1.  Understanding and Analysis relevant psychological theories and models  demonstrate your application of relevant psychological theory and models in the clinical or organisational context  respond appropriately to ethical issues  synthesise national policy and guidance with the clinical material

2. Bobbie, Caroline, Jason and Jo

3.  Introduction and definitions ◦ Neuroanatomy ◦ Frontal lobe – overview ◦ Orbitofrontal damage ◦ Brain injury –terms ◦ Associated head injury difficulties ◦ Executive difficulties ◦ Frontal lobe specific difficulties ◦ BADS ◦ Epidemiology ◦ Critique  Psychological Issues ◦ Emotional impact ◦ Behavioural difficulties ◦ Systemic issues ◦ Theoretical stance  Interventions ◦ Functional analysis ◦ Behavioural interventions ◦ Aims of cognitive rehabilitation ◦ Group work &systemic support  Organisational issues National policy& guidance Ethical issues

4. INTRODUCTION & DEFINITIONS

6.  Emotional control centre and home to personality, with damage  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)

7. Bechara et al,1994; Kringelbach, 2005; Schore, 2000; Stone, Baron-Cohen, & Knight, 1998; Snowden et al 2001  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.

8. 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) ◦ An injury that occurs since birth ◦ stroke, haemorrhage, infection, hypoxic/anoxic brain injury and medical accidents ◦ Google books has latest edition of the Textbook of Traumatic Brain injury (APA, 2011) http://books.google.co.uk/books?id=N_lVQ7Z- YooC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false Traumatic (acquired) brain injury and behavioural difficulties http://books.google.co.uk/books?id=N_lVQ7Z- YooC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false  Traumatic brain injury (TBI) ◦ If the head receives a serious blow or jolt the brain can be damaged “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

9.  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 nausea 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)

10.  Epilepsy JO  Hormonal changes? CAROLINE  Coma  Marital breakdown (Landau & Hissett, 2008)  Loss of self (Pollack 1994)  Relating to others (Campbell, 2003) BOBBIE  Executive functioning (Dysexecutive syndrome)

11.  http://en.wikipedia.org/wiki/Executive_functi oning http://en.wikipedia.org/wiki/Executive_functi oning  General overview  Range of models/theories  Impact when damaged  JASON AND HELPERS

12. An umbrella term to describe a range 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 goal-directed behaviour (Levin & Hanten, 2005; Lezak, 2004).

14.  Associated difficulties  Dysexecutive syndrome (Baddeley 1988; p214) is used as umbrella term to describe a pattern of deficits in executive functioning.  Use of Behavioural assessment of the Dysexecutive Syndrome (BADS) to address problems with DES, namely high-level tasks such as planning, organising, initiating, monitoring and adapting behaviour (Wilson, Alderman,Burgess, Emslie, and Evans (2003; p. 33).

15.  Use of six tests Wilson et al 1998; p215-219:  Rule Shift Cards - Assesses the subject's ability to ignore a prior rule after being given a new rule to follow.  Action Program - This test requires the use of problem solving to accomplish a new, practical task.  Key Search - This test reflects the real life situation of needing to find something that has been lost. It assesses the patient's ability to plan how to accomplish the task and monitor their own progress.  Temporal Judgment - Patients are asked to make estimated guesses to a series of questions such as, "how fast do racehorses gallop?". It tests the ability to make sensible guesses.  Zoo Map - Tests the ability to plan while following a set of rules.  Modified Six Elements - This test assesses the subject's ability to plan, organize and monitor behaviour

16.  Just the figures!  Limited figures available  CAROLINE

17.  Confusion over terminology  Complexity of neuro understanding  Dysexecutive syndrome based on Baddeleys hypothetical construct of a central executive, (Wilson, Evans, Emslie, Alderman & Burgess; p214) ◦ Diagram of Baddeley’s model – difficulty that theoretical, not definitive, only a model ◦ Research in support of executive functioning

