Arts-based social skills interventions for adolescents with acquired brain injuries: Five case reports

Objective: Previous research has demonstrated the value of arts-based programs for adolescents with childhood brain disorder to facilitate social skills and participation. The current study extends this work by examining the feasibility and effectiveness of an arts-based intervention for youth with acquired brain injuries (ABI).

Methods: A case study approach was used with four adolescent participants and one case control. A battery of quantitative measures were administered four and one week pre-intervention, one week post-intervention, as well six to eight month post-intervention.

Results: Improvements in pragmatic communication skills and social and participation goals were observed across intervention participants. Similar improvements were not seen with the case control participant.

Conclusion: Results support the use of an arts-based intervention for youth with ABI to facilitate social skills and participation. Findings also highlight the need for more sensitive measures of these skills for these youth. Suggested guidelines for program implementation are provided.     

The contribution of social cognition in predicting social participation following moderate and severe TBI in youth

ABSTRACT

Youth with moderate or severe traumatic brain injury (TBI) are at risk for reduced social participation after the injury, and the contribution of social cognition to these changes in functioning has been little studied. This study aimed to examine social participation and to measure the contribution of social and non-social cognitive functions to social participation impairment in youth (ages 12–21) who sustained moderate or severe TBI. Youth with TBI (n?=?23) were compared to typically developing (TD) controls on self- and parent-rated social participation questionnaires. Direct testing of social cognition (mentalising, social knowledge, emotion recognition) and higher order cognitive abilities (intellectual abilities, attention and executive functions) was also conducted. Significant differences were found between the TBI participants and TD controls on social participation measures. Mentalising and problem-solving abilities revealed to be significant correlates of social participation as reported by youth with brain-injury and their parents. Overall, these results corroborate previous findings by showing that social participation is significantly reduced after TBI, and further shows that mentalising, which is not always considered during rehabilitation, is an important contributing factor. In addition to executive function measures, social cognition should therefore be systematically included in assessment following youth TBI for intervention and prevention purposes.     

Relationships between obsessive-compulsive disorder,depression and functioning before and after exposure and response prevention therapy

Objective: Obsessive-compulsive disorder (OCD) is associated with impaired functioning and depression. Our aim was to examine relationships between OCD symptoms, depression and functioning before and after exposure and response prevention (ERP), a type of cognitive-behavioural therapy for OCD, specifically examining whether functioning, depression and other cognitive factors like rumination and worry acted as mediators.

Methods: Forty-four individuals with OCD were randomised to 4 weeks of intensive ERP treatment first (n?=?23) or waitlist then treatment (n?=?21). We used a bootstrapping method to examine mediation models.

Results: OCD symptoms, depression and functioning significantly improved from pre- to post-intervention. Functioning mediated the relationship between OCD symptoms and depression and the relationship between functioning and depression was stronger at post-treatment. Depression mediated the relationship between OCD symptoms and functioning, but only at post-intervention. Similarly, rumination mediated the relationship between OCD symptoms and depression at post-intervention.

Conclusions: Our findings suggest that after ERP, relationships between depression and functioning become stronger. Following ERP, treatment that focuses on depression and functioning, including medication management for depression, cognitive approaches targeting rumination, and behavioural activation to boost functionality may be important clinical interventions for OCD patients.     

Community integration interventions for youth with acquired brain injuries: A review

Objective: To identify and summarize published literature that examined the effectiveness of social and community integration interventions for children and adolescents with ABI in order to provide recommendations regarding future research on this topic.

Methods: A literature review was conducted to identify studies that focused on social and community integration interventions for youth with ABI. Further manual searching of relevant journals with a paediatric rehabilitation focus was also carried out.

Results: Currently, limited research has been published evaluating such interventions. The lack of research may stem largely from issues relating to how to measure community integration. Recommendations regarding intervention settings and structure are discussed.

Conclusion: Additional studies investigating social and community integration interventions are necessary, including those with measures tailored specifically to community integration, larger samples, as are better controls and recruitment of youth with varying severities of brain injuries.     

School-based social skills training for young people with autism spectrum disorders

ABSTRACT

Background: The Secret Agent Society (SAS) Program, an intervention to enhance social–emotional skills, was provided by schools for children with autism spectrum disorder (ASD). The program was assessed to determine if it improved social skills at school and home, and whether improvements were maintained.

