Self awareness in persons with brain injury

Self advisedness in persons with dotway smirchAcquired maven stain (ABI) is a major medical issue which understructure affect any wiz regardless of class, race, ethnicity, gender, or age. It can be defined as damage to the brilliance, which occurs after present and is not related to a congenital or a degenerative disease. These balks whitethorn be maverick or permanent and cause partial functional disability or psycho favorable mal plantment (Brain defacement Association, 2009). People who allow sustained an acquired wizardry injury be not easily pinpointed in society due to the neglect of external symptomology, and thitherfore ABI is usually referred to as the hidden disability. This title, named accordingly, is due to the extensive damage to their cognitive and social functioning and less to do with their bodily appearance, which in many cases remained unchanged.So what causes ABI, and who can be moved(p) by it? This type of injury can occur due to a series of incidents, and anyone can be affected by it. Some achievable incidents include a road traffic accident, a fall, an assault, a stroke which causes damage to the brilliance, complications during point surgery, tumours, viral infections, or lack of oxygen to the brain (a possible import of a heart attack, hypoxia, or anoxia). ABI can be split into two types traumatic and non-traumatic. A traumatic brain injury can occur due to a closed or open injury. The much mutual type, closed injury, occurs when the brain is bounced around in the skull due to a blow to the head, such as the impact from a road traffic accident. What this impact leaves in is damage to the brain tissue. An open injury, on the other hand, occurs when an object such as a bullet, fractures the skull and enters the brain (Headway, 2009). This type of injury is less common and usually damages a specific part of the brain, therefore resulting in specific problems. The other type, non-traumatic injury, is scarcely one that does not occur as a result of a trauma, such as a stroke or a tumour.Prevalence of ABI is unknown inside Ireland, however Headway (2009), an Irish government activity specialising in brain injury refilling, accumulated ABI data from motley countries and applied this to an Irish population in order to estimate the preponderance. With this information they suggested that between 9,000 and 11,000 commonwealth sustain a traumatic brain injury from each one year in Ireland. They estimated that there are approximately 30,000 people in Ireland between the ages of 16-65 with coherent term problems pursuit trauma to the brain, and that the 15-29 year old group are trine times more than probable to sustain a brain injury than any other group. Another Irish assume, OBrien Phillips (1994), preserve individual patient details for all head injury admissions to the Neurosurgical Unit at Beaumont Hospital, Dublin. They estimated a prevalence of head injury among patients in Ir eland to be approximately 13,441 per year, which is just s neatly higher than Head shipway (2009) estimation. Results from the 225 patients they canvass depicted that road traffic accidents accounted for 48% of injuries sustained (the largest proportion), and falls accounted for 36%. The seekers too appoint that between 1987 and 1993 there were 3,154 people killed and 64,971 injured on Irish roads. Alcohol consumption prior to the injury was also found in 31% of cases. In a larger study, Tagliaferri et al. (2006) attempted to locate the prevalence order of brain injury, this time in Europe. They claimed that the absence of prevalence data hampers the full assessment of medical word and rehabilitation needs (p. 265) and that prevalence studies in Europe are essential, and should be undertaken extensively. With this in mind they suggest that brain injury patients will increase by 775,500 each year in the EU, and that 6,246,400 people are vivacious with some(a) degree of TBI tr aumatic brain injury (p. 260). Thus we can conclude from these studies that Ireland has a prevalence rate of ABI from round 9,000 to 13,5000, a slight impingement upon Europes figures, but a worryingly high statistic for Ireland alone.There are collar levels of brain injury, which indicate the severity of the neurological injury lenient, moderate, and spartan brain injury. To qualify for a mild brain injury, one must score between 13 15 on the Glascow Coma Scale, which records the conscious state of a person. This type of brain injury can occur due to a shortened loss of consciousness, and the patient may present himself or herself as confused, and deplorable from a concussion. Symptoms that occur within this severity of brain injury are predominantly headaches, fatigue, irritability, sensitivity to noise or light, balance and retention problems, nausea, decreased speed of thinking, depression, and mood swings. A moderate traumatic brain injury can be diagnosed when the pat ient scores a 9 12 on the Glascow Coma Scale. This injury occurs when there is a loss of consciousness that lasts from a few minutes to a few hours, and confusion lasts from days to weeks. Patients in this category usually make a good recovery with give-and-take. The last level of brain injury is severe brain injury, and this occurs when there is a pro wanted unconscious state or coma that lasts days, weeks, or months. This category can be categorized into subgroups of coma, vegetative state, persistent vegetative state, minimally responsive state, akinetic mutism, and locked-in syndrome. (Brain Injury Association, 2009).There are many changes and consequences that affect a person after they have suffered from an acquired brain injury, whether mild, moderate, or severe. These changes may be temporary, meliorate in time, or permanent, dictating the way they live the rest of their lives. Not further do the changes affect the victim, but they also affect the victims support system (i.e. their surrounding family and community). Each brain injury is unique and subject to change, and depending on the severity of the injury, a patient will witness cognitive changes shifts in the ability to think and