A conceptual model for treatment of externalizing behaviour in acquired brain injury

The experience of being a parent with an acquired brain injury (ABI) as an inpatient at a neuro-rehabilitation centre, 0-2 years post-injury

PRIMARY OBJECTIVE

Little research has been conducted exploring the issues surrounding parenting with an acquired brain injury (ABI). This study aimed to explore the experiences and needs of parents who suffered an ABI in the last 2 years from their own perspectives. For individuals with an ABI who have dependent children their ABI has the potential to impact upon their parenting abilities, skills and relationships.

RESEARCH DESIGN

Interpretive phenomenological analysis (IPA) was used to analyse the data. Using IPA allowed the research questions and inquiry to be positioned epistemologically and directed towards 'meaning' rather than 'difference' or 'causality'.

METHODS

Five participants (two female, three male) were interviewed using a semi-structured interview schedule.

MAIN OUTCOMES

Four main themes were identified: (i) Multiple losses, (ii) A mix of resigned acceptance and uncertain future, (iii) Giving and receiving support is part of the healing process and (iv) Hopes and aspirations.

CONCLUSIONS

The results indicated that the participants experienced an oscillation between experiencing the multiple losses of their parental role and attempting to adapt and adjust to these changes. These findings are discussed in relation to clinical and theoretical implications for parents who are inpatients with an ABI up to 2 years post-injury.

Cognitive Rehabilitation Revisited

Many controversies remain with respect to how best to work with individuals who are challenged by cognitive impairments. Yet in the last decade, there has been substantial new research and a proliferation of literature, which has served to clarify major principles underlying cognitive interventions, and specified training procedures and teaching techniques that have demonstrated some effectiveness. Increasingly, it is possible to identify what techniques are likely to work for a particular individual, based on a number of variables including their cognitive profile, level of insight, and capacity for self-regulation. Education, the development of compensatory behaviours, the use of specialised instructional techniques and the inclusion of activities to improve self awareness and self-efficacy are but a few of the important components of most efforts at rehabilitation for cognitive impairments. Cognitive rehabilitation must be creative, eclectic, functionally oriented, and based in a partnership between clients, families/caregivers, and professionals.

Single Participant Studies in Positive Behaviour Support for Parents of Individuals With Brain Injuries

Three single participant studies examined effects of in-home parent-implemented Positive Behaviour Support (PBS) interventions on behaviour of individuals with brain injuries. Parental and independent observations of morning routine behaviour or problem behaviour (viz., noncompliance during meals or morning routines, yelling, kicking, swearing, and so on) were taken during baselines and PBS interventions, which consisted of person-centred functional assessments of behaviour, emphasis on changing behavioural antecedents, parent participation in assessing, treating, and evaluating behaviour change, and in-home parent coaching and support. Results show decreased problem behaviour or improved morning routine behaviour, which corroborate and add to the few studies that applied similar parent-implemented interventions. Future comparative studies between PBS and out-patient interventions are indicated.

Managing Challenging Behaviours: Getting Interventions to Work in Nonspecialised Community Settings

The ABI Behaviour Consultancy (the Consultancy) is a community-based service specialising in the management of challenging behaviour following acquired brain injury (ABI). Although there are many accounts in the literature of behaviour management techniques, very few describe how to tailor and implement programs to work in nonspecialised community settings where a client's environment has little structure and few resources. The Consultancy is often called upon to manage situations where existing behaviour interventions have not been successful, often because of incorrect assumptions about the client with ABI or because of unrealistic expectations of the setting. The Consultancy has developed a six-stage framework for the management of challenging behaviours that includes site visit, crisis management, engagement, intervention, education, and ongoing review. Case examples are used to illustrate each of these stages.

Reliability and Validity of the Supports Intensity Scale (SIS) Measured in Adults with Physical Disabilities

The objective of this study was to investigate the internal consistency and the construct validity of the Dutch version of the Supports Intensity Scale (SIS-NL1.0; Buntinx 2006) in individuals with physical disabilities (N = 65). To investigate the construct validity, the relationship between SIS subscales and practical skills (Barthel Index; BI) was calculated. Support was provided for the internal consistency. The SIS subscales (except Behavior) had moderate to high intercorrelations and the SIS was able to discriminate between groups with different number of disabilities. However, weak relationships were found between the BI and four out of eight SIS subscales. For people with physical disabilities, future revisions of the SIS should also take into consideration limitations in practical skills in other support domains.

