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Prevalence, Comorbidities, and Correlates of Challenging Behavior Among Community-Dwelling Adults With Severe Traumatic Brain Injury: A Multicenter Study

Sabaz, Mark PhD; Simpson, Grahame K. PhD; Walker, Alexandra J. PhD; Rogers, Jeffrey M. PhD; Gillis, Inika MPsych (ClinNeuro); Strettles, Barbara Dip Health Manag

The Journal of Head Trauma Rehabilitation: March/April 2014 - Volume 29 - Issue 2 - p E19–E30
doi: 10.1097/HTR.0b013e31828dc590
Original Articles

Objective: Investigate the prevalence, comorbidities, and correlates of challenging behaviors among clients of the New South Wales Brain Injury Rehabilitation Program.

Setting: All community-based rehabilitation services of the statewide program.

Participants: Five hundred seven active clients with severe traumatic brain injury.

Design: Prospective multicenter study.

Main Measures: Eighty-eight clinicians from the 11 services rated clients on the Overt Behaviour Scale, Disability Rating Scale, Sydney Psychosocial Reintegration Scale–2, Care and Needs Scale, and Health of the Nation Outcome Scale–Acquired Brain Injury.

Results: Overall prevalence rate of challenging behaviors was 54%. Inappropriate social behavior (33.3%), aggression (31.9%), and adynamia (23.1%) were the 3 most common individual behaviors, with 35.5% of the sample displaying more than 1 challenging behavior. Significant associations were found between increasing levels of challenging behavior and longer duration of posttraumatic amnesia, increasing functional disability, greater restrictions in participation, increased support needs, and greater degrees of psychiatric disturbance, respectively (P < 0.004). Multivariate binomial logistic regression found that premorbid alcohol abuse, postinjury restrictions in participation, and higher levels of postinjury psychiatric disturbance were independent predictors of challenging behavior.

Conclusions: Challenging behaviors are widespread among community-dwelling adults with severe traumatic brain injury. Services need to deliver integrated anger management, social skills, and motivational treatments.

Supplemental Digital Content is Available in the Text.

Liverpool Brain Injury Rehabilitation Unit, Liverpool Hospital (Drs Sabaz and Simpson), Rehabilitation Studies Unit, Sydney School of Medicine, University of Sydney (Dr Simpson), Westmead Brain Injury Rehabilitation Unit, Westmead Hospital (Dr Walker), Australian Catholic University (Dr Rogers) School of Psychiatry and Black Dog Institute, Faculty of Medicine, University of New South Wales (Ms Gillis), and Agency of Clinical Innovation (Ms Strettles), Sydney Australia.

Corresponding Author: Mark Sabaz, PhD, Liverpool Brain Injury Rehabilitation Unit, Liverpool Hospital, Locked Bag 7279 Liverpool BC, Sydney, NSW 1871, Australia (

The New South Wales Agency for Clinical Innovation funded the project. Dr Sabaz, Dr Rogers, and Ms Gillis were employed by the Agency for Clinical Innovation when working on the project. The authors thank Natalie Pride, Dr Adeline Hodgkinson, Suzanne Benson, Naomi Brookes, Matthew Dowton, Marion Fisher, Kate O'Reilly, Vicki Solomon, and Maysaa Daher.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

The authors declare no conflicts of interest.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins