Sexually intrusive behaviour following brain injury: approaches to assessment and rehabilitation

Implementing Interventions for Women and Youth with Traumatic Brain Injury at Transition from Custodial Settings: A Call to Action

Traumatic brain injury (TBI) is a serious public health concern and overrepresented among justice-involved populations. An emerging area of research focuses on the complex, interrelated and unmet health and social needs of justice-involved women and youth with TBI. Evidence of these needs continues to grow, yet the health and justice systems continue to underperform in supporting the health and social care of justice-involved women and youth. This commentary is a call to action to begin to redress these gaps. We first provide an overview of the needs of women and youth with TBI that affect their transition from custody to community, including those related to victimization, trauma, mental health, substance use, and homelessness. We then highlight the current gaps in knowledge and practice with respect to interventions for women and youth with TBI at transition from custody. The available evidence for the impact of interventions on people with head injury who are justice-involved is sparse, especially studies of interventions focused on women and youth. We conclude with a call for implementation science studies to support translation from research to practice, emphasizing that researchers, practitioners, policy makers, and women and youth at transition should collaborate to develop, implement, and evaluate accommodations and interventions for TBI. To have meaningful, positive impacts on the systems that serve these women and youth, interdisciplinary service delivery approaches should aim to prevent, raise awareness, identify, and provide timely support and services for the varied needs of women and youth with TBI in transition.

A window into the reality of families living long term with challenging behaviours after a TBI

Challenging behaviours are a long-term burden for people with traumatic brain injury (TBI) and their families. Families frequently shoulder the responsibility alone, but little is known about the strategies they use to manage these behaviours. This study aimed to 1) identify the coping strategies used by people with TBI living in the community and their family caregivers to manage challenging behaviours; and 2) describe the similarities and differences between strategies used by people with TBI and caregivers. In this qualitative descriptive design, individual semi-structured interviews were conducted with adults with TBI and their caregivers and were inductively analyzed. The sample included 10 dyads and two triads, totalling 12 caregivers (8 women) and 14 individuals with TBI (6 women; 21.71 ± 10.84 years post-injury). Participants' strategies were proactive (prevention), reactive (response), or retroactive (aftercare). Most strategies were described by caregivers. Some of them were effective and lasting, others not, reflecting how they adapted their approaches over time. Families put in place various strategies in their life's journey, such as giving feedback or adapting the environment. Despite these strategies supporting long-term community living, the need for ongoing support is underscored, as crises may still occur, impacting families' quality of life.

The dual reality of challenging behaviours: Overlapping and distinct perspectives of individuals with TBI and their caregivers

Challenging behaviours significantly impact the lives of people with traumatic brain injury (TBI) and their family caregivers. However, these behaviours are rarely defined from the perspectives of both individuals, a necessary step to developing interventions targeting meaningful goals for individuals and caregivers. This study aimed to (1) explore and confirm the perspective of individuals with TBI living in the community and their family caregivers on behaviours they consider challenging and, (2) identify overlapping or distinct views on challenging behaviours. A qualitative descriptive design was used. Twelve caregivers (8 females; 59.67 ± 11.64 years old) and 14 participants with mild-severe TBI (6 females; 43.21 ± 10.98 years old; time post-injury: 21.71 ± 10.84 years) were interviewed (10 dyads and two triads). Data were analysed using inductive qualitative analysis. Challenging behaviours most frequently reported by all participants were aggressive/impulsive behaviours, inappropriate social behaviours, and behavioural manifestations of cognitive impairments. Overlapping perspectives were identified regarding aggressive behaviours. Distinctions exist as inappropriate social behaviours and cognitive difficulties were mainly reported by caregivers. Our results confirm that perspectives may vary between dyad members. Interventions should include dyad inputs to formulate goals that are significant to the person with TBI and their caregiver.

The Behaviour Support Elements Checklist: Profiling intervention elements in community-based behaviour support for sexualised behavior after acquired brain injury

BACKGROUND

The challenges associated with behavior dysregulation post acquired brain injury (ABI) are well documented. In a previous publication, we described a case series in which sexualized behavior post-ABI was reduced using multi-element behavior support interventions. In this publication, we describe the intervention elements used, as summarized using a one-page recording tool: The Behavior Support Elements Checklist (BSEC).

