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

2. Content Introduction and definitions Psychological Issues
Brain injury –terms
Types of traumatic brain injury
Neuroanatomy
Frontal lobe – overview
Orbitofrontal damage
Executive functioning
Working memory
Baddeley’s working model
Deficits in executive functioning
Neuropsychological assessments
Epidemiology
Psychological Issues
Interpersonal issues
Systemic issues
Emotional impact
Theories of depression
Adjustment
Behavioural difficulties
Interventions
Functional analysis
Behavioural approaches
Aims of cognitive rehabilitation
Organisational issues
National policy& guidance
Ethical issues
Summary
Discussion
Questions
Jason
Complexity of traumatic brain injury – psychological, social, financial, behavioural, relational, yadiyadiyada

3. INTRODUCTION & DEFINITIONS
Jason

4. Brain injury
Types of injury:
Acquired brain injury (ABI)
“Damage to the brain, which occurs after birth and is not related to a congenital or a degenerative disease. These impairments may be temporary or permanent and cause partial or functional disability or psychosocial maladjustment .”
The World Health Organization (1996)
Traumatic brain injury (TBI)
“Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue.”
National Institute of Neurological Disorders and Stroke (2012)
Difficulties
Lack of consistency with definitions
Brain injury network (2012) has called for this to be addressed
Bobbie
There is a lot of varied terminology around brain injury so though we would explain some of the terms that we’ll use during the presentation
Acquired Brain injury or ABI
Traumatic brain injury (TBI)
Confusing terminology, difference in UK and America, in America these are often treated as two separate conditions whereas in the UK a traumatic brain injury is also seen as a type of acquired brain injury.
the Brain injury network has called for the inconsistencies to be addressed.

5. Types of Traumatic brain injury
Three types:
Concussion: An impact to the head that jars the brain and temporally disrupts its normal functioning
Closed head injury: A concussion or head trauma, the symptoms of which include loss of consciousness after the trauma, confusion, headache, nausea or vomiting, blurred vision, loss of short-term memory and perseverating.
Contusion: A severe head trauma in which the brain is not just jarred but the impact also causes bruising to the brain.
(Davey 2008; p.504)
Bobbie
So briefly some of the impacts that an injury can have ;
Concussion –
Closed head injury is a concussion or head trauma where in addition to other symptoms the individual may experience confusion, short term memory difficulties and perseveration.
and
Contusion -

6. Neuroanatomy Jo

7. Frontal lobe - Overview
Emotional control centre and home to personality
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) Jo

8. 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.
Caroline
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

9. Associated head injury difficulties
Epilepsy
Hormonal changes
Coma
Marital breakdown
Loss of self
Relating to others
Executive functioning (Dysexecutive syndrome)
Caroline
Here are some general areas of difficulty, some of which we will explore in more detail in this presentation.

10. Executive functioning - Historical
Abnormal cognition and behaviour following the war (Luria, 1966)
First documented case Phineas Gage (Harlow, 1848)
Costandi, M (2010)
Early EF models described it in unitary, homogenous terms with no individual components and generalised to the frontal lobes, “frontal lobe syndrome” (Anderson, Jacobs & Anderson 2008, p. xxviii)
Jason
Increasing attention has been paid to the concept of EF spanning well over half century after case reports by Luria (1966) on abnormal cognition and behaviour following war injuries.
Although, EF type deficits had been reported over a century early, with the most frequently cited example of frontal lobe damage affecting EF being that of Phineas Gage. Whose erratic behaviour and change of personality after a tamping iron penetrated his skull and damaged his frontal cortex, are well documented (Harlow, 1848).
The early models of EF described it in unitary, homogenous terms with no individual components and generalised to the frontal lobes, “frontal lobe syndrome (Anderson, Jacobs & Anderson 2008, p. xxviii).

