Contemporary approaches to the management of irritability and aggression following traumatic brain injury

Personality disorder and mild traumatic brain injury

Mild traumatic brain injury (mTBI) poses risk to the neurocognitive, emotional, and financial well-being of affected individuals. While aggression and impulsivity have been examined in relation to mTBI, little work has been done to evaluate the relationship between history of mTBI and personality disorder (PD). The authors examined the associations between history of mTBI and PD in a control group without history of mTBI (N = 1189) and individuals with history of mTBI (N = 267). Results demonstrated that any PD diagnosis is a significant risk factor for mTBI (p < 0.001). Cluster B diagnoses, particularly borderline and antisocial PD, were independently significant risk factors for mTBI. These data suggest a role for screening for a history of mTBI in patients with PDs and associated traits.

Irritability in Mood Disorders: Neurobiological Underpinnings and Implications for Pharmacological Intervention

Feeling irritable is a common experience, both in health and disease. In the context of psychiatric illnesses, it is a transdiagnostic phenomenon that features across all ages, and often causes significant distress and impairment. In mood disorders, irritability is near ubiquitous and plays a central role in diagnosis and yet, despite its prevalence, it remains poorly understood. A neurobiological model of irritability posits that, in children and adolescents, it is consequent upon deficits in reward and threat processing, involving regions such as the amygdala and frontal cortices. In comparison, in adults with mood disorders, the few studies that have been conducted implicate the amygdala, orbitofrontal cortices, and hypothalamus; however, the patterns of activity in these areas are at variance with the findings in youth. These age-related differences seem to extend to the neurochemistry of irritability, with links between increased monoamine transmission and irritability evident in adults, but aberrant levels of, and responses to, dopamine in youth. Presently, there are no specific treatments that have significant efficacy in reducing irritability in mood disorders. However, treatments that hold some potential and warrant further exploration include agents that act on serotonergic and dopaminergic systems, especially as irritability may serve as a prognostic indicator for overall clinical responsiveness to specific medications. Therefore, for understanding and treatment of irritability to advance meaningfully, it is imperative that an accurate definition and means of measuring irritability are developed. To achieve this, it is necessary that the subjective experience of irritability, both in health and illness, is better understood. These insights will inform an accurate, comprehensive, and valid interrogation of the qualities of irritability in health and illness, and allow not only a clinical appreciation of the phenomenon, but also a deeper understanding of its important role within the development and manifestation of mood disorders.

Long-Term Presentation of Postconcussion Symptoms and Associated Factors: Analysis of Latent Class Modeling

OBJECTIVE

Postconcussion symptoms (PCS) are commonly reported by patients with mild traumatic brain injury (MTBI). Although PCS significantly recovered by 3-month postinjury, a number of patients still experienced persistent PCS for >1 year. As few researchers investigated long-term PCS endorsement, the present study thus aims to show the latent structure of long-term PCS and further uncover its associating factors.

METHODS

In total, 110 patients with MTBI and 32 healthy participants were prospectively enrolled. PCS was evaluated at 2 weeks and long-term evaluations (mean = 2.90 years) after MTBI. In addition, cognitive functions, which include memory, executive function, and information processing, and emotional disturbances, which include depression, anxiety, and irritability, were also examined at 2-week postinjury.

RESULTS

Patients reported significantly more PCS at 2-week postinjury than healthy participants did, but PCS significantly improved at long-term evaluations when comparing with PCS at acute stage after MTBI. Both of PCS at 2 weeks and long-term evaluations can be further subdivided into subgroups based on the severity of PCS, in which specific PCS (e.g., fatigue, loss of energy, insomnia, slowness of information processing, irritability, and blurred vision) can be well differentiated among subgroups at long-term evaluations.

CONCLUSIONS

This study directly showed the characteristics of long-term PCS and associating factors. It further evidenced that specific physical, cognitive, and emotional symptoms might be determinant to identify the subgroups of patients with long-term PCS endorsement.

The Psychosocial Impact of Neurobehavioral Disability

Neurobehavioral disability (NBD) comprises elements of executive and attentional dysfunction, poor insight, problems of awareness and social judgement, labile mood, altered emotional expression, and poor impulse control, any or all of which can have a serious impact upon a person's decision-making and capacity for social independence. The aim of this narrative review is to explore some of the more intrusive forms of NBD that act as obstacles to psychosocial outcome to act as a frame of reference for developing effective rehabilitation interventions. Special consideration is given to the psychosocial impact of three core forms of NBD: a failure of social cognition, aggressive behavior, and problems of drive/motivation. Consideration is also given to the developmental implications of sustaining a brain injury in childhood or adolescence, including its impact on maturational and social development and subsequent effects on long-term psychosocial behavior.

The Efficacy and Harms of Pharmacological Interventions for Aggression After Traumatic Brain Injury-Systematic Review

Background: Aggression is a commonly reported problem following traumatic brain injury (TBI). It may present as verbal insults or outbursts, physical assaults, and/or property destruction. Aggressive behavior can fracture relationships and impede participation in treatment as well as a broad range of vocational and social activities, thereby reducing the individual's quality of life. Pharmacological intervention is frequently used to control aggression following TBI. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for aggression following TBI in adults.

