Scott Ankrett DClinPsy Thesis 2020 Paper One: The Efficacy of Interventions That Facilitate Social Participation on Outcomes of Social Participation and Quality of Life in Adults with Acquired Brain Injury. Paper Two: Improving Peer Relationships for Adolescents with Acquired Brain Injury: Using Intervention Mapping as a Framework to Identify Targets for Intervention.

Abstract

Paper One Abstract: Background and aims. Social participation is a key determinant for health and wellbeing across the lifespan, and is a frequent goal for rehabilitation. Acquired brain injury (ABI) is a leading cause of death and disability worldwide that can result in persistent difficulties within cognitive, emotional, behavioural, physical, and social domains that contribute to chronic disability and restricted participation. Consequently, survivors are at higher risk of social isolation and reduced quality of life (QoL). The social participatory goals of rehabilitation are increasingly advocated for to support QoL and minimise disability post-ABI. The aim of this review was to explore the efficacy of interventions that facilitate social participation on outcomes of social participation and QoL in adult survivors of ABI. The synthesis of available evidence might support rehabilitation professionals to consider how to improve such outcomes in post-acute settings. Methods. A systematic review was conducted to locate, appraise, and synthesise evidence relating to the review questions. Appropriate intervention studies were identified using a pre-determined search strategy. These were then assessed for inclusion against pre-defined eligibility criteria to investigate the efficacy of their interventions on the target outcomes for this review, social participation and QoL. Results. Of the 1119 possible articles identified in the initial search, 12 studies met the inclusion criteria for this review. Data were then extracted and methodologies were critically appraised. Intervention programmes were grouped according to intervention methods, and included peer-mentoring, community integration, leisure activities, outpatient neuropsychological rehabilitation, intensive cognitive rehabilitation, and health-promotion. Seven of the 12 studies found statistically significant differences on at least one target outcome following intervention. Four of these identified efficacy on both social participation and QoL, and varied in methodological design and quality. Conclusion. Currently, there is limited evidence for the efficacy of interventions that facilitate social participation on outcomes of social participation and QoL for adults with ABI. The varying objectives, quality, and potential bias of the 12 included studies limits the conclusions that can be drawn. Social participatory interventions appear to have objective and subjective benefits for adults post-ABI. Appropriate intervention methods (i.e., delivery and focus) to support target outcomes is uncertain from the limited literature included in this review. However, interventions that showed efficacy on both target outcomes (four of the 12) were multifaceted and intensive. Rehabilitation of social participation to support social participation and QoL post-ABI may benefit from supporting participants to develop the skills and self-belief needed to actively participate in social activities that are important to them, however, further evidence is needed. Considerations for future research and clinical implications are outlined. Paper Two Abstract: Background and aims. Adolescence is a time for significant social development, facilitated by successful peer relationships. Those with reduced social skills are at risk of being rejected or victimised by peers, and can face significant emotional ramifications and implications for quality of life (QoL). Peer relationships for adolescents with acquired brain injury (ABI) have been largely under-recognised in the paediatric neuropsychology literature. Previous interventions aiming to improve social skills (needed for peer relationships) in this population have shown inconsistent efficacy and the targets for intervention are unclear. The intervention mapping (IM) framework offers a systematic and iterative protocol for the co-production of interventions through engagement with key stakeholders. This consists of six steps for intervention design, implementation, and evaluation: (1) creating a logic model of the target problem; (2) stating programme objectives; (3) programme design; (4) programme production; (5) implementation plan; and (6) evaluation plan. This study aimed to: (a) develop a collaborative understanding of peer relationship difficulties for adolescents with ABI; and (b) seek the views of adolescents and other key stakeholders on what might be required to improve peer relationships post-ABI, and what intervention the goals might be. Qualitative methodology was used to support these aims. The findings of this study can inform the co-development of a meaningful intervention to support peer relationships and QoL in adolescents with ABI using the IM protocol in future research. Method. Consistent with IM protocol, a planning group comprising four ABI clinical-researchers provided consultation at each stage of the study. First, the planning group completed a survey to develop an initial logic model. This is a framework for understanding peer relationship difficulties following ABI, the determinants (or contributing factors) for these, and the long-term impact on QoL for adolescents. Focus groups and semi-structured interviews were then conducted with four stakeholder groups to develop an in-depth understanding of peer relationship difficulties post-ABI, the impact of these, and the determinants contributing to such difficulties, and to further develop the initial logic model: (1) adolescents with ABI (n=4); (2) parents of adolescents with ABI (n=7); (3) adults who sustained an ABI in adolescence (n=2); and (4) specialist practitioners (n=3). Perspectives were also obtained from stakeholders concerning what might need to change to support peer relationships post-ABI and what the targets for intervention might be. Qualitative data from focus groups and interviews were analysed using thematic analysis. Results. The analysis of stakeholder conversations yielded 11 themes, grouped into two domains: (1) understanding peer relationship difficulties (e.g., dropped and excluded, a need to belong, restricted independence); and (2) supporting peer relationships (e.g., building understanding, meaningful social connection). The logic model underwent six iterations following planning group and stakeholder feedback. This was provided by stakeholders in the focus groups and interviews, and by planning group members and stakeholders through further member-checking procedures following the analysis. Conclusions. Adolescents with ABI were reported to experience difficulties with peer relationships. At an important time for social development, peer rejection can increase feelings of isolation, loneliness, shame, and hopelessness. This can have further implications for mental health, peer relationships, and QoL. The individual, psychological, behavioural, and environmental determinants for peer relationship difficulties are broad. A meaningful intervention would need to be multifaceted attempting to build understanding in others, facilitate meaningful social opportunities, offer early support post-injury, and help manage psychological wellbeing. A primary focus would be to empower adolescents post-ABI. The presented logic model provides a robust understanding of peer relationship difficulties for adolescents with ABI that can be used to guide intervention development in future research.