Descriptive analysis of challenging behaviours shown by adults with acquired brain injury

The Efficacy and Harms of Pharmacological Interventions for Aggression After Traumatic Brain Injury-Systematic Review

Background: Aggression is a commonly reported problem following traumatic brain injury (TBI). It may present as verbal insults or outbursts, physical assaults, and/or property destruction. Aggressive behavior can fracture relationships and impede participation in treatment as well as a broad range of vocational and social activities, thereby reducing the individual's quality of life. Pharmacological intervention is frequently used to control aggression following TBI. The aim of this systematic review was to critically evaluate the evidence regarding efficacy of pharmacological interventions for aggression following TBI in adults.

Methods: We reviewed studies in English, available before December 2018. MEDLINE, PubMed, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched, with additional searching of key journals, clinical trials registries, and international drug regulators. The primary outcomes of interest were reduction in the severity of aggression and occurrence of harms. The secondary outcomes of interest were changes in quality of life, participation, psychological health (e.g., depression, anxiety), and cognitive function. Evidence quality was assessed using the Cochrane Risk of Bias tool and the Joanna Briggs Institute Critical Appraisal Instruments.

Results: Ten studies were identified, including five randomized controlled trials (RCTs) and five case series. There were positive, albeit mixed, findings for the RCTs examining the use of amantadine in reducing irritability (n = 2) and aggression (n = 2). There were some positive findings favoring methylphenidate in reducing anger (n = 1). The evidence for propranolol was weak (n = 1). Individual analysis revealed differential drug response across individuals for both methylphenidate and propranolol. The less rigorous studies administered carbamazepine (n = 2), valproic acid (n = 1), quetiapine (n = 1), and sertraline (n = 1), and all reported reductions in aggression. However, given the lack of a control group, it is difficult to discern treatment effects from natural change over time.

Conclusions: This review concludes that a recommendation for use of amantadine to treat aggression and irritability in adults following TBI is appropriate. However, there is a need for further well-designed, adequately powered and controlled studies of pharmacological interventions for aggression following TBI.

Understanding Australian Community ABI Therapists’ Preferences for Training in and Implementing Behaviour Interventions: A Focus on Positive Behaviour Support

Objective:

Individuals with acquired brain injury (ABI) may experience persistent and distressing challenging behaviours (CB), and therefore, effective delivery of behaviour interventions is crucial. This study aimed to investigate community ABI therapists’ experiences of using, training in and implementing behaviour interventions with a focus on Positive Behaviour Support (PBS).

Methods:

A sample of Australian community ABI therapists (n = 136) completed an online survey about their experiences with behaviour interventions, including PBS. Data from open-ended questions were analysed using content analysis. Frequency and descriptive statistics were computed, and a multiple regression was performed to determine factors predicting readiness to learn and implement new behaviour interventions. Rank-based non-parametric tests were conducted to investigate the influence of clinical role on experiences with behaviour interventions and training preferences.

Results:

Consistent with PBS, participants indicated that the following were important in addressing CB: teamwork and collaboration, person-centred practice, working with antecedents, environmental modification, improving quality of life and skill-building. Despite a high level of desire and readiness, 80% of participants reported facing barriers to learning and implementing new behaviour interventions (e.g., lack of time). Participants’ confidence in using behaviour interventions (β = 0.31; p = 0.002) and the number of barriers faced (β = −0.30; p = 0.002) predicted their readiness to learn and implement new behaviour interventions. Confidence, duration of past training in behaviour interventions and preferred duration of future training did not differ based on clinical role.

Conclusion:

Implications for the development of training in behaviour interventions such as PBS and implementation into community practice are discussed.

Brain injury, behaviour support, and family involvement: putting the pieces together and looking forward

Purpose: (1) to provide insight into the family's experience and support needs following acquired brain injury (ABI) specific to behavioural changes; (2) to provide an overview of empirically-based behaviour support approaches for individuals with ABI; and (3), to examine family involvement in implementing behavioural interventions.Methods: Review of the literature.Results: Family members experience significant distress resulting from neurobehavioural changes in relatives with ABI, and report unmet informational and practical support needs regarding this issue. The importance of utilising family expertise within the rehabilitation process is widely acknowledged, with the increasing involvement of family members being promoted. There is growing evidence supporting the use of positive behaviour support approaches for individuals with ABI in community settings, and evidence supporting the involvement of family within behavioural interventions.Conclusions: This review suggests the need to develop alternative support models that shift the focus towards building competence in everyday support people rather than dependency on the service system. A bottom-up approach is recommended, with the aim of addressing unmet support needs and increasing the competence of family members in supporting behaviour change in individuals with ABI. Recommendations are provided in informing an optimal community-based neurobehavioural support model. Implications for RehabilitationPositive behaviour support is recommended in supporting behavioural changes following brain injury, with family expertise utilised in this process.Evidence suggests that family members can be effectively trained in developing and implementing behaviour support strategies.Family involvement in behavioural interventions may address unmet support needs and increasing the competence of family members in supporting behavioural changes following brain injury.

Effect of distance caregiver coaching on functional skills of a child with traumatic brain injury

OBJECTIVE

To assess the effect of distance caregiver coaching on skill acquisition of a child with traumatic brain injury. Interactions between caregivers and persons with brain injury may play a critical role in the rehabilitation process, and coaching caregivers is one method that may foster more positive functional outcomes for the individual as caregiver skills may generalize across domains.

METHOD

This study utilised a single-subject, multiple baseline across behaviours design to examine the effects of caregiver behaviours on skill acquisition by a child with a traumatic brain injury. The caregiver-client dyad in this study was a mother and her 10-year-old adopted child. The caregiver was coached using telehealth technology. Distance coaching consisted of in-vivo feedback on the caregiver's use of general behaviour analytic skills, such as use of effective prompting and positive social consequences, while engaging with the child with a brain injury.

CONCLUSION

Improvements in the child's independent task completion across three functional skills were observed, as a function of improvements in the caregiver's skills.

The lived experience of behaviours of concern: A qualitative study of men with traumatic brain injury

BACKGROUND AND AIMS

Behaviours of Concern (BoC) are a debilitating consequence of Traumatic Brain Injury (TBI). Whilst perspectives of clinicians, carers and family members on BoC have been previously explored, few qualitative studies have included individuals with TBI. The aim of this study was to explore the lived experience of BoC in individuals with TBI, their close others and clinicians.

METHOD

Eleven males with TBI and BoC were recruited and 25 semi-structured qualitative interviews were conducted (9 individuals with TBI, 9 close others, 7 clinicians). A six-phase thematic analysis approach was utilised.

RESULTS

Frequent and persistent BoC were reported and the key themes identified included the brain injury, control, environment, mood, identity, social relationships, and meaningful participation. Whilst the brain injury contributed to BoC in all cases, the way the other themes manifested and interacted was variable.

CONCLUSIONS

This study enriches our understanding of factors associated with BoC. Themes emerging from this study will inform interventions designed to reduce BoC and ultimately maximise quality of life for individuals with TBI and their families.

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.