r elevant psychological theory
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R elevant Psychological Theory. Understanding and Analysis relevant psychological theories and models demonstrate your application of relevant psychological theory and models in the clinical or organisational context respond appropriately to ethical issues - PowerPoint PPT PresentationTRANSCRIPT
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Understanding and Analysis relevant psychological theories and models
demonstrate your application of relevant psychological theory and models in the clinical or organisational context
respond appropriately to ethical issues synthesise national policy and guidance
with the clinical material
Relevant Psychological Theory
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Challenges of working with a traumatic frontal lobe
brain injuryBobbie, Caroline, Jason and Jo
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Complexity of traumatic brain injury – psychological, social, financial, behavioural, relational, yadiyadiyada
Content
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INTRODUCTORY AND DEFINITIONS
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Neuroanatomy
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Emotional control centre and home to personality, with damage Area of brain where damage presents with broadest range of
symptoms (Kolb & Milner, 1981)
Involved in motor function, spontaneity, problem solving, memory, judgement, language, initiation, social and sexual behaviour and impulse control
◦ Damage can affect flexibility of thinking, problem solving, attention and memory even following a ‘good’ recovery from a TBI (Stuss et al., 1985)
MRI studies identified frontal as most common region of injury following mild to moderate traumatic brain injury (Levin et al., 1987)
Frontal lobe - Overview
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Orbitofrontal cortex damage
Bechara et al,1994; Kringelbach, 2005; Schore, 2000; Stone, Baron-Cohen, & Knight, 1998; Snowden et al 2001
Area of the brain associated with:◦ regulating planning behaviour◦ sensitivity to reward and
punishment◦ ToM◦ sensory integration◦ representing the affective
value of reinforcers, and decision making & expectation
Destruction of the OFC through acquired brain injury typically leads to a pattern of disinhibited behaviour.
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Types of injury:
Traumatic brain injury◦ If the head receives a serious blow or jolt the brain can be damaged
Acquired brain injury◦ An injury that occurs since birth◦ stroke, haemorrhage, infection, hypoxic/anoxic brain injury and
medical accidents◦ Google books has latest edition of the Textbook of Traumatic Brain
injury (APA, 2011)http://books.google.co.uk/books?id=N_lVQ7Z-YooC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false
Traumatic (acquired) brain injury and behavioural difficulties
Brain injury
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Epilepsy Hormonal changes? Coma Marital breakdown (Landau & Hissett,
2008) Loss of self (Pollack 1994) Relating to others (Campbell, 2003)
Associated head injury difficulties
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Just the figures!
Epidemiology
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Associated difficulties Dysexecutive syndrome (Baddeley 1988; p214)
is used as umbrella term to describe a pattern of deficits in executive functioning.
Use of Behavioural assessment of the Dysexecutive Syndrome (BADS) to address problems with DES, namely high-level tasks such as planning, organising, initiating, monitoring and adapting behaviour (Wilson, Alderman,Burgess, Emslie, and Evans (2003; p. 33).
Frontal lobe specific stuff
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Use of six tests Wilson et al 1998; p215-219: Rule Shift Cards - Assesses the subject's ability to ignore a prior
rule after being given a new rule to follow. Action Program - This test requires the use of problem solving to
accomplish a new, practical task. Key Search - This test reflects the real life situation of needing to
find something that has been lost. It assesses the patient's ability to plan how to accomplish the task and monitor their own progress.
Temporal Judgment - Patients are asked to make estimated guesses to a series of questions such as, "how fast do racehorses gallop?". It tests the ability to make sensible guesses.
Zoo Map - Tests the ability to plan while following a set of rules. Modified Six Elements - This test assesses the subject's ability to
plan, organize and monitor behaviour
BADS
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Confusion over terminology Complexity of neuro understanding Dysexecutive syndrome based on
Baddeleys hypothetical construct of a central executive, (Wilson, Evans, Emslie, Alderman & Burgess; p214)
Critique
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IMPACTS
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“Coping refers to the persons’ cognitive and behavioural efforts to manage (reduce, minimise, master or tolerate) the internal and external demands of the person-environment transaction that is appraised as taxing or exceeding the person’s resources.”◦ Folkman, Lazarus, Gruen & DeLongis (1986, pg. 572)
Direct result of the structural lesion Psychological reaction to the lesion
◦ Somatising Evidence for both
Emotional Impact
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Behavioural difficulties associated with frontal lobe injury impact Challenging behaviour
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CBT for loss/grief◦ Loss of future prospects, adjusting to irreversible
nature of impairments etc. Anxiety and depression
Theories of hopeless and helplessness depression Adjustment disorders
◦ Many patients suffer poor psychosocial adjustment and experience a reduced quality of life Wolters et al. (2010)
◦ Effectiveness of psychotherapy and adjustment Ratzel-kurzdorfer, Franke & Wolfersdorf (2003) Strain & Newcorn (2006)
Theoretical Stance
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ROLE OF PSYCHOLOGY (WHAT CAN BE DONE?)
