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There is a robust body of research regarding outcomes following pediatric acquired brain injury (ABI). However, these studies generally explore medium-term outcomes (i.e., 3 to 12-months postinjury), whereas functioning during acute stages following ABI is poorly understood. In particular, there is limited knowledge regarding caregiver functioning during a child’s hospitalization immediately after ABI. This study sought to identify and model caregiver and child predictors of ‘caregiver confidence’ in caring for their hospitalized child. Caregivers of 45 children with diverse types of new-onset acquired brain injuries completed self-report measures of their own psychological functioning, stress, and confidence levels, as well as their perceptions of their child’s stress and coping. Results showed that caregiver psychological functioning was negatively associated with caregiver confidence, and caregiver perceptions of child coping were positively associated with caregiver confidence. Child functional status did not serve as a significant mediator in this relationship as per the hypothesized model.

There is a robust body of research regarding outcomes following pediatric acquired brain injury (ABI). However, these studies generally explore medium-term outcomes (i.e., 3 to 12-months postinjury), whereas functioning during acute stages following ABI is poorly understood. In particular, there is limited knowledge regarding caregiver functioning during a child’s hospitalization immediately after ABI. This study sought to identify and model caregiver and child predictors of ‘caregiver confidence’ in caring for their hospitalized child. Caregivers of 45 children with diverse types of new-onset acquired brain injuries completed self-report measures of their own psychological functioning, stress, and confidence levels, as well as their perceptions of their child’s stress and coping. Results showed that caregiver psychological functioning was negatively associated with caregiver confidence, and caregiver perceptions of child coping were positively associated with caregiver confidence. Child functional status did not serve as a significant mediator in this relationship as per the hypothesized model.

Individuals with and acquired brain injury (ABI) often experience low motivation to engage in rehabilitation. However, measures of motivation and engagement in ABI populations are scarce. Currently, four such measures exist: the Brain Injury Rehabilitation Trust Motivation Questionnaire-Self (BMQ-S), the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire (MOT-Q), the BMQ-Relative (BMQ-R), and the Rehabilitation Therapy Engagement Scale (RTES), but are without sufficient psychometric investigations and lack a theoretical framework. The purpose of this thesis was to evaluate the psychometric properties of the BMQ-S, MOT-Q, BMQ-R, and RTES in adults with an ABI, and to discuss how motivation theory can inform assessment of motivation in ABI. Thirty-nine adult ABI participants and 20 clinicians were recruited from an ABI rehabilitation program. Patient participants completed the BMQ-S, the MOT-Q, and self-rated measures of insight, apathy, depression, and anxiety. Clinician participants completed the BMQ-R, the RTES, and clinician-rated measures of insight and apathy. The MOT-Q and the BMQ-S had excellent internal consistency and test-retest reliability. The MOT-Q correlated with insight, while the BMQ-S correlated with apathy, depression, anxiety, and insight. The MOT-Q and the BMQ-S did not correlate with each other. The RTES and BMQ-R had excellent internal consistency and good inter-rater reliability. The RTES and the BMQ-R correlated with apathy and insight, and with each other. In light of the result that the BMQ-S and the MOT-Q did not correlate, it was determined that each measure may represent equally important but distinct aspects of motivation. By drawing upon Self-determination Theory, it was concluded that the BMQ-S and the MOT-Q may represent intrinsic and extrinsic motivation, respectively, and that utilizing both can provide a more comprehensive understanding of what factors are influencing a patient’s level of motivation to engage. / Thesis / Master of Science (MSc) / Low motivation to engage in rehabilitation is a common problem in acquired brain injury (ABI) populations. Four current measures of patient and clinician-rated motivation and engagement designed for ABI exist: the Brain Injury Rehabilitation Trust Motivation Questionnaire-Self (BMQ-S), the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire (MOT-Q), the BMQ-Relative (BMQ-R), and the Rehabilitation Therapy Engagement Scale (RTES). However, these measures have insufficient investigations into whether they accurately measure motivation, and lack a theoretical framework as a basis of assessment. The goal of this thesis was to determine the reliability and validity of four motivation and engagement measures in an ABI population, and discuss the role of motivation theory in improving assessment of motivation in ABI. The results of this thesis suggest that all measures have good to excellent reliability and validity, and that the BMQ-S and the MOT-Q may represent distinct but equally important aspects of motivation in ABI.

