Behavioural Approaches in Neuropsychological Rehabilitation

Optimising Rehabilitation Procedures

Barbara A. Wilson, Camilla M. Herbert, Agnes Shiel

• Publisher: Psychology Press
• Year: 2004
• ISBN:
  9781135431846
• Edition: 1
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

The potential of behavioural approaches for improving the lives of people with acquired brain injury is immense. Here that potential is laid out and explored with a thoroughgoing regard for clinical practice and the theoretical frameworks that underpin that practice. This book will prove an invaluable resource for clinical psychologists and the whole range of therapists working with patients suffering from acquired brain damage.

CHAPTER 1
A brief history of behavioural approaches in neuropsychological rehabilitation

In 1977, Lane published a detailed account of Itard’s work with Victor, the Wild Boy of Aveyron, in the eighteenth century. Many of the methods adopted by Itard to teach Victor certain skills were later incorporated into behaviour modification techniques. Itard used approximations that today we would call shaping; he identified the component parts of complex activities and taught the individual parts that today we would call chaining; and he was concerned with limitation and generalisation, which are widely used today in the teaching of people with learning disability. Lane (1977) concludes that, “his [ Itard’s] armamentarium…anticipated that of modern behavioural modification by nearly two centuries” (p. 165).

Although they did not use the terms behaviour therapy or behaviour modification, Luria and colleagues employed behavioural techniques in their work with brain-injured people in the Soviet Union ( Luria, 1963; Luria, Naydin, Tsvetkova, & Vinarskaya, 1969). They argued that following a brain lesion there is primary damage resulting in the death of neurons, and secondary damage due to the inhibition of intact neurons. They describe successful rehabilitation programmes based on the principles of de-inhibition. De-blocking or de-inhibiting secondary damage can be accomplished by combining pharmacological treatment with careful training procedures. Luria et al. believed that because the inhibition resulted from poor synaptic transmission, drugs modifying this transmission should be used. If, at the same time, patients were enabled to use residual powers and substitute these for the original, habitual way of carrying out an activity, then behavioural change could occur. The procedures described are similar to shaping procedures used today in behaviour therapy. In their 1969 paper, for example, Luria et al. describe Perelman’s work with post-concussional deaf patients. These patients were asked to read sentences that were, at the same time, read aloud by a therapist. Of course the deafened patients could not hear the therapist but they could read with no trouble. Gradually, the written sentences were made less and less legible while the spoken sentences were always clearly pronounced. Those patients who possessed inhibited traces of hearing were gradually guided by the sound of the sentences and learned to “hear” the sounds even when the written word was illegible. As shaping can be defined as successive approximations to a final goal, these patients were being shaped to hear again.

One of the first people to describe explicitly and advocate the use of behavioural techniques with brain-injured adults was Goodkin (1966). He used operant conditioning to improve a number of skills including handwriting, machine operating, and wheelchair pushing with three stroke patients and one patient with Parkinson’s disease. A further paper by Goodkin (1969) described how operant conditioning resulted in language improvement in a patient with dysphasia following a stroke.

The 1970s saw several reports of behavioural methods used with braininjured adults. Taylor and Persons (1970) used social attention to (a) reinforce reading skills in a 22-year-old quadriplegic man, (b) reduce the number of complaints made by a 54-year-old woman with multiple sclerosis, and (c) extinguish psychotic speech in a 37-year-old quadriplegic man. All patients became easier for ward staff to manage. A similar approach with money as a reward was employed by Booraem and Seacat (1972) to reinforce exercising in braindamaged adults in a general hospital. Zlutnick, Mayville, and Moffat (1975) were able to reduce the number of epileptic seizures sustained by a 17-year-old girl by interrupting the sequence of behaviours that led up to the seizure. Ince (1976), in his book on behaviour modification in rehabilitation, concentrated on the reduction of problem behaviours although he also included suggestions on how behaviour modification could be used in other areas of rehabilitation. Lincoln (1978) produced a short paper entitled “Behaviour modification in physiotherapy” describing three programmes designed to extend exercising in physiotherapy for one stroke and two head-injured patients. In the same year Series and Lincoln reported on the applications of behaviour therapy to people with brain injury (Series & Lincoln, 1978). Lincoln and colleagues later published work on behaviour therapy as an aid to treating language disorders (Lincoln & Pickersgill, 1984; Lincoln, Pickersgill, Hankey, & Hilton, 1982).

