Clinical practice guideline recommendations for the management of challenging behaviours after traumatic brain injury in acute hospital and inpatient rehabilitation settings: a systematic review.

PURPOSE: Clinical practice guideline (CPG) recommendations for the management of challenging behaviours after traumatic brain injury (TBI) in hospital and inpatient rehabilitation settings are sparse. This systematic review aims to identify and appraise CPGs, and report high-quality recommendations for challenging behaviours after TBI in hospital and rehabilitation settings. MATERIALS AND METHODS: A three-step search strategy was conducted to identify CPGs that met inclusion criteria. Two reviewers independently scored the AGREE II domains. Guideline quality was assessed based on CPGs adequately addressing four out of the six AGREE II domains. Data extraction was performed with a compilation of high-quality CPG recommendations. RESULTS: Seven CPGs out of 408 identified records met the inclusion criteria. Two CPGs were deemed high-quality. High-quality CPG recommendations with the strongest supporting evidence include behaviour management plans; beta-blockers for the treatment of aggression; selective serotonin reuptake inhibitors for moderate agitation; adamantanes for impaired arousal/attention in agitation; specialised, multi-disciplinary TBI behaviour management services. CONCLUSIONS: This systematic review identified and appraised the quality of CPGs relating to the management of challenging behaviours after TBI in acute hospital and rehabilitation settings. Further research to rigorously evaluate TBI behaviour management programs, investigation of evidence-practice gaps, and implementation strategies for adopting CPG recommendations into practice is needed.Implications for rehabilitationTwo clinical practice guidelines appraised as high-quality outline recommendations for the management of challenging behaviours after traumatic brain injury in hospital and inpatient rehabilitation settings.High-quality guideline recommendations with the strongest supporting evidence for non-pharmacological treatment include behaviour management plans considering precipitating factors, antecedents, and reinforcing events.High-quality guideline recommendations with the strongest supporting evidence for pharmacological management include beta blockers for aggression in traumatic brain injury.Few guidelines provide comprehensive detail on the implementation of recommendations into clinical care which may limit adoption.

There is hope and help: Reach and reception of a methamphetamine education campaign in Los Angeles County, California.

Introduction: In the context of increasing rates of methamphetamine (meth) overdose in Los Angeles County, California, USA, in 2021 the Los Angeles County Department of Public Health relaunched Meth Free LA County, a methamphetamine public education campaign built on Rescue Agency's Decision BlocksTM Strategic Framework. Methods: To assess campaign reach and reception, we examined media data and an online cross-sectional post-campaign survey in 2021 with a convenience sample of 750 county residents ages 18-54 who had used meth, were at-risk, or had personal relationships with people at-risk. We assessed campaign awareness, receptivity, and perceived effectiveness. Participants also reported concern about meth use in their community, recall of 10 facts from campaign content, and if they had taken promoted actions such as seeking help. We compared proportions between campaign-aware and unaware participants and explored if recall predicted these measures. Results: Most participants recalled the campaign (84.1%), felt it offered a new way of looking at meth (73.8%), and reported it made them feel that help is available (84.0%) or that it could help reduce their own use (82.4%). Video advertisements received high perceived effectiveness scores. Greater campaign recall was associated with significantly increased odds of being concerned about meth use in the community, recalling facts, and taking promoted actions. Conclusion: In 2021, Meth Free LA County reached its high-risk audiences. Unlike fear-based campaigns its message resonated with high-risk individuals, providing an example of how public education campaigns on meth and similar illicit substances can connect with their audiences.

Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study.

