1. Principles & Practice of Neurobehavioural Rehabilitation
Prof. Rodger Ll., Wood
College of Medicine
Swansea University
Wales, UK

2. ‘NEURO’
Identifies ‘organic’ constraints on:-
Social learning.
Emotional control.
Regulated behaviour.
Adaptive behaviour.
Affect (emotional expression).

3. Barriers to Good Psychosocial Outcome after TBI
Poor inhibitory control:- aggression, disinhibition
Diminished drive, interest, and motivation
Poor social cognition
Lack of initiative & purposeful behaviour.
Problems planning or making decisions
Diminished awareness & poor judgement
Unrealistic aspirations

4. ‘BEHAVIOURAL’ Disability construed behaviourally Rehabilitation goals
in terms of social handicap.
Rehabilitation goals
designated in terms of specific social or functional behaviours.
Progress
measured in terms of behaviour change.

5. COMPONENTS Post-acute. Slow stream rehabilitation.
Behaviour Management Capability
Structured environment.
System of reinforcement
Principles of Learning Theory
Community-Based training.
Behaviourally-defined rehabilitation goals
Organisational structure of staff

6. Why Post Acute? Intensive rehabilitation at an acute stage:-
does not prevent cognitive and behavioural problems persisting beyond early recovery phase.
Problems of awareness, judgement and self-regulation,
often not evident until after discharge.

7. WHY SLOW STREAM?
Cognitive deficits impose constraints on learning and rehabilitation
Rehabilitation interventions
long term, not ‘intensive’.
Aim is to establish habit patterns
Which takes time.
Learned components of organically determined behaviour disorders take time to unlearn.

8. Behaviour Management Capability
Behaviour disorders act as a barrier to rehabilitation and good psychosocial outcome.
NBR must be capable of:-
Containing & reducing frequency of challenging behaviour.
Creating opportunities to reinforce adaptive & appropriate behaviour.
Raising awareness of socially appropriate behaviour.

9. Structured Environment
Clearly identified system of rules
and frequent feedback opportunities.
Continuity of rehabilitation procedures
and regular practice of functional/social skills.
System to ensure reliable communication:-
of observations regarding patient’s behaviours and functional abilities
of staff roles and responsibilities
Opportunities for constructive use of leisure time

10. Dual Role of Reinforcement
Reward: To motivate behaviour.
Feedback: To promote awareness and understanding.
The Token Economy

11. ‘Token Economy’ Points System Material Reward Value
In form of tokens or points given or removed based on behaviour/achievement/effort within a time frame.
Material Reward Value
Exchanged for small short term rewards or larger - long term rewards
Social ‘Status’ Value
Allocation of points marked on chart in communal area.
Shows relative earnings of client group.
Comments/feedback from other clients
Cultivates habit of self-monitoring & improves self-awareness.

12. Benefits to staff Helps focus staff attention on important behaviours
Raises staff awareness of client’s performance over time.
Provides basis for meaningful feedback
Opportunity for meaningful engagement & social reinforcement.
Improves client’s self-awareness.

13. Some benefits of improved self awareness
Improved self-monitoring.
Better compliance and motivation
Better self-regulation
Improved potential for adaptive behaviour.

14. Community Rehabilitation
Hospitals are for ill people to be cared for; rehabilitation is about learning to do things for yourself.

15. Community Training Minimises drive and motivational problems.
Provides direction, purpose and meaning to life.
Opportunities for meaningful feedback to improve awareness.
Sheltered work opportunities
Initiative, planning and organisation.
Development of social routines
Helps skills generalise.
Opportunities to consolidate skills as habit patterns.

16. The Neurobehavioural Rehabilitation Team
Therapy does not only take place in time-limited formal sessions, with qualified therapists during the nine-to-five working day.
Continual application of interventions.
Effort and achievements reinforced through interaction with every member of the team.
The whole team are empowered to regard their role as that of agent for behaviour change.

17. Working relationships between different therapy disciplines
Need to be inter-disciplinary rather than multidisciplinary.
Careful interdisciplinary assessment and structured observations identify how problems of attention, awareness, and executive function undermine aspects of everyday behaviour.

18. Rehabilitation Process
Therapists conduct assessments and prescribe interventions.
Interventions largely carried out by therapy care assistants or rehabilitation support workers under the guidance of clinicians.
Departure from the traditional division of hospital labour between doctors, nurses, therapists on one hand, and auxiliaries or healthcare assistants who were allocated domestic responsibilities.

19. A Psychological-Learning Framework
Therapy interventions in every discipline place an emphasis on learning theory methods of intervention.
Practitioners need to have knowledge of associational learning methods to devise effective rehabilitation interventions .
Rehabilitation programmes therefore led by clinical neuropsychologists rather than medical doctors.

20. The Rehabilitation Plan
Understand the brain injury
In relation to nature of neurobehavioural disability and constraints on learning or generalising
Establish obstacles to achieving goals.
Nature of impairment & disability
Time constraints & Staff resources
Determine treatment goals
That have functional value for the individual & his/her family.
Measure progress in ways that reflects functional change.

21. Structured observations of behaviour
During different activities.
At different times of day.
In different social (or inter-personal) contexts.

22. ABC Analysis
The aim is to identify what triggers or reinforces specific behaviours.
A B C
Antecedent Behaviour Consequences
Helps establish behavioural contingencies

23. Time Sampling:- Monday: 08.00 - 09.00 13.00 - 14-00
Tuesday:
Wednesday:
Thursday:
Friday:

24. Measure of quality or intensity of behaviour
Likert Rating Scale
Rude Polite
Angry Calm
Inappropriate Appropriate

25. Predicting Progress

26. Setting Treatment Goals A ‘Smart’ Approach
Specific
Measurable
Appropriate
Realistic
Time Framed
(Standards of client, not staff)

27. Treatment Goals Behaviourally defined.
Socially & functionally relevant.
Part of a discharge plan.
Inter-disciplinary.

28. Rehabilitation Plan Discharge Goals Intermediate Goal Intermediate
Target
Behaviour
Target
Behaviour
Target
Behaviour
Target
Behaviour
Target
Behaviour
Target
Behaviour

29. The Learning Paradigm Procedural or Declarative ?
Learning through understanding
Concept formation.
Awareness of principles.
“A passive store of information”
PROCEDURAL
Learning by experience
Making associations
Practice and rehearsal

30. Procedural Learning Not dependent on memory. Knowing how, not why!
Slow acquisition.
Repeated practice.
Situation specific.

31. What I learn I learn by doing. Excellence is not an art, it’s a habit.
Aristotle
What I learn I learn by doing. Excellence is not an art, it’s a habit.

32. Development of Habit Patterns
Habit patterns are over-learned skills
Repeated practice of statements and actions.
Associational learning between overt language and action sequences.
Practice in a variety of social settings to promote generalisation.