Objectives: To explore living situation, support and participation outcomes of people with severe acquired brain injury (ABI) residing in either home-like or disability-specific accommodation settings, who were provided with 3 years of occupational therapy intervention based on the Community Approach to Participation (CAP).

To examine transitions for a subgroup whose accommodation and support model changed during this 3-year period and identify factors critical to this change.

Method: Forty-three participants who had sustained severe to extremely severe ABI, and were an average of 6.73 years post-injury, were provided with CAP intervention over a 3-year period. Living situation and support model, participation levels and accommodation transition data were collected at four time points.

Results: Participants were living in a range of home-like and disability-specific accommodation settings at baseline. The disability-specific accommodation group had mainly noncompensable injuries and required a significantly higher level of daily support at all four time points. They also received higher total hours of support, which averaged 170.83 hours per week at baseline and did not change significantly over the 3 years. In contrast, 86% of the participants residing in home-like settings had compensable injuries and received an average of 91.46 hours of support per week at baseline. This reduced to 70.97 hours per week over the 3-year intervention period, a change that was statistically significant.

Conclusion: It is possible to achieve accommodation transitions to more independent, home-like situations many years post-injury and regardless of injury severity. Home-like settings provide scope to adjust support along a continuum to reflect gains in independence, community integration and role participation that the fixed models and hours of support in disability-specific accommodation do not. Over time, these gains can flow into a significant reduction in hours of support.

Paediatric acquired brain injury (ABI) is the most common cause of acquired disability in childhood. It frequently results in significant personality, cognitive, emotional and behavioural changes, and consequent impairment in independent functioning, education, employment and interpersonal relationships. Additionally, paediatric ABI impacts on the entire family system, with parents commonly reporting significant distress and adjustment difficulties. Despite this, there is currently limited research into effective programmes to support families following their child's ABI. This protocol describes a wait-list randomised controlled trial of a behavioural family intervention plus a parent stress management programme for paediatric ABI. Interventions will be conducted with parents in a group format, aiming to improve child outcomes by improving parenting behaviour and coping. Outcomes assessed will be: (i) child behaviour and emotional outcome as measured by parent and teacher reports; (ii) parental style and confidence; (iii) parental adjustment (stress, anxiety and depression symptoms); (iv) family functioning; (v) parent relationship; and (vi) parent psychological flexibility. Assessments will be via questionnaires conducted pre-, mid- and post- intervention, and at a 6-month follow-up. The theoretical basis, study hypotheses, methods and planned analyses are described.

Background: Aboriginal and Torres Strait Islander Australians experience stroke and traumatic brain injury (TBI) with much greater frequency than non-Aboriginal Australians. Acquired communication disorders (ACD) can result from these conditions and can significantly impact everyday life. Yet few Aboriginal people access rehabilitation services and little is known about Aboriginal peoples’ experiences of ACD. This paper describes the protocol surrounding a study that aims to explore the extent and impact of ACD in Western Australian Aboriginal populations following stroke or TBI and develop a culturally appropriate screening tool for ACD and accessible and culturally appropriate service delivery models.

Method/Design: The 3-year, mixed methods study is being conducted in metropolitan Perth and five regional centres in Western Australia. Situated within an Aboriginal research framework, methods include an analysis of linked routine hospital admission data and retrospective file audits, development of a screening tool for ACD, interviews with people with ACD, their families, and health professionals, and drafting of alternative service delivery models.

Discussion: This study will address the extent of ACD in Aboriginal populations and document challenges for Aboriginal people in accessing speech pathology services. Documenting the burden and impact of ACD within a culturally secure framework is a forerunner to developing better ways to address the problems faced by Aboriginal people with ACD and their families. This will in turn increase the likelihood that Aboriginal people with ACD will be diagnosed and referred to professional support to improve their communication, quality of life and functioning within the family and community context.

