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Introduction   

Positive behavior support (PBS) primary goal is to change an individual’s lifestyle in a way that positively impacts the individual and the people around them to attain a better quality of life for all involved (Carr et al., 2002). PBS is used when an individual exhibits inappropriate behaviors, which may arise from three categories: biological, developmental, or social learning (Wheeler & Richey, 2010). In order to achieve the goal of an improved quality of life, PBS’s second goal seeks to make inappropriate behaviors useless in the pursuit to get them what they wanted. New and appropriate behaviors are taught that will replace the existing problem behaviors allowing the individual to use a more socially acceptable way to get the things they desire. PBS achieves these goals by: preventing challenging behaviors; reinforcing appropriate behavior; teaching replacement behaviors, and reducing challenging behaviors (Carr et al., 2002)

Theory

The PEO model focuses on the interaction of three components: the person, the environment, and the occupation (Law et al., 1996). All of these are used to assess an individual’s occupational functioning and their occupational performance within their environment. If there is minimal overlap between the three components it can lead to occupational dysfunction and results in a poor fit (Law et al., 1996). The person component is unique to the individual and focuses on the behavior of a person. The environment component is where the context of the behavior takes place and the occupation component looks at meaningful activities and tasks a person wants to be able to accomplish (Law et al., 1996). To change a client’s behavior, the occupational therapist has to enhance the performance and function of the individual to be maximally supported within their environment to promote positive behavior. The therapist would also make sure the environment supports the maximal amount of participation for the individual to engage in their occupations to promote appropriate behavior.

Evidence

Current literature suggests the importance of using behavioral supports with individuals who have a TBI (Yivisaker et al., 2007). People with TBI demonstrate many challenging behaviors including disinhibition irritability, aggression, sexual acting out, impaired social perception, egocentrism, depression, and social withdrawal. Decreasing challenging behaviors by using appropriate methods will support the growing evidence of using positive behavior support with individuals who sustained a TBI.

Case Study

Samuel is still displaying secondary effects due to his TBI. According to his family, Samuel’s behavior has dramatically changed since his TBI. Samuel reports that he is often unable to control his behavior when someone disagrees with him. He mentioned that he becomes aggressive and will punch the wall once he gets angry. Samuel is concerned about his behavior because his friends and family are afraid to be around him when he gets aggressive. Samuel recognizes that his friends avoid controversial topics around him because they do not know how he is going to respond. He has become hesitant to venture into public because he is easily angered with people in the service industry. Samuel reported that he got into an argument with the bartender last week and started breaking glasses over the bar. Samuel hopes his behavioral change isn’t permanent and is interested in trying a positive behavioral support approach with his occupational therapist. Based on Samuel’s behavior problems, the occupational therapist is going to work on reinforcing positive behavior and teaching replacement behaviors to promote behavioral change and improve his quality of life.

Intervention plan

Problem statement

Samuel is unable to engage in social participation secondary to violent acts of aggression causing bodily harm, social isolation, and destruction of property.

Long term goals

1. Client will be able to engage in social participation with 0 negative behaviors in 4 weeks.
2. Client will be able to participate in a 5-minute conversation with a person that triggers his anger in a public place without becoming aggressive and destroying property in 4 weeks.
3. Client will be able to engage in social participation after a trigger has occurred by using a replacement behavior in 4 weeks.

Short term goals

1. Client will be able to role-play with the therapist in a 2-minute conversation that triggers his aggression by using positive reinforcement to promote social participation in 2 weeks.
2. Client will identify 3 positive replacement behaviors to use when engaging in social participation in 2 weeks.

Intervention format

Individual

Setting

Samuel will meet with the occupational therapist 2x a week for 60 minutes for 4 weeks in an outpatient center.