11. Executive functioning - Definition
Limitations of frontal lobe syndrome
(Anderson, Jacobs & Anderson 2008, p. xxviii)
EF umbrella term describing a range of highly complex and interrelated group of cognitive phenomena such as:
attention control, inhibition, working memory, goal setting, planning, problem solving, multi tasking and abstract reasoning
(Senn, Espy, & Kaufmann, 2004; Welsh, Pennington, & Groisser, 1991)
In order to achieve a goal-directed behaviour
(Levin & Hanten, 2005; Lezak, 2004).
Critique Agreed upon definitions problematic
(Anderson, 2008; p. 6)
While initially appealing, the limitations of this standpoint soon became apparent when those working in the field noticed individual patterns of deficits in different patients and that varing areas affected within the frontal lobes did not produce the same behavioural profiles across patients group.
This has led the more recent to the view of EF as an umbrella term to describe a range of highly complex interrelated group of cognitive phenomena such as attention control, inhibition, working memory, goal setting, planning, solving, multi tasking and abstract reasoning (Senn, Espy, & Kaufmann, 2004; Welsh, Pennington, & Groisser, 1991) that enable goal-directed behaviour (Levin & Hanten, 2005; Lezak, 2004). E.g going to the shops.
Critique - makes an agreed upon definition problematic.

12. Executive functioning – Models
Should be theoretically sound, encompass the various cognitive functions, explain the different presentation of impairments, provide a link between brain and behaviour and be able to suggest assessment methods as well as interventions
(Gioia, Guy & Isquith, 2001; p.329).
Self Regulation model; the ability to inhibit behavioural responses
(Barkley, 1997)
Developmental model; how EF profile develops in children (Anderson, 2002).
(for brief review of prominent EF models see Anderson 2008).
Critique - No one model has been uniformally accepted but,
current work is evolving at defining an integrated one see Cascade- of control model (Banich, 2009)
Jason
This has led to a number of theoretical models being proposed looking at both distinct and overlapping areas that have influenced research and clinical practice. Gioia, Guy & Isquith (2001, p.329) has suggested that to be useful such a model should be theoretically sound, encompass the various cognitive functions, explain the different presentation of impairments, provide a link between brain and behaviour and be able to suggest assessment methods as well as interventions. The differences of the underlying assumptions as well as the rationale for formulating these models, explains both the number and variety available. Some focus on a specific domain like self regulation (Barkley, 1997) while others are adopt a developmental stance (Anderson, 2002). See Anderson (2008) for a review of EF.
Critique - There are a number of models proposed as no one model has been uniformally accepted but, current work is evolving at defining an integrated one see Cascade-of control model (Banich, 2009)

13. Working Memory
One leading model that addresses Gioia et al (2001) recommendations is the working memory model of Baddeley and Hitch (1974; see also Baddeley 1997 and 2001);
Two discrete functions holding information as the focus of attention and the retrieval of information from long term memory (Spillers, & Unsworth, 2011; p, 1532).
Jason
One leading model that addresses the recommendations laid out by Gioia et al (2001) is working memory model Baddeley and Hitch (1974).
Working memory is defined has having two discrete functions; holding information as the focus of attention and the retrieval of information from long term memory (Spillers, & Unsworth, 2011; p, 1532).

14. Baddeley’s working memory model
Central Executive
Visuospatial Sketchpad
Episodic buffer
Phonological loop
Visual Episodic Language
Semantics LTM
Jason
In Baddeleys’s (2001) working memory model there are two sub systems that manage this process, one concerned with verbal information, the phonological loop, the other with visual and spatial information, the visuospatial sketch pad. These are in turn managed by an attentional controller, the central executive. The model further includes an additional feature for the central executive namely the episodic buffer; this is argued to form an interface between the two subsystems and long term memory. See model diagram.

15. Deficits in Executive Functioning
TBI can lead to deficits in executive functioning such as working memory, in particularly the central executive of Baddeleys model, where it is argued that the systems impaired are collective known as Dysexecutive syndrome (DES) (Wilson, Alderman,Burgess, Emslie, and Evans 2003; p. 33)
DES is used as umbrella term to describe a pattern of deficits in executive functioning such as planning, abstract thinking and behavioural control (Baddeley 1988; p214)
Assessment of these deficits are typically conducted using performance based neuropsychological tests (Gerstadt, Hong, & Diamond,1994)
Critique ecological validity of such tests has been questioned because the tests are highly structured, administered in a distraction-free environment, and in some instances, provide cues on how to respond (Goldbery & Podell, 2000)
Jason
TBI can lead to deficits in executive functioning and namely baddeleys theory of working memory and in particularly the central executive of his model are argued as the systems impaired in what is known as Dysexecutive syndrome.
DES is used as umbrella term to describe a pattern of deficits in executive functioning such as planning, abstract thinking and behavioural control.
Dysexecutive syndrome based on Baddeleys hypothetical construct of a central executive, (Wilson, Evans, Emslie, Alderman & Burgess; p214)
Goldberg, E., & Podell, L. (2000). Adaptive decision making, ecological
validity, and the frontal lobes. Journal of Clinical and Experimental
Neuropsychology, 22, 56–68.

