Challenging Behaviours

Behaviour can be defined as any interaction between an organism and their environment. This encompasses almost everything that humans do; however, most people tend to think of behavioural problems in a more restricted sense of antisocial, uncooperative or negative interactions associated with interpersonal problems. Challenging behaviour following a brain injury occurs with a relatively high frequency (25-50%). Challenging behaviour can include, but is not limited to, the following: non-compliance with treatment, anger, agitation, verbal and/or physical aggression and depression. The emergence of these behaviours likely arises from injury to the frontal lobes and results in disinhibited behaviour and a lack of recognition for the consequences of one’s behaviour (Kim 2002). Typically behavioural management techniques and pharmacological interventions are used to minimize and/or alleviate these challenges with varying degrees of success. 

Few investigators have examined predictors of aggressive symptoms following brain injury, although it has been suggested that disinhibition and depression may result in aggressive behaviour in some individuals after injury (Bakchine et al. 1989; Kim & Humaran 2002). In a sample of 228 patients with moderate to severe brain injury, Baguley et al. (2006) found depression and younger age to be a main predictors of aggression following brain injury at 6, 24, and 60 months. Similarly, Wolffbrandt et al. (2013) found younger age to be associated with agitation in patients with TBI along with lower FIM scores. Due to small sample sizes in previous studies and the inconsistency in tools used to measure aggression, making comparisons between studies is difficult (Baguley et al. 2006).

Agitation and Aggression

Agitation is generally defined as wandering, edginess, distractibility, non-compliance, and/or impulsiveness, while aggression is defined as physical or verbal violence that may put the individual and others at risk for injury (Eisenberg et al. 2009). Aggressive behaviours post TBI are associated with the presence of depression, frontal lobe lesions, and a history of substance or alcohol abuse (Singh et al. 2014; Tateno et al. 2003). TBI injuries that can lead to aggressive or agitated behaviour may result from a diffuse injury, lesions in the frontal lobe (Warriner & Velikonja 2006) and/or injuries to the left hemisphere (Tateno et al. 2003). Agitation is more common among younger individuals and those with lower FIM scores on admission (Wolffbrandt et al. 2013). Individuals found to have poorer social functioning often engage in a variety of aggressive or agitated behaviours including: hitting, kicking, refusing to participate in activities, memory deficits and slowness, decreased attention span, impulsivity, wondering off the unit, throwing objects, verbal aggression and engaging in self-abusive behaviours (McNett et al. 2012; Rao et al. 2009).

Following an ABI, studies have suggested that aggressive behaviour is linked to the level of serotonin in the brain. An ABI often results in serotonergic dysfunction thus increasing the risk of aggressive behaviours (Jorge & Starkstein 2005).

Prevalence and predictors of education

Table: Non-Intervention Studies of Agitation Post ABI

Pharmacological interventions for Agitation and Aggression

Agitation occurs in approximately 33-55% of patients with TBI (Singh et al. 2014; Tateno et al. 2003). The term agitation encompasses a wide variety of behaviours including restlessness, wandering, shouting, etc. This diversity of behaviours is typical of the agitation seen post ABI, but creates problems in terms of research regarding treatment efficacy (e.g., targeting interventions to particular types of agitation). Agitation is often a recovery-limiting factor as it creates both a disruptive and unsafe environment for rehabilitation (Rosati 2002). Pharmacological interventions are often used to treat this problem and include a variety of medications such as: anti-epileptics, dopaminergic agents, anti-depressants, beta-blockers, and anti-psychotics, as well as others. This section will look at each in detail.

Dopaminergic Medications

Dopamine is a fundamental neurotransmitter that plays a role in frontal lobe stimulation through the activation of dopaminergic receptors, affecting a range of functions such as behaviour, mood, motor ability, and arousal, to name a few (Sawyer et al. 2008). Dopaminergic medications have been previously used in the treatment of Parkinson’s disease and for remediation of cognitive impairments post TBI.

