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    Driving reassessment following neurological damage : an integrated approach
    (Massey University, 1996) Wood, Karen Julie
    The impetus for the present study was a lack of guidelines for evaluating neuropsychologically-impaired drivers, and the need for relevant exploratory research within a New Zealand context. The overall aim was to provide an integrated approach describing the driving performance and behaviour of neuropsychologically-impaired drivers. The researcher anticipated that social and neuropsychological factors could be identified which were related to various measures of practical driving ability, including current New Zealand driving test measures. The present study involved a quasi-experimental analysis of four subject groups, each comprising ten subjects. Neuropsychologically-impaired subjects comprised two groups: (i) neuropsychologically-impaired presenters who were seeking driving reassessment; and (ii) neuropsychologically-impaired drivers who were driving again following a successful assessment outcome. The other two subject groups comprised: (i) control drivers who were similar for age, gender, and number of years driving experience to the neuropsychologically-impaired presenters, and (ii) professional drivers who provided a criterion for a high standard of driving. All subjects underwent extensive neuropsychological and driver testing, as well as supplying background sociodemographic and driving-related questionnaire data. Seven neuropsychological tests (Mini Mental State Examination, Benton Visual Retention Test - Revised, Standardised Money Road Map Test, Southern California Figure Ground Test, Stroop Colour Word Test, Trail Making A and B Test, and reaction time) were included on the basis of several criteria. Practical driving measures included the New Road Test, which is the standard test for driver licensing in New Zealand, and the Advanced Driver Assessment, which is used in circumstances where an independent driving evaluation is required. These practical driving measures were complemented by an informal global driver instructor rating, as well as subject's own comparative driver self-ratings. Questionnaire data gave some practical insight into the effects of neurological damage. Notably, all neuropsychologically-impaired subjects reported some reduction in driving frequency and a change in driving patterns. Post-injury driver self-report ratings for the two ueuropsychologically-impaired groups indicated some important perceived differences relating to stages in return to driving. Both the neuropsychologically-impaired groups performed less well on the neuropsychological and practical driving test measures. Across the neuropsychological tests, slowed response time and a difficulty with complex tasks were characteristic of many neuropsychologically-impaired subject's test performance. In particular, mean scores for the Mini Mental State Examination (Total Score), the Standardised Road Map Test of Direction Sense, and two of the reaction time conditions were significantly lower for neuropsychologically-impaired groups. For the practical driving test measures, type of driving errors made by the neuropsychologically-impaired subjects differed qualitatively from control and professional drivers. However, these differences were not necessarily reflected in overall driving test scores. Multiple linear regression analyses were performed on composite groups of neuropsychologically-impaired versus neuropsychologically-intact subjects. Of the neuropsychological tests, the Standardised Road Map Test of Direction Sense, and some of the reaction time measures were related to both the practical driving tests. Interestingly, reaction time measures suggested an important differential relationship between neuropsychologically-impaired and neuropsychologically-intact subjects. Here. faster reaction times were associated with fewer driving errors in neuropsychologically-intact subjects. By contrast, slower reaction time for the combined neuropsychologically-impaired subjects was associated with better driving performance. The present results demonstrated the importance of an integrated approach toward understanding the complexity of the driving process. An important theme to emerge from both qualitative and quantitative data was a relationship between subjects' perceived neurological deficit and the utilisation of compensatory driving strategies. Thus, the questionnaire data, and the driver self-rating scales suggested that the neuropsychologically-impaired subjects had some insight into their neurological deficit. Furthermore, the inverse relationship between some of the reaction time data and practical driving test outcome suggested the neuropsychologically-impaired subjects were compensating their driving, either by driving slower or by allowing a greater margin for error. The integrated approach also provided some insight into the process of return to driving through subject's reports of change, and comparison of retrospective and current driver self-ratings. Here, inclusion of the two neuropsychologically-impaired groups was an important feature of the research design, enabling further insight into different stages of this process. Overall, the present study provided an entry point for further research, and has practical and safety implications for the reassessment of drivers following neurological damage.