This study aimed to describe the recovery of impairments after severe traumatic brain injury (TBI) over a 3-year period. An inception cohort over 2 years was recruited from 11 brain injury rehabilitation units participating in a state-wide program. The 131 individuals with TBI were assessed at admission to the rehabilitation program, 18 months and 3 years post-trauma. This report described results from the Disability Rating Scale (DRS) and Mayo-Portland Adaptability Index (MPAI). Regression analyses, examining the influence of five acute injury variables on DRS and MPAI, revealed that posttraumatic amnesia (PTA) was a significant individual predictor. Data were thus analysed according to duration of PTA: 1 to 2 weeks (n = 19), 2 to 4 weeks (n = 44) and more than 4 weeks (n = 68). At program admission there was poorer overall level of functioning on the DRS in the longest PTA group, but no difference between the shorter PTA groups. Significant improvements occurred on the DRS for all PTA groups over the first 18 months posttrauma, with improvements continuing between 18 months and 3 years. At the 3-year follow-up, frequency data from the MPAI indicated that clinically significant impairments in mobility, hand function, communication and behaviour were uncommon in the shorter PTA groups, although 36% to 47% continued to experience cognitive impairments. Impairments were common in the longest PTA group in some areas, particularly cognition where two thirds or more continued to experience clinically significant impairments in attention, memory and novel problem-solving. These results confirm the predictive significance of PTA duration regarding longer-term level of recovery. They also highlight the limitation in classifying the ‘severe’ TBI category as an homogenous group: significant subgroup differences occurred on medical and functional variables at program admission, 18 months and 3 years posttrauma. These data further substantiate the persistence of neuropsychological impairments in the face of good physical recovery at all levels of severity within the severe TBI group.

Transitional Living Programs (TLPs) have been a standard component of traumatic brain injury (TBI) rehabilitation services for over two decades. The twofold aim of this study was to describe a TLP service model, and to examine the efficacy of standardised TBI-specific outcome scales for TLPs. A consecutive series of 50 residents admitted to the TLP over an 18-month period were administered a number of outcome measures at both admission and discharge. Mean duration of PTA for the sample was 60 days and average length of stay was 7 weeks. Measures included the Sydney Psychosocial Reintegration Scale (SPRS), the Mayo-Portland Adaptability Inventory (MPAI), the Brain Injury Community Rehabilitation Outcome (BICRO) scales and the Assessment of Living Skills and Resources Scale (ALSAR). Results showed significant improvements in the global scores for the SPRS, MPAI and ALSAR from admission to discharge. In contrast, a number of the BICRO scales exhibited floor or ceiling effects. Correlational analysis found moderate to strong associations between the SPRS, MPAI and ALSAR across a number of functional domains. Results to date show promise in identifying measures that are able to detect change over the course of a TLP admission. The findings lay the foundation for ongoing research into the effectiveness of such programs.

Current management attempts for Alzheimer's disease (AD) focus on the identification of individuals in the preclinical stage. This has led to the development of the diagnostic concept of Mild Cognitive Impairment (MCI), which applies to individuals with declining cognitive abilities but largely preserved everyday functioning. Previous findings indicate that prospective memory deficits are a sensitive marker of preclinical AD and that awareness of prospective memory failures is particularly high, based on its dependence on executive functions. Thus, the goal of this study was to evaluate the usefulness of subjective prospective versus retrospective memory complaints for an initial screening for MCI and their respective associations with executive functions. 71 healthy older adults, 27 MCI patients, and 9 patients with mild AD completed the Prospective and Retrospective Memory Questionnaire (PRMQ) and three executive functions tests. The healthy and the MCI group could not be distinguished by their level of subjective prospective or retrospective memory complaints, but the mild AD patients differed from the other groups by complaining more about retrospective than prospective memory failures. For the healthy older adults, the prospective memory complaints were correlated to an inhibition test, whereas they did not correlate with any of the executive function tests in the MCI patients. In contrast, in both groups the retrospective memory complaints were related to a task switching test. The findings are discussed with respect to differences between the three groups in cognitive abilities, attention to failures of, use of mnemonic aids for, and everyday demands of prospective and retrospective memory.

This study aimed to assess planning ability in adults with traumatic brain injury (TBI) using a 4-disk version of the Tower of London (TOL). Thirty three individuals with TBI were compared with equivalent numbers of matched controls. Overall, the TOL4 was shown to be sensitive to the effects of brain injury, with the TBI group performing significantly more poorly on this version of the planning test than the matched controls. More specifically, group differences were found to be related to the complexity of the planning problems, particularly among a TBI subgroup with localised prefrontal damage. Results of the study provide support for the adverse effects of TBI on planning ability, and the important role of the prefrontal cortex in planning.

This study investigated the effect of severe traumatic brain injury (TBI) on prospective memory. It also sought to identify the relative contributions of executive functioning and retrospective memory to prospective memory. Thirteen patients with severe TBI and 13 matched control subjects were assessed on two novel, yet ecologically valid, experimental measures of prospective memory and standard tests of neuropsychological functioning. Participants with TBI performed significantly worse than did controls on neuropsychological tests and a time-based prospective memory task, indicating that TBI affected not only retrospective but also prospective memory functioning. Multiple regression analyses identified relationships between executive functioning and time-based prospective memory and between retrospective memory and event-based prospective memory. Implications of these findings for the assessment and rehabilitation of memory impairment in individuals with TBI are discussed.

