AMSER AM NEWID - NEUROREHABILITATION EDUCATION CRIMINAL JUSTICE SPORT-RELATED TRAUMATIC BRAIN INJURY WELFARE BENEFITS SYSTEM - UKABIF
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AMSER AM NEWID
NEUROREHABILITATION
EDUCATION
CRIMINAL JUSTICE
SPORT-RELATED TRAUMATIC BRAIN INJURY
WELFARE BENEFITS SYSTEM
July 2021
www.ukabif.org.uk
This report is based on ‘Acquired Brain Injury and Neurorehabilitation – Time for Change’ published in October
2018 by the All-Party Parliamentary Group on Acquired Brain injury. The original version has been edited so it is
specific for Wales.
Thank you to all the contributors to the original version and to the following who have contributed to this version:
• Educational Psychology Service Gwynedd and Môn
• Neurological Conditions Implementation Group
• Headway Regional Groups and Branches in Wales
• Her Majesty’s Prison and Probation Service Wales
• Noah’s Ark Children’s Hospital,
• North Wales Brain Injury Service
• South Wales Acquired Brain Injury Forum
• South Wales Major Trauma Network
• South Wales Police
• Stroke and Neurological Conditions Implementation Group
• Swansea University
• Swansea Bay University Health Board
• The Child Brain Injury Trust
• University of East Anglia
• University Hospital of Wales
• Wales Neurological Alliance
• Welsh Neuropsychiatry Service
Special thanks to Dr Leanne Rowlands, Senior Lecturer and Researcher in Neuropsychology, Arden University and
Bangor University, for researching and drafting this document.
The production of this report was made possible with the support of Kyle’s Goal.
2 TIME FOR CHANGE IN WALES REPORT 2021
CONTENTS
TIME FOR CHANGE IN WALES 4
07
SUMMARY OF KEY RECOMMENDATIONS 5
OVERVIEW OF ACQUIRED BRAIN INJURY 6
NEUROREHABILITATION 9
Key issues
Recommendations
Overview
Case studies: Josh and Kyle
Political aspirations
EDUCATION 19
Key issues
Recommendations
Overview
Case study: Sioned
CRIMINAL JUSTICE 23
Key issues
Recommendations
Overview
Case study: Lucinda
SPORT-RELATED TRAUMATIC BRAIN INJURY 27
Key issues
Recommendations
Overview
Case study: Lee
WELFARE BENEFITS SYSTEM 33
Key issues 40
Recommendations
Overview
Case study: Euron
TIME FOR CHANGE IN WALES REPORT 2021 3
Amser am Newid
In 2018 the All-Party Parliamentary Group (APPG) on
Acquired Brain Injury (ABI), chaired by Chris Bryant MP
for Rhondda, launched a report ‘Acquired Brain Injury
and Neurorehabilitation – Time for Change’ to raise
awareness of ABI, and to seek improvements in the
support available for individuals that are directly
affected by ABI, and for their families and carers1.
Although much of the information in the original
report is applicable to individuals with ABI in Wales,
this document focuses on neurorehabilitation in
Wales because:
• With the establishment of a Major Trauma Network
(MTN) for South Wales and Powys, it is timely to
advise the members of the Senedd, Health Boards,
Local Committees and health professionals of the
crucial role of neurorehabilitation in optimising
recovery from ABI, and ensuring that services are
‘fit for purpose’
• There are currently no inpatient rehabilitation
services in North Wales, despite an identified need
and efforts to improve this provision2
• Appropriate provision of support for people with
ABI is necessary for a sustainable and healthy Wales,
and for meeting the goals of the ‘Well-being of
Future Generations (Wales) Act 2015’3
REFERENCES
1. Acquired Brain Injury and Neurorehabilitation - Time for Change. All-Party Parliamentary Group on Acquired Brain Injury
Report. September 2018. https://cdn.ymaws.com/ukabif.org.uk/resource/resmgr/campaigns/appg-abi_report_time-for-cha.pdf
(accessed April 2020)
2. Llandudno Hospital Project. Cycle Two Report for Rehabilitation Project Team: Identification of preferred Service Solution.
Betsi Cadwaladr University Health Board. May 2010. Accessed April 2020 http://www.wales.nhs.uk/sitesplus/documents/861/
Cycle%202%20SBAR%20Rehabilitation.pdf (accessed April 2020)
3. Welsh Government. Well-being of Future Generations Act: The Essentials. Welsh Government, Cardiff; 2015.
https://futuregenerations.wales/wp-content/uploads/2017/02/150623-guide-to-the-fg-act-en.pdf (accessed April 2020)
4 TIME FOR CHANGE IN WALES REPORT 2021
SUMMARY OF KEY RECOMMENDATIONS
NEUROREHABILITATION CRIMINAL JUSTICE
• There is an urgent need in Wales to review the • Criminal justice procedures, practices and
incidence of Acquired Brain Injury and ensure existing processes need to be reformed to take into
neurorehabilitation services are adequate and ‘fit for account the needs of individuals with Acquired
purpose’ for children, young people and adults, with Brain Injury
new services implemented as required • Training and information about Acquired Brain
• Children, young people and adults with Acquired Brain Injury is required across all services including the
Injury in Wales should have access to high quality police, probation, prison services and the Courts
inpatient and community-based neurorehabilitation. • Brain injury screening for children, young people
Their neurorehabilitation needs should be assessed and adults is required routinely, and at the earliest
shortly after admittance to hospital, delivered during point of contact with the Criminal Justice System
the inpatient phase, and continued, if required, in the • If an Acquired Brain Injury is identified,
local community neurorehabilitation is required with the
• There is a need for cooperation between Health, appropriate interventions planned and
Social, and Education departments, and funding for implemented depending on injury severity. This
inpatient and community neurorehabilitation services could include Acquired Brain Injury Awareness
needs to be reviewed training for current Criminal Justice System staff
• Neurorehabilitation must be a key consideration in to adapt their practices. In the cases of more
the new Major Trauma Network for South and West severe brain injury, they may require specialist
Wales and South Powys, with a clear pathway to intervention with trained professionals
appropriate services
• It should be mandatory for the Rehabilitation
SPORT-RELATED TRAUMATIC
Prescription to be given to all individuals with an
BRAIN INJURY
Acquired Brain Injury, not just those who have • Funding for collaborative research is required
been in a Major Trauma Centre, on discharge from to evaluate and improve assessment tools,
hospital. Copies should also be sent to their General develop objective diagnostic markers, and better
Practitioner and given to the patient and family understand the recovery process including post-
concussion syndrome and potential long-term
EDUCATION risks of sport-related brain injury
• An education campaign is required in schools
• There is a need to review the incidence of children and communities to improve awareness and
and young people with Acquired Brain Injury in the understanding of sport-related brain injury.
