Search

A complexity of biological, psychological, environmental and systemic factors influences a child's adaption after acquired brain injury (ABI), all of which transform as the child matures. Multidisciplinary rehabilitation teams are challenged by balancing family system needs and the child's needs, whilst promoting the child's functional skills in difficult or unappealing tasks. This paper presents the conceptual basis for a model for use in childhood ABI neurorehabilitation to address these challenges. A non-systematic narrative review of literature pertinent to integrated neurorehabilitation of pediatric ABI was conducted. Contemporary models of adult and pediatric psychosocial adaptation involving identity following ABI were reviewed. Key findings were then synthesized with models of pediatric resilience and self-concept development. The resulting model describes a cyclical adaptation process whereby the child learns experientially about their self and their world after ABI. Processes of identity development play a central role - particularly emotive processes of self-evaluation - by influencing the child's motivation for participation, tolerance for challenge, self-regulation and emerging self-awareness. The model directs clinicians to use the psychosocial processes of identity development to enhance the child's willingness and capacity to engage in the daily challenges of rehabilitation. Further systematic development and evaluation of the model is needed.

This study explored the process of identity adjustment following adolescent brain injury, within the systemic context of the parent–adolescent dyad. Six young people with an ABI (mean age 16.5 years, range 15–18 years; TBI: n = 3) were individually interviewed, and six respective mothers (mean age 45 years, range 37–50 years). A novel relational qualitative grounded theory approach was used, with analyses of dyads linked in an attempt to capture the shared process of adaptation post-injury for young people and their parents. Shared themes emerged for adolescents and mothers regarding “continuity and change” and “acknowledging or rejecting” experiences of change post injury. Adolescents experienced change as an, at times, distressing sense of being “not normal”. While mothers turned towards their child, working hard to try to “fix everything”, adolescents sought continuity of identity in the context of peer relationships, withdrawing socially to avoid feeling abnormal, reframing or finding new relationships. Some mothers sought to fill social losses through family or disability-specific activity. This study provides a relational understanding of the process of identity adjustment post adolescent BI. Future research and clinical practice should recognize the significant work of mothers, and significance of social relationships to adolescents’ emerging post-injury identity.

It has been suggested that cognitive behavioural therapy for older adults be augmented with age-appropriate methods to enhance outcomes for depression treatment.This study investigated whether a CBT wisdom enhancement timeline technique for older adults reduced depression, as well as increase self-compassion and self-assessed wisdom.AnSix participants competed the study and were subject to standardised and single-case data analyses. Four participants were deemed responders with reliable changes in depression post-intervention with idiographic changes coinciding with intervention onset. Two participants saw clinically significant changes in depression scores at follow-up. One responder saw significant changes in measures of self-compassion and self-assessed wisdom.The examined technique shows promise as an effective technique for reducing depression in older adults. There is insufficient evidence to implicate wisdom and/or self-compassion as significant mechanisms of change. Clinical and theoretical implications are discussed.

Background Traumatic brain injury has a significant effect on uninjured family members. Typically, this has been examined with a focus on psychopathological outcomes including stress, depression and anxiety. However, in recent years there has been increasing interest in the subjective experiences of families post-injury leading to a plethora of qualitative studies. Therefore, an in-depth examination and synthesis of this literature is now relevant and timely. Objective To examine the subjective experiences of families following traumatic brain injury in adult populations in the sub/post-acute period through the synthesis of original qualitative research. Design This paper presents a meta-synthesis using Thomas and Harden's framework of ‘thematic synthesis’ rooted in a critical realist philosophy. Data sources In July 2019 five electronic databases, were searched for the terms ‘traumatic brain injury’, ‘family’ and ‘qualitative’. Studies were included if the primary research reported qualitative data about the subjective experiences of family members of adults with traumatic brain injury and had been published in a peer reviewed journal. Studies with mixed brain injury samples, child or adolescent traumatic brain injury or disorders of consciousness were excluded. Hand searching and citation searches were also completed. Review methods Two reviewers screened titles, abstracts and full text and reached consensus through critical discussion. Thirty papers were finally agreed for inclusion in this review. Each study was then assessed for relevance, resonance and rigour using the Critical Appraisal Skills Programme (CASP) tool. Line by line coding of the findings in each paper was conducted as the basis for a thematic analysis and synthesis. Results Descriptive themes were identified followed later by analytical themes. This final stage was informed by a narrative lens and from these, eight narrative functions belonging to four dimensions were identified from the subjective experiences of families post-traumatic brain injury. Specifically, these were: (1) Displacing and Anchoring; (2) Rupturing and Stabilising; (3) Isolating and Connecting; (4) Harming and Healing. Conclusions The interpretation of the narrative functions revealed the substantial existential work involved in negotiating lives, maintaining family system equilibrium and moving forward. As such, family members have their own unique narrative needs. Despite contemporary service models built around the injured person, service providers are well placed to support families in this everyday narrative work through actively attending to narrative structures and understanding the implications of these for family experience. The study protocol was registered with PROSPERO (International prospective register of systematic reviews) in July 2018 (Registration number: CRD42018085824). Tweetable abstract: This synthesis showed the immense and invisible work required for family members to maintain family system equilibrium and negotiate their lives post-TBI.