Methods: Eighty-four students participated. Key outcomes were parent and teacher ratings of emotion regulation, social skills, and direct child social problem-solving measures. The standard school curriculum served as the control condition. Phase 1 was a two-group waitlist-control comparison of SAS versus the standard curriculum. Phase 2 was a follow up of all participants before and after the intervention and at 12-months post-intervention.

Results: Parent and child measures improved after the intervention but not in the waitlist condition. Improvements in parent, child, and teacher measures were apparent at 12 months.

Conclusions: The SAS Program warrants further research as a potential program for schools that serve children with ASD.     

Rehabilitation of executive skills post-childhood traumatic brain injury (TBI): A pilot intervention study

Background: Following TBI in childhood it is common for deficits to be seen in higher order skills, such as executive functions, both in the acute and longer-term post-injury. Despite this, very little evaluative research has been conducted with children post-TBI, particularly in the area of EF.

Methods: The current study aimed to develop and implement a pilot intervention programme for adolescent/young adults (n = 3), in the chronic phase of recovery, when EF skills are no longer in a rapid state of development.

Results and conclusions: Study results highlight the importance and need for accurate and relevant outcome measures that capture subtle as well as more obvious changes following intervention.     

Comparing Observations and Perceptions of Mother-adolescent Conflict: Youth with Typical Development,Intellectual Disability,or Autism Spectrum Disorders

ABSTRACT

Introduction: While transitioning to adulthood presents challenges for youth with developmental disabilities (DD), opportunities to develop adult social roles and communication skills may foster more optimal outcomes. One such opportunity is developing conflict resolution skills within parent-adolescent relationships.

Methods: We examined how reported conflict and observed conflict resolution behaviors differed between adolescents with typical development or DD, specifically intellectual disability (ID) and/or autism spectrum disorder, and their mothers. Participants (n = 167) were mid-adolescents (age 15) from a longitudinal study of how psychopathology develops in youth with or without DD.

Results: While mothers’ Reported Conflict was similar across groups, Mother Problem Solving was highest, and Youth Problem Solving lowest, in families of youth with ID. Higher Reported Conflict related to more negative observed conflict resolution behaviors across all groups.

Conclusions: Results are considered in the context of transitioning to adulthood.     

The emergence of age‐dependent social cognitive deficits after generalized insult to the developing brain: A longitudinal prospective analysis using susceptibility‐weighted imaging

Childhood and adolescence are critical periods for maturation of neurobiological processes that underlie complex social and emotional behavior including Theory of Mind (ToM). While structural correlates of ToM are well described in adults, less is known about the anatomical regions subsuming these skills in the developing brain or the impact of cerebral insult on the acquisition and establishment of high‐level social cognitive skills. This study aimed to examine the differential influence of age‐at‐insult and brain pathology on ToM in a sample of children and adolescents with traumatic brain injury (TBI). Children and adolescents with TBI (n = 112) were categorized according to timing of brain insult: (i) middle childhood (5–9 years; n = 41); (ii) late childhood (10–11 years; n = 39); and (iii) adolescence (12–15 years; n = 32) and group‐matched for age, gender, and socioeconomic status to a typically developing (TD) control group (n = 43). Participants underwent magnetic resonance imaging including a susceptibility‐weighted imaging (SWI) sequence 2–8 weeks postinjury and were assessed on a battery of ToM tasks at 6‐ and 24‐months after injury. Results showed that for adolescents with TBI, social cognitive dysfunction at 6‐ and 24‐months postinjury was associated with diffuse neuropathology and a greater number of lesions detected using SWI. In the late childhood TBI group, we found a time‐dependent emergence of social cognitive impairment, linked to diffuse neuropathology. The middle childhood TBI group demonstrated performance unrelated to SWI pathology and comparable to TD controls. Findings indicate that the full extent of social cognitive deficits may not be realized until the associated skills reach maturity. Evidence for brain structure–function relationships suggests that the integrity of an anatomically distributed network of brain regions and their connections is necessary for the acquisition and establishment of high‐level social cognitive skills. Hum Brain Mapp 36:1677–1691, 2015. © 2014 Wiley Periodicals, Inc.     

