Positive behaviour support for challenging behaviour after acquired brain injury: An introduction to PBS + PLUS and three case studies.

Challenging behaviours are a common and distressing consequence of acquired brain injury (ABI). There are no evidence-based guidelines for managing challenging behaviours after ABI, leaving clinicians with few resources to guide practice. Findings from case studies and single-subject experimental designs support the use of positive behaviour support (PBS) interventions for challenging behaviour post-ABI. This paper introduces PBS + PLUS: a multi-component and flexible PBS intervention using a person-driven collaborative approach to build a meaningful life and self-regulate behaviour after ABI. PBS + PLUS is currently being examined in a randomized controlled trial (RCT). Three detailed pilot case studies illustrate the highly individualized implementation of the programme, delivered to the individuals with ABI and carers over 12 months by a transdisciplinary team including neuropsychologists, occupational therapists, and psychiatrists. Objective behavioural outcomes are reported for participants using the Overt Behaviour Scale at baseline and four-monthly intervals for two years. Goal attainment scaling was used to measure personally meaningful goals. The qualitative appraisals of the intervention by participants, families and carers, and 12-month follow-up outcomes are described. The advantages and challenges of programme delivery are discussed. These case studies will assist clinicians and service providers to implement PBS + PLUS in anticipation of the results of the RCT.

Efficacy of Activities of Daily Living Retraining During Posttraumatic Amnesia: A Randomized Controlled Trial.

OBJECTIVE: To assess the efficacy of activities of daily living (ADL) retraining during posttraumatic amnesia (PTA) compared with ADL retraining commencing after emergence from PTA. DESIGN: Randomized controlled trial. SETTING: Inpatient rehabilitation center. PARTICIPANTS: Participants with severe TBI (N=104), admitted to rehabilitation and remaining in PTA for >7 days, were randomized to receive either treatment as usual (TAU) with daily ADL retraining (treatment), or TAU alone (physiotherapy and/or necessary speech therapy) during PTA. INTERVENTIONS: ADL retraining was manualized, followed errorless and procedural learning principles, and included individualized goals. Both groups received occupational therapy as usual after PTA. MAIN OUTCOME MEASURES: Primary outcome was the FIM completed at admission, PTA emergence, discharge, and 2-month follow-up. Secondary outcomes included length of rehabilitation inpatient stay, PTA duration, Agitated Behavior Scale scores, and Community Integration Questionnaire (CIQ) scores at follow-up. Groups did not significantly differ in baseline characteristics. RESULTS: On the primary outcome, FIM total change, random effects regression revealed a significant interaction of group and time (P<.01). The treatment group had greater improvement in FIM scores from baseline to PTA emergence, which was maintained at discharge, but not at follow-up. Twenty-seven percent more of the treatment group reliably changed on FIM scores at PTA emergence. Group differences in length of stay, PTA duration, agitation, and CIQ scores were not significant; however, TAU trended toward longer length of stay and PTA duration. CONCLUSIONS: Individuals in PTA can benefit from skill retraining.

The ecological and construct validity of a newly developed measure of executive function: the Virtual Library Task.

Virtual reality (VR) assessment paradigms have the potential to address the limited ecological validity of pen and paper measures of executive function (EF) and the pragmatic and reliability issues associated with functional measures. To investigate the ecological validity and construct validity of a newly developed VR measure of EF, the Virtual Library Task (VLT); a real life analogous task--the Real Library Task (RLT); and five neuropsychological measures of EF were administered to 30 patients with traumatic brain injury (TBI) and 30 healthy Controls. Significant others for each participant also completed the Dysexecutive Questionnaire (DEX), which is a behavioral rating scale of everyday EF. Performances on the VLT and the RLT were significantly positively correlated indicating that VR performance is similar to real world performance. The TBI group performed significantly worse than the Control group on the VLT and the Modified Six Elements Test (MSET) but the other four neuropsychological measures of EF failed to differentiate the groups. Both the MSET and the VLT significantly predicted everyday EF suggesting that they are both ecologically valid tools for the assessment of EF. The VLT has the advantage over the MSET of providing objective measurement of individual components of EF.