The Bangor Gambling Task (BGT, Bowman & Turnbull, 2004) is a simple test of emotion-based decision-making, with contingencies varying across five blocks of 20 trials. This is the first study to characterise BGT performance in survivors of traumatic brain injury (TBI) relative to healthy controls. The study also aimed to explore sub-groups (cluster analysis), and identify predictors of task performance (multiple regression). Thirty survivors of TBI and 39 controls completed the BGT and measures of premorbid IQ, working memory, and executive function. Results showed that survivors of TBI made more gamble choices than controls (total BGT score), although the groups did not significantly differ when using a cut-off score for ‘impaired’ performance. Unexpectedly, the groups did not significantly differ in their performance across the blocks, however, the cluster analysis revealed three subgroups (with survivors of TBI and controls represented in each cluster). Findings also indicated that age and group were significant predictors of overall BGT performance, but not gender, premorbid IQ, or working memory and executive function. In conclusion, the study findings are consistent with an individual differences account of emotion-based decision-making, and a number of issues need to be addressed prior to recommending the clinical use of the BGT.

BACKGROUND: Outcome measurement challenges rehabilitation services to select tools that promote stakeholder engagement in measuring complex interventions. OBJECTIVES: To examine the suitability of outcome measures for complex post-acute acquired brain injury (ABI) rehabilitation interventions, report outcomes of a holistic, neuropsychological ABI rehabilitation program and propose a simple way of visualizing complex outcomes. METHODS: Patient/carer reported outcome measures (PROMS), experience measures (PREMS) and staff-rated measures were collected for consecutive admissions over 1 year to an 18-week holistic, neuropsychological rehabilitation programme at baseline, 18 weeks and 3- and 6-month follow-up. RESULTS: Engagement with outcome measurement was poorest for carers and at follow-up for all stakeholders. Dependence, abilities, adjustment, unmet needs, symptomatology including executive dysfunction, and self-reassurance showed improvements at 18 weeks. Adjustment, social participation, perceived health, symptomatology including dysexecutive difficulties, and anxiety were worse at baseline for those who did not complete rehabilitation, than those who did. A radar plot facilitated outcome visualization. CONCLUSIONS: Engagement with outcome measurement was best when time and support were provided. Supplementing patient- with staff-rated and attendance measures may explain missing data and help quantify healthcare needs. The MPAI4, EBIQ and DEX-R appeared suitable measures to evaluate outcomes and distinguish those completing and not completing neuropsychological rehabilitation.

This paper provides a commentary on Salas and Yuen (this issue) who propose a revision to the ‘left convexity hypothesis’ of Kaplan-Solms and Solms, that there is no evidence for involvement of left hemisphere regions in the mental apparatus. Salas and Yuen provide a theoretical review and detailed clinical description that forms the basis for their argument that left dorso-medial frontal regions may be involved in ego regulation of emotion. In this commentary, the theoretical basis for Salas and Yuen’s argument is considered in light of cognitive and affective neuroscience models of emotion regulation. Whilst this commentary is supportive of Salas’ and Yuen’s position, the models discussed distinguish different roles of inner language associated with labeling and reappraisal, or with distancing or shifting of inner perspective. However this clinical, theoretical and empirical extension of Salas and Yuen’s position raises further questions regarding the role and nature of inner language with regard to the experience and regulation of emotion.

