Timothy Feeney

Rehabilitation and ongoing support after pediatric TBI: twenty years of progress.

This article summarizes major developments of the past 20 years in both acute and chronic management of children with traumatic brain injury. The article begins with brief summaries of developments in acute and rehabilitative medical management and physical rehabilitation. Because long-term cognitive, behavioral, academic, and family issues tend to be dominant after pediatric TBI, more attention is given to these topics. The article ends with a list of general themes that have been identified as critical in providing effective long-term services and supports to children with TBI and their families.

Educating students with TBI: themes and recommendations.

Ten educational consultants and researchers, each with extensive experience working with children with traumatic brain injury (TBI) in school settings, identified seven themes related to serving this population in public schools. These themes are discussed under the headings (1) incidence of TBI and prevalence of persistent educational disability, (2) diversity and central tendencies within the population, (3) assessment, (4) intervention and support in school settings, (5) training and support for educators, (6) intervention and support for families, and (7) systems change and flexibility. For each theme, a set of recommendations is provided, forming an educational research and policy agenda for pediatric TBI.

Positive supports for people who experience behavioral and cognitive disability after brain injury: A review

Background:Behavioral and cognitive problems are among the most common and troubling consequences of traumatic brain injury. Furthermore, behavioral and cognitive challenges typically interact in complex ways, necessitating an integrated approach to intervention and support. Objectives:This article reviews literature on behavioral outcome in children and adults with traumatic brain injury, traditional approaches to behavioral intervention and cognitive rehabilitation, and the history, principles, and assessment and treatment procedures associated with context-sensitive, support-oriented approaches to behavioral and cognitive intervention. We propose a clinical framework that integrates cognitive and behavioral intervention themes.

Executive functions, self-regulation, and learned optimism in paediatric rehabilitation: a review and implications for intervention

Success for children and adults alike in educational, vocational, and social pursuits depends heavily on effective self-regulation of cognitive and social behaviour. Our goal in this article has been to summarize recent literature on executive self-regulatory functions, their importance, their development during childhood, the types of disability associated with EF impairment, and intervention approaches that have been shown to be useful for related disability groups. We also examined the literature on learned helplessness and learned optimism for clues to a comprehensive approach to helping children with EF impairment, in particular those with acquired brain injury. The central rehabilitation-relevant themes that we have derived from these reviews are: (a) although brain injury can directly impair executive self-regulation, aspects of the environment and the presence or absence of support behaviours of others can reduce or amplify the neurologic impairment; (b) interventions need to be context sensitive; (c) everyday routines of instruction and parent-child interaction are the ideal context within which to provide EF facilitation; and (d) a primary role for rehabilitation specialists is to help everyday people effectively organize and modulate their support for and everyday interactions with children with disability. In an ideal world, competent and optimistic rehabilitation professionals work collaboratively with children and their parents, teachers and others to ensure an optimistic vision of the future that includes an increasingly autonomous child with the executive self-regulatory skill needed to succeed in adult life.

Context-sensitive behavioral supports for young children with TBI: Short-term effects and long-term Outcome

Objective:To investigate the effects of a multicomponent cognitive-behavioral intervention on the challenging behavior of two young children with growing behavioral concerns after traumatic brain injury. Design:Single-subject reversal designs were used to document the effects of the intervention on the specific dependent variables. In addition, qualitative data were collected to determine the childrens long-term outcome and staff evaluations of the intervention. Participants:Both children were normally developing before injury at age 5 years. Both experienced increasing behavior problems as expectations in school escalated. Main Outcome Measures:Quantitative data included frequency and intensity of aggression and amount of work completed. Qualitative data included childrens general engagement in school work and peer interaction and staff evaluations of the intervention. Intervention:The intervention included components of positive behavior supports, cognitive supports, and an executive function routine. Results:The targeted challenging behaviors were reduced to near zero with decreased intensity. Long-term outcome was positive. Conclusions:These results illustrate the potential for successfully treating behavior disorders in young children with traumatic brain injury using a support-oriented intervention that combines behavioral and cognitive components.

Community supports for individuals with challenging behavior after brain injury: an analysis of the New York state behavioral resource project.

