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REHABILITATION ARTICLEEffectiveness of NeurobehaviouralRehabilitation for Young Peopleand Adults with Traumatic BrainInjury and Challenging BehaviourProfessor NickAldermanis Consultant ClinicalNeuropsychologist, SpecialtyLead and Associate Director atthe National Brain Injury Centre,St Andrew's Healthcare,Northampton. He specialises inneurobehavioural rehabilitation,and the assessment and managementof the dysexecutivesyndrome in people withacquired brain injury. He is VisitingProfessor at the universities ofGlamorgan, the West of Englandand Newman University College,Birmingham, and Visiting SeniorLecturer at the Institute ofPsychiatry, King's College London.Correspondence to:Prof N Alderman,Consultant ClinicalNeuropsychologist,National Brain Injury Centre,St Andrew’s Healthcare,Billing Road,Northampton,NN1 5DG, UK.Tel: +44 (0)1604 616381Email: nalderman@standrew.co.ukTraumatic brain injury (TBI) can happen toanyone at any time. Very young children, youngmen and older people are particularly at risk.TBI is often caused by road traffic accidents, falls,violence and sport. It has been described as the‘silent epidemic’: a conservative estimate is 295new cases per 100,000 in the UK which equates toapproximately 180,000 people each yearpresenting with head injury at hospital. Improvedmedical services mean more people survive butthe long term effects can be devastating. Theseinclude a wide range of physical, cognitive, sensory,functional and emotional impairments, disabilitiesand handicaps which can be long-term. Despitehigh prevalence and the proven effectiveness ofneurorehabilitation, brain injury has been regardedas a ‘Cinderella’ condition for many years withtreatment and care provided to survivors beingpatchy, under-resourced and of variable quality.Neurobehavioural disability and outcomeNeurobehavioural disability (NBD) and socialhandicap arising from this has a major impact onlong-term outcome. NBD comprises a complex,subtle, pervasive constellation of cognitive-behaviouralchanges that typify post-acute TBI. Thisundermines social independence and is associatedwith poor prognosis. Emotional difficultiesand challenging behaviour are characteristic ofNBD. Relatives frequently describe their familymember as having undergone a personalitychange. In some cases, aggression and sexuallyinappropriate behaviour are evident. Stress andburden on family members are immense. It hasbeen estimated that one new TBI case per 300,000people each year in the UK has severe, persistentbehaviour problems that exclude them from mainstreamservices. 1 As a consequence, at least 200people per year gravitate to care homes, prison andmental health units that are unable to meet theircomplex needs.Neurobehavioural rehabilitationThe National Brain Injury Centre (NBIC) was theUK’s first provider to offer rehabilitation to peoplewith TBI and other types of acquired brain injurywho also presented with challenging behaviour. Partof St Andrew’s Healthcare, the UK's largest not-forprofitmental health care charity, NBIC admitted itsfirst six patients in January 1979. Thirty years later, theservice has grown to over 100 beds with separatecare pathways for young people, men and women,units that cater for those with very challengingbehaviour, and others that offer slow-stream, longstayrehabilitation, both within a hospital setting andthe community. Patients are typically referredbecause they present with challenging behaviour ofsuch severity to preclude them from mainstreamneurorehabilitation services, and often from thecommunities in which they live.The treatment model is psychosocial and NBICwas the first service to evolve what is now termed‘neurobehavioural rehabilitation’. 2 This approachacknowledges that challenging behaviour is primarilya product of physical damage to the brain, butrecognises this is further shaped by the environment.This can help sustain challenging behaviour,which can be unwittingly maintained by thosepeople charged with the care of a person with abrain injury. This clinical population is not popularwith rehabilitation professionals because of theirirritating, threatening, and embarrassing behaviour,as well as their general lack of motivation. 3Consequently, patients with brain injuries may beavoided by staff and carers, and become sociallyisolated. Unfortunately, while challenging behaviourmay be primarily attributable to damagedneural systems, it can be reinforced by environmentsin which there are limited opportunities forappropriate social behaviour. Under conditions inwhich people are habitually ignored for longperiods, it is possible their only social contact iswhen staff intervene when managing challengingbehaviour. This can inadvertently reinforce andmaintain it.Whilst the environment can unwittingly maintainNBD and social handicap, it can also bemanipulated to benefit rehabilitation.Neurobehavioural rehabilitation services attemptto reduce NBD and social handicap by creating anenvironment in which people are re-taught skillsthey have lost through brain injury, which are thenencouraged and reinforced in the context ofeveryday behaviour. Treatment interventions workprimarily to reverse contingencies that previouslymaintained challenging behaviour, first byrequiring staff to interact with patients who maypreviously have been ignored, and second, byensuring social reinforcement is directed at desirable,rather than challenging behaviour. 4 In thisway, interventions based on operant learningtheory create enriched environments that changethe behaviour of people working with challengingbrain-injured patients and encourage developmentof a positive social climate that promotes therapeuticrelationships. Provision of these interventionswithin a highly structured environmentencourages new learning, skill acquisition, andpromotion of independence, giving patients morechoice, control, and freedom as they progress.26 > ACNR > VOLUME 11 NUMBER 4 > SEPTEMBER/OCTOBER 2011