SUMMARY Twenty four patients with severe brain injury who had disturbed behaviours preventing rehabilitation or care in ordinary settings were treated in a token economy. This long-term follow-up study indicates that post-traumatic behaviour disorders can be lastingly improved, and that lengthy rehabilitation can have surprisingly good effects.A significant proportion of those who suffer severe head injury develop, as a more or less direct result of their injury, disorders of behaviour which impede or prevent physical, social and occupational rehabilitation. Often rehabilitation therapy staff are unable to cope with such patients, and find their demeanour and lack of motivation discouraging and frustrating, as well as frightening. Many such patients find their way to psychiatric, geriatric or mental handicap hospitals, where they are very out of place. The usual result is a lack both of rehabilitation and of treatment of the behaviour disorder. Often there is progressive worsening of the behaviour disorder.The nub of the problem is to find a way of managing behaviour which will produce cooperation and effort from the patient to allow therapists to apply their skills, and also allow the patient to learn the behavioural controls needed for him or her to become acceptable in the outside or "rear' world.Behaviour Modification (in a Token Economy setting) has been practised for many years with patients who show disorders of behaviour similar to those of the head-injured, though from different causes. ' The approach has been successfully applied in various clinical settings, and, to our knowledge, the only group of patients who have failed to gain long-term lasting benefit has been the chronic schizophrenic group. However, there seems to have been no previous attempt to apply the approach to the problem of the rehabilitation of head-injured patients with behaviour disorders.For the past five years, we have been involved in

Fifty-five brain-injured adults (of 64 discharged) were followed up from 19 to 101 months after discharge from a rehabilitation unit. Change was assessed in terms of discharge and current placement, as compared with pre-admission placement. The results demonstrate that rehabilitation achieved improvements in functional skills and social behaviour that lastingly affected the type of placement possible, and thus improved quality of life. In most cases where improvements were seen during rehabilitation, further improvements occurred after discharge. The findings also have implications for the timing of rehabilitation and for discharge and resettlement planning.

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