16. Neuropsychological assessments
Two test that address these criticism are the Behavioural assessment of the Dysexecutive Syndrome (Wilson, Alderman, Burgess, Emslie, & Evans 1996)
Delis–Kaplan Executive Function System both of which use a battery of test to identify specific executive functioning deficits (D-KEFS, Delis, Kaplan & Krammer, 2001)
The BADS (1996) is designed to require participants to plan, initiate, monitor and adjust behaviour in response to the explicit and implicit demands of a series of tasks using six test, such as the zoo map which test the ability to plan while following a set of rules. It also contains the 20 item dysexecutive questionnaire which lists statements common problems of everyday life and to rate them according to their personal experience (Wilson, Alderman,Burgess, Emslie, and Evans 2003; p. 33).
While the D-KEFS (2001) aims for a similar goal in both children and adults but using nine tests. It is also able to be utilised in different clinical populations from TBI like multiple sclerosis (Parmenter et al, 2007)
Jason
Two test that address these criticism are the Behavioural assessment of the Dysexecutive Syndrome
Delis–Kaplan Executive Function System both of which use a battery of test to identify specific executive functioning deficits
The BADS (1996) is designed to require participants to plan, initiate, monitor and adjust behaviour in response to the explicit and implicit demands of a series of tasks using six test, such as the zoo map which test the ability to plan while following a set of rules. It also contains the 20 item dysexecutive questionnaire which lists statements common problems of everyday life and to rate them according to their personal experience
While the D-KEFS (2001) aims for a similar goal in both children and adults but using nine tests. It is also able to be utilised in different clinical populations from TBI like multiple sclerosis

17. ? Epidemiology No FL damage statistics found
Hospital Episode statistics for 2000/2001
112,978 admissions to hospitals in England with a primary diagnosis of head injury.
75% were male
33% were children
NICE, (2007)
70-88% of people who sustain a head injury are male
10-19% are aged ≥ 65 years ?
Bobbie
Triage - assessment - investigation and early management of head injury in infants, children and adults, NICE Clinical Guideline (September 2007).

18. PSYCHOLOGICAL ISSUES
Team

19. Interpersonal issues
Difficulties with empathy, perspective taking and cognitive flexibility (Grattan, 1994)
Theories of interpersonal relationships
Attachment theory
Social exchange theory (Homans, 1958)
Human relationships formed by use of cost-benefit analysis & the comparison of alternatives
(Although some critique re. basis in economic theory; based on openness which not relevant to all & places relationships in linear structure rather than flexible in path followed – Miller, 2005)
Uncertainty reduction theory (Berger and Calabrese, 1975)
Individuals seek to reduce uncertainty with each other when first interacting, based on self-disclosure
Critics discuss driving force of interaction is desire of positive relational experiences (e.g. Sunnafrank, 1986) Jo

20. Interpersonal issues
All discuss in some form a sense of giving and receiving of emotional and/or cognitive information
Empathy positively associated with relationship satisfaction, negatively associated with depression and conflict; depression and conflict negatively associated with relationship satisfaction
(Cramer, 2010)
Cognitive flexibility positively related to interpersonal effectiveness
(Adler, Rosenfold & Proctor, 2007) Jo

21. Systemic issues Neighbours/society Colleagues Extended family Parents
Partner
Children
Friends Jo
References etc. to be added
Employer
Healthcare/social professionals

22. Emotional issues
Major depressive disorder (MDD) may be the most common and disabling psychiatric condition in individuals with TBI
Poorer cognitive functioning, aggression and anxiety, greater functional disability, poorer recovery, higher rates of suicide attempts, and greater health care costs associated with MDD after TBI
(Bombardier et al., 2010)
Incidence of major depression among 559 people with traumatic brain injury was nearly eight times greater than would be expected in the general population
"less than half of the people who were found to have major depression received any treatment during the first year“
(Fann et al., 2010)
Treating depression can be effective and can decrease functional impairment, somatic symptoms, and perception of impairment
(Varney et al., 1987) Jo