Methods: We reviewed studies in English, available before December 2018. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in the severity of aggression and occurrence of harms. The secondary outcomes of interest were changes in quality of life, participation, psychological health (e.g., depression, anxiety), and cognitive function. Evidence quality was assessed using the Cochrane Risk of Bias tool and the Joanna Briggs Institute Critical Appraisal Instruments.

Results: Ten studies were identified, including five randomized controlled trials (RCTs) and five case series. There were positive, albeit mixed, findings for the RCTs examining the use of amantadine in reducing irritability (n = 2) and aggression (n = 2). There were some positive findings favoring methylphenidate in reducing anger (n = 1). The evidence for propranolol was weak (n = 1). Individual analysis revealed differential drug response across individuals for both methylphenidate and propranolol. The less rigorous studies administered carbamazepine (n = 2), valproic acid (n = 1), quetiapine (n = 1), and sertraline (n = 1), and all reported reductions in aggression. However, given the lack of a control group, it is difficult to discern treatment effects from natural change over time.

Conclusions: This review concludes that a recommendation for use of amantadine to treat aggression and irritability in adults following TBI is appropriate. However, there is a need for further well-designed, adequately powered and controlled studies of pharmacological interventions for aggression following TBI.

Assessing aggression following Acquired Brain Injury (ABI): a systematic review of assessment measures

Objective: To conduct a systematic review to identify and examine the reliability and validity of standardized measures used to assess aggression in people with ABI. Data sources: Systematic searches of PsychInfo, Medline, Embase, PubMed and CINAHL databases along with hand searching of gray literature and review articles. Study selection: Studies were included if the sample had an ABI, and the measure included assessment of aggression. Data extraction: Sample and measure characteristics and psychometric properties were extracted. Measure quality was assessed using the COSMIN checklist. Data synthesis: Of 5,100 abstracts screened, 78 were reviewed in full against the inclusion and exclusion criteria, and 25 articles met the criteria for analysis. Included articles assessed the psychometric properties of 17 different measures of aggression in adults with ABI. Quality of evidence was often low. Four measures (MBPC-1990R, NFI, SASNOS and KSMS) demonstrated positive evidence of at least one psychometric property with good quality evidence. Conclusions: Although a large number of general measures were available, there are few measures that only assess post-ABI aggression, and many are not well-validated. Future research should assess the psychometric properties of these measures.

Executive (dys)function after traumatic brain injury: special considerations for behavioral pharmacology

Executive function is an umbrella term that includes cognitive processes such as decision-making, impulse control, attention, behavioral flexibility, and working memory. Each of these processes depends largely upon monoaminergic (dopaminergic, serotonergic, and noradrenergic) neurotransmission in the frontal cortex, striatum, and hippocampus, among other brain areas. Traumatic brain injury (TBI) induces disruptions in monoaminergic signaling along several steps in the neurotransmission process - synthesis, distribution, and breakdown - and in turn, produces long-lasting deficits in several executive function domains. Understanding how TBI alters monoamingeric neurotransmission and executive function will advance basic knowledge of the underlying principles that govern executive function and potentially further treatment of cognitive deficits following such injury. In this review, we examine the influence of TBI on the following measures of executive function - impulsivity, behavioral flexibility, and working memory. We also describe monoaminergic-systems changes following TBI. Given that TBI patients experience alterations in monoaminergic signaling following injury, they may represent a unique population with regard to pharmacotherapy. We conclude this review by discussing some considerations for pharmacotherapy in the field of TBI.

Why do people misunderstand stroke symptoms? How background knowledge affects causal attributions for ambiguous stroke symptoms

Primary objective: People often misattribute stroke survivors' symptoms to other causes such as their personality, especially when the survivors are young. As a result, these stroke survivors experience feelings of resentment towards and from their acquaintances, and may struggle to retain employment. This study aimed to clarify how people's misattributions for stroke symptoms were affected by varying information about the stroke. Methods: Experiment 1 examined whether the stroke survivor's age (72, 32 or unstated) and the information about the person's stroke (no information, explicit stroke or implied stroke) influenced participants' causal attributions for the stroke survivor's four ambiguous symptoms, such as fatigue. Experiment 2 examined the effect of the rapidity (a week or a year) with which the symptoms appeared. Results: When the scenario explicitly referred to stroke, participants attributed the ambiguous symptoms more to stroke, whereas when it did not mention stroke, participants attributed these symptoms more to other factors. When stroke was merely implied by reference to unilateral paralysis, participants rated stroke the best explanation when the target person was 72 but not when he was 32. Experiment 2 showed that stating that the symptoms happened rapidly heightened attributions to stroke in the 72-year-old but not the 32-year-old. Conclusions: These findings show how different information about stroke survivors affect people's attributions for survivors' behaviour; this has important implications for accurate diagnosis and effective rehabilitation that targets these attributions.

