Twenty-month effectiveness of a non-aversive, long-term, low-cost programme for persons with persisting neurobehavioural disability

PRIMARY OBJECTIVE

To examine the effectiveness of a programme developed for persons with persisting neurobehavioural/ neuropsychiatric disorders.

RESEARCH DESIGN

Descriptive study of a programme that has a philosophy of normalization, respect, non-confrontation, positive engagement, support and functional and behavioural skill development.

METHODS AND PROCEDURES

Participants were the 40 clients admitted during the initial 20 months of operation. Prior to admission clients had recurrent placement failures secondary to behavioural disregulation and typically were housed at County or State Hospitals. An expanded version of the Overt Aggression Scale Modified for Neurorehabilitation was used to provide detailed descriptions of assaults.

MAIN OUTCOMES AND RESULTS

Over the 20-month period, 49 incidents of client-to-client aggression occurred representing a rate of 0.11 incidents per client month. Thirty-five of 40 clients remained at the end of 20 months, with only three discharges due to behaviour.

CONCLUSIONS

A long-term, stable living environment has been provided for individuals who had been intractable management problems elsewhere.

Palliative physicians persuade procurators fiscal

Mesothelioma caused by occupational exposure to asbestos is well recognized and sufferers who have been employed in a prescribed occupation can claim compensation. Stringent criteria must be fulfilled in order to establish the link between occupational exposure and mesothelioma, and to this end the procurator fiscal is involved after the patient's death, both to elucidate the individual situation and 'for the common good'. Problems were experienced locally by the use of uniformed police officers, as the appointed Crown agents, as interviewers of recently bereaved relatives, irrespective of the degree of tact and sensitivity shown. The likelihood of an autopsy was also distressing. It is important to recognize the role of the procurator fiscal and to ensure that workers' compensation procedures exist and are followed. However, in order to minimize grief and distress to relatives, discussion took place with the local procurator fiscal. He was appreciative of the issues raised and practice has now changed substantially. In particular, police officers are no longer required to interview relatives either for the purpose of identification or to ascertain the deceased's occupational history. A pro forma has been produced and agreed locally to obviate the need for medical staff to be interviewed by police officers. Following subsequent discussion with the Crown Office our local arrangements have been incorporated in Crown Office guidance for national use.

A consecutive series of adults with brain injury treated with a washing and dressing retraining program

OBJECTIVES

Single-case reports indicate that behavioral methods can assist persons with brain injury to redevelop self-care skills. However, the proportion of patients who could benefit from these interventions is unknown. The present study used a specific retraining protocol to treat all patients admitted to a single facility over a 3-year period who were unable to wash and dress independently.

METHOD

Four patients out of 48 met the study criteria and were treated with the washing and dressing protocol. Three had traumatic brain injury, and one had brain injury after cerebral bleed. The training program involved behavioral observation, task analysis, consistent practice, and cue fading. The Adaptive Behavior Scale was used to measure behavior change.

RESULTS

Three subjects achieved rapid independence in washing and dressing (20 days, 37 days, and 11 days of treatment), and one did not show significant clinical improvement.

CONCLUSION

All patients admitted to the facility during a 3-year period who required washing and dressing retraining were treated with the same protocol. The consecutive series design prevented researchers from selecting patients who they believed were good treatment candidates; therefore, the findings support the general applicability of the training program.

Illness behavior after severe brain injury: two case reports

This paper introduces the concept of illness behavior to occupational therapists working with patients with acquired neurological impairments. The paper presents two case reports of patents with unequivocal severe brain trauma who demonstrated help-seeking and dependency behaviors that could not be accounted for by brain damage alone. Incorporating the illness behavior concept in an understanding of the patients' behavior difficulties assisted in the development of an appropriate treatment plan and interventions. This paper emphasizes that severe neurological sequelae and illness behavior may coexist in the same patient. Without an understanding of the personality and environmental factors that may influence recovery, rehabilitative efforts may be less than optimally effective.

