1. SASNOS: Development and Application of a Tool for Measuring Neurobehavioural Disability
Welcome back from Lunch everyone – I do hope that you all enjoyed.
Our next session will discuss the development and application of a tool for measuring neurobehavioural disability - The St Andrew’s – Swansea Neurobehavioural Outcome Scale

2. Who’s Who? Dr Claire Williams Dr Caroline Knight
Professor Nick Alderman
There are a few of us from both Swansea University and Partnerships in Care contributing to this session including myself – Dr Claire Williams, but also Dr Caroline Knight, Professor Nick Alderman, Dr Jenny Brooks, Dr Paula Foscarini-Craggs
Dr Jenny Brooks
Dr Paula Foscarini-Craggs

3. Overview Background and Development of the SASNOS
Practical use of the SASNOS – scoring and interpretation
Responsiveness of the SASNOS
Clinical case studies
Looking ahead: SASNOS-R
Now, between us, we will be providing an overview of the SASNOS, including information on its initial development, practical issues surrounding it’s use in clinical and research practice, such as scoring and interpretation, recent work examining the responsiveness of the SASNOS, as well as clinical case studies and a look at what’s next for the tool.

4. Neurobehavioural Disability
Useful framework for helping us to understand what drives challenging behaviour after ABI.
Complex, subtle, pervasive constellation of cognitive-behavioural changes that characterise post-acute ABI (Wood, 2001).
So by way of a brief introduction, we know that the concept of neurobehavioural disability provides a useful framework for understanding the complex nature of behaviour change after ABI.
The term has gained considerable attention over the past three decades, and is now used to describe the complex, subtle, and pervasive constellation of cognitive-behavioural changes that characterise post-acute ABI (Wood, 2001).

5. Neurobehavioural Disability
Product of interactions between damaged neural systems and neurocognitive impairment, further modified by premorbid personality traits and learning.
Executive and attentional dysfunction
Altered emotional expression
Poor impulse control
Range of personality changes
Poor insight
Problems of awareness and judgement

6. Neurobehavioural Disability
Behavioural characteristics associated with NBD are enduring and impose serious long-term social handicap.
NBD = poor prognosis.
Neurorehabilitation has shown that many behavioural problems can be ameliorated to reduce their psychosocial impact.
Consistent with this, outcome studies have consistently highlighted NBD as a sequalae of ABI, with its presence associated with poor prognosis
However, in order for neurobehavioural rehablitation to successfully target these behaviours, reliable and valid methods of assessing them must first be available.

7. Measuring NBD has proved to be challenging!
Given the Potentially Catastrophic Impact of NBD, How Can We Measure It?
Understand how it develops over time
Rehabilitation planning
Track progress
Recovery/rehabilitation outcomes
Discharge planning
Effectiveness of rehabilitation services
To inform cost-savings
Research
Measuring NBD has proved to be challenging!
Given the potentially catastrophic long-term impact of NBD, how do we measure it? After all, being able to reliably measure and capture the presence and extent of NBD is critical to furthering our understanding of how it develops and evolves over time, and we need to be able to capture symptoms of NBD to assist with rehabilitation planning, to monitor effectiveness of services, to inform cost savings, to support research, and to track progress during rehabilitation.
Unfortunately however, measuring NBD has proved to be as challenging as me completing my rubik’s cube from 1988 which I confess is an ongoing project!!

8. Widely Used Measures of NBD
Neurobehavioural Rating Scale (NRS)
Neurobehavioural Rating Scale – Revised (NRS-R)
Neurobehavioural Functioning Inventory (NFI)
Neurobehavioural Functioning Inventory-66 (NFI-66)
Neuropsychology Behaviour and Affect Profile (NBAP)
Key Behaviours Change Inventory (KBCI)
Head Injury Behaviour Scale (HIBS)
Ruff Neurobehavioural Inventory (RNBI)
Initial attempts to characterise NBD relied on importing measurement tools from the psychiatric literature and importing them to people with acquired neurological conditions, a well known example being the MMPI. However, such measures were neither designed with the symptoms of NBD in mind, nor standardised for people with ABI. Equally, modifying existing measures threaten the integrity, reliability and validity of the original measures.
In response to the shortcomings associated with the adoption of psychiatric measures in the context of ABI, a number of instruments have been developed specifically to measure behavioural and other and other non-cognitive characteristics of ABI.
Included in this pool of instruments are those listed here, such as the NRS-R and RNBI.