Purpose – Clinically significant childhood acquired brain injury (ABI) is associated with increased risk of emotional and behavioural dysfunction and peer relationship problems. The purpose of this paper is to determine how emotional and peer related problems for children with ABI compare with those of children referred to mental health services, and to identify clinical predictors of peer relationship problems in a heterogeneous sample typical of a specialist community rehabilitation setting. Design/methodology/approach – Participants were 51 children with clinically significant ABI (32 traumatic brain injury; 29 male) referred for outpatient neuropsychological rehabilitation. Emotional, behavioural and social outcomes were measured using the Strengths and Difficulties Questionnaire (SDQ), and executive functioning was measured with the Behaviour Rating Inventory of Executive Functions. Correlational analyses were used to explore variables associated with peer relationships. A subgroup (n=27) of children with ABI were compared to an age and sex matched mental health group to determine differences on SDQ subscales. Findings – The SDQ profiles of children with clinically significant ABI did not significantly differ from matched children referred to mental health services. Time since injury, peer relationship problems, metacognitive, and behavioural problems correlated with age at injury. These variables and SDQ emotional problems correlated with peer relationship problems. Linear multiple regression analysis indicated that only metacognitive skills remained a significant predictor of peer relationship problems, and metacognitive skills were found to significantly mediate between age at injury and peer relationship problems. Research limitations/implications – The study confirms the significant effect of childhood ABI on relationships with peers and mental health, those injured at a younger age faring worst. Within the methodological constraints of this study, the results tentatively suggest that age of injury influences later peer relationships via the mediating role of poor metacognitive skills within a heterogeneous clinical sample. Originality/value – This is the first study to examine the roles of emotional, behavioural and executive variables on the effect of age at injury on peer relationship problems in a sample with a wide range of ages and ages of injury.

Purpose – Needs of people following acquired brain injury vary over their life-course presenting challenges for community services, especially for those with “hidden” neuropsychological needs. Characterisation of subtypes of rehabilitation service user may help improve service design towards optimal targeting of resources. This paper aims to characterise a neuropsychologically complex group of service users. Design/methodology/approach – Preliminary data from 35 participants accepted for a holistic neuropsychological rehabilitation day programme were subject to cluster analysis using self-ratings of mood, executive function and brain injury symptomatology. Findings – Analysis identified three clusters significantly differentiated in terms of symptom severity (Cluster 1 least and Cluster 2 most severe), self-esteem (Clusters 2 and 3 low self-esteem) and mood (Cluster 2 more anxious and depressed). The three clusters were then compared on characteristics including age at injury, type of injury, chronicity of problems, presence of pre-injury problems and completion of rehabilitation. Cluster 2 were significantly younger at time of injury, and all had head injury. Research limitations/implications – Results suggest different subgroups of neuropsychological rehabilitation service user, highlighting the importance of early identification and provision of rehabilitation to prevent deterioration, especially for those injured when young. Implications for design of, and research into, community rehabilitation service design for those with “hidden disability” are considered. Originality/value – The paper findings suggests that innovative conceptual frameworks for understanding potentially complex longer term outcomes are required to enable development of tools for triaging and efficient allocation of community service resources.

Delivering effective psychotherapy to address the significant emotional consequences of acquired brain injury (ABI) is challenged by the presence of acquired cognitive impairments, especially retrieval of detailed autobiographical memories of emotional trigger events. Initial studies using a wearable camera (SenseCam) suggest long-term improvements in autobiographical retrieval of recorded events. In this study a single-case experimental design was implemented to explore the use of SenseCam as a memory aid for a man with a specific anxiety disorder and memory and executive difficulties following ABI. We predicted that SenseCam supported rehearsal of memories of events that trigger high levels of anxiety would yield improved retrieval of both factual detail and internal state information (thoughts and feelings) compared with a conventional psychotherapy aid (automatic thought record sheets, ATRs) and no strategy. The findings indicated SenseCam supported retrieval of anxiety trigger events was superior to ATRs or no strategy in terms of both detail and internal state information, with 94% of the information being recalled in the SenseCam condition, compared to 39% for the "no strategy" and 22% for the ATR conditions. It is concluded that SenseCam may be of use as a compensatory aid in psychotherapies relying on retrieval of emotionally salient trigger events.

A complex and dynamic set of biological, psychological and social factors interact to determine the consequences of acquired brain injury (ABI). This has led to recognition of the need for an integrated biopsychosocial approach to assessment, formulation and rehabilitation after ABI, drawing on multiple methods and models. This presents a significant challenge for the development and evaluation of complex rehabilitation programmes that may involve multiple interventions. In psychotherapy research, such problems are addressed through an approach which emphasises theoretical modelling of the disorder from which treatment programmes are developed and then evaluated. The resulting outcome studies, in which theoretically grounded change processes are measured, thus provide not only a test of the efficacy of the intervention but also an empirical evaluation of the underpinning model. In this paper we advocate such an approach to ABI rehabilitation, and to this end propose a model of the change process in rehabilitation called the "Y-shaped" model. This integrates findings from research into psychosocial adjustment, awareness and well-being following brain injury. The notion of discrepant or threatened identity is central to the model. Specific interventions are identified from the model, along with processes and interactions that may be central to change in rehabilitation. In conclusion, we propose that development of integrated models of change in rehabilitation is required. We also note that outcome should focus not only on level of activity or social participation, but also on the personal meaning of this to the person with brain injury.