Healthy and abnormal development of the prefrontal cortex

Background: While many children with brain conditions present with cognitive, behavioural, emotional, academic and social impairments, other children recover with seemingly few impairments. Animal studies and preliminary child studies have identified timing of brain lesion as a key predictor in determining functional outcome following early brain lesions.

Review: This research suggests that knowledge of healthy developmental processes in brain structure and function is essential for better understanding functional recovery and outcome in children with brain lesions. This review paper aims to equip researchers with current knowledge of key principles of developmental processes in brain structure and function. Timetables for development of the prefrontal cortex (PFC), a brain region particularly vulnerable to lesions due to its protracted developmental course, are examined. In addition, timetables for development of executive skills, which emerge in childhood and have a prolonged developmental course that parallels development of the PFC, are also discussed.

Conclusions: Equipped with this knowledge, researchers are now in a better position to understand functional recovery and outcome in children with brain conditions.     

Impact of a culturally adapted behavioural family psychoeducational programme in patients with schizophrenia in Egypt

Objective: To study the effect of a culturally adapted, structured family intervention on symptom severity, medication attitudes and knowledge, social functioning and quality of life in patients with schizophrenia.

Methods: Thirty subjects with schizophrenia were selected to receive 14 sessions of a culturally adapted behavioural family psychoeducational programme (BFPEP). Another 30 subjects received standard treatment as usual (STU) for 6 months. Pre- and post-intervention outcomes were assessed using the Positive and Negative Syndrome Scale (PANSS), Drug Attitude Inventory 10-item scale (DAI-10), Quality of Life Scale (QLS) and Social Functioning Questionnaire (SFQ).

Results: There was a no significant difference between BFPEP and STU at baseline on all measures. There was a significant difference (p?<?.05) between pre- and post-treatment scores for BFPEP on all measures, a significant difference (p?<?.05) between pre- and post-treatment scores for STU on all measures (favouring pre-treatment scores) and a significant difference (p?<?.05) favouring BFPEP over STU on all measures post-treatment.

Conclusions: These results demonstrate the feasibility and effectiveness of implementing family therapy psychoeducational interventions in different cultural settings, with relatively minor modifications. This may have implications for mental health policy makers to make available such programmes for patients and mental health professionals.     

Impact of Mood Disorders,Psychotic Disorders,and Histories of Abuse on Adaptive Functioning Deficits in Adolescents with Intellectual Impairment

ABSTRACT

Background: There is no study to date that has examined the association between history of abuse and adaptive functioning deficits in youth with co-occurring and psychotic disorders or mood disorders.

Method: This study used a retrospective chart review of 98 youth under the age of 18 (Mean age = 16.06 years) with co-occurring intellectual impairment (Mean IQ = 63.9) and psychotic disorders, mood disorders, or other psychiatric disorders. Using multi-mediation models in the path analytic framework, this study examined the relationships between psychiatric diagnosis (based on DSM-IV criteria), cognitive functioning (Full Scale IQ Scores), adaptive functioning (Socialization, Communication, Motor Skills, Daily Living Skills), and the presence of the history of physical, sexual, and/or emotional abuse/neglect.

Results: A very high incidence of all three forms of abuse was present in the study sample, with more than three-quarters of the youth having experienced at least one form of abuse and more than half having experienced two or the three forms of abuse. A history of sexual abuse was significantly and directly associated with an increased incidence of mood disorders. Mood disorders were the strongest predictors of adaptive functioning deficits. Youth with schizophrenia spectrum disorder scored significantly lower in communication skills than those with bipolar disorder.

Conclusion: Results are discussed in terms of the need for treatment studies and further investigations of the relationship between childhood maltreatment and adaptive functioning in youth with intellectual impairment and psychiatric disorders.     

Use of Auditory and Visual Stimulation to Improve Cognitive Abilities in Learning-Disabled Children

ABSTRACT

Introduction. Learning disabilities (LD) comprise cognitive deficits in executive functioning which include working memory, encoding, visual-motor coordination, planning, and information processing. This study examined the effects of auditory and visual stimulation (AVS) on four specific cognitive abilities in children diagnosed with LD who demonstrated low and below average scores on the Wechsler Intelligence Scale for Children, Third Edition (WISC-III) Symbol Search, Coding, Arithmetic, and Digit Span (SCAD) profile to determine if such a treatment intervention could improve these specific cognitive weaknesses.