Amantadine

Amantadine is a non-competitive N-methyl-D-aspartate receptor antagonist that decreases glutamate levels, which may improve learning, memory, and behaviour deficits (Hammond et al. 2014). Additionally, Amantadine has dopaminergic function; it can indirectly facilitate dopamine release pre-synapatically and directly inhibit dopamine reuptake at the post-synapse (Hammond et al. 2014). Originally, Amantadine was used as an anti-viral medication for influenza A, but later gained popularity as an anti-Parkinsonian treatment. However, the effects of amantadine on reducing irritability and aggression have yet to be established among the TBI population. 

Table: Effects of Amantadine on Reducing Aggression

Discussion

One placebo-controlled RCT compared the effects of Amantadine on irritability and aggression. The frequency and severity of irritability were reduced when individuals were on Amantadine for 28 days, compared to placebo. However, Amantadine only significantly reduced aggression in individuals who had moderate-severe aggression at baseline (Hammond et al. 2014). A second RCT furthered Hammond et al. (2014) findings by assessing the effects of Amantadine on irritability and aggression for up to 60 days. Amantadine produced a non-significant reduction in irritability compared to placebo at 28 and 60 days, according to the most problematic and aberrant items on the neuropsychiatric inventory (Hammond et al. 2015).

Conclusion           

There is conflicting evidence of the effects of Amantadine on reducing irritability and aggression in individuals with moderate-severe traumatic brain injury.

 

 

Amantadine requires further research before conclusions can be drawn on its effects on aggression.

 

AntiConvulsants

Typically following a TBI there is diffuse injury with primary involvement in fronto-subcortical and temporolimbic regions. As a result, seizure disorders following TBI are not uncommon and may result in episodic lack of control. In the use of any medication, a balance must be struck between managing the behaviour and maintaining cognitive functioning. Thus, some anticonvulsants have been found to be a good alternative to antipsychotics and/or benzodiazepines in managing aggression, as they tend to have fewer cognitive side effects (e.g., sedation, confusion, memory impairment).   

Carbamazepine

Carbamazepine, an antiepileptic has been shown to successfully treat various seizure disorders and OCD. It has been suggested that carbamazepine may be effective in treating aggressive behaviour post TBI, offering an effective alternative to lithium (Azouvi et al. 1999).

Individual Study

Table: Effects of Carbamazepine on Reducing Aggressive Behaviour Post ABI

Discussion

Azouvi et al. (1999) in an 8-week open drug trial administered carbamazepine (Tegretol) to 10 individuals with severe brain injury who had significant behavioural challenges that were interfering with care and/or family integration. Results indicated improvement on the behavioural scales at the first assessment (2 weeks), which were maintained only for the scales of irritability and disinhibition by the end of the trial; although, overall neurobehavioural and social functioning had improved. It should be noted that drowsiness was a frequent adverse event which limited the dosage being increased in 40% of the participants.

Conclusion

There is Level 4 evidence that carbamazepine decreases the incidence of aggressive behaviours following a traumatic brain injury.

 

Carbamazepine may decrease agitated behaviour post-traumatic brain injury.

 

 

Lamotrigine 

The benefits of lamotrigine as an antiepileptic and mood stabilizer have been well established; however, its effectiveness as a mood stabilizer for patients with ABI has yet to be established (Gao & Calabrese 2005; Tidwell & Swims 2003).

Individual Study

Table: Effects of Lamotrigine on Reducing Aggressive Behaviour Post ABI​

Discussion

Results from a single study, indicate that lamotrigine helps to reduce unwanted behaviours such as pathologic laughter but did not address impulsivity (Chahine & Chemali 2006). All four participants were on other medications to control for additional behaviours, however in each case these medications were eventually eliminated once lamotrigine was introduced. No formal outcome assessments were conducted making it challenging to draw conclusions from this study. Further research is needed.

Conclusion

There is Level 5 evidence to suggest that lamotrigine helps to reduce inappropriate behaviours post-traumatic brain injury. 

