Overview and inter-rater reliability of an incident-based rating scale for aggressive behaviour following traumatic brain injury: The Overt Aggression Scale–Modified for Neurorehabiltation–Extended (OAS-MNR-E)

Effectiveness of deep brain stimulation on refractory aggression in pediatric patients with autism and severe intellectual disability: meta-analytic review

Some patients with autism and severe intellectual disability may experience uncontrolled aggression, causing serious injury or harm to others, and the therapeutic ineffectiveness of traditional pharmacological and behavioral treatment may aggravate symptoms. Deep brain stimulation (DBS) has been tested in patients with little evidence in children and adolescents. Therefore, we analyzed the efficacy and safety of DBS in refractory aggression in pediatric subjects with autism (ASD) and severe intelligence deficit (ID).Methods A meta-analytic review of Web of Science (WOS) and Scopus articles, following Prisma criteria. A total of 555 articles were identified, but after applying the inclusion criteria, only 18 were analyzed. The review of the registries and the extraction of information was performed by 2 independent groups, to reduce the evaluator's bias. For the description of the results, pediatric patients with ASD or ID present in each registry, with an application of specialized scales (Overt aggression scale, OAS, and THE modified version of the OAS, MOAS) pre and post-DBS, with a clinical follow-up of at least 12 months, were considered valid. Clinical improvement was calculated using tests of aggressiveness. In each registry with available data and then pooling the means of all patients in the OAS and MOAS, the effect size of DBS (overall and per study) was estimated. Finally, the adapted NOS scale was applied to rate the studies' quality and level of bias.Results In the studies analyzed, 65/100 were pediatric patients, with a mean age of 16.8 years. Most of the studies were conducted in South America and Europe. In all teams, aggressive behavior was intractable, but only 9 groups (53/65) applied specialized scales to measure aggressiveness, and of these, only 51 subjects had a follow-up of at least 12 months. Thus, in 48/51 a clinical improvement of patients was estimated (94.2%), with a considerable overall effect size (OAS: d = 4.32; MOAS: d = 1.46). However, adverse effects and complications were found in 13/65 subjects undergoing DBS. The brain target with the most evidence and the fewest side effects was the posteromedial hypothalamic nuclei (pHypN). Finally, applying the adapted NOS scale, quality, and bias, only 9 studies show the best indicators.Conclusion An optimal level of efficacy was found in only half of the publications. This is mainly due to design errors and irrelevant information in the reports. We believe that DBS in intractable aggressiveness in children and adolescents with ASD and severe ID can be safe and effective if working groups apply rigorous criteria for patient selection, interdisciplinary assessments, objective scales for aggressiveness, and known surgical targets.

Children With PANS May Manifest POTS

Objectives

Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by an abrupt-onset of severe psychiatric symptoms including OCD, anxiety, cognitive difficulties, and sleep issues which is thought to be a post-infection brain inflammatory disorder. We observed postural orthostatic tachycardia syndrome (POTS) which resolved with immunomodulation in a patient with Pediatric acute-onset neuropsychiatric syndrome (PANS). Here, we aim to present a case of POTS and to examine the prevalence of (POTS) in our PANS cohort, and compare the clinical characteristics of patients with and without POTS.

Study Design

We conducted this cohort study of patients meeting PANS criteria who had at least three clinic visits during the study period. We included data from prospectively collected questionnaires and medical record review. We present a case followed by statistical comparisons within our cohort and a Kaplan-Meier analysis to determine the time-dependent risk of a POTS diagnosis.

Results

Our study included 204 patients: mean age of PANS onset was 8.6 years, male sex (60%), non-Hispanic White (78%). Evidence of POTS was observed in 19/204 patients (9%) with 5/19 having persistent POTS defined as persistent abnormal orthostatic vitals, persistent POTS symptoms, and/or continued need for pharmacotherapy for POTS symptoms for at least 6 months). In this PANS cohort, patients with POTS were more likely to have comorbid joint hypermobility (63 vs 37%, p = 0.04), chronic fatigue (42 vs 18%, p = 0.03), and a family history of chronic fatigue, POTS, palpitations and syncope. An unadjusted logistic regression model showed that a PANS flare (abrupt neuropsychiatric deterioration) was significantly associated with an exacerbation of POTS symptoms (OR 3.3, 95% CI 1.4–7.6, p < 0.01).