BACKGROUND: Challenging behaviours after traumatic brain injury (TBI) in the acute setting are associated with risk of harm to the patient and staff, delays in commencing rehabilitation and increased length of hospital stay. Few guidelines exist to inform practice in acute settings, and specialist services providing multi-disciplinary expertise for TBI behaviour management are predominantly based in subacute inpatient services. This study aims to investigate acute and subacute staff perspectives of barriers and enablers to effectively managing challenging behaviours after TBI in acute hospital settings. METHODS: Qualitative focus groups were conducted with 28 staff (17 from acute setting, 11 from subacute setting) across two sites who had experience working with patients with TBI. Data were analysed using inductive-deductive reflexive thematic analysis. Data were applied to the constructs of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to generate themes representing barriers and enablers to managing challenging behaviours after TBI in the acute hospital setting. RESULTS: Four barriers and three enablers were identified. Barriers include (1) Difficulties with clinical decision making; (2) Concerns for risks to staff and patients; (3) Hospital environment; (4) Intensive resources are required. Enablers were (1) Experienced staff with practical skills; (2) Incorporating person-centred care; and (3) Supportive teams. CONCLUSION: These findings can inform pre-implementation planning for future improvements to TBI behaviour management in acute hospital settings. Difficulties with clinical decision making, concerns for risks of injury, the hospital environment and lack of resources are major challenges. Implementation strategies developed to address barriers will need to be trialled, with multi-disciplinary team approaches, and tailored to the acute setting.

Family experiences of the management of challenging behaviours after traumatic brain injury in the acute hospital setting.

PURPOSE: This study explored experiences of the management of challenging behaviours after traumatic brain injury (TBI) in the acute hospital setting from the perspectives of family members. MATERIALS AND METHODS: A qualitative, interpretive phenomenological approach was adopted involving semi-structured interviews with 10 family members. Interviews were transcribed and analysed using thematic analysis, with Ecological Systems Theory applied as a guiding framework to discuss findings and implications for practice. RESULTS: Four primary themes were identified: 1) The hospital environment; 2) Hospital staffing; 3) Identifying and preventing triggers, and 4) Family support and information. CONCLUSIONS: This qualitative study highlights the need for further information, education, and support to families of patients with TBI in the acute setting. Further research investigating the implementation of best practice approaches for managing challenging behaviours practice in acute settings is needed to overcome the barriers of the hospital environment, inexperienced and inconsistent staffing, and difficulties identifying triggers within the acute hospital setting, experienced by families. Approaches for family involvement in behaviour management strategies, and facilitation of communication for people with TBI in the acute setting requires exploration.

Families reported the hospital environment, inexperienced and inconsistent staffing, and difficulty identifying triggers were challenges in effectively managing challenging behaviours after traumatic brain injury (TBI) in the acute setting.Clinicians can support family involvement in preventative strategies with patients with TBI.Clinicians can enable quality of care by building rapport and providing compassionate care to patients with TBI.Families need more support and information during the acute stage of TBI in hospital settings.

Community in the pandemic: experiences and strategies by people with acquired brain injury and their families during COVID-19.

PURPOSE: This study explored the experiences of people with acquired brain injury and their families during the COVID-19 pandemic, focusing on how they maintained their communities and sense of belonging, the strategies they found helpful, and advice they have for improving service provision and community connectedness. METHODS: Semi structured interviews with pictorial mapping were conducted with ten adults with ABI and six of their family members. Participants responded to recruitment information circulated by a state-wide ABI peer support network in South Australia. RESULTS: Four primary themes were identified from the findings: (1) disruptions to routine; (2) social isolation; (3) using technology; and (4) strategies for staying safe and keeping well. Results are discussed using a social and urban geography lens and a conceptual framework of belonging to explore the experiences of people with ABI and their communities. CONCLUSIONS: The study reinforces the role of robust peer/support networks to stay connected, stay well and support others. Government, health services and community groups must provide clear and accessible information and supports, and regularly reach out to ensure the safety and wellbeing of people with ABI and their families during the pandemic.IMPLICATIONS FOR REHABILITATIONPeople with acquired brain injury and their families experienced increased challenges to maintaining contact with their communities during the COVID-19 pandemic.The main challenges were disruptions to routine, social isolation, and use of technology for health, therapy and social contact.Strategies to support people with ABI to maintain connections, stay engaged, and access technology and information to stay safe and well during lock-down are presented.

Implementing a behavior management approach in the hospital setting for individuals with challenging behaviors during acute traumatic brain injury.

