Bobbie, Caroline, Jason and Jo
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Introduction and definitions
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Brain injury –terms
Types of traumatic brain injury
Neuroanatomy
Frontal lobe – overview
Orbitofrontal damage
Executive functioning
Working memory
Baddeley’s working model
Deficits in executive functioning
Neuropsychological assessments
Epidemiology
Psychological Issues
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Interpersonal issues
Systemic issues
Emotional impact
Theories of depression
Adjustment
Behavioural difficulties
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Interventions
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Functional analysis
Behavioural approaches
Aims of cognitive rehabilitation
Organisational issues
National policy& guidance
Ethical issues
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Summary
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Discussion
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Questions
INTRODUCTION &
DEFINITIONS
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)
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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)
Difficulties
◦ 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)
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No FL damage statistics found
Hospital Episode statistics for 2000/2001
112,978 admissions to hospitals in England with a primary diagnosis of
head injury.
75% were male
33% were children
NICE, (2007)
 70-88% of people who sustain a head injury are male
 10-19% are aged ≥ 65 years
?
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Emotional control centre and home to personality
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Area of brain where damage presents with broadest range of
symptoms (Kolb & Milner, 1981)
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Involved in motor function, spontaneity, problem solving, memory,
judgement, language, initiation, social and sexual behaviour and
impulse control
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Damage can affect flexibility of thinking, problem solving, attention and
memory even following a ‘good’ recovery from a TBI (Stuss et al., 1985)
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MRI studies identified frontal as most common region of injury following
mild to moderate traumatic brain injury (Levin et al., 1987)
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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
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Epilepsy
Hormonal changes
Coma
Marital breakdown
Loss of self
Relating to others
Executive functioning (Dysexecutive syndrome)
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Abnormal cognition and behaviour following the war (Luria,
1966)
First documented case Phineas Gage (Harlow, 1848)
Costandi, M (2010)
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Early EF models described it in unitary, homogenous terms
with no individual components and generalised to the frontal
lobes, “frontal lobe syndrome” (Anderson, Jacobs & Anderson
2008, p. xxviii)
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Limitations of frontal lobe syndrome
(Anderson, Jacobs & Anderson 2008, p. xxviii)
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EF umbrella term describing a range of highly complex
and interrelated group 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)
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In order to achieve a goal-directed behaviour
(Levin & Hanten, 2005; Lezak, 2004).
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Critique
Agreed
upon definitions problematic
(Anderson, 2008; p. 6)
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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).
◦ Self Regulation model; the ability to inhibit behavioural responses
(Barkley, 1997)
◦ Developmental model; how EF profile develops in children
(Anderson, 2002).
 (for brief review of prominent EF models see Anderson 2008).
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Critique - No one model has been uniformally accepted but,
current work is evolving at defining an integrated one see Cascadeof control model
(Banich, 2009)
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One leading model that addresses Gioia et al
(2001) recommendations is the working memory
model of Baddeley and Hitch
(1974; see also Baddeley 1997 and 2001);
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Two discrete functions holding information as
the focus of attention and the retrieval of
information from long term memory
(Spillers, & Unsworth, 2011; p, 1532).
Central
Executive
Visuospatial
Sketchpad
Episodic
buffer
Visual
Semantics
Episodic
LTM
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Phonological
loop
Language
Baddeley’s working memory model (2001)
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TBI can lead to deficits in executive functioning such as working memory, in
particularly the central executive of Baddeleys model, where it is argued that the
systems impaired are collective known as Dysexecutive syndrome (DES)
(Wilson, Alderman,Burgess, Emslie, and Evans 2003; p. 33)
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DES is used as umbrella term to describe a pattern of deficits in executive
functioning such as planning, abstract thinking and behavioural control
(Baddeley 1988; p214)
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Assessment of these deficits are typically conducted using performance based
neuropsychological tests
(Gerstadt, Hong, & Diamond,1994)
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Critique ecological validity of such tests has been questioned because the tests
are highly structured, administered in a distraction-free environment, and in
some instances, provide cues on how to respond
(Goldbery & Podell, 2000)
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Two test that address these criticism are the Behavioural assessment of the Dysexecutive
Syndrome
(Wilson, Alderman, Burgess, Emslie, & Evans 1996)
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Delis–Kaplan Executive Function System both of which use a battery of test to identify
specific executive functioning deficits
(D-KEFS, Delis, Kaplan & Krammer, 2001)
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The BADS (1996) is designed to require participants to plan, initiate, monitor and
adjust behaviour in response to the explicit and implicit demands of a series of tasks
using six test, such as the zoo map which test the ability to plan while following a set
of rules. It also contains the 20 item dysexecutive questionnaire which lists
statements common problems of everyday life and to rate them according to their
personal experience
(Wilson, Alderman,Burgess, Emslie, and Evans 2003; p. 33).
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While the D-KEFS (2001) aims for a similar goal in both children and adults but using nine
tests. It is also able to be utilised in different clinical populations from TBI like multiple
sclerosis
(Parmenter et al, 2007)
PSYCHOLOGICAL
ISSUES
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Difficulties with empathy, perspective taking and cognitive
flexibility (Grattan, 1994)
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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
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Critics discuss driving force of interaction is desire of positive
relational experiences (e.g. Sunnafrank, 1986)
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All discuss in some form a sense of giving
and receiving of emotional and/or cognitive
information
◦ 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
effectiveness
 (Adler, Rosenfold & Proctor, 2007)
Neighbours
/society
Colleagues
Extended family
Parents
Partner
Children
Friends
Employer
Healthcare/social
professionals
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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
(Bombardier et al., 2010)
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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“
(Fann et al., 2010)
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Treating depression can be effective and can decrease functional
impairment, somatic symptoms, and perception of impairment
(Varney et al., 1987)
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Theories of depression
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Learned helplessness theory: Clinical depression may
result from perceived absence of control over a
situation’s outcome (Seligman, 1975)
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When suffering uncontrollable events, can impact on
emotions, aggressions, physiology and problem-solving
tasks (Roth, 1980)
Critique
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Does not account for varying reactions to same situations
(Peterson & Park, 1998)
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“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)
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Direct result of the structural lesion
Psychological reaction to the lesion (Brown et al, 1988)
◦ Somatising
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Evidence for both
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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)
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Challenging behaviour
◦ Not a diagnostic category
◦ Culturally abnormal behaviour
◦ Risk to self or others & limits access to community services
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Why the change
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Difficulties communicating needs / understanding incoming information
Frustration / memory of previous abilities
Attachment
Effect of injury / site of injury
Environmental factors
Critique
◦ Almost all literature is based in learning disabilities
◦ Limited research into prevalence or differences in CB
◦ Aggression / challenging behaviour
Baguley et al, 2006; Emerson, 1995; Kelly et al, 2008; Pfafflin & Adshead, 2004;
Yody et al, 2000
INTERVENTIONS
“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
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method - descriptive functional analysis.
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Found – all participants exhibited at least one behaviour which was socially reinforced.
- Functional analysis was a useful assessment intervention
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Recommended - Assessment using functional analysis in the field of
neurorehabilitation.
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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)
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Behavioural treatment models have been successfully applied for ABI (Corrigan & Bach, 2005)
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Rahman et al (2010) “such behaviours can be decreased and managed by adopting treatment
approaches based on operant conditioning.”
any combination of 3 reinforcers motivate challenging behaviours (Carr,1977)
o
Social positive reinforcement.
o Social attention, or tangible items /activities given in response to behaviours (Kodak,
Northup and Kelley, 2007)
o
Social-negative reinforcement
o Behaviours which serve to 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.Pain attenuation (Sandman & Hetrick, 1995)
Experimental functional analysis – systematic manipulation of environmental controls to identify which
bring about a change in behaviour. (Rahman et al , 2010)
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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)
Parente (in Shaughnessy & Beyer, 2010)
•
•
•
An American approach for working with patients with brain injury,
incorporates therapy group and individual work.
Focusses on topics identified as problematic by the client and family
Examples –
Memory training - devices – mobile phones, digital recorders , planners and checklists
Disinhibition and hostility – family & patient learning to defuse situations, cue words.
Emotional dysregulation & Impulse control – Medication, making client aware of issue, looking at
scenarios and possible responses.
Awareness of normative social behaviour – teach techniques, pair work, video recordings.
Other focusses
Loss of hope
Co-occuring PTSD
Shame and embarrassment (around social behaviour)
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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
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Who provides rehabilitation?
NICE guidelines, - Only for Triage, Assessment, Investigation and early management of head injury.
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
changes
No equivalent yet in England and Wales
British Society of Rehabilitation Medicine - 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.
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Communication problems
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Informed consent
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Family issues
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DNA policy – appropriate for FL patients (Spontaneity, impulse control,
disinhibited behaviour etc.)
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Clinical responsibility / Organisational
◦ Which services are best to deal with traumatic brain injury and in
particular support with the challenging behaviour?
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Compensation claims
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Sexual difficulties – under acknowledged, lack of information
Study by Rolls, Honack, Wade and McGrath (1994)
Problematic sexual behaviour in patients with FL
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sexually explicit language,
actual sexual advances
being over friendly, kissing and hugging
exposure
Difficulties for the patient and partner
Headway (charity)
Patient information leaflets mention sexual difficulties (? Psychological )
– suggests;
- sexual counselling from e.g. Relate
- a clinical neuropsychologist who specialises in sexual relationships