Training functional skills following herpes simplex encephalitis: a single case study

This paper presents a treatment program for the development of personal hygiene behavior in a patient who was 5 years post herpes simplex encephalitis. The patient has severe memory and organizational problems, but is of average overall intelligence. The program consists in part of chaining a series of nine discrete activities by using linking phrases. The program allowed the patient to structure his behavior and wash in a well-organized nonrepetitive way. Results are discussed in the light of previous failures to affect behavior using apparently similar methods.

A rapid method for teaching severely brain injured adults how to wash and dress

The use of a rapid method of teaching a severely brain injured patient to wash and dress is described. The patient, who was injured in an automobile accident eight months earlier, remained dependent in self-care after five months in an acute rehabilitation unit. He was then transferred to a Transitional Living Facility where the program was performed. The patient's physical and cognitive status remained unchanged during the program which lasted for 12 treatment days, but he did become independent in washing and dressing. Independence was maintained at six-month follow-up. Issues relating to the individual's severe memory impairment are discussed in terms of the relevance of such impairments to outcome of training techniques.

The use of behavioral techniques in functional skills training after severe brain injury

This paper discusses the application of behavioral methods to functional skills training in the adult with severe brain damage. Four cases are described demonstrating the effectiveness of this type of intervention in teaching washing and dressing skills. Three patients had deficits arising from traumatic brain injury and one had continuing problems following herpes simplex encephalitis. Theoretical issues in adapting behavioral methods to the needs of such patients who have severe disorders of memory, attention, and motivation are discussed.

The behavioural treatment of verbal interaction skills following severe head injury: a single case study

This study reports the improvement of verbal interaction skills in a 27-year-old severely head-injured male who presented with an inappropriate attention-seeking circumlocutory conversational style. The patient was baselined on verbal response to three differing question forms, and then treated using combined cognitive behavioural methods on a daily sessional basis. Treatment resulted in a significant clinical change out of sessions, whilst the overall in-session improvement proved significant at the 0.05 level. Follow-up at 2 months indicated that the trend of improvement had continued beyond the treatment period.

Behavioral treatment of attention deficits in mentally impaired subjects

This paper describes an operant approach to the remediation of the behavioral aspects of attention deficits in three mentally impaired subjects. Two of the subjects also displayed severe atypical psychiatric disorders. Contingent reinforcement within an ABAC experimental design was used to increase levels of attending behavior. The efficacy of this approach within a group setting was demonstrated. Results suggest that some forms of additional deficit may be treated behaviorally despite differing etiologies of the cognitive deficit. The implications for occupational therapy are discussed within the context of the design of the ward program.

125Iodine implantation after lymphadenectomy in early carcinoma of the prostate

The interim results of planned lymphadenectomy and 125Iodine implantation for carcinoma of the prostate in 122 patients are reported. The incidence of positive pelvic lymph nodes found at lymphadenectomy ranged from 15% in A-2 to 55% in B-2 lesions, as well as in 13% of well-differentiated tumors. Poorly differentiated histology, B-2 and D-1 tumors, had early treatment failure indicating a group of patients in whom this procedure is contraindicated. Occult disease (A-2) and well-differentiated tumors do not exhibit early failure. However, these patients will also fare well with radical external radiation or prostatectomy. The radiobiology of the low dose rate continuous irradiation of 125Iodine is questioned. It may be inadequate for long-term tumor control. Longer follow-up of this series may indicate that external radiation for clinically localized carcinoma of the prostate is the most effective treatment policy.

Anorexia nervosa and bulimia: an activity-oriented approach

In recent years, there has been a growing trend away from a dogmatic adherence to any one approach in the treatment of eating disorders. This paper adds the new element of practice in relation to cognitive change. The activity-oriented approach outlined here stresses that patients with anorexia nervosa or bulimia must maintain responsibility for their own food intake throughout treatment. The key role of the occupational therapist in the treatment team is outlined, and suggestions for assessment and management of this type of patient are given.