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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.

Emotionalism can develop following a range of neurological disorders; however the aetiology of emotionalism is still unclear. To identify anatomical, neuropsychological and psychological predictors and correlates of emotionalism across neurological disorders: stroke, Parkinson’s disease, multiple sclerosis, traumatic brain injury, Alzheimer’s disease, vascular dementia and amyotrophic lateral sclerosis. To explore if these predictors and correlates of emotionalism differ across neurological disorders. A comprehensive systematic search was completed of four databases: MEDLINE, CINAHL Complete, PsycINFO and EMBASE. Methodological quality was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and each study was graded according to the level of evidence using the Scottish Intercollegiate Guidelines Network. Fifty papers (participants N = 1922) were included. 25 studies were rated as “Fair,” 21 “Good” and 4 “Poor.” The review identified predictors and correlates found in several neurological disorder such as bulbar networks, serotonergic pathways, genetics and female gender. Multiple studies across diseases (stroke, MS, ALS) indicate emotionalism is associated with cognitive impairment, especially frontal deficits. Due to the disproportionate number of studies identified across neurological disorders, it is difficult to draw definitive answers. Further research is required across neurological disorders to explore similarities and differences in anatomical, neuropsychological and psychological predictors and correlates.

Objectives Posttraumatic growth (PTG) is of increased theoretical and clinical interest. However, less is known about PTG in older adults specifically. This systematic review aimed to identify domains where PTG is studied for older adults; investigate factors associated with PTG in older adults; consider how these might differ between historical and later life traumas. Methods Online databases were searched for quantitative studies examining PTG outcomes in adults aged >= 60 years. Results 15 studies were subject to a narrative synthesis. Conclusions Older adults can experience substantial levels of PTG, from traumas during later life or across the lifespan, and historical wartime traumas. Traumas can be diverse, some studies found equivalent levels of PTG from different traumas across the lifespan. Social processes may be a key variable for older adults. Additional psychosocial factors are found; however, diverse findings reflect no overall model, and this may be consistent with variations found in other PTG literature. Clinical Implications Clinical considerations are discussed. As diverse studies, findings may not be widely generalizable and directions for further research are highlighted. PROSPERO: CRD42020169318.

The experiences of family members following Acquired Brain Injury (ABI) are well established, with spouses in particular facing multiple relational and personal changes. Qualitative studies have analysed accounts pertaining to a range of sequelae, however, "change" itself has yet to be addressed. This study explored the experiences of realisation of change for married women living with their husbands following ABI. Nine participants took part in semi-structured interviews focussing on becoming aware of changes in both their spouse and themselves post-injury. An Interpretative Phenomenological Analysis (IPA) was completed, arriving at two overarching themes; "bravery to face changes" and "lost and trapped in an unsolvable maze," with accompanying subthemes. Participants generally experienced realisation of change gradually, in some cases finding strategies to control their exposure to distress. They often referred to "acceptance," which held varied meanings, and metaphors appeared to aid personal meaning making. Relationship changes generated both dilemmas and the feeling of being trapped. Overall, this study contributes greater insights into the experiential mechanisms underpinning realisation of change in spouses after brain injury.

Purpose Post-stroke emotionalism (PSE) is a common consequence of stroke characterised by episodes of crying or laughing. There is only one published qualitative study exploring the experience of emotionalism to date. This study aimed to explore individual's experience of PSE and develop a theoretical client-derived framework to shape future psychological interventions. Materials and methods A primary analysis of the qualitative pseudonymised pre-collected semi-structured interview data of the TEARS study was completed. Participants were recruited from nine acute stroke units in Scotland with participants commencing the study at baseline (two-weeks) and they either continued or dropped out. Interviews were completed at two-weeks, six-months and 12-months post-stroke. Results Data was analysed from 52 participants at two-weeks, 25 participants at six-months and 23 participants at 12-months. Three major themes were identified: "In the moment," describing characteristics and triggers, "Ways of coping," highlighted a variation of coping strategies including avoidance or acceptance and "Impact," outlining the longer-term effects of PSE such as individuals' beliefs. Conclusion The results indicate specific psychological aspects of PSE which could be viable targets in psychological interventions such as increasing adaptive coping strategies and challenging negatively held beliefs.IMPLICATIONS FOR REHABILITATIONEmotionalism can cause emotional consequences such as distress, embarrassment and fear.Helping individuals to develop insight into triggers for emotionalism could be beneficial to help gain understanding and awareness whereby post-stroke emotionalism (PSE) has the potential to be anticipated and adapted to psychologically.Potential adaptive responses such as acceptance or control and better anticipation of episodes of emotionalism could help to reduce the emotional consequences of PSE.

