Principles & Practice of Neurobehavioural Rehabilitation

1. Principles & Practice of Neurobehavioural Rehabilitation Prof. Rodger Ll., Wood College of Medicine Swansea University Wales, UK

2. ‘NEURO’ • Identifies ‘organic’ constraints on:- • Social learning. • Emotional control. • Regulated behaviour. • Adaptive behaviour. • Affect (emotional expression).

3. Barriers to Good Psychosocial Outcome after TBI • Poor inhibitory control:- aggression, disinhibition • Diminished drive, interest, and motivation • Poor social cognition • Lack of initiative & purposeful behaviour. • Problems planning or making decisions • Diminished awareness & poor judgement • Unrealistic aspirations

4. ‘BEHAVIOURAL’ • Disability construed behaviourally • in terms of social handicap. • Rehabilitation goals • designated in terms of specific social or functional behaviours. • Progress • measured in terms of behaviour change.

5. COMPONENTS • Post-acute. • Slow stream rehabilitation. • Behaviour Management Capability • Structured environment. • System of reinforcement • Principles of Learning Theory • Community-Based training. • Behaviourally-defined rehabilitation goals • Organisational structure of staff

6. Why Post Acute? • Intensive rehabilitation at an acute stage:- • does not prevent cognitive and behavioural problems persisting beyond early recovery phase. • Problems of awareness, judgement and self-regulation, • often not evident until after discharge.

7. WHY SLOW STREAM? • Cognitive deficits impose constraints on learning and rehabilitation • Rehabilitation interventions • long term, not ‘intensive’. • Aim is to establish habit patterns • Which takes time. • Learned components of organically determined behaviour disorders take time to unlearn.

8. Behaviour Management Capability • Behaviour disorders act as a barrier to rehabilitation and good psychosocial outcome. • NBR must be capable of:- • Containing & reducing frequency of challenging behaviour. • Creating opportunities to reinforce adaptive & appropriate behaviour. • Raising awareness of socially appropriate behaviour.

9. Structured Environment • Clearly identified system of rules • and frequent feedback opportunities. • Continuity of rehabilitation procedures • and regular practice of functional/social skills. • System to ensure reliable communication:- • of observations regarding patient’s behaviours and functional abilities • of staff roles and responsibilities • Opportunities for constructive use of leisure time

10. Dual Role of Reinforcement • Reward: To motivate behaviour. • Feedback: To promote awareness and understanding. • The Token Economy

11. ‘Token Economy’ • Points System • In form of tokens or points given or removed based on behaviour/achievement/effort within a time frame. • Material Reward Value • Exchanged for small short term rewards or larger - long term rewards • Social ‘Status’ Value • Allocation of points marked on chart in communal area. • Shows relative earnings of client group. • Comments/feedback from other clients • Cultivates habit of self-monitoring & improves self-awareness.

12. Benefits to staff • Helps focus staff attention on important behaviours • Raises staff awareness of client’s performance over time. • Provides basis for meaningful feedback • Opportunity for meaningful engagement & social reinforcement. • Improves client’s self-awareness.

13. Some benefits of improved self awareness • Improved self-monitoring. • Better compliance and motivation • Better self-regulation • Improved potential for adaptive behaviour.

14. Community Rehabilitation Hospitals are for ill people to be cared for; rehabilitation is about learning to do things for yourself.

15. Community Training • Minimises drive and motivational problems. • Provides direction, purpose and meaning to life. • Opportunities for meaningful feedback to improve awareness. • Sheltered work opportunities • Initiative, planning and organisation. • Development of social routines • Helps skills generalise. • Opportunities to consolidate skills as habit patterns.

16. The Neurobehavioural Rehabilitation Team • Therapy does not only take place in time-limited formal sessions, with qualified therapists during the nine-to-five working day. • Continual application of interventions. • Effort and achievements reinforced through interaction with every member of the team. • The whole team are empowered to regard their role as that of agent for behaviour change.

17. Working relationships between different therapy disciplines • Need to be inter-disciplinary rather than multidisciplinary. • Careful interdisciplinary assessment and structured observations identify how problems of attention, awareness, and executive function undermine aspects of everyday behaviour.

18. Rehabilitation Process • Therapists conduct assessments and prescribe interventions. • Interventions largely carried out by therapy care assistants or rehabilitation support workers under the guidance of clinicians. • Departure from the traditional division of hospital labour between doctors, nurses, therapists on one hand, and auxiliaries or healthcare assistants who were allocated domestic responsibilities.

19. A Psychological-Learning Framework • Therapy interventions in every discipline place an emphasis on learning theory methods of intervention. • Practitioners need to have knowledge of associational learning methods to devise effective rehabilitation interventions . • Rehabilitation programmes therefore led by clinical neuropsychologists rather than medical doctors.

20. The Rehabilitation Plan • Understand the brain injury • In relation to nature of neurobehavioural disabilityand constraints on learning or generalising • Establish obstacles to achieving goals. • Nature of impairment & disability • Time constraints & Staff resources • Determine treatment goals • That have functional value for the individual & his/her family. • Measure progress in ways that reflects functional change.

21. Structured observations of behaviour • During different activities. • At different times of day. • In different social (or inter-personal) contexts.

22. ABC Analysis The aim is to identify what triggers or reinforces specific behaviours. A B C Antecedent Behaviour Consequences Helps establish behavioural contingencies

23. Time Sampling:- • Monday: 08.00 - 09.00 13.00 - 14-00 • Tuesday: 09.00 - 10.00 14.00 - 15-00 • Wednesday: 10.00 - 11.00 15.00 - 16.00 • Thursday: 11.00 - 12.00 16.00 - 17.00 • Friday: 12.00 - 13.00 17.00 - 18.00

24. Measure of quality or intensity of behaviour Likert Rating Scale Rude 0 ------------------------ 5 Polite Angry 0 ------------------------ 5 Calm Inappropriate 0 ------------------------ 5 Appropriate

25. Predicting Progress

26. Setting Treatment Goals A ‘Smart’ Approach • Specific • Measurable • Appropriate • Realistic • Time Framed • (Standards of client, not staff)

27. Treatment Goals • Behaviourally defined. • Socially & functionally relevant. • Part of a discharge plan. • Inter-disciplinary.

28. Rehabilitation Plan Discharge Goals Intermediate Goal Intermediate Goal Intermediate Goal Target Behaviour Target Behaviour Target Behaviour Target Behaviour Target Behaviour Target Behaviour

29. The Learning ParadigmProcedural or Declarative ? • DECLARATIVE • Learning through understanding • Concept formation. • Awareness of principles. • “A passive store of information” • PROCEDURAL • Learning by experience • Making associations • Practice and rehearsal

30. Procedural Learning • Not dependent on memory. • Knowing how, not why! • Slow acquisition. • Repeated practice. • Situation specific.

31. Aristotle What I learn I learn by doing. Excellence is not an art, it’s a habit.

32. Development of Habit Patterns • Habit patterns are over-learned skills • Repeated practice of statements and actions. • Associational learning between overt language and action sequences. • Practice in a variety of social settings to promote generalisation.