9. Work is Still Needed
Kolitz et al (2003) argued that there was still a need to develop a valid and comprehensive ‘global’ instrument for the measurement of NBD.
However, in spite of these efforts and development of specific tools,

10. Professor Nick Alderman
Director of Clinical Services and Consultant Clinical Neuropsychologist at Brain Injury Services, Partnerships in Care. He previously held senior posts at the Brain Injury Rehabilitation Trust and St Andrew’s Hospital, Northampton. He holds a number of honorary and visiting academic appointments, including at Swansea University, University of the West of England, and the University of Birmingham. Principal interests include neurobehavioural rehabilitation, challenging behaviour, dysexecutive syndrome and outcome measurement.
Dr Claire Williams
Senior Lecturer in the Department of Psychology at Swansea University. She has a strong track record of applied and translational research, leadership experience of delivering research projects with clinical impact, and experience of developing specialist neurobehavioral assessment tools for use in brain injury. Principal research interests include neurobehavioural disability, emotional processing and regulation, dysregulated behaviours, and outcome measurement.
Professor Rodger Llewellyn Wood
Professor Emeritus of Clinical Neuropsychology at Swansea University and Honorary Consultant Clinical Neuropsychologist at ABM University Health Board. He has worked in brain injury rehabilitation since 1978, at the Kemsley Unit, Northampton, Casa Colina Hospital, California, and the Brain Injury Rehabilitation Trust, UK.  His current research focuses on the nature and assessment of neurobehavioural legacies of traumatic brain injury.
In response to this, myself, Rodger and Nick commenced a body research exploring the measurement of NBD after ABI.

11. Review of Existing Measures of NBD
Undertook review of the psychometric properties of 8 widely used measures of NBD.
Determine a set of recommendations for future measures of NBD.
Wood, Alderman & Williams (2008). Assessment of neurobehavioural disability: a review of existing measures and recommendations for a comprehensive assessment tool. Brain Injury, 22, 905–918

12. Existing Measures of NBD - Comparison of Psychometric Properties (Wood, Alderman & Williams, 2008)
Review the psychometric and other well known qualities of some of most well known and widely used instruments.

13. Review of Existing Measures of NBD
Existing tools contained methodological problems of definition, conceptualisation and measurement of NBD.
Scores difficult to use in a way that is clinically or socially meaningful as an indication of outcome.
We concluded that existing tools contained methodological problems or definition, conceptualization and measurement of NBD.
Consequently, we argued that scores from such tools are difficult to use in a way that is clinically or socially meaningful as an indication of outcome.

14. There is a solution To this puzzle!
How Can NBD be Measured?
There is a solution To this puzzle!

15. St Andrew’s-Swansea Neurobehavioural Outcome Scale (SASNOS)
Designed specifically to capture NBD.
Measurement tool that can be used for clinical work and for research purposes.
Meets many of the recommendations made in our 2008 review paper.

17. How Can I get It?
us:

18. What Do I Need? SASNOS self vs. other versions Guidance Notes
Excel Scoring File (new and old versions)
Multiple SASNOS PowerPoint Template
SASNOS Protocol

19. But I’m really keen to know even more!

20. SASNOS Items 49 items describing symptoms of NBD
Items rated by choosing one of seven verbal descriptors
Balanced keying to reduce likelihood of acquiescence responding (bias)
Scoring constructive – higher ratings reflect perception of ability

21. Verbal Descriptors (ordinal)
Rank Order
Rank Order items 16, 27-42, 44-49
Descriptor
Definition 1 7
‘Never’
no behaviour/symptom observed within the review period 2 6
‘Rarely’
the behaviour/symptom has been observed once or twice 3 5
‘Occasionally’
the behaviour/symptom has been observed a few times 4
‘Sometimes’
the behaviour/symptom has been observed on about 50% of occasions when applicable
‘Fairly Often’
the behaviour/symptom has been observed on many occasions
‘Very Often’
the behaviour/symptom has been evident nearly all the time
‘Always’
the behaviour/symptom has been a constant feature of the person throughout the review period