education system in Wales This should be effected with the support of
• All education professionals should have a minimum government departments potentially including
level of awareness and understanding about Acquired the Department for Education and Skills,
Brain Injury and the educational requirements of Department of Health and Social Services,
children and young people with this condition and Public Health Wales
(i.e. completion of a short online course for all • Government should take the lead with clear
school-based staff), with additional training for the sport-independent concussion guidance and
named lead professional supporting the individual policies. Sport associations should work
with an Acquired Brain Injury and Additional Learning collaboratively with government and professional
Needs Coordinators clinical bodies to implement these policies and
• Many children and young people with Acquired Brain to improve health professionals’ knowledge of
Injury require individually-tailored, collaborative and concussion management
integrated support for their return to school, and • The National Health Service should develop
throughout their education better pipelines for the diagnosis and care of
• An agreed ‘return-to-school’ pathway plan is required, sport-related brain injury, including post-injury
led and monitored by a named lead professional, to follow-up for earlier detection of post-concussion
provide a consistent approach and support for the syndrome
individual, their family, and teachers
• There is a need to ensure that Statements of Special WELFARE BENEFITS SYSTEM
Educational Needs (and Individual Development • Training is required for all assessors involved
Plans in future) have consistent input from with individuals who have Acquired Brain Injury
neuropsychological services to ensure that provision • Re-assessment for welfare benefits should only
is fit for the individual’s needs. The advice in the take place every five years
Statement should be specific, with no room for • A brain injury expert should be on the consultation
interpretation, to ensure that each individual is getting panel when changes to the welfare system
the appropriate support consistently are proposed
TIME FOR CHANGE IN WALES REPORT 2021 5
OVERVIEW OF ACQUIRED BRAIN INJURY
DEFINITION OF ACQUIRED BRAIN INJURY
Acquired Brain Injury (ABI) is any injury to the brain which has occurred following birth. ABI includes:
Traumatic Brain Injuries (TBIs) such as those caused by trauma (e.g. from a road traffic accident, fall or assault)
and Non-Traumatic Brain Injuries (non-TBIs) related to illness or medical conditions (e.g. encephalitis, meningitis,
stroke, substance abuse, brain tumour, and hypoxia).
ABI is a leading cause of death and disability in the United Kingdom (UK)1. It is a chronic condition, with ‘hidden’
disabilities and life-long consequences. The prevalence is difficult to quantify due to inconsistencies in definitions and
classifications, data collection discrepancies and inadequate reporting. Table 1 presents key UK (which also includes
Wales) and Wales-specific statistics, and Table 2 includes the ABI admissions across the seven Health Boards in
Wales. However, the number of individuals in Wales living with the effects of ABI is unknown, and a review of the
incidence of brain injury in children, young people, and adults in Wales is needed.
Table 1: Key UK (England and Wales) facts
WALES (DATA OBTAINED FROM HEALTH BOARDS)
• 16,872 ABI hospital admissions in Wales (2016-2017) = 46 admissions a day / 1.9 per hour
• 6,937 Admissions with head injury in Wales (2016-2017)
• 84,374 ABI admissions in Wales in 5 years (2012-2017)
• Most ABI admissions were to Betsi Cadwaladr University Health Board (20,187 in 5 years)
• Men were 1.4 times more likely to be admitted for a head injury than women in Wales (2016-2017)
UK1,2
• 1.3 million people are living with Traumatic Brain Injury (TBI) related disabilities in the UK
• 348,934 admissions to hospital with an ABI in the UK (2013-2014)
• Incidence of female head injury has increased by 24% since 2005-2006
• Estimated cost of TBI in the UK is £15 billion (based on premature death, health and social care, lost work
contributions and continuing disability), equivalent to approximately 10% of total annual NHS budget
Table 2: ABI admissions across Health Boards in Wales
Year 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017
Total number of ABI admissions 16,406 17,152 16,945 16,999 16,872
BRAIN INJURY IN WALES
Wales has a population of 3.1 million; almost 2.3 million Individuals from lower socio-economic backgrounds
people live in South Wales and there are large, rural, are more likely to suffer an ABI and experience poorer
sparsely populated areas. The country comprises outcomes3. Rurality is associated with poor general
1909 small areas, with a number of relatively deprived health outcomes4, and geographical challenges in
locations (see Figure 1). The Welsh language has equal accessing ongoing rehabilitation services. Currently,
language status with English (The Welsh Language Act many individuals with ABI access inpatient rehabilitation
1993). Nearly 28% of the population, and 75% of adults services in England which impacts on the opportunity
in Gwynedd, can speak Welsh. The geographical nature for bilingual service provision.
and language status have a number of implications for
ABI and neurorehabilitation in Wales.
6 TIME FOR CHANGE IN WALES REPORT 2021
Figure 1: WELSH INDEX OF MULTIPLE DEPRIVATION
(WIMD, 2019)
Indicates areas of relative deprivation.
BY LOWER LEVEL SUPER OUTPUT AREA RANK
1 – 191 10% Most Deprived
192 – 382 10-20% Most Deprived
383 – 573 20-30% Most Deprived
574 – 955 30-50% Most Deprived
956 – 1909 50% Least Deprived
Local Authority
Map from https://gov.wales/welsh-index-multiple-deprivation-full-index-update-ranks-2019
THE CONSEQUENCES OF AN ABI physical, cognitive, academic, emotional, and psychosocial
The consequences of an ABI depend on which part of effects; they may be temporary or permanent, but an
the brain is affected (see Figure 2). An ABI can cause individual will often have life-long disabilities.