 

Lamotrigine may be successful in reducing pathologic laughing post-traumatic brain injury. More research is needed, with a greater number of subjects, to validate these findings.

 

 

Valporic Acid/Depakene

Valproic acid, an antiepileptic, has been used to successfully treat seizure disorders in both adults and children. Moreover, it has been used to treat bipolar, PTSD and mania (McElroy et al. 1987). It has also been found to reduce episodic explosiveness with an individual with TBI (Geracioti 1994).

Individual Study

Table: Effects of Valproic Acid on Reducing Aggressive Behaviour Post TBI​

Discussion

Wroblewski and colleagues (1997) examined the effects of valproic acid (Depakene) on reducing aggressive behaviour in a case series (N=5). Although the study reports that all patients showed a substantial reduction in challenging behaviour (i.e., outbursts, agitation, anger), no statistical analyses were carried out. Researchers relied on visual inspection of data and graphs were only presented for 3 of the 5 patients, which may bias results. Further, patients were also part of a specialized neurobehavioural unit, which may have contributed to the positive results.  

Conclusion

There is Level 5 evidence that valproic acid decreases the incidence of aggressive behaviours.

 

Valproic acid may assist in the reduction of aggressive behaviours; however more research is needed.

 

 

Divalproex/Epival

Divalproex, another anticonvulsant, is believed to help reduce aggressive behaviours in individuals post TBI. 

Individual Study 

Table: Effects of Divalproex on Reducing Agitation Post ABI​

Discussion

Divalproex was used to treat symptoms of agitation in 29 patients with brain injuries (Chatham Showalter & Kimmel 2000). Symptoms decreased in the majority of patients, indicating that divalproex may be an effective treatment to reduce agitation following brain injury.

Conclusion

There is Level 4 evidence that divalproex decreases the incidence of agitation post-traumatic brain injury. 

 

Anticonvulsants may be used to decrease the incidence of agitated behaviour; however, more research is needed.

 

Anti-Depressants

Two studies examined the effect of antidepressants on reducing agitation and/or aggression in patients with brain injuries (Kant et al. 1998; Mysiw et al. 1988). Kant et al. (1998) examined the effect of sertraline, a serotonin selective re-uptake inhibitor, on reducing aggression and irritability in patients with brain injury, whereas Mysiw et al. (1988) examined the effect of amitriptyline (a tricyclic antidepressant with both serotonergic and noradrenergic reuptake inhibition). 

Table: Effects of Sertraline and Amitriptyline on Reducing Aggression and Irritability Post ABI​

Discussion

Both studies showed potential to improve aggressive and agitated behaviour in patients with brain injuries. Kant et al. (1998) examined the effect of sertraline HCl (Zoloft) on reducing aggression and irritability in patients with closed head injuries of varying severities, two years post injury. The patients responded positively at both the four and eight week follow-ups, showing significant reduction in aggressive and irritable behaviour (Kant et al. 1998). The patients treated also had improvements in depression at week four. Mysiw et al. (1988) focused on 20 individuals who displayed agitation during their rehabilitation program and received amitriptyline. 70% of patients displayed significant reductions agitation within the first week (Mysiw et al. 1988). Both studies had similar limitations, those being small sample sizes and no true control groups. 

Conclusions

There is Level 4 evidence that sertraline HCL can decrease the incidence of aggression and irritability.

There is Level 4 evidence that amitriptyline may be useful in reducing the incidence of agitated behaviour.

 

Sertraline HCl may be useful in reducing aggressive and irritable behaviours.

Amitriptyline may be used to decrease agitation.

 

Beta-Blockers

It has been suggested that Beta-blockers may improve agitation, anxiety and aggressive symptoms following brain injury, and reduce restlessness. Oftentimes, dosage is high, leaving patients vulnerable to adverse effects such as sedation, depression and lethargy, although it does not seem to negatively affect motor recovery post injury (Levy et al. 2005). 

