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Vital link in solving prison problem?

Offenders at every prison and probation setting in the UK should have access to a member of staff trained in brain injury signs and symptoms, experts have urged.

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“My head’s like a patchwork quilt under there,” says Wendy, an inmate at HM Prison Drake Hall in Staffordshire. “He beat me bad, bad, bad… I was just knocked out, unconscious, so many times.”

Before slipping into the criminal justice system, Wendy suffered domestic violence in a four-year relationship. She is now part of a damning statistic; more than six in 10 female offenders have a history of acquired brain injury (AB)).

This is according to research led by The Disabilities Trust, which found that of 173 female offenders at Drake Hall examined against the Brain Injury Screening Index, 64% had a history indicative of a brain injury.

The vast majority of injuries (96%) were traumatic, while a third were sustained before the individual committed their first known offence.

The Disabilities Trust’s findings follow the introduction of the charity’s Brain Injury Linkworker Service at the facility. The service provides support to women with a history of ABI, developing a “sustainable pathway” that supports rehab and helps prisoners to manage the transition between custody and the community.

From the women supported through the service, there were 196 reports of severe blows to the head – 62% of which were sustained through domestic violence.

Nearly half (47%) of the women with brain injuries had been in an adult prison five or more times and 33% sustained their first injury prior to their first offence.

Following its findings, The Disabilities Trust has called for linkworkers – or a similar role with a strong understanding of brain injury – to be accessible to all prisons and probation settings.

To date, the linkworker service has been rolled out into eight prisons, HMP Drake Hall, Preston, Leeds, Aylesbury, Bullingdon, Durham, Deerbolt and Cardiff.

An independent assessment of the charity’s research by Royal Holloway, University of London, found that women seen by the linkworker experienced improved mood and self-esteem, and enhanced confidence and positivity; key factors that have been previously identified as being essential for a woman to engage in rehabilitative programmes.

The linkworker service also offered practical guidance for staff working with women with a brain injury, and alleviated pressure from other service provision such as mental health.

It concluded that a brain injury linkworker service provides a strong framework which will benefit offenders and prisons by identifying and managing brain injury. Offenders helped by the service include ‘Sarah’ who says of her brain injury: “I was becoming very anxious about these problems that I was seeing …not remembering the names of the people I’d spoken to or not being able to express myself properly ‘cause I’m forgetting what I’m saying.”

Another, ‘Helen’, says: “When I was counting screws in the work area I had to count them three times. It gets me very stressed, like when people tell me ‘go and tell this person [something]’ and [I’m] forgetting it.”

As well as the rollout of a linkworker service, or something similar, The Disabilities Trust called for the inclusion of brain injury screening as a routine part of the induction assessment on entry to prison or probation services.

All prison and probation staff should also receive basic brain injury awareness training, it said. The charity also sought assurances that brain injury support would be aligned with “gender-informed” practice. It also recognised that further research is needed to examine the potential effect of brain injury on re-offending behaviour – as well as the role of neuro-rehab in contributing towards the reduction of re-offending behaviour.

The landmark Time for Change report, published in October, made similar recommendations. The report, by the All-Party Parliamentary Group for ABI, called for reforms to criminal justice procedures and processes to factor in the needs of people with ABI.

More ABI training for staff in the police, court, probation and prison services was also urged; as was brain injury screening for children and adults on entry to the criminal justice system. If a brain injury is identified, its impact, severity and related deficits should be measured and “appropriate interventions planned by a trained team”, the report said.

Also, it recommended that all agencies working with young people in the criminal justice system, schools, psychologists, psychiatrists, GPs and youth offending teams work together to ensure individual needs are addressed.

As the APPG report stated, evidence now emphatically links ABI to offending in young people, with prevalence rates for traumatic brain injury (TBI) as high as 60% in some studies (most recently, a 2018 comprehensive review published in The Lancet Psychiatry).

In comparison, UK brain injury charity Headway says only around one in 200 people in the general population has been admitted to hospital with a head injury.

But some experts have warned that it is misleading to suggest brain injury causes crime – and that crime/ABI links are highly complex and must be investigated further. Ryan Aguiar, consultant clinical neuropsychologist at Ashworth Secure Hospital in Liverpool, told the Guardian last year: “Brain injury does not lead to crime even though there are more prisoners with head injury and cognitive impairment per capita, or as a percentage, than there is in the general population.