The purpose of this thesis is to explore the changes to family dynamics that result from invisible symptoms of acquired brain injury The perspective put forth is that of individuals living with invisible symptoms of acquired brain injury. This study is based on a thematic analysis of the findings from nine semi-structured interviews with individuals (aged 24-64 yrs.; 6 men, 3 women) who have been formally diagnosed with an acquired brain injury. The data is interpreted and discussed using a critical framework, specifically, Critical Disability Theory. The findings from this analysis illustrate how invisible symptoms such as cognitive impairments, memory loss, mood changes etc., of acquired brain injury affect family dynamics in relation to emotional roles, domestic roles, financial roles, and perception and treatment of the affected individual. These changes were either exacerbated or minimized by the assumptions, misconceptions and knowledge level of the individual’s family in relation to understanding brain injury and the ways in which disability can manifest. Also important to family relations are the perceptions of participants that they must prove that they do have a disability; the roles healthcare professionals play in the validation of the injuries, both to the individual and the family; and how powerfully dominant constructions of disability – and invisible acquired brain injury in particular – are ingrained in social discourse and impact upon family dynamics for people living with invisible acquired brain injury. Lastly, an important part of this research is a compilation of recommendations put forth by the participants for healthcare professionals to keep in mind when working with individuals who either are suspected of having or have an acquired brain injury. / Thesis / Master of Social Work (MSW)

Acquired Brain Injury (ABI) can result in significant and long lasting additional needs for children, their families and the professionals tasked with supporting them (Middleton, 2001b; Walker & Wicks, 2005). This paper reports the two parts of a small scale study, the aim of which was to illuminate the factors (areas of good practice, issues & challenges) involved in educating children after ABI. The first paper explores the views and experiences of children and young people with ABI and their parents. It identifies how children describe their experiences of school since injury, their parent’s experience of the injury and schooling thereafter, as well as what areas of need exist in terms of improvement in support for this group of children and young people. The second part explores the views and experiences of school based practitioners as well as professionals from a range of external agencies that work with children, young people, their families and schools. The main aims were to stimulate discussion of what roles school staff and external agency professionals have in supporting children with ABI, the ways in which they work together and with children, young people and families and what, if any, improvements were thought to be important. Together, both parts of this research seek to illuminate pertinent factors for those involved, in order to inform future practice for Educational Psychologists (EPs) and the professionals they work with in schools and external agencies.

Adults with mild to moderate acquired brain injury (ABI) often pursue post-secondary or professional education after their injuries in order to enter or re-enter the job market. An increasing number of these adults report problems with reading-to-learn. The problem is particularly concerning given the growing population of adult survivors of ABI. Combat-related brain trauma and sports concussions are two factors contributing to increases in traumatic brain injuries, while higher incidences of stroke in young adults and better rates of survival after brain tumors are contributing to increases in non-traumatic brain injuries. Despite the rising need, empirical evaluation of reading comprehension interventions for adults with ABI is scarce. This study used a within-subject design to evaluate whether adult college students with ABI with no more than moderate cognitive impairments benefited from using a multi-component reading comprehension strategy package to improve comprehension of expository text. The strategy package was based on empirical support from the cognitive rehabilitation literature that shows individuals with ABI benefit from metacognitive strategy training to improve function in other academic activities. Further empirical support was drawn from the special education literature that demonstrates other populations of struggling readers benefit from reading comprehension strategy use. In this study, participants read chapters from an introductory-level college Anthropology textbook in two different conditions: strategy and no-strategy. The results indicated that providing these readers with reading comprehension strategies was associated with better recall of correct information units in two free recall tasks: one elicited immediately after reading the chapter, and one elicited the following day. The strategy condition was also associated with better efficiency of recall in the delayed task and a more accurate ability to recognize statements from a sentence verification task designed to reflect the local and global coherence of the text. The findings support further research into using reading comprehension strategies as an intervention approach for the adult ABI population. Future research needs include identifying how to match particular reading comprehension strategies to individuals, examining whether reading comprehension performance improves further through the incorporation of systematic training, and evaluating texts from a range of disciplines and genres.