Conclusions

Our study describes a high prevalence of POTS in patients with PANS (compared to the general population) and supports an association between POTS presentation and PANS flare within our cohort.

The Overt Aggression Scale Modified (OAS-M) for clinical trials targeting impulsive aggression and intermittent explosive disorder: Validity, reliability, and correlates

While aggressive behavior is common, and a disorder of impulsive aggression has been defined in the DSM-5 (Intermittent Explosive Disorder: IED), there are no currently FDA approved interventions to reduce these behaviors. One obstacle to the development of interventions to treat aggression is the paucity of psychometrically valid measures to assess aggressive behavior in the context of clinical trials, especially those in the outpatients setting. While there are many assessment of trait aggression, very few attempt to assess current aggressive behavior over time and/or in individuals not in a closed setting. The Overt Aggression Scale Modified (OAS-M) was developed to fill this void and this paper reviews its development along with presenting new data on its validity, reliability, and correlates with related constructs. Overall, the OAS-M is a valid and reliable measure of state (e.g., week to week) aggression, has good psychometric properties, and shows evidence of change in clinical trials of agents with putative anti-aggressive efficacy.

Assessing aggression following Acquired Brain Injury (ABI): a systematic review of assessment measures

Objective: To conduct a systematic review to identify and examine the reliability and validity of standardized measures used to assess aggression in people with ABI. Data sources: Systematic searches of PsychInfo, Medline, Embase, PubMed and CINAHL databases along with hand searching of gray literature and review articles. Study selection: Studies were included if the sample had an ABI, and the measure included assessment of aggression. Data extraction: Sample and measure characteristics and psychometric properties were extracted. Measure quality was assessed using the COSMIN checklist. Data synthesis: Of 5,100 abstracts screened, 78 were reviewed in full against the inclusion and exclusion criteria, and 25 articles met the criteria for analysis. Included articles assessed the psychometric properties of 17 different measures of aggression in adults with ABI. Quality of evidence was often low. Four measures (MBPC-1990R, NFI, SASNOS and KSMS) demonstrated positive evidence of at least one psychometric property with good quality evidence. Conclusions: Although a large number of general measures were available, there are few measures that only assess post-ABI aggression, and many are not well-validated. Future research should assess the psychometric properties of these measures.

Prevalence and characteristics of neuropsychiatric symptoms, quality of life and psychotropics in people with acquired brain injury in long-term care

Aim

Establishing the prevalence of neuropsychiatric symptoms (NPS), quality of life and psychotropic drug use in people aged ≤65 years with acquired brain injury in nursing homes.

Design

Cross‐sectional, observational study among patients aged 18–≤65 years with acquired brain injury admitted to special care units in Dutch nursing homes.

Methods

According to the Committee on Research Involving Human Subjects in January 2017 this study did not require ethics approval. Nursing homes will be recruited through the national acquired brain injury expertise network for patients with severe brain injury, the regional brain injury teams and by searching the internet. Patient characteristics will be collected through digital questionnaires. Neuropsychiatric symptoms will be assessed with the NeuroPsychiatric Inventory‐Nursing Home version, the Cohen–Mansfield Agitation Inventory and the St. Andrews Sexual Behaviour Assessment; cognition with the Mini‐Mental State Examination, quality of life with the Quality of Life after Brain Injury Overall Scale and activities of daily living with the Disability Rating Scale. Medication will be retrieved from the electronic prescription system. Data collection commenced in 2017 and will be followed by data analysis in 2019. Reporting will be completed in 2020.

Discussion

Little is known about NPS among patients with acquired brain injury in nursing homes. In patients up to the age of 65 years, only six studies were found on prevalence rates of NPS.

Impact

Patients with severe acquired brain injury experience lifelong consequences, that have a high impact on them and their environment. Although there is increasing attention for the survival of this vulnerable group of patients, it is also important to enlarge awareness on long‐term consequences, specifically the NPS, quality of life and psychotropic drug use in acquired brain injury. Insight into the magnitude of these issues is necessary to achieve appropriate care for these patients.

Correlates and Prevalence of Aggression at Six Months and One Year After First-Time Traumatic Brain Injury

Few studies have examined clinical correlates of aggression after first-time traumatic brain injury (TBI) within the first year after injury. The authors aimed to identify the rates of aggression at 6 and 12 months post-TBI and establish clinical and demographic correlates. A total of 103 subjects with first-time TBI were seen within 12 months postinjury and evaluated for aggression. Post-TBI social functioning and new-onset depression (within 3 months of the TBI) may serve as particularly important predictors for aggression within the first year of TBI, as these factors may afford intervention and subsequent decreased risk of aggression.