“Crime is a much more complex condition that is brought about by a myriad of social, environmental, personality, mental health and situational circumstances.

“Head injury is only one among many and not even a first among equals.”

Similarly, Graeme Fairchild, a reader in psychology at the University of Bath, warned: “One of the main problems is that many of the risk factors for criminal offending and violence, eg. being male, coming from a low socioeconomic status background, having ADHD, being physically abused, and abusing alcohol and other substances, are also risk factors for sustaining head injuries, so it is very difficult to disentangle cause and effect here.”

Certainly there is an abundance of evidence of head injury prevalence in prison populations, even if studies unpicking the reasons for this link are lacking.

A 2015 study of 613 adult prisoners found that 47% reported a history of TBI when screened on admission to HMP Leeds.

It also found that 70% of those offenders reported their first injury before their first offence, backing up previous research linking TBI as a risk factor for offending.

In 2011, a 35-year Swedish population study led by psychiatrist Seena Fazel calculated that people with a head injury on their records had a 9% chance of becoming violent offenders. This compared to the general population average of 2.5%.

Recognising that brain injuries could be related to upbringing, the researchers also monitored the siblings of those with brain damage. They discovered a 4.5% chance of becoming offenders too.

There are numerous older studies linking head injury with the changing behaviour and lack of self-control that could theoretically lead to crime. Among them is a lengthy investigation into brain-injured Vietnam veterans in the US.

It evidenced increased aggression in many veterans who had damaged their frontal lobe in the conflict.

Public debate – and wild speculation – about ABI and crime has been fuelled over the decades by infamous examples of brain injured criminals.

Ian Brady and Fred West both reportedly had some experience of head trauma, while Ronnie Kray was almost killed at age nine by a head injury sustained in a fight with his twin brother Reggie.

No expert has ever suggested that their heinous crimes could be attributed to a brain injury but their medical history has at least raised questions about the impact of neurological injury on behaviour.

Aside from such conjecture, there is now hard evidence – and lots of it – to show a vastly disproportionate level of head injury in offender populations.

The criminal justice system and the many agencies that may interact with an individual on the slippery slope to prison have a series of recommendations they must address – and urgent action is needed.

A promising development in recent years has been Headway’s Brain Injury Identity Card scheme (read more on p20). It is designed to help the police identify brain injury survivors and ensure they are given appropriate support when they come into contact with the criminal justice system.

Brain-injured individuals carry a card which reads “My name is … I have a brain injury”. All the challenges they may experience as a result of the injury – such as fatigue, anxiety and information processing problems – are listed on the card.

The scheme was launched in 2017 with the backing of the NHS, the National Police Chiefs Council, the College of Policing, Police Scotland, The Police Service of Northern Ireland and the National Appropriate Adult Network.

Stories like that of ID card holder Dominic Hurley underline its practicality. He was arrested three times for being drunk and disorderly but in each case, he was simply showing symptoms of his brain injury. His card enables him to avoid these misunderstandings.

Meanwhile, events unfolding in the courtroom, particularly in the US, could potentially see brain injuries become a bigger consideration by jurors in years to come.

A number of papers, including that led by Owen D. Jones of Vanderbilt University in Tennessee, are recognising the growing role of neuroscientific evidence in court.

Jones references the story of Grady Nelson, who, in 2005, brutally murdered his wife Angelina. After stabbing her 61 times, he left a butcher’s knife embedded in her brain.

Later, his own life hung in the balance as the Florida jury that convicted him of murder next had to decide whether he would be executed or spend his life behind bars.

Nelson’s attorney offered to provide neuroscientific evidence, specifically quantitative electroencephalography (QEEG) introduced through the testimony of a neuroscientist, to suggest that Nelson had potentially relevant brain abnormalities.

The jury should hear this evidence, the attorney argued, because although it may not excuse Nelson’s behaviour, it should mitigate his punishment.

In order for wife-killer Grady Nelson to be sentenced to death, seven of the twelve jurors (a simple majority) had to vote in favour of executing him.

Only six did, so his life was spared by the narrowest possible margin. Following the vote, it appeared that the neuroscientific evidence had been crucial.

Two of the jurors who voted against executing Nelson told the press that the neuroscientific QEEG evidence had changed their minds, given that they had each initially favoured his execution.

One of them said: “It turned my decision all the way around. The technology really swayed me. After seeing the brain scans, I was convinced this guy had some sort of brain problem.”