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“challenging behaviours exhibited by those with ABI are significant obstacles to achieving successful rehabilitative outcomes.”Rahman, Oliver & Alderman, (2010 pg. 213)
“the neurorehabilitation field has been slow to embrace the practice of functional analyses prior to behavioural intervention.”Rahman, et al (2010, pg 212)
STUDY (Rahman et al , 2010) 9 ABI survivors with challenging behaviours (physical aggression, property destruction, self-injury & verbal aggression.)
method -descriptive functional analysis. Found – 1)all 9 participants exhibited at least one behaviour which was socially reinforced. Across all 9 , 88% of challenging behaviours showed a significant concurrent association with an environmental event. Summary Challenging behaviour by 9 ABI survivors adhered to a social model of reinforcement and were functional Assessment using functional analysis in the field of neurorehabilitation may lead to better treatment outcomes.
Critique Repp, Felce and Barton, (1988) “an accurate assessment of behavioural function is required to devise and effective programme of
behaviour change.” There were a variety of injury types and frontal lobe damage was not specified.
Clinical interventions based on functional assessments are still limited (Ager & O’May, 2001)
Functional analysis
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Rahman, Oliver and Alderman (2010) “such behaviours can be decreased and managed by adopting treatment approaches based on operant conditioning.”
any combination of 3 contingencies (Carr,1977) o Social positive reinforcement.
o Social attention, or tangible items /activities (Kodak, Northup and Kelley, 2007) o Social-negative reinforcement
o Behaviours which remove postpone or reduce aspects e.g not needing to do tasks or engage in social contacts (Iwata, Pace, Kalsher, Cowdery, & Cataldo,1990 )
o Automatic reinforcemento non environmental BUT internal e.g.perceptual feedback (Lovaas, Newsom & Hickman, 1987)Pain attenuation (Sandman & Hetrick, 1995)
Behavioural treatment models have been successfully applied for ABI (Corrigan & Bach, 2005)
Behavioural approaches
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Assessment Formulation Intervention etc……………..
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Brain Injury Association of America National Institute of Neurological Disorders and Stroke (NINDS) Brain Injury Association of Canada Brain Injury Association of Queensland Australia Headway - the brain injury association Ontario Shores Centre for Mental Health Sciences Ontario Brain Injury Association NICE guidelines, but only for Triage, assessment, investigation and early management of
head injury in infants, children and adults Head injury (CG56 It does not address the rehabilitation or long-term care of patients with a head injury http://www.nice.org.uk/nicemedia/live/11836/36260/36260.pdf Rehabilitation following acquired brain injury National clinical guidelines - by Royal
College of physicianshttp://bookshop.rcplondon.ac.uk/contents/43986815-4109-4d28-8ce5-ad647dbdbd38.pdf ◦ Included recommendation for clinical psychology provision! per 500000 of population (pg18)
More British ones - found Headwayhttp://www.headway.org.uk/home.aspx
National Policy and guidance
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Teaching the patient and family to adapt their lifestyle
Taking into account the severity of cognitive and behavioural problems
Patient being stimulated to learn new skills and compensatory strategies
To return to activities of daily life and participate in society ◦ Wilson (2000)
Aims of cognitive rehabilitation
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Jo
Group work
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Parente (in Shaughnessy & Beyer, 2010)
An approach (American) incorporates therapy group and individual work. Using around topics identified by client and family surveys prior to therapy;
Memory training - devices – mobile phones, digital recorders , planners and checklists
Disinhibition and hostility – learning to defuse situations , cue words.
Emotional dysregulation & Impulse control – Medication, making client aware of issue, looking at scenarios and possible responses.
Less aware of normative social behaviour – teach techniques, pair work, video recordings.
Other Psychological effectsLoss of hopeCo-occuring PTSDShame and embarrassment (around social behaviour)
Cognitive Rehabilitation - an approach
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Systemic issues
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Increase in traumatic brain injuries in veterans returning from war◦ America, rehab, v pricey
Current issues
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Communication problems Family issues Informed consent Clinical responsibility / Organisational
◦ Which services are best to deal with traumatic brain injury and in particular support with the challenging behaviour?
Social care needs
Issues of ethics and capacity
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Who has overall clinical responsibility?