Figure 2: Functional areas of the brain BRAIN INJURY LOCATION –
FUNCTIONS AFFECTED
FRONTAL Frontal lobe: Movement, short-term
PARIETAL LOBE
LOBE
1 2
memory, planning, reasoning, speed of
processing, personality, behaviour and
judgement, language production
4 Parietal lobe: Perception and interpretation
3 of touch, position, vibration; integrating
sensory information
OCCIPITAL
LOBE
Occipital lobe: Perceiving and processing
vision
TEMPORAL LOBE
CEREBELLUM Temporal lobe: Sound perception and
language comprehension; long-term memory
BRAINSTEM
Cerebellum: Balance and coordination and
LOBES OF THE BRAIN AND LOCATION OF some cognitive functions
SOME SPECIALISED BRAIN FUNCTIONS:
1 Primary motor area – movement of opposite side of body Brain stem: Connections from brain
2 Primary sensory area – touch, vibration, body position of to spinal cord; control of movement
opposite side of body of eye, face, swallowing, vocalisation;
3 Regions involved in language production control of breathing and heart rate;
4 Region involved in language comprehension modulating consciousness
TIME FOR CHANGE IN WALES REPORT 2021 7
Brain injury is associated with greater mental health physical disabilities are more easily apparent, a
difficulties2, higher rates of depression or mood large majority of individuals with ABI have ‘hidden’
disorders5, and/or childhood developmental disorders disabilities (See Table 3). ABI affects the entire family,
including disruptive behaviour difficulties6. While and appropriate support is required for all.
Table 3: Long-term effects of ABI
• Impaired memory • Poor impulse control
• Reduced concentration and attention • Decreased awareness of one’s own or others
• Poor initiation and planning emotional state
• Lack of self-monitoring • Sleep disturbances
• Poor judgement • Mental health problems
• Impaired social skills • Impaired communication skills
• Other medical conditions e.g. post-traumatic epilepsy • Motor and sensory impairments
BEHAVIOURAL AND EMOTIONAL DIFFICULTIES
CONDUCT DISORDER
ATTENTION PROBLEMS
INCREASED AGGRESSION
IMPULSE CONTROL PROBLEMS
COGNITIVE PROBLEMS
EDUCATIONAL UNDERACHIEVEMENT
SOCIAL/RELATIONSHIP DIFFICULTIES
ABI MAY PREDISPOSE TO LATE diseases such as Alzheimer’s disease and Parkinson’s
NEURODEGENERATIVE DISEASE disease later in life7. Repeated brain trauma, including
In addition to the disabilities directly attributable to all repetitive exposure to sub-concussive trauma may also
types of ABI, there is increasing evidence that moderate result in a particular form of neurodegenerative disease
and severe TBI may be a risk factor for neurodegenerative – Chronic Traumatic Encephalopathy (CTE).
REFERENCES
1. Acquired Brain Injury: the numbers behind the hidden disability. Headway 2015.
2. Traumatic brain injury and offending: an economic analysis. Parsonage M. Centre for Mental Health. 12 July 2016 https://www.
centreformentalhealth.org.uk/publications/traumatic-brain-injury-and-offending (accessed April 2020)
3. Humphries TJ, Ingram S, Sinha S et al. The effect of socioeconomic deprivation on 12 month Traumatic Brain Injury (TBI)
outcome. Brain Injury 2020;1-7. DOI: https://doi.org/10.1080/02699052.2020.1715481
4. Jones J, Curtin M. Traumatic brain injury, participation, and rural identity. Qualitative Health Research 2010 Jul;20(7):942-
951. DOI: https://doi.org/10.1177/1049732310365501
5. Hesdorffer DC, Rauch SL, Tamminga CA. Long-term psychiatric outcomes following traumatic brain injury: a review of the
literature. The Journal of Head Trauma Rehabilitation 2009;24(6):452-9. DOI: 10.1097/HTR.0b013e3181c133fd
6. Max JE. Neuropsychiatry of Pediatric Traumatic Brain Injury. Psychiatric Clinics 2014;37(1):125-40. DOI: 10.1016/j.
psc.2013.11.003
7. Wilson L, Stewart W, Dams-O’Connor K et al. The chronic and evolving neurological consequences of traumatic brain injury.
The Lancet Neurology 2017;16(10):813-25. DOI: 10.1016/S1474-4422(17)30279-X.
8 TIME FOR CHANGE IN WALES REPORT 2021
NEUROREHABILITATION
KEY ISSUES
• Early access to neurorehabilitation for children, young people, and adults with Acquired Brain Injury in Wales
is crucial to optimise their recovery and maximise their potential
• There are currently few specialist neurorehabilitation services in Wales, and even fewer paediatric services.
For the people of North Wales there is no inpatient unit and no specialised paediatric service
• Rehabilitation Prescriptions are not made available to all individuals with an Acquired Brain Injury, and
General Practitioners do not always receive a copy, so cannot facilitate access to neurorehabilitation services
post-discharge
RECOMMENDATIONS
• There is an urgent need in Wales to review the incidence of Acquired Brain Injury and ensure existing
neurorehabilitation services are adequate and ‘fit for purpose’ for children, young people, and adults, with new
services implemented as required
• Children, young people, and adults with Acquired Brain Injury in Wales should have access to high quality inpatient
and community-based neurorehabilitation. Their neurorehabilitation needs should be assessed shortly after
admittance to hospital, delivered during the inpatient phase, and continued, if required, in the local community
• There is a need for cooperation between Health, Social Care, and Education departments, and funding for in-
patient and community neurorehabilitation services needs to be reviewed
• Neurorehabilitation must be a key consideration in the new Major Trauma Network for South and West Wales
and South Powys, with a clear pathway to appropriate services
• It should be mandatory for the Rehabilitation Prescription to be given to all individuals with an Acquired Brain
Injury, not just those who have been in a Major Trauma Centre, on discharge from hospital. Copies should also
be sent to their General Practitioner and given to the patient and family
OVERVIEW
WHAT IS NEUROREHABILITATION?
Neurorehabilitation is a process of assessment, treatment and management by which individuals with a brain
injury, and their family and carers, are supported to achieve their maximum potential for physical, social, and
psychological function, and promoting quality of living.
Neurorehabilitation is delivered by a multidisciplinary team (MDT) with specialist training. An MDT commonly
includes a Rehabilitation Consultant (trained and accredited), Rehabilitation Nurse, Neuropsychologist, Speech
and Language Therapist, Physiotherapist, and Occupational Therapist.
Neurorehabilitation has a key role in the management of individuals with ABI. The extent of the neurorehabilitation
required will depend on the nature and severity of the brain injury, and the programme should be tailored according
to the individual’s needs. Each individual’s care pathway should be clearly defined, and a referral made at the earliest
opportunity to a local specialist rehabilitation service.
