Neurobehavioural Disability and Social Handicap Following Traumatic Brain Injury

Tom McMillan, Rodger Wood, Tom M. McMillan, Rodger Ll. Wood

• Publisher: Psychology Press
• Year: 2017
• ISBN:
  9781317409984
• Edition: 2
• Topic: Psychology
• Subtopic: Neuropsychology
• Index: Psychology

Neurobehavioural disability (NBD) follows many forms of serious brain injury and is a major constraint on social independence. This book brings together a group of leading academics and practising clinicians to provide an overview of the nature of NBD, considering how it translates into social handicap, and what can be done to address associated problems, through social and behavioural rehabilitation, vocational training and family education.

This fully revised edition takes into account advances in the field, exploring the range of cognitive, emotional, and behavioural effects of brain damage most commonly associated with damage to the frontal and associated structures of the brain that govern social behaviour. This edition also features increased emphasis on psychological interventions, as well as new chapters on brain imaging, pharmacotherapy and assistive technology for disability.

Neurobehavioural Disability and Social Handicap Following Traumatic Brain Injury is essential reading for clinical psychologists, psychiatrists and neurologists working in brain injury rehabilitation. The book will also be of interest to relatives of those with brain injury seeking better knowledge to understand neurobehavioural disability, as well as the growing number of therapy care assistants, case managers, support workers, and social workers responsible for the day to day care of brain injured people in the community.

Part I
Nature and impact

1
Neurobehavioural Disability over the Past Four Decades

Andrew Worthington, Rodger Ll. Wood and Tom M. McMillan

Origins and early development

The concept of neurobehavioural disability developed from early pioneering efforts to find better ways of understanding and treating the more debilitating and chronic behavioural consequences of serious brain injury. Although the origins of this approach can be traced back at least as far as the First World War it was not until the final decades of the twentieth century that significant advances were made. Prior to this it had been left to one or two gifted and enlightened clinicians to prepare the hinterland from which later practitioners benefitted. Key figures in an approach that would develop into neurobehavioural rehabilitation were Kurt Goldstein and Alexander Luria, both of whom recognised the importance of the frontal lobes in the regulation of human social behaviour.

Goldstein’s recognition of the importance of injury to the frontal lobes is evident in the distinction he drew between the impact of injury on new learning as opposed to established habit patterns – ‘in patients with lesions of the frontal lobe, active (abstract) behaviour is lacking, but the concrete behaviour may be very well preserved’ (Goldstein, 1936, p. 38). About the same time Luria developed his theory of frontal lobe functioning, which was most comprehensively set out in English in his 1973 work, The Working Brain:

For any mental process to take place a certain level of cortical tone is necessary and this cortical tone must be modified in accordance both with the task to be accomplished and the stage of the activity reached. The first important function of the frontal lobes is to regulate this state of activity.

(p. 188)

Luria then emphasised the role of the frontal lobes in the regulation of attention control and social cognition:

Maintenance of the optimal cortical tone is absolutely essential for the basic condition of all forms of conscious activity, namely the formation of plans and intentions that are stable enough to become dominant and to withstand any distracting or irrelevant stimulus . . . capable of controlling the subject’s subsequent conscious behaviour.

(pp. 197–198)

Here is an explicit statement of the importance of a region of the brain, often thought at that time to be silent, in regulating thought and action. It followed that frontal brain damage led to disruption of complex forms of behaviour and, especially, ‘activity which is controlled by motives formulated with the aid of speech’ (p. 199). This has, in turn, provided an important neurological rationale for recruiting speech processes in neurobehavioural rehabilitation (Vocate, 1987).

More recent descriptions of disability have developed from these early concepts by focussing on the role of the prefrontal cortex in the self-regulation of behaviour (Stuss and Benson, 1987; Damasio et al., 1991). Diminished self-regulation is a major legacy of traumatic brain injury and central to the concept of ‘neurobehavioural disability’ (Wood, 1987). This new concept of disability pointed to patterns of maladaptive behaviour characterised by impulsivity; inappropriate social or sexual behaviour; lack of tact and discretion during interpersonal activities; diminished self or social awareness; an egocentric attitude lacking in warmth and empathy towards others; labile mood with shallow irritability that can escalate into impulsive aggression; poor attention control resulting in an inability to maintain goal directed behaviour; a lack of ability to spontaneously initiate purposeful behaviour; and fatigue, often associated with a lack of drive and motivation.