Others who touched on aspects of cognitive remediation were Goodkin (1969), and Diller and his colleagues working with right hemisphere stroke patients exhibiting visuoperceptual and visuospatial problems ( Diller & Weinberg, 1977; Weinberg et al, 1979). Although Diller and his colleagues did not describe their methods as behavioural, in many ways they incorporated behavioural principles in that they thought it important to establish the nature of the problem, obtain a baseline, and start training with easy tasks before progressing to more complex ones. They also point out the importance of providing cues and environmental supports in the early stages before progressing to the more complex ones. Feedback and evaluation are also considered to be crucial aspects of training. Thus they were following the behavioural principles of task analysis, observation and recording of the problem behaviours, shaping, reinforcement, and monitoring or evaluation of treatment effectiveness, all of which are components of behavioural assessment and treatment programmes (Yule & Carr, 1987).

It was in the 1980s that behavioural techniques began to be applied to cognitive problems in earnest. In a later book by Ince (1980), Diller wrote a chapter on cognitive rehabilitation describing the techniques established during the 1970s ( Diller, 1980). Wilson (1981) published a survey of behavioural treatments carried out at a brain injury rehabilitation centre. These included programmes for people with memory, perceptual, and language disorders. Around the same time, Miller (1980) discussed the application of psychological (including behavioural) techniques to the treatment of people with central nervous system damage. Miller emphasised that treatment should be concerned with the amelioration of deficits rather than attempting to restore lost functioning. He expanded these ideas in a later book (Miller, 1984) in which he stated that amelioration helps an individual to function as well as possible despite handicaps, whereas restitution implies the recovery or regaining of lost abilities which, in his view, is not possible. This debate continues today and, while it is likely that Miller’s views are correct for the majority of patients, there are documented cases where some restoration or restitution of functioning does appear to have taken place despite permanent organic damage (Wilson, 1998).

In the last 20 years or so more papers have appeared reporting the use of behavioural approaches in neuropsychology (see, for example, Alderman, 1996; Bellus, Kost, Vergo, & Dinezza, 1998; Wilson, 1988, 1999; Wilson & Robertson, 1992, and others). These publications discuss several reasons why behavioural methods are suitable and effective for people with brain injury, and many of these we list below.

(1) There are many treatment techniques to either decrease problem behaviours or increase desirable behaviours that can be adapted or modified for use with our patient population.
(2) The underlying theoretical frameworks of behavioural approaches come from a number of fields including learning theory, neuroplasticity, information processing, linguistics, psychiatry, and so forth. This richness and complexity of theoretical support and clinical treatment means that behavioural medicine can be applied to a wide range of patients, problems, and situations.
(3) The targets, aims, and goals of therapy are made clear from the beginning of each programme. Unlike, say, interpretative psychotherapy, which arrives at its specification at the end of therapy, behavioural approaches specify the goals at the beginning of the process. Furthermore, the goals are explicit, small, and usually easy to achieve.
(4) Fourth, assessment and treatment are frequently inseparable in behavioural treatment programmes, unlike other treatments. Neuropsychological or cognitive assessments, for example, are typically unrelated or indirectly related to the treatment. Poor scores on intelligence tests or memory tests are not targeted for treatment; we do not teach people to pass these tests. The scores are important in helping us to understand a person’s cognitive strengths and weaknesses, and to plan our intervention appropriately, but they do not inform us in any detail about everyday problems, how families cope, what brain- injured people want to achieve, or how environments may affect behaviour. For such information we must employ behavioural assessments that are often part of the treatment strategy itself.
(5) Behavioural interventions are continuously monitored. Without measurement we are in danger of giving subjective or intuitive opinions about behavioural change or treatment effectiveness. Some of the most valuable evaluation techniques in neuropsychological rehabilitation are the single-case experimental designs developed in the field of behavioural medicine. These designs help us tease out whether change is due to natural recovery (or some other nonspecific factor) or to our intervention.
(6) Within a behavioural approach it is possible to individualise treatment, and this is particularly helpful for some brain-injured patients who will probably not respond to “packaged treatment” such as computerised cognitive retraining or memory exercises. These “packaged” programmes have not been designed to take into account the complex mixture of cognitive, social, emotional, and behavioural problems of brain-injured people and may have not been properly evaluated. In contrast, behavioural programmes typically take into account the biological condition of the individual, precipitating events, consequences of events, social factors, and the environment in which the individual is functioning. “Lesions in the same general areas do not always show the same symptoms and potential for restitution” (Finger & Stein, 1982, p. 336), thus a more individually oriented approach to therapy is called for, “one that would take into account not only features of the lesion, but factors such as motivation, age, experiential history, and the status of the rest of the brain.”
(7)Behavioural approaches provide a set of principles and a structure to follow when designing treatment programmes. Task analysis, goal setting, appropriate and detailed assessments, recording, monitoring, and evaluating the programme provide sound guidelines for psychologists, therapists, or teachers to follow.
(8) Behavioural approaches have been successful, as we demonstrate in later chapters of this book.