learn, affecting memory, concentration, flexibility, communication, insight, and responses. Physical changes will also be apparent in the form of fatigue, headaches, chronic pain, visual and hearing problems, and sexual function. Behavioural changes may include impulsivity, irritability, inappropriate behaviour, self-centredness, depression, lack of initiative, and sexual behaviour.Challenging BehaviourAs stated earlier, most people who have a head injury are left with a change in the form of their emotional or behavioral pattern. This is inevitable as the brain is the seat and control centre of all our emotions and behaviour (Powell, 1994, p.96). With this in mind, thought-provoking behaviour alone has find synonymous with ABI as one of the main behavioral defic its that occur following injury. The belles-lettres of ABI has accentuated that challenge behaviour presents the most significant behavioral disturbance within this diagnosis, and can aim serious problems for their recovery, their family, and also their community. Kelly et al. (2008) provided evidence that repugn behaviours have often been associated with risks such as family disintegration, loss of accommodation, cut back access to rehabilitation or community facilities and legal charges (p.457). Results of their study indicated that 94% of the patients they studied showed broad behavioural disturbance, with 60% engaging in four or more behaviour problems (p.463). However, due to convergent opinions on what constitutes a gainsay behaviour, defining such behaviour has become difficult. However, Headway Ireland (2009) have made one such attempt to define gainsay behaviourany behaviour, or lack of behaviour of such intensity, absolute frequency and/or duration that has the po tential to cause di separate out or harm to clients/carers/staff or one which creates feelings of discomfort, powerlessness, frustration, fear or anxiety. It is also behaviour, which delays or limits access to ordinary community facilities and is outside socially acceptable norms.As mentioned earlier, types of behavioural problems that may occur following an acquired brain injury include agitation, depression, anxiety, self-centredness, withdrawal, physical aggression, increased/decreased libido, impulsivity, self harm, restlessness, paranoia, and many others. As each brain injury is unique, some patients may suffer with some symptoms, whereas others may not. Each person is entirely unique, with severities and symptoms being completely individual.So why exactly do patients suffering from an ABI present with contend behaviours? Powell (1994) suggests that there seems to be four main reasons why these challenging behaviours exist (a) direct neurological damage (b) exaggeration of pre vious personality (c) the stresses of adjustment and (d) the environment the person lives in (p.97). With regards to direct neurological damage, the challenging behaviour results directly from the damage done to the true area of the brain. umpteen of the challenging behaviours stem from damage done to the frontal lobes, which are important for the standard of emotions, motivation, sexual libido, self-control and self-awareness. Following a brain injury, the patients existing personality traits, tendencies, and problems may be exaggerated, it is as if the controls or brakes which modify and regulate the personality have been loosened, and traits and mannerisms become distorted and exaggerated (p.97). It is extremely important for the professionals working along side the patient to be aware of the patients previous personality when attempting to get a line their challenging behaviour. Thirdly, stress of adjustment can also be a major contributor to the challenging behaviour that persists in patients with ABI. Finding out that one can no longer do the unsubdivided things in life anymore, such as play their favourite sport or instrument, can be extremely frustrating and stressful for the patient. It is more likely that under these extreme conditions of stress that one would become more angry and irritable, and become more preoccupied with their problems than before. Finally, the social and physical environment can also support to the onset of behavioural problems. The social environment relates to the natural supports surrounding the patient such as family, friends, neighbours, and professional staff, whereas the physical environment depicts the patients setting, whether its an institutional setting or a family star sign. Taking into consideration twain the social and physical environment, if the person suffering from ABI is not understood, and communication and support is poor, whence their behaviour is likely to deteriorate as a result. It is crucial for the patient to be in the correct environment to get out the best opportunities possible.How others respond to the challenging behaviour of a person with an ABI plays a crucial role in the rehabilitation process, as well as the quality of life of family and friends surrounding the patient. Of concern is the setting in which the patient is located these behaviours can endure and worsen over time, particularly in unstructured settings where there is often little control over the environmental contingencies that govern behaviour (Kelly et al., 2006). Alderman (2001) has stated how behaviour qualifying broadcastmes can create profound changes within the neurorehabilitation setting. There exists an amalgamation of research conducted in this area with some very mentionable results.Watson et al. (2000) conducted a case study on patient, JH, who had sustained a brain injury as a result of a gunshot wound, and developed severe behavioural problems. A differential funding of low rates of responding (DRL) intervention was devised for 85 weeks, which allowed JH the opportunity to gain stars at the end of the day if he had absolved from aggressive behaviour to a created limit. This treatment resulted in JHs level of Clopixol being reduced from three times a day, down to two without any side effects on his challenging behaviour. DRL has demo the effectiveness in reducing both the frequency and severity of aggressive behaviour 10 