Patterns of agitated behaviour during acute brain injury rehabilitation

OBJECTIVE

To monitor daily shift-by-shift changes in agitated behaviour during adult brain injury rehabilitation.

DESIGN

A prospective, descriptive study.

METHODS

Eight participants were monitored daily for up to 28 days. The Agitated Behaviour Scale (ABS) evaluated behaviour during three nursing shifts (morning, afternoon, night). Severity of agitation, peak intensity and concomitant behaviours were calculated. Shift differences and patterns of behavioural changes were analysed.

RESULTS

Four hundred and seven recordings were taken with the ABS. All participants demonstrated multiple agitated behaviours (between 3-13 concomitant behaviours per person); the most common behaviours were representative of the ABS Disinhibition sub-scale. Weekly peak intensity ranged from 14-55 on the ABS. Mean ABS scores were highest during the afternoon shift and lowest at night. Improved cognition was associated with resolving agitated behaviour; while persistent agitated behaviour was associated with low levels of cognition. Minimal agitated behaviour was observed in participants who emerged from post-traumatic amnesia.

CONCLUSIONS

Agitated behaviour during acute brain injury rehabilitation has a complex clinical presentation. High levels of agitation observed during the afternoon shift may be associated with low levels of structured activities available at that time, higher levels of environmental stimuli during visiting times and increased cognitive fatigue. Lower cognitive ability was related to consistently higher levels of agitated behaviour and vice-versa.

What environmental factors irritate people with acquired brain injury?

PURPOSE

This study aims to determine the environmental factors nurses identify as being irritating to people with acquired brain injury.

METHOD

This was a qualitative study. An experienced interviewer used the Critical Decision Method to interview 28 nurses working in 10 inpatient brain injury rehabilitation units in Australia on a one to one basis for 1-1.5 h on two consecutive days. Transcripts of interviews were analysed using thematic analysis.

RESULTS

Nurses identified five groups of irritants that acted as triggers for aggression:

CONCLUSION

The nurses in this study identified many environmental factors that irritate people with acquired brain injury. Some irritants appeared unavoidable but others could be addressed by staff expertise.

Errorless Priming

Reactive aggressive children experience social encoding and interpretation difficulties. Such deficits increase the likelihood that reactive aggressive children perceive the actions of others as provocative and respond in an aggressive manner. Errorless priming was developed as a proactive and success-focused treatment for an 8-year-old boy demonstrating severe reactive aggression (RA). Observations of the child revealed several antecedents that immediately preceded his aggression. This information enabled prediction of aggressive outbursts and development of an intervention that involved providing the child with preparatory information (i.e., priming statements) to moderate his reaction to upcoming stressors. As is characteristic of errorless approaches, a graduated hierarchy was used to systematically fade priming statements. Following treatment, the child was able to tolerate, without problem behavior, antecedent conditions that he found challenging prior to treatment. Errorless priming may have broad potential as a brief and time-efficient intervention for RA.

Positive behavioural disturbances in the rehabilitation phase after severe traumatic brain injury: an historic cohort study

PRIMARY OBJECTIVE

To investigate the association of post-traumatic amnesia (PTA) with positive behavioural disturbances (PBD) in an historic cohort of patients with severe traumatic brain injury (TBI) and to evaluate the use and effects of neuroleptic drugs in this cohort.

RESEARCH DESIGN

Historic cohort study.

METHODS

The medical files of 60 patients with severe TBI, selected for inpatient rehabilitation during a period of 5.5 years, were independently examined for the presence of PTA and PBD at admission in the rehabilitation centre as well as for the concomitant use of neuroleptic drugs. All TBI patients with PBD at admission were subjected to special nursing measures consisting of a structured and safe environment, a minimum number of caregivers and provision of simple and consistent feedback. As a basic policy, the use of neuroleptic medication was minimized or stopped.