To expand on the view expressed in the foreword, we believe that the employment of behavioural methods in rehabilitation should not be at the expense of other approaches. Most British neuropsychologists or clinical psychologists working in the field of brain injury rehabilitation will draw on several fields, methodologies, and theoretical models from their training. Cognitive psychology provides models of memory, language, perception, attention, and so forth to help us understand and explain related phenomena; neuropsychology provides us with an understanding of the organisation of the brain; and behavioural psychology provides us with assessment and treatment methods to try to change behaviour. In addition, we are likely to be influenced by cognitive-behaviour therapy and psychotherapy to change attitudes and reduce emotional distress; findings from neuroplasticity to help understand and predict recovery; linguistics to help remediate language disorders; phenomenology for the understanding of individual differences—and influences abound from other related fields. The strength of neuropsychological rehabilitation is that it is not confined to or constrained by one theoretical framework. We would argue that such constraint is dangerous, in rehabilitation. No single approach can help us understand in totality the nature of our client’s deficits, or inform us as to how best to select or apply appropriate treatment and management strategies; no approach on its own can succeed in reducing all the consequences of brain injury, or enable patients and their families to achieve all their everyday goals. Instead we need to combine theories, methodologies, and approaches from a number of fields in order to encourage optimum levels of cognitive, emotional, and physical rehabilitation.

Similarly, no single approach can claim to be more benevolent than any other, although it would be true to say that there have been occasions when opponents of behavioural approaches have defended themselves as being more caring of the patient, as though this was inherently part of their philosophy or methodology. In fact a caring attitude can and indeed must be shown towards the patient at all times by each therapist, irrespective of treatment strategies. Caring for the patient is as much part of behaviourism as it is part of any approach, and no one has the right to claim a greater share of benevolence as though it were intrinsic to their philosophy, or a natural part of their theory or practice.

CHAPTER 2
Assessment for rehabilitation: Integrating information from neuropsychological and behavioural assessment

BACKGROUND

An acceptable definition of assessment, for the purpose of this chapter, is that offered by Sundberg and Tyler (1962) when they describe it as “…the systematic collection, organisation and interpretation of information about a person and his (or her) situation” (p. 8). Of the several ways of obtaining this information, the two most relevant for rehabilitation of people with brain injury are assessment procedures from neuropsychological and behavioural disciplines. Both approaches have important and complementary roles to play in assessing the nature of cognitive impairments, remaining capabilities, and the problems likely to be confronted in daily life by the person with brain injury.

Neuropsychology is the study of the relationship between brain and behaviour, and neuropsychological testing is mostly (although not solely) concerned with assessing cognitive functions. Other areas of human functioning, involving motor skills, and physical, emotional, and social behaviour are also frequently adversely affected as a result of injury to the brain. In order to assess damage in these areas we can employ investigative techniques based on behavioural theory, although, again, we need to add the proviso that in some cases neuropsychological testing may also be appropriate.

Behaviour can be defined as any observable or measurable response made by an organism. Behavioural assessments are typically concerned with identifying and measuring problem behaviours encountered in the everyday lives of those who have suffered injury to the brain. Because assessments are conducted in order to answer particular questions, the nature of the questions posed in any particular case will determine the assessment tool or procedure adopted. Neuropsychological and behavioural assessments answer different questions, both sets of which are required in rehabilitation.

NEUROPSYCHOLOGICAL ASSESSMENT

Examples of questions that can often be answered with a reasonable degree of accuracy by neuropsychological tests or assessment procedures are as follows:

• Is this person intellectually impaired?
• What is the predicted level of premorbid functioning for this person?
• What kind of language/reading/perceptual/memory disorder does this person have?
• Which cognitive skills remain intact or appear less damaged?
• How does this person compare with others of the same age or others with the same diagnosis?
• Is the score on a particular test in the abnormal range?
• Is failure on a particular test due to a disorder of comprehension, recognition, planning, or memory?
• Is the person faking or exaggerating problems?