Critique
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Summary
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What would be different if it was an organically caused brain injury?
Impact on client, carer, wider system, CP
What issues would be unique to TBI?
How would impact of CP differ?
Discussion Points
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Questions
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Ager, A., & O’May, F. (2001). Issues in the definition and implementation of “best practice” for staff delivery of interventions for challenging behaviour. Journal of Intellectual & Developmental Disability, 26, 243–256.
Baddeley, A., & Wilson, B. (1988). Frontal amnesia and the dysexecutive syndrome. Brain and Cognition, 7, 212-230
Bechara, A., Damasio, A.R., Damasio H., & Anderson, S.W. (1994) "Insensitivity to future consequences following damage to human prefrontal cortex". Cognition 50: 7-15.
Carr, E. G. (1977). Motivation of self-injurious behavior: A review of some hypotheses. Psychological Bulletin, 84, 800–816.
Folkman, S. Lazarus, R. S., Gruen, R. J. & DeLongis, A. (1986) Appraisal, coping, health status and psychological symptoms Journal of Personality and Social Psychology, 50, 571-579.
Guess, D., & Carr, E. (1991). Emergence and maintenance of stereotypy and self-injury.American Journal on Mental Retardation, 96, 299–319.
Iwata, B. A., Pace, G. M., Kalsher, M. J., Cowdery, G. E., & Cataldo, M. F. (1990). Experimentalanalysis and extinction of self-injurious escape behavior. Journal of Applied Behavior Analysis, 23, 11–27.
Kodak, T., Northup, J., & Kelley, M. E. (2007). An evaluation of the types of attention that maintain problem behavior. Journal of Applied Behavior Analysis, 40, 167–171.
Kolb, B., & Milner, B. (1981). Performance of complex arm and facial movements after focal brain lesions. Neuropsychologia, 19:505-514.
Kringelbach, M.L. (2005) The orbitofrontal cortex: linking reward to hedonic experience. Nature Reviews Neuroscience 6: 691-702.
References
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Lovaas, I., Newsom, C., & Hickman, C. (1987). Self–stimulatory behavior and perceptual reinforcement. Journal of Applied Behavior Analysis, 20, 45–68.
Levin et al. (1987). Magnetic resonance imaging and computerized tomography in relation to the neurobehavioral sequelae of mild and moderate head injuries. Journal of Neurosurgery, 66, 706-713.
Rahman,B., Oliver,C.& Alderman,N.(2010) Descriptive analysis of challenging behaviours shown by adults with acquired brain injury. Neuropsychological Rehabilitation,20 (2), 212–238
Repp, A. C., Felce, D., & Barton, L. E. (1988). Basing the treatment of stereotypic and selfinjurious behaviors on hypotheses of their causes. Journal of Applied Behavior Analysis, 21, 281–289.
Sandman, C. A., & Hetrick, W. P. (1995). Opiate mechanisms in self-injury. Mental Retardation and Developmental Disabilities Research Reviews, 1, 130–136.
Shaughnessy,M.F.& Beyer,J.(2010) An interview with Rick Parente:head injury and brain trauma, N.American journal of psychology, Vol.12, No 2, 221-232.
Schore A.N., (2000) Attachment & the Regulation of the Right BrainAttachment & human Development 2(1) 23-47.
Snowden, J. S.; Bathgate, D.; Varma, A.; Blackshaw, A.; Gibbons, Z. C. & Neary. D. (2001) Distinct behavioural profiles in frontotemporal dementia and semantic dementia. Journal of Neurological Neurosurgical Psychiatry 70: 323-332.
Stone, V.E.; Baron-Cohen, S. & Knight, R. T. (1998a) "Frontal Lobe Contributions to Theory of Mind." Journal of Medical Investigation 10: 640-656.
Stuss, D. et al. (1985). Subtle neuropsychological deficits in patients with good recovery after closed head injury. Neurosurgery, 17, 41-47.
Wilson, B.A., Evans, J.J., Emslie, H., Alderman, N., & Burgess, P. (1998). The development of an ecologically valid test for assessing patients with a dysexecutive syndrome. Neuropsychological Rehabilitation, 8, 213-228.
Wilson, B.A., Alderman, N., Burgess, P.W., Emslie, H., and Evans J.J. (2003). Behavioural assessment of the Dysexecutive Syndrome (BADS). Journal of Occupational Psychology Employment and Disability, 5 (2), 33-37.
Wolters, G., Stapert, S., Brands, I. & Van Heugten, C. (2010) Coping styles in relation to cognitive rehabilitation and quality of life after brain injury. Neuropsychological Rehabilitation 20(4), 587- 600.
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