18. PSYCHOLOGICAL ISSUES

19.  “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 ◦ Somatising  Evidence for both

20.  Challenging behaviour  CAROLINE

21.  Relationship difficulties  Employment etc.  Social involvement  Self view  JO

22.  CBT for loss/grief ◦ Loss of future prospects, adjusting to irreversible nature of impairments etc.  Anxiety and depression  Theories of hopeless and helplessness depression  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)

23. INTERVENTIONS

24. “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 212 - 13) 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)

25.  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 contingencies (Carr,1977) o Social positive reinforcement. o Social attention, or tangible items /activities (Kodak, Northup and Kelley, 2007) o Social-negative reinforcement o Behaviours which remove postpone or reduce aspects e.g not needing to do tasks or engage in social contacts ( Iwata, Pace, Kalsher, Cowdery, & Cataldo,1990 ) o Automatic reinforcement o non environmental BUT internal e.g. perceptual feedback (Lovaas, Newsom & Hickman, 1987) Pain attenuation (Sandman & Hetrick, 1995)

26.  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)

27. Parente (in Shaughnessy & Beyer, 2010) An approach (American) incorporates therapy group and individual work. Using around topics identified by client and family surveys prior to therapy; Memory training - devices – mobile phones, digital recorders, planners and checklists Disinhibition and hostility – learning to defuse situations, cue words. Emotional dysregulation & Impulse control – Medication, making client aware of issue, looking at scenarios and possible responses. Less aware of normative social behaviour – teach techniques, pair work, video recordings. Other Psychological effects Loss of hope Co-occuring PTSD Shame and embarrassment (around social behaviour)

28. Assessments including family members etc. JO

29.  CBT etc.  EVERYONE

30.  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

31. There was an action plan of services for Acquired brain injury In Northern Ireland in 2009 this identified that  Services are disjointed and the current provision a patient receives depends on  - underlying cause of the condition  - complexity and severity  - age of the individual  - existing comorbidities  - social and geographical factors The plan suggested amongst other suggestions;  Making the services more Joined up leadership by the Regional Acquired Brain Injury Implementation Group regional commissioning of ABI services a virtual ABI networked approach; better links between general hospitals and ABI network to Promote early identification  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 although British Society of Rehabilitation Medicine has 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)

32. 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. UKABIF are also asking for an audit of rehabilitation services for acquired brain injury

34.  Brain Injury Association of America Brain Injury Association of America  National Institute of Neurological Disorders and Stroke (NINDS) National Institute of Neurological Disorders and Stroke (NINDS)  Brain Injury Association of Canada Brain Injury Association of Canada  Brain Injury Association of Queensland Australia Brain Injury Association of Queensland Australia  Headway - the brain injury association Headway - the brain injury association  Ontario Shores Centre for Mental Health Sciences Ontario Shores Centre for Mental Health Sciences  Ontario Brain Injury Association 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  http://www.nice.org.uk/nicemedia/live/11836/36260/36260.pdf http://www.nice.org.uk/nicemedia/live/11836/36260/36260.pdf  Rehabilitation following acquired brain injury National clinical guidelines - by Royal College of physicians http://bookshop.rcplondon.ac.uk/contents/43986815-4109-4d28-8ce5-ad647dbdbd38.pdf http://bookshop.rcplondon.ac.uk/contents/43986815-4109-4d28-8ce5-ad647dbdbd38.pdf ◦ Included recommendation for clinical psychology provision! per 500000 of population (pg18)  More British ones - found Headway http://www.headway.org.uk/home.aspx http://www.headway.org.uk/home.aspx

35.  Communication problems  Family issues  Informed consent  Avoidance of asking re. problems with sexual functioning BOBBIE  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?  Social care needs  Compensation claims

36.  Sexual difficulties – under acknowledged, lack of information Study by Rolls, Honack, Wade and McGrath (1994) Problematic sexual behaviour in patients with frontal lobe damage that they studied e.g. - sexually explicit language, - actual sexual advances - being over friendly, kissing and hugging - exposure Difficulties for the patient and partner Patient information (e.g. Headways) mentions sexual difficulties (? Psychological ) Orbital frontal lobe damage – peculiar sexual habits Headway (charity) – suggests; - sexual counselling from e.g. Relate - a clinical neuropsychologist who specialises in sexual relationships

37.  Who has overall clinical responsibility?

39.  What would be different if it was an organically caused brain injury?  Impact on client, carer, wider system, CP  What issues would be unique to TBI?  How would impact of CP differ?

