Neuropsychological rehabilitation following acquired brain injury is increasingly recognized as essential with the advancements in research evidence of its effectiveness, particularly as current estimates of disability following the most common forms of brain injury (traumatic brain injury and cerebrovascular accident) are so high. Improvements in predictive capabilities of researchers and clinicians are paramount in designing effective interventions. As many variables associated with outcome following brain injury are not controllable (e.g. severity of the injury, age, education), it is essential that rehabilitation programs design interventions to target those variables that are susceptible to amelioration. While personality factors have been shown to affect outcome in other medical illnesses, only a few studies have examined the influence of personality on outcome following neurorehabilitation for acquired brain injury. The results of these studies have been mixed. This study used the Millon Behavioral Medicine Diagnostic (MBMD) to predict outcome as measured by the Mayo-Portland Adaptability Index (MPAI-4) following brain injury rehabilitation in a heterogeneous sample of persons with acquired brain injuries (N = 50). It was hypothesized that specific coping styles scales from the MBMD (Introversive, Dejected, Oppositional), which are based on Millon's personality system, would predict outcome. Results indicated that both the Introversive and Oppositional coping styles scales accounted for significant amounts of variance in outcome beyond that accounted for by the severity of the injury alone (p < .001). In both cases, individuals with mild/moderate-moderate/severe limitations following completion of the rehabilitation program had significantly higher scores on the Introversive and Oppositional coping compared to individuals with more successful outcomes. The hypothesis that a dejected coping style would predict outcome was not supported. Implications for rehabilitation are discussed in the context of Millon's personality system.

While the cognitive disturbances that frequently follow severe TBI are relatively well understood, the ways in which these affect the psychosocial functioning of people with TBI are yet to be determined and have thus received little attention in treatment research. Growing evidence indicates that that a significant proportion of individuals with TBI demonstrate deficits in the perception of affective information from the face, voice, bodily movement and posture. As accurate evaluation of emotion in others is critical for the successful negotiation of social interactions, effective treatments are necessary. Until recently, however, there have been no rehabilitation efforts in this area with TBI groups. The present research aims to redress this absence. The literature on emotion perception deficits in TBI is examined, and a theoretical rationale for intervention is presented. Several lines of research are reviewed which suggest that rehabilitation targeting such deficits is tenable. These include research on emotion perception remediation with other cognitively impaired populations, findings from cognitive neuroscience suggesting the potential for neuronal restoration after brain damage, and the successful applications of remediation techniques, in particular errorless learning and self-instruction, for treating other cognitive deficits in a range of neurological disorders and TBI. Discussion of this research is followed by a description of two randomised controlled trials aimed at improving emotion perception in individuals with TBI. The findings are discussed with reference to useful theoretical models of rehabilitation, learning and emotion perception. Suggestions for future directions of research are outlined together with relevant design issues.

While the cognitive disturbances that frequently follow severe TBI are relatively well understood, the ways in which these affect the psychosocial functioning of people with TBI are yet to be determined and have thus received little attention in treatment research. Growing evidence indicates that that a significant proportion of individuals with TBI demonstrate deficits in the perception of affective information from the face, voice, bodily movement and posture. As accurate evaluation of emotion in others is critical for the successful negotiation of social interactions, effective treatments are necessary. Until recently, however, there have been no rehabilitation efforts in this area with TBI groups. The present research aims to redress this absence. The literature on emotion perception deficits in TBI is examined, and a theoretical rationale for intervention is presented. Several lines of research are reviewed which suggest that rehabilitation targeting such deficits is tenable. These include research on emotion perception remediation with other cognitively impaired populations, findings from cognitive neuroscience suggesting the potential for neuronal restoration after brain damage, and the successful applications of remediation techniques, in particular errorless learning and self-instruction, for treating other cognitive deficits in a range of neurological disorders and TBI. Discussion of this research is followed by a description of two randomised controlled trials aimed at improving emotion perception in individuals with TBI. The findings are discussed with reference to useful theoretical models of rehabilitation, learning and emotion perception. Suggestions for future directions of research are outlined together with relevant design issues.

