Predictors of Treatment Response to a Psychoeducational Intervention for Anger in Chronic Moderate-Severe Traumatic Brain Injury.

OBJECTIVE: The investigators examined predictors of treatment response to anger self-management training (ASMT) among patients with chronic moderate-severe traumatic brain injury (TBI). METHODS: A multicenter randomized clinical trial comprising 90 participants with moderate-severe TBI was conducted. Fifty-four participants who were randomly assigned to receive active treatment and provided complete data were included in the current secondary analysis. Model averaging was used to examine the relative importance and significance of pretreatment variables for predicting change during treatment. Dependent variables were pre- to posttreatment changes in trait anger (TA) and anger expression-out (AX-O) subscale scores of the State-Trait Anger Expression Inventory-Revised. Predictors included demographic, injury-related, and neuropsychological variables, including both objective and self-reported measures of executive function, as well as readiness to change and participation of a significant other in treatment. RESULTS: Change in both dependent variables was predicted by higher baseline anger. Greater change in TA was additionally predicted by White race, higher education, shorter posttraumatic amnesia, and worse self-reported (but not objectively measured) executive dysfunction; the latter predictor may have indicated better self-awareness. Greater change in AX-O was additionally predicted by better episodic memory and, paradoxically, lower readiness to change. CONCLUSIONS: Further research should focus on adapting psychoeducational anger treatments to better serve the diverse populations affected by moderate-severe TBI. These findings suggest that providing memory aids to support the use of learned strategies after treatment cessation would be beneficial. Further research should also examine the construct of readiness to change and specific aspects of executive function that may affect treatment response in psychoeducational treatments. These findings were derived from only one model of anger intervention, and the relevance to other treatment approaches cannot be assumed.

Psychoeducational Interventions for Problematic Anger in Chronic Moderate to Severe Traumatic Brain Injury: A Study of Treatment Enactment.

OBJECTIVES: Treatment enactment, a final stage of treatment implementation, refers to patients' application of skills and concepts from treatment sessions into everyday life situations. We examined treatment enactment in a two-arm, multicenter trial comparing two psychoeducational treatments for persons with chronic moderate to severe traumatic brain injury and problematic anger. METHODS: Seventy-one of 90 participants from the parent trial underwent a telephone enactment interview at least 2 months (median 97 days, range 64-586 days) after cessation of treatment. Enactment, quantified as average frequency of use across seven core treatment components, was compared across treatment arms: anger self-management training (ASMT) and personal readjustment and education (PRE), a structurally equivalent control. Components were also rated for helpfulness when used. Predictors of, and barriers to, enactment were explored. RESULTS: More than 80% of participants reported remembering all seven treatment components when queried using a recognition format. Enactment was equivalent across treatments. Most used/most helpful components concerned normalizing anger and general anger management strategies (ASMT), and normalizing traumatic brain injury-related changes while providing hope for improvement (PRE). Higher baseline executive function and IQ were predictive of better enactment, as well as better episodic memory (trend). Poor memory was cited by many participants as a barrier to enactment, as was the reaction of other people to attempted use of strategies. CONCLUSIONS: Treatment enactment is a neglected component of implementation in neuropsychological clinical trials, but is important both to measure and to help participants achieve sustained carryover of core treatment ingredients and learned material to everyday life.

Examining a Statewide Educational Consulting Program for Pediatric Brain Injury.

This study describes characteristics of students with acquired brain injury enrolled in a statewide educational consultation program and the program's support activities. Utilizing deidentified data from a statewide brain injury school consultation program, descriptive analyses of demographic and injury characteristics, including medical diagnosis (concussion/mild traumatic brain injury [TBI], moderate-severe TBI, and non-TBI), referral characteristics, educational placement, and the types of program activities were undertaken. 70% of students were referred for concussions/mild TBI and students were infrequently referred by medical professionals. Most students with concussion/mild TBI experienced recreational injuries (59%), while students with moderate/severe TBI commonly experienced road traffic injuries (48%). The greatest proportion of program team members' time was spent in consultation with school personnel (24%), communication with families (20%), and communication with school personnel (16%). Results suggest that the program addresses important communication and coordination needs among families, medical professionals, and educators and identifies opportunities to enhance program utilization.

Goal intention reminding in traumatic brain injury: A feasibility study using implementation intentions and text messaging.

OBJECTIVE: To examine feasibility of participant-created implementation intentions, delivered as text message reminders, to enhance goal-related activity in persons with chronic, moderate/severe traumatic brain injury (TBI). DESIGN: Pilot randomized controlled trial on effects of 8 weeks receiving goal-related implementation intentions (GI) compared to control condition, educational review regarding goals (GR). PARTICIPANTS: Eight persons with moderate/severe TBI nearing discharge from intensive outpatient brain injury treatment. MEASURES: Neuropsychological tests to characterize cognitive status; Participation with Recombined Tools-Objective (PART-O) assessing community activity, social relations and productivity; Brief Symptom Inventory-18 (BSI-18) assessing depression, anxiety and overall distress; Goal Attainment Scales (GAS). PART-O, BSI-18 and GAS were completed at baseline and 8 weeks; significant others provided ratings on PART-O and GAS. RESULTS: Participants replied to SMS messages at high rates. Statistically significant group × time interactions with medium-to-large effect sizes favouring the GI group were observed on PART-O community activity and social relations. Neither BSI-18 nor GAS revealed differences or trends by group. Qualitative results suggested overall acceptance and success of SMS reminders. CONCLUSIONS: Given positive preliminary findings, implementation intentions delivered by text holds promise as a simple, low-cost intervention to help people with moderate/severe TBI to implement goal-relevant behaviours.