Objective: To articulate a framework for supporting individuals with behavioral challenges following brain injury, to describe a state-funded clinical intervention program established to provide community support to individuals with challenging behaviors following brain injury using such a framework, to present data from which it can be concluded that such a program is cost-effective, and to offer policy recommendations. Design: Retrospective analysis of cost data and living arrangements for individuals with behavioral challenges served for a period of 3–4 years through the New York State Home and Community-Based Services Traumatic Brain Injury (HCBS-TBI) Waiver program and the State Behavioral Resource Project. Subjects: 80 individuals with TBI and severe behavioral challenges that included criminal behavior, physical threats, assault and physical aggression, sexually inappropriate behavior, substance abuse, refusal to participate in intervention programs, and psychiatric disturbances, all of whom were at least 2 years postinjury (&OV0398; = 7.33 years postinjury). Results: The majority of individuals (82% of the 1996 cohort; 89% of the 1997 cohort) with challenging behaviors were living successfully in their home communities 3–4 years after the initiation of behavioral supports. In addition, the costs of serving these individuals decreased in the first year of community integration and for that last year that a cost analysis was completed. Conclusions: Many individuals with behavioral impairments can be supported successfully in community settings, so long as those supports are flexibly implemented to meet the changing needs of those individuals. Moreover, even with intensive supports, it is cost-effective to serve this population in the community.

Context-sensitive cognitive-behavioural supports for young children with TBI: a replication study.

Objective: To replicate an investigation of the effects of a multi-component cognitive-behavioural intervention on the challenging behaviour of two young children with growing behavioural concerns after TBI. Experimental design: Single-subject reversal designs used to document the effects of the combined behavioural, cognitive and executive function intervention on the following dependent variables: frequency and intensity of aggressive behaviours, amount of work accomplished. Participants: Two young children with escalating behaviour problems after TBI. Intervention: Integrated components of positive behaviour supports, cognitive supports (e.g. graphic organizers) and an executive function routine (goal-plan-do-review). Results: Reduced frequency and intensity of challenging behaviours; increased quantity of work completed. Conclusions: Positive replication of previous single-subject experiments demonstrating the potential for successfully treating behaviour disorders in young children with TBI using a support-oriented intervention that combines behavioural, cognitive and executive function components.

Context-Sensitive Cognitive-Behavioral Supports for Young Children with TBI: A Second Replication Study.

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.

Reflections on Dobermanns, poodles, and social rehabilitation for difficult-to-serve individuals with traumatic brain injury

In workshops dealing with social rehabilitation of adolescents and young adults with brain injury, we often show a cartoon of a once proud Dobermann pinscher, now with a look of panic and despair in his eyes as he throws himself out of a second-story window. The caption reads, `The Dobermann threw himself out the second-storey window soon after he realized the family had indeed named him ``Binky’’.’ Veterans of brain injury rehabilitation recognize immediately that the Dobermann represents that clinically challenging population of risk-taking adolescents and young adults who sometimes ®nd themselves after a severe brain injury in a situation that they interpret as binki®cationÐthe typically counterproductive process of attempting to transform tough Dobermanns into passive and `socially appropriate’ poodles. We follow this with a cartoon showing two dogs seated on a delicate pink Victorian settee. One of the dogs is a dainty poodle with freshly coiåed white hair. The other is a tough looking Dobermann-type dog with a frightening studded collar around his bull neck. The poodle is barking into the ear of Spike the Stud Dog, who has his eyes shut as tight as possible, resisting the dreaded words, `Spike, that behaviour is simply inappropriate! ’ Our comment : `This, folks, is binki®cation ; furthermore (pointing to Spike), this is the predictable result of illconceived binkifying attempts.’ Although anybody at any age can have an accident that results in traumatic brain injury (TBI), the population is disproportionately dominated by adolescent and young adult males, many of whom led risky and sometimes checkered lives prior to their injury. The subpopulation to which we direct our attention in this article includes adolescents and young adults with TBI whose high degree of oppositionality and resistance to professional eåorts to shape their goals and behaviour create signi®cant challenges for rehabilitation specialists. Many, though not all, of these individuals demonstrated oppositional behaviour prior to their injury. We currently work with young adults with an additional pre-injury history of serious substance abuse and con ̄ict with the law, although this degree of antisocial behaviour is not part of our operational de®nition of `Dobermann’. In capitalizing on the metaphorical meaning oåered by the terms Dobermann

School reentry following mild traumatic brain injury: A proposed hospital-to-school protocol

Mild traumatic brain injury (TBI) in children is generally associated with excellent long-term outcome. In rare cases sequelae persist indefinitely. More commonly, cognitive and behavioral symptoms persist for a few days to a few weeks, possibly resulting in academic and social failure that could generate consequences that outlive the neurological sequelae. This article presents a mild TBI hospital-to-school protocol that uses real academic and social tasks and contexts as the screening procedure and creates a system of temporary accommodations in the event of persisting cognitive or behavioral consequences of the injury.