23. Theories of depression
Learned helplessness theory: Clinical depression may result from perceived absence of control over a situation’s outcome (Seligman, 1975)
When suffering uncontrollable events, can impact on emotions, aggressions, physiology and problem-solving tasks (Roth, 1980)
Critique
Does not account for varying reactions to same situations (Peterson & Park, 1998) Jo

24. 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 (Brown et al, 1988)
Somatising
Evidence for both
Caroline

25. Adjustment 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)
Caroline

26. Behavioural difficulties associated with frontal lobe injury impact
Challenging behaviour
CAROLINE
Caroline
Effects of Injury
Site of damage
Extent of damage
Emotional reaction to injury
Epilepsy
Environmental Factors
Interpersonal relationships (staff, family, friends)
Occupation / Leisure
Litigation

27. INTERVENTIONS
Team

28. Functional analysis
“challenging behaviours exhibited by those with ABI are significant obstacles to achieving successful rehabilitative outcomes.”
“the neurorehabilitation field has been slow to embrace the practice of functional analyses”
Rahman, Oliver & Alderman(2010, pg )
Rahman et al (2010) 9 ABI survivors with challenging Behaviours
method - descriptive functional analysis.
Found – all participants exhibited at least one behaviour which was socially reinforced.
- Functional analysis was a useful assessment intervention
Recommended - Assessment using functional analysis in the field of neurorehabilitation.
Critique - 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)
Bobbie
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?”
Attention maintaining function in 13 cases,
5 participants presented challenging behaviours with multiple functions.

29. Behavioural approaches
Behavioural treatment models have been successfully applied for ABI (Corrigan & Bach, 2005)
Rahman et al (2010) “such behaviours can be decreased and managed by adopting treatment approaches based on operant conditioning.”
any combination of 3 reinforcers motivate challenging behaviours (Carr,1977)
Social positive reinforcement.
Social attention, or tangible items /activities given in response to behaviours (Kodak, Northup and Kelley, 2007)
Social-negative reinforcement
Behaviours which serve to 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.Pain attenuation (Sandman & Hetrick, 1995)
Experimental functional analysis – systematic manipulation of environmental controls to identify which bring about a change in behaviour. (Rahman et al , 2010)
Bobbie
Corrigan and Bach ……
Following on from their work on functional analysis Rahman et al also suggested that behavioural approaches are used in working with ABI patients who exhibit challenging behaviours that are assessed as functional.
Operant conditioning association between behaviour and consequence.
They based their recommendations on the work of Carr

30. 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)
Caroline

31. Cognitive Rehabilitation - an approach
Parente (in Shaughnessy & Beyer, 2010)
An American approach for working with patients with brain injury,
incorporates therapy group and individual work.
Focusses on topics identified as problematic by the client and family
Examples –
Memory training - devices – mobile phones, digital recorders , planners and checklists
Disinhibition and hostility – family & patient learning to defuse situations, cue words.
Emotional dysregulation & Impulse control – Medication, making client aware of issue, looking at scenarios and possible responses.
Awareness of normative social behaviour – teach techniques, pair work, video recordings.
Other focusses
Loss of hope
Co-occuring PTSD
Shame and embarrassment (around social behaviour)
Caroline
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.
Cue words – words that are known to the patient and family members and if situation is becoming hostile then one person will say the word and this triggers an agreement to leave the room and spend a period of time apart.

32. Organisational
Local issues – referrals into neuropsychological services
Head injury and PTSD? Who treats them?
NHS vs private, increasing pressure to meet targets and prove effectiveness in outcome measures, impact on actual treatment received?
Increase in traumatic brain injuries in veterans returning from war
America, rehab, v pricey
Who provides rehabilitation?
JO AND CAROLINE
Caroline