The pattern of disability exhibited by individuals can vary considerably depending upon the nature, location, and severity of their brain injury; pre-injury behaviour and personality, and post-injury circumstances. In many cases the disability can be subtle but still have a pervasive psychosocial impact because of problems with interpersonal relationships, an inability to adapt behaviour to changing situations, and poor temper control.

The neurobehavioural rehabilitation paradigm

Goldstein’s approach to rehabilitation was influenced by the Gestalt psychology movement (see Prigatano and Salas, Chapter 14, this volume) and included an appreciation of context in driving behaviour. His approach recognised that effective rehabilitation required a change from focusing on physical and cognitive symptoms to addressing long-term behavioural and personality change (Goldstein, 1952). Challenges of caring humanely for those with disordered behaviour came to the fore in the 1960s and 1970s, initially for people with psychiatric conditions, what were then called ‘mental handicaps’, and latterly for acquired brain injury. From the 1970s this gave rise to two streams of rehabilitation. Although both were to consider rehabilitation in a ‘holistic’ sense and embrace the role of the family and of the environment as a milieu for intervention, one focused on higher functioning adults with predominantly emotional and adjustment problems, epitomised by Prigatano et al. (1984) and Ben-Yishay (Ben-Yishay et al., 1985). The other was a neurobehavioural approach that initially developed in response to the needs of a very severely injured, challenging population who were otherwise excluded from treatment on the basis of their disturbed behaviour (Wood and Eames, 1981; Eames and Wood, 1985). Left untreated, or inappropriately medicated, the disproportionate impact of this population had become increasingly apparent in terms of the effects on the wider family. Panting and Merry (1972) for example noted

the majority of our patients suffered from outbursts of very vivid emotional rage . . . the patient’s accident had been a great strain on all relatives, especially to wives and mothers, and 61% had needed supportive treatment with tranquillisers and sleeping tablets which had not been necessary previously.

(p. 35)

It was these personality changes rather than injury severity per se that were linked to stress amongst relatives (Oddy et al., 1978; McKinlay et al., 1981). The emerging awareness of the impact of behaviour and personality problems led Bond (1979) to comment that

the nature of rehabilitation techniques for patients over and above those required to prevent secondary complications of physical disabilities, which have formed the basis of most rehabilitation to date, will entail various psychological and social therapies, and excursions into the fields of occupational training.

(p. 158)

There was clearly a need for a new type of rehabilitation and in the same year the management of St Andrews Hospital, an independent psychiatric institution in Northampton, England, was persuaded to run an experimental programme at the Kemsley Unit, using behaviour modification techniques already in use elsewhere in the hospital, to treat adults with severe brain injury (Wood and Eames, 1981). Chief amongst behavioural methods in vogue at the time was the token economy system, which was an all-encompassing system of rewards contingent upon certain behaviours that had proved effective in its application to a wide range of conditions (Kazdin, 1977). It is easy now to forget that this was very much unchartered territory in rehabilitation, as epitomised in Lishman’s (1984) comments on ‘the brave attempts underway to tackle the more disruptive behavioural aftermaths in severely damaged patients by behaviour modification techniques – pioneering work at the rehabilitation unit of St. Andrew’s Hospital Northampton’ (p. 1148). Underpinning this new approach was a shift from a primarily psychiatric perspective on behaviour disorders at that time to a psychological model of learning. The traditional medical model had been syndrome-based, viewing disordered behaviour as dispositional rather than situational, enduring rather than transitory, and consequently treatments were largely drug-based. In contrast, learning theory promoted a more dynamic approach whereby behaviour was largely situationally determined, accessible to functional analysis and amenable to modification by altering contingencies of reinforcement in the environment. The initial outcomes for those with severe brain injury were said to be surprisingly good (Eames and Wood, 1985). A cohort treated approximately four years post-injury (i.e. beyond the period of likely natural resolution of their behaviour disturbance) showed that clear gains from treatment were still evident at follow-up, an average of 18 months later. Better outcomes were associated with longer periods of intervention but longer admissions were not necessary to achieve good outcomes. Token economy programmes began to be used elsewhere with reports of improved efficacy over drug treatment in the so-called ‘frontal lobe syndrome’ (Whale et al., 1986; Tate, 1986).