INSTRUMENT

The BSEC contains three categories indicating the target for change: the individual with ABI, their support network members, or other environmental aspects. Each category lists a number of elements being used in the routine practice of a community-based behavior support service.

RESULTS

In total, 173 intervention elements were recommended, averaging seven per participant. Elements from all three categories were routinely incorporated into interventions, but changes to the (category) environment were rated by clinicians as most effective in changing behavior; some elements (e.g., meaningful activities) were considered more effective than others (e.g., ABI education).

CONCLUSIONS

The BSEC could assist service agencies and researchers to record and analyze clinician practices to improve service delivery, detect professional development needs, and steer resource allocation. Although the BSEC reflects the context in which it was constructed, it could readily be adapted to other service contexts.

Rehabilitation among individuals with traumatic brain injury who intersect with the criminal justice system: A scoping review

Traumatic brain injury (TBI), a leading cause of morbidity and mortality globally, is highly prevalent among individuals who intersect with the criminal justice system (CJS). It is well-established that TBI negatively impacts individuals' interactions both within the CJS and upon release and is associated with serious disciplinary charges and higher recidivism rates. Although rehabilitation is fundamental to TBI recovery, it is not known to what extent rehabilitation is available to, or used by, individuals who intersect with the CJS. This scoping review explores the availability and extent of rehabilitation for individuals with TBI who intersect with the CJS, based on available literature. A systematic search of electronic databases (MEDLINE, Embase, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, and Proquest Nursing and Allied Health), relevant organizations' websites, and reference lists of eligible articles identified 22 peer-reviewed articles and 2 gray literature reports that met predetermined eligibility criteria. Extracted data were synthesized through a descriptive numerical summary and qualitative content analysis. This review provides evidence that existing rehabilitation interventions are already serving individuals with TBI with a history of CJS involvement; however, they rarely consider or acknowledge TBI or CJS in their interventions. Findings also suggest opportunities to integrate rehabilitation for individuals with TBI who intersect with the CJS through TBI screening, education on TBI within CJS settings, and linkages to the community to facilitate continuity of care. This review also highlights significant gaps in knowledge regarding sex, gender, and other intersecting factors. Research to understand how these experiences impact the rehabilitation process throughout the CJS is urgently needed to enable timely and appropriate rehabilitation and continuity of care for diverse individuals with TBI who intersect with the CJS.

Survey on the experiences, attitudes, and training needs of Australian healthcare professionals related to sexuality and service delivery in individuals with acquired brain injury

Following acquired brain injury (ABI), sexuality, self-esteem and practices are often negatively impacted. Whilst sexuality is recognized as an essential part of a person's life regardless of medical condition, it is poorly understood in the ABI rehabilitation context. This study examined current assessment and treatment practices for sexual health and wellbeing in ABI rehabilitation, including perceived barriers and facilitators to discussing sexuality with individuals after ABI. We also assessed the need for further education and training in this area. Two hundred and thirty-nine Australian healthcare professionals predominantly working with both traumatic brain injury (TBI) and stroke populations completed an online survey comprising thirty-four questions. The 12-item sexuality attitudes and beliefs survey (SABS) was included as an additional objective outcome measure. Findings suggest that healthcare professionals infrequently raise sexuality with individuals with ABI. Inadequate education and training, not knowing whose role it is and when to raise the topic, and the view that individuals with ABI will ask for the information were all identified as key barriers contributing to poor sexuality management after ABI. More education and training opportunities with greater access to resources are needed to facilitate the incorporation of sexuality into routine practice across the continuum of ABI care.