Pindolol

Pindolol is a beta-blocker unlike many others in that it exerts a partial agonist effect, providing a slight stimulation of the blocked receptor and maintaining a better resting sympathetic tone. 

Table: Effects of Pindolol on Behaviour Post ABI

Discussion

Greendyke and Kantor (1986) investigated the effectiveness of the beta-blocker, pindolol, for the improvement of behavioural disturbances. A significant reduction in behaviours that lead to assaults was demonstrated during treatment with pindolol, with the authors stating the optimal dose ranged between 40-60 mg per day. No therapeutic advantage was gained with doses beyond that but rather it lead to adverse events (Greendyke & Kanter 1986). Although the frequency of supplemented psychotropic medications was reduced in the pindolol group, these medications were still given and may have attributed to the reduction in assaultive episodes.

Conclusion

There is Level 1b evidence that pindolol decreases aggression following brain injury based on one random control trial.

 

Pindolol can decrease aggressive behaviour following brain injury.

 

 

Propranolol

Propranolol is a non-selective beta-blocker that has been used for the reduction of aggressive behaviours associated with compromised brain function. It is not known how this drug works to affect behaviour, however it appears to lack the serious cognitive and affective side effects of other medications or physical restraints used to treat agitation post injury (Levy et al. 2005).

Individual Study

Table: Effects of Propranolol on Behaviour Post ABI

Discussion

Greendyke et al. (1986) investigated the effectiveness of the beta-blocker, propranolol, for the improvement of behaviour associated with brain disease in a randomized, crossover trial. Significantly fewer assaults and attempted assaults occurred during the 11-week propranolol treatment as compared to the placebo group. Of the nine patients, five showed marked improvement, two demonstrated moderate improvement, and two showed little or no improvement of assaultive behaviour. It should be noted that the participants also had severe dementia; therefore, this study was not used to draw conclusions for an ABI population as a whole. A later study by Brooke et al. (1992) found that propranolol was effective in reducing the intensity of the agitation but was not significantly more effective in reducing the number of episodes compared to a placebo. 

Conclusion

There is Level 1b evidence that propranolol reduces the intensity of agitated symptoms following brain injury.

 

Propranolol may reduce the intensity of aggressive and agitated symptoms following brain injury.

 

Antipsychotics

Quetiapine (Seroquel)

Quetiapine has been used to reduce aggressive behaviour among those diagnosed with schizophrenia and Alzheimer’s disease (Volavka et al. 2004; Webb & Glueckauf 1994). A closer examination of its impact within a brain injury population is discussed below. 

Individual Study

Table: Effects of Quetiapine on Aggressive Behaviour post ABI

Discussion

In one case series quetiapine assisted in helping to reduce aggressive behaviour in seven individuals (Kim & Bijlani 2006). They also noted significant improvements in the Overt Aggression Scale-Modified, the Clinical Global Impression scores, and the overall scores of the Repeatable Battery for the Assessment of Neuropsychological Status. Quetiapine may be considered as an alternative to haloperidol or chlorpromazine if additional research finds it is just as effective in treating aggressive behaviours without the side effects (Kim & Bijlani 2006).

Conclusion

There is Level 4 evidence (from one small study) to suggest that quetiapine helps reduce aggressive behaviour.

 

Although there is evidence to suggest that quetiapine does help reduce aggressive behaviour, more research is needed.

 

 

Ziprasidone

Ziprasidone has been approved for acute agitation in those diagnosed with schizophrenia. It has also been found to work in the treatment of acute mania, often associated with bipolar disorder. For those who sustain a TBI, the period of post traumatic amnesia (PTA), has been defined as a period where the individual is disorientated, and may lack the ability to learn new things and suffer from behaviour alterations (Brooke et al. 1992). Researchers believe that these behaviour alternations may result from the individual’s lack of self-awareness which may be related to memory alterations that appear after the injury (Noé et al. 2007).

