Thursday, January 24, 2013

Behavioural, Cognitive and Emotional Concerns of Brain Injured Clients, TLABC, Mexco, 2013

The following are the rough notes I took of Dr. Lee's splendid compassionate and informative presentation at the Trial Lawyers Association of British Columbia Conference Mexico, 2013.  He has doal specialization and certification in Cognitive Behaviour Therapy and Behavourial Analysis.  His work proceeded as I've had the priviledge of seeing patients who his work has already helped significantly.  A leader in the field, his presentation was fascinating to say the least. I'm only sorry I can only give this overview but share it as some idea of where the cutting edge in the field is going. 

Effectively dealing with the behavioural, cognitive and emotional concerns of more seriously brain injured clients"
TLABC Conference, 11 th Annual Medical Legal Conference 2013 Mexico Conference
Dr. Douglas Lee, R. Psych, ABPP, BCBA-D
Registered Psychologist BC/AB
Clinical Faculty Department of Psychiatry, University of BC
Behavioural Solutions Inc - Surrey, North Vancouver, Lethbridge Alberta

Brain and Behaviour

Neuropsychology and Clnical Psychology and behavioural psychology overlap
- Behavioural Psychology - most of work is done in field, home, worksite, school with children
Academic areas of psychology - psychology has splintered into so many areas
Behavioural psychology is a very empirical area of Clinical Psychology

TBI and Behavioural psychology

Injury - demonstrable tissue damage - structural or functional 
Impairment - loss of behavioural capacity that can be formally measured - loss of function that is related to the injury
Disability - measureable impact of an impairment on everyday skills and behaviour - type and level of interference the impairment causes in the person in their everyday life

Injury - mild , moderate, severe
Impairment - mild, moderate, severe
Disability - mild, moderate, severe

Neuropsych assessments may or may not match daily functioning
Behavioral assessments can assist in discovering why this may be the case

People who have a loss of function may find that mild loss of function on exam very difficult when they return to work, sometimes related to environment
- example returning to the 'pace' of workplace - patient might be able to do a previous task but no longer able to do them at the pace

Cognitive Behavioural Therapy (CBT) and /or Applied Behavioural Analysis (ABA) - Dr. Douglas Lee is certified in both
- to do cognitive therapy you need relatively normal cognitive functioning - need cbt therapist experienced in tbi
- if the injury is more mild, use the cbt model but if there is moderate  injury, consider more aba - in latter make sure they bring somebody else so they can remember, but if it's severe, I need to work specifically with caregivers.

Discussion of anger management problems in a moderate severe brain injury group
The group identified the individual anger management events but the group of other brain injured patiients were able to identified all their episodes occurred 3 to 6 pm and related to whether or not they had a nap, something the individual hadn't been able to see.

Brain X Behaviour X Environoment
1)Small farming community in Alberta with long ties may allow someone with significant brain injury to function relatively independently
- his day was utterly structured
-all events scheduled
-as long as he was in grasslands he was fine
-happy as long as he could stay with schedule and people around understood

2) Man attempting to return to UBC pharmaceutical sciences program unsupported following Mild Concussion, attempted suicide - when having difficulties - refered for therapy with benefit

3) Demonstrating the actual effects of a 20 point IQ drop (140 to 120 results in a significantly larger settlement - this was a catastrophic loss - originally lawyer was going to settle for a small settlement - behavoioral analysis - showed difficulty at level of even filling puppy bowl 

Outcome following traumatic brain injury , a comparison between 2 and 5 years after injury
Brain Injury 1996 10 841-848
Olver J, Ponsford,
List different 

Brain Inury 1998 4 283-296  Catellani Lombardin

Disturbances at long term follow up

# children at e years
Baseline and 3 year follow up
With ortho injury in risk takers get better
In TBI get worse.

I deal with 3 forms of severity
-amt of physical damage done to the brain
-challenges unique to person achieing functional recovery outcomes
-impact of person's social and family support network

First type puts stres on other two types and biological limits to recovery

Translation of neuropsychological findings to the everyday contexts

Coordinating involvement of professionals and family towards meeting the cognitive behavioural and emotional rehabilitation goals. 

Assisting specific professionals regarding presenting problems that are interferening with their rehabilitation activities

Consulting with caregiver gives

Long term consulting
- longest 17 years

Behavioural rehabilitation assistance
- for client with predominately cognitie and or behaviour problems
Input regarding cost of future care costs
 Expert witness testimony


Dr. Armstrong - raised the issue of neuroplastic change after the brain injury can be positive or negative and this can result in change in behaviour in active

Question - re cogntive learning - Dr. Lee noted it can take longer and it's not good if it's stopped earlier since there's a longer period of learning - discussion of computer apps application and biofeedback techniques. 

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