RESULTS

Of the 28 patients suffering from PTA at admission, 16 demonstrated PBD (positive predictive value 0.57 (95% CI 0.45-0.70)). In contrast, all the 32 patients without PTA but one did not show PBD (negative predictive value 0.97 (95% CI 0.93-1.00)). Seven of the 17 patients with PBD (41%) had been prescribed neuroleptic medication, of whom five patients (81%) experienced undesired side effects. Because of the special nursing measures, these drugs could be stopped or substituted by non-neuroleptic behaviour-modifying drugs in all patients within 3 weeks, without aggravation of their PBD.

CONCLUSIONS

These results suggest that impaired attention and memory may play a critical role in the development of PBD in patients with severe TBI. From this perspective, maximum effort must be made to improve TBI patients' level of attention, memory and orientation instead of using mechanical or chemical restraints.

[Non-pharmacological treatment of neurobehavioural disorders following severe traumatic brain injury. A commented literature review]

OBJECTIVES

Neurobehavioural disorders are a major public health problem and a daily challenge for neurological rehabilitation. This review presents the state of art in the field of traumatic brain injury regarding non-pharmacological treatments of neurobehavioral disorders.

METHODOLOGY

Medline data base and main reference books going back for 15 years were searched.

RESULTS

Prevention is based on information and counselling for a better coherence in the care and a better understanding of behaviour problems. Prevention of complications is based on adaptation of units and management (one-on-one care for example). Non-pharmacological treatment can be classified according to 3 approaches: (1) Behavioural approaches: with well-established procedures for each patient; (2) Holistic approaches: addressing both lesional and psychopathological as well as environmental features; (3) Psychotherapeutic approaches: either integrated to holistic programs, or adapted from classical psychotherapy, or systemic therapy.

CONCLUSION

Practices trend to a convergence through a comprehensive approach: behaviour analysis and management of its neuropsychological, psychopathological and environmental components. Everybody will be able to pick out elements adaptable for his own practice.

"Errorless" rehabilitation: strategies of proactive intervention for individuals with brain injury and their children

BACKGROUND

Individuals with brain injury are prone to severe behavior problems related to various postinjury variables, including confusion, emotional distress, fear of challenging activity, and loss of skills to access desired outcomes.

OBJECTIVES

This article proposes the use of a new model, errorless rehabilitation, to improve rehabilitation outcomes by systematically focusing on graduated and success-based exposure of clients with brain injury to increasingly demanding circumstances, to provide them with the ability to tolerate and manage the natural environment.

MAIN OUTCOME MEASURES

Research on difficulties parents with brain injury experience with their children is subsequently reviewed and a new approach (based on the same principles as Errorless Rehabilitation) to treatment of parent-child relationship issues after brain injury is described.

CONCLUSIONS

A case study of a father with brain injury and his oppositional son is presented to demonstrate a specific application of this model for enhancing the quality of life of parents with such impairments.

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.

Errorless compliance training: building a cooperative relationship between parents with brain injury and their oppositional children

Errorless compliance training, a noncoercive intervention for improving child compliance, was evaluated in a multiple baseline across-subjects design with 12 oppositional children (ages 2-7 years) and their brain-injured parents, who suffered from cognitive deficits, impulsivity, and/or emotional instability. Generalized and durable increases were observed in child compliance after treatment. Pre/post improvements were also noted on a measure of parent self-esteem. Errorless compliance training may be well suited to intervention with parents with cognitive and behavioral impairments that decrease their potential to benefit from traditional parenting approaches.

Applied behavior management and acquired brain injury: approaches and assessment

Individuals who have acquired brain injury (ABI) may express themselves through the use of challenging behaviors, such as aggression, withdrawal, disinhibition, and self-destructive behaviors. This article describes the effectiveness of behavior interventions derived from the assessment of behavior in a community-based setting. The premise is that behavior, no matter how difficult, has function, purpose, and meaning for the individual. A therapeutic model of behavior assessment is presented that bases its strength on behavior assessment and well-trained staff. A well-formulated behavior management plan is developed, reinforcing alternative behaviors teaching skills, and reducing unwanted behaviors. Through the use of data collection methods, the treatment team identifies variables related to unwanted behavior and outcomes of consequences as they relate to the behavior. Illustrated through a case study, the behavioral treatment model is defined through behavior identification, initial assessments, treatment approaches, and tracking outcomes.