Relevant Psychological Theory Understanding and Analysis relevant psychological theories and models demonstrate your application of relevant psychological theory and models in the clinical or organisational context respond appropriately to ethical issues synthesise national policy and guidance with the clinical material

Challenges of working with a traumatic frontal lobe brain injury Bobbie, Caroline, Jason and Jo

Content Complexity of traumatic brain injury – psychological, social, financial, behavioural, relational, yadiyadiyada

INTRODUCTORY AND DEFINITIONS

Neuroanatomy

Brain injury Types of injury: Traumatic brain injury If the head receives a serious blow or jolt the brain can be damaged Acquired brain injury An injury that occurs since birth stroke, haemorrhage, infection, hypoxic/anoxic brain injury and medical accidents

Traumatic Brain Injury Definition ‘Complex needs refer to multiple interlocking needs that span health and social issues’. For the DCS component of this assessment, you will be required to demonstrate your application of relevant psychological theory and models in the clinical or organisational context, respond appropriately to ethical issues and synthesise national policy and guidance with the clinical material. Google books has latest edition of the Textbook of Traumatic Brain injury (APA, 2011) http://books.google.co.uk/books?id=N_lVQ7Z- YooC&printsec=frontcover&source=gbs_ge_summary_r&ca d=0#v=onepage&q&f=false Traumatic (acquired) brain injury and behavioural difficulties

Epidemiology

Frontal lobe specific stuff Neuroanatomy Associated difficulties Dysexecutive syndrome (Baddeley 1988; p214) is used as umbrella term to describe a pattern of deficits in executive functioning. Use of Behavioural assessment of the Dysexecutive Syndrome (BADS) to address problems with DES, namely high-level tasks such as planning, organising, initiating, monitoring and adapting behaviour (Wilson, Alderman,Burgess, Emslie, and Evans (2003; p. 33).

BADS Use of six tests Wilson et al 1998; p215-219: Rule Shift Cards - Assesses the subject's ability to ignore a prior rule after being given a new rule to follow. Action Program - This test requires the use of problem solving to accomplish a new, practical task. Key Search - This test reflects the real life situation of needing to find something that has been lost. It assesses the patient's ability to plan how to accomplish the task and monitor their own progress. Temporal Judgment - Patients are asked to make estimated guesses to a series of questions such as, "how fast do racehorses gallop?". It tests the ability to make sensible guesses. Zoo Map - Tests the ability to plan while following a set of rules. Modified Six Elements - This test assesses the subject's ability to plan, organize and monitor behaviour

Frontal lobe - Overview Emotional control centre and home to personality, with damage Area of brain where damage presents with broadest range of symptoms (Kolb & Milner, 1981) Involved in motor function, spontaneity, problem solving, memory, judgement, language, initiation, social and sexual behaviour and impulse control Damage can affect flexibility of thinking, problem solving, attention and memory even following a ‘good’ recovery from a TBI (Stuss et al., 1985) MRI studies identified frontal as most common region of injury following mild to moderate traumatic brain injury (Levin et al., 1987)

Orbitofrontal cortex damage Area of the brain associated with: regulating planning behaviour sensitivity to reward and punishment ToM sensory integration representing the affective value of reinforcers, and decision making & expectation Destruction of the OFC through acquired brain injury typically leads to a pattern of disinhibited behaviour. Destruction of the OFC through acquired brain injury typically leads to a pattern of disinhibited behaviour. Examples include swearing excessively, hypersexuality, poor social interaction, compulsive gambling, drug use (including alcohol and tobacco), and poor empathising ability. Disinhibited behaviour by patients with some forms of frontotemporal dementia is thought to be caused by degeneration of the OFC Bechara et al,1994; Kringelbach, 2005; Schore, 2000; Stone, Baron-Cohen, & Knight, 1998; Snowden et al 2001

Critique Confusion over terminology Complexity of neuro understanding Dysexecutive syndrome based on Baddeleys hypothetical construct of a central executive, (Wilson, Evans, Emslie, Alderman & Burgess; p214)

IMPACTS

Emotional Impact “Coping refers to the persons’ cognitive and behavioural efforts to manage (reduce, minimise, master or tolerate) the internal and external demands of the person-environment transaction that is appraised as taxing or exceeding the person’s resources.” Folkman, Lazarus, Gruen & DeLongis (1986, pg. 572) Direct result of the structural lesion Psychological reaction to the lesion Somatising Evidence for both