Brain injury, behaviour support, and family involvement: putting the pieces together and looking forward

Purpose: (1) to provide insight into the family's experience and support needs following acquired brain injury (ABI) specific to behavioural changes; (2) to provide an overview of empirically-based behaviour support approaches for individuals with ABI; and (3), to examine family involvement in implementing behavioural interventions.Methods: Review of the literature.Results: Family members experience significant distress resulting from neurobehavioural changes in relatives with ABI, and report unmet informational and practical support needs regarding this issue. The importance of utilising family expertise within the rehabilitation process is widely acknowledged, with the increasing involvement of family members being promoted. There is growing evidence supporting the use of positive behaviour support approaches for individuals with ABI in community settings, and evidence supporting the involvement of family within behavioural interventions.Conclusions: This review suggests the need to develop alternative support models that shift the focus towards building competence in everyday support people rather than dependency on the service system. A bottom-up approach is recommended, with the aim of addressing unmet support needs and increasing the competence of family members in supporting behaviour change in individuals with ABI. Recommendations are provided in informing an optimal community-based neurobehavioural support model. Implications for RehabilitationPositive behaviour support is recommended in supporting behavioural changes following brain injury, with family expertise utilised in this process.Evidence suggests that family members can be effectively trained in developing and implementing behaviour support strategies.Family involvement in behavioural interventions may address unmet support needs and increasing the competence of family members in supporting behavioural changes following brain injury.

Anger Self-Management Training for Chronic Moderate to Severe Traumatic Brain Injury: Results of a Randomized Controlled Trial

OBJECTIVE

To test efficacy of 8-session, 1:1 treatment, anger self-management training (ASMT), for chronic moderate to severe traumatic brain injury (TBI).

SETTING

Three US outpatient treatment facilities.

PARTICIPANTS

Ninety people with TBI and elevated self-reported anger; 76 significant others (SOs) provided collateral data.

DESIGN

Multicenter randomized controlled trial with 2:1 randomization to ASMT or structurally equivalent comparison treatment, personal readjustment and education (PRE). Primary outcome assessment 1 week posttreatment; 8-week follow-up.

PRIMARY OUTCOME

Response to treatment defined as 1 or more standard deviation change in self-reported anger.

SECONDARY OUTCOMES

SO-rated anger, emotional and behavioral status, satisfaction with life, timing of treatment response, participant and SO-rated global change, and treatment satisfaction.

MAIN MEASURES

State-Trait Anger Expression Inventory-Revised Trait Anger (TA) and Anger Expression-Out (AX-O) subscales; Brief Anger-Aggression Questionnaire (BAAQ); Likert-type ratings of treatment satisfaction, global changes in anger and well-being.

RESULTS

After treatment, ASMT response rate (68%) exceeded that of PRE (47%) on TA but not AX-O or BAAQ; this finding persisted at 8-week follow-up. No significant between-group differences in SO-reported response rates, emotional/behavioral status, or life satisfaction. ASMT participants were more satisfied with treatment and rated global change in anger as significantly better; SO ratings of global change in both anger and well-being were superior for ASMT.

CONCLUSION

ASMT was efficacious and persistent for some aspects of problematic anger. More research is needed to determine optimal dose and essential ingredients of behavioral treatment for anger after TBI.

Mild Traumatic Brain Injury and Aggression, Impulsivity, and History of Other- and Self-Directed Aggression

Mild traumatic brain injury (mTBI) is highly prevalent, with an estimated occurrence in the United States of more than 1.3 million per year. While one consequence of mTBI is impulsive aggressive behavior, very few studies have examined the relationship between history of mTBI and aggressive behavior in impulsively aggressive individuals. The authors examined the relationship between history of mTBI in a healthy control group (HC; N=453), a control group with psychiatric disorders (PC; N=486), and individuals with intermittent explosive disorder (IED; N=695), a disorder of primary impulsive aggression. Results demonstrated that IED study participants were significantly more likely to have a history of mTBI (with or without history of a brief loss of consciousness [LOC]) compared with both HC and PC participants. A similar observation was made with regard to self-directed aggression (i.e., suicidal or self-injurious behavior), although group differences were only among those with mTBI with LOC. For both other- and self-directed aggression variables, the authors observed a stepwise increase in dimensional aggression and impulsivity scores across participants as a function of mTBI history. Given that impulsive aggressive behavior begins very early in life, these data are consistent with the hypothesis that lifelong presence of an impulsive aggressive temperament places impulsive aggressive individuals in circumstances that put them at greater risk for mTBI compared with other individuals with and without nonimpulsive aggressive psychopathology.

Interventions to enhance coping after traumatic brain injury: A systematic review

Background/Aims:

The aim of this study was to identify effective psychosocial interventions to enhance coping in people who have experienced a traumatic brain injury, in order to inform clinical practice and articulate future research directions.