PRIMARY OBJECTIVE: This study aimed to determine if implementing a clinically pragmatic behavior management approach for challenging behaviors during acute TBI reduces use of restraints, security incidences, acute length of stay admission and cost, thereby improving progress to rehabilitation. RESEARCH DESIGN: This pilot study involved a behavior management group (n = 27), compared with a historical control group (n = 74). METHOD AND PROCEDURES: The behavior management group received care following the implementation of a behavior management approach for challenging behaviors during acute TBI at two hospitals in South Australia. MAIN OUTCOMES AND RESULTS: Fidelity results demonstrated high level of adherence to the implemented behavior management approach. The behavior management group had significant lower use of mechanical restraints (p = 0.03), and significantly lower acute admission costs (p = 0.034). Trends in lower pharmacological restraint usage, lower acute hospital length of stay and time from admission to rehabilitation acceptance were recorded. CONCLUSIONS: These pilot results contribute to improving quality of health care but methodological limitations make outcomes difficult to interpret as a direct result of the intervention. Future studies are required to investigate evidence-based behavior management interventions for acute TBI patients using more rigorous knowledge translation implementation designs.

"The bucket of gold at the end of the rainbow": personal experiences of hope after acquired brain injury.

PURPOSE: To investigate personal experiences of, and factors influencing hope following Acquired Brain Injury (ABI). METHODS: A qualitative phenomenological approach was adopted consisting of semi-structured interviews with 15 adults with ABI. Interviews were transcribed and analysed using thematic analysis, and the Social Ecological Model (SEM) applied as a guiding framework to discuss findings and implications for policy and practice. RESULTS: Five themes emerged: the importance of hope, changes in hope over time, the connection between hope and positivity, factors influencing hope and the importance of fostering hope. Participants reported varying experiences, with increased levels of hope influenced by: faith; supportive networks and professionals; goals; experiencing progress; having something to look forward to; and seeing others achieve. Professional attitudes were reported to either foster or negatively impact hope after brain injury. CONCLUSIONS: These findings suggest that hope can play an important and often essential role in the lives of people with ABI. Factors influencing experiences of hope are organised against a SEM framework, identifying intrapersonal, interpersonal, institutional, community, and state and national implications for policy, professional practice and research.Implications for rehabilitationHope plays a critical role in the lives of people following acquired brain injury.Factors which positively influence hope include faith, supportive networks, goals, experiencing progress, and having something to look forward to.Professionals can impact an individual's experience of hope through person-centred and supportive therapeutic relationships.

Family perspectives on the acceptability and usefulness of the FAB Positive Behaviour Support program: A pilot study.

Purpose: This pilot feasibility study aimed to gain preliminary insight into the acceptability and usefulness of the FAB-PBS program for providing behavior support to families following acquired brain injury (ABI) in community settings. The FAB-PBS program is based on a Positive Behavior Support (PBS) framework and principles of Family-Centered Care and Family-Directed Intervention. It consists of an education phase followed by individualized sessions during which the family is supported to develop and implement a PBS plan.Methods: A mixed-methods design was utilized, with feedback obtained from family members via short questionnaires and semi-structured interviews post education phase and individualized sessions, and at three-month follow up.Results: Two family members completed the full FAB-PBS program and reported high satisfaction with the program and increased confidence in providing behavior support. Findings also suggested an increase in desired behaviors and a decrease in challenging behaviors presented by family members with ABI.Conclusions: The FAB-PBS program may be an acceptable and feasible approach to increasing the capability of family caregivers in providing behavior support following ABI. Further pilot testing is required to inform the development of a larger feasibility study.

Brain injury, behaviour support, and family involvement: putting the pieces together and looking forward.

Purpose: (1) to provide insight into the family's experience and support needs following acquired brain injury (ABI) specific to behavioural changes; (2) to provide an overview of empirically-based behaviour support approaches for individuals with ABI; and (3), to examine family involvement in implementing behavioural interventions.Methods: Review of the literature.Results: Family members experience significant distress resulting from neurobehavioural changes in relatives with ABI, and report unmet informational and practical support needs regarding this issue. The importance of utilising family expertise within the rehabilitation process is widely acknowledged, with the increasing involvement of family members being promoted. There is growing evidence supporting the use of positive behaviour support approaches for individuals with ABI in community settings, and evidence supporting the involvement of family within behavioural interventions.Conclusions: This review suggests the need to develop alternative support models that shift the focus towards building competence in everyday support people rather than dependency on the service system. A bottom-up approach is recommended, with the aim of addressing unmet support needs and increasing the competence of family members in supporting behaviour change in individuals with ABI. Recommendations are provided in informing an optimal community-based neurobehavioural support model. Implications for RehabilitationPositive behaviour support is recommended in supporting behavioural changes following brain injury, with family expertise utilised in this process.Evidence suggests that family members can be effectively trained in developing and implementing behaviour support strategies.Family involvement in behavioural interventions may address unmet support needs and increasing the competence of family members in supporting behavioural changes following brain injury.