Table: Effects of Ziprasidone on Agitation Post ABI

Discussion

Noe et al. (2007) studied individuals who were still in PTA stage at admission to rehabilitation. Within these participants, a decrease in agitation scores was reported during the first two weeks of ziprasidone administration. It was also noted that all who participated tolerated the medication with no clinical side effects observed. A larger RCT would be beneficial before any firm conclusions are made.

Conclusion

There is Level 4 evidence from one study to suggest that ziprasidone assists in the controlling of agitation post-traumatic brain injury.

 

Ziprasidone in one small study has been shown to assist in the controlling of agitation; however more research is needed.

 

 

Lithium Carbonate

Lithium carbonate has been used for many years in the treatment of mania and bipolar disorder (Kim 2002). It has been suggested that mood disorders, such as mania, occurring after the TBI, may contribute to the development of aggression (Kim 2002; Wroblewski et al. 1997). In the search for a pharmacological agent that reduces aggression following TBI with limited side effects, in comparison to antipsychotics and benzodiazepines, lithium has been tried. Lithium carbonate also functions as a mood stabilizer. 

Table: Effects of Lithium Carbonate on Aggressive Behaviour Post ABI

Discussion

Lithium carbonate was used in a series of case reports with ten individuals with either TBI or stroke (Glenn et al. 1989). Glenn et al. (1989) reported favourable outcomes for the majority of patients (i.e., a decrease in observed aggressive, combative, or self-destructive behaviour or severe affective instability). However, this study highlights that there is a high risk of potential neurotoxicity among individuals with brain injuries, specifically in combination with neuroleptic drugs. 

Conclusion

There is Level 5 evidence to suggest that an antimanic agent (lithium carbonate) reduces aggressive/agitated behaviour following a brain injury.

 

Lithium may reduce behavioural problems but is associated with a high risk of neurotoxicity.

 

Sexually Disinhibited Behaviour

Sexual dysfunction following TBI has been reported to occur in at least 50% of patients (Emory et al. 1995). Hypersexuality is less common than hyposexuality (decreased libido) but results in a greater negative effect for the individual and results in a great burden of care by limiting independence. Hypersexual behaviour can encompass a range of behaviours, from indiscriminate sexual advances, promiscuity, and exhibitionism, to assault and/or rape (Mania et al. 2006). A recent study revealed inappropriate sexual talk to be the most common inappropriate sexual behaviour in a sample of patients with TBI (Simpson et al. 2013). Treatment for sexual offenders without brain injuries has included pharmacological intervention and or counselling and education. Typically, medication is used to reduce the sexual drive, but it is unclear if it has effect on cognitive processing (i.e., preservative thoughts regarding sex).

Table: Effects of Depo-Provera on Sexually Aggressive Behaviour Post ABI​

Discussion

As shown by the findings from Simpson et al. (2013), inappropriate sexual behaviour is a concern for individuals post injury; specifically, verbal inappropriateness among younger and more severely injured individuals. In a retrospective study, Depo-Provera, an anti-androgen drug, was evaluated in terms of its efficacy for controlling sexual aggression in eight males with TBI experiencing onset of sexual aggression three years post injury (Emory et al. 1995). Weekly intramuscular injections of Depo-Provera (400 mg) in conjunction with monthly psychoeducational counseling resulted in a cessation of hypersexual behaviour and reduced testosterone levels. Three subjects re-offended when the drug was stopped, three remained on it and two stopped taking the drug and had maintained cessation of hypersexual behaviour.

Conclusion

There is Level 4 evidence that Depo-Provera and counselling reduces sexually aggressive behaviour.

 

Medroxyprogesterone intramuscularly may reduce sexual aggression.

 

 

Methotrimeprazine

Methotrimeprazine (Nozinan) is a psychotropic medication. It has antipsychotic (mediated by dopamine blocking), tranquilizing, and analgesic properties. It appears to have an effect on opiate (pain) receptors as well (Maryniak et al. 2001). 