Can behaviour support interventions successfully treat inappropriate sexual behaviour after acquired brain injury in community settings? A case series (N = 24)

Inappropriate sexual behaviours (ISX) are challenging clinical sequelae of acquired brain injury (ABI). Limited evidence exists about treatment approaches, with few case studies published to date. This study reports an exploratory clinical trial of community-based behaviour support interventions as a treatment approach to ISX after ABI. From routine referrals to a state-wide service specializing in challenging behaviours after ABI, a cohort (n = 24) displaying ISXs were selected. The interventions addressed multiple behavioural domains, and used a variety of approaches including environmental change, psychoeducation, and specific behavioural techniques. These approaches targetted change in the person with ABI, support personnel, or other environmental domains. Behaviour data were collected using the Overt Behaviour Scale (OBS) at baseline, closure and follow-up. Visual inspection and multilevel models were used to analyse the data. For the sample as a whole, there was a significant decline in ISXs from baseline to closure that was maintained at follow-up. Results at an individual level are also presented. Specificity of the intervention was demonstrated by comparison with concurrent challenging behaviours (aggression, perseveration, absconding) which showed no significant change over the same three time points. The results demonstrate the potential efficacy of community-based behaviour support interventions in treating ISXs after ABI.

Changes in sexual functioning following traumatic brain injury: An overview on a neglected issue

Traumatic brain injury (TBI) is any damage to the skull and/or the brain and its frameworks due to an external force. Following TBI, patients may report cognitive, physiological and psychosocial changes with a devastating impact on important aspects of the patient's life, such as sexual functioning. Although sexual dysfunction (SD) occurs at a significantly greater frequency in individuals with TBI, it is not commonly assessed in the clinical setting and little information is available on this crucial aspect of patients' quality of life. As the number of people with TBI is on the rise, there is a need for better management of TBI problems, including SD, by providing information to patients and their caregivers to achieve sexual health, with a consequent increase in their quality of life. Discussing and treating sexual problems in TBI patients enters the framework of a holistic approach. The purpose of this narrative review is provide clinicians with information concerning changes in sexual functioning and relationships in individuals with TBI, for a better management of patient's functional outcomes and quality of life.

Physical Therapist, Physical Therapist Assistant, and Student Response to Inappropriate Patient Sexual Behavior: Results of a National Survey

BACKGROUND

A recent survey found that 84% of physical therapist, physical therapist assistant, and student respondents experienced inappropriate patient sexual behavior (IPSB) over their careers and 47% over the prior 12 months. Prevalence data justify consideration of how to address IPSB.

OBJECTIVE

The objective was to determine how physical therapist clinicians (used here to mean physical therapists, physical therapist assistants, and students) address IPSB and examine strategy impact.

DESIGN

The design was observational and cross-sectional.

METHODS

Several sections of the American Physical Therapy Association and selected education programs fielded the electronic survey. Respondents reported on the frequency and effect of IPSB response strategy. Response-strategy impact was tested for statistical significance. Open-ended comments were analyzed using qualitative methods.

RESULTS

Of 1027 respondents, 396 had experienced IPSB over the prior 12 months; 391 provided data on the frequency and effect of response strategies used. Common informal responses included distraction, ignoring IPSB, and altering treatment to avoid physical contact or being alone. Common formal responses included reporting the behavior within the facility and documenting the behavior. Successful strategies included distraction, avoidance, direct confrontation, behavioral contracts, transfer of care, and chaperone use. Experienced clinicians were more likely to be direct, whereas novice clinicians were more likely to engage in unsuccessful actions of ignoring and joking.

LIMITATIONS

Limitations included self-report, clinician memory, and convenience sampling.

CONCLUSIONS

The first findings in 20 years on physical therapist, physical therapist assistant, and student response to IPSB provide direction for the profession. Results indicate a need for clear workplace policies coupled with training for managers and supervisors to support clinicians in resolving IPSB. Policies on using behavioral contracts, chaperones, and transfer of care could empower staff to consider these successful options. Professional education and training for all physical therapy professionals on assertive communication and redirection strategies with IPSB appears warranted.