Behavioural difficulties associated with frontal lobe injury impact Challenging behaviour

Theoretical Stance CBT for loss/grief Adjustment disorders Loss of future prospects, adjusting to irreversible nature of impairments etc. Anxiety and depression Theories of hopeless and helplessness depression Adjustment disorders Many patients suffer poor psychosocial adjustment and experience a reduced quality of life Wolters et al. (2010) Effectiveness of psychotherapy and adjustment Ratzel-kurzdorfer, Franke & Wolfersdorf (2003) Strain & Newcorn (2006)

ROLE OF PSYCHOLOGY (WHAT CAN BE DONE?)

Functional analysis “challenging behaviours exhibited by those with ABI are significant obstacles to achieving successful rehabilitative outcomes.” Rahman, Oliver & Alderman, (2010 pg. 213) “the neurorehabilitation field has been slow to embrace the practice of functional analyses prior to behavioural intervention.” Rahman, et al (2010, pg 212) STUDY (Rahman et al , 2010) 9 ABI survivors with challenging behaviours (physical aggression, property destruction, self-injury & verbal aggression.) method -descriptive functional analysis. Found – 1)all 9 participants exhibited at least one behaviour which was socially reinforced. Across all 9 , 88% of challenging behaviours showed a significant concurrent association with an environmental event. Summary Challenging behaviour by 9 ABI survivors adhered to a social model of reinforcement and were functional Assessment using functional analysis in the field of neurorehabilitation may lead to better treatment outcomes. Critique Repp, Felce and Barton, (1988) “an accurate assessment of behavioural function is required to devise and effective programme of behaviour change.” There were a variety of injury types and frontal lobe damage was not specified. Clinical interventions based on functional assessments are still limited (Ager & O’May, 2001) Challenging behaviours described were physical and verbal aggression, self injury, agitation and sexually inappropriate behaviours. Descriptive functional analysis – assessment of environmental conditions that precipitate Challenging behaviours Social , perceptual and material stimuli that reinforce them 152 hours of observation across all participants. Functional implications of CB can be appraised. “what purpose does the b serve?” “does it fulfil a communicative role ?” “how is it reinforced?” 1) 2) Demand escape function for 13 behaviours Attention maintaining function in 13 cases, the complete repertoire of 3 participants served the same function 5 participants presented challenging behaviours with multiple functions.

Behavioural approaches Rahman, Oliver and Alderman (2010) “such behaviours can be decreased and managed by adopting treatment approaches based on operant conditioning.” any combination of 3 contingencies (Carr,1977) Social positive reinforcement. Social attention, or tangible items /activities (Kodak, Northup and Kelley, 2007) Social-negative reinforcement Behaviours which remove postpone or reduce aspects e.g not needing to do tasks or engage in social contacts (Iwata, Pace, Kalsher, Cowdery, & Cataldo,1990 ) Automatic reinforcement non environmental BUT internal e.g. perceptual feedback (Lovaas, Newsom & Hickman, 1987) Pain attenuation (Sandman & Hetrick, 1995) Behavioural treatment models have been successfully applied for ABI (Corrigan & Bach, 2005) Social reinforcement – the delivery of environmental reinforcers e.g. social allienation or tangible items e.g. food, favoured items or preferred activities.

Assessment Formulation Intervention etc……………..

National Policy and guidance Brain Injury Association of America National Institute of Neurological Disorders and Stroke (NINDS) Brain Injury Association of Canada Brain Injury Association of Queensland Australia Headway - the brain injury association Ontario Shores Centre for Mental Health Sciences Ontario Brain Injury Association NICE guidelines, but only for Triage, assessment, investigation and early management of head injury in infants, children and adults Head injury (CG56 It does not address the rehabilitation or long-term care of patients with a head injury http://www.nice.org.uk/nicemedia/live/11836/36260/36260.pdf Rehabilitation following acquired brain injury National clinical guidelines - by Royal College of physicians http://bookshop.rcplondon.ac.uk/contents/43986815-4109-4d28-8ce5-ad647dbdbd38.pdf Included recommendation for clinical psychology provision! per 500000 of population (pg18) More British ones - found Headway http://www.headway.org.uk/home.aspx