Individual Studies

Table: Effects of Methotrimeprazine on Agitation Post ABI

Discussion

The oral administration of methotrimeprazine (MTZ) for agitation was evaluated in a retrospective chart review of 56 patients during inpatient rehabilitation (Maryniak et al. 2001). This was the first report on MTZ’s use in treating agitation after ABI and the authors found that in most cases MTZ was both safe and effective for controlling agitation. No standardized outcome measures were used within this study, and there was no control group; therefore, a more rigour study examining the safety and efficacy of MTZ within an ABI population is necessary before a level of evidence statement can be provided.   

Conclusion

There is Level 4 evidence that methotrimeprazine is safe and effective for controlling agitation after an acquired brain injury.

 

Methylphenidate may be safe for controlling agitation following an acquired brain injury.

 

Methylphenidate

One RCT examined the effect of methylphenidate on the control of anger following a brain injury (Mooney & Haas 1993).

Table: Effects of Methylphenidate on Anger and Attention Post ABI​

Discussion

In a RCT, Mooney and Haas (1993) demonstrated that methylphenidate helped to significantly reduce anger following brain-injury as demonstrated using several anger outcome measures. Despite the differences between the groups on one anger measure, a significant group main effect of the drug treatment was demonstrated. 

Conclusion

There is Level 2 evidence (from one random control trial) to suggest that treatment with methylphenidate following brain injury can significantly reduce anger.

 

Methylphenidate is effective in reducing anger following a brain injury.

 

Neuroleptic butyrophenones

Droperidol (Inapsine)

Droperidol is a butyrophenone antipsychotic agent that closely resembles haloperidol in structure. It has been used for the treatment of psychosis in Europe (Stanislav & Childs 2000).

Individual Study

Table: Effects of Droperidol for Improving Behaviour Post ABI

Discussion

When an individual is agitated, not only is the effectiveness of the medication administered important but also the time it takes to have a calming effect. One retrospective controlled trial found that a single-dose of droperidol calmed patients displaying agitated behaviour faster than other drugs (haloperidol, lorazepam, and diphenhydramine) (Stanislav & Childs 2000). The study also found that droperidol calmed individuals without heavily sedating the patients like some of the comparative medications did. It is worth noting however that a large proportion of the sample had psychiatric co-morbidities, this should be kept in mind when generalizing the findings.

Conclusion

There is Level 4 evidence that administration of a single-dose of droperidol calms agitated patients with acquired brain injuries more quickly than other agents. 

 

Droperidol may be an effective agent for calming agitated patients.

 

 

Haloperidol

Haloperidol is a psychotropic drug found to reduce agitation. It also blocks or disrupts dopamine receptors. Thus, while it improves agitation, there is a theoretical concern that it may impede recovery by reducing arousal.

Table: Effects of Haloperidol on Agitation Post ABI

Discussion

In a retrospective chart review, agitation was managed in eleven patients with haloperidol and in fifteen patients without haloperidol (Rao et al. 1985). No significant differences were found between the two groups with regards to success of rehabilitation outcome; however, none of the patients in the treatment group obtained independence in intellectual skills (Rao et al. 1985).

Conclusion

There is Level 4 evidence that haloperidol does not have a negative effect on the success of rehabilitation.  

 

Haloperidol appears to have little negative effect on recovery following traumatic brain injuries.

 

 

Summary Regarding the Use of Pharmaceuticals to Reduce Aggressive Behaviour 

The use of pharmacological agents can help to prevent injury to the patient and others. An ideal medication should have, “a rapid onset of action, achieve maximal effect with a single dose, cause minimal adverse effects, and allow the patient to resume normal daily activities as quickly as possible without causing protracted sedation or cognitive impairments” (pg 263-4, Stanislav & Childs 2000). A fairly consistent limitation across the studies in this section is the lack of a control group. Ideally, the efficacy of pharmacological interventions for agitation would be studied using a randomized, double-blinded, placebo design; however, few of these trials have been conducted (Levy et al. 2005). When investigating aggressive symptomology following brain injury there is difficulty in comparing across studies, and different treatment types, due to the lack of consistency in how aggression is measured. For example, some studies used standard outcome measures while others relied on reported/ observational behaviour ratings. 