Background and aims: The ‘transition’ phase from hospital to home following brain injury is well established as a critical period of adjustment for individuals and their families. There is, however, a lack of knowledge about the experience of transition following nontraumatic brain injury (e.g., stroke, aneurysm) for individuals of working age. The purpose of this study was to explore the transition experiences of individuals with nontraumatic brain injury using mixed methods approach.

Methods: Six individuals with nontraumatic brain injury were recruited from a larger study using maximum variation sampling criteria. Individuals participated in semistructured interviews at 6-months postdischarge and completed quantitative measures of psychosocial outcomes predischarge and at 6-months postdischarge. Results: Qualitative content analysis of interviews identified three themes: (1) changes in role performance, (2) support and services and (3) coping with life after brain injury. The transition experience was characterised by loss of valued roles including driving and work, identified as major barriers to regaining independence postdischarge. Informal support provided by family and friends were relied on, while formal supports were accessed infrequently. Life post-injury presented a number of challenges including adjusting to changes in physical and cognitive abilities and a fear of reinjury. Qualitative data were supported by an overall trend of improved functioning on the quantitative measures over the 6 months.

Conclusions: Key life circumstances of working age adults with nontraumatic brain injury influence the transition experience. Clinically, the findings support the need for individualised, structured transition services pre- and postdischarge for this group.

Impaired self-awareness may affect clients' emotional status, engagement in rehabilitation and community reintegration following traumatic brain injury (TBI). The study aimed to investigate the relationship between self-awareness, emotional distress and community integration in adults with TBI during the transition from hospital to the community. Thirty-four rehabilitation clients with TBI were assessed in the week before and 2 months after discharge home. Measures of self-awareness and emotional functioning were administered predischarge and repeated at follow-up along with a measure of community integration. Nonparametric tests were used to compare levels of self-awareness and emotional distress pre- and postdischarge, their interrelationships and association with community integration. Self-awareness significantly increased following discharge, and a trend towards increased depression was found. There were no consistent relationships found between level of self-awareness, emotional functioning, and community integration. The development of self-awareness in the immediate postdischarge phase suggests this is an important time for clinical interventions targeting compensation strategies and adjustment to disability.

Many studies of cognitive rehabilitation use neuropsychological tests to plan and evaluate treatment. This paper suggests that this is not a good rehabilitation procedure. The main purposes of rehabilitation are to achieve the maximum physical, psychological, social and vocational wellbeing of each individual and to enable people to return to their own, most appropriate environment. We do not engage in rehabilitation in order to help people achieve better scores on tests. This might be acceptable if there were a direct relationship between test scores and real life problems but there is not such a relationship. Although tests are useful in providing a picture of strengths and weaknesses, they are extremely limited in identifying everyday disabilities and handicaps. People can lead improved lives by compensating for or by-passing some of their cognitive problems yet remain unchanged on test scores. Conversely, they can improve on test scores yet remain severely handicapped in everyday life. One approach that is gaining ground in rehabilitation is goal planning. This allows patients/clients, their relatives and rehabilitation staff to negotiate appropriate and meaningful goals, determine how these should be achieved and measure success, or failure in real life situations. Goal planning both reduces the artificial distinction between rehabilitation practice and outcome measures, and allows the integration of theory and practice. The processes and procedures involved in goal planning are described and followed by an evaluative discussion.

The purpose of the present article is to describe the issues associated with providing lifelong accommodation and support to people with severe brain injury, neurobehavioural disability, and overt challenging behaviours. In particular, the article focuses on two groups of people within an Australian context: (a) those who live in community settings but whose behaviour is not adequately managed even by specialist outreach behaviour management services, and (b) those who are confined to aged care residential facilities and who show challenging behaviour. These groups bring to the fore different lifelong behaviour management issues. At present, if community-based clients seriously offend or have an adequate psychiatric diagnosis, they may be placed in heavily secured psychiatric units or prison. Otherwise, by default, they will reside in less restrictive options such as family homes and shared supported accommodation. We will argue that the current service system lacks the ability to apply appropriate structure and control to many clients with serious challenging behaviours, and propose that specialised facilities would make an important addition to the service system. Conversely, young clients confined to residential aged care facilities live in impoverished environments that often contribute to challenging behaviour that can be enormously disruptive, distressing, and unsafe. We will review the recent Australian State and Federal Government initiative aimed at transitioning some young people out of nursing homes, and we raise considerations for future service development. There are many individuals with the potential to make significant gains in a tightly structured setting before returning to the community, while others will manage well with long-term placement in a setting designed for residents with neurobehavioural disability. Case studies and service data are used to support these arguments, and key elements of accommodation and rehabilitation models for those in need of long-term neurobehavioural support are described.