Differences between staff groups in perception of risk assessment and risk management of inappropriate sexual behaviour in patients with traumatic brain injury

This research explored staff perceptions of risk assessment and management of inappropriate sexual behaviour (ISB) displayed in patients following a Traumatic Brain Injury (TBI). The primary focus was to determine differences in perceptions between qualified (N = 40) and direct care staff (N = 47). Vignettes depicting ISB displayed by a male following a TBI were rated. The vignettes varied in behaviour (intimate versus non-contact) and age of the victim (child versus adult). Ratings for causal explanations (poor management, attention seeking, negative emotion and education), attributions (need for action and increase awareness) and emotions were analysed alongside risk assessment and management variables. Intimate contact ISB and ISB directed towards a child were perceived to be more serious and in need of intervention. Direct care staff perceived ISB to be due to sexual motivations, poor emotion control and to seek attention. They elicited greater negative emotions and based their judgements of risk on seriousness. On the other hand, qualified staff were more concerned about implementing interventions based on the risk of recurrence. Differences between staff groups could cause conflict regarding the assessment and management of ISB in TBI. Training to increase awareness of the behaviour could minimise differences and produce greater cohesion within clinical practise.

Behavioral Interventions for Inappropriate Sexual Behavior in Individuals With Developmental Disabilities and Acquired Brain Injury: A Review

Inappropriate sexual behavior (ISB) is a common, but understudied, issue for individuals diagnosed with developmental disabilities (DD), intellectual disability (ID), and/or acquired brain injuries (ABI). We conducted a systematic review to identify, analyze, and synthesize published behavior-analytic approaches to intervention for ISB in DD, ID, or ABI populations. Twenty-three studies employing single-subject research methodology were identified and evaluated using quality indicators described by Horner et al. (2005) . Results of our analysis suggest insufficient evidence exists to consider any specific response-suppression technique an overarching treatment for decreasing ISB using the Horner et al. criteria. However, broadly speaking, behavior analytic approaches have been highly effective. Practitioners should consider function-based intervention and draw from studies identified as having strong supporting evidence.

Sexual behavior and its correlates after traumatic brain injury

PURPOSE OF REVIEW

Traumatic brain injury (TBI) is one of the leading causes of permanent disability in young adults and is frequently accompanied by changes in sexual behaviors. Satisfying sexuality is an important factor for overall quality of life in people with disabilities. The purpose of this article is to review the studies evaluating the assessment, correlates and management of sexuality following TBI.

RECENT FINDINGS

The Brain Injury Questionnaire of Sexuality is the first validated questionnaire specifically developed for adults with TBI. A considerable amount of individuals with TBI show inappropriate sexual behaviors and sexual dysfunctions. Whereas inappropriate sexual behaviors are related to younger age, less social participation and more severe injuries, sexual dysfunctions show an association with higher fatigue, higher depression scores, less self-esteem and female sex. Healthcare professionals have suggested that because of discomfort at the individual or institutional level, sexual problems are often not sufficiently addressed and have suggested that a specialist should treat sexual problems.

SUMMARY

Although some important correlates of sexual problems could be identified, methodological differences across studies limit their comparability. Furthermore, there is an absence of evidence-based treatment strategies for addressing sexual problems. Therapeutic efforts should take into account the identified correlates of sexual problems following TBI.

Compulsive sexual behavior among male military veterans: prevalence and associated clinical factors

BACKGROUND AND AIMS

Compulsive sexual behavior (CSB) is highly prevalent among men, often co-occurring with psychiatric disorders and traumatic experiences. Psychiatric disorders and trauma are highly prevalent among military veterans, yet there is a paucity of research on CSB among military samples. The aim of this study was to examine the prevalence of and factors associated with CSB among male military veterans.

METHODS

Surveys were administered to veterans of Operations Iraqi Freedom, Enduring Freedom, or New Dawn at baseline (n = 258), 3 months(n = 194), and 6 months (n = 136). Bivariate analyses and Generalized Estimating Equations were utilized to estimate associations between CSB and the following variables: psychiatric co-morbidity, childhood physical or sexual trauma, pre- and post-deployment experiences, TV/ Internet usage, and sociodemographics. Associations between CSB and specific PTSD symptom clusters were also examined.

RESULTS

CSB was reported by 16.7% of the sample at baseline. Several variables were associated with CSB in bivariate analyses; however, only PTSD severity, childhood sexual trauma, and age remained significant in multivariable GEE models. The PTSD symptom cluster re-experiencing was most strongly associated with CSB.