How Do Intensity and Duration of Rehabilitation Services Affect Outcomes From Severe Traumatic Brain Injury? A Natural Experiment Comparing Health Care Delivery Systems in 2 Developed Nations.

OBJECTIVE: To determine the effects of inpatient and outpatient treatment intensity on functional and emotional well-being outcomes at 1 year after severe traumatic brain injury (TBI). DESIGN: Prospective, quasiexperimental study comparing outcomes in a U.S. TBI treatment center with those in a Denmark (DK) center providing significantly greater intensity and duration of rehabilitation. SETTING: Inpatient and outpatient TBI rehabilitation. PARTICIPANTS: Persons with severe TBI (N=274). INTERVENTIONS: Inpatient rehabilitation interventions were counted daily by discipline. Outpatient treatments were estimated per discipline using a structured interview administered to patients, caregivers, or both, at 12 months. MAIN OUTCOME MEASURES: FIM, Glasgow Outcome Scale-Extended, Disability Rating Scale, Participation Assessment with Recombined Tools-Objective, Perceived Quality of Life, Medical Outcomes Study 12-Item Short-Form Health Survey, Brief Symptom Inventory-18-item version. RESULTS: Despite identical inclusion criteria, patient severity on admission was greater at the DK site. After adjustment for patient/injury characteristics, there were no site differences in either functional or emotional outcome at 12 months. Significantly more inpatient plus outpatient treatment was administered to DK patients than to those in the U.S. For functional but not emotional treatments, more severely impaired patients received higher doses. One-year outcomes were predicted by admission severity, age, employment, and other baseline characteristics. CONCLUSIONS: Contrary to expectation, DK patients who received significantly more rehabilitation services during the year after severe TBI did not differ in outcome from their less intensively treated U.S. counterparts, after adjusting for initial severity. The negative association of functional treatment dose with extent of early disability suggests that dose was driven by unmeasured factors reflecting need for services. Improved measures of injury-related factors driving treatment allocation are needed to model the independent effects of treatment on outcomes.

Anger self-management in chronic traumatic brain injury: protocol for a psycho-educational treatment with a structurally equivalent control and an evaluation of treatment enactment.

Anger and irritability are important and persistent clinical problems following traumatic brain injury (TBI). Treatment options include medications, behavioral modification, and psychotherapies, but some are impractical and none have proven efficacy with this population. We describe a randomized multi-center clinical trial testing a novel, one-on-one, 8-session psychoeducational treatment program, Anger Self-Management Training (ASMT), designed specifically for people with TBI who have significant cognitive impairment. The trial is notable for its use of a structurally equivalent comparison treatment, called Personal Readjustment and Education (PRE), which was created for the study and is intended to maximize equipoise for both participants and treaters. Fidelity assessment is conducted in real time and used in therapist supervision sessions. The primary outcome is change in self-reported anger on validated measures from pre-treatment to 1 week after the final session. Secondary outcomes include participant anger as reported by a significant other; emotional distress in domains other than anger/irritability; behavioral functioning; and quality of life. An interim assessment after the 4th session will allow examination of the trajectory of any observed treatment effects, and a follow-up assessment 2 months after the end of intervention will allow examination of persistence of effects. A treatment enactment phase, in which participants are interviewed several months after the last therapy session, is designed to provide qualitative data on whether and to what extent the principles and techniques learned in treatment are still carried out in daily life.

Anger self-management training for people with traumatic brain injury: a preliminary investigation.

OBJECTIVE: : To examine the feasibility and gather preliminary data on the efficacy of a fully manualized, 8-session, psychoeducational treatment for irritability and anger after traumatic brain injury (TBI), called anger self-management training (ASMT). PARTICIPANTS: : A total of 10 persons with moderate to severe, chronic TBI with significant cognitive impairment and elevated levels of anger and irritability participated in the study; 8 had significant others (SOs) who participated in portions of the treatment and provided pre- and posttreatment measures; 1 SO provided only data. MAIN OUTCOME MEASURE: : Two subscales of the State-Trait Anger Expression Scale-Revised and Brief Anger-Aggression Questionnaire. DESIGN: : Pre- to posttreatment pilot study. RESULTS: : There was significant improvement on all 3 measures of self-reported anger, with large effect sizes (>1.0), and on 1 of 3 SO-reported scales. Qualitative feedback from participants was positive and dropout rate was low (1 of 11). CONCLUSIONS: : The treatment model represented by the ASMT appears worthy of further study in persons with TBI who have both problematic anger and cognitive impairment.

Internet resources for traumatic brain injury: A selective review of websites for consumers.

This article provides a selective review of brain injury resources found on the Internet. It is geared toward the needs of survivors of brain injury and their families. Provided are listings of websites that focus on brain injury, those with sections pertaining to brain injury, and those with brain injury information found by searching the site. Sites that afford communication in the form of chatrooms, message boards, and mailing lists are described and listed. The value of this technology for consumers, as well as some of the challenges in searching for relevant materials on this topic, is discussed.