Methods:

Five electronic databases (CINAHL, Medline, EMBASE, PsycINFO, and Cochrane Library) were searched. Titles and abstracts were independently screened by two of the authors and selected for inclusion. The full text of all potentially relevant studies were retrieved and assessed for eligibility, reporting and methodological quality, and risk of bias.

Findings:

Eight included studies were very heterogeneous in terms of study design, type of intervention, the population studied and instruments used to evaluate coping. All studies were judged to have a moderately high risk of bias. Six studies used cognitive behavioural therapy-based interventions. Two interventions (a peer-mentoring programme and cognitive behavioural therapy combined with motivational interviewing) showed significant treatment effects on maladaptive coping. Two cognitive behavioural therapy-based group programmes improved adaptive coping, but increases were either not sustained over time or no longer significant when compared to an active control.

Conclusions:

There is insufficient evidence to support practice recommendations strongly. Targeting specific subgroups of people who have experienced traumatic brain injury might allow the development of more effective coping interventions. Further, a more unified concept of coping in traumatic brain injury needs to be articulated allowing larger scale evaluations.

Effects of a behaviour management technique for nursing staff on behavioural problems after acquired brain injury

The ABC method is a behaviour management technique for use by nurses. ABC refers to the identification of Antecedent events, target Behaviours, and Consequent events. In this longitudinal intervention study with double baseline measurements we evaluated the effectiveness of the ABC method in patients with behavioural problems after acquired brain injury. Fifty-six patients participated in this study. Outcome was measured in terms of overall neuropsychiatric problem behaviour, aggression, apathy and emotional burden experienced by nurses. A process evaluation was performed to investigate usability and acceptability of the method and identify factors that influenced effectiveness. Friedman's ANOVA showed a small significant reduction over time in overall neuropsychiatric problem behaviour and aggression. The reduction was most prominent between the first baseline measurement and the post-implementation and follow-up measurements, not between the second baseline measurement and the post-implementation or follow-up measurements. This first group study on the effects of the ABC method could not prove this technique is effective for patients with behavioural problems after acquired brain injury. Nurses indicated that the ABC method was not fully implemented in their daily routines. This may have influenced results and makes it yet premature to draw firm conclusions on the effects of the ABC method.

A multifactorial and integrative approach to impulsivity in neuropsychology: insights from the UPPS model of impulsivity

Risky and excessive behaviors, such as aggressive and compulsive behaviors, are frequently described in patients with brain damage and have dramatic psychosocial consequences. Although there is strong evidence that impulsivity constitutes a key factor at play in these behaviors, the literature about impulsivity in neuropsychology is to date scarce. In addition, examining and understanding these problematic behaviors requires the assumption that impulsivity is a multidimensional construct. Consequently, this article aims at shedding light on frequent risky and excessive behaviors in patients with brain damage by focusing on a unified, comprehensive, and well-validated model, namely, the UPPS model of impulsivity. This model considers impulsivity as a multidimensional construct that includes four facets: urgency, (lack of) premeditation, (lack of) perseverance, and sensation seeking. Furthermore, we discuss the psychological mechanisms underlying the dimensions of impulsivity, as well as the laboratory tasks designed to assess each mechanism and their neural bases. We then present a scale specifically designed to assess these four dimensions of impulsivity in patients with brain damage and examine the data regarding this multidimensional approach to impulsivity in neuropsychology. This review supports the need to adopt a multifactorial and integrative approach toward impulsive behaviors, and the model presented provides a valuable rationale to disentangle the nature of brain systems and mechanisms underlying impulsive behaviors in patients with brain damage. It may also foster further relevant research in the field of impulsivity and improve assessment and rehabilitation of impulsive behaviors in clinical settings.

The lived experience of behaviours of concern: A qualitative study of men with traumatic brain injury

BACKGROUND AND AIMS

Behaviours of Concern (BoC) are a debilitating consequence of Traumatic Brain Injury (TBI). Whilst perspectives of clinicians, carers and family members on BoC have been previously explored, few qualitative studies have included individuals with TBI. The aim of this study was to explore the lived experience of BoC in individuals with TBI, their close others and clinicians.

METHOD

Eleven males with TBI and BoC were recruited and 25 semi-structured qualitative interviews were conducted (9 individuals with TBI, 9 close others, 7 clinicians). A six-phase thematic analysis approach was utilised.

RESULTS

Frequent and persistent BoC were reported and the key themes identified included the brain injury, control, environment, mood, identity, social relationships, and meaningful participation. Whilst the brain injury contributed to BoC in all cases, the way the other themes manifested and interacted was variable.

CONCLUSIONS

This study enriches our understanding of factors associated with BoC. Themes emerging from this study will inform interventions designed to reduce BoC and ultimately maximise quality of life for individuals with TBI and their families.

Identifying Current Practices and Supports in Behaviour Management Following ABI in South Australian Community Settings: A Delphi Study

Objectives: To consider the strategies currently used by family care givers to manage challenging behaviour in the community following ABI, and to identify what supports are available that support family care givers in addressing this issue.