Paediatric acquired brain injury (pABI) can lead to an array of long term physical, cognitive, emotional, and behavioural difficulties. Due to the long-term sequelae of more severe pABI, it presents a significant challenge to the child’s family. Studies have suggested that social support can positively impact psychological adjustment following a stressful life event, and can aid personal resilience. There remains limited qualitative investigation of subjective family and parental adjustment experiences following pABI. Researchers have argued for future research that include the experiences of parents who have children younger than 16 years old, and are able to shed light on the individual experiential journey of parents. The current study used interpretative phenomenological analysis (IPA) to explore to the experiences of adjustment and social support of parents of children with pABI. Purposive sampling was used to recruit 10 participants who were individually interviewed. Five superordinate themes emerging from the data were identified: 1) Lives changed forever, 2) Sense of self, 3) Interaction with services, 4) The psychological experience, 5) Coping and adjustment. Relevant literature and implications for future research and clinical practice are discussed.

Background: Ventilator-associated pneumonia is a major cause of morbidity and mortality for patients in an intensive care unit. Once present, ventilator-associated pneumonia is known to increase the duration of mechanical ventilation, time in the intensive care unit, and length of hospital stay. Patients with acquired brain injury are commonly admitted to the intensive care unit and considered to be at a high risk for the development of respiratory complications such as ventilator-associated pneumonia, which could potentially impact on the intensive care unit costs and outcomes. Respiratory physiotherapy is often provided to prevent and/or treat ventilator-associated pneumonia in patients with acquired brain injury. The theoretical rationale of the respiratory physiotherapy is to improve airway clearance and enhance ventilation which may reduce the incidence of pulmonary infections and thus ventilator-associated pneumonia, and may in turn decrease the duration of mechanical ventilation, prevent the need for tracheostomy and hence result in reduced costs and shorter hospital stay. Although respiratory physiotherapy may be beneficial in reversing or preventing ventilator-associated pneumonia, to date there are no data concerning the effectiveness of respiratory physiotherapy in patients with acquired brain injury. Hence from an evidence-based perspective, at present there is no justification for the role of respiratory physiotherapy in the management of patients with acquired brain injury in the intensive care unit. Aim: This two-part, prospective randomised controlled trial aimed to investigate the effect of regular prophylactic respiratory physiotherapy on the incidence of ventilator-associated pneumonia, duration of mechanical ventilation, and length of intensive care unit stay in adults with acquired brain injury, as compared to a control group (Part A). / The second part of the study (Part B) randomised those subjects from Part A who developed a ventilatorassociated pneumonia into a treatment or control group to establish if the provision of a regimen of regular respiratory physiotherapy influenced the outcome of ventilator-associated pneumonia. Additionally, this study also aimed to provide the first description of the financial costs of respiratory physiotherapy time in providing interventions to patients with acquired brain injury in the intensive care unit and investigated the cost effectiveness of respiratory physiotherapy interventions in decreasing the incidence of ventilator-associated pneumonia, duration of mechanical ventilation and length of intensive care unit stay. Subjects: 144 adult patients with acquired brain injury admitted with a Glasgow Coma Scale of nine or less, requiring intracranial pressure monitoring, and invasive ventilatory support for greater than 24 hours, were randomised to a treatment group or a control group. Methods: For subjects randomised to the treatment groups, the regimen of respiratory physiotherapy treatment was repeated six times per 24-hour period and continued until the subject was weaned from mechanical ventilatory support. Each respiratory physiotherapy intervention of 30 minute duration comprised a regimen of positioning, manual hyperinflation and suctioning. In both Parts A and B, the control group received standard nursing and medical care but no respiratory physiotherapy interventions. Results: Consent was obtained for 144 subjects, with 72 randomised for treatment in Part A. Part A groups were comparable with respect to demographic variables, with the exception of body mass index and gender distribution. / Using intention to treat philosophy, there were no significant differences for incidence of ventilator-associated pneumonia [Treatment Group 14/72 (19.4%) vs. Control 19/72 (26.4%); p = 0.32], duration of mechanical ventilation (hr) [172.8 vs. 206.3); p = 0.18], or length of intensive care unit stay (hr) [224.2 vs. 256.4; p = 0.22]. For subjects with acquired brain injury receiving this prophylactic regimen of respiratory physiotherapy in the intensive care unit, in an attempt to prevent ventilator-associated pneumonia, the cost of physiotherapy was $487 per subject. Comparatively the intensive care unit mechanical ventilation bed day cost was $33,380 per subject. The cost of Part A respiratory physiotherapy time for Treatment Group 1 was 1.7 per cent of the cost of subject's intensive care unit mechanical ventilation bed days. Thirty-three subjects (22.9%) from Part A developed ventilator-associated pneumonia, and were transferred to Part B and re-randomised, 17 to the Treatment Group 3. Part B groups were comparable with respect to demographic variables. No significant differences were detected in the dependent variables for Part B of the study, with similar duration of mechanical ventilation (hr) [342.0 vs. 351.0); p = 0. 