long time after a very severe TBI had been sustained (p.1011).Other studies stress different approaches to treatment of challenging behaviours, such as remedial behaviour therapy approaches, or Rothwell et al. (1999) who suggest the main emphasis in treating challenging behaviours should be upon behavioural assessment as it engenders an empathic understanding of what is often offensive behaviour, which helps reduce the stress experienced by the people affected by the behaviour and leads to respectful, individualized and holistic intervention s (p.530).Self-AwarenessAs mentioned earlier, challenging behaviour is synonymous with ABI, however deficits in self-awareness have also been well established in the literature to be evident in patients with brain injury. Impaired self-awareness poses great challenges for rehabilitation, and also for the safety of the patient suffering from the ABI. Self-awareness can be defined as the capacity to perceive the self in relatively verifiable terms while maintaining a sense of subjectivity (Prigtano Schacter, 1991, p. 13). The ability to think subjectively and objectively of ourselves, and to adjust our behaviours accordingly, are abilities that are often overlooked, but are none-the-less crucial for daily living, and integration into society. These skills are ordinarily impaired following a brain injury, as both are constructs associated with executive functions and related to frontal-executive systems dysfunction (Goverover et al. 2007, p. 913).Oddy et al. (1985) undertook a stud y in a bid to portray the implications of a decreased level of self-awareness (specifically behavioural limitations) after traumatic brain injury. The researchers asked patients and their surrounding families to describe the behavioural problems that prevailed seven years following the brain injuries occurrence. The results mention that patients tended to underestimate their problems in comparison to their families reports. For example, 53% of patients noted that memory problems were the most common long term difficulty, whereas 79% of the families noted memory problems as significant sequelae. Also, patients failed to report two problems that the families reported. 40% of the families noted that the patient behaved in a much more childlike manner, and also that the patients refused to admit to their difficulties. This study brought to light the issue of self-awareness stultification.We have so far spoken of self awareness deficits and its prevalence within people who have ABI, bu t what exactly are the implications of such a deficit? It is widely suggested that an increased impairment of self-awareness is associated with increased problems in most other areas of the patients life. For example, Larn et al. (1998) studied that ABI patients with poor self-awareness show less compliance and participation during treatment in rehabilitation. Malec Degiorgio (2002) found that ABI patients with decreased level of self-awareness are considerably more at risk of being referred for more intensive rehabilitation. Malec et al. (2000) found that such patients require longer lengths of stay in rehabilitation Sherer et al. (2003) found that patients are more likely to be associated with a poorer functional status at time of discharge from rehabilitation. Ezrachi et al. (1991) found that deficits in a patients level of self-awareness is foretelling of a low rate of return to employment following a brain injury. And finally, Ergh et al. (2002) found that a high level of impa irment of self-awareness with the ABI patient is reflective of higher distress among caregivers (as cited in High, 2005).With regards to treatment of impaired self-awareness in individuals with ABI, there is a vast range of methods which have been studied. Crosson et al. (1989) have shown that group therapy programmes can be beneficial in change magnitude intellectual awareness. Zhou et al. (1996) studied three adult male persons who were trained in knowledge of ABI residuals using a game format to present training information (p. 1). Results suggested that all participants increased their knowledge relating to areas of behaviour, emotion, cognition, communication, physical, and sensory residuals. Many studies have exemplified the role of observation and feedback to alter individuals level of self-awareness. For example, Schlund (1999) undertook a case study of a 21-year-old male who was a TBI survivor and was 5 years post-injury. Results of this study showed that report- executin g measurement, feedback and review, positively altered the patients awareness deficit. However, observation and feedback are not without its faults as Bieman-Copland Dywan (2000) point out. Their study suggested that direct feedback becomes confrontational and can lead to agitation among patients with severe brain injury. This study highlights the need for each treatment to be individualised to ensure the best possible outcomes of treatment. Fleming et al. (2006) evaluated the usefulness of an individualised occupation-based approach for participants dealing with ABI, specifically with regards to the level of self-awareness and emotional status. The unique focus of the program was the use of meaningful occupations to provide the individuals with experiential feedback of their current level of ability finished the use of self-monitoring and confirmatory therapist feedback (p. 51). The results supported the use of this type of therapy in increasing self-awareness, and that occupati onal performance may be highly important in increasing the self-awareness of people with ABI. Finally, Goverover et al. (2007) conducted a randomised controlled study on the self-awareness treatment model, stipulated upon Toglia and Kirks model (2000). Their study provided evidence for experiencing different tasks and everyday activities for enhancing self-awareness and self-regulation.Although treatment of impaired self-awareness is crucial for the patients full recovery, it has been studied that increasing the level of self-awareness in ABI patients can also have some negative consequences. Fleming Strong (1995) suggested that the impression that