Numerous theoretical influences might come into play when answering these questions. For example, psychometric assessments are based on statistical analysis and include measures of reliability, validity, and performance of a selected sample of a given population. Anastasi (1988) provides a succinct account of the characteristics of psychological tests. The Revised Wechsler Scales ( Wechsler, 1981, 1987) are examples of tests influenced by psychometry. Theoretical models from cognitive neuropsychology have led to the development of specialised and sophisticated assessment tools. For example, models of reading ( Coltheart, 1985; Patterson, 1994) have led to systematic and careful assessment of the ability to read parts of speech, words of different length, nonsense words, irregular versus regular words, words acquired at different ages, and highly imageable versus abstract words. These models enable us to understand and explain such phenomena as the ability of some subjects to read nouns but not verbs, or words that are spelled regularly but not irregularly, or concrete but not abstract words.

The working memory model ( Baddeley & Hitch, 1974) is another example of a theoretical cognitive model that has influenced neuropsychological assessment procedures. As a result of this model, clinicians are now more likely to assess separately those individual components specified in the model known as the central executive, the visuospatial sketchpad, and the phonological loop. Furthermore, the model helps to predict or explain the differences between people with short-term and long-term memory deficits.

Localisation studies have encouraged other approaches to assessment whereby, for example, the examiner attempts to assess deficits in the right and left hemispheres, and the frontal, temporal, parietal, and occipital lobes. The HalsteadReitan Battery ( Halstead, 1947; Reitan & Davison, 1974) is such an approach, and was originally used to discriminate between patients with frontal lobe lesions and normal control subjects.

The identification of neuropsychological syndromes such as agnosia and apraxia require a different set of guidelines that encourage the examiner to eliminate or exclude other explanations for the disorder. Although apraxia, for example, is a disorder of movement, it is not due to paralysis, weakness, or

failure to understand the task, and the examiner must therefore exclude motor and comprehension deficits in order to diagnose the deficit.

Lezak (1995) discusses both theoretical and practical considerations in her comprehensive account of the characteristics of neuropsychological assessment.

BEHAVIOURAL ASSESSMENT

While it is true that the discipline of neuropsychology has provided important and sophisticated understanding of cognitive problems such as those described above, it is also true that the discipline cannot, at least as yet, directly help us find answers to other important questions in the field of rehabilitation. Standardised or traditional neuropsychological tests cannot readily answer questions such as the following:

• How is the person with brain injury and the family affected by the cognitive or neuropsychological problems identified?
• Can the client return home or continue with schooling?
• What coping strategies could be employed by the person with neuropsychological deficits?
• Which problems should be targeted in rehabilitation?
• What treatment methods should be employed?
• How should efficacy of treatment be measured?

In order to plan effective rehabilitation we need answers to such questions. People with brain injury and their carers are more concerned with proble...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• PREFACE
• LIST OF TABLES AND FIGURES
• CHAPTER 1 A BRIEF HISTORY OF BEHAVIOURAL APPROACHES IN NEUROPSYCHOLOGICAL REHABILITATION
• CHAPTER 2 ASSESSMENT FOR REHABILITATION: INTEGRATING INFORMATION FROM NEUROPSYCHOLOGICAL AND BEHAVIOURAL ASSESSMENT
• CHAPTER 3 PLANNING A REHABILITATION PROGRAMME USING A BEHAVIOURAL FRAMEWORK
• CHAPTER 4 BEHAVIOURAL APPROACHES TO ASSESSMENT AND MANAGEMENT OF PEOPLE IN STATES OF IMPAIRED CONSCIOUSNESS
• CHAPTER 5 BEHAVIOURAL APPROACHES TO THE REMEDIATION OF COGNITIVE DEFICITS
• CHAPTER 6 BEHAVIOURAL APPROACHES TO DISRUPTIVE DISORDERS
• CHAPTER 7 BEHAVIOURAL APPROACHES TO COOPERATION WITH TREATMENT: THE EFFECTS OF MOOD, INSIGHT, AND MOTIVATION
• CHAPTER 8 STAFF AND FAMILY MEMBERS EDUCATING STAFF AND FAMILY MEMBERS IN THE LONG-TERM MANAGEMENT OF BEHAVIOUR DISORDERS
• REFERENCES