Conclusion

There is limited evidence that pharmacological interventions can reduce verbal, physical and/or sexual aggressive behaviours. Rigorous, randomized controlled trials are needed.

Behavioural Management Post ABI

Common sequelae to brain injury are behavioural disturbances that impact the patients’ relationships and recovery. In some cases, individuals with brain injury develop behavioural difficulties that impact their compliance with rehabilitation, resulting in early discharge and/or limited participation in rehabilitation activities (Alderman 1991; Alderman et al. 2013). When challenging behaviours take the form of aggressive acts, this may prevent or decrease functional gains in neurorehabilitation (Alderman et al. 1999). In a cross-sectional study of 69 subjects admitted to a brain injury unit, Lequerica et al. (2007) found an inverse relationship between agitation and the individual’s engagement in physical and occupational therapy.

It is difficult to compare across studies when evaluating interventions using behavioural management techniques as they are tailored to the needs/requirements of the person being treated. Studies may examine diverse techniques to manage challenging behaviours following an ABI, including antecedent controls, positive reinforcement, and token economies, whereas other studies have examined the efficacy of specific training programs (i.e., anger management, social skills training, etc.) in reducing agitation/aggression.

Specific Behavioural Techniques 

Behavioural techniques have been used for many years with a variety of disorders. Techniques are often used to teach new skills, socially appropriate behaviour and improve independent functioning. Teaching behavioural techniques does not involve coercing people to do anything against their will; instead it encourages positive behaviours through an individualized approach. Behavioural analysis examines the relationship between events and behaviour with the goal of increasing social interactions and independence (Ashley et al. 1995). In the past, the alternative to behavioural strategies has been sedation, physical restraint, and/or institutionalisation. Not only are behavioural techniques applicable in a variety of settings and with a variety of behaviours, but they also address the main goals of rehabilitation – the development of functional life skills (Jacobs 1993). 

Individual Studies

Table: Effects of Antecedent Behavioural Interventions on Reducing Aggressive Behaviour Post ABI​

Discussion

Different behavioural interventions have been trialed in hopes of reducing aggressive behaviour. One such intervention is a psychoeducational treatment program called anger self-management training, for irritability and anger (Hart et al. 2012). The 8 session program was designed to help the individual identify anger signals, and to learn specific problem solving skills. Following treatment, anger declined significantly (p<0.03) (Hart et al. 2012). Another success was an antecedent behavioural intervention, by structuring the environment with high support and then reducing it was able to significantly reduce aggressive behaviour (Feeney & Ylvisaker 1995). Aboulafia et al. (2013) used CBT with emphasis on reduction of aggression and found that self-reported aggressive behaviours were significantly fewer from pre-intervention to 4-5 month follow-up. This finding aligns with a review by Waldron et al (2013) reporting that CBT is efficacious at reducing symptomology when the therapy is targeted for a specific problem (e.g. aggression). In summary, a recent meta-analysis for behavioural interventions discovered an overall substantial reduction in aggressive behaviours for single and group-based therapy (Byrne & Coetzer 2016).

Three studies explored the impact of systematic data based feedback on maladaptive behaviour. Schlund and Pace (1999) demonstrated that by using frequency data as feedback (as opposed to only verbal-based feedback), the occurrence of “maladaptive” behaviour could be reduced. However, their group consisted of three mildly cognitively impaired individuals attending a medical rehab program five days a week. Maladaptive behaviours consisted of pseudoseizures, non-compliance with rules, verbal aggression and sexually inappropriate behaviour. Wesolowski et al. (1999) utilized a “non-contingent escape” paradigm (i.e., planned mini-breaks in work periods) to increase compliance in three TBI clients in order to effect positive change with vocational placement. Burke et al. (1988) used a program that was structured so that positive behaviours, that were incompatible with aggression, would be more likely to occur, thereby decreasing aggressive behaviour. Percentage of change scores from baseline revealed success.