The paper states: “It is becoming increasingly common for lawyers to offer neuroscientific evidence, particularly brain images, in both criminal and civil litigation. In our view, this development is both promising and perilous depending on whether and how well courts can come to distinguish, within the contours of distinctly adversarial proceedings, between justifiable and unjustifiable inferences.

“Neuroscientists have crucial parts to play in a legal system that needs to understand and interpret neuroscientific evidence and to separate the wheat from the chaff.

“The ability of neuroscientific techniques to shed light on important aspects of human cognition has generated hope that neuroscience can help to answer some perennial questions in courts of law.

However, one should keep in mind that it is easier to misunderstand or mis-apply neuroscience data than it is to under- stand and apply it correctly, and this is crucially important when lives and livelihoods depend on it.

Whether courts can successfully navigate these challenging waters will depend on the level of engagement by neuroscientists.”

Neuroscience in court is nothing new, but as brain mapping techniques and evidence on exactly how a brain injury can lead to crime becomes clearer, this development may well give ABI survivors a fairer deal in the criminal justice system.

 

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Update:concussion in sport

A run through the latest developments in concussion in sport research and protocols.

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A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.

Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.

“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.

“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”

Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.

Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.

Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.

Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.

“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”

The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.

The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.

Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.

These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.

The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.

Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.

“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”

A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.

There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.

A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.

EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.

This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.

This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.

SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.

“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”

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Stepping up the fight against alcohol-related brain injury

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Alcohol-related brain injury (ARBI) is becoming more widely recognised, but specific rehab services for the condition are surprisingly rare.

With few dedicated units for patients with ARBI, many patients in need of specialist care instead find themselves in a hospital or even an elderly care home.

ARBI is characterised by prolonged cognitive impairment and changes in the brain due to chronic alcohol consumption.

The average age of diagnosis in men is 55, and only 45 for women – following at least five years of excessive alcohol consumption, of around 50 units per week in men and 35 for women.

ARBI is not a degenerative condition, with up to 75 per cent of patients recovering to some degree with the correct support; and the first three months following diagnosis are recognised as key in a person’s recovery. Access to appropriate provision, therefore, is even more crucial at this time.

In February, UK-wide charity Leonard Cheshire opened a residential unit in Northern Ireland to help some of the many patients in need in the country. It is the first facility of its kind on the island of Ireland. 

The 14-bed unit, near Belfast, opened inconveniently – after years of planning – just as the COVID-19 crisis was emerging.

Its work goes on, however, with the centre taking patients from across the country, though initially from the capital and surrounding areas.

The residential centre aims to support residents over a two to three-year period, although that can be shorter for some patients. It helps them to live independently, by building the life skills and confidence to do so. 

Naomi Brown, clinical lead at the centre, joined Leonard Cheshire late last year to oversee the opening of the facility, following an extensive career in brain injury work and in being part of multidisciplinary teams.  

She says: “The background here in Northern Ireland is that the acquired brain injury (ABI) service is really well structured and established but for ARBI, often the person wouldn’t meet the criteria for addiction services, but their needs would not be such that they needed to be admitted to hospital, or even fulfil the criteria for ABI services, so they would fall through the cracks.

“The provision they receive would often come from the care sector, but to end up in a care home at what could be a very young age is not appropriate either.

“There is a real lack of options. Their care managers recognise they aren’t in the appropriate setting for them, but through a lack of alternatives, it is very difficult.

“A lot of symptoms are very similar to those under the influence of alcohol, difficulty with balance and memory for example, which can make ARBI difficult to diagnose.

“Often it can be something like liver failure that gets them into hospital, but then it becomes obvious there are cognitive issues there too.

“Our centre only has 14 beds, which we don’t pretend is going to answer the scale of the problem, but the decision to restrict it to that number is that we don’t want quantity over quality. To try and accommodate huge numbers would risk the patient-centred approach that we are really proud of, so we wanted to keep it on a small scale.

“But there are 14 places here at any one time for people to get access to the specialist rehabilitation they need, so we are really pleased to be able to offer this.”

With the centre’s goal being the independent living of its patients, a resident-led rehab plan is created for each individual, based around their individual goals and aspirations.

It is delivered by Leonard Cheshire’s team of rehab assistants, supported by clinicians, occupational therapists, physiotherapists, speech and language therapists and neuropsychologists who come in to hold sessions with the residents, and overseen by Naomi. 

