Ylvisaker M.A positive, communica- tion-based approach to challenging behavior after ABI. In: Glang A, Singer GHS, Todis B, eds. Students with Acquired Brain Injury: The School’s Response. Baltimore, MD: Paul H Brookes; 1997: 229–254

29. Ylvisaker M, Feeney TJ. Collaborative Brain Injury Intervention: Positive Everyday Routines. San Diego, CA: Singular Publishing; 1998

30. Stage SA, Quiroz DR. A meta-analysis of interventions to decrease disruptive classroom behavior in public education settings. School Psych Rev 1997;26:333–368

31. Aeschleman SR, Imes C. Stress inoculation train- ing for impulsive behaviors in adults with traumatic brain injury. J Rational-Emotive Cog Behav Ther 1999;17:51–65

32. Wade SL, Michaud L, Maines T. Putting the pieces together: preliminary efficacy of a family problem-solving intervention for children with traumatic brain injury. J Head Trauma Rehabil 2005:(in press)

33. Medd J, Tate RL. Evaluation of an anger manage- ment therapy program following acquired brain injury: a preliminary study. Neuropsychol Rehabil 2000;10:185–201

34. Rolls ET. The orbitofrontal cortex and reward. Cereb Cortex 2000;10:284–294

35. Schlund MW. Effects of acquired brain injury on adaptive choice and the role of reduced sensitivity to contingencies. Brain Inj 2002;16:527–535

36. Damasio AR. Descartes’ Error: Emotion, Reason, and the Human Brain. New York: Avon Books; 1994

37. Anderson SW, Bechara A, Damasio H, Tranel D, Damasio AR. Impairment of social and moral behavior related to early damage in human pre- frontal cortex. Nat Neurosci 1999;2:1032–1037

38. Damasio AR, Tranel D, Damasio H. Individuals with sociopathic behavior caused by frontal damage

fail to response autonomically to social stimuli. Behav Brain Res 1990;41:81–94

39. Tranel D, Bechara A, Denburg NL. Asymmetric functional roles of right and left ventromedial prefrontal cortices in social conduct, decision- making, and emotional processing. Cortex 2002; 38:589–612

40. Rubin KH, Bukowski W, Parker J.Peer interac- tions, relationships, and groups. In: Eisenberg N, eds. Handbook of Child Psychology: Social, Emo- tional, and Personality Development. New York: Wiley; 1998:619–700

41. Hoofien D, Gilboa A, Vakil E, Donovick PJ. Traumatic brain injury (TBI) 10–20 years later: a comprehensive outcome study of psychiatric symp- tomatology, cognitive abilities and psychosocial functioning. Brain Inj 2001;15:189–209

42. Kersel DA, Marsh NV, Havill JH, Sleigh JW. Psychosocial functioning during the year following severe traumatic brain injury. Brain Inj 2001;15: 683–696

43. Harrick L, Krefting L, Johnston J, Carlson P, Minnes P. Stability of functional outcomes follow- ing transitional living programme participation: 3-year follow-up. Brain Inj 1994;8:439–447

44. Turkstra LS, Dixon TM, Baker KK. Theory of mind and social beliefs in adolescents with traumatic brain injury. Neurorehabilitation 2004; 19:245–256

45. Gresham FM, Sugai G, Horner RH. Interpreting outcomes of social skills training for students with high-incidence disabilities. Exceptional Children 2001;67:331–344

46. Barkley RA. Adolescents with attention-deficit/ hyperactivity disorder: an overview of empirically based treatments. J Psychiatr Pract 2004;10:39–56

47. Struchen M. Social communication interventions for persons with traumatic brain injury. In: High WM, Sander AM, Struchen MA, Hart KA, eds. Rehabilitation Interventions following Traumatic Brain Injury: State of the Science. New York: Oxford University Press; 2005:88–117

48. Helffenstein D, Wechsler R. The use of inter- personal process recall (IPR) in the remediation of interpersonal and communication skill deficits in the newly brain injured. Clin Neuropsychol 1982; 4:139–143

49. Cicerone KD, Dahlberg C, Kalmar K, et al. Evidence-based cognitive rehabilitation: recom- mendations for clinical practice. Arch Phys Med Rehabil 2000;81:1596–1615

50. World Health Organization. International Classi- fication of Functioning, Disability and Health. Report. Geneva: Switzerland: World Health Orga- nization; 2001

51. Girolametto L, Sparks B, Weitzman E, Pearce PS. The Effects of Language Intervention on the Play

266 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 26, NUMBER 4 2005

and Behaviour Competencies of Late Talkers. Toronto, Canada: University of Toronto; 2003

52. Kagan A, Black S, Duchan J, Mackie N, Square P. Training volunteers as conversation partners using ‘‘Supported Conversation for Adults with Aphasia’’ (SCA): a controlled trial. J Speech Lang Hear Res 2001;44:624–638

53. Ripich D, Ziol E, Fritsch T, Durand E. Training Alzheimer’s disease caregivers for suc-

cessful communication. Clin Gerontol 1999;21: 37–53

54. Togher L, McDonald S, Code C, Grant S. Training communication partners of people with traumatic brain injury: a randomised controlled trial. Aphasiology 2004;18:313–335

55. Ylvisaker M, Feeney T. Construction of identity after traumatic brain injury. Brain Impairment 2000;1:12–28

BEHAVIORAL AND SOCIAL INTERVENTION/YLVISAKER ET AL 267