DISCUSSION

This exploratory study suggests that CSB is prevalent amongst veterans returning from combat and is associated with childhood trauma and PTSD, particularly re-experiencing.

CONCLUSIONS

Further study is needed to identify the mechanisms linking PTSD and CSB, define the context and severity of CSB in veterans, and examine the best ways to assess and treat CSB in VA clinical settings.

The neuropsychology of sex offenders: a meta-analysis

Typically, neuropsychological studies of sex offenders have grouped together different types of individuals and different types of measures. This is why results have tended to be nonspecific and divergent across studies. Against this background, the authors undertook a review of the literature regarding the neuropsychology of sex offenders, taking into account subgroups based on criminological theories. They also conducted a meta-analysis of the data to demonstrate the cognitive heterogeneity of sex offenders statistically. Their main objective was to test the hypothesis to the effect that the neuropsychological deficits of sex offenders are not broad and generalized compared with specific subgroups of participants based on specific measures. In all, 23 neuropsychological studies reporting data on 1,756 participants were taken into consideration. As expected, a highly significant, broad, and heterogeneous overall effect size was found. Taking subgroups of participants and specific cognitive measures into account significantly improved homogeneity. Sex offenders against children tended to obtain lower scores than did sex offenders against adults on higher order executive functions, whereas sex offenders against adults tended to obtain results similar to those of non-sex offenders, with lower scores in verbal fluency and inhibition. However, it is concluded that neuropsychological data on sex offenders are still too scarce to confirm these trends or to test more precise hypotheses. For greater clinical relevance, future neuropsychological studies should consider specific subgroups of participants and measures to verify the presence of different cognitive profiles.

Aggressive behaviour and its prevalence within five typologies

Crucial to understanding an individual, presenting with intellectual disability and the management of their challenging behaviours, is the knowledge of the types of those specific behaviours. The term aggressive behaviour is a universal term that embraces many aspects of behaviour that vary in terms of severity, frequency and seriousness for the individual and those around them. Hence, greater consideration regarding intervention, management, person-centred strategies and prevalence and frequency rates are required in service provision for individuals with intellectual disability and aggressive behaviour. This review presents the context of aggressive behaviour and its prevalence within the five typologies of aggressive behaviour: verbal aggression, aggression against others, sexually inappropriate behaviour, self-injurious behaviour and aggression against property, as identified by Crocker et al. (2007). The focus of this review is to report on the prevalence of aggressive behaviour reported for individuals with intellectual disability and consider the ambiguity in defining aggressive behaviour.

Evaluation of electrical aversion therapy for inappropriate sexual behaviour after traumatic brain injury: a single case experimental design study

Inappropriate sexual behaviour after acquired brain injury is a severe complication. Evidence for effective treatment is not available. Electrical aversion therapy (EAT) is a behavioural therapeutic option used in persons with intellectual disabilities, which might be suitable for brain-injured individuals for whom other therapies are not effective. The effect of EAT in brain injury has not been investigated previously. A single case experimental design was used. In an ABBA (baseline-treatment-treatment-withdrawal) design the frequency of the target behaviour (ie, inappropriate sexual behaviour) in a 40-year-old man was measured daily. A total of 551 measurements were recorded. A significant reduction of the target behaviour was seen after the first treatment phase (baseline 12.18 (2.59) vs 3.15 (3.19) mean target behaviours daily); this reduction remained stable over time. We conclude that EAT was effective in this patient with inappropriate sexual behaviour due to severe brain injury. EAT can therefore be considered in therapy resistant inappropriate sexual behaviour in brain-injured patients.