TIME FOR CHANGE IN WALES REPORT 2021 9
NEUROREHABILITATION HAS A CRUCIAL ROLE IN THE ABI CARE PATHWAY
Table 1: Key roles of neurorehabilitation
• For individuals admitted to hospital with an ABI who have complex rehabilitation needs
• Implemented after the individual’s immediate medical and/or surgical needs have been met
• Improves physical, cognitive, behavioural, and emotional outcomes
• Has a major role in relieving the pressure on beds in the acute services
• Supports the safe transition of the individual back into the community
Reduced length of hospital stays, and associated reductions in staffing costs
Decreased requirement for residential and nursing care
Improved functional independence
Reduced carer burden
Avoids and/or minimises disability
Improves return to work
Optimises recovery
Enables individuals to reach their maximum potential post-injury
DIFFERENT LEVELS OF referred to the relevant neurorehabilitation service,
NEUROREHABILITATION SERVICES ranging from Level 1 to Level 3 units. Level 1 units
ARE REQUIRED represent high cost/low volume services for Category
Individuals with an ABI requiring neurorehabilitation A individuals. Level 2 units mainly provide services for
are categorised as A, B, C or D, depending on the Category B individuals, and Level 3 units mainly serve
severity of their condition (A = most severe), and Category C and D individuals (see Figure 1).
Figure 1: Care pathway for individuals with an ABI
Patients with Complex Rehabilitation
Immediate Care Specialist Rehabilitation Prescription needs Specialist Level 1 and 2 services
Acute Care
ITU
Neurosurgical / Trauma Centre Hyper-acute
Acute Stroke Unit Rehabilitation
Level 2 Secondary
Category B needs
Level 3 Rehabilitation
services Level 3-inpatient services
HOSPITAL
HOME
Specialist Community Rehabilitation
Supported Discharge
Multidisciplinary rehabilitation
Hospital at home
Specialist vocational rehabilitation
Early community rehabilitation
Slow stream residential rehabilitation
Community Reintegration
Enhanced participation
DEA – supported return to work
Integrated Care Planning
Long term support
Single point of contact
Join health and social service planning
SEVERE DISABLING ILLNESS OR INJURY Multi-agency care
10 TIME FOR CHANGE IN WALES REPORT 2021NEUROREHABILITATION IS EFFECTIVE Currently, Level 1 neurorehabilitation services
AND SAVES MONEY are provided across South Wales from University
There is a great deal of robust evidence to support the Hospital Llandough near Cardiff and in West Wales at
clinical and cost-effectiveness of neurorehabilitation1-6. Neath Port Talbot Hospital.
It is one of most cost-effective interventions that the
National Health Service (NHS) provides, and one of The new rehabilitation unit opened at University
the few services in medicine that results in a long-term Hospital Llandough (UHL) in June 2021 and replaced
decreased cost to the economy. The front-loaded the unit at Rookwood Hospital. There are 22
cost of providing early neurorehabilitation is rapidly neurorehabilitation beds and 26 spinal beds and the
offset by longer-term savings in the cost of community unit also benefits from out-of-hours medical support
care, making it highly cost-efficient7,8. These savings being co-located with Radiology services at the UHL
are substantial, and have been estimated at £500 per site. The new facilities include a dedicated SMART
week for each ABI survivor that requires specialist assessment room, a self-contained bungalow providing
neurorehabilitation. The cost savings are accompanied patients the opportunity to practice independent
by better physical, cognitive, behavioural, and living skills and to stay overnight, a hydrotherapy pool,
emotional outcomes. Where recovery is incomplete, gymnasium and consultation rooms. New therapy
neurorehabilitation improves functional independence garden spaces will also be established for patients.
and reduces the burden on carers. Where outcomes
are better, neurorehabilitation improves the rates of Neath Port Talbot Hospital has 13 beds for complex
return to work and productivity9,10. These benefits are neurological cases.
amplified when neurorehabilitation is followed through
into the community11. There is an established weekly in-reach service to
UHW for spinal injury, TBI, and amputee patients.
CURRENT STATUS OF ADULT Rehabilitation triage, assessment, intervention, and
NEUROREHABILITATION SERVICES support is provided across Mid and South Wales, and
IN WALES appropriate transfer to is made to rehabilitation units.
Neurorehabilitation was largely overlooked when the
Major Trauma Networks (MTNs) were established Community neurorehabilitation services are also
in England, following the 2010 NHS Clinical Advisory provided by Health Boards across Wales:
Group for Major Trauma recommendation that • The Community Brain Injury Team (Cardiff & Vale
MTNs provide coordinated care pathways. With UHB)
the establishment of the MTN in Wales, there is an • The Community Neuro-rehab Service (Cwm Taf
opportunity to ensure this mistake is avoided. Morgannwg UHB)
• The Community Neuro Services (Powys THB)
North Wales • Community Neurorehabilitation Service (Stroke)
The Betsi Cadwaladr University Health Board (BCUHB) (Aneurin Bevan UHB)
is part of the West Midlands MTN, that supports the • The Regional Clinical Neuropsychology
Major Trauma Centre (MTC) in North Staffordshire. Service, including the Community Brain Injury
BCUHB sends individuals with major trauma to the Rehabilitation Service (Swansea Bay UHB), and the
Royal Stoke University Hospital (RSUH). Residents of Brain Injury and Complex Neuro Service (Hywel
North Powys also feed into the West Midlands MTN, Dda UHB)
and the Birmingham, Black County, Hereford, and
Worcester MTN. LIMITED NEUROREHABILITATION
SERVICES FOR CHILDREN AND
The North Wales Brain Injury Service (NWBIS), YOUNG PEOPLE
developed in 1998, is a community-based multi Neurorehabilitation services for children in Wales
disciplinary team (MDT), providing outpatient are limited. From April 2010, neurorehabilitation
rehabilitation for individuals with ABI. Assessment for children with ABI was transferred to the seven
and longer-term low intensity rehabilitation and Health Boards, and planning undertaken through
review are provided within the community. Individuals a joint committee, the Welsh Health Specialised
in North Wales cross the border into England for Services Committee (WHSSC). Individuals who
inpatient neurorehabilitation. meet the criteria for specialist inpatient paediatric
neurorehabilitation under the WHSSC policy are
South Wales referred to Alder Hey Children’s Hospital, Liverpool
The MTN for South and West Wales and South Powys (North Wales) or Noah’s Ark Children’s Hospital for
is currently being established and UHW has become a Wales (NACHfW) in Cardiff (South Wales).