23. SASNOS Administration and Scoring
In inpatient context, ideally completed by MDT members, as a group, who know the patient well.
Items rated from observations of the patient during the preceding 14 day period.
Ratings entered into Excel file which converts to standardised distribution based on ratings of neurologically healthy controls.
total sum of ratings
5 principal domains
12 sub domains
3 graphical representations of data

24. Principal Domains
Sub Domains
Interpersonal
Behaviour 15
Social interaction 5
Relationships 5
Engagements 5
Cognition 12
Executive function 6
Attention & memory 6
Inhibition 6
Sexual 3
Social 3
Aggression 12
Provocative behaviour 5
Irritability 4
Overt aggression 3
Communication 4
Speech & language 2
Mental state 2

25. How Often Should SASNOS Be Administered?
Neurobehavioural Rehabilitation:
Week 3 of admission
At subsequent CPA, every 3-6 months
When clinically useful!

26. A Few of the (many) Strengths of the SASNOS…

27. A Few of the (many) Strengths of the SASNOS…
I Agree With David!
Simon’s
Great!
Do different people rating the same patient do so similarly?

28. Inter-Rater Reliability
Do different people rating the same patient do so similarly?
Good measures minimise error due to inter-scorer differences (interpretation, subjectivity), changes are real (outcome)
50 patients rated independently by pairs of raters
ICC total sum ratings = .81 ‘outstanding’* (*Landis & Koch, 1977).

29. Availability of Normative Data
Neurologically healthy control data used to transform ratings into T-Scores (mean 50, sd 10)
Use of standardised distribution enables direct comparison of factor scores and interpretation
Suggests what scores may fall within the ‘normal’ or expected range
Profile of strengths and needs
Benefits to clinical practice

30. Not adapted from non-ABI measure
Comparison of psychometric properties between the SASNOS and the existing measures of neurobehavioural disability and social handicap reviewed by Wood, Alderman & Williams (2008)
Content Validity
Construct Validity
Reliability
Not adapted from non-ABI measure
No.
item
Informant
version
Content
Face
Factorial/
data
reduction (no.Items)
Internal
consistency
Convergent/
divergent
Discriminant/
Diagnostic Validity
Inter-rater
Test-retest
SASNOS
yes 49 5
NRS1 27 4
NRS-R2 29
NFI3 70 6
NFI-664 66
NBAP5
KBCI6 64 8
HIBS7 20 2
RNBI8
243 3
In addition to CTT techniques, Rasch analysis also employed

31. TOTAL RATINGS AND PRIMARY FACTORS
SASNOS
TOTAL RATINGS AND PRIMARY FACTORS
>2 SD
>1 SD
Normal
Range
T-score
<1 SD
<2 SD
<3 SD

32. SASNOS SECONDARY FACTORS T-score >2 SD >1 SD Normal Range

33. SASNOS
Individual Item Ratings
Communication
Inhibition
Interpersonal
Relationships
Aggression
Cognition

34. Reporting and Interpretation
Profile of strengths and needs
Potential rehab goals
Progress and outcome
Context!

35. Strengths Needs Insight & Goals

36. Progress & Outcome

37. Visual Representation of Functional, Neurobehavioural and Social Outcome Following ABI Rehabilitation
Communication
Cognitive
Function
Self Care
Inhibition
Interpersonal
Behaviour
Psychosocial
Adjustment
Sphincter
Control
Mobility/
Transfers
Aggression
Communication
Cognition
Locomotion
Admission
Current
Goal

38. Context Ratings Made in #1

39. Context Ratings Made in #2

40. Context Ratings Made in #2b

41. Additional measure to reflect levels of support?
1 No help or support
2 Requires help and support
3 Requires structured programme/intervention
Additional measure to reflect levels of support?
1 – no help or support
2 – requires help or support
3 – requires structured programme/intervention