Methods. The WISC-III SCAD profile was administered pre- and post-12, biweekly 35-minute AVS sessions. Two index scores from the SCAD profile were also assessed: Freedom from Distractibility and Processing Speed. The study design was quasi-experimental, with repeated measures pre- and post-treatment.

Results. Findings demonstrated that AVS produced significant changes in all of the specific cognitive abilities as measured by the WISC-III SCAD profile, suggesting that AVS may benefit children with LD.

Discussion. AVS technology has the potential to greatly enhance cognitive abilities and quality of life for the learning-disabled individual who may be at risk for social, psychological, and a multitude of personal disappointments and life-long failures without such intervention.     

Training adults with acquired brain injury how to help-seek when wayfinding: an understudied critical life skill

The objective of this study was to investigate the efficacy of a group treatment protocol called NICE (Noticing you have a problem, Identifying the information you need for help, Compensatory strategies, Evaluating progress) to train help-seeking when wayfinding for individuals with acquired brain injury (ABI). Seven participants completed the NICE group treatment in an outpatient rehabilitation department at a university medical centre. A single subject multiple baseline design was employed to evaluate the efficacy of the NICE group treatment. The Social Behaviour Rating Scale and the Executive Function Route-Finding Task- Revised were repeated measures used to evaluate potential changes in help-seeking and wayfinding. Secondary outcome measures included pre- and post-treatment evaluation of social problem solving and social cognition. Results revealed that all participants improved on measures of help-seeking and wayfinding. Patterns of improvement and implications for rehabilitation are discussed. This is the first experimental study to evaluate the treatment of help-seeking behaviours and discuss its application to wayfinding in adults with ABI. Preliminary evidence supports further investigation of the NICE group treatment protocol.     

Aggression Replacement Training in Australia: Youth Justice Pilot Study

This article describes the findings of a 10-week pilot programme of aggression replacement training (ART) in an Australian youth justice, custodial setting. Five male subjects (17–18 years old) completed pre- and post-treatment self-report measures of aggression, social skills, and cognitive distortions typically associated with violent and antisocial behaviour. As expected, results showed a significant reduction in overall aggression and improved social skills from before to after assessment, but the predicted reduction in cognitive distortions was not supported. Treatment outcomes were examined relative to the specific multi-modal (cognitive, behavioural, and affective) components of ART. Hence, results are discussed in relation to a cognitive behavioural theory of change, which underpins ART. A single case study is presented to illustrate qualitative change throughout participation in ART. Overall the results provide preliminary support for the efficacy of ART in an Australian context, and further investigation with a larger, multi-informant sample is warranted.     

Social Participation and Navigation (SPAN): Description and usability of app-based coaching intervention for adolescents with TBI

ABSTRACT

Background: Adolescents with brain injury (BI) often experience impairment in participation, which is an important predictor of outcomes. Objective: Describe the Social Participation and Navigation (SPAN) program, and report participant feedback and preliminary outcomes. Method: Four adolescents and four coaches participated. SPAN included a mobile app, online didactic information, and peer coaching. Adolescents met weekly with coaches via video-conference, developed participation goals, and plans to achieve goals. Social and behavioral functioning before and after was assessed, and feedback about SPAN was collected. Results: SPAN was well received. Participants used the app to define and achieve goals. Medium to large effect sizes were found on adolescent self-reported measures, with negligible effects on parent-report measures. Positive and critical feedback is described. Conclusions: Findings support the usability of SPAN, which has the potential to improve social participation of adolescents with a history of TBI through an innovative use of technology and peer coaching.     

Further validation of the Child and Adolescent Scale of Participation (CASP)

Primary objective: To further validate the Child and Adolescent Scale of Participation (CASP) for children and youth with acquired brain injuries and other disabling conditions.

Research design and methods: A cross-sectional design was used. Data were collected on 313 children and youth, aged 3–22, with and without disabling conditions. Children with acquired brain injuries (ABI) were the largest group (56%). Cronbach's alpha, factor analyses and Rasch analyses were used to examine internal scale consistency and structure. Correlation analyses were conducted to examine associations between CASP scores and scores that reflect extent of impairment and impact of environmental barriers. Independent t-tests or analyses of variance were used to examine mean differences in CASP scores in relation to sex, age and disability groups.