Eames et al. (1985) examined the quality of life of 24 severely injured ABI patients following intensive behavioural treatment utilizing a token economy (admission to a structured unit). Results indicated that generally the quality of life had improved and was maintained, as measured by improved relationships with care-givers and an improvement in living arrangements. However, when examining results reported, actual behaviours of aggression, sexual inappropriate behaviours, drive/motivation and odd behaviours increased in occurrence from discharge to follow-up.  

Conclusions

There is Level 4 evidence to suggest that anger self-management training is effective in reducing irritability and anger after a traumatic brain injury.

There is Level 4 evidence that behavioural approach using antecedent management and/or feedback of consequences reduces undesirable behaviour (e.g., aggression/agitation).

 

Anger self-management training is effective in teaching those with a traumatic brain injury identify anger signals and develop more appropriate ways of dealing with anger and frustration.

Cognitive Behavioural Therapy with focus on anger and aggression management may be effective at reducing aggressive behaviours.

Antecedent management and/or feedback of consequences may reduce undesirable behaviour.

 

Multi-intervention Training Programs

Training programs that combine a number of behavioural interventions have been utilized with some success. For example, anger management, social skills, and coping skills training programs have been used in the past to alleviate aggressive/agitated behaviour in individuals with an ABI.

Individual Studies

Table: Effects of Training Programs on Alleviating Aggressive Behaviour Post ABI​

Discussion

A RCT conducted by McDonald et al. (2008) compared social skills training, social activity, and a control group. Those in the social skills group showing a positive improvement in behaviour compared to the other interventions but the treatment effect was modest at best. Therefore, improving social behaviour, changing social perceptions, and improving mood and self-esteem seem to be somewhat influential in improving behaviour (McDonald et al. 2008). In reviewing the studies education alone was not effective in improving behaviour; however, education in combination with other interventions resulted in positive behavioural change. Carnevale et al. (2006) found that at 30 weeks following treatment, significant changes in behaviour were apparent for participants receiving an individualized program and education compared to education alone. Other interventions have been shown to benefit individuals post injury with alleviating aggression, such as an anger management therapy program (Medd & Tate 2000), a combination of anger management and coping skills training (O'Leary 2000) and social skills training (Brotherton et al. 1988); although the evidence is weak. 

Conclusions

There is Level 1b evidence that social skills training has a limited impact on changing inappropriate behaviours and mood disturbances of those who have sustained a severe traumatic brain injury.

There is Level 2 evidence that community based program combining education and an individualized behaviour plan (e.g., Natural Setting Behaviour Management intervention) helps to change behaviour.

There is Level 2 evidence that participating in a Coping Skills Group assists in improving adaptive coping in the long term.

There is Level 2 evidence that anger management reduces aggressive behaviour.

 

Anger management and social skills training reduce aggressive behaviour.

 

Music Therapy

Music therapy is an approach that “consists of using music therapeutically to address physical, psychological, cognitive and/or social functioning for patients of all ages” (American Music Therapy Association 2004). It was first used with World War I veterans in hospital and was formally recognized as a therapeutic tool in 1950. Music therapy has been used with a variety of patients (neurological, psychiatric, medical, pervasive and developmental disorders) and has been found to result in physiological changes (e.g. respiration, blood pressure, heart rate, decrease cortisol levels and increase endorphins) and increased wellbeing. More recently music therapy has been used with patients with TBI to decrease agitation.

Individual Studies

Table: Effects of Music Therapy on Agitation Post ABI

Discussion

One study, Formisano et al. (2001) reported that music therapy had a beneficial effect in reducing post-coma agitation and inertia in 62% of their subjects in a slow-to-recover group one month after starting music therapy. More research is needed.

Conclusion

There is Level 4 evidence that music therapy reduces psychomotor agitation post coma following a severe traumatic brain injury in a slow-to-recover group.

 

Music therapy may reduce psychomotor agitation post coma and improve mood following severe traumatic brain injury.