33. Organisational
NICE guidelines, - Only for Triage, Assessment, Investigation and early management of head injury.
Does not address the rehabilitation or long-term care of patients with a head injury (NICE 2007).
There was an action plan of services for Acquired brain injury In Northern Ireland in 2009
The plan suggested amongst other suggestions;
Making the services more Joined up
Standardised care pathway including targets around waiting times
improving information around prevalence to plan future service provision
Recognising the importance of family support & importance of promoting independence
Support education and training of staff .
Between 2009/10 and 2011/12 and additional £1.2 million was invested in implementing these changes
No equivalent yet in England and Wales
British Society of Rehabilitation Medicine - called for a joint framework between employment , social services , and independent/voluntary providers to guide brain injury services (British Society of Rehabilitation Medicine 2008; p. 3)
Bobbie
Nice guideline that exists is for infants, children and adults
NICE guideline that does exist -
When a person who has undergone imaging of the head and/or been admitted to hospital experiences persisting problems, there should be an opportunity available for referral from primary care to an outpatient appointment with a professional trained in assessment and management of sequelae of brain injury (for example, clinical psychologist, neurologist, neurosurgeon, specialist in rehabilitation medicine).
An investigation of brain injury services was carried out in Northern Ireland in 2009 which showed…..
As far as we could ascertain there is no equivalent for England and Wales
Services are disjointed and the current provision a patient receives argueably depends on
- underlying cause of the condition
- complexity and severity
- age of the individual
- existing comorbidities
social and geographical factors
This has been recognised by a number of charities and pressure groups and the British society has called for ….

34. Organisational
National Audit Office ( 2011)Report Almost £1billion wasted through people with neurological conditions being unnecessarily admitted to hospital. The MS Society, Motor Neurone Disease (MND) Association, Parkinson’s UK Neurological Alliance, Neurological Commissioning Support – urging Government to create a targeted, properly resourced national strategy for neurological conditions which would include acquired brain injury.
Bobbie
This is further supported by a report carried out by the NAO in 2011…
And the following charities and groups have urged the government to create a …

35. Issues of ethics and capacity
Communication problems
Informed consent
Family issues
DNA policy – appropriate for FL patients (Spontaneity, impulse control, disinhibited behaviour etc.)
Clinical responsibility / Organisational
Which services are best to deal with traumatic brain injury and in particular support with the challenging behaviour?
Compensation claims
Bobbie
In terms of ethical issues we were aware of the communication difficulties and abilitiy to express their needs that can be experienced by clients with frontal lobe damage and the potential difficulties that could arise from this in terms of gaining informed consent.
Difficulties in relationships with family could mean that the clients permisssion to share information with their family could be changeable and this needs to be monitored by staff.
We thought about appointments and how usual policy is to discharge a client after a number of unattended appointments . Given that these clients are likely to experience difficulties around spontaneity, impulse control and disinhibited behaviour we felt that there could easily be situations that arose unexpectedly and resulted in non attendance at appointments.
With the current arrangement of services there is a lack of clarity around where particular responsibilities lye and if this is confusing for services the difficulties for those attempting to access services is apparent.
When patients sustain head injurys this may lead to legal proceedings and compensation claims which can be a complicating factor in assessing and working with them as we may be asked to participate in the legal process.
Social care needs

36. Ethical issues
Sexual difficulties – under acknowledged, lack of information
Study by Rolls, Honack, Wade and McGrath (1994)
Problematic sexual behaviour in patients with FL
- sexually explicit language,
- actual sexual advances
- being over friendly, kissing and hugging
- exposure
Difficulties for the patient and partner
Headway (charity)
Patient information leaflets mention sexual difficulties (? Psychological )
– suggests;
- sexual counselling from e.g. Relate
- a clinical neuropsychologist who specialises in sexual relationships
Bobbie
Psychological – arising from changes in role, status, becoming cared for , self esteem issues, possible relationship problems
Orbital frontal lobe damage – peculiar sexual habits
It was difficult to find information around this .
FOR INFO ONLY
How it works
Limbic system – Thalmus is the 1st point of contact for incoming info
Info passes through the limbic system to the hypothalamus (hypothalamus decides what is important) one of the roles of the hypothalamus is sex drive.
When it is working properly it screams “have sex now”
That information is sent to the frontal lobe for filtering e.g the suggestions “lets find an opportunity”
When there is frontal lobe damage , may be filtered out so having sex is not prioritised OR
Filtering system does not work.