Aims of cognitive rehabilitation Teaching the patient and family to adapt their lifestyle Taking into account the severity of cognitive and behavioural problems Patient being stimulated to learn new skills and compensatory strategies To return to activities of daily life and participate in society Wilson (2000)

Group work Jo

Cognitive Rehabilitation - an approach Parente (in Shaughnessy & Beyer, 2010) An approach (American) incorporates therapy group and individual work. Using around topics identified by client and family surveys prior to therapy; Memory training - devices – mobile phones, digital recorders , planners and checklists Disinhibition and hostility – learning to defuse situations , cue words. Emotional dysregulation & Impulse control – Medication, making client aware of issue, looking at scenarios and possible responses. Less aware of normative social behaviour – teach techniques, pair work, video recordings. Other Psychological effects Loss of hope Co-occuring PTSD Shame and embarrassment (around social behaviour) Shaughnessy and Beyer interviewed Parente who runs groups in America for people with Head injury and their families and has written numerous articles and a book on the topic.

Systemic issues

Current issues Increase in traumatic brain injuries in veterans returning from war America, rehab, v pricey

Issues of ethics and capacity Communication problems Family issues Informed consent Clinical responsibility / Organisational Which services are best to deal with traumatic brain injury and in particular support with the challenging behaviour? Social care needs

Critique Who has overall clinical responsibility?

Summary

Discussion Points What would be different if it was an organically caused brain injury? Impact on client, carer, wider system, CP What issues would be unique to TBI? How would impact of CP differ?

Questions

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Lovaas, I. , Newsom, C. , & Hickman, C. (1987) Lovaas, I., Newsom, C., & Hickman, C. (1987). Self–stimulatory behavior and perceptual reinforcement. Journal of Applied Behavior Analysis, 20, 45–68. Levin et al. (1987). Magnetic resonance imaging and computerized tomography in relation to the neurobehavioral sequelae of mild and moderate head injuries. Journal of Neurosurgery, 66, 706-713. Rahman,B., Oliver,C.& Alderman,N.(2010) Descriptive analysis of challenging behaviours shown by adults with acquired brain injury. Neuropsychological Rehabilitation,20 (2), 212–238 Repp, A. C., Felce, D., & Barton, L. E. (1988). Basing the treatment of stereotypic and selfinjurious behaviors on hypotheses of their causes. Journal of Applied Behavior Analysis, 21, 281–289. Sandman, C. A., & Hetrick, W. P. (1995). Opiate mechanisms in self-injury. Mental Retardation and Developmental Disabilities Research Reviews, 1, 130–136. Shaughnessy,M.F.& Beyer,J.(2010) An interview with Rick Parente:head injury and brain trauma, N.American journal of psychology, Vol.12, No 2, 221- 232. Schore A.N., (2000) Attachment & the Regulation of the Right BrainAttachment & human Development 2(1) 23-47. Snowden, J. S.; Bathgate, D.; Varma, A.; Blackshaw, A.; Gibbons, Z. C. & Neary. D. (2001) Distinct behavioural profiles in frontotemporal dementia and semantic dementia. Journal of Neurological Neurosurgical Psychiatry 70: 323-332. Stone, V.E.; Baron-Cohen, S. & Knight, R. T. (1998a) "Frontal Lobe Contributions to Theory of Mind." Journal of Medical Investigation 10: 640-656. Stuss, D. et al. (1985). Subtle neuropsychological deficits in patients with good recovery after closed head injury. Neurosurgery, 17, 41-47. Wilson, B.A., Evans, J.J., Emslie, H., Alderman, N., & Burgess, P. (1998). The development of an ecologically valid test for assessing patients with a dysexecutive syndrome. Neuropsychological Rehabilitation, 8, 213-228. Wilson, B.A., Alderman, N., Burgess, P.W., Emslie, H., and Evans J.J. (2003). Behavioural assessment of the Dysexecutive Syndrome (BADS). Journal of Occupational Psychology Employment and Disability, 5 (2), 33-37. Wolters, G., Stapert, S., Brands, I. & Van Heugten, C. (2010) Coping styles in relation to cognitive rehabilitation and quality of life after brain injury. Neuropsychological Rehabilitation 20(4), 587- 600.