Community-based rehabilitation for people with acquired brain injury (ABI) is largely driven by goals set in the course of rehabilitation by clients and service providers. A preliminary study investigating the perspectives and practice of experienced rehabilitation coordinators was undertaken to explore issues that influence goal-setting in community rehabilitation settings. Detailed interviews and subsequent rounds of clarification were conducted with six experienced rehabilitation coordinators. Key themes identified through inductive analysis include cognitive influences, other client influences, service provider influences and the client-service provider relationship in the goal-setting process. Based on the findings, a preliminary descriptive schema of goal-setting in a community-based rehabilitation service for people with acquired brain injury is suggested. Factors such as training, experience, and values of the rehabilitation coordinators are also discussed in terms of their influence on goal-setting. Some strategies to assist a person with ABI to identify and work towards achieving realistic goals are identified. Suggestions for enhancing community-based rehabilitation practices with people with ABI, and scope for future research are noted. This paper constitutes a general overview of goal-setting in community-based ABI rehabilitation.

This study aimed to investigate the effects of methylphenidate on children with Attention Deficit Hyperactivity Disorder (ADHD). The study employed a conceptual framework of attention, consistent with contemporary theory, and including the following components: sustained attention, selective attention, divided attention, shifting attention, and speed of information processing. Fifteen children (12 boys and 3 girls) of normal intelligence, with a diagnosis of ADHD according to the DSM-IV criteria, and ranging in age from 8 to 11 years participated in the study. Children's attentional abilities were evaluated using the Test of Everyday Attention for Children (TEA-Ch: Manly, Roberston, Anderson, & Nimmo-Smith, 1999). A double-blind counterbalanced repeated-measures design approach was employed to tap on–off medication effects, and deviations from normal. Results showed that comparisons between on–off medication conditions generally detected few differences with respect to sustained and selective attention measures and simple processing speed. In contrast, for higher-level attention domains, including shifting and divided attention, children on medication demonstrated a speed–accuracy trade-off, exhibiting greater accuracy, but slower completion times. When data from the ADHD group were compared to controls a consistent pattern emerged, with children with ADHD in the medication condition being more accurate across all attention domains on all measures. While these children also tended to record slower completion times, group differences and effect sizes were of smaller magnitude. The findings of this study suggest a possible speed–accuracy trade-off effect for children with ADHD on medication.

Objective: To examine the care and support and participation outcomes for individuals with severe Acquired Brain Injury (ABI) provided with three consecutive years of Community Approach to Participation (CAP) intervention. Method: A case series study design was undertaken with a total of 43 participants from two private occupational therapy practices specialising in community-based, CAP rehabilitation for people with severe ABI. Data were collected at four time points: January 2004 (Baseline), January 2005 (T1), January 2006 (T2), and January 2007 (T3) and included rating on the Care and Needs Scale (CANS); number of hours of paid and gratuitous weekly support; FIM™ and Community Integration Questionnaire scores; and number of current life roles (as recorded on Part 1 of the Role Checklist). Participants were an average of 6.73 years post injury and were living in a range of community environments and residential facilities. Results: There was considerable change in participants' CANS rating across the intervention period, with statistically significant decreases occurring from Baseline to T1 and T1 to T2. Ninety-five per cent of participants received some level of weekly paid support throughout the intervention period, with the amount varying considerably. Paid care decreased by an average of 10.78 hours per week from 85.85 hours per week at Baseline to 75.06 at T3. Although not statistically significant, this equated to an average cost saving of AU$324.84 per participant per week by the end of CAP intervention. There was an overall mean reduction of 4.96 hours of gratuitous care per week per participant over the intervention period, which was statistically significant. Increases in functional independence, community integration, and role participation were also found. On the FIM™, statistically significant improvement occurred between Baseline and T1 and on the CIQ between Baseline and T1 and T1 and T2. Significant increase on the Role Checklist occurred between Baseline and T1 and between T2 and T3. The number of life roles in which participants engaged increased by an average of 1.65 roles by the end of the intervention period. A reduction in care and support needs (measured by the CANS) was significantly associated with: (1) a reduction in total care hours, (2) and an increase in functional independence on the FIM™, and (3) an increase in community integration on the CIQ. Conclusion: With a long term approach and contextualised intervention targeted at skill development in the areas that underpin personally valued participation, increased role performance and community integration can be achieved by people with severe ABI, even many years post injury. This increased capacity has been found to be associated with a reduction in care and support needs, including paid and gratuitous care hours, over time.