Supplies

None

Agenda

• Meet with Samuel / develop rapport / form a partnership (5 min)
• Engage with Samuel and discuss his maladaptive behaviors (15 min)
  • Potential open-ended questions
    • What causes you to become angry?
    • Describe a time you were unable to control your behavior in public?
    • How do you respond when someone disagrees with you?
• Teach positive replacement behaviors (15 min)
  • Provide examples of how to respond to his previous negative encounters
    • “Would you mind if we change topics”
    • “I appreciate your opinion but I am uncomfortable talking about this”
    • Stop, relax, and disengage to allow yourself time to respond in a positive way
    • Instead of retaliating, take a deep breath and count to 10 inside your head
• Practice using replacement behaviors in a scenario (20 min)
  • Allow the client to pick a topic that bothers him
    • Talk politics with therapist
    • Use a different point of view than the client
    • Disagree with him
    • Facilitate the client using replacement behaviors
    • Evaluate how he feels and reacts
• Provide summary / feedback on the session  (5 min)
  • Ask him how he thought the session went
  • Provide an overview and summary of his performance
    

Documentation

S: “My behavior is causing me to lose friends”

O: Client reports that he is frustrated because his TBI changed his behavior patterns. Client stated that he is worried he will continue to lose people in his life due to his irrational reactions. Client was provided with open-ended questions to allow him to expand on his behavior problems and identify his point of view. The client had no problem reporting that he becomes angry when: people are rude in customer service, people do not say excuse me after bumping into him, and topics such as gun control and political stances. He states that he reacts without thinking when people make him mad and will punch walls to ease his frustration. He reports that if a person disagrees with him and tells him that he is wrong he will start cussing and attack the individual with words. Client was educated on replacement behaviors that would diffuse the situation and allow him to act appropriately when engaging in conversations. Examples were given of how to respond instead of using his typical responses that were unsuccessful. The client was willing to try them and eager to practice. Client was asked to pick a topic that would cause him discomfort and often make him react with negative behaviors. The client chose the presidential election and whether you should vote republican or democrat. The scenario was given to allow the client to respond in a controlled environment and practice the new replacement behaviors. Initially the client was unable to remain calm in the scenario and needed a break to discuss his behavior. As the scenario went on the client was able to incorporate one replacement behavior. Client was debriefed on his performance and was asked to try these behaviors throughout the week.

A: It is apparent that the client is having difficulty adapting after the TBI. The client would benefit from education explaining the effects of a TBI and the journey to recovery. The client does present with room for improvement and is able to benefit from PBS because he is aware of the conversations and situations that bother him. His insight will help him incorporate new techniques to improve his behavior. The client’s positive attitude during therapy will help foster a client-therapist relationship to increase the effect of therapy. The scenario caused the client to present with his negative behaviors, which indicates his ability to control his behavior is quite low. Once the client was allowed to take a break and ease back into the scenario he was capable of executing a replacement behavior. This shows that the client would benefit from taking deep breaths, slowing down his responses, and giving himself time to react.

P: Client will meet the OT 2x a week for 60 minutes. Next session the client should identify two more positive replacement behaviors to use in a scenario. Client will be given positive reinforcement to enhance the likelihood that he will use his new replacement behaviors.

References

Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., & al, e. (2002). Positive behavior support: Evolution of an applied science. Journal of Positive Behavior Interventions, 4(1), 4. Retrieved from http://ezproxy.fiu.edu/login?url=https://search.proquest.com/docview/218766782?accountid=10901

Law, M., Cooper, B,. Strong, S., Stewart, D., Rigby, P. & Letts, L. 1996. The Person-Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy. 63(1):9-23.

Wheeler, J. J., & Richey, D. D. (2010). Behavior management: Principles and practices of positive behavior supports. Pearson.

Ylvisaker, M., Turkstra, L., Coehlo, C., Yorkston, K., Kennedy, M., Sohlberg, M. M., & Avery, J. (2007). Behavioural interventions for children and adults with behaviour disorders after TBI: A systematic review of the evidence. Brain Injury, 21(8), 769-805.