1. Leading Psychosocial Treatment Programmes For Challenging Behaviour in People with Acquired Brain Injury Dr Caroline Knight, Lead Consultant Neuropsychologist Prof Nick Alderman, Director of Clinical Services Brain Injury Services, Partnerships in Care

3. Post-ABI Challenging Behaviour That Might Be Referred for Intervention  blunt social behaviour  irritability  low frustration tolerance  impulsive behaviour  non-cooperation  sexual disinhibition  shouting  passivity/low arousal  apathy/lack of drive  escape/avoidance  verbal aggression  self-injurious behaviour  aggression towards objects  physical assaults on others

4. Neurobehavioural disability has a major impact on long-term psychosocial outcome Capacity for independent living Employment Relationships Contact with forensic services Quality of life Presence of NBD = poorer prognosis

6. 2016: Effective Treatment for NBD? Or “varnished by eloquent mission statements, and masked by fine buildings and glossy brochures”? (Kitwood, 1997)

7. What do Leading Programmes Look Like? Service model – clarity of purpose Evidence based practice Clear treatment objectives Programme structure Research and service evaluation Therapeutic Milieu Interpersonal elements Everyone feels part of endeavour Engagement and motivation Every interaction is an opportunity

8. Neurobehavioural Rehabilitation aims to reduce challenging behaviour which prevent progress after ABI …….and has been shown to be successful, therefore:- increased opportunities for the individual to access more traditional neurorehabiltation aid functional and social independence reintegrate with community facilities.

9. Treatment Evidence based practice Versus Eminence based practice

10. Neurobehavioural Rehabilitation Eames & Wood 1985 Eames, Cotterill et al 1996 RCPhys & BSRM 2010 Oddy & da Silva Ramos 2013 10

11. Elements of NbR Clear leadership and accountability Ownership by all Transdisciplinary Clear treatment goals Daily therapeutic programme Ward rules Levels/step system Functional analysis Formulation and sharing ideas about way forward Individual programmes Reinforcers Feedback Points/tokens Recordings

12. 12 So how do we get there???

13. How do we Create NbR Culture? 13 Aggression associated with “burnout” and turnover of staff e.g. Todd & Watts, 2005 Natural response: fight or flight Apathy Consistency is impossible? Controllability: failure to recognise impact of ABI

14. 14 Strategy for Change 2. Resistance 1. Denial 3. Exploration 4. Acceptance performance

15. 15 Rolling with Resistance Initiate Develop Monitor Evaluate Advocate idea –Clear, open communication about what planned Ensure service follows –Inquiry, listen, explore resistance, negotiation Make it a success –Set objectives, communicate to all, attention to the detail Publicise –Evaluate, acknowledge gains and how can improve, tell others

16. Unlocking Potential How do we Deliver the Key Elements of NbR?

17. Key Components of Structures in NbR physical environment transdisciplinary team daily routine and therapeutic timetable positive behavioural support feedback basket of outcome measures

18. Physical Environment Encourage independence and skill building through –Orientation boards and cues –Real life settings not just therapy “session bound” –Outside space –Community –Enrichment –Care pathways 18

19. Transdisciplinary Team Goal setting Share goals collaboratively with the person with brain injury Share roles to meet these goals Consistent approach 24/7

20. The TDT Ward Managers Qualified Nurses Speech and Language Therapist Physiotherapist Technical Instructors Assistant Psychologist Rehabilitation Assistants Director of Clinical Services Hospital Director (RMN) Lead Consultant Clinical Neuropsychologist Consultant Psychiatrist Lead Nurse Vocational and Therapies Manager Lead Social Worker Housekeeping Health, Safety and Security Maintenance HR Catering Administration 20

21. Therapeutic Timetable Daily routine Hygiene programmes Mealtime experience Individual and group sessions 12 week programme Vocational opportunities Leisure time Getting the right balance: activity, fatigue and motivation

22. Positive Behaviour Support / Functional Analytical Approach Identify relationship of behaviour with environment Antecedents that evoke behaviour? Reinforcing consequences that maintain it? Informant led, Descriptive or Experimental Support plan created to identify reactive and more importantly preventative strategies

23. Evaluation Intervention information collected by team about behaviour Formulation Assessment information integrated by team within a therapeutic framework to create a hypothesis about behaviour appropriate intervention designed and implemented by team effectiveness of intervention determined by team

24. neurocognitive factors organic premorbid traits neuro- psychiatric poor adjustment poor insight learned response environment Behaviour

26. Specialist Training Bespoke local induction –Mandatory training –Clinical topics including Understanding ABI and NbR Rolling weekly CPD –Training –Supervision –Team meeting / reflection –Case discussion / formulation 26

27. Feedback & Reinforcement Individual positive behaviour support plans Scheduled Keyworker sessions Attending TDT meeting each month Community meeting weekly 2 way to refine programme Positive practice award NbR audit of treatment integrity 27

28. How do we Show we do what we Say we do? Objective measurement necessary Seen as good clinical practice and essential to demonstrate evidence based treatments Service users and their families Show progress, objective feedback Enjoy benefits of increased behavioural control - increased access to therapeutic activities / less restrictive settings in the community Staff Monitor behaviour and flag up potential difficulties Assessment, formulation and design of appropriate interventions Evaluate treatment (clinical evidence versus guessing) Commissioners and funders Share results: value for money?

29. Basket of Outcome Measures Every 3 months –Supervision Rating Scale –FIM/FAM –SASNOS –START risk assessment Ongoing observational recording tools –OAS-MNR –SASBA 29

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31. Keeper of the Vision Attributes Engagement Owned at all levels External focus Standards Feedback Review & development

33. Leadership in the Future Improve evidence base about getting there Research effective leadership & staff teams in NbR Strategic recruitment Standards particular to NbR Built environment IT solutions