A review of awareness interventions in brain injury rehabilitation.

Unawareness related to brain injury has implications for participation in rehabilitation, functional outcomes, and the emotional well-being of clients. Addressing disorders of awareness is an integral component of many rehabilitation programmes, and a review of the literature identified a range of awareness interventions that include holistic milieu-oriented neuropsychological programmes, psychotherapy, compensatory and facilitatory approaches, structured experiences, direct feedback, videotaped feedback, confrontational techniques, cognitive therapy, group therapy, game formats and behavioural intervention. These approaches are examined in terms of their theoretical bases and research evidence. A distinction is made between intervention approaches for unawareness due to neurocognitive factors and approaches for unawareness due to psychological factors. The socio-cultural context of unawareness is a third factor presented in a biopsychosocial framework to guide clinical decisions about awareness interventions. The ethical and methodological concerns associated with research on awareness interventions are discussed. The main considerations relate to the embedded nature of awareness interventions within rehabilitation programmes, the need for individually tailored interventions, differing responses according to the nature of unawareness, and the risk of eliciting emotional distress in some clients.

Convergent validity of self-awareness measures and their association with employment outcome in adults following acquired brain injury.

PRIMARY OBJECTIVE: To examine the convergent validity of three measures of self-awareness and their correlation with employment status in 38 adults with acquired brain injury. RESEARCH DESIGN: A cross-sectional study examining correlations between standardized measures of self-awareness and employment outcome. METHODS AND PROCEDURES: Self-awareness was assessed using the Self-Awareness of Deficits Interview (SADI), the Self-Regulation Skills Interview (SRSI) and the Awareness Questionnaire (AQ). Employment outcome was classified using a five-point work status rating scale and work items from the Sydney Psychosocial Reintegration Scale (SPRS). MAIN OUTCOMES AND RESULTS: Significant correlations were found between the SADI total score and the AQ discrepancy score and between the total SADI score and the SRSI indices. The work status rating scale was significantly correlated with the SADI and SRSI scores but not the AQ. CONCLUSIONS: The findings support the convergent validity of the three measures of self-awareness and highlight the need to address self-awareness deficits in vocational rehabilitation.

Memory remediation in long-term acquired brain injury: two approaches in diary training.

This study investigated the remediation and assessment of everyday memory impairment in a sample of long-term acquired brain injury (ABI) subjects. The Rivermead Behavioural Memory Test (RBMT) and subtests of the Wechsler Memory Scale-Revised (WMS-R) were selected to measure global memory performance. A memory questionnaire and a daily memory checklist were developed from a review of existing self-report questionnaires. The interrelationships among self-report measures and standardized psychometric tests of memory were examined and the findings suggest that self-report measures may be used to obtain relatively accurate information about everyday memory performance. A baseline across groups' design evaluated the relative effectiveness of two different approaches in training subjects to use a diary to compensate for memory problems. There was a Diary Only (DO) approach, which emphasized compensation based upon task specific learning, and a Diary and Self-Instructional Training (DSIT) approach, which taught compensation using higher cognitive skills of self-awareness and self-regulation. The results obtained show that, during the treatment phase, the DSIT group more consistently made diary entries, reported less memory problems, and made more positive ratings associated with treatment efficacy. The implications arising from the current study are that: (1) the choice of memory assessment procedures need to be guided by the patients' real daily living needs; and (2) an approach based upon self-instructional training has greater ecological validity than an approach that focuses on task specific learning. In general, successful assessment and rehabilitation of memory deficits requires a well-established theoretical basis and sound ecological validity.

Depression after traumatic brain injury: conceptualization and treatment considerations.

The understanding and treatment of depression that develops following traumatic brain injury (TBI) is still unclear and likely to be the result of a complex variety of interacting factors. Past researchers have developed ways to classify important variables related to patients' depression into broad domains such as: Pre-injury assets and liabilities, the nature and severity of brain injury; and reaction to difficulties. However, a better conceptualization of the problem is required in order to guide the assessment and treatment considerations for depressed patients with TBI. This review provides this conceptualization by postulating six theoretical relationships between depression and TBI. The degree of empirical support provided in the literature for these links is indicated. Research findings suggested that an individual with TBI is the most susceptible to depression when any of the following conditions exist: a pre-existing psychiatric disturbance is exacerbated; the injury sustained involved the left anterior region of the brain; and when her individual has poor insight into her deficits, attempts to resume her pre-injury roles and experiences significant failure. For each relationship, a likely outcome is predicted if the recommended treatment plan is not conducted. The present conceptualization and treatment considerations will be of substantial benefit to clinicians working in the area.

Development and standardization of the Self-regulation Skills Interview (SRSI): a new clinical assessment tool for acquired brain injury.

The Self-regulation Skills Interview (SRSI) is a clinical tool designed to measure a range of metacognitive skills essential for rehabilitation planning, monitoring an individual's progress, and evaluating the outcome of treatment interventions. The results of the present study indicated that the SRSI has sound interrater reliability and test-retest reliability. A principle components analysis revealed three SRSI factors: Awareness, Readiness to Change, and Strategy Behavior. A comparison between a group of 61 participants with acquired brain injury (ABI) and a group of 43 non-brain-injured participants indicated that the participants with ABI had significantly lower levels of Awareness and Strategy Behavior, but that level of Readiness to Change was not significantly different between the two groups. The significant relationship observed between the SRSI factors and measures of neuropsychological functioning confirmed the concurrent validity of the scale and supports the value of the SRSI for post-acute assessment.