The relational neurobehavioral approach: can a non-aversive program manage adults with brain injury-related aggression without seclusion/restraint?

PURPOSE

The Relational Neurobehavioral Approach (RNA) is a set of non-aversive intervention methods to manage individuals with brain injury-related aggression. New data on interventions used in the RNA and on how the RNA interventions can be used with patients with acquired brain injury (ABI) who have differing levels of functional impairment are provided in this paper.

METHOD

The study was conducted over a 6-week period in a secure 65-bed program for individuals with ABI that is housed in two units of a skilled nursing facility (SNF). Implementation of the RNA was compared between two units that housed patients with differing levels of functional impairment (n = 65 adults). Since this was a hierarchical clustered dataset, Generalized Estimating Equations regression was used in the analyses.

RESULTS

RNA interventions used to manage the 495 aggressive incidents included the following: Aggression ignored, Closer observation, Talking to patient, Reassurance, Physical distraction, Isolation without seclusion, Immediate medication by mouth, Holding patient. Different interventions were implemented differentially by staff based on level of functional impairment and without use of seclusion or mechanical restraint.

CONCLUSIONS

The RNA can be used to non-aversively manage aggression in patients with brain injury and with differing levels of functional impairment. Programs adopting the RNA can potentially manage brain injury-related aggression without seclusion or mechanical restraint. Implications for Rehabilitation The Relational Neurobehavioral Approach (RNA) is a set of non-aversive intervention methods to manage individuals with brain injury-related aggression. RNA methods can be used to manage aggression in patients with brain injury who have differing levels of functional impairment. Successful implementation of the RNA may allow for the management of brain injury-related aggression without seclusion or mechanical restraint.

What can structured professional judgement tools contribute to management of neurobehavioural disability? Predictive validity of the Short-Term Assessment of Risk and Treatability (START) in acquired brain injury

Aggression is a frequently cited outcome of acquired brain injury (ABI). Paradoxically, evidence suggests that ABI clinicians underestimate the risk of violence, and aggression in neurobehavioural services appears more frequent than in forensic/secure psychiatric settings. Risk assessment tools are endemic in the latter and highly beneficial in managing harm. However, none has been validated for ABI. This study examines the predictive validity of ABI violence using one established tool, the Short-Term Assessment of Risk and Treatability (START). It is argued that successful management of aggression in neurobehavioural rehabilitation is partly attributable to ongoing programme calibration following regular review of measures conceptualised for ABI. The predictive ability of START and ABI measures was determined through correlational, receiver operating characteristic and hierarchical multiple regression analyses, using 4559 aggression recordings concerning 76 patients over 4 weeks. The START risk of violence was classed "low" for 50% of the sample and "high" for 13.7%. Significant relationships between individual measures and aggression were evident. However, multivariate analysis confirmed that the best fitting model comprised ABI measures of neurobehavioural disability and functional abilities: START data did not increase explained variance. ABI risk prediction may benefit from development of specific tools. However, these should be conceptualised for ABI to incorporate the diverse range of variables underpinning neurobehavioural disability.

Patient Aggression in Real Time on Geriatric Inpatient Units

This study focused on verbal and physical aggression against nursing staff, in real time, by elderly patients. The aggressive incidents were recorded at the end of each shift when they were more likely to be accurately remembered. Before beginning the study, nursing staff were taught how to use the Modified Overt Aggression Scale (MOAS) to identify aggressive acts. High rates of verbal and physical aggression among the elderly were observed by nurses, and data show that 75% of nursing staff experienced aggression on their shift. They either experienced aggression themselves or observed aggression on every single shift; that is at least five violent incidents in a work-week. Even if one is not the target of aggression, such observation is associated with elevated levels of stress.

Staff-reported antecedents to aggression in a post-acute brain injury treatment programme: what are they and what implications do they have for treatment?