Research design: Delphi study.

Methods: Service providers (n = 8) and family care givers (n = 3) completed a three-round Delphi process with the aim of reaching consensus (75% agreement) regarding research objectives. Round 1 consisted of an open-ended questionnaire in which items were identified; these items were then rated in Round 2 and 3 using a Likert scale. Statistical aggregation then allowed for quantitative analysis.

Results: The findings suggest a number of behaviour management approaches are being used by family care givers, including basic antecedent strategies, agreeing with the person's demands, and medication. Consensus was reached that only two services in SA provide specific support to family care givers regarding behaviour management in the community: Families4Families Inc. (a peer support network) and Private Specialists (e.g., [neuro]psychologists and [neuro]psychiatrists).

Conclusions: Findings emphasise the need for more specialised services specific to educating and supporting family care givers in the management of challenging behaviours following ABI. These services should be accessible, centralised, and easy for family care givers to navigate.

Mild traumatic brain injury and suicide risk among a clinical sample of deployed military personnel: Evidence for a serial mediation model of anger and depression

Research has demonstrated a robust link between traumatic brain injuries (TBIs) and suicide risk. Yet, few studies have investigated factors that account for this link. Utilizing a clinical sample of deployed military personnel, this study aimed to examine a serial meditation model of anger and depression in the association of mild TBI and suicide risk. A total of 149 military service members referred for evaluation/treatment of a suspected head injury at a military hospital participated in the present study (92.6% male; M_age = 27.9y). Self-report measures included the Suicidal Behaviors Questionnaire-Revised (SBQ-R), Automated Neuropsychological Assessment Metrics (ANAM) anger and depression subscales, and Behavioral Health Measure-20 depression subscale. A current mild TBI diagnosis was confirmed by a licensed clinical psychologist/physician. Overall, 84.6% (126/149) of participants met diagnostic criteria for a current mild TBI. Bootstrapped serial mediation analyses indicated that the association of mild TBI and suicide risk is serially mediated by anger and depression symptoms (bias-corrected 95% confidence interval [CI] for the indirect effect = 0.044, 0.576). An alternate serial mediation model in which depression symptoms precede anger was not statistically significant (bias-corrected 95% CI for the indirect effect = -0.405, 0.050). Among a clinical sample of military personnel, increased anger and depression statistically mediated the association of mild TBI and suicide risk, and anger appears to precede depression in this pathway. Findings suggest that therapeutically targeting anger may serve to thwart the trajectory to suicide risk among military personnel who experience a mild TBI. Future research should investigate this conjecture within a prospective design to establish temporality.

Correlates and Prevalence of Aggression at Six Months and One Year After First-Time Traumatic Brain Injury

Few studies have examined clinical correlates of aggression after first-time traumatic brain injury (TBI) within the first year after injury. The authors aimed to identify the rates of aggression at 6 and 12 months post-TBI and establish clinical and demographic correlates. A total of 103 subjects with first-time TBI were seen within 12 months postinjury and evaluated for aggression. Post-TBI social functioning and new-onset depression (within 3 months of the TBI) may serve as particularly important predictors for aggression within the first year of TBI, as these factors may afford intervention and subsequent decreased risk of aggression.

Reducing anger outbursts after a severe TBI: a single-case study

Anger outbursts constitute a frequent behavioural issue after a traumatic brain injury (TBI) and have a strong negative impact on the social outcomes resulting from the TBI. However, few studies have examined the efficacy of specific intervention strategies to reduce the frequency and intensity of anger outbursts. We therefore performed a single-case study on this topic by administering two successive and complementary psychological interventions with an AB design with maintenance (first intervention) and an AC design with maintenance plus a one-month follow-up (second intervention) to a patient with a severe TBI. Whereas the first intervention focused on improving the recognition and expression of basic emotions, the second consisted of a self-regulation programme, including various features such as psychoeducation about self-control strategies, relaxation and assertiveness training that aimed to establish adequate behaviours, which were further promoted by an implementation intentions strategy in the patient's daily life. The results indicated that all interventions resulted in a reduced frequency and intensity of anger outbursts, and the data upheld the specificity of these effects. In addition, a meta-analytic integration of the effects of both interventions on the outcomes indicated a medium effect size. Further research is needed on other patients who experience long-standing anger outbursts to examine whether the observed gains can be replicated, sustained on a longer-term basis and improved.