MTC. The Morriston Hospital, Swansea is a Trauma Unit
(TU) with specialist services. There will be a further The Noah’s Ark Children’s Hospital for Wales
four TUs, and two rural trauma facilities. The NACHfW, situated at UHW, provides secondary
TIME FOR CHANGE IN WALES REPORT 2021 11and tertiary services for children and young people There are currently no dedicated or commissioned
(from birth to sixteen years), in areas specifically mental health/neuropsychiatry services for ABI
relevant to trauma care. This is a consultant-led MDT survivors within secondary care mental health services
service, and includes a specialist inpatient paediatric or Community Mental Health Teams (CMHTs) in
neurorehabilitation unit with capacity for four Wales. This often leads to barriers in stepping
children and young people with ABI. Outpatient care patients down and managing their often lifelong and
is provided for up to one year, linking with general burdensome mental health and neuropsychiatric
paediatric services. sequelae of ABI in the community. Some patients may/
have been accepted and managed with CMHTs but this
There are no other specialist NHS paediatric is dependent on the clinical enthusiasm, experience and
neurorehabilitation services in Wales, either inpatient expertise of the lead psychiatrist within that team.
or long-term in the community.
Community mental health services for ABI survivors
ADULT NEUROPSYCHIATRY SERVICES therefore can be variable and inconsistent and
The high prevalence of mental health problems in inequitable – a problem which is exacerbated by the
survivors of brain injury is well known, however this geography of Wales.
does not translate into commissioning of targeted
mental health services. REHABILITATION PRESCRIPTIONS
GUIDE ACCESS TO SERVICES
The Welsh Neuropsychiatry Service is an All- The Rehabilitation Prescription (RP) is a valuable tool
Wales tertiary neuropsychiatry service based at that comprehensively documents the rehabilitation
the University Hospital Llandough, Cardiff and Vale needs of the individual with ABI. It identifies how these
University Health Board. The service is commissioned needs will be addressed in the longer term (see Table
and funded by the Welsh Health Specialised Services 2). An effective RP improves communication along
Committee (WHSSC). the care pathway and optimises access to individual
services.
Its remit is primarily for tertiary and specialised
neurobehavioural and neuropsychiatric assessment and A ‘best practice’ tariff-based RP system was introduced
neurorehabilitation. The service is for the assessment, to NHS England in 2019. RPs must be completed for
management and care of patients with non-progressive all major trauma patients seen at an MTC in England,
and non-degenerative acquired brain injury who including individuals from North Wales seen at the
present with mental health, neurobehavioural and West Midlands MTC . Copies of the RP should
neuropsychiatric presentations that are difficult be given to the General Practitioner (GP) and the
for other services to manage. Patients may be individual with ABI and their family. Individuals with an
accepted into the service for Inpatient, Outpatient, ABI treated outside an MTC are still unlikely to receive
Community or Day Rehabilitation treatment and/ a RP. The Clinical Reference Group for Major Trauma
or neurorehabilitation. The service has funding for 10 is currently reviewing the use of MTC RPs, to see if
inpatient beds and covers the whole of Wales. they should be rolled out to all TUs and how this might
be implemented.
The service has close working relationships with the
regional adult neurorehabilitation services and the For people with ABI seen at the new South and West
community neurorehabilitation services in Mid and Wales and South Powys MTN, RPs are required for
South Wales. all individuals seen at the MTC, using the ‘Patient
Knows Best’ platform, which is accessible to all health
The service can provide specialist neuropsychiatry professionals, the individual, and their family. People
liaison assessment and advice to: the regional Level 1 seen at all the TUs will also have RPs on the ‘Patient
specialist neurorehabilitation services (based at Knows Best’ platform.
LLandough and Neath Port Talbot Hospitals); to the
Major Trauma Centre and neurosciences services at RPs should be made available to all individuals with ABI,
University Hospital Wales; and to the general and treated outside an MTN, on discharge from hospital.
district hospitals within the region - but only after If the individual and GP do not receive a copy of a
an initial liaison psychiatry assessment has been RP, they do not know what rehabilitation is required,
completed, and the patient is deemed to require and access to neurorehabilitation services cannot be
additional neuropsychiatry input. effectively planned and implemented.
12 TIME FOR CHANGE IN WALES REPORT 2021Table 2: Key criteria for a Rehabilitation Prescription12
• Patient held, electronic/updatable, and • Accessible/forwarded to General Practitioner
accessible to all • Clearly document neurorehabilitation plan
• Commence 24-48 hours after admission, • Clearly document future arrangements and
reviewed weekly till discharge responsibilities (who/when/where)
• Evolving document with input from • Provide key contacts (Major Trauma Centre/
multidisciplinary team support agencies)
• Completion by transfer of care/discharge • Signpost information and expectations
• Consider psychological/emotional needs • Can be used for audit and service improvement
CASE STUDY: JOSH Table 3 shows that although the NHS spent a
Josh, from North Wales, was 18 considerable amount on Josh’s neurorehabilitation, the
years of age when he was in the costs were offset within 27 months (inpatient) and six
front seat of a car involved in months (community), due to the reduced amount of
road traffic accident. He was care that he would have otherwise have needed, and
taken to a Major Trauma Centre the state would have had to fund. Assuming Josh has
with a severe brain injury and a life expectancy of 52 years, then the lifetime savings
other serious trauma. As soon without community rehabilitation are £3 million and
as Josh’s injuries were stabilised, further savings with community rehabilitation would be
he commenced intensive rehabilitation which continued £2.2 million.
on an inpatient basis for 12 months, and on discharge
he was able to walk, albeit with the use of a Zimmer
frame. He now lives with his parents and brother in
the family home. He has no care input, but does have
2.5 hours of physiotherapy and occupational therapy
each week in the community brain injury service. He
has outpatient neuropsychology reviews at 3-6 month
intervals and has been discharged from speech and
language therapy with exercises and advice. Josh has
made huge progress and regained some independence
as a result of the neurorehabilitation he received and
his reliance on carers is now much reduced. The
time to offset the costs of Josh’s treatment has been
calculated (see Table 3).