Acquired Brain Injury (ABI) significantly affects individuals across multiple areas of intimate, familial, and parental domains. Gender and identity are pivotal research areas in navigating life after ABI. To date, scant research has explored gendered experiences, particularly those related to the masculine lifeworld. This study aimed to explore how men who were fathers before their injuries experience fatherhood after ABI. An Interpretative phenomenological analysis (IPA) methodology was used, and seven fathers participated in the semi-structured interviews (time since injury 1-18 years, age range 27-66 years) which explored their meaning-making. Four superordinate themes were drawn from all interviews through engaging with the qualitative research process: (1) what being a father means, (2) altered relationships with others, (3) becoming lost and finding their way through, and (4) renewed fatherhood. The findings show intersectionality between pre-and post-injury comparisons of self and social identities, alongside the contextual and societal identities in the subjective fathering experiences. Through increased understanding, we may enable fathers to find new ways to resolve, reformulate, and connect to move into their future possible fatherhood. The importance of this research is in giving voice to these less represented men so that we may shape our understanding to aid future fathers post-ABI.

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.

The parent-reported Strengths and Difficulties Questionnaire (SDQ-P) is commonly used to assess for mental health problems, but its psychometric properties have not been studied in the paediatric Acquired Brain Injury (ABI) population. This study investigated the properties of the SDQ-P and its subscales in this population using Rasch analysis. One hundred and forty-three SDQ-Ps and 123 Impact Supplements were analyzed. Sixty-nine percent of SDQ-Ps were completed by female carers, 59% of young people were male, and 58% had Traumatic Brain Injury (TBI). In this population the SDQ-P Total Difficulties Scale and the Conduct Problems subscale showed questionable construct validity. The individual subscales and Impact Supplement did not meet the criteria for reliability. Two items had disordered thresholds. The individual subscales showed mistargeting and 13-24% person misfit. Two items were significantly underdiscriminating. There was differential item functioning with age and time post-injury, and local dependence between subscale items. The Total Difficulties scale was multidimensional. The most easily endorsed items were in keeping with common symptoms of brain injury. These findings suggest the SDQ-P in its current form may not be a reliable and valid assessment measure for mental health difficulties in the paediatric ABI population and requires further investigation.

Purpose: An acquired brain injury (ABI) is often described as a devastating experience and yet positive changes as a result of this event have been described. This study sought to understand the process of developing posttraumatic growth (PTG) following ABI. Method: Semi-structured interviews were conducted with 10 adults with ABI, recruited from three sites of a community day service for people with ABI. Grounded theory was used to explore the development of positive changes experienced as a result of the injury. Results: PTG appeared to occur in a non-linear way as participants negotiated processes captured in the following themes: “living with a life changing injury,” “trying to beat it and acceptance,” “identifying with a new you and others,” and “meaningful positive change.” Intra- and inter-personal comparisons emerged as important in accepting changes and reconnecting with pre-injury identity. This seemed to underpin accessing social and practical opportunities giving rise to connection with strengths and growth. Conclusions: This study extends prior research into the process of adjustment and positive outcomes such as growth, although conclusions are limited to this specific sample and context. Further research and clinical practice development addressing acceptance and community engagement to develop positive change following ABI is required. Implications for rehabilitation: Experience of PTG develops over time and influenced by intra-and-inter-personal processes. Acceptance and shared experiences with others may contribute to positive psychological change. Interventions supporting pre-and-post injury comparisons with others could help acceptance. The focus on the management and expression of emotions associated with loss may be beneficial.

Distress intolerance has been suggested to be a maintaining factor in several mental health conditions. Distress tolerance skills training has been found to be beneficial in emotionally unstable personality disorder (EUPD) and post-traumatic stress disorder (PTSD). Short-term targeted interventions are increasingly being implemented in response to demand. This study investigates the efficacy of a distress tolerance brief psychological intervention (DT BPI) delivered by non-psychologists within an adult secondary care mental health service. Questionnaire data (pre and post) are reported from 43 participants who completed the intervention. Results suggest that the intervention was associated with significant improvements in distress tolerance, mood, anxiety and wellbeing. This indicates that a DT BPI can be effective when delivered by non-psychologists to real-world adult secondary care clients. The findings offer promising evidence that DT BPI could be a beneficial, cost-effective intervention and warrants further large-scale investigation. Key learning aims (1) To enhance practitioners’ awareness of distress intolerance as a potential maintaining factor and therefore treatment target. (2) To outline a transdiagnostic distress tolerance brief psychological intervention. (3) To illustrate the potential of this distress tolerance brief psychological intervention to produce positive reliable change with real-world clients when delivered by non-psychologists.

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.

Research indicates that Acquired Brain Injury (ABI) is associated with significant and chronic impairment across multiple areas of functioning including physical, cognitive, emotional and behavioural domains. Whilst impairments associated with ABI can be ameliorated, cure is seldom possible. The emergence of positive psychology reflects a paradigm shift in health and wellbeing research, highlighting the role of character strengths, positive emotions, meaning, and resilience. Positive psychology interventions have been demonstrated to improve wellbeing in a variety of populations, although research investigating the impact of positive psychotherapy for people living with ABI are sparse. Here we characterize the experience of an 8-week positive psychotherapy intervention for 13 people living with ABI including four mentors and nine participants using thematic analysis of transcripts collected during mini-groups and one-to-one interviews. Six main themes were identified including empowerment, social opportunity, coping, cultivation of positive emotion, consolidation of skills and barriers. Results indicated that wellbeing can be promoted and improved in individuals with ABI. Recent theoretical developments in wellbeing science highlight scope to improve the intervention by connecting individuals to their communities and spending time in nature.

Understanding of emotional adjustment after stroke is limited. Under one-third of stroke survivors reporting emotional problems receive support. The aim of this study was to explore the process of emotional adjustment post-stroke and investigate the role played by participation in an online stroke community. We applied thematic analysis to 124 relevant posts within 114 discussion threads, written by 39 survivors and 29 carers. The contribution of online community engagement to emotional adjustment was explored using the Social Support Behaviour Code. Stroke survivors share common experiences of emotional adjustment and may not necessarily reach complete acceptance. Positive and negative trajectories of emotional adjustment were identified. Survivors progressed along, or moved between, positive and negative pathways not in a time-dependent manner but in response to "trigger events," such as physical setbacks or anti-depressant treatment, which may occur at any chronological time. An adapted version of Suhr's 1990 Social Support Behaviour Code showed that support provided through the online community took many forms, including advice, teaching, empathy and normalization of concerns. Participation in the stroke community was itself deemed to be a positive "trigger event." There is need to improve awareness of emotional adjustment and their "triggers" amongst stroke survivors, carers and clinicians.

This chapter presents the conceptual background to Cognitive behavioural therapy (CBT) and its application following acquired brain injury (ABI). Working with people with ABI means engaging with a very diverse range of presenting needs and challenges, responded to in diverse ways by individuals with varied profiles of functioning. The transdiagnostic cognitive behavioural model of adaptation post-ABI describes the ways in which immediate understandable momentary emotional reactions in the context of changed life post ABI can be made sense of in terms of ‘threats to self’, echoing Goldstein’s description of the psychological consequences of ABI. Some in the wider world of CBT seem intent on salami-slicing and distinguishing the various CBT ‘products’ available into behavioural, cognitive and third wave, focusing on differences more than commonalities. A longitudinal CBT formulation was developed to help Robert make sense of his aggressive behaviour and to help his family and the other professionals involved in his care to understand.

This chapter describes an interdisciplinary neuropsychological assessment process for children and young people (CYP) with acquired brain injuries (ABI). Suzanna is a clinical psychologist who worked with CYP and families in community neurodevelopmental services before specialising to work in neurorehabilitation for children with ABIs. The chapter also describes the context of the approach to assessment of children with ABIs and the understanding of ideas from the literature that shape this process. From the child or young person’s individual neuropsychological functioning to the functioning of his or her context, the assessment aims to develop a shared understanding. The assessment and understanding of a child’s injury are ongoing processes that require constant reformulation as the young person recovers from his or her injury, his or her brain continues to develop and he or she develop his or her skills and identity.

Objective: To increase understanding of the community neuropsychological rehabilitation goals of young people with acquired brain injuries (ABIs). Method: Three hundred twenty-six neuropsychological rehabilitation goals were extracted from the clinical records of 98 young people with ABIs. The participants were 59% male, 2–19 years old, and 64% had a traumatic brain injury. Goals were coded using the International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY). Descriptive statistical analysis was performed to assess the distribution of goals across the ICF-CY. Chi-squared and Cramer’s V were used to identify demographic and injury-related associations of goal type. Results: The distribution of goals was 52% activities and participation (AP), 28% body functions (BF), 20% environmental factors (EF), and V = .14). Non-traumatic causes of ABIs were associated with more EF goals (V = .12). There was no association between sex or time post-injury and the distribution of goals across the ICF-CY. Conclusions: Young people with ABIs have a wide range of community neuropsychological rehabilitation goals that require an individualized, context-sensitive, and interdisciplinary approach. Community neuropsychological rehabilitation services may wish to ensure they are resourced to focus intervention on AP, with increasing consideration for EF as a young person progresses through adolescence. The findings of this research support models of community neuropsychological rehabilitation that enable wellness by combining direct rehabilitative interventions with attention to social context and systemic working across agencies. (JINS, 2019, 25, 403–412)