Family-directed approach to brain injury (FAB) model: a preliminary framework to guide family-directed intervention for individuals with brain injury.

PURPOSE: This article proposes a theoretical framework to help professionals include family as active members in brain injury rehabilitation. A trend towards greater family involvement has lead to the development of family-collaboration models. However, current models appear to focus on information sharing rather than increasing the capability of family members. This article introduces a family-directed approach to brain injury model, which provides a theoretical framework for supporting family as facilitators of change. METHODS: Family-collaboration models and literature regarding family experiences following brain injury and support needs are reviewed to identify the driving forces behind family engagement in rehabilitation, including effective professional-family relationships, and important factors in the delivery of education underpinned by evidence-based practices. RESULTS: The family-directed approach to brain injury model is based on principles of hope, family expertise, education/skill building, and family-directed intervention. CONCLUSIONS: The family-directed approach to brain injury model provides a theoretical framework for educating and training family members as facilitators in the management process: promoting competence rather than dependency on service systems. Guiding recommendations encourage professionals to reflect on the importance of their therapeutic relationships and their capacity to positively impact rehabilitation outcomes beyond the technical aspects of health care and treatment. Implications for Rehabilitation Training family members as facilitators in the rehabilitation process is suggested to reduce dependency on the service system, address families' unmet support needs, and to optimize rehabilitation outcomes for individuals with brain injury. The family-directed approach to brain injury model is proposed to guide the increased involvement of family as active members in the rehabilitation team and to define potential active ingredients in this process.

Seizure-related hospital admissions, readmissions and costs: Comparisons with asthma and diabetes in South Australia.

PURPOSE: Seizures are listed as an Ambulatory Care Sensitive Condition (ACSC), where, in some cases, hospitalisation may be avoided with appropriate preventative and early management in primary care. We examined the frequencies, trends and financial costs of first and subsequent seizure-related hospital admissions in the adult and paediatric populations, with comparisons to bronchitis/asthma and diabetes admissions in South Australia between 2012 and 2014. METHODS: De-identified hospital separation data from five major public hospitals in metropolitan South Australia were analysed to determine the number of children and adults admitted for the following Australian Refined Diagnosis Related Groups: seizure related conditions; bronchitis/asthma; and diabetes. Additional data included length of hospital stay and type of admission. Demographic data were analysed to identify whether social determinants influence admission, and a macro costing approach was then applied to calculate the financial costs to the Health Care System. RESULTS: The rate of total seizure hospitalizations was 649 per 100,000; lower than bronchitis/asthma (751/100,000), yet higher than diabetes (500/100,000). The highest proportions of subsequent separations were recorded by children with seizures regardless of complexity (47% +CSCC; 17% -CSCC) compared with asthma (11% +CSCC; 14% -CSCC) or diabetes (14% +CSCC; 13% -CSCC), and by adults with seizures with catastrophic or severe complications/comorbidity (25%), compared with diabetes (22%) or asthma (14%). The mean cost per separation in both children and adults was highest for diabetes (AU$4438/$7656), followed by seizures (AU$2408/$5691) and asthma (AU$2084/$3295). CONCLUSIONS: Following the lead of well-developed and resourced health promotion initiatives in asthma and diabetes, appropriate primary care, community education and seizure management services (including seizure clinics) should be targeted in an effort to reduce seizure related hospitalisations which may be avoidable, minimise costs to the health budget, and maximise health care quality.

Information, connection and giving back: peer support outcomes for families following acquired brain injury in South Australia.