However, it gradually became evident that the particular kind of cognitive impairment associated with TBI imposed constraints on associational learning that was fundamental to operant learning methods intrinsic to a behaviour management approach (Wood, 1987; 1989). The principal deficits were (a) a loss of attention control, which prevented the patient making consistent/frequent associations between stimulus and response, or response and reinforcement; (b) lack of awareness of the target behaviour being a problem and therefore rejecting reinforcement as a response contingency, and (c) indifference to reinforcement itself, such that it had neither rewarding or aversive/punishing properties (Wood, 1992). A final limitation of behaviour management with these patients was a recognition that conditioned responses often failed to generalise outside the narrow and highly structured context in which the reinforcement contingencies took place (Wood, 1990).

These constraints on association learning, as a vehicle for developing better self-control and socially appropriate or constructive behaviours, changed the narrow focus of behaviour management to one of cognitive-behaviour management which recognised the organically mediated constraints on learning and response generalisation. In order to accommodate deficits in attention control and other neuropsychological factors that interfere with associational learning (which is the basis of behaviour modification) Wood (1984) argued that it was important to administer reinforcement as immediately as possible, in an obvious way to ensure correct associations are made, as frequently as possible, and over an extended period to promote overlearning, which would help generalisation to other less structured situations.

A neurobehavioural paradigm for brain injury rehabilitation (Wood, 1987; 1990; 1992; Wood and Worthington, 2001a; 2001b) evolved out of this behaviour management approach. The ‘neuro’ prefix was intended to remind rehabilitation practitioners that some aspects of disturbed or otherwise socially inappropriate behaviour was a result of cerebral injury, over which the individual had little or no control and, often, incomplete awareness, rather than being gratuitous or pre-planned, or directly under the control of (external) environmental events (Wood, 1987; Wood and Cope, 1989). Some of the techniques have changed over time as the focus of neurobehavioural approaches to TBI rehabilitation therefore gradually shifted from control over inappropriate and challenging behaviour to the development of effective learning strategies to promote the acquisition of functional abilities likely to lead to greater social independence (Wood, 1989; Manchester and Wood, 2001). This in turn has opened up neurobehavioural rehabilitation to a range of awareness-based and insight-oriented therapies (see Chapters 4 and 11 this volume). This development was anticipated by Wood (1987) who noted:

A neurobehavioural approach also avoids the conflict of whether to use a predominantly behavioural or cognitive method of treatment. This is because it combines elements of both, emphasising the objective characteristics of cognitive processes which are reflected in the behaviour of an individual.

(p. 155)

It is worth noting that the term ‘neurobehavioural’ had previously been in use but lacked any coherence and conceptual validity, being applied either specifically to psychiatric symptoms or in general terms to any form of behaviour without any clear link to underlying brain function. There was no notion of neurobehavioural disability encapsulating diverse functional and behavioural consequences of the breakdown of frontally-mediated regulatory control processes, and no theoretical link to intervention. Thus an early text entitled Neurobehavioural Consequences of Closed Head Injury (Levin et al., 1982) focused on psychotherapy and does not even mention ‘behaviour’ or ‘behaviour management’ in the index, stating in a single reference to this aspect of rehabilitation: ‘behavioural management is facilitated by providing a supportive, calm environment and encouraging the participation of the patient’s family in achieving a sense of security and reorientation’ (p. 210).

The neurobehavioural approach in TBI rehabilitation became distinguished from the traditional neurorehabilitation approach (that primarily addressed problems associated with cerebrovascular accident) by its organisational structure of staff as well as procedural methods in the way rehabilitation interventions were employed (Eames and Wood, 1985; 1989; Wood, 1989). The organisational structure primarily involved the working relationships between different therapy disciplines which, in a neurobehavioural context, needed to be inter-disciplinary rather than multidisciplinary (Wood, 1990; 1993). Therapy interventions in every discipline placed an emphasis on psychological methods of intervention that, through careful assessment and structured observation (Wood, 1987), recognised how problems of attention, awareness, and executive function undermined many aspects of everyday behaviour, either social or functional, and did not respond to conventional methods of therapy management (e.g. Worthington et al....

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• Notes on contributors
• Preface
• PART I Nature and impact
• PART II Assessment methodologies
• PART III Treatment and rehabilitation
• PART IV Service delivery and development
• Index