Prevalence of traumatic brain injury in intimate partner violence offenders compared to the general population: a meta-analysis

Intimate partner violence (IPV) is widespread. Several risk factors are associated with IPV perpetuation, including alcohol use and educational level. The aggression and violence associated with traumatic brain injury (TBI) suggest that brain trauma may also be a risk factor for IPV. To examine the association between TBI and IPV, the authors conducted a meta-analysis of peer-reviewed published studies reporting the prevalence of TBI in IPV perpetrators. The authors compared the frequency of TBI among IPV perpetuators to estimates of TBI in the general population using a single-sample test of proportions. Six studies containing a total of 222 subjects met inclusion criteria. Fifty-three percent (119) of the IPV perpetuators had a history of TBI, a prevalence significantly higher (p < .0001) than estimates of TBI in the general population. The prevalence of TBI among perpetuators of IPV appears significantly higher than the prevalence of TBI in the general population. To the extent that this association is causal, TBI may be a risk factor for interpersonal violence, although comparatively few source studies, lack of standardized information about TBI severity, and the inability to investigate potential confounding variables necessarily limit this conclusion.

Inappropriate sexual behaviour and dementia: An exploration of staff experiences

Research assessing the impact of inappropriate sexual behaviour (ISB) on staff working in dementia care is circumscribed, yet studies from comparable settings indicate that ISB appears uniquely challenging, particularly to personal and cultural values. This study explored staff experiences of ISB exhibited by older adults with a dementia. Fourteen staff working within an in-patient setting were interviewed. Participants’ experiences of ISB appeared underpinned by complex social and psychological processes. Shock, embarrassment and incomprehension were prominent when ISB was initially encountered. Knowledge of dementia, familiarity with patients and social norms were important in contextualising ISB and staff often minimised its impact by construing a lack of capacity. Feelings about ISB appeared equivocal and findings suggest that the effect of ISB should be routinely considered in preparing staff who work within dementia care.

Behavioural interventions for children and adults with behaviour disorders after TBI: A systematic review of the evidence

OBJECTIVE

To systematically review the evidence for the effectiveness of behavioural interventions for children and adults with behaviour disorders after TBI.

DESIGN

Using a variety of search procedures, 65 studies were identified. This literature was reviewed using a set of questions about participants, interventions, outcomes and research methods.

PARTICIPANTS

The 65 studies included 172 experimental participants, including children and adults.

INTERVENTIONS

A number of specific intervention procedures were used, falling into three general categories: traditional contingency management, positive behaviour interventions and supports and combined.

RESULTS

All of the studies reported improvements in behavioural functioning.

CONCLUSIONS

Behavioural intervention, not otherwise specified, can be considered a treatment guideline for children and adults with behaviour disorders after TBI. Both traditional contingency management procedures and positive behaviour support procedures can be said to be evidence-based treatment options. However, a variety of methodological concerns block stronger conclusions.

Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment

The subject of Inappropriate Sexual Behaviour (ISB) amongst clients with neurological impairment, specifically Acquired Brain Injury (ABI) and dementia, has received limited coverage to date within the literature. This paper discusses some of the problems encountered in the definition and quantification of ISB, in particular the absence of standardized measurement tools to record ISB within an inpatient setting. Whilst ISB is reported to be less prevalent than other behavioural sequelae of brain injury or dementia, it is suggested that its impact on patients and carers can be significant. Ill-defined terminology and the absence of relevant assessment tools add to the specific challenges of understanding and managing ISB within a care or rehabilitation setting. As a result, it is argued that the subjective attitudes of staff and the culture of an institution can dominate the approach taken to dealing with ISB for these client groups.

An integrative theoretical framework for understanding sexual motivation, arousal, and behavior

An integrative theoretical framework and model for understanding sexual motivation, arousal, and behavior is presented, combining the principles of incentive motivation theory and the hierarchical control of behavior. It is intended to stimulate discussion. The framework can serve as a "route map" in understanding the links between different component processes and their interactions, as well as the relations between different academic perspectives on understanding sexuality. It is suggested that both excitation and inhibition of sexual motivation, arousal, and behavior act at various levels in a hierarchical structure, and much confusion can be avoided by distinguishing these levels. The model integrates information from different branches of psychology: biological, evolutionary, clinical, cognitive, developmental, and social. It describes interactions between sexual behavior and anxiety, attachment, aggression, and drug taking; and it is applied to gender differences, evolutionary psychology, sexual deviancy, sexual addiction, and the biological bases of sexuality.