This study aimed to identify the experiences and outcomes of participation in Families4Families Inc., a peer support network for families following acquired brain injury (ABI) in South Australia. Prior to the programme's launch in January 2013, new members of the network were invited to participate in pre- and post-programme phone interviews to identify benefits and limitations of the programme, and identify outcomes of participation. Fifty-five members (20 people with ABI; 35 caregivers) participated in pre-programme interviews, with 34 repeating the final interview at the end of the 18-month pilot programme in June 2014. Interview transcripts were imported into Nvivo 10, where comments were analysed using inductive data-driven thematic analysis. Responses to rating questions were analysed using SPSS 20. Attendance records indicate that 39 of 55 participants were involved in the programme (12 active, 27 occasional) and 16 participants did not attend. Active attenders reported that they provided and received higher levels of support and information than those who attended only occasionally, including the significantly higher development of new friendships and contacts (P < 0.001). Statistically significant improvements in knowledge of services by both active and occasional attenders were reported (P = 0.014 and 0.026 respectively) with non-significant improvements for non-attenders. Qualitative analysis of interview transcripts revealed three major thematic benefits of involvement. These include the opportunity to access information, receive emotional support and give back to others in the network. Reasons for no longer participating in the network are explored. Peer support programmes can enable families to share experiences, knowledge, positive coping strategies, understanding of systems and develop new social networks that last beyond the programme. The continuing need for extended regional access is highlighted, with follow-up and referral to counselling and other services also critical to ensure members are appropriately supported through difficult personal experiences.

Parents' experiences of their child's return to school following acquired brain injury (ABI): A systematic review of qualitative studies.

OBJECTIVE: To examine parents' experiences during their child's return to school following ABI. RESEARCH DESIGN: Systematic literature review. METHODS: Six electronic databases relevant to the fields of brain injury and education were searched between 1980-2015. In addition, two qualitative journals and references from articles were hand-searched for further literature. Search results were screened independently by two reviewers for relevance. Studies meeting the inclusion criteria were analysed using the McMasters Critical Review Form for Qualitative Studies. RESULTS: Two hundred and sixteen articles were screened after duplicates had been removed and 11 were assessed for relevance, resulting in six full text articles for review. The quality of studies was mixed, with only two presenting a high number of quality indicators for qualitative research. Ten themes were identified and grouped into three clusters: influencing factors (environment, school, parent and child factors); features of interaction (information, communication and collaboration); and quality levels of outcome (conflict, coping and construction of new roles and identities). CONCLUSIONS: Parents' experiences are influenced by the quality of information, communication and collaboration between the school, health professionals and the family. Further well designed qualitative studies examining parents' experiences and support needs are required.

Epilepsy-related deaths: An Australian survey of the experiences and needs of people bereaved by epilepsy.

PURPOSE: This study explores the experiences and needs of bereaved family and friends following an epilepsy-related death in Australia. METHOD: An online survey was used to collect demographic details of the person with epilepsy, epilepsy status, time since the death, satisfaction with service providers at the time of death, follow-up support, perceptions on how well the death was explained, and gaps in support or services. RESULTS: The survey was completed by 101 respondents describing 90 deceased individuals. Mean age at death was 32.1 years, with causes of death including SUDEP, epilepsy, drowning, cardiac arrest, asphyxiation, and motor vehicle accidents. Over half of the respondents indicated that they did not know, prior to the death, people could die of epilepsy. In addition, 38% indicated the death had not been adequately explained to them. Comments revealed services and supports which should be available following a death, and recommendations for existing epilepsy support services which might help to prevent future deaths. CONCLUSION: Findings highlight the need to improve community understanding and support for those affected by epilepsy and to promote informed risk assessment and communication amongst patients, families and health professionals. People bereaved by epilepsy require both immediate and long-term epilepsy-specific information and support from professionals, informal communities and peer supporters.

Family involvement in behaviour management following acquired brain injury (ABI) in community settings: A systematic review.