increased self-awareness is essential for positive outcomes in rehabilitation and needs to undergo further investigation, as a literature review suggests that the development of self-awareness can be associated with emotional distress in the individual (p. 55). This study further exemplifies the necessity to create individual treatment p lans when in rehabilitation.InterventionsWith technology constantly advancing in the medical sector, it is evident that sustaining a brain injury no longer suggests a death sentence. With this in consideration, the emphasis has shifted towards rehabilitation of those who have sustained such an injury in order to help them micturate the best quality of life possible. Many interventions have been conducted and researched for improving self-awareness, and also for managing challenging behaviours, which directly improve the life of the patient.There are limited studies focusing on the effectiveness of interventions in reducing self-awareness deficits, and whether these interventions contribute to positive outcomes in rehabilitation. However, in a literature review, Lucas Fleming (2005) suggest that interventions in self-awareness can be broken in into two categories restorative/facilitatory, or compensatory. Within the restorative/facilitatory category, education, direct feedback, a nd experiential feedback are the most a great deal recommended (p.163), with others such as behavioural therapy, psychotherapy and rating of task performance also being recommended. information relates to ensuring the patient understands his or her injury and the impairments that this injury brings. This can be delivered through a variety of ways such as group therapy, visual aids, and support groups. Direct feedback following a task performance can be used to facilitate intellectual, emergency, and anticipatory awareness (p.164), whereas experiential feedback allows the patient to go through difficulty in a real-life situation and is useful in emergent and anticipatory awareness (p.164).Compensatory strategies thenAs noted earlier, challenging behaviours and problematic social interaction have been liked to individuals with brain injury, which result in an amelioration of difficulties in areas such as family life, integration into the community and employment, to name but a few. Applied Behaviour Analysis (ABA) works with environmental stimuli that impede on the challenging behaviour, and it is behavioral sic research in the field of brain injury rehabilitation that is an effective means of identifying techniques for reducing challenging behaviours and improving adaptive skills (Selznick Gurdin, Huber Cochran, 2005, p.15). This research is extensive and incorporates many different behavioural interventions, all of which have been proven to be successful.Within schools and residential programs, intervention procedures have been undertaken to reduce challenging behaviours that disrupt academic behaviour. Feeney Ylvisaker (1995) structured ascendent treatment using graphic organizers, curing, plan-do-review routines, and inclusion of the participant in decision-making. This treatment reduced the intensity and frequency of aggressive behaviour evident in three males with TBI. Gardner, Bird, Maguire, Carrario, Abenaim (2003) also reduced challenging behavio urs using preceding control procedures, however their success was due to interspersal and fading techniques. Selznick Savage (2000) examined self-monitoring methods for individuals who had sustained a brain injury. These methods proved to be effective for increasing attending, academic responding, and task accuracy as well as for improving social skills with individuals with behaviour disorders, mental retardation, and learning disabilities (p.243 ). This study found that on-task behaviour increased to 89 100% for three boys with brain injury when these self monitoring procedures were undertaken. Consequence-based interventions have also been studied extensively in this area and prove to have significant positive results. Peck, Potoczny-Gray, and Luiselli (1999) used instructional motor activities when a 15 year old boy with ABI showed signs of stereotypy in the classroom. This intervention reduced stereotypy and maintained its reduction when treatment was faded.Within the rehabi litation area, there has been extensive research depicting behavioural procedures that reduce challenging behaviour. Hegel (1988) utilize a figure economy system to an 18 year old boy with a brain injury during therapy session in order to reduce his disruptive vocalizations and his noncompliance. As a result of the memento economy system, his vocalizations decreased and his achieved goals increased. On a similar note, Silver et al. (1994) used a monetary reinforcement system on a 12 year old girl with an anoxic brain injury. This was incorporated in a bid to improve her performance of morning tasks. She was reinforced with one penny for each step that she correctly completed. Reinforcement was gradually faded, and by the end of the intervention her verbal cues and physical tending had decreased by 70 92%. Differential reinforcement of alternative behaviour (DRA) has also been proven to be successful in reducing challenging behaviour. Slifer et al. (1993) used this technique wi th extinction, response cost, and a token economy, to reduce disruptive behaviour. In most cases, DRA reduced disruptive behaviour and also increased compliance. From examining these studies, it suggests that various reinforcement procedures may facilitate more efficient therapeutic goal attainment and subsequent home and community reintegration (Gurdin et al. 2005, p.12).Purpose of current studyThe purpose of the current study was to investigate the prevalence of self-awareness and challenging behaviours in persons with acquired brain injury, intervention types, and success ratings. This study will incorporate a sample of Irish patients who have ABI, which is presently absence in the research conducted to date. It will also provide information on what intervention types are most regularly used among persons with ABI, and the success ratings of such intervention types.