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    From unconscious to self-conscious : cognitive rehabilitation from the perspective of symbolic interactionism : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Social Policy and Social Work at Massey University
    (Massey University, 1996) Sutherland, Deborah
    There is increasing awareness and concern that psychosocial problems prevent people with brain damage reestablishing an acceptable quality of life. Changes in perception and cognition appear to alter a person's relationships, preventing a successful reintegration into the community. As a result, many researchers and rehabilitation practitioners have been calling for more holistic models of recovery which recognise the psychosocial domain and which offer strategies to counteract these problems. In this study, the principles of symbolic interactionism are used to explore the experience of four people with traumatic brain injury. A life history was collected for each person and the four life histories were examined for common patterns and themes. A videocamera was then used to record their daily life in a residential rehabilitation programme. The film collected included formal one-to-one therapy sessions, group situations and informal interaction in the living areas, dining room and passageways etc. The four people (and also those with whom they interacted) were shown selected excerpts from this film and interviewed about what was happening. Several common themes emerged from this process and these themes are examined within a theoretical framework which recognises the central role of a dual, interacting and interpreting self, creating meaning through an adapting and accommodating process. Theory and literature about brain damage and about inner brain processes is revisited from this perspective of the person as a meaning negotiator and some conclusions are reached about the impact of brain damage upon lived experience. In particular, the role of a moral self or an inner conjured audience is considered, as well as the role of emotional intersubjectivity within relationships. Some new insights are offered as to how people resolve the problem of continuing to interact with their world when it is difficult for them to make sense of it or interpret it, and how other people's responses influence this process. The findings of the research suggest adaptations to both settings and relationships may be necessary for a successful recovery after brain injury. The importance of providing scaffolding of the meaning-negotiating process during a liminal period of recovery is noted. Some suggestions are offered as to interactive strategies which foster adaptive, purposeful and independent lifestyles. The thesis concludes that because realities are created through interaction, the principles of symbolic interactionism should become more central in the designing of rehabilitation programmes.
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    Development of systematic behavioural observation to quantify ongoing cognitive activity limitations after brain injury : a dissertation presented in partial fulfilment of the requirements for the degree of Doctor of Psychology at Massey University, Wellington, New Zealand
    (Massey University, 2010) Lewis, Mark
    One of the goals of cognitive rehabilitation following traumatic brain injury is to help people perform everyday tasks. However, options for the rigorous assessment of everyday cognitive effectiveness after rehabilitation are limited. Performance on neuropsychological tests is only moderately correlated with everyday functioning, while previous measures of everyday functioning include only fairly general estimates of overall cognitive functioning. The aim of the current study was to develop an ecologically valid measure that captured a number of subdomains of executive functioning, using systematic behavioural observation of an everyday task. The initial phase of the research involved identifying an everyday task that was sufficiently complex to ensure that executive functioning was utilised in the completion of the task. Participants with traumatic brain injury were then asked to prepare chocolate brownies, using a recipe provided, and a hot drink. Participants were allowed to use any compensatory strategy to help complete the task. Participant performance was directly observed by an examiner and videotaped for subsequent inter-rater reliability. Two independent raters assessed nine components of executive functioning. During this phase, the examiner manuals were modified improving inter-rater reliability. The final version of the measure was then trialled with participants with and without traumatic brain injury. Final inter-rater reliability indicated the approach had merit. Significant and moderate correlations were found between traditional measures of executive functioning and the everyday task. This study employed systematic behavioural observation to obtain fine-grained information regarding a person’s cognitive functioning. With further development, this approach may prove useful for targeting and monitoring specific functional difficulties during cognitive rehabilitation.
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    Efficacy of cognitive behavioural therapy for clients who have sustained a traumatic brain injury (TBI) : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy (PhD) in Psychology at Massey University, Wellington, New Zealand
    (Massey University, 2009) Christianson, Muriel Katherine
    While the focus of rehabilitation following traumatic brain injury (TBI) is often on management of physical and cognitive impairments, emotional and behavioural changes in the person with the injury may represent major hurdles in adjustment following injury. Mood, anxiety and adjustment disorders are common following TBI. A manualised cognitive behavioural therapy (CBT) treatment programme was developed that incorporated provision of education on consequences of TBI, used cognitive and behavioural strategies to recognise and manage emotional reactions to injury, and promoted achievement of personal goals. Participants were nine people with TBI referred to Massey University Psychology Clinic Wellington, for psychotherapy to assist in managing symptoms of psychological distress or adjustment difficulties following injury. Measures used included the Hospital Anxiety and Depression Scale (HADS) to monitor progress in reduction of symptoms of Anxiety and Depression; the Patient Competency Rating Scale (PCRS) to assess competency across areas of day-to-day living; and the Homework Rating Scale Second Edition (HRS-II) to assess the value of homework assignments for participants. Results were presented graphically in group format and in the form of individual case studies outlining progress in achieving individual goals. There was considerable variation in the responses of participants to treatment. When anxiety and depression were secondary to other referral issues such as fatigue and pain that remained high over treatment sessions, there was limited movement on HADS Anxiety and Depression scores. The small number of participants impacted on the ability to detect differences between Patient and Informant ratings on the PCRS or to demonstrate increased levels of awareness over treatment sessions. Consistent completion of Homework assignments proved difficult for participants. Factors that impacted on achievement of personal goals included ongoing levels of fatigue and pain, levels of personal expectation, interpersonal and organisational skills, insight into emotional reactions, and good family and social support. There is a part for a CBT approach in adjusting to changes following TBI, particularly in assisting with reassessing expectations following injury.