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

Relevant Psychological Theory

Challenges of working with a traumatic frontal lobe

brain injuryBobbie, Caroline, Jason and Jo

Complexity of traumatic brain injury – psychological, social, financial, behavioural, relational, yadiyadiyada

Content

INTRODUCTORY AND DEFINITIONS

Neuroanatomy

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

Brain injury

Definition ‘Complex needs refer to multiple interlocking needs that span

health and social issues’. For the DCS component of this assessment, you will be required to demonstrate your application of relevant psychological theory and models in the clinical or organisational context, respond appropriately to ethical issues and synthesise national policy and guidance with the clinical material.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

Traumatic Brain Injury

Epidemiology

Neuroanatomy Associated difficulties

Frontal lobe specific stuff

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)

Frontal lobe - Overview

Orbitofrontal cortex damage

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.

Confusion over terminology Complexity of neuro understanding

Critique

IMPACTS

“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

Emotional Impact

Behavioural difficulties associated with frontal lobe injury impact Challenging behaviour

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)

Theoretical Stance

ROLE OF PSYCHOLOGY (WHAT CAN BE DONE?)

“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)

Functional analysis

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) 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 reinforcemento 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)

Behavioural approaches

Assessment Formulation Intervention etc……………..

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 head injury 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

National Policy and guidance

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)

Aims of cognitive rehabilitation

Jo

Group work

Systemic issues

Increase in traumatic brain injuries in veterans returning from war◦ America, rehab, v pricey

Current issues

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

Issues of ethics and capacity

Who has overall clinical responsibility?

Critique

Summary

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?

Discussion Points

Questions

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.

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.American Journal on Mental Retardation, 96, 299–319.

Iwata, B. A., Pace, G. M., Kalsher, M. J., Cowdery, G. E., & Cataldo, M. F. (1990). Experimentalanalysis 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.

Kringelbach, M.L. (2005) The orbitofrontal cortex: linking reward to hedonic experience. Nature Reviews Neuroscience 6: 691-702.

References

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 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.

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.

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.