Bobbie, Caroline, Jason and Jo
Introduction and definitions
Frontal lobe – overview
Orbitofrontal damage
Brain injury –terms
Associated head injury difficulties
Executive difficulties
Frontal lobe specific difficulties
Psychological Issues
Emotional impact
Behavioural difficulties
Systemic issues
Theoretical stance
Functional analysis
Behavioural interventions
Aims of cognitive rehabilitation
Group work &systemic support
Organisational issues
• National policy& guidance
• Ethical issues
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)
Traumatic brain injury (TBI)
“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)
◦ Lack of consistency with definitions
◦ Brain injury network (2012) has called for this to be addressed
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 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)
Emotional control centre and home to personality
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)
Area of the brain
associated with:
◦ regulating planning
◦ sensitivity to reward and
◦ ToM
◦ sensory integration
◦ representing the affective
value of reinforcers, and
decision making &
Destruction of the OFC
through acquired brain
injury typically leads to a
pattern of disinhibited
Bechara et al,1994; Kringelbach, 2005; Schore, 2000;
Stone, Baron-Cohen, & Knight, 1998; Snowden et al 2001
Hormonal changes
Marital breakdown
Loss of self
Relating to others
Executive functioning (Dysexecutive syndrome)
First documented case Phineas Gage (Harlow, 1848)
Early EF models no individual components and location
covered whole of frontal lobes (Anderson, Jacobs &
Anderson 2008, p. xxviii)
A highly complex and interrelated group of cognitive
phenomena (Anderson 2008, p 6) 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).
Should be theoretically sound, encompass the various
cognitive functions, explain the different presentation of
impairments, provide a link between brain and behaviour
and be able to suggest assessment methods as well as
interventions. (Gioia, Guy & Isquith, 2001; p.329)
no one model has been uniformally accepted for brief
review of prominent EF models see Anderson (2008).
Working memory (Baddeley 1997; 2001); developmental
(Anderson, 2002).
One that addresses Gioia et al (2001) list Baddeley’s
Working memory model (2001)
Two functions holding information as the focus of
attention and the retrieval of information from long
term memory (Spillers, & Unsworth, 2011; p,
Handout of Baddeleys’s (2001) model?
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).
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
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
Difficulties with empathy, perspective taking and cognitive
flexibility (Grattan, 1994)
Theories of interpersonal relationships
◦ Attachment theory
◦ Social exchange theory (Homans, 1958)
 Human relationships formed by use of cost-benefit analysis & the
comparison of alternatives
 (Although some critique re. basis in economic theory; based on
openness which not relevant to all & places relationships in linear
structure rather than flexible in path followed – Miller, 2005)
◦ Uncertainty reduction theory (Berger and Calabrese, 1975)
 Individuals seek to reduce uncertainty with each other when first
interacting, based on self-disclosure
Critics discuss driving force of interaction is desire of positive
relational experiences (e.g. Sunnafrank, 1986)
All discuss in some form a sense of giving
and receiving of emotional and/or cognitive
◦ Empathy positively associated with relationship
satisfaction, negatively associated with depression
and conflict; depression and conflict negatively
associated with relationship satisfaction
 (Cramer, 2010)
◦ Cognitive flexibility positively related to interpersonal
 (Adler, Rosenfold & Proctor, 2007)
Extended family
Major depressive disorder (MDD) may be the most common and disabling
psychiatric condition in individuals with TBI
Poorer cognitive functioning, aggression and anxiety, greater functional
disability, poorer recovery, higher rates of suicide attempts, and greater
health care costs associated with MDD after TBI
Incidence of major depression among 559 people with traumatic brain
injury was nearly eight times greater than would be expected in the
general population
"less than half of the people who were found to have major depression
received any treatment during the first year“
(Bombardier et al., 2010)
(Fann et al., 2010)
Treating depression can be effective and can decrease functional
impairment, somatic symptoms, and perception of impairment
(Varney et al., 1987)
Theories of depression
Learned helplessness theory: Clinical depression may
result from perceived absence of control over a
situation’s outcome (Seligman, 1975)
When suffering uncontrollable events, can impact on
emotions, aggressions, physiology and problem-solving
tasks (Roth, 1980)
Does not account for varying reactions to same situations
(Peterson & Park, 1998)
“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
◦ Folkman, Lazarus, Gruen & DeLongis (1986, pg. 572)
Direct result of the structural lesion
Psychological reaction to the lesion (Brown et al, 1988)
◦ Somatising
Evidence for both
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)
Challenging behaviour
“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
Critique - There were a variety of injury types and frontal lobe damage was not
Clinical interventions based on functional assessments are still limited.