Main outcomes and results: Children without disabilities had significantly greater extent of participation (higher CASP scores) than children with disabilities. Greater extent of participation was associated with lesser extent of impairment and environmental barriers. Evidence of internal consistency and internal structure validity was demonstrated. Factor analyses showed that items from similar domains loaded onto one of three factors and a large (63%) proportion of variance was explained. Rasch analyses revealed essentially one unidimensional construct. The item difficulty order closely matched the expected pattern of life situations that children would find more to less challenging to participate in.

Conclusions: Findings were similar to prior research and suggested that the CASP is a promising new measure of participation. However, study design features limit generalizations and definitive conclusions that can be made. Future research is needed to assess the ability of the CASP to detect change over time and to include a larger and more diverse sample.     

Conversational turn-taking in adults with acquired brain injury

Background: Social communication problems are a major contributor to negative life outcomes for adults with brain injury, yet the basic skill deficits underlying these problems are poorly understood.

Aim: To examine one aspect of social communication that may have a negative impact on social interactions: the ability to successfully take turns in a conversation.

Methods & Procedures: Seventeen adults with traumatic brain injury and two with bilateral strokes, and their typical peers matched for age and sex, viewed video-recorded conversations and indicated when they could join in the conversation. Turn timing was compared between groups using a novel statistical method designed for this study.

Outcomes & Results: There was a significant between-groups difference in timing of turn-taking but no significant difference in number of turns. The novel analysis method revealed between-groups differences in responding to specific conversational cues.

Conclusions: Adults with brain injury may miss or misinterpret verbal and non-verbal cues to turn-taking, which could contribute to conversation partners’ perceptions of impaired conversation skills in adults in this population.     

Evaluation of brief interventions for managing depression and anxiety symptoms during early discharge period after stroke: a pilot randomized controlled trial

Abstract

Background:

Prevalence estimates for depression and anxiety in individuals post-stroke are approximately 33 and 29%, yet there are few effective preventive interventions. Interventions which commence pre-discharge and continue during the early post-discharge period may support individuals during the critical transition to home adjustment period. This study aimed to evaluate the efficacy of a self-management intervention and a coping skills intervention, compared to usual care, on anxiety and depression post-stroke.

Methods:

A pilot, three-arm randomized trial involving 33 stroke patients (coping skills: n?=?11, self-management: n?=?12, usual care: n?=?10) recruited from an Australian stroke unit. Both interventions were eight 1-hour weekly sessions, with the first two pre-discharge and the remainder at home; targeted both anxiety and depression; and tailored content to individuals. Primary outcome was severity of depressive and anxiety symptoms (measured using Montgomery andÅsberg Depression Rating Scale and Hospital Anxiety and Depression Scale). Secondary measures were: self-efficacy, stroke knowledge, basic and extended activities of daily living, and quality of life. Outcome measures were administered at baseline, one week post-intervention, and at a three month follow-up by a blinded assessor.

Results:

Thirty (91%) participants completed the trial. Immediately post-intervention there was a small improvement in stroke knowledge and a small increase in depression symptoms (on one of the two measures of depression symptoms) in the coping skills group compared to usual care. These differences did not remain significant at the 3-month follow-up, nor were there any other significant differences.

Conclusion:

Neither a coping skills nor self-management intervention reduced anxiety nor depression symptoms early post-stroke more than usual care. Lack of statistical power may have contributed to the non-significant findings in this pilot study.     

Neurological outcome in children and youth with acquired brain injury 2-year post-injury

ABSTRACT

Objective: To determine neurological outcome in children and youth with acquired brain injury (ABI) and explore associated factors.

Design: Cross-sectional study, two-years post-injury. Patients: Hospital-based sample (n=112) aged 6-22 years.

Methods: Neurological outcome and participation were assessed with a multidimensional neurological examination and the Child and Adolescent Scale of Participation. Logistic regression analyses were used to explore the relationships.

Results: Both sensorimotor and cognitive deficits were found in 30-31%, language deficits and behavioural deficits in 10-17%. Non-traumatic injury had a negative impact on neurological outcome, specifically regarding sensorimotor and language deficits. Lower education level showed a significantly poorer neurological outcome. High levels of age-expected participation were reported, with a significant relation between deficits and participation restrictions, especially at school.

Conclusion: One out of three have a poor neurological outcome, related to type of injury and lower level of education. The amount of deficits is associated with participation restrictions.