Pharmacological interventions to treat Human Immunodeficiency Virus (HIV) with antiretrovirals (ARVs), have dramatically improved the survival rates of HIV positive children maturing into adulthood. However, HIV-associated neurocognitive decline still persists in the era of ARVs. Within the framework of brain plasticity, a number of researchers have begun to assess the feasibility of cognitive rehabilitation therapy as a complement to ARVs to reverse neurocognitive decline as a result of HIV (e.g., Becker et al., 2012). Only one study has been conducted in South Africa, by Zondo & Mulder (2014), assessing the efficacy of cognitive rehabilitation in a paediatric sample. The current research builds on the above mentioned study by implementing an experimental approach to examine the effect of cognitive rehabilitation in a sample of both HIV positive and HIV negative children. Five HIV positive and six HIV negative children were assigned to either an experimental or control group. The experimental group underwent two months of cognitive rehabilitation therapy remediating sustained attention, whereas the control group took part in placebo activities. Sustained attention measures were taken before and after the intervention training sessions, using a sustained attention subtest from the Test of Everyday Attention for Children (TEA-CH). A Mann Whitney U Test revealed that the experimental group (Mdn=38.50) did not differ significantly from the control group (Mdn = 37.00) after the cognitive rehabilitation intervention, U=12.00, z= -.55, p= .66, r= -.17. But a Wilcoxon Signed Rank Test found that there was a significant improvement from pretest scores (Mdn=31.00) to posttest scores (Mdn=38.00) following the rehabilitation for HIV positive participants in the sample, T=15.00, z = -2.02, p= .04, r= -.90. This raises the possibility that cognitive rehabilitation could be used as a low cost intervention in underdeveloped contexts

The development of emergency department medical interventions and the implementation of fast-transport trauma systems has decreased the rate of death resulting from traumatic brain injury (TBI). Without corresponding methods for long-term treatment and recovery, the prevalence of people disabled by TBI has increased, creating a growing public health problem. Investigations generated by physicians, rehabilitation programs, and social scientists, which attempt to associate standard measures of injury severity with outcome, leave unexplained variance in long-term functional status for persons with TBI. The purpose of this investigation was to use persons with brain injury and their family members, to guide an analysis of the factors that foster successful recovery from brain injury. Three studies were conducted. In Study #1, the method for observation generated by Kurt Goldstein (1934) was adopted to conduct 20 case studies of persons who sustained brain injury. The Schema of the EsEx Couple (Maynard. 1992) was used to orient the investigation. The EsEx Couple Schema proposes that events in human life must be understood by considering the whole system of Person (Essence) in the Environment (Exchange), and the transactions that flow in a recursive loop from Person to Environment and back. Kurt Goldstein's Laws of Organismic Life (1934), a model consistent with that of the EsEx Couple, was used to evaluate the data. Strong patterns associated family and social networks, autonomy, and perceived self-determination with higher levels of recovery, and were used to generate a Model for Recovery. In Study #2. the Motivational Analysis of Self-Systems Processes (Connell & Wellborn, 1991) was combined with results from Study #1 to generate a Development Model, and to build a survey which was administered to 248 persons with brain injury. Results (1) confirmed the model, indicating factors that contribute to recovery were hypothesized measures of Social Context, Perception, and Engagement; and (2) established a valid instrument, generated by persons with brain injury and their families, for measuring functional status. In Study #3. results of the survey research were used to return to the case studies to consider where individual lives differ from expected patterns, and why. Deviations from expected patterns were explored to identify how individual differences operate to affect outcome. Recommendations for clinical practice include (1) directing interventions toward family as well as patient, as a method of enhancing the Social Context for the patient, and (2) using careful evaluation of each patient's idiosyncrasies to consider individual interventions.

published_or_final_version / Social Work and Social Administration / Doctoral / Doctor of Philosophy

