Use of behavioural contracting to increase adherence with rehabilitation treatments on an inpatient brain injury unit: a case report.

BACKGROUND: This systematic, single-subject case study presents a 37-year old male with a severe traumatic brain injury who exhibited agitation and poor adherence with rehabilitation treatment on an inpatient traumatic brain injury unit. Attempts to address presumed awareness issues were unsuccessful. Medication trials also failed to produce an observable response in the patient's behaviour. CASE STUDY: A behavioural contract was presented by staff that specified positive behaviours the patient needed to demonstrate in order to reach his goal of being discharged from the hospital. Immediately, patient agitation ratings decreased and soon normalized. Statistical analysis of single subject times series data using the method of Nonoverlap of all Pairs results in a ratio of 0.875, indicating a moderate effect size for the intervention. CONCLUSIONS: The patient was able to comply with all requests and, with supports, was able to be safely discharged from the hospital ahead of schedule. Factors that could have contributed to this outcome and potential limitations are discussed.

Development and validation of the Subjective Awareness of Neuropsychological Deficits Questionnaire for Children (SAND-C).

Although lowered awareness of abilities has been associated with poorer outcome in adults with neurological compromise, a dearth of research exists examining whether lowered awareness exists in younger populations. Using findings from recent literature and expert opinion, a 47-item Subjective Awareness of Neuropsychological Deficits Questionnaire for Children (SAND-C) was created to assess awareness of cognitive functioning in 6 domains (attention, psychomotor, visual-spatial, language, memory, and executive functioning). Confirmatory factor analysis (CFA) of the SAND-C was conducted on a sample consisting of 365 healthy children and 48 children with epilepsy. The SAND-C was found to have strong reliability. Factor analysis confirmed the a priori 6 factor model, but the 6-factor model was only marginally better than a more parsimonious 1-factor solution. Post-hoc exploratory factor analyses indicate that the SAND-C may measure more constructs for adolescents than for younger children. The difference between younger and older children may reflect developmental changes in metacognitive awareness and abstraction about their own abilities.