Table 3: Cost of Josh’s neurorehabilitation
In-patient Community
Length of stay 40 weeks 50 weeks
Episode cost £127,224 £21,150
Admission date Discharge date Follow-up date
03/05/2016 06/02/2017 01/2018
Northwick Park Nursing 64 16 3
Dependency tool
Care hours/week 66.5 35 14
Care cost/week £2,768 £1,612 £800
Reduction in care costs £1,156 £812
Time to offset costs 27 months 6 months
TIME FOR CHANGE IN WALES REPORT 2021 13CASE STUDY: KYLE Kyle defied all the odds and slowly regained
In 2009 Kyle Beere from South consciousness, but was unable to talk or move his
Wales was a typical healthy, head and limbs. He needed urgent neurorehabilitation
intelligent, active 12-year old. but there was no paediatric rehabilitation service in
In November that year he had Wales and so Kyle had to travel 160 miles to Tadworth
a massive brain haemorrhage in Surrey for treatment. He is now 23 years old and
which left him fighting for his life. lives at home with his mum. Kyle has 2 to 1 care, 24
This was subsequently found to hours a day, and requires ongoing community-based
be the result of a rare condition rehabilitation such as hydrotherapy and physiotherapy
called arteriovenous malformation (AVM), where there which are difficult to access. These therapies are
is a tangle of abnormal blood vessels connecting arteries extremely important as they enable Kyle to be as
and veins in the brain. Kyle was taken to the Accident comfortable as possible.
and Emergency unit at the University Hospital of Wales
and over the following weeks he was in a coma and on
life support following several operations to remove the
AVM and associated blood clots.
14 TIME FOR CHANGE IN WALES REPORT 2021REFERENCES
1. Turner L. Stokes L, Pick A, Nair A et al. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age.
Cochrane Database of Systematic Reviews 2015(12). DOI: https://doi.org/10.1002/14651858.CD004170.pub3
2. Turner-Stokes L. Evidence for the effectiveness of multi-disciplinary rehabilitation following acquired brain injury: a synthesis
of two systematic approaches. Journal of Rehabilitation Medicine 2008;40(9):691-701.DOI: https://doi.org/10.2340/16501977-
0265
3. Semlyen JK, Summers SJ, Barnes MP. Traumatic brain injury: efficacy of multidisciplinary rehabilitation. Archives of Physical
Medicine and Rehabilitation 1998;79(6):678-783. DOI: https://doi.org/10.1016/S0003-9993(98)90044-2
4. Powell J, Heslin J, Greenwood R. Community based rehabilitation after severe traumatic brain injury: a randomised controlled
trial. J Neurol Neurosurg Psychiatry 2002;72(2):193-202. DOI: http://dx.doi.org/10.1136/jnnp.72.2.193
5. Turner-Stokes L. The evidence for the cost-effectiveness of rehabilitation following acquired brain injury. Clinical Medicine
2004;4(1):10-12. DOI: 10.7861/clinmedicine.4-1-10
6. Aronow H. Rehabilitation effectiveness with severe brain injury: translating research into policy. Journal of Head Trauma
Rehabilitation 1987;2:24-36. DOI: https://doi.org/10.1097/00001199-198709000-00005
7. Turner-Stokes L, Paul S, Williams H. Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care
for adults with complex acquired brain injuries. Journal of Neurology, Neurosurgery & Psychiatry 2006;77(5):634-639. DOI:
http://dx.doi.org/10.1136/jnnp.2005.073411
8. Turner-Stokes L. Cost-efficiency of longer-stay rehabilitation programmes: can they provide value for money?. Brain injury
2007;21(10):1015-1021. DOI: https://doi.org/10.1080/02699050701591445
9. Turner-Stokes L, Pick A, Nair A et al. Rehabilitation for adults of working age who have a brain injury. 2015. Cochrane Review.
http://www.cochrane.org/CD004170/INJ_rehabilitation-adults- working-age-who-have-brain-injury (accessed May 2018).
10. Turner-Stokes L. Evidence for the effectiveness of multi-disciplinary rehabilitation following acquired brain injury: a synthesis of
two systematic approaches. J Rehabil Med 2008;40:691-701.
11. Turner-Stokes L, Williams H, Bill A et al. Cost-efficiency of specialist inpatient rehabilitation for working-aged adults with
complex neurological disabilities: a multicentre cohort analysis of a national clinical data set. BMJ Open 2016;6:e010238
doi:10.1136/bmjopen-2015-010238.
12. The National Clinical Audit of Specialist Rehabilitation following Major Injury (NCASRI). October 2016. https://www.kcl.
ac.uk/ nursing/departments/cicelysaunders/about/rehabilitation/ NCASRI-Audit-Report.pdf (Accessed May 2020)
TIME FOR CHANGE IN WALES REPORT 2021 15POLITICAL ASPIRATIONS
Improvements in the quality of neurorehabilitation are Though these recommendations are for the UK in
a long-standing aspiration, however its implementation general, they are still highly relevant for Wales. Whilst
has been neglected across the UK over the last many of the recommendations relating to acute care
two decades. In 2001 the parliamentary Health have been implemented to some extent, the last 19 years
Select Committee published a report ‘Head injury: have not seen any substantial implementation of the
rehabilitation’ containing over 20 recommendations. recommendations for neurorehabilitation (see Table 1).