When children have a moderate to severe traumatic brain injury (TBI), they are treated in a continuum of care that includes triage and emergency care, hospitalization, rehabilitation and outpatient therapy. Physical and cognitive recovery from brain injury may take several years. Children’s recovery varies, depending on numerous factors including pre-injury conditions and injury severity. While children and families are eager to return home to familiar activities, there are often significant physical, cognitive, behavioral and emotional changes that challenge families. Successful community reintegration depends on the ability of the family to understand and support the child, dealing with and responding effectively to those challenges. The purpose of this study is to understand how parents manage the care and community reintegration of their child who has experienced a TBI over time. This study utilized a mixed methods approach exploring the dimensions of the health challenge faced by parents caring for a child after a TBI, critical turning points as they face health challenges, and approaches for movement toward resolving health challenges. Story theory and story inquiry method were used to gather stories from 10 parents of children who experienced moderate to severe traumatic brain injury between the ages of 12 and 18, and between 2 and 5 years ago. Parents’ perceptions of their child’s quality of life and their ability to manage their child’s health challenge were explored using the Pediatric Quality of Life Inventory and Family Management Measure. Health challenges identified were: living with overwhelming personal upheaval, navigating the unknown, and struggling with how to support independence/dependence. Turning points were chronological or epiphanies. Approaches for movement toward resolving were continuously re-creating a new normal, being fully engaged in meeting the needs of one’s child, and embracing caring relationships to construct the new normal. Qualitative and quantitative data were analyzed to synthesize the findings. Results include a sense of ease in managing the health condition of the child associated with continuously creating a new normal. Healthcare providers can support and strengthen family management of children after TBI by understanding the health challenge, critical turning points and how parents move toward resolving. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2014. / FAU Electronic Theses and Dissertations Collection

Doctor of Philosophy / Persons with acquired brain injury require continuing support and care in various aspects of their lives many years post-injury. Their care and support are mainly provided by family members. While respite is one of a range of critical support systems for carers and people with life-long disability, very little is known about respite in the area of acquired brain injury. The majority of the research on respite has been undertaken in developmental disability, mental health and in aged care, but there is no research to date about respite from the perspectives of the person with a disability, the carer and respite provider. There is also no research that examines these perspectives in the acquired brain injury literature. This study was aimed to address this gap in the literature by investigating respite from the perspectives of the person with acquired brain injury, the carer and the respite provider. It also examined the profile of respite services being provided in the Australian state of New South Wales as there had not been a comprehensive mapping of respite before. Survey methodology was used to gather information from persons with acquired brain injury and their carers who were members of the New South Wales Brain Injury Association, which is the peak advocacy association of people with brain injury. The same methodology was used to gather similar information from members of Interchange Respite Care New South Wales, which is a peak association representing respite providers in the state. The survey questionnaires were developed and designed after an extensive review of the literature, and were reviewed by experts in the fields of respite, disability and acquired brain injury. The survey questionnaire was also trialled on a sample of families. The survey questionnaires for the three participant groups shared several common sections, such as demographic information; factors influencing respite use; expectations of respite; and satisfaction with respite services used by persons or carers. The responses from the three participant groups were analysed and compared using logistic regression and descriptive statistics. The key findings of the study are (a) several characteristics or factors of the person with acquired brain injury and their carer were significantly associated with the use of respite, (b) there were several common factors that all three participant groups reported to influence respite use, and (c) there were several common expectations of respite among the three participant groups. Some of the characteristics or factors that were significantly associated with respite use included the severity of disability, the high level of dependency of the person with acquired brain injury, and the number of days spent in a coma. Common factors reported by all three participant groups to influence respite use included the stress level of the carer and the severity of disability. Factors reported to influence respite use appear to be consistent with the literature in developmental disability. There were common perspectives regarding the expectations of respite among all three participant groups, such as the need for trained and qualified respite staff; a wider range of respite services and more flexibility of respite service provision. The study also indicated a reported lack of sufficient respite for persons with acquired brain injury and their carers. Some of the findings of the study appeared to be consistent with the research literature on acquired brain injury; such as the majority of carers being mainly female; there is a reliance on informal networks for the care and support of the person with acquired brain injury; and the majority of the persons with acquired brain injury being male. The study also found that many respite providers in New South Wales had extensive experience in running a respite service. The findings of the study have important implications for policy direction and development, practice and service delivery, and research. In terms of policy direction and development, implications explored included: a flexible funding model that is responsive to the needs of carer and person with acquired brain injury, and adequately trained and qualified staff and volunteers play an important role in respite provision. Further research is required to understand empirically the benefits and quality of life outcomes over a period of time, such as what types and extent of respite are more beneficial for certain demographic profiles. The study highlights the perspectives of persons with acquired brain injury, their carers and respite providers. Respite is an important support system to enable persons with acquired brain injury to receive the continuing care and support from their carers. Respite in acquired brain injury is a new field that merits further research as it holds the potential for addressing the needs of people with acquired brain injury and their carers.