“From the minute someone is admitted to us, we are already planning for their discharge, even though that may be a long time and a lot of work away.

“From the very start, it’s about the individual, it’s absolutely not a generic approach, even though the ultimate outcome for everyone may be the same. Most people who move in do want to live independently, so if that’s their goal and we will do all we can to help them achieve that, with a plan individualised for them. 

“Some people will come to us and we realise they won’t be here very long as they do very well very quickly, but for others, they are going to be with us for two or three years.

“Some people arrive and love it here and say they don’t want to leave, which is a great reflection on the work we do and the centre we’ve created, but the ambition is that the point will come where they realise they don’t need us anymore.

“Through the work we do and our interventions, we can make very good progress. We’ve had some people here already who have been in quite an acute state but the progress they make brings joy into my heart.”

One such patient is David* who, despite only being with the centre for a matter of weeks, has made significant progress in his recovery.

Prior to moving to Leonard Cheshire, he lived in a nursing home for two years.

Before his arrival, Naomi remembers he had low mood, minimal spontaneous conversation and spent long periods of time in his bed sleeping.

He had no clear weekly routine and lacked any scheduled therapeutic or recreational activities.

Naomi says: “David initially required a significant amount of support to initiate activities, engage with others or even leave his room. He has slowly adjusted to the active therapeutic programme in the unit and his mood has improved significantly.

“His mobility and exercise tolerance has greatly increased, he participates in group activities, is now more spontaneous in conversation and has developed facial expressions. David has been able to self-identify rehabilitation goals and discovered a new love for playing the drums and guitar. 

“He is in the very early stages of his rehabilitation but having spent three months in the ARBI unit, the change is his quality of life is already dramatic.

“He engages in an individual, weekly timetable which includes activities of daily living, physical, cognitive and social activities, and is reportedly very happy in his current placement. Once the COVID-19 restrictions are lifted, we very much hope to begin reintegrating David to the local community and making future plans for his discharge.”

David’s experience is one which the unit is keen to replicate, by engaging patients from the earliest stages of their arrival at Leonard Cheshire in building a new and healthier daily routine.

“We are always keen to introduce routine, as that is so important in the longer-term. Where some people have maybe traditionally watched TV all night then get up into the afternoon, we try to create a new routine with lots of support services available in the morning. A healthy routine is what we want them to have when they go back home,” says Naomi.  

“We encourage people to do things for themselves – to get up, make yourself breakfast, maybe do some gardening or help with the cleaning, all things which promote the ability to do things independently.

“If they put the washer on, they’ll need to go back to it when it’s finished. We have rehab assistants on-hand to support them, but we do actively encourage independence.”

Everyone has an individual timetable for the week based on their own interests, combined with their clinical requirements, which centres on promoting reintegration into the community.

“It’s very individualised, so if someone wants to do an online course or learn how to cook for themselves, or learn a musical instrument, we’ll focus on that. We have a fantastic team here who will turn their hand to anything for the benefit of our residents,” says Naomi.

“As well as activities in the centre, we do a lot in the community, or rather we did before COVID-19, but that will resume when it’s safe to do so. We did sports activities, yoga classes, bowling, it’s not just your classic physio. We want people to be engaged and comfortable with the world outside. 

“We will always ensure residents have support once they leave us, and are setting that up long before they go.

“If there was someone who was with us who wasn’t from Belfast, we would use resources we knew were transferable to where they lived, so they didn’t leave us and not know how to access support.

“We build up these links with community services in the relevant discharge areas, so ideally the person will already be confident at being independent and will have the added assurance of knowing they continue to be supported.”

The Leonard Cheshire centre’s launch came amid changes to Northern Ireland’s legislative backdrop with the implementation of the Mental Capacity Act (NI) 2016. This has new deprivation of liberty regulations, a significant new introduction for the country and its approach to capacity and consent.

Naomi says: “When planning for the opening of a new centre, a global pandemic wasn’t on the radar, and for it also to coincide with the new mental capacity legislation meant it was a really busy time for us in the early stages, the COVID-19 aspect of which we could not have foreseen. 

“The pandemic did present challenges for our residents, many have a certain level of confusion so it’s difficult for them to always remember that they can’t be close to someone else, they have to regularly wash their hands. There is a lot of prompting which leads to a certain amount of frustration. While they are watching these things on TV about how COVID is affecting the world, it’s hard to relate that to everyday life.”