Research in psychiatric settings has found that staff attribute the majority of inpatient aggression to immediate environmental stressors. We sought to determine if staff working with persons with brain injury-related severe and chronic impairment make similar causal attributions. If immediate environmental stressors precipitate the majority of aggressive incidents in this client group, it is possible an increased focus on the management of factors that initiate client aggression may be helpful. The research was conducted in a low-demand treatment programme for individuals with chronic cognitive impairment due to acquired brain injury. Over a six-week period, 63 staff and a research assistant reported on 508 aggressive incidents. Staff views as to the causes of client aggression were elicited within 72 hours of observing an aggressive incident. Staff descriptions of causes were categorised using qualitative methods and analysed both qualitatively and quantitatively. Aggression towards staff was predominantly preceded by (a) actions that interrupted or redirected a client behaviour, (b) an activity demand, or (c) a physical intrusion. The majority of aggressive incidents appeared hostile/angry in nature and were not considered by staff to be pre-meditated. Common treatment approaches can be usefully augmented by a renewed focus on interventions aimed at reducing antecedents that provoke aggression. Possible approaches for achieving this are considered.

Rehabilitation Approaches to the Management of Aggressive Behaviour Disorders after Acquired Brain Injury

Symptoms of neurobehavioural disability acquired through brain injury, especially aggression, are associated with severe social handicap. Differences in terminology have resulted in varying estimates, but aggressive behaviour disorder appears to be characteristic of survivors at some point in their recovery journey. This paper provides a brief review regarding the prevalence, development and causes of aggression associated with acquired brain injury (ABI), and what can be done to help manage them. The advantages of using standardised measures conceptualised for ABI in the assessment and formulation of aggressive behaviour disorders are especially highlighted. A range of treatment methods and the evidence base relating to these are described. The contribution of pharmacological therapies, cognitive behavioural therapy and behavioural interventions are explored. It is argued that the strongest evidence base is associated with behaviour therapy, especially when carried out in the context of neurobehavioural rehabilitation, and two case studies are described to illustrate the clinical advantages of interventions derived from operant theory. Comparative lack of ABI experts trained in the management of post-acute behaviour disorders remains a limiting factor.

Potential severity of aggressive behaviour after acquired brain injury: implications for recording

Aggression is a consequence of acquired brain injury that may necessitate admission to neurobehavioural services. The 'Overt Aggression Scale - Modified for Neurorehabilitation' (OAS-MNR) is a valid, reliable means of capturing this. A criticism of observational rating scales is they do not reflect factors like intent to harm which results in recording anomalies. 'Attacks' has been proposed as a measure which achieves this within psychiatric settings. Principal goals of this study are to determine the usefulness of measuring similar concepts in neurobehavioural services and further validating both scales. A total of 1066 physical assaults were recorded in 6 weeks by 25 patients in an inpatient neurobehavioural programme using the OAS-MNR. Fifty incidents were also rated on Attacks. Convergent validity for using both measures in neurobehavioural services was found. Modifying OAS-MNR severity scores using one of two factors found to underlie Attacks produced an index that successfully discriminated incidents whose risk necessitated more intrusive intervention, which was not evident otherwise. Modifying scores that objectively reflect severity of physical assaults using measures of perceived intent should be a feature of observational recording scales such as the OAS-MNR. Ensuring robust inter-rater reliability will be essential in any development work.

The effects of enhanced program review and staff training on the management of aggression among clients in a long-term neurobehavioral rehabilitation program

OBJECTIVE

This article examined the effects of staff training, staff support groups, and increased client behavior monitoring on the rate of physical aggression toward peers and objects in an older neurobehavioral population treated in a long-term neurorehabilitation program.

METHODS

During the 15 months of data collection, programmatic enhancements were introduced including: Staff training and support groups, comprehensive assessment and individualized program development, and client-centered weekly and systemic monthly behavior management review. Incidents of physical aggression were assessed using staff report. Data were corroborated using multiple sources including, medical records, written incident reports, and Overt Aggression Scale-Modified for Neurorehabilitation - Extended (OAS-MNR-E).

RESULTS

A total of 267 clients were present in the facility during the reporting period. The clients had neurobehavioral disability of various origins, 73% had a psychiatric diagnosis in addition to one or more medical diagnoses, and 58% had a dementia diagnosis. An already low rate of incidents of physical aggression per client month (0.02) was reduced by 77% following the implementation of programmatic enhancements.

CONCLUSION

Enhanced systematic behavioral review of clients provided concurrently with staff training in non-aversive principles and ongoing staff support groups reduced the incidents of behavioral disregulation in older persons with psychiatric diagnoses, medical comorbidities, and neurobehavioral disabilities.