(Ager & O’May, 2001)
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)
Social positive reinforcement.
o Social attention, or tangible items /activities (Kodak, Northup and Kelley, 2007)
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 )
Automatic reinforcement
o non environmental BUT internal e.g.
perceptual feedback (Lovaas, Newsom & Hickman, 1987)
Pain attenuation (Sandman & Hetrick, 1995)
Teaching the patient and family to adapt their
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)
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)
Local issues – referrals into neuropsychological
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?
NICE guidelines, but only for Triage, assessment, investigation and early management of head injury
in infants, children and adults Head injury It does not address the rehabilitation or long-term care
of patients with a head injury (NICE 2007).
There was an action plan of services for Acquired brain injury In Northern Ireland in 2009
The plan suggested amongst other suggestions;
 Making the services more Joined up
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
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)
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.
Communication problems
Family issues
Informed consent
Avoidance of asking re. problems with sexual
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
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
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?
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.
Anderson, P. (2002). Assessment and development of executive function (EF) during childhood. Child Neuropsychology, 8(2),
Anderson P.J. (2008). Models of executive function. In V Anderson, Jacobs R, Anderson PJ. Executive functions and the frontal
lobes: A lifespan perspective. New York: Taylor & Francis. pp. 3–21.
Baddeley, A. (1997). Human Memory: Theory and practice, revised edn, Psychology Press: Hove.
Baddeley A.D. (2002) Is working memory still working? American Psychologist; 56 (11), 851-864.
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 on 13/01/2012
British Society for Rehabilitation Medicine (2008). Vocational assessment and rehabilitation after acquired brain injury inter-agency
guidelines. Retrieved from
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
and Social Psychology, 50, 571-579.
Gioia, G.A., Guy, S.C., Isquith, P.K. (2001), Assessment of Executive Functions in Children with Neurologic Impairment. In G.A. Gioia, S.C. Guy,
& P.K. Isquith (Eds.), Psychological and Development Assessment, (pp. 317-356). New York, NY: Guilford Press.
Guess, D., & Carr, E. (1991). Emergence and maintenance of stereotypy and self-injury.American Journal on Mental Retardation, 96, 299–
Headway (2012) sex and sexuality after brain injury, retrieved from on 13/01/2012
Harlow, J. (1848). The passage of an iron rod through the head. Boston medical and surgical journal, 39, 389-393. Retrieved from
Kringelbach, M.L. (2005) The orbitofrontal cortex: linking reward to hedonic experience. Nature Reviews Neuroscience 6: 691-
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
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
moderate head injuries. Journal of Neurosurgery, 66, 706-713.
mild and
Levin, H.S., Culhane, K.A., Hartmann, J., Evankovich, K., Mattson, A.J., Howard, H., et al. (1991). Developmental changes in performance on
tests of purported frontal lobe functioning. Developmental Neuropsychology, 7(3), 377-395.
Lezak, M.D. (1995). Neuropsychological Assessment. New York: Oxford University Press.
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 on 13/01/12
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–
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-
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
semantic dementia. Journal of Neurological Neurosurgical Psychiatry 70: 323-332.
frontotemporal dementia and
Spillers, G.J., & N. Unsworth. (2011). Variation in Working Memory Capacity and Temporal–Contextual Retrieval From Episodic
Memory. Journal of experimental psychology: Learning, Memory and Cognition, 37, (6), 1532-1539. DOI: 10.1037/a0024852
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). 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.
World health organisation (1996) Geneva
Bombardier, C. .H., Fann, J. R., Temkin, N. .R., Esselman, P. C., Barber, J. & Dikmen, S. S. (2010). Rates of Major Depressive
Disorder and Clinical Outcomes Following Traumatic Brain Injury. JAMA, 303 (19): 1938-1945.
Fann JR, Katon WJ, Uomoto JM. (1995) Psychiatric disorders and functional disability in outpatients with traumatic brain injuries.
Am J Psychiatry, 152:1493-1499.
Varney, N.R, Martzke, J.S, & Roberts R.J. (1987) Major depression in patients with closed head injury. Neuropsychology, 1(7), 9.
Adler, R.B., Rosenfold, L.B. & Proctor, R.F. (2007) Interplay: The process of interpersonal communication, 10th Ed., Oxford
University Press: New York.
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
Rehabilitation following acquired brain injury National clinical guidelines - by Royal College of
Included recommendation for clinical psychology provision! per 500000 of population (pg18)
More British ones – found at Headway