New referrals continue to arrive during the pandemic, from both hospital discharge and moving from a care home environment, although happily the Leonard Cheshire unit has remained COVID-19 free.

“We were keen to admit new residents and take referrals from hospitals and care homes, subject to extra measures being in place to protect ourselves and our residents.

“We wanted to continue to support hospitals and free up beds, but also to offer the appropriate care to people whose specific needs through their ARBI diagnosis meant they would be better in our centre than a hospital environment or care home.

“This has certainly been a challenging period in which to start our ARBI unit, but we have come through it well together so far and we look forward to continuing to develop ourselves as we come out of the pandemic and go into the future.”

*Name changed for anonymity.

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Neurobehavioural rehab in aggression management after TBI

Changes in personality following TBIs are often more problematic than neurocognitive, functional deficits or even physical disabilities. Dr Grzegorz Grzegorzak, consultant neuropsychiatrist at St Peter’s Hospital, South Wales, explains why taking a neurobehavioural approach to treating TBI can be highly effective.

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Personality changes are sometimes referred to as neurobehavioural disability (ND), especially when associated with social difficulties.

The concept of ND involves impairments of numerous aspects of functioning including the abilities to self- monitor and self-regulate, to control frustration, anger and aggression, to tolerate delay in gratification, and to self-motivate.

These impairments can lead to a sense of being overwhelmed when facing situations requiring control and management of internal impulses or coping with social situations or tasks.

Impulsivity, disinhibition and aggression all have significant potential to interfere with rehabilitation efforts, jeopardize recovery and become a major obstacle to successful functioning in social roles.

Research estimates the prevalence of aggression in survivors of TBI as being as high as 33.7 per cent.

Addressing aggression as soon as it arises is critical to the individual’s recovery.

Sometimes aggressive behaviour is so intense and frequent that its management takes priority over all other aspects of care and rehabilitation.

Neurobehavioural rehabilitation (NR) was introduced in the late 1970‘s as an attempt to improve functional abilities of TBI patients.

NR stems from recognising that people who survive TBI can still learn new skills to self-regulate and to modify their behaviour.

The basis of NR is embedded in learning theory and thus the success of NR is reliant on the patient’s ability to make use of new information and experiences.

Therefore, NR is only suitable for the post-acute phase of recovery from TBI, and in fact is intended as a medium to long term rehabilitation programme.

​NR interventions are composed of comprehensive and multidisciplinary efforts to create a user-friendly, supportive and encouraging social environment which facilitates therapeutic interactions and activities.

Specific goals and detailed routines are constructed for each patient individually, based on structured collection of data informed by behavioural analysis.

The process of designing and implementing the interventions puts emphasis on personal autonomy.

Clinical formulation is preferred over medical diagnosis. The attitude of the MDT should always be positive, embracing a strong belief in the patient’s ability to achieve their goals, improve and recover.

Carefully managed feedback and positive reinforcement are an essential part of NR.

Consistent interactions with every member of the team are of utmost importance, given that neurobehavioural intervention should not be limited to scheduled activities but in fact incorporated in every interaction.

Over the last forty years the model has been implemented by many neurorehabilitation services worldwide.

Several case studies describing recovery pathways through NR paint a very positive picture, and our own experience at St Peter’s of adopting a neurobehavioural approach has demonstrated it can produce real and measurable outcomes for both our patients andtheir families.

Case Study: Mehmet

On admission to St Peter’s Hospital, Mehmet presented with extreme challenging behaviours including serious assaults on staff, destruction of environment, verbal abuse and shouting.

Mehmet has frontal lobe dysfunction as a result of a head injury he sustained. For the previous 18 months he had been in a general hospital.

At St Peter’s a bespoke positive behaviour support plan and activity plan were developed with Mehmet’s input and reflecting his cultural needs which, under the supervision of his MDT, promoted positive changes to his social interactions, routines and activities.

Over nine months Mehmet’s challenging behaviours reduced significantly and he now enjoys a wide range of activities including regular community visits and has strengthened his relationship with his family.

Dr Grzegorz Grzegorzak is one of the consultant neuropsychiatrists at St Peter’s Hospital a specialist 39-bed Neuropsychiatric facility in Newport, South Wales run by the Ludlow Street Healthcare Group. www.saintpetershospital.co.uk

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