Nick Alderman

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.

Contemporary approaches to the management of irritability and aggression following traumatic brain injury

In this paper, the principal means of managing irritability and aggression following traumatic brain injury (TBI) will be briefly reviewed. The paper will initially consider the prevalence of irritability, what it is and some of the likely causes that drive the condition. Aggression will then be similarly contemplated. Prior to a discussion regarding those methods most regularly employed in their management, the attention of the reader will be directed to a range of methodological issues that need to be considered in relation to reporting treatment efficacy, including lack of homogeneity and the need to use standardised assessment tools. Three principal management approaches will then be described and appraised, these being pharmacology, psychotherapy, and behaviour therapy. Within the discussion of psychotherapeutic methods, special mention will be made with regard to use of cognitive behaviour therapy, and two detailed case studies will be employed to illustrate issues relating to both cognitive behaviour therapy and behaviour therapy.

Improvement of self-monitoring skills, reduction of behaviour disturbance and the dysexecutive syndrome: Comparison of response cost and a new programme of self-monitoring training

Abstract Impairment of executive functioning may impose particular neuropsychological constraints on the ability to learn. Some categories of behaviour disorder are secondary to the presence of the “dysexecutive syndrome”, particularly impairment in the ability for accurate self-monitoring. In these cases behaviour modification interventions using reinforcement and extinction methods may be unsuccessful. Response cost has been reported previously as one method which facilitates learning in such cases. However, there are practical difficulties that limit its use, or make practitioners reluctant to employ it. In this paper a case is described in which behaviour incompatible with rehabilitation was attributable to inaccuracies in self-monitoring. Two treatment methods were utilised. Whilst response cost was used successfully the results did not generalise to a second environment. A new programme of self-monitoring training was implemented to: teach inhibitory control in this environment; evolve an alternativ...

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.

Central Executive Deficit and Response to Operant Conditioning Methods

Behaviour problems may exclude some patients with severe brain injury from rehabilitation. However, rehabilitation potential can be achieved when a behaviour modification approach is used. Not all patients respond favourably to the reinforcement, extinction and tim e-out interventions frequently cited in the literature. In this study neuropsychological factors are examined in an attempt to account for poor response. Tests of general intelligence, memory and frontal lobe functioning were poor at discriminating between brain injured “responders” and “non-responders”. However, performance on a dual-task experiment did discriminate them. Controls and brain injured responders were able to allocate attentional resources appropriately when confronted with the need to monitor multiple events, while non-responders could not. Performance of the non-responders was taken as evidence of impairm ent of the central executive component of working mem ory. This inability to monitor two concurrent events results in functio...

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.

Behavioural treatment of the dysexecutive syndrome: Reduction of repetitive speech using response cost and cognitive overlearning

Abstract Damage to the frontal lobes frequently precedes the development of behavioural disorders that may prevent an individual gaining access to rehabilitation services. In recent years the use of behaviour modification, particularly programmes based on the use of positive reinforcement and time-out, has been increasingly reported in the literature as a means of remediating behaviour disturbance. However, it is becoming clear that there is a subgroup of brain-injured individuals who do not respond to the use of such methods and who present with the “Dysexecutive Syndrome”, which imposes neuropsychological constraints on their ability to learn using these techniques. This study describes the use of two behavioural methods—response cost and cognitive overlearning—in the treatment of a behaviourally disturbed, herpes simplex encephalitis survivor who presented with a dysexecutive syndrome. Treatment resulted in significant statistical and clinical change within sessions. This change was found to have gener...

The effectiveness of DRL in the management and treatment of severe behaviour disorders following brain injury.

Effective management of behaviour disorders following brain injury is essential if individuals are to achieve their rehabilitation potential. Best practice dictates that the intrusiveness of any operant approach used be minimal, remain in operation for the shortest time possible, and emphasize skill building. Ideally, treatment gains should maintain following its withdrawal. Reinforcement methods fulfil these criteria in that they are less intrusive, concerned with the establishment of pro-social behaviours, and encourage positive staff-patient interaction. While their efficacy has been well documented with other clinical populations, less is known regarding treatment of behaviour disorders in survivors of brain injury. Some existing studies are characterized by methodological weakness that limit understanding of any contribution made to observed improvement, and little is known regarding maintenance of treatment effects. In this paper the effectiveness of a variant of differential reinforcement, DRL, will be examined. Three cases will be presented which demonstrate increased behavioural control in response to the use of DRL. A strength of this paper is that the use of appropriate single-case design methodology, and follow-up data up to 18 months after treatment, permits more robust conclusions regarding the efficacy of DRL to be made. These are discussed, together with practical points regarding programme design.

Prevalence, characteristics and causes of aggressive behaviour observed within a neurobehavioural rehabilitation service: Predictors and implications for management

Primary objective: To describe the characteristics and determinants of aggressive behaviour observed within a neurobehavioural unit. Research design: Statistical analysis of a database of routinely administered clinical measures, including the Overt Aggression Scale–Modified for Neurorehabilitation. Methods and procedures: Records of aggressive behaviour shown by 108 patients over 14 days were studied. Patient characteristics were also captured using 23 items from the Rehabilitation Institute of Chicago–Functional Assessment Scale. Four factors were identified: ‘communication’, ‘cognition/function’, ‘neurobehavioural disability’ and ‘mood & self-esteem’. Relationships between patient characteristics, external factors and their interactions with aggression were examined. Main outcomes and results: Many (5548) episodes of aggression were recorded. Whilst most comprised verbal aggression, 729 physical assaults were made on others. Aggressive behaviour typically followed staff prompting or no obvious antecedent. Medical intervention was rare, most aggression was managed by staff not reinforcing this behaviour. Over 80% of physical assaults were made by people rated as having severe symptoms of neurobehavioural disability and poor communication. Conclusions: Neurobehavioural units require sufficient staff resources to engage patients in purposeful activities as these were associated with the least severe aggression. Despite increased OAS-MNR usage, a standardized methodology for investigating aggression is required to ensure compatibility between datasets.