What are the challenges? Understanding and coping with emotional and behavioural problems

Understanding People can generally understand and empathise with someone in a wheelchair or with a physical disability Some may even relate to a person with speech or memory problems

Understand and empathise It is more difficult for people to accept someone who is being abusive or disinhibited Emotional and behavioural problems may be the biggest source of stress for families

What are the behaviours ? Agitation Explosive anger and irritability Emotional blunting Lack of insight and awareness Impulsive/disinhibited Emotional lability Self centredness Apathy and poor motivation Depression Anxiety Inflexible/obsessive Sexual problems

Who has these problems? After a brain injury some people have few of these problems and some have many The severity of the problems also vary The behaviour can be a stage the person goes through

Four main reasons Direct neurological damage particularly frontal lobe Exaggeration of pre-injury personality “brakes” loosened Stress of adjustment frustration, emotional upheaval and stress Environment needs not understood, poor communication, reduced attention

Managing these behaviours Research suggests that treatment of these behaviours requires - –The carer to be supportive, encouraging, calm, understanding, knowledgeable, non-judgemental and have time to spend with the individual –The environment needs to be calm/relaxing, structured, comfortable, therapeutic

What may happen if the behaviours are not managed? Relationship breakdown Social isolation Impaired self care Health implications Stigma Exploitation Loss of role, employment, status Criminal activity

The Angus Picture In Angus there is an ABI resource worker and ABI support worker who work with individuals following ABI and beyond, covering…… Continuing rehabilitation, building physical and mental stamina Care management – statutory services - community alarm, SCO, housing support, skill building centre, nursing home care Support for individual and carer Individual goal setting Utilising coping strategies Planning and structure of routines Support into home based and community based activities - peer groups, Headway, Angus college, Angus carers Education and support for relevant individuals/groups

If the behaviour is too challenging….. Consideration of continuing care needs Specialist rehabilitation Hospital admission to specialist unit Training from specialist unit Use of AWIA, MHA, ASP

Continuing Care Draft protocol in place to enable consideration of funding issues with colleagues from health Successful work undertaken to obtain joint funding of placements in specialist units Complex community based care packages, where there are clear health needs identified Financial contribution may be required from service user

The NHS continuing care tool (Complex needs protocol) Broadly assesses individuals in 10 domains Behaviour Cognition Continence Skin Nutrition Breathing Psychological issues Medication Altered states of consciousness Mobility The tool provides a score which evidences how the care package should be funded

Community options available in Angus Slow Stream Rehabilitation Neurodisability Unit Mainstream nursing care often mismatch of needs Limited knowledge and understanding/specialist area of work “Buy in” or provide specialist training in order to up-skill potential carers. This would be done on an individual basis, dependent on need

Legislation Adults with Incapacity Act 2000 (AWIA) The person is incapable of informed decision making. Links to ‘mental disorder’ in terms of the person being incapable or unable to communicate, principally that mental disorder is defined is ABI in that there is an impairment of cognition

Burden of Proof This is often hard to evidence in ABI The gatekeepers are psychiatrists who don’t always have specialist knowledge of ABI Must be a Section 22 approved doctor Although other reports are sometimes considered, ultimately it is the psychiatrist report that decides

What can you do within AWIA? Broadly defined into two categories Financial Guardianship Allows the guardian to manage the persons financial affairs. Welfare Guardianship Allows the guardian to decide on a range of welfare issues, not related to finance. There is a perception that when someone is subject to guardianship you can implement these powers without challenge. This is NOT the case.

Benefits of Guardianship Does give some authority to the responsible person Gives a much stronger position in bargaining and negotiation Allows the responsible person to approach the Sherriff to seek additional powers such as warrant's, in order to enforce compliance Allows the responsible person to access information about the individual requiring protection Allows the responsible person to direct matters of finance and welfare to the individuals benefit In the case of someone being resistant and mobile it could be argued that the AWIA may not be very useful.

The Mental Health Act 2003 Problems? Not all agree that ABI is a mental disorder, although there are clear links to - –Depression –ABI induced psychosis –Adjustment disorder etc. Are these problems not of significant magnitude to justify the use of the MHA? –Challenging behaviour may be difficult to link to mental disorder –Some believe that ABI can’t be treated under the MHA –Dilemmas arise between general psychiatry, ABI specialists and neurology

Continued.... Local hospitals, (general or psychiatric) are not generally geared up or have suitably qualified people who are confident in dealing with challenging behaviours arising from ABI This is a specialist area of expertise Problems are likely to be long term Compulsory treatment orders do provide the enforcement aspect, if a psychiatrist and an MHO agrees but treatment must then be carried out in hospital, back to square one!

Problems relating to CTO’s After discharge from hospital, behaviours can return Forcing / restraint in the community is not an option under any of the current legislation The use of force or restraint requires the person to be returned to hospital

Statutory Services Can not use force or physically restrain a person Must rely heavily on bargaining and negotiation Must have good links with all other service areas such as health, voluntary sector, police etc in order to achieve good outcomes for individuals with ABI The picture is not all negative and these are examples of the more severe end of the spectrum

Adult Support and Protection Act 2007 The adult must meet a 3 point test Must be at risk of harm Must be unable to safeguard their own interests Is more vulnerable than others because of health or disability

What can you do within ASPA? Three types of protection order Banning orders Issued by a Sherriff and enforced by the police Removal orders Remove someone at risk to a place of safety (7 days) and issued by a Sherriff Assessment orders To take someone from a place for a medical examination or questioning and issued by a Sherriff (7 days)

Other supports in Angus Headway group Glenloch, skill building Homecare, SCO support Housing support service Community alarm (smart technology) Community meals Community laundry Joint work with CMHT and alcohol and drug team Access to other private and voluntary organisations Access to nursing home care

Too challenging? It is not always obvious which cases will be the most challenging Sometimes the lower tariff cases will often present the most challenges in terms of good outcomes There are no resources in this locality for high level cognitive behavioural cases to be cared for at present Managing complex cases requires highly developed joint working between social work and NHS