Table 1: Abbreviated recommendations: 2001 Health Select Committee Report:
‘Head injury: rehabilitation’, classified according to progress made since publication
SUBSTANTIAL PROGRESS
1. Acute assessment and management by specialist staff appropriate to injury severity
2. Explicit allocation of responsibility for planning different levels of rehabilitation
PARTIAL PROGRESS
1. Improved data collection on epidemiology and consequences of TBI: acute incidence and severity data
available but no reliable data on prevalence and disability
2. Involvement of families in recovery, rehabilitation and support services
3. Timely post-acute rehabilitation in appropriately resourced services - remains a target, but with incomplete
and variable implementation
4. Acute sector to take responsibility for planning onward care journey – variable implementation
5. Clear plans for care pathways, including tertiary services - achieved in acute stage, but skilled assessment and
delivery of specialist neurorehabilitation remains inconsistent
6. Each individual to have a clear care plan for rehabilitation post-discharge from hospital - Implementation
incomplete, especially outside Major Trauma Centres
7. Improved provision of information on head injury to patients and families from hospitals and GP, with
inclusion of information provided by Headway
8. Targeted mental health services for TBI - variable implementation
9. Trusts, Health Authorities and Local Authorities to have a case management system to help guide carers and
patients through whole care pathway
10. Every NHS Trust should have a named manager for head injury rehabilitation who can liaise with patients,
carers, and services; and is responsible for coordinating care
11. Recognition of contributions by independent sector, and collaboration with the statutory sector
LITTLE OR NO PROGRESS
1. Greater allocation of Department of Health (DoH) research budget to TBI rehabilitation
2. Learning lessons of vocational rehabilitation from other complex neurological disorders
3. Assessment for disability living should be by individuals who have specialist skills and understanding of head
injury, with input of a patient advocate
4. DoH should take responsibility for providing community rehabilitation for both physical and cognitive
disability, with service design in consultation with rehabilitation professionals
5. Social Service departments should have an additional classification of user group in planning services for
complex neurological conditions including TBI, included in the Community Care Plan
6. DoH should help charitable organisations which provide core services
7. There should be allocation of rehabilitation responsibilities between health and social services, with
identified managers, clear responsibilities and close collaboration
8. There should be a Government subsidised publication which provides an inventory of resources available for
people with head injury, for circulation to health authorities
9. Health Improvement Plans and Community Care Plans should include a section on planning rehabilitation
for complex neurological conditions (including head injury)
10. Clear plans to improve rehabilitation services for head injury, with implementation before 2005
11. Urgent formulation of policy for long term rehabilitation of head-injured people; Intermediate Care,
National Institute for Health and Care Excellence guidelines, and National Service Framework on long term
conditions do not provide a satisfactory solution
16 TIME FOR CHANGE IN WALES REPORT 2021In 2010 the NHS Clinical Advisory Group for Major Care Excellence, have made recommendations for
Trauma reported to the Department of Health (DoH) improving the consistency and quality of care for
and recommended the establishment of services brain injury survivors. However, without fundamental
in MTCs to provide coordinated pathways of care. changes in the provision of neurorehabilitation
Subsequently 22 MTCs were established for adults services these documents are redundant.
following major trauma across the UK. As a result of
this reorganisation and advances in emergency and PROGRESS IN WALES
acute medicine, survival for individuals with an ABI has The Welsh Government’s updated ‘Neurological
increased by approximately 50% or 500 individuals per Conditions Delivery Plan 2017’ sets out a vision for
year. While many of these individuals experience good improving neurological services across Wales1. It
outcomes, the number of survivors with significant focuses on seven themes, abbreviated versions of
disability or catastrophic brain injury has also which can be seen in Table 2, and key actions for
increased, with long-term consequences. the vision of a high standard of care for people
with neurological conditions in Wales. It does not
National guidelines and standards documents, focus exclusively on ABI. In March 2018 the report
including those from the DoH, the British Society ‘Neurological Conditions: Annual Statement of
of Rehabilitation Medicine, the Royal College of Progress’ was published, highlighting key achievements
Physicians, and the National Institute for Health and and areas which need further development2.
Table 2: Abbreviated key areas of development for the Neurological Conditions
Delivery Plan 20171, key achievements and areas for focus set out in the 2018 Annual
Statement of Progress
SEVEN AREAS FOR DEVELOPMENT AND KEY ACTIONS OF NEUROLOGICAL
CONDITIONS DELIVERY PLAN 2017
• Awareness of neurological conditions
• Timely diagnosis of neurological conditions
• Fast, effective, safe care and rehabilitation
• Living with neurological condition
• Children and young people
• Targeting research
KEY ACHIEVEMENTS SET OUT IN 2018 ANNUAL STATEMENT OF PROGRESS
• Total NHS expenditure for neurological conditions increased by 2% from 2011-2012 to 2015-2016
• Reduction in time spent in hospital, emergency admissions, and total emergency bed days
• Increased focus on patient reported outcome and experience measures
• Supporting Health Boards to develop effective neurorehabilitation services
• The Neurological Conditions Implementation Group and Stroke Implementation Group jointly invested
£1.2m for development of neurorehabilitation services across Wales (See Table 3)
AREAS OF FOCUS FROM 2018 ANNUAL STATEMENT OF PROGRESS
• In 2016-2017 6,000 individuals waited longer than 26 weeks for a first outpatient appointment. There is a
need to improve quick and easy access to a first appointment
• There is a need to improve the pathway of care, to ensure that individuals are seen and treated within
26 weeks following referral. In 2016-2017 an average of 86% of patients waited less than 26 weeks from
referral to start of treatment, the expected goal is 95%
• There is a need to ensure appropriate referrals, and new models of care, so that individuals can be treated
closer to home in community settings
• Support for individuals with a brain tumour, and raising awareness of signs and symptoms
• Ensure timely access to specialist palliative care
TIME FOR CHANGE IN WALES REPORT 2021 17The Plan states that progress will be reviewed at least throughout the care pathway, and may not meet the
once a year, £1m of annual funding will be allocated, requirement for the rehabilitation of people with ABI.
monitored, and reported, and a national statement of There is a need for a further review, to ensure that
achievement will be produced annually. The Statement individuals’ needs are being met and that the Plan is being
highlights important improvement, especially in relation implemented.
to emergency admissions, acute care, and developing
rehabilitation across the wide range of neurological The Neurological Conditions Implementation Group and
disorders. However, no update to the Statement has Stroke Implementation Group allocated £1.2m to Health
been issued. Steps have been taken to improve Boards (see Table 3) to improve neurorehabilitation
neurorehabilitation services for ABI. However the services. Nine bids were approved for recurrent funding3.
funding allocated is for all neurological conditions The funding is relatively low to develop such services.
Table 3: Approved Health Board bids for neurorehabilitation investment
Health Board Amount (£) Project
Aneurin Bevan UHB £206,000 Community neurorehabilitation service (Stroke)
Abertawe Bro Morgannwg UHB £152,000 Early supported neurology discharge team – or –
(Swansea Bay UHB) Stratified community neurorehabilitation team
Betsi Cadwaladr UHB £100,000 Support towards level 2 rehabilitation unit
Cardiff & Vale UHB £174,000 Community neurorehabilitation service
Cwm Taf UHB £117,000 Multidisciplinary community neurorehabilitation team
Hywel Dda UHB £145,000 Integrated community neurostroke rehabilitation
Powys THB £96,000 Community rehabilitation
Neuro Muscular Network £60,000 Physiotherapy service for people with
neuromuscular conditions
Welsh Health Specialised £150,000 Paediatric neurorehabilitation service
Services Committee
The Plan has set an ambitious and inspiring vision for their long-term needs. The Cross Party Group on
Wales, and has laid a strong foundation, but there is still Neurological Conditions Survey4 (2018) concluded that
much that needs to be done for ABI. This is especially people living with neurological conditions, including ABI,
true for children, and young people with ABI, where there are missing out on vital services, highlighting that there
is still limited specialist support. There is also work to be is currently not enough multidisciplinary and multi-
done to ensure that adequate neurorehabilitation is agency collaboration, across health and social care
accessible for all individuals with ABI in Wales, and fit for services, to meet rehabilitation needs.