Enactive Approach and Dual-Tasks for the Treatment of Severe Behavioral and Cognitive Impairment in a Person with Acquired Brain Injury: A Case Study

One of the most important sequela in persons who suffer from acquired brain injury is a behavioral disorder. To date, the primary approaches for the rehabilitation of this sequela are Applied Behavior Analysis, Cognitive-Behavior Therapy, and Comprehensive-Holistic Rehabilitation Programs. Despite this theoretical plurality, none of these approaches focuses on rehabilitating behavioral disorders considering the relation between affordance and environmental adaptation. To introduce this therapeutic view to neurorehabilitation, we apply the theoretical tenets of the enactive paradigm to the rehabilitation of a woman with severe behavioral and cognitive impairment. Over seventeen sessions, her behavioral and cognitive performance was assessed in relation to two seated affordances (seated on a chair and seated on a ball 65 cm in diameter) and the environmental adaptation while she was working on various cognitive tasks. These two seated affordances allowed to incorporate the theoretical assumptions of the enactive approach and to know how the behavior and the cognition were modified based on these two postural settings and the environmental adaptation. The findings indicate that the subject exhibited better behavioral (physical and verbal) and cognitive (matching success and complex task) performances when the woman worked on the therapeutic ball than when the woman was on the chair. The enactive paradigm applied in neurorehabilitation introduces a level of treatment that precedes behavior and cognition. This theoretical consideration allowed the discovery of a better relation between a seated affordance and the environmental adaptation for the improvement behavioral and cognitive performance in our case study.

What can structured professional judgement tools contribute to management of neurobehavioural disability? Predictive validity of the Short-Term Assessment of Risk and Treatability (START) in acquired brain injury

Aggression is a frequently cited outcome of acquired brain injury (ABI). Paradoxically, evidence suggests that ABI clinicians underestimate the risk of violence, and aggression in neurobehavioural services appears more frequent than in forensic/secure psychiatric settings. Risk assessment tools are endemic in the latter and highly beneficial in managing harm. However, none has been validated for ABI. This study examines the predictive validity of ABI violence using one established tool, the Short-Term Assessment of Risk and Treatability (START). It is argued that successful management of aggression in neurobehavioural rehabilitation is partly attributable to ongoing programme calibration following regular review of measures conceptualised for ABI. The predictive ability of START and ABI measures was determined through correlational, receiver operating characteristic and hierarchical multiple regression analyses, using 4559 aggression recordings concerning 76 patients over 4 weeks. The START risk of violence was classed "low" for 50% of the sample and "high" for 13.7%. Significant relationships between individual measures and aggression were evident. However, multivariate analysis confirmed that the best fitting model comprised ABI measures of neurobehavioural disability and functional abilities: START data did not increase explained variance. ABI risk prediction may benefit from development of specific tools. However, these should be conceptualised for ABI to incorporate the diverse range of variables underpinning neurobehavioural disability.

The experience, expression, and control of anger following traumatic brain injury in a military sample

OBJECTIVE

To investigate the impact of traumatic brain injury (TBI) on the experience and expression of anger in a military sample.

PARTICIPANTS

A total of 661 military personnel with a history of TBI and 1204 military personnel with no history of TBI.

DESIGN

Cross-sectional, between-group design, using multivariate analysis of variance.

MAIN MEASURE

State-Trait Anger Expression Inventory-2 (STAXI-2).

RESULTS

Participants with a history of TBI had higher scores on the STAXI-2 than controls and were 2 to 3 times more likely than the participants in the control group to have at least 1 clinically significant elevation on the STAXI-2. Results suggested that greater time since injury (ie, months between TBI and assessment) was associated with lower scores on the STAXI-2 State Anger scale.

CONCLUSION

Although the results do not take into account confounding psychiatric conditions and cannot address causality, they suggest that a history of TBI increases the risk of problems with the experience, expression, and control of anger. This bolsters the need for proper assessment of anger when evaluating TBI in a military cohort.

Further developments in summarising and meta-analysing single-case data: An illustration with neurobehavioural interventions in acquired brain injury

Data analysis for single-case designs is an issue that has prompted many researchers to propose a variety of alternatives, including use of randomisation tests, regression-based procedures, and standardised mean difference. Another option consists in computing unstandardised or raw differences between conditions: the changes in slope and in level, or the difference between the projected baseline (including trend) and the actual treatment phase measurements. Apart from the strengths of these procedures (potentially easier interpretation clinically, separate estimations and an overall quantification of effects, reasonable performance), they require further development, such as (a) creating extensions for dealing with methodologically strong designs such as multiple baseline, (b) achieving comparability across studies and making possible meta-analytical integrations, and (c) implementing software for the extensions. The proposals are illustrated herein in the context of a meta-analysis of 28 studies on (neuro)behavioural interventions in adults who have challenging behaviours after acquired brain injury.

