Prevalence, comorbidities, and correlates of challenging behavior among community-dwelling adults with severe traumatic brain injury: a multicenter study.

OBJECTIVE: Investigate the prevalence, comorbidities, and correlates of challenging behaviors among clients of the New South Wales Brain Injury Rehabilitation Program. SETTING: All community-based rehabilitation services of the statewide program. PARTICIPANTS: Five hundred seven active clients with severe traumatic brain injury. DESIGN: Prospective multicenter study. MAIN MEASURES: Eighty-eight clinicians from the 11 services rated clients on the Overt Behaviour Scale, Disability Rating Scale, Sydney Psychosocial Reintegration Scale-2, Care and Needs Scale, and Health of the Nation Outcome Scale-Acquired Brain Injury. RESULTS: Overall prevalence rate of challenging behaviors was 54%. Inappropriate social behavior (33.3%), aggression (31.9%), and adynamia (23.1%) were the 3 most common individual behaviors, with 35.5% of the sample displaying more than 1 challenging behavior. Significant associations were found between increasing levels of challenging behavior and longer duration of posttraumatic amnesia, increasing functional disability, greater restrictions in participation, increased support needs, and greater degrees of psychiatric disturbance, respectively (P < 0.004). Multivariate binomial logistic regression found that premorbid alcohol abuse, postinjury restrictions in participation, and higher levels of postinjury psychiatric disturbance were independent predictors of challenging behavior. CONCLUSIONS: Challenging behaviors are widespread among community-dwelling adults with severe traumatic brain injury. Services need to deliver integrated anger management, social skills, and motivational treatments.

Effectiveness of a group anger management programme after severe traumatic brain injury.

PRIMARY OBJECTIVE: This study examined the effectiveness of a group approach to the treatment of anger management difficulties for people with severe traumatic brain injury (TBI). RESEARCH DESIGN: Repeated-measures design with convenience sampling. METHOD AND PROCEDURE: Participants were community living clients of a tertiary brain injury service. The group programme consisted of 12 weekly sessions based on a cognitive behavioural therapy (CBT) model, with modifications to incorporate compensations for TBI-related cognitive impairment. Treatment effectiveness was measured using the State-Trait Anger Expression Inventory (STAXI), at pre-treatment, post-treatment and follow-up. MAIN OUTCOMES AND RESULTS: The programme was completed by 52 people across nine groups over the years 1998-2006 and 31 of these attended a follow-up session. Completion of the programme was associated with significant decreases in self-reported frequency with which anger was experienced (STAXI Trait Anger) and frequency of expression of anger (Anger Expression-Out), as well as a significant increase in reported attempts to control feelings of anger (Anger Control); changes were maintained at follow-up assessment. CONCLUSIONS: A group CBT approach shows promise as an effective community-based treatment for anger control issues after severe TBI. Future research directions should include a wait-list control group and objective rating of anger expression.

Diagnostic efficiency of demographically corrected Wechsler Adult Intelligence Scale-III and Wechsler Memory Scale-III indices in moderate to severe traumatic brain injury and lower education levels.

Despite the sensitivity of neuropsychological tests to educational level, improved diagnostic accuracy for demographically corrected scores has yet to be established. Diagnostic efficiency statistics of Wechsler Adult Intelligence Scale-III (WAIS-III) and Wechsler Memory Scale-III (WMS-III) indices that were corrected for education, sex, and age (demographically corrected) were compared with age corrected indices in individuals aged 16 to 75 years with moderate to severe traumatic brain injury (TBI) and 12 years or less education. TBI participants (n = 100) were consecutive referrals to an outpatient rehabilitation service and met careful selection criteria. Controls (n = 100) were obtained from the WAIS-III/WMS-III standardization sample. Demographically corrected indices did not provide higher diagnostic efficiency than age corrected indices and this result was supported by reanalysis of the TBI group against a larger and unmatched control group. Processing Speed Index provided comparable diagnostic accuracy to that of combined indices. Demographically corrected indices were associated with higher cut-scores to maximize overall classification, reflecting the upward adjustment of those scores in a lower education sample. This suggests that, in clinical practice, the test results of individuals with limited education may be more accurately interpreted with the application of demographic corrections. Diagnostic efficiency statistics are presented, and future research directions are discussed.

Perinatal loss of Nkx2-5 results in rapid conduction and contraction defects.

Homeobox transcription factor Nkx2-5, highly expressed in heart, is a critical factor during early embryonic cardiac development. In this study, using tamoxifen-inducible Nkx2-5 knockout mice, we demonstrate the role of Nkx2-5 in conduction and contraction in neonates within 4 days after perinatal tamoxifen injection. Conduction defect was accompanied by reduction in ventricular expression of the cardiac voltage-gated Na+ channel pore-forming alpha-subunit (Na(v)1.5-alpha), the largest ion channel in the heart responsive for rapid depolarization of the action potential, which leads to increased intracellular Ca2+ for contraction (conduction-contraction coupling). In addition, expression of ryanodine receptor 2, through which Ca2+ is released from sarcoplasmic reticulum, was substantially reduced in Nkx2-5 knockout mice. These results indicate that Nkx2-5 function is critical not only during cardiac development but also in perinatal hearts, by regulating expression of several important gene products involved in conduction and contraction.

Cognitive rehabilitation after severe traumatic brain injury: a pilot programme of goal planning and outdoor adventure course participation.

PRIMARY OBJECTIVE: To describe and evaluate a pilot community based rehabilitation programme for severe brain injury. RESEARCH DESIGN: A prospective repeated-measures design with a single convenience sample was conducted. METHODS AND PROCEDURES: Eleven participants with a history of severe brain injury completed the programme, which featured an outdoor adventure course, skill development and goal-based learning. In the first stage, practical activities facilitated the development of social skills, group cohesiveness and community integration. The second stage was a 9-day outdoor adventure course, which included physically challenging activities such as camping, bushwalking, abseiling, caving and high rope work. The third stage encouraged individuals to work on the personal goals they had developed. MAIN OUTCOMES AND RESULTS: Over 80% of stated goals were achieved; suggesting that such a programme may be effective in enabling clients to attain specified goals. CONCLUSIONS: The programme shows promise as a form of community rehabilitation.

The differentiation of mild frontotemporal dementia from Alzheimer's disease and healthy aging by neuropsychological tests.

BACKGROUND: Frontotemporal dementia (FTD) is difficult to diagnose in the early stages and may be misdiagnosed as Alzheimer's disease (AD) or as a psychiatric disorder. This study aimed to investigate neuropsychological function in FTD of mild severity and compare it to that of mild AD and healthy control participants. METHODS: The study comprised 11 individuals with FTD, 29 with AD and 27 healthy controls. Participants completed a comprehensive neuropsychological assessment in which each area of cognitive function was examined with several widely used clinical tests. Test scores were converted to age-corrected scaled scores and combined to form indices for six areas of cognitive function. These indices were attention, psychomotor speed, memory acquisition, memory recall, executive function and constructional ability. RESULTS: The FTD group performed below the level of the controls in all areas except constructional ability. FTD and AD groups showed distinct patterns of neuropsychological performance. The FTD group showed predominantly executive dysfunction with less impaired memory function, while the AD group showed the opposite pattern. The capacity of the tests to discriminate between groups was good overall, with 90% of the total sample correctly classified. Predictive success for the FTD group was 64%, given a base rate of 16%. CONCLUSION: Administration of a comprehensive neuropsychological protocol including several tests of executive function allows increased certainty about accurate clinical diagnosis of mild FTD.