Efficacy of Cognitive and Behavioral Interventions after ABI Kari Begnaud Master of Occupational Therapy Student LSU Health Shreveport

Objectives Background Purpose of Review Study Objective Search Strategies Summary of Study Procedures Methodology Outcomes Implications for OT Practice Implications for Future Research

Background

Acquired Brain Injury ginacarson.com

Glasgow Coma Scale braininjuryhawaii.com Glasgow Coma Score

Severity of Brain Injury Mild Brain Injury Score Unconscious ≤ 30 minutes No PTA >24 hours Moderate Brain Injury Score 9-12 Unconscious 30 minutes – 24 hours PTA 30 minutes – 24 hours Severe Brain Injury Score ≤ 8 Unconscious/ PTA > 24 hours

Purpose of Review

Cost to Society and Client Financial Emotional Behavioral Cognitive Small window of opportunity brainline.org

Types of Rehabilitation Cognitive Rehabilitation Behavioral Rehabilitation Improves quality of life Retrains the brain in organization Patient education Compensatory strategies Adaptive devices Retrain individuals with disruptive tendencies Socially appropriate behavior System of rewards & consequences

The objective of this review is to investigate the efficacy of cognitive rehabilitation and behavioral rehabilitation for individuals who have an acquired brain injury resulting in attention, memory, and behavioral deficits. Study Objective

Search Terms Databases Brain Injury Cognitive Rehabilitation Behavioral Rehabilitation Occupational Therapy CINAHL Google Scholar PubMed Search Strategies

Summary of Study Procedures

Types of Studies Prospective Randomized Controlled Trial (2) One-group Pre-Post Study (2) One-group Pre-Post Study/ Group Qualitative Study with Triangulation of Data (2) Qualitative Inquiry Case-Control Study with Pre-Existing Groups Case-Control Study/ Group Qualitative Study with Triangulation of Data Single-subject study

Participants Acquired Brain Injuries Age o 6.7 to 66 years Gender o Predominately male Time since injury o 77 days to 34 years Sample Size o 1 to 120 participants

Inclusion Exclusion ABI (10) Cognitive deficits (7) Behavioral outbursts (3) Family members/ caregivers willing to participate (2) Severity of Injury Good awareness of deficit & completed cognitive rehab program (1) Children 6-18 Adults Aphasia (2) History of substance abuse (2) Previous injuries (10) Deficits prior to ABI (10) Study Criteria

Cognitive Rehabilitation Interventions Personal Digital Assistants (PDAs) (Gentry et al., 2008) Amsterdam Memory and Attention Training for Children (AMAT-C) (van’t Hooft et al., 2003; Sjo et al., 2010) Insight of deficits and its impact on use of compensatory strategies (Dirette, 2002) o Qualitative study Functional Training in vs. Cognitive Education (Salazar et al., 2000) Attention Process Training (Boman et al., 2004) Categorization Program (CP) (Constantinidou et al., 2008)

Behavioral Rehabilitation Interventions Token Economy (Mottram & Berger-Gross, 2004) o Response costs o Mystery motivators Intensive positive supports (Gardner et al., 2003) o Teenagers Operant conditioning-based behavioral intervention (Slifer et al., 1995) o 8 year old female o PTA

Outcome Measurements Cognitive o Interview process o Canadian Occupational Performance Measure (COPM) o Craig Handicap Assessment and Rating Technique-Revised (CHART) o Visual & Auditory Reaction Time Tests o Wechsler Intelligence Scale for Children III Behavioral o Behavior Assessment System for Children Student Observation System (BASC-SOS) o Observations Qualitative o Interview o Questionnaires

Control Group (3) Randomized Groups (2) Small Sample Sizes (7) o < 10 participants Inter-rater reliability (2) Inclusion/Exclusion Criteria o No Mention o Vague Large variability of intervention length Methodology

Limitations Variability of sample sizes o Variability in time since injury o 77 days – 34 years Lack of consistency Length of intervention o Only 1 study looked at long-term effects

Results

Cognitive Outcomes: Setting Functional training in hospital setting vs. cognitive education in the home = no difference hickokcenter.org

Cognitive Outcomes: APT Attention process training (APT) 3 month follow up improvements in: Attention Selective Attention Alternating Attention

Cognitive Outcomes: CP Categorization Program (CP) Improvements in : o Ability to categorize familiar objects o Implement logical rules to categorize objects o Implement learned skills to categorize new objects

Cognitive Outcomes: PDA Personal Digital Assistants (PDAs) o Pre & Post COPM o Pre & Post Satisfaction

Cognitive Outcomes: AMAT-C Amsterdam Memory and Attention Training for Children (AMAT-C) Greatest improvements in Sustained Attention Tests of Attention, Tempo, Visuo-Constructive, Learning and Memory, and Executive Functions

Cognitive Outcomes: Insight Insight of deficits and its impact on use of compensatory strategies qef.org.uk

Behavioral Outcomes Token Economy Intensive positive supports Operant conditioning-based behavioral intervention

Discussion Cognitive rehabilitation is effective Behavioral intervention programs that use a reward system are effective

Future Implications

Implications for OT Practice Understand phenomenological experience of ABI Generalization of skills Awareness and understanding of cause of deficit

Implications for Future Research In-depth qualitative exploration of phenomenological experience Increased control/comparison groups Stricter inclusion/exclusion criteria Increased sample sizes Consistency with interventions studied

Questions

References Boman, L., Lindsted, M., Hemmingsson, H., & Barfai, A. (2004). Cognitive training in home environment. Brain Injury, 18(10), Centre for Neuro Skills. (2011). Overview of traumatic brain injury. Retrieved from Centers for Disease Control and Prevention. (2011, Octo 6). Traumatic brain injury. Retrieved from Constantinidou, F., Thomas, R.D., & Robinson, L. (2008). Benefits of categorization training in patients with traumatic brain injury during post-acute rehabilitation: Additional evidence from a randomized controlled trial. Journal of Head Trauma and Rehabilitation, 23(5), Dirette, D. (2002). The development of awareness and the use of compensatory strategies for cognitive deficits. Brain Injury, 16(10), Gardner, R.M., Bird, F.L., Maguire, H., Carriero, R., & Abenaim, N. (2003). Intensive positive behavior supports for adolescents with acquired brain injury; long-term outcomes in community settings. Journal of Head Trauma Rehabilitation, 18(1), Gentry, T., Wallace, J., Kvarfordt, C., & Lynch, K.B. (2008). Personal digital assistants as cognitive aids for individuals with severe traumatic brain injury: A community-based trial. Brain Injury, 22(1),

References cont. Mottram, L., & Berger-Gross, P. (2004). An intervention to reduce disruptive behaviours in children with brain injury. Pediatric Rehabilitation, 7(2), Salazar, A.M., Warden, D.L., Schwab, K., Spector, J., Braverman, S., & et al. (2000). Cognitive rehabilitation for traumatic brain injury, a randomized trial. Journal of American Medical Assoication, 283(23), Sjo, N.M., Spellerberg, S., Weidner, S., Kihlgren, M. (2010). Training of attention and memory deficits in children with acquired brain injury. Acta Paediatrica, 99, Slifer, K.J., Cataldo, M.D., & Kurtz, P.F. (1995). Behavioural training during acute brain trauma rehabilitation: an empirical case study. Brain Injury, 9(6), 585 – 593. The Brain Injury Recovery Network. (2003). The brain injury recovery network. Retrieved from van't Hooft, I., Andersson, K., Sejersen, T., Bartfai, A., & von Wendt, L. (2003). Attention and memory training in children with acquired brain injuries. Acta Paediatrica, 92,