Predictors of longitudinal outcome and recovery of pragmatic language and its relation to externalizing behaviour after pediatric traumatic brain injury

The purpose of the present investigation was to evaluate the contribution of age-at-insult and brain pathology on longitudinal outcome and recovery of pragmatic language in a sample of children and adolescents with traumatic brain injury (TBI). Children and adolescents with mild to severe TBI (n=112) were categorized according to timing of brain insult: (i) Middle Childhood (5-9 years; n=41); (ii) Late Childhood (10-11 years; n=39); and (iii) Adolescence (12-15 years; n=32) and group-matched for age, gender and socio-economic status (SES) to a typically developing (TD) control group (n=43). Participants underwent magnetic resonance imaging (MRI) including a susceptibility weighted imaging (SWI) sequence 2-8 weeks after injury and were assessed on measures of pragmatic language and behavioural functioning at 6- and 24-months after injury. Children and adolescents with TBI of all severity levels demonstrated impairments in these domains at 6-months injury before returning to age-expected levels at 2-years post-TBI. However, while adolescent TBI was associated with post-acute disruption to skills that preceded recovery to age-expected levels by 2-years post injury, the middle childhood TBI group demonstrated impairments at 6-months post-injury that were maintained at 2-year follow up. Reduced pragmatic communication was associated with frontal, temporal and corpus callosum lesions, as well as more frequent externalizing behaviour at 24-months post injury. Findings show that persisting pragmatic language impairment after pediatric TBI is related to younger age at brain insult, as well as microhemorrhagic pathology in brain regions that contribute to the anatomically distributed social brain network. Relationships between reduced pragmatic communication and more frequent externalizing behavior underscore the need for context-sensitive rehabilitation programs that aim to increase interpersonal effectiveness and reduce risk for maladaptive behavior trajectories into the long-term post injury.

Anger self-management in chronic traumatic brain injury: protocol for a psycho-educational treatment with a structurally equivalent control and an evaluation of treatment enactment

Anger and irritability are important and persistent clinical problems following traumatic brain injury (TBI). Treatment options include medications, behavioral modification, and psychotherapies, but some are impractical and none have proven efficacy with this population. We describe a randomized multi-center clinical trial testing a novel, one-on-one, 8-session psychoeducational treatment program, Anger Self-Management Training (ASMT), designed specifically for people with TBI who have significant cognitive impairment. The trial is notable for its use of a structurally equivalent comparison treatment, called Personal Readjustment and Education (PRE), which was created for the study and is intended to maximize equipoise for both participants and treaters. Fidelity assessment is conducted in real time and used in therapist supervision sessions. The primary outcome is change in self-reported anger on validated measures from pre-treatment to 1 week after the final session. Secondary outcomes include participant anger as reported by a significant other; emotional distress in domains other than anger/irritability; behavioral functioning; and quality of life. An interim assessment after the 4th session will allow examination of the trajectory of any observed treatment effects, and a follow-up assessment 2 months after the end of intervention will allow examination of persistence of effects. A treatment enactment phase, in which participants are interviewed several months after the last therapy session, is designed to provide qualitative data on whether and to what extent the principles and techniques learned in treatment are still carried out in daily life.

Emotional and behavioral dyscontrol after traumatic brain injury

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.

Social communication mediates the relationship between emotion perception and externalizing behaviors in young adult survivors of pediatric traumatic brain injury (TBI)

Traumatic brain injury (TBI) is a common cause of childhood disability, and is associated with elevated risk for long-term social impairment. Though social (pragmatic) communication deficits may be among the most debilitating consequences of childhood TBI, few studies have examined very long-term communication outcomes as children with TBI make the transition to young adulthood. In addition, the extent to which reduced social function contributes to externalizing behaviors in survivors of childhood TBI remains poorly understood. The present study aimed to evaluate the extent of social communication difficulty among young adult survivors of childhood TBI (n=34, injury age: 1.0-7.0 years; M time since injury: 16.55 years) and examine relations among aspects of social function including emotion perception, social communication and externalizing behaviors rated by close-other proxies. Compared to controls the TBI group had significantly greater social communication difficulty, which was associated with more frequent externalizing behaviors and poorer emotion perception. Analyses demonstrated that reduced social communication mediated the association between poorer emotion perception and more frequent externalizing behaviors. Our findings indicate that socio-cognitive impairments may indirectly increase the risk for externalizing behaviors among young adult survivors of childhood TBI, and underscore the need for targeted social skills interventions delivered soon after injury, and into the very long-term.

Staff-reported antecedents to aggression in a post-acute brain injury treatment programme: what are they and what implications do they have for treatment?

Research in psychiatric settings has found that staff attribute the majority of inpatient aggression to immediate environmental stressors. We sought to determine if staff working with persons with brain injury-related severe and chronic impairment make similar causal attributions. If immediate environmental stressors precipitate the majority of aggressive incidents in this client group, it is possible an increased focus on the management of factors that initiate client aggression may be helpful. The research was conducted in a low-demand treatment programme for individuals with chronic cognitive impairment due to acquired brain injury. Over a six-week period, 63 staff and a research assistant reported on 508 aggressive incidents. Staff views as to the causes of client aggression were elicited within 72 hours of observing an aggressive incident. Staff descriptions of causes were categorised using qualitative methods and analysed both qualitatively and quantitatively. Aggression towards staff was predominantly preceded by (a) actions that interrupted or redirected a client behaviour, (b) an activity demand, or (c) a physical intrusion. The majority of aggressive incidents appeared hostile/angry in nature and were not considered by staff to be pre-meditated. Common treatment approaches can be usefully augmented by a renewed focus on interventions aimed at reducing antecedents that provoke aggression. Possible approaches for achieving this are considered.