89], and length of ICU stay (hr) [384.7 vs. 397.9; p = 0.84] noted. In those subjects with acquired brain injury in whom ventilator-associated pneumonia developed, the regimen of respiratory physiotherapy for the remaining duration of mechanical ventilation following diagnosis of ventilator-associated pneumonia costed an average of $788. Comparatively the intensive care unit bed day cost for the period of mechanical ventilation was $43,865. The cost of Part B respiratory physiotherapy time for Treatment Group 3 was 1.8 per cent of the cost of their intensive care unit mechanical ventilation bed days. / Subjects with a ventilator-associated pneumonia were significantly younger, were admitted with a lower Glasgow coma scale, and more likely to have been admitted with a chest injury than subjects without a ventilator-associated pneumonia. Duration of mechanical ventilation and length of intensive care unit stay were significantly increased in subjects with ventilatorassociated pneumonia, but length of hospital stay was not significantly different. Significant differences in the costs of respiratory physiotherapy and intensive care unit mechanical ventilation bed day costs were evident between those subjects with ventilator-associated pneumonia as compared to those without ventilator-associated pneumonia. For subjects with ventilator-associated pneumonia, the respiratory physiotherapy time cost was $1,029 per subject, compared to $510 for subjects without ventilator-associated pneumonia. The intensive care unit mechanical ventilation bed day cost for subjects with ventilator-associated pneumonia was $61,092 per subject, and $25,142 for those without a ventilator-associated pneumonia, giving an incremental health cost of $35,950 per episode of ventilatorassociated pneumonia. No significant differences were evident in the cost of respiratory physiotherapy as a per cent of the cost of their intensive care unit mechanical ventilation bed days, with findings of 1.4 per cent in those with ventilator-associated pneumonia and 1.1 per cent in those without ventilator-associated pneumonia. / Conclusion: Use of a regular prophylactic respiratory physiotherapy regimen comprising of positioning, manual hyperinflation and suctioning, in addition to routine medical and nursing care, did not appear to prevent ventilator-associated pneumonia, reduce length of ventilation or intensive care unit stay in adults with acquired brain injury. Furthermore, in those acquired brain injury subjects with ventilator-associated pneumonia, regular respiratory physiotherapy did not appear to expedite recovery in terms of reducing length of ventilation or intensive care unit stay. It can be concluded from the findings of this study that the presence of ventilator-associated pneumonia has a significant influence on morbidity and costs in subjects with acquired brain injury. Whilst statistically significant results were not found with clinical variables, it is suggested that the provision of a prophylactic respiratory physiotherapy regimen costing $487 per subject is a worthwhile investment in attempts to avoid the incremental health cost of $35,950 per episode of ventilator-associated pneumonia. In subjects with ventilator-associated pneumonia it is concluded that the cost of respiratory physiotherapy would not appear to be justified in attempts to reduce the duration of mechanical ventilation.

Objective: The aim of this study was to examine the impact of social identity, coping style and cognitive impairment, on quality of life and well-being in a group of people with head injury compared to patients with chronic pain. Design: A correlational design using sixty participants recruited from Devon was employed: thirty adults with acquired brain injuries (ABI) were recruited from a charity and thirty adults with chronic pain difficulties from a NHS pain management service. Results: Analysis showed that there was little difference between the two groups on the variables measured. The role of social identity was not associated with better psychosocial outcome or coping style. Maladaptive coping strategies were associated with poorer adjustment in the ABI group and support-seeking strategies were correlated with improved outcomes in the chronic pain group. Objective neuropsychological variables were not associated with coping style, however, a relationship was observed between maladaptive coping styles and self-reported executive functioning. Conclusions: The results add to the literature on social identity, coping and quality of life post-ABI including improved understanding of how cognitive impairment might influence the use of particular coping strategies. The findings are discussed in relation to improved interventions to increase the use of more adaptive coping strategies.