IntroductionPeople often experience distress following stroke due to fundamental challenges to their identity.ObjectivesTo evaluate (1) the acceptability of ‘HeART of Stroke’ (HoS), a community-based arts and health group intervention, to increase psychological well-being; and (2) the feasibility of a definitive randomised controlled trial (RCT).DesignTwo-centre, 24-month, parallel-arm RCT with qualitative and economic components. Randomisation was stratified by centre and stroke severity. Participant blinding was not possible. Outcome assessment blinding was attempted.SettingCommunity.ParticipantsCommunity-dwelling adults ≤2 years poststroke recruited via hospital clinical teams/databases or community stroke/rehabilitation teams.InterventionsArtist-facilitated arts and health group intervention (HoS) (ten 2-hour sessions over 14 weeks) plus usual care (UC) versus UC.OutcomesThe outcomes were self-reported measures of well-being, mood, capability, health-related quality of life, self-esteem and self-concept (baseline and 5 months postrandomisation). Key feasibility parameters were gathered, data collection methods were piloted, and participant interviews (n=24) explored the acceptability of the intervention and study processes.ResultsDespite a low recruitment rate (14%; 95% CI 11% to 18%), 88% of the recruitment target was met, with 29 participants randomised to HoS and 27 to UC (57% male; mean (SD) age=70 (12.1) years; time since stroke=9 (6.1) months). Follow-up data were available for 47 of 56 (84%; 95% CI 72% to 91%). Completion rates for a study-specific resource use questionnaire were 79% and 68% (National Health Service and societal perspectives). Five people declined HoS postrandomisation; of the remaining 24 who attended, 83% attended ≥6 sessions. Preliminary effect sizes for candidate primary outcomes were in the direction of benefit for the HoS arm. Participants found study processes acceptable. The intervention cost an estimated £456 per person and was well-received (no intervention-related serious adverse events were reported).ConclusionsFindings from this first community-based study of an arts and health intervention for people poststroke suggest a definitive RCT is feasible. Recruitment methods will be revised.Trial registration numberISRCTN99728983.

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.

Acquired brain injury (ABI) has a negative impact on self-esteem, which is in turn associated with mood disorders, maladaptive coping and reduced community participation. The aim of the current research was to explore self-esteem as a multi-dimensional construct and identify which factors are associated with symptoms of anxiety or depression. Eighty adults with ABI aged 17-56 years completed the Robson Self-Esteem Scale (RSES), of whom 65 also completed the Hospital Anxiety and Depression Scale; 57.5% of the sample had clinically low self-esteem. The RSES had good internal consistency (α = .89), and factor analysis identified four factors, which differed from those found previously in other populations. Multiple regression analysis revealed anxiety was differentially predicted by "Self-Worth" and "Self-Efficacy", R2 = .44, F(4, 58) = 9, p < .001, and depression by "Self-Regard", R2 = .38, F(4, 58) = 9, p < .001. A fourth factor, "Confidence", did not predict depression or anxiety. In conclusion, the RSES is a reliable measure of self-esteem after ABI. Self-esteem after ABI is multidimensional and differs in structure from self-esteem in the general population. A multidimensional model of self-esteem may be helpful in development of transdiagnostic cognitive behavioural accounts of adjustment.

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.

Background. Acquired brain injury (ABI) can impair executive function, impeding planning and attainment of intentions. Research shows promise for some goal-management rehabilitation interventions. However, evidence that alerts assist monitoring and completion of day-to-day intentions is limited. Objective. To examine the efficacy of brief goal-directed rehabilitation paired with periodic SMS text messages designed to enhance executive monitoring of intentions (assisted intention monitoring [AIM]). Methods. A randomized, double-blind, controlled trial was conducted. Following a baseline phase, 74 people with ABI and executive problems were randomized to receive AIM or control (information and games) for 3 weeks (phase 1) before crossing over to either AIM or no intervention (phase 2). The primary outcome was change in composite score of proportion of daily intentions achieved. A total of 59 people (71% male; 46% traumatic brain injury) completed all study phases. Results. Per protocol crossover analysis found a significant benefit of AIM for all intentions [ F(1, 56) = 4.28; P = .04; f = 0.28; 3.7% mean difference; 95% CI = 0.1%-7.4%] and all intentions excluding a proxy prospective memory task [ F(1, 55) = 4.79; P = .033; f = 0.28, medium effect size; 3% mean difference; 95% CI = 0.3%-5.6%] in the absence of significant changes on tests of executive functioning. Intention-to-treat analyses, comparing AIM against control at the end of phase 1 revealed no statistically significant differences in the attainment of intentions. Conclusion. Combining brief executive rehabilitation with alerts may be effective for some in improving achievement of daily intentions, but further evaluation of clinical effectiveness and mechanisms is required.