Traumatic brain injury (TBI) is a leading cause of death and morbidity in children and can result in cognitive, behavioural, social and emotional difficulties that may impact quality of life. This study examined the impact of mild, moderate, and severe childhood TBI, when compared to severe orthopaedic injury, on behaviour as measured by the Child Behavior Checklist (CBCL) in a sample of 74 children with TBI and 13 with orthopaedic injury aged 4 to 13 years at the time of injury. Correlational analyses revealed that within the TBI sample increased anxiety/depression and somatisation were related to increased age at the time of injury and shorter inpatient hospital stay. Increased age was also related to increased parental reports of attention problems; while increased hospital stay was related to increased withdrawal and thought problems. Symptomatology was within normal limits for all groups, approaching the borderline clinical range in the moderate TBI group for somatic symptoms and in the severe TBI group for thought and attention problems. Those with severe TBI had more thought and attention problems, and to a lesser extent social problems, than those with mild or moderate TBI; while those with moderate TBI had the highest levels of somatic and anxious–depressed symptoms. The only scale where performance seemed to increase in relation to injury severity was the attention problems scale. It is suggested that the findings for those with moderate TBI reflect increased awareness of one's own vulnerability/mortality, with the implication that issues such as grief, loss, and mortality may need to be addressed therapeutically.

Social cognition can be impaired in a range of neuro-degenerative conditions, yet the impact of these difficulties on behaviour and social relationships is not yet fully understood. This study assessed social cognition in 27 participants with Dementia of the Alzheimer Type (DAT) and their co-residing partners (N = 27) and explored the relationships between social cognition, cognitive ability, relationship continuity and behaviour following diagnosis. In line with previous research, participants with dementia scored lower on social cognition tasks compared to their partners. Behaviour changes such as apathy, disinhibition and agitation in participants with dementia were significantly related to relationship continuity; however, no significant associations were found with measures of social cognition. The results of this study are discussed within a therapeutic context and in line with current guidelines and policies.

Aims: To identify and compare, family support needs following an acquired brain injury (ABI) in metropolitan and regional/remote areas in order to inform the development of a state-wide family peer support network.

Design: Mixed methods design including postal survey and focus groups.

Results: The survey was completed by 194 family members who provide support to an adult with ABI. Focus groups included 43 participants (29 family members, 14 people with ABI). Thematic analysis of open-ended survey responses and focus group transcripts revealed 15 areas of needed support. Although all themes were identified by both geographic groups, regional/remote participants commented more frequently on the need for coordinated, accessible and tailored services. A strong focus was placed on the need for counselling and emotional support, as well as family support groups from both major city and regional/remote participants. Each support was reviewed to identify those which could be augmented through peer-supports, including: emotional support; family support groups; ABI information; family social activities; help to navigate the system; early supports (within the first year of ABI); and self-advocacy training.

Conclusions: Results highlight a need for ongoing supports for the entire family following ABI in both metropolitan and regional/remote regions of SA (South Australia). Support themes can inform the development of family-centred services, including the role of peer-support networks.

Background: International research identifies indigeneity as a risk factor for traumatic brain injury (TBI). Aotearoa New Zealand studies show that mokopuna (grandchildren; used here to encompass the ages and stages of infant, child and adolescent development and those in young adulthood) are significantly overrepresented in TBI populations. The important role of whānau (family) is also well established in child and adolescent TBI scholarship. Despite awareness of these factors, no studies have been identified that explore whānau knowledge about mokopuna TBI. The aim of this study was to explore two questions: (1) What do Māori people say about mokopuna TBI in the context of the Māori cultural belief that the head is the most sacred part of the body? and (2) How could this information be used to build theory that could inform addressing the rehabilitation needs of this group?

Method: Eighteen marae wānanga (culture-specific fora in traditional meeting houses) were held. The wānanga typically lasted approximately 2 hours. Footage and written transcripts were analysed using Rangahau Kaupapa Māori (Māori indigenous research methods).

Results: The wairua theory of mokopuna TBI proposes that TBI not only injures brain anatomy and physiology but also injures wairua (defined here as a unique connection between Māori and all aspects of the universe). Injury to wairua means that culturally determined interventions are both indicated and expected. The wairua theory of mokopuna TBI thereby provides a guide to intervention.

Conclusion: A Māori theory of mokopuna TBI has been identified which describes a culture-specific aspect of TBI. This theory proposes that pre-existing whānau knowledge salient to TBI is critical to optimising recovery. Further research is needed to test this theory not only in TBI but also in other areas such as in mental illness, neurodegenerative disease and addiction.