The single subject alternating treatment design experiment reported here compared the effectiveness of pencil-and-paper versus computerized communication treatment for neurologically impaired adults. Five stroke patients receiving outpatient speech/language treatment (ages 51-72) served as subjects. One subject completed the experiment as designed and clearly supported the hypothesis that a higher number of correct responses would be produced using the computer generated exercises than the pencil-and-paper version. Two subjects were unable to demonstrate improvement using the experimental treatment program and the other two subjects were unable to master keyboarding skills necessary to use the computer effectively. However, four out of five subjects preferred using the computer even though it did not result in improved performance. Details of specific subjects' performance, and benefits and cautions regarding computer use are discussed. Results suggest that adequate receptive language skills favor effective computer use while impulsivity and visual spatial deficits may be expected to interfere. Careful matching of treatment task to the individual is important; if the task is too easy or too difficult potential benefit of computer use may be masked. The study also supports the finding that computer use is a highly motivating treatment technique for some patients and may be of benefit even if improved task performance does not result. Suggestions for further research include comparison of computerized versus non-computerized treatment for a greater variety of tasks, careful task analysis of currently available software, examination of techniques for training the mechanics of computer use, examination of specific subject characteristics which correlate with successful use of the computer, and determination of which aspect of computer use, specific feedback or improved motivation, is responsible for improved performance. / Graduation date: 1992

While the focus of rehabilitation following traumatic brain injury (TBI) is often on management of physical and cognitive impairments, emotional and behavioural changes in the person with the injury may represent major hurdles in adjustment following injury. Mood, anxiety and adjustment disorders are common following TBI. A manualised cognitive behavioural therapy (CBT) treatment programme was developed that incorporated provision of education on consequences of TBI, used cognitive and behavioural strategies to recognise and manage emotional reactions to injury, and promoted achievement of personal goals. Participants were nine people with TBI referred to Massey University Psychology Clinic Wellington, for psychotherapy to assist in managing symptoms of psychological distress or adjustment difficulties following injury. Measures used included the Hospital Anxiety and Depression Scale (HADS) to monitor progress in reduction of symptoms of Anxiety and Depression; the Patient Competency Rating Scale (PCRS) to assess competency across areas of day-to-day living; and the Homework Rating Scale Second Edition (HRS-II) to assess the value of homework assignments for participants. Results were presented graphically in group format and in the form of individual case studies outlining progress in achieving individual goals. There was considerable variation in the responses of participants to treatment. When anxiety and depression were secondary to other referral issues such as fatigue and pain that remained high over treatment sessions, there was limited movement on HADS Anxiety and Depression scores. The small number of participants impacted on the ability to detect differences between Patient and Informant ratings on the PCRS or to demonstrate increased levels of awareness over treatment sessions. Consistent completion of Homework assignments proved difficult for participants. Factors that impacted on achievement of personal goals included ongoing levels of fatigue and pain, levels of personal expectation, interpersonal and organisational skills, insight into emotional reactions, and good family and social support. There is a part for a CBT approach in adjusting to changes following TBI, particularly in assisting with reassessing expectations following injury.