The objective of the study was to identify the potential target and effect size of goal management training (GMT) enhanced with life-logging technology compared with standard GMT on a range of possible primary outcomes reflecting cognitive and ecological aspects of executive functioning and quality of life. Sixteen patients with acquired brain injury involving executive dysfunction were randomly allocated to one of the two interventions: seven weeks of GMT (n = 8), or seven weeks of GMT+Lifelog (n = 8). Outcome measures included a battery of executive function tests, the Dysexecutive Questionnaire (DEX) and the Quality of Life after Brain Injury scale (QOLIBRI), measured pre- and post-interventions. Within-group changes were assessed with related-samples t-tests and estimation of effect sizes. GMT+Lifelog was associated with significant changes, of medium to large effect size, in response inhibition (Stroop), multitasking (Strategy Application and Multiple Errand tests), DEX Intentionality and Positive Affect subscales and QOLIBRI Daily Life and Autonomy, subscales. GMT alone was associated with significant changes of overall quality of life. It was concluded that GMT+Lifelog holds promise to optimise the impact of GMT on executive dysfunction and quality of life.

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.

Common sequelae following frontal acquired brain injury include problems in maintaining relationships with significant others, and dysexecutive deficits (cognitive difficulties in initiation, planning, organizing, sequencing, and monitoring). The efficacy of psychotherapy interventions aimed at exploring psychosocial and relationship issues with these clients is in itself challenged by these problems: the therapeutic relationship is also subject to dysexecutive influences. A working clinical reformulation of relationship problems in the context of dysexecutive impairment is suggested. This is achieved via an integration of the supervisory attentional system neuropsychological model of Shallice and Burgess (1991, 1996) and a form of relationally focused brief psychotherapy, cognitive analytic therapy. The use of electronic alerting and other compensatory interventions is specified within this reformulation. Two case studies are presented for illustrative purposes, including one outcome evaluation using sta...

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.

Introduction Over 152 000 people in the UK have strokes annually and a third experience residual disability. Low mood also affects a third of stroke survivors; yet psychological support is poor. While Arts for Health interventions have been shown to improve well-being in people with mild-to-moderate depression post-stroke, their role in helping people regain sense of self, well-being and confidence has yet to be evaluated. The main aim of this study is to explore the feasibility of conducting a pragmatic multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of an Arts for Health group intervention (‘HeART of Stroke’ (HoS)) for stroke survivors. HoS is a 10-session artist-facilitated group intervention held in the community over 14 weeks. It offers a non-judgemental, supportive environment for people to explore sense of self, potentially enhancing well-being and confidence. Methods and analysis Sixty-four people, up to 2 years post-stroke, recruited via secondary care research staff or community stroke/rehabilitation teams in two UK centres will be randomised to either HoS plus usual care or usual care only. Self-reported outcomes, measured at baseline and approximately 5 months postrandomisation, will include stroke-related, well-being, mood, self-esteem, quality of life and process measures. Analyses will focus on estimating key feasibility parameters (eg, rates of recruitment, retention, intervention attendance). We will develop outcome and resource use data collection methods to inform an effectiveness and cost-effectiveness analysis in the future trial. Interviews, with a sample of participants, will explore the acceptability of the intervention and study processes, as well as experiences of the HoS group. Ethics and dissemination National Health Service (NHS), Research and Development and University ethical approvals have been obtained. Two peer-reviewed journal publications are planned plus one service user led publication. Findings will be disseminated at key national conferences, local stakeholder events and via institutional websites. This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0212-27054).

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.

The field of neuropsychological rehabilitation of childhood brain injury is still in the early stages of development, with the evidence base predominantly focused on cogntive and behavioural problems (Laatsch et al, 2007; Ylvisaker et al, 2007; Slomine and Locascio, 2009, Ross et al., 2011). Less attention has been paid to understanding the emotional and mental health issues fully. Yet there is mounting evidence to indicate mental health and quality of life to be major areas of concern across a range of ages and severity (Brown et al., 1981; Max et al., 1997, 1998, 2004, 2011; Fuemmeler et al., 2002; Limond et al., 2009; Tonks et al., 2010; Ross et al., 2011; Gracey et al., 2014a; Tsai et al., 2014).

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.