REFERENCES
1. Welsh Government. Neurological Conditions Delivery Plan. High standard of care for everyone with a neurological condition.
Welsh Government, Cardiff. The Neurological Conditions Implementation Group; 2017. Retrieved from https://gov.wales/
sites/default/files/publications/2019-02/neurological-conditions-delivery-plan-july-2017.pdf (accessed April 2020)
2. Welsh Government. Neurological Conditions: Annual Statement of Progress. Government, Cardiff; 2018. Retrieved from
https://gov.wales/sites/default/files/publications/2019-03/neurological-conditions-annual-statement-of-progress-march-2018.pdf
(accessed April 2020)
3. Wales Neurological Alliance. Annual Report 2016 and Financial Statement Cross-Party Group for Neurological Conditions;
2016 http://www.senedd.assembly.wales/documents/s68927/Annual%20Report%20and%20Financial%20Statement%20Final%20
2016.pdf (accessed April 2020)
4. National Assembly for Wales Cross Party Group on Neurological Conditions. People living with neurological conditions and
the Social Services and Well-being (Wales) Act (2014); 2018. Retrieved from http://senedd.assembly.wales/documents/s83582/
People%20living%20with%20neurological%20conditions%20and%20the%20Social%20Services%20and%20Well-being%20
Wales%20Act%20Novemb.pdf (accessed April 2020)
18 TIME FOR CHANGE IN WALES REPORT 2021EDUCATION
KEY ISSUES
• There is limited knowledge about the incidence of children and young people with Acquired Brain Injury in the
education system in Wales
• There is lack of awareness and understanding amongst education professionals about Acquired Brain Injury, its
consequences and its impact on learning
• Education professionals have difficulty identifying what specific education support is required in terms of
assessment tools, learning strategies and interventions
• There is a lack of liaison, including information sharing regarding assessment and support, between health and
education professionals, as well as a lack of involvement and communication with the family
RECOMMENDATIONS
• There is a need to review the incidence of children and young people with Acquired Brain Injury in the education
system in Wales
• All education professionals should have a minimum level of awareness and understanding about Acquired Brain
Injury and the educational requirements of children and young people with this condition (i.e. completion of a
short online course for all school-based staff), with additional training for the named lead professional supporting
the individual with an Acquired Brain Injury and Additional Learning Needs Coordinators
• Many children and young people with Acquired Brain Injury require individually-tailored, collaborative and
integrated support for the return to school, and throughout their education.
• An agreed ‘return-to-school’ pathway plan is required, led and monitored by a named lead professional, to
provide a consistent approach and support for the individual, their family, and teachers
• There is a need to ensure that Statements of Special Educational Needs (and Individual Development Plans in
future) have consistent input from neuropsychological services to ensure that provision is fit for the individual’s
needs. The advice in the Statement should be specific, with no room for interpretation, to ensure that each
individual is getting the appropriate support consistently
OVERVIEW
Despite pockets of good practice and awareness about ABI in the education system, too many children
and young people with ABI, and their families, encounter difficulties. These failings prevent the delivery of
the tailored education that children and young people with ABI need in order to maximise their potential.
Potential solutions to these problems are complex, and education professionals are already stretched in many
directions. However, the incidence and long-term consequences for children and young people with ABI in
the education system in Wales warrant proactive measures.
The functional impact of the ABI, including the ‘hidden’ difficulties, are affected by the age and developmental
stage at the time of the injury. ABI frequently disrupts the process of learning, and the consequences may not
be obvious until years later. Dedicated neurorehabilitation services are rare, so most neurorehabilitation for
children and young people occurs in schools,via services that are not specialised for ABI.
TIME FOR CHANGE IN WALES REPORT 2021 19BURDEN OF ABI IN THE EDUCATION admission, are less easily available, but approximate
SYSTEM IS NOT WIDELY RECOGNISED figures are provided1. The true prevalence of ABI in
Figure 1 shows the overall UK statistics for the annual children and young people is unknown, but likely to be
incidence of TBI in children that results in hospital much higher. Table 1 shows Wales-specific statistics
admission. The incidence figures for ABI from causes regarding children and young people admitted to
other than TBI, or ABIs that do not result in hospital hospital across Health Boards.
Figure 1: UK annual incidence of ABI in children1
NON-TBI HOSPITAL ADMISSIONS
35,000
• Encephalopathy ~4000 Patients with ABI not admitted
Total number of children
• Brain tumour ~525 to hospital: Number unknown
admitted to hospital for TBI
• Stroke ~300
2,000 3,000 30,000
will have sustained severe TBI will have sustained moderate TBI will have sustained mild TBI
Table 1: The number of children and young people admitted to hospital with ABI
across Health Boards for 2006-2011 and 2011-2016
Health Board Cases 2006-2011 Cases 2011-2016 % Increase
Swansea Bay 192 2671 1291
Aneurin Bevan 345 225 -35
Betsi Cadwaladr 98 314 220
Cardiff & Vale 208 2564 1133
Cwm Taf 31 94 203
Hywel Dda 41 383 834
Powys (No Paediatric) 0 0 0
TOTAL 915 6251 583
ABI HAS LONG-TERM CONSEQUENCES However, the long-term effects may arise many months
FOR LEARNING or even years later, when the injured part of the brain
Children and young people may appear to make a good reaches a key stage of development (see Table 2).
physical recovery after the acute phase of the ABI.
Table 2: Effects of Acquired Brain Injury that may Impact on Learning12
• Limb weakness and poor mobility • Difficulties processing information
• Fatigue • Mental health problems e.g. anxiety and depression
• Reduced concentration and attention • Difficulties understanding and using language
• Changes in behaviour e.g. irritability, behaving • Difficulties with organisation and planning
impulsively or inappropriately • Social difficulties, including a lack of empathy and
• Impaired memory awareness about their own or other people’s
• Visual and visuo-perceptual impairments emotional situation
• Hearing difficulties
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