37. Summary Introduction and definitions Psychological Issues
Brain injury –terms
Types of traumatic brain injury
Neuroanatomy
Frontal lobe – overview
Orbitofrontal damage
Executive functioning
Working memory
Baddeley’s working model
Deficits in executive functioning
Neuropsychological assessments
Epidemiology
Psychological Issues
Interpersonal issues
Systemic issues
Emotional impact incl. theories of depression
Adjustment
Behavioural difficulties
Interventions
Functional analysis
Behavioural approaches
Aims of cognitive rehabilitation
Organisational issues
National policy & guidance
Ethical issues Jo

38. Discussion
Think about the experience and knowledge you have of working with services offering neuropsychological assessment, formulation and intervention
Imagine you are a qualified psychologist working in this field. Based on the above, complete a SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis of factors you think are likely to be experienced by psychologists in this area Jo

39. Environment Discussion Political Economic Social Technological Legal
Additional areas for consideration:
Political
Economic
Social
Technological
Legal
Environment Jo

40. Questions
Team

41. References
Adler, R.B., Rosenfold, L.B. & Proctor, R.F. (2007) Interplay: The process of interpersonal communication, 10th Ed., Oxford University Press: New York. Ager, A., & O’May, F. (2001). Issues in the definition and implementation of “best practice” for staff delivery of interventions for challenging behaviour. Journal of Intellectual & Developmental Disability, 26, 243–256. Anderson, P. (2002). Assessment and development of executive function (EF) during childhood. Child Neuropsychology, 8(2), Anderson P.J. (2008). Models of executive function. In V Anderson, Jacobs R, Anderson PJ. Executive functions and the frontal lobes: A lifespan perspective. New York: Taylor & Francis. pp. 3–21. Baddeley, A. (1997). Human Memory: Theory and practice, revised edn, Psychology Press: Hove. Baddeley A.D. (2002) Is working memory still working? American Psychologist; 56 (11), Baddeley, A. D., & Hitch, G. (1974). Working memory. In G. H. Bower (Ed.), Recent advances in learning and motivation (Vol. 8, pp. 47–90). New York: Academic Press. Baddeley, A., & Wilson, B. (1988). Frontal amnesia and the dysexecutive syndrome. Brain and Cognition, 7, Banich, M.T. (2009). Executive function the search for an integrated account. Current directions in Psychological Science18, (2), Barkley, R.A. Behavioural inhibition, sustained attention, and executive functions: Constructing a theory of ADHD. Psychological Bulletin, 121, (1),

42. References
Bechara, A., Damasio, A.R., Damasio H., & Anderson, S.W. (1994) "Insensitivity to future consequences following damage to human prefrontal cortex". Cognition 50: 7-15.
Bombardier, C. .H., Fann, J. R., Temkin, N. .R., Esselman, P. C., Barber, J. & Dikmen, S. S. (2010). Rates of Major Depressive Disorder and Clinical Outcomes Following Traumatic Brain Injury. JAMA, 303 (19):
Brain Injury network, (2012 ) who are we , retrieved from on 13/01/2012
British Society for Rehabilitation Medicine (2008). Vocational assessment and rehabilitation after acquired brain injury inter-agency guidelines. Retrieved from
Costandi, M. (2010, November 8). Phineas Gage and the effect of an iron bar through the head on personality. The Guardian. Retrieved from
Davey, G. (2008) Psychopathology Research, Assessment and Treatment In Clinical Psychology. West Sussex: Wiley-Blackwell.
Delis, D. C., Kaplan, E., & Kramer, J. (2001). Delis–Kaplan Executive Function System. San Antonio, TX: Psychological Corporation.
Folkman, S. Lazarus, R. S., Gruen, R. J. & DeLongis, A. (1986) Appraisal, coping, health status and psychological symptoms Journal of Personality and Social Psychology, 50,
Gerstadt, C. L., Hong, Y. J., & Diamond, A. (1994). The relationship between cognition and action: Performance of children 3[1/2]–7 years old on Stroop-like day–night test. Cognition, 53, 129–153.
Goldberg, E., & Podell, L. (2000). Adaptive decision making, ecological validity, and the frontal lobes. Journal of Clinical and Experimental Neuropsychology, 22, 56–68.

43. References
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46. Further reading 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
Rehabilitation following acquired brain injury National clinical guidelines - by Royal College of physicians
Included recommendation for clinical psychology provision! per of population (pg18)
More British ones – found at Headway