OBJECTIVES: To examine family involvement in the management of behavioural problems following ABI in the community. RESEARCH DESIGN: Systematic literature review. METHODS: Six electronic databases relevant to the field of brain injury were searched between 1980-2013. Citation indexes were used and references from articles hand searched for further literature. Studies that met the broad inclusion criteria were screened for relevance and articles selected for full-text review independently considered by two reviewers. Those found to be relevant were analysed using PEDro and McMasters critical appraisal tools. RESULTS: Three hundred and three studies were identified after duplicates were removed and 56 were assessed for relevance, yielding 10 studies for review. Although the majority of studies were weak in design, five revealed significant findings supportive of family involvement in the management of behavioural problems following ABI, especially where interventions consisted of both educational components and individualized behavioural plans. Findings revealed no significant changes in family burden following behavioural interventions. CONCLUSIONS: There is limited research and lack of high evidence studies evaluating family involvement in behaviour management following ABI; therefore, no conclusions can be drawn regarding its efficacy. More research is needed, with larger sample sizes and more rigorous design, including proper comparison groups.

Choice and control: how involved are people with epilepsy and their families in the management of their epilepsy? Results from an Australian survey in the disability sector.

This study explored the extent to which people with epilepsy and their families have choice and control over the management of their epilepsy and the support provided in the Australian disability sector. It measured the level of direct involvement in planning and recording of their epilepsy health-care needs and support required through the use of epilepsy management plans. An Australian online survey was completed by 118 adults with epilepsy and 171 family members of children and adults with epilepsy, providing demographic and diagnostic data and details of their epilepsy management plan, whether they were involved in writing the plan and the extent to which it included their views on how they want to be supported. Results indicate that just over half of all respondents had an epilepsy management plan, with 83% revised within the past 12 months. Although the majority of respondents were directly involved in writing their plan (87%), only two-thirds (66%) felt that their plan included their views on how they wanted to be supported. Open-ended comments from 111 respondents indicated their desire to be actively involved in this process, as either collaborative team members or 'in charge' of the process. In spite of a move towards person-centered approaches and greater choice and control, further emphasis must be placed on actively involving the person with epilepsy and their family in writing and incorporating their views on support within their epilepsy management plans. This research was undertaken by the Epilepsy Foundation to inform the development of epilepsy support resources for the newly introduced Australian National Disability Insurance Scheme.

Post concussion syndrome ebb and flow: longitudinal effects and management.

This research identified persistent post concussion symptoms (PCS) in a group of 20 adult subjects. PCS generally lasted for two years with a mean of 3.35 years. Typical symptoms included physical and cognitive fatigue, depressive behaviors, sensitivity to noise, social withdrawal, irritability, concentration and problem solving difficulties, loss of libido and much difficulty making decisions at even the simplest strategic level. They represented a hard core group for whom the original symptoms persisted well beyond the 6~month period. Participants identified their PCS according to sensory, somatic affective and cognitive items immediately following their trauma (01) and two years later (02). Counseling and psychotherapy intervention took place between 01 and 02. Items on the PCS schedules and the Beck Depression Inventory (II) demonstrated significant decline in the presence of overall symptoms most noticeably in reduction of agitation, irritability and suicidal wishes. However, subjects throughout generally experienced the feeling that they were being punished which equated with behaviors comparable with learned helplessness. The PCS group considered themselves to be different people after trauma. They had different goals, changing lifestyle, relationships and employment and were more often in a dependent state. Comparability with other conditions such as PTSD and chronic fatigue syndrome (CFS) was demonstrated by individuals who experienced persistent and invasive post concussion symptoms.

The effect of context on communication: a study of the language and communication skills of adults with acquired brain injury.

PRIMARY OBJECTIVE: To examine the effects of changing contexts on language and communication skills of adults with acquired brain injury. RESEARCH DESIGN: Repeated measures design. METHODS: Four adults with brain injury were observed in four contexts with pragmatic language and communication behaviours recorded. Contexts included baseline, two intervention phases (a 3-day camp and post-camp period) and 2-month follow-up. RESULTS: Participants demonstrated improvements in constructive language production during intervention phases. Results indicate structure, cueing and positive experiences created language which was observed to overcome the influence of organic damage. However, at follow-up, the language and communication levels returned to baseline levels. CONCLUSION: Clinically, these results have implications for the development of sustained interventions for language and communication skills in community-based rehabilitation programmes. Creating supporting contexts may serve as an effective means of improving language and communication behaviours, while also facilitating optimum community inclusion.