Introduction and definitions
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◦

Brain injury –terms
Types of traumatic brain injury
Neuroanatomy
Frontal lobe – overview
Orbitofrontal damage
Executive functioning
Working memory
Baddeley’s working model
Deficits in executive functioning
Neuropsychological assessments
Epidemiology
Psychological Issues
◦
◦
◦
◦
◦
Interpersonal issues
Systemic issues
Emotional impact incl. theories of
depression
Adjustment
Behavioural difficulties

Interventions
◦
◦
◦
◦
•
•
Functional analysis
Behavioural approaches
Aims of cognitive rehabilitation
Organisational issues
National policy & guidance
Ethical issues


Think about the experience and knowledge you have of
working with services offering neuropsychological
assessment, formulation and intervention
Imagine you are a qualified psychologist working in this field.
Based on the above, complete a SWOT (Strengths,
Weaknesses, Opportunities and Threats) analysis of factors
you think are likely to be experienced by psychologists in this
area
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Additional areas for consideration:
Political
Economic
Social
Technological
Legal
Environment
Questions
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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
physicians
http://bookshop.rcplondon.ac.uk/contents/43986815-4109-4d28-8ce5-ad647dbdbd38.pdf
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Included recommendation for clinical psychology provision! per 500000 of population (pg18)
More British ones – found at Headway
http://www.headway.org.uk/home.aspx