Rehabilitation Approaches to the Management of Aggressive Behaviour Disorders after Acquired Brain Injury

Symptoms of neurobehavioural disability acquired through brain injury, especially aggression, are associated with severe social handicap. Differences in terminology have resulted in varying estimates, but aggressive behaviour disorder appears to be characteristic of survivors at some point in their recovery journey. This paper provides a brief review regarding the prevalence, development and causes of aggression associated with acquired brain injury (ABI), and what can be done to help manage them. The advantages of using standardised measures conceptualised for ABI in the assessment and formulation of aggressive behaviour disorders are especially highlighted. A range of treatment methods and the evidence base relating to these are described. The contribution of pharmacological therapies, cognitive behavioural therapy and behavioural interventions are explored. It is argued that the strongest evidence base is associated with behaviour therapy, especially when carried out in the context of neurobehavioural rehabilitation, and two case studies are described to illustrate the clinical advantages of interventions derived from operant theory. Comparative lack of ABI experts trained in the management of post-acute behaviour disorders remains a limiting factor.

Emotional regulation impairments following severe traumatic brain injury: an investigation of the body and facial feedback effects

The object of this study was to evaluate the combined effect of body and facial feedback in adults who had suffered from a severe traumatic brain injury (TBI) to gain some understanding of their difficulties in the regulation of negative emotions. Twenty-four participants with TBI and 28 control participants adopted facial expressions and body postures according to specific instructions and maintained these positions for 10 s. Expressions and postures entailed anger, sadness, and happiness as well as a neutral (baseline) condition. After each expression/posture manipulation, participants evaluated their subjective emotional state (including cheerfulness, sadness, and irritation). TBI participants were globally less responsive to the effects of body and facial feedback than control participants, F(1,50) = 5.89, p = .02, η(2) = .11. More interestingly, the TBI group differed from the Control group across emotions, F(8,400) = 2.51, p = .01, η(2) = .05. Specifically, participants with TBI were responsive to happy but not to negative expression/posture manipulations whereas control participants were responsive to happy, angry, and sad expression/posture manipulations. In conclusion, TBI appears to impair the ability to recognize both the physical configuration of a negative emotion and its associated subjective feeling.

Neurobehavioral disorders

Neurobehavioral disorders are composed of a large group of behavioral impairments seen in association with brain disease (e.g., stroke, multiple sclerosis, dementia, and neuro-oncological conditions), transient as well as permanent brain impairments (e.g., metabolic and toxic encephalopathies), and/or injury (e.g., trauma, hypoxia, and/or ischemia). The neurorehabilitative assessment and management of such disorders is often poorly addressed in the context of overall neurological, psychiatric, and rehabilitative care. Too often, more basic, yet critical, aspects of behavioral assessment and treatment are not addressed or only superficially addressed by evaluating clinicians. Physicians often overly rely on pharmacological interventions as initial and/or sole treatment approaches rather than taking a pragmatic biopsychosocial approach that focuses on holistic disease state management. This chapter provides readers with an overview of the common behavioral impairments associated with brain dysfunction due to disease, injury, or toxicity. Details regarding the nature of impairments such as localization-related syndromes, affective disorders and personality disorders, among others are expounded. Principles of neurobehavioral assessment and treatment are examined including general guidelines for eliciting a history and physical, behavioral analysis, and functional behavioral assessment. General treatment caveats are provided including discussion of impairment and disability adaptation, and creation of positive behavioral supports. The topic of pharmacological management of neurobehavioral disorders is covered in numerous other references including Chapter 33 of this text.

Moving Ahead: A New Centre of Research Excellence in Brain Recovery, Focusing on Psychosocial Reintegration Following Traumatic Brain Injury

Severe traumatic brain injury (TBI) is the most common cause of brain injury in the Western world and leads to physical, cognitive and emotional deficits that reduce independence. Changes to psychosocial function are the most disruptive, resulting in vocational difficulties, family stress and deteriorating relationships, and are a major target for remediation. But rehabilitation is expensive and its evidence base is limited. Thus, new collaborative initiatives are needed. This article details the development of ‘Moving Ahead’, a model for a Centre of Research Excellence (CRE) for Traumatic Brain Injury Rehabilitation. This CRE offers several major innovations. First, it provides an integrated, multi-faceted approach to addressing psychosocial difficulties embracing different clinical standpoints (e.g., psychological, speech pathology, occupational therapy) and levels of investigation (e.g., basic science to community function) across the lifespan. It is based upon a close relationship with clinicians to ensure transfer of research to practice and, conversely, to ensure that research is clinically meaningful. It provides an integrated platform with which to support and train new researchers in the field via scholarships, postdoctoral fellowships, websites, meetings, mentoring and across-site training, and thus build workforce capacity for individuals with TBI and their families. It has input from the international community to contextualise research more broadly and ensure scientific rigour. Finally, it provides collaboration across sites to facilitate research and data collection.