sign130

6 Rehabilitation of behavioural and emotional
disorders
6.1 CHAllENGING oR AGGRESSIVE BEHAVIouR
Challenging behaviours are frequent neurobehavioural sequelae of a brain injury. Behavioural disturbance
may include inappropriate vocalisation, intolerance of medical management or equipment, directed or diffuse
aggressive, disinhibited or sexualised behaviour. Agitated patients may resist direct care, be disruptive or
pose a physical risk to themselves, family and staff. Reported prevalence ranges from 10-96% of patients
with estimates varying according to the exact definition used and the setting studied. All studies recognise
that it is a major burden on care givers.
Agitated behaviour in brain injured patients may not be the result of their brain injury in itself but reflect
other factors including:
y premorbid personality
y drug/alcohol intoxication and withdrawal
y mood disorder, phobic anxiety and emotional adjustment
y pain
y urinary retention
y constipation.
After acquired brain injury medically remediable causes of agitation should be excluded before
therapies are started. Therapies should take account not just of the nature of the brain injury but the
characteristics of the individual affected and the potential adverse effects of treatment.
6.1.1 NON-PHARMACOLOGICAL INTERVENTIONS
A wide range of non-pharmacological interventions has been used with adults presenting with challenging
behaviours following ABI, including specifically tailored contingency management procedures based in
operant learning theory; positive behaviour interventions focusing on proactive prevention of maladaptive
behaviours through supportive work with the individual and environmental modifications; CBT; music
therapy; and comprehensive neurobehavioural rehabilitation programmes. In many cases elements of
different therapeutic models are combined in order to devise a multimodal treatment programme suited
to the needs of the individual.
Contingency management and positive behaviour interventions
Two systematic reviews identified 98 studies which adopted contingency management procedures (CMP),
positive behaviour interventions (PBI) or a combination of both. 105,106 This evidence included only three
RCTs while the remaining studies were individual case reports or case series. Two trials adopted a combined
treatment approach with samples of patients with acquired brain injury of mixed causes but failed to find
a substantial improvement for the treatment sample relative to the control groups. The uncontrolled case
series showed inconsistent results in terms of treatment effect.
Comprehensive neurobehavioural rehabilitation programmes
6 • Rehabilitation of behavioural and emotional disorders
A systematic review reported one study of patients with ABI of mixed causes (n=76) who presented
with persisting aggressive behaviour and were unable to live independently. 107 The cohort underwent a
programme of social and neurobehavioural rehabilitation for a mean duration of 14 months. The intervention
was supported by non-professional therapy care assistants, however the intensity of input and make up
of the rehabilitation team was not specified. Positive outcomes were reported in terms of improved living
arrangements, hours of care required and employment. These effects were maintained at follow up (mean=2.8
years).
| 23
3
2 +