Caroline Knight

Ecological validity of a simplified version of the Multiple Errands Shopping Test.

Shallice and Burgess (1991) reported the utility of the Multiple Errands Test (MET) in discriminating executive deficits in three frontal lobe patients with preserved high IQ, who were otherwise unimpaired on tests of executive function. The aim of this study was to ascertain the value of a simplified version of the MET (MET-SV) for use with the range of people more routinely encountered in clinical practice. Main findings were as follows: 1) The test discriminated well between neurological patients and controls, and the group effects remained when the difference in current general cognitive functions (WAIS-R FSIQ) was taken into account. 2) The best predictors of performance in the healthy control group (n = 46) were age and the number of times participants asked for help (with more requests associated with poorer performance). 3) In the neurological group, two clear patterns of failure emerged, with performance either characterized by rule breaking or failure to achieve tasks. These two patterns were associated with different dysexecutive symptoms in everyday life. 4) The patients not only made more errors than controls, but also different ones. A scoring method that took this into account markedly increased test sensitivity. 5) Many patients passed traditional tests of executive frontal lobe function but still failed the MET-SV. This pattern was strongly associated with observed dysexecutive symptoms in everyday life. The results demonstrate the clinical utility of the test, and suggest that there are two common and independent sources of failure on multitasking tests in a general neurological population: memory dysfunction, and initiation problems.

Development of a simplified version of the multiple errands test for use in hospital settings

Problems with executive functioning may have catastrophic consequences following brain injury. Valid neuropsychological assessment procedures are required if the nature and extent of these are to be understood. However, some existing measures do not adequately reflect how executive impairments are manifested in the context of everyday functioning. Shallice and Burgess (1991) described one procedure, the Multiple Errands Test (MET), which did attain this goal. While successful, it was designed for people who performed within or above the normal range when tested using existing psychometric measures: however, it is acknowledged that many patients seen in routine clinical practice perform below normal limits. Furthermore, while the procedure was carried out in a public place a range of constraints may prevent this with some patients. In this paper the utility of a simplified MET designed for use within a hospital environment is explored. Twenty neurologically healthy participants and 20 people with acquired brain injury took part. People with acquired brain injury were clearly discriminated from healthy controls through the number of errors made. Furthermore, one category of error proved highly predictive of difficulties attributable to executive dysfunction observed in the context of everyday living. While one other test correlated almost as well with these difficulties, it was argued that MET methodology is more advantageous to clinicians regarding assessment and rehabilitation.

Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment

The subject of Inappropriate Sexual Behaviour (ISB) amongst clients with neurological impairment, specifically Acquired Brain Injury (ABI) and dementia, has received limited coverage to date within the literature. This paper discusses some of the problems encountered in the definition and quantification of ISB, in particular the absence of standardized measurement tools to record ISB within an inpatient setting. Whilst ISB is reported to be less prevalent than other behavioural sequelae of brain injury or dementia, it is suggested that its impact on patients and carers can be significant. Ill-defined terminology and the absence of relevant assessment tools add to the specific challenges of understanding and managing ISB within a care or rehabilitation setting. As a result, it is argued that the subjective attitudes of staff and the culture of an institution can dominate the approach taken to dealing with ISB for these client groups.

The St Andrew's Sexual Behaviour Assessment (SASBA): Development of a standardised recording instrument for the measurement and assessment of challenging sexual behaviour in people with progressive and acquired neurological impairment

Inappropriate sexual behaviour (ISB) as a sequela of neurological impairment is often overlooked in comparison to other challenging behaviours such as agitation and aggression, yet the impact on patients and carers can be equally significant and pervasive. Inconsistencies in terminology and lack of standardised measurement tools for ISB limit the degree to which such behaviour can be objectively and consistently identified, reported and managed within and between services. This paper proposes a new ISB scale, the St Andrews Sexual Behaviour Assessment (SASBA) based on the Overt Aggression Scale – Modified for Neurorehabilitation (OAS-MNR: Alderman, Knight, & Morgan, 1997). The validity and reliability of the SASBA for use with people who have both progressive neurological conditions and acquired brain injury admitted to in-patient services is explored. This scale allows continuous observations of four categories of ISB, each of which has four levels of severity, that were developed with reference to relevant literature (Johnson, Knight, & Alderman, 2006). Statistical properties of the scale were obtained using written descriptions and video enactments of ISB generated by clinicians. Results indicate strong construct and content validity, and good inter-rater and test-retest reliability. Some preliminary field data are presented with 924 incidents of challenging behaviour captured by the OAS-MNR and SASBA over a 10-week period for 36 patients; 16.34% of incidents were sexual behaviour. Clinical uses of the scale and perceived concerns or benefits for staff are discussed.

Aggressive behaviour observed within a neurobehavioural rehabilitation service: utility of the OAS-MNR in clinical audit and applied research

The Overt Aggression Scale-Modified for Neurorehabilitation (OAS-MNR) has been proposed as a means of standardizing descriptions of post-acute aggressive behaviour disorders amongst people with acquired brain injury. Single cases in the literature have illustrated its clinical utility. In this paper, its contribution to clinical audit and applied research is explored. The scale was used to record all aggressive behaviour exhibited by 46 patients participating in a neurobehavioural programme during a 14 day period. Data for 3914 acts of aggression were captured. Whilst most was verbal, 443 comprised physical assaults on others. Results suggest the OAS-MNR can be usefully employed to audit practice, and has a role to play in resource allocation: however, efficacy remains best judged at the single case level. Regarding clinical research, it was found that patients with low language function were more likely to physically assault others in the absence of identifiable antecedents. Furthermore, this was more severe and required more intrusive interventions to manage it than aggression shown by the same patients which had identifiable antecedents, or any aggression exhibited by patients whose language was better preserved. It is argued that poor language function creates significant barriers to the treatment of aggression, and, whilst intervention methods with good outcome have previously been described, these are no longer routinely available in the UK. An appeal to reverse this is made.

Is accurate self-monitoring necessary for people with acquired neurological problems to benefit from the use of differential reinforcement methods?

Challenging behaviour exhibited by people with acquired neurological problems must be managed if their maximum rehabilitation potential is to be achieved. Differential reinforcement of low rates of responding (DRL) appears to be an effective method for this. The effectiveness of DRL in the presence of severe cognitive deficits, including disorders of attention and memory, is nevertheless surprising. Indeed, such difficulties may prevent individuals with brain injury benefiting from operant conditioning procedures because of impairment of the central executive component of working memory. Consequently, use of other behavioural techniques such as response cost and self-monitoring training (SMT) have been adopted, as it has been argued they circumvent neuropsychological constraints to learning by directing attention to aspects of behaviour not being monitored. DRL, however, may be more desirable as it involves minimal intrusion; is concerned with establishment of pro-social behaviour; and treatment gains can occur rapidly and be maintained for long periods following withdrawal. Whether DRL is dependent upon accurate self-monitoring is addressed through the study of three people participating in rehabilitation. This shows DRL can be effective, despite severe cognitive impairments, but SMT facilitates greater improvements in selective attention. How DRL may circumvent cognitive impairment is discussed.