There is a growing body of literature on the nature of subjective changes experienced following brain injury. This study employs personal construct and qualitative research methods to address the question of how people make sense of, or construe, themselves after brain injury. Thirty-two individuals who had experienced acquired brain injury engaged in small group exercises based on a personal construct approach. Bipolar constructs were elicited through systematic comparison of pre-injury, current and ideal selves. The constructs elicited in this way were subjected to a thematic analysis. Nine themes were derived and an acceptable level of reliability of the definitions of these themes achieved. The highest proportion of constructs fell into the theme "experience of self in the world", followed by "basic skills" (cognitive, sensory, physical, social) and "experience of self in relation to self". It is concluded that following brain injury, people make sense of themselves in terms of the meanings and felt experiences of social and practical activity. This is consistent with social identity theory and stands in contrast to traditional neuropsychological sense making in terms of impairments and abilities alone, or activity or social participation alone. The implications of these findings for future research and rehabilitation are briefly considered.

Successful cognitive and behavioural therapies for anxiety disorders in separate cases of acquired brain injury and seizure disorder have been reported although evidence of efficacy is limited. This paper describes the presentation and cognitive-behavioural therapy (CBT) of seizure-related panic symptoms in the context of subarachnoid haemorrhage and cavernoma. Multidisciplinary clinical assessment was conducted and 12 sessions of CBT according to the model of Clark (1986) were delivered. Outcome was measured in terms of goal attainment, belief ratings of target cognitions and completion of standardised questionnaire measures pre and post-treatment. Process was measured through client's ratings of anxiety-related beliefs through treatment. The client attained all goals, eliminated avoidance and other unhelpful coping behaviour, and rated reduced levels of anxiety on a standardised measure. Changes in identified target cognitions were also evident. It is concluded that a cognitive-behavioural approach may be helpful in understanding and treating anxiety disorders where symptom presentation is complicated by neurological problems. Further investigation of the relationship between development of anxiety disorders, occurrence of neurological events, and processes of CBT following acquired brain injury is suggested.

Primary objective: To evaluate the factor structure of the Hospital Anxiety and Depression Scale (HADS) as a mood assessment in a sample of individuals with acquired brain injury (ABI).Research design: Cohort study.Methods and procedures: HADS data from 140 people with ABI was subjected to principle components analysis (PCA).Experimental interventions: None.Main outcomes and results: A three-factor solution emerged. Items loading on the first two factors map on to the anxiety and depression scales. However, two items from the depression sub-scale did not load significantly on either of these two main factors. Possible reasons are discussed.Conclusions: This study suggests that the HADS is a useful tool for examining depression and anxiety in a brain injured population, but interpretation of responses to some items should be cautious.

This study reports on the case of a young woman who, at the age of 26, developed a severe encephalomyelopathy and was in a vegetative state or minimally conscious state for 6 months. She showed a sleep-wake cycle, but no evidence of cognitive functioning. Six months after her illness, she began to respond to her environment and eventually returned home to the care of her parents, with regular periods of respite care in a home for people with severe physical disabilities. She remains in a wheelchair with a severe dysarthria and communicates via a letter board. Two years after her illness, staff at the home requested an assessment of her cognitive functioning. On the WAIS-R verbal scale and the Raven's Progressive Matrices, the woman's scores were in the normal range. So too were her recognition of real versus nonsense words and her memory functioning (apart from a visual recognition memory test which was in the impaired range). Although she enjoyed the tests, she became distressed when asked about her illness and previous hospitalization. She was reassessed 1 year later, when there were few significant changes in her test scores but she could talk about her illness and hospitalization without becoming distressed. She was angry, however, about her experiences in the first hospital. Further tests suggested good executive functioning. In short, this woman's cognitive functioning is in the normal range for most tasks assessed, despite a severe physical disability and dysarthria, and despite the fact that she was vegetative for 6 months. Although some recovery following 6 months of being vegetative/minimally conscious is not unknown, it is rare, particularly for those with non-traumatic injuries, and the majority of people similarly affected remain with significant cognitive deficits. This client has, by and large, made an almost complete cognitive recovery. She feels positive about her life now and says the formal assessment showed people she was not stupid and this made her happy. The paper concludes with the young woman's own comments and views about what happened to her and her present feelings.