Principles & Practice of Neurobehavioural Rehabilitation Prof. Rodger Ll., Wood College of Medicine Swansea University Wales, UK

‘NEURO’ Identifies ‘organic’ constraints on:- Social learning. Emotional control. Regulated behaviour. Adaptive behaviour. Affect (emotional expression).

Barriers to Good Psychosocial Outcome after TBI Poor inhibitory control:- aggression, disinhibition Diminished drive, interest, and motivation Poor social cognition Lack of initiative & purposeful behaviour. Problems planning or making decisions Diminished awareness & poor judgement Unrealistic aspirations

‘BEHAVIOURAL’ Disability construed behaviourally Rehabilitation goals in terms of social handicap. Rehabilitation goals designated in terms of specific social or functional behaviours. Progress measured in terms of behaviour change.

COMPONENTS Post-acute. Slow stream rehabilitation. Behaviour Management Capability Structured environment. System of reinforcement Principles of Learning Theory Community-Based training. Behaviourally-defined rehabilitation goals Organisational structure of staff

Why Post Acute? Intensive rehabilitation at an acute stage:- does not prevent cognitive and behavioural problems persisting beyond early recovery phase. Problems of awareness, judgement and self-regulation, often not evident until after discharge.

WHY SLOW STREAM? Cognitive deficits impose constraints on learning and rehabilitation Rehabilitation interventions long term, not ‘intensive’. Aim is to establish habit patterns Which takes time. Learned components of organically determined behaviour disorders take time to unlearn.

Behaviour Management Capability Behaviour disorders act as a barrier to rehabilitation and good psychosocial outcome. NBR must be capable of:- Containing & reducing frequency of challenging behaviour. Creating opportunities to reinforce adaptive & appropriate behaviour. Raising awareness of socially appropriate behaviour.

Structured Environment Clearly identified system of rules and frequent feedback opportunities. Continuity of rehabilitation procedures and regular practice of functional/social skills. System to ensure reliable communication:- of observations regarding patient’s behaviours and functional abilities of staff roles and responsibilities Opportunities for constructive use of leisure time

Dual Role of Reinforcement Reward: To motivate behaviour. Feedback: To promote awareness and understanding. The Token Economy

‘Token Economy’ Points System Material Reward Value In form of tokens or points given or removed based on behaviour/achievement/effort within a time frame. Material Reward Value Exchanged for small short term rewards or larger - long term rewards Social ‘Status’ Value Allocation of points marked on chart in communal area. Shows relative earnings of client group. Comments/feedback from other clients Cultivates habit of self-monitoring & improves self-awareness.

Benefits to staff Helps focus staff attention on important behaviours Raises staff awareness of client’s performance over time. Provides basis for meaningful feedback Opportunity for meaningful engagement & social reinforcement. Improves client’s self-awareness.

Some benefits of improved self awareness Improved self-monitoring. Better compliance and motivation Better self-regulation Improved potential for adaptive behaviour.

Community Rehabilitation Hospitals are for ill people to be cared for; rehabilitation is about learning to do things for yourself.

Community Training Minimises drive and motivational problems. Provides direction, purpose and meaning to life. Opportunities for meaningful feedback to improve awareness. Sheltered work opportunities Initiative, planning and organisation. Development of social routines Helps skills generalise. Opportunities to consolidate skills as habit patterns.

The Neurobehavioural Rehabilitation Team Therapy does not only take place in time-limited formal sessions, with qualified therapists during the nine-to-five working day. Continual application of interventions. Effort and achievements reinforced through interaction with every member of the team. The whole team are empowered to regard their role as that of agent for behaviour change.

Working relationships between different therapy disciplines Need to be inter-disciplinary rather than multidisciplinary. Careful interdisciplinary assessment and structured observations identify how problems of attention, awareness, and executive function undermine aspects of everyday behaviour.

Rehabilitation Process Therapists conduct assessments and prescribe interventions. Interventions largely carried out by therapy care assistants or rehabilitation support workers under the guidance of clinicians. Departure from the traditional division of hospital labour between doctors, nurses, therapists on one hand, and auxiliaries or healthcare assistants who were allocated domestic responsibilities.

A Psychological-Learning Framework Therapy interventions in every discipline place an emphasis on learning theory methods of intervention. Practitioners need to have knowledge of associational learning methods to devise effective rehabilitation interventions . Rehabilitation programmes therefore led by clinical neuropsychologists rather than medical doctors.

The Rehabilitation Plan Understand the brain injury In relation to nature of neurobehavioural disability and constraints on learning or generalising Establish obstacles to achieving goals. Nature of impairment & disability Time constraints & Staff resources Determine treatment goals That have functional value for the individual & his/her family. Measure progress in ways that reflects functional change.

Structured observations of behaviour During different activities. At different times of day. In different social (or inter-personal) contexts.

ABC Analysis The aim is to identify what triggers or reinforces specific behaviours. A B C Antecedent Behaviour Consequences Helps establish behavioural contingencies

Time Sampling:- Monday: 08.00 - 09.00 13.00 - 14-00 Tuesday: 09.00 - 10.00 14.00 - 15-00 Wednesday: 10.00 - 11.00 15.00 - 16.00 Thursday: 11.00 - 12.00 16.00 - 17.00 Friday: 12.00 - 13.00 17.00 - 18.00

Measure of quality or intensity of behaviour Likert Rating Scale Rude 0 ------------------------ 5 Polite Angry 0 ------------------------ 5 Calm Inappropriate 0 ------------------------ 5 Appropriate

Predicting Progress

Setting Treatment Goals A ‘Smart’ Approach Specific Measurable Appropriate Realistic Time Framed (Standards of client, not staff)

Treatment Goals Behaviourally defined. Socially & functionally relevant. Part of a discharge plan. Inter-disciplinary.

Rehabilitation Plan Discharge Goals Intermediate Goal Intermediate Target Behaviour Target Behaviour Target Behaviour Target Behaviour Target Behaviour Target Behaviour

The Learning Paradigm Procedural or Declarative ? Learning through understanding Concept formation. Awareness of principles. “A passive store of information” PROCEDURAL Learning by experience Making associations Practice and rehearsal

Procedural Learning Not dependent on memory. Knowing how, not why! Slow acquisition. Repeated practice. Situation specific.

What I learn I learn by doing. Excellence is not an art, it’s a habit. Aristotle What I learn I learn by doing. Excellence is not an art, it’s a habit.

Development of Habit Patterns Habit patterns are over-learned skills Repeated practice of statements and actions. Associational learning between overt language and action sequences. Practice in a variety of social settings to promote generalisation.