R elevant Psychological Theory

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

3. Content • Complexity of traumatic brain injury – psychological, social, financial, behavioural, relational, yadiyadiyada

4. INTRODUCTORY AND DEFINITIONS

5. Neuroanatomy

6. Frontal lobe - Overview • 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. 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. Bechara et al,1994;Kringelbach, 2005; Schore, 2000; Stone, Baron-Cohen, & Knight, 1998; Snowden et al 2001

8. Brain injury Types of injury: • Traumatic brain injury • If the head receives a serious blow or jolt the brain can be damaged • Acquired brain injury • 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=falseTraumatic (acquired) brain injury and behavioural difficulties

9. Associated head injury difficulties • Epilepsy • Hormonal changes? • Coma • Marital breakdown (Landau & Hissett, 2008) • Loss of self (Pollack 1994) • Relating to others (Campbell, 2003)

10. Epidemiology • Just the figures!

11. Frontal lobe specific stuff • 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 DysexecutiveSyndrome (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).

12. BADS • 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

13. Critique • Confusion over terminology • Complexity of neuro understanding • Dysexecutive syndrome based on Baddeleys hypothetical construct of a central executive, (Wilson, Evans, Emslie, Alderman & Burgess; p214)

14. IMPACTS

15. 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 • Somatising • Evidence for both

16. Behavioural difficulties associated with frontal lobe injury impact • Challenging behaviour

17. Theoretical Stance • 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)

18. ROLE OF PSYCHOLOGY (WHAT CAN BE DONE?)

19. Functional analysis “challenging behaviours exhibited by those with ABI are significant obstacles to achieving successful rehabilitative outcomes.” Rahman, Oliver & Alderman, (2010 pg. 213) “the neurorehabilitation field has been slow to embrace the practice of functional analyses prior to behavioural intervention.” Rahman, et al (2010, pg 212) STUDY (Rahman et al , 2010) • 9 ABI survivors with challenging behaviours (physical aggression, property destruction, self-injury & verbal aggression.) • method -descriptive functional analysis. • Found – • 1)all 9 participants exhibited at least one behaviour which was socially reinforced. • Across all 9 , 88% of challenging behaviours showed a significant concurrent association with an environmental event. • Summary • Challenging behaviour by 9 ABI survivors adhered to a social model of reinforcement and were functional • Assessment using functional analysis in the field of neurorehabilitation may lead to better treatment outcomes. • Critique • Repp, Felce and Barton, (1988) “an accurate assessment of behavioural function is required to devise and effective programme of behaviour change.” • 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)

20. Behavioural approaches • Rahman, Oliver and Alderman (2010) “such behaviours can be decreased and managed by adopting treatment approaches based on operant conditioning.” any combination of 3 contingencies (Carr,1977) • Social positive reinforcement. • Social attention, or tangible items /activities (Kodak, Northup and Kelley, 2007) • Social-negative reinforcement • 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 ) • Automatic reinforcement • non environmental BUT internal e.g. perceptual feedback (Lovaas, Newsom & Hickman, 1987) Pain attenuation (Sandman & Hetrick, 1995) Behavioural treatment models have been successfully applied for ABI (Corrigan & Bach, 2005)

21. Assessment • Formulation • Intervention etc……………..

22. 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 headinjury • http://www.nice.org.uk/nicemedia/live/11836/36260/36260.pdf • Rehabilitation following acquired brain injury National clinical guidelines - by Royal College of physicianshttp://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 Headwayhttp://www.headway.org.uk/home.aspx

23. 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)

24. Group work • Jo

25. Cognitive Rehabilitation - an approach 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)

26. Systemic issues

27. Current issues • Increase in traumatic brain injuries in veterans returning from war • America, rehab, v pricey

28. Issues of ethics and capacity • Communication problems • Family issues • Informed consent • Clinical responsibility / Organisational • Which services are best to deal with traumatic brain injury and in particular support with the challenging behaviour? • Social care needs

29. Critique • Who has overall clinical responsibility?

30. Summary

31. Discussion Points • 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?

32. Questions

33. References 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. Carr, E. G. (1977). Motivation of self-injurious behavior: A review of some hypotheses. Psychological Bulletin, 84, 800–816. 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.AmericanJournal on Mental Retardation, 96, 299– 319. 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 BehaviorAnalysis, 40, 167–171. Kolb, B., & Milner, B. (1981). Performance of complex arm and facial movements after focal brain lesions. Neuropsychologia, 19:505-514. Kringelbach, M.L. (2005) The orbitofrontal cortex: linking reward to hedonic experience. Nature Reviews Neuroscience 6: 691-702.

34. 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. 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 selfinjuriousbehaviors 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. Shaughnessy,M.F.& Beyer,J.(2010) An interview with Rick Parente:head injury and brain trauma, N.American journal of psychology, Vol.12, No 2, 221-232. Schore A.N., (2000) Attachment & the Regulation of the Right BrainAttachment & human Development 2(1) 23-47. Snowden, J. S.; Bathgate, D.; Varma, A.; Blackshaw, A.; Gibbons, Z. C. & Neary. D. (2001) Distinct behavioural profiles in frontotemporal dementia and semantic dementia. Journal of Neurological Neurosurgical Psychiatry 70: 323-332. Stone, V.E.; Baron-Cohen, S. & Knight, R. T. (1998a) "Frontal Lobe Contributions to Theory of Mind." Journal of Medical Investigation 10: 640-656. Stuss, D. et al. (1985). Subtle neuropsychological deficits in patients with good recovery after closed head injury. Neurosurgery, 17, 41-47. Wilson, B.A., Evans, J.J., Emslie, H., Alderman, N., & Burgess, P. (1998). The development of an ecologically valid test for assessing patients with a dysexecutive syndrome. Neuropsychological Rehabilitation, 8, 213-228. Wilson, B.A., Alderman, N., Burgess, P.W., Emslie, H., and Evans J.J. (2003). Behavioural assessment of the Dysexecutive Syndrome (BADS). Journal of Occupational Psychology Employment and Disability, 5 (2), 33-37. Wolters, G., Stapert, S., Brands, I. & Van Heugten, C. (2010) Coping styles in relation to cognitive rehabilitation and quality of life after brain injury. Neuropsychological Rehabilitation 20(4), 587- 600.