40. Questions

41. 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. Baddeley, A., & Wilson, B. (1988). Frontal amnesia and the dysexecutive syndrome. Brain and Cognition, 7, 212-230 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. Brain Injury network, (2012 ) who are we, retrieved from http://www.braininjurynetwork.org/aboutbin.html on 13/01/2012http://www.braininjurynetwork.org/aboutbin.html British Society for Rehabilitation Medicine (2008). Vocational assessment and rehabilitation after acquired brain injury inter-agency guidelines. Retrieved from http://bookshop.rcplondon.ac.uk/contents/fbc3513a-5642-459a-9b2c-a1e47e8745ad.pdfhttp://bookshop.rcplondon.ac.uk/contents/fbc3513a-5642-459a-9b2c-a1e47e8745ad.pdf Carr, E. G. (1977). Motivation of self-injurious behavior: A review of some hypotheses. Psychological Bulletin, 84, 800–816. Davey, G. (2008) Psychopathology Research, Assessment and Treatment In Clinical Psychology. West Sussex: Wiley-Blackwell. 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, 571-579. Guess, D., & Carr, E. (1991). Emergence and maintenance of stereotypy and self-injury.American Journal on Mental Retardation, 96, 299– 319. Headway (2012) sex and sexuality after brain injury, retrieved from http://www.headway.org.uk/sex-and-sexuality-after-brain-injury.aspx on 13/01/2012 Kringelbach, M.L. (2005) The orbitofrontal cortex: linking reward to hedonic experience. Nature Reviews Neuroscience 6: 691- 702.

42. Iwata, B. A., Pace, G. M., Kalsher, M. J., Cowdery, G. E., & Cataldo, M. F. (1990). Experimental analysis and extinction of self-injurious escape behavior. Journal of Applied Behavior Analysis, 23, 11–27. Kodak, T., Northup, J., & Kelley, M. E. (2007). An evaluation of the types of attention that maintain problem behavior. Journal of Applied Behavior Analysis, 40, 167–171. Kolb, B., & Milner, B. (1981). Performance of complex arm and facial movements after focal brain lesions. Neuropsychologia, 19:505-514. Lovaas, I., Newsom, C., & Hickman, C. (1987). Self–stimulatory behavior and perceptual reinforcement. Journal of Applied Behavior Analysis, 20, 45–68. Levin et al. (1987). Magnetic resonance imaging and computerized tomography in relation to the neurobehavioral sequelae of mild and moderate head injuries. Journal of Neurosurgery, 66, 706-713. National Audit Office (December 2011) services for people with neurological conditions, The stationary office:London. National Institute of Neurological disorders and stroke (2012 ) Traumatic Brain Injury Information Page retrieved from http://www.ninds.nih.gov/disorders/tbi/tbi.htm on 13/01/12 http://www.ninds.nih.gov/disorders/tbi/tbi.htm Rahman,B., Oliver,C.& Alderman,N.(2010) Descriptive analysis of challenging behaviours shown by adults with acquired brain injury. Neuropsychological Rehabilitation,20 (2), 212–238 Repp, A. C., Felce, D., & Barton, L. E. (1988). Basing the treatment of stereotypic and selfinjurious behaviors on hypotheses of their causes. Journal of Applied Behavior Analysis, 21, 281–289. Sandman, C. A., & Hetrick, W. P. (1995). Opiate mechanisms in self-injury. Mental Retardation and Developmental Disabilities Research Reviews, 1, 130–136.

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