Do we need to know about cyberscams in neurorehabilitation? A cross-sectional scoping survey of Australasian clinicians and service providers

Abstract Cyberscams, such as romance scams, are prevalent and costly online hazards in the general community. People with Acquired Brain Injury (ABI) may be particularly vulnerable and have greater difficulty recovering from the resultant emotional and financial hardships. In order to build capacity in the neurorehabilitation sector, it is necessary to determine whether clinicians currently encounter this issue and what prevention and intervention approaches have been found effective. This scoping study aimed to explore clinicians’ exposure to and experiences with cyberscams in their adult clients with ABI. Method: Participants were clinicians recruited from multidisciplinary networks across Australia and New Zealand. Eligible participants (n = 101) completed an online customised survey. Results: More than half (53.46%) the participants had one or more clients affected by cyberscams, predominantly romance scams. Cognitive impairments and loneliness were reportedly associated with increased vulnerability. Cyberscams impacted treatment provision and were emotionally challenging for participants. No highly effective interventions were identified. Conclusions: These findings indicate that cyberscams are a clinical issue relevant to neurorehabilitation providers, with prevalence studies now required. The lack of effective interventions identified underscores the need for the development of evidence-based prevention and treatment approaches to ultimately help people with ABI safely participate in online life.


Introduction
Picture this: you are a community neuropsychologist assisting Colin to manage the cognitive, psychological and behavioural problems he experiences after severe acquired brain injury (ABI). Colin's wife informs you that he has been embroiled in an online romance scam and defrauded of thousands of dollars. She has cancelled his bank access, but has been unable to convince Colin to stop contacting his fake online lover. What do you do? This real clinical scenario catalysed years of trialling numerous interventions and collaborative investigations, as Colin and author KG learned together about the prevalence and power of romance scams, and worked to untangle him from their herculean grip. As anyone can be scammed, it was unclear whether Colin was targeted or at greater risk because of his ABI. Nevertheless, his memory and executive impairments appeared to interfere with intervention attempts to help him acknowledge the scam responses and ability to hide their disability. However, for people with ABI, a lack of support and supervision in navigating the challenges of social media was reported, including two accounts of online relationship scams (Brunner et al., 2019). Within the neurorehabilitation sector, online technologies are nevertheless increasingly promoted by therapists as part of interventions to support socialisation (Brunner, Hemsley, Palmer, Dann & Togher, 2015), meaningful activities (Jamieson et al., 2020) and social communication (Wong et al., 2017).
It is unclear whether neurorehabilitation clinicians are aware of cybercrime risk and vulnerability factors, are able to recognise scamming of their clients with ABI, and whether they utilise effective prevention or treatment approaches. The perspectives of clinicians and service providers are needed to guide recommendations for professional development and service delivery. Therefore, the aim of the present scoping study was to explore the experiences and perspectives of ABI clinicians with and without cyberscams in their clients, specifically to determine: i) whether clinicians encounter individuals with ABI affected by cyberscams, ii) their views on associated risk factors and impacts and iii) their appraisals of possible approaches to cyberscam prevention and treatment. In regards to aim iii, we hypothesised that cyberscam case experience would be associated with higher ratings of intervention effectiveness based on their lived-expertise of clinical involvement.

Method
An exploratory cross-sectional survey design was used to determine current clinical exposure, experience and capacity of neurorehabilitation clinicians in identifying, preventing and treating individuals with ABI who had been scammed online. Institutional ethics approval was obtained and all participants provided digital consent (Monash University, MUHREC Project ID 17984).

Participants
Participants were a convenience sample of clinicians and community ABI workers from Australia and New Zealand who provided informed consent. Individuals were eligible to participate if they currently or previously worked with adults (aged 18 years or older) living with ABI. There was no requirement for participants to have experience supporting a client with ABI who had been scammed. A total of 101 participants completed the survey. Refer to Figure 1 for the participation flow chart.

Procedure
In order to recruit a broad cross-section of neurorehabilitation clinicians, the study was advertised via multiple means including social media posts by the researchers, emails from the researchers to a mailing list of over 100 colleagues, and distributed to three ABI/neuropsychology list-serves (NPinOz, BRAINSPaN, VicNic). In addition, approximately 40 hospitals, organisations and multidisciplinary networks with large memberships of psychologists, speech therapists and occupational therapists were asked to distribute the recruitment invitation, for example, professional organisations (e.g. Australasian Society for the Study of Brain Impairment), community advocacy groups (e.g. Brain Injury Australia) and state-based accident insurers (e.g. the Transport Accident Commission in Victoria). Due to the recruitment methodology, the number of individuals approached could not be determined. Prospective participants were emailed the study invitation with an online survey link and explanatory statement. The survey was administered online using Qualtrics and required approximately 30 minutes to complete. All participants completed the eligibility screening and provided digital consent after reviewing the explanatory statement. Participants completed the online survey between May and August 2019.

Survey development
Due to a lack of suitable extant measures identified from a review of the literature and a need to ensure relevance to individuals with ABI, an online survey was developed by the researchers. Survey items were informed by findings from a concurrent qualitative study (Gould & Ponsford, In Preparation), in which 10 clinicians and service providers who had clients with ABI who were scammed were interviewed and analysed using a six-stage iterative thematic analysis (Braun & Clarke, 2006). Emerging themes related to the relationships between the ABI, cyberscam vulnerability and impacts including cognitive, psychological and behavioural factors, meaningful participation and social relationships, financial access, online competency and the availability of a trusted person (Gould & Ponsford, In Preparation). In addition, the survey design was informed by previous studies on romance scams (Buchanan & Whitty, 2014;Whitty, 2018;Whitty, 2019;Whitty & Buchanan, 2012 and the authors' clinical experiences.
To determine content face validity, the survey was piloted in two rounds by seven community ABI therapists, researchers and university psychology students, with feedback incorporated into the final version. Construct and criterion-related validity were unable to be conducted due to a paucity of existing measures.

Survey design
To address the aims of the study, the survey collected information on participant: 1. Demographics and 2. Cyberscam self-efficacy. Participants were asked whether they had seen a client with ABI who had been scammed. Subsequent survey sections for participants with exposure to a scammed client included 3. Client characteristics, 4. Cyberscam details, 5. Perceived risk factors of clients and scam impact, 6. Perceived efficacy of prevention approaches and 7. Perceived efficacy of intervention approaches. Participants could repeat sections 3 to 7 to provide information for a second client or to describe multiple scams relating to one client. Participants without experience supporting a client with scam exposure were not administered sections 3, 4 or 5 and were asked to complete the survey sections relating to potential rather than perceived aspects of sections 6 and 7. Most items utilised Likert scales and checklists; participants could also submit their own response using an 'other' item or select 'not applicable'. Survey sections are described in detail below.

Demographics
Participants provided demographic information including age, gender, years and highest level of education obtained, occupation and work setting within the ABI sector.

Cyberscam clinical self-efficacy
The survey included definitions of key terms. 'Cyberscam' referred to dishonest schemes, or outright fraud initiated online using the internet or social media, including dating and romance scams, investment scams, or attempts to gain personal information, many of which result in financial loss (Australian Criminal Intelligence Commission, 2022; Oxford University Press, 2019). The term 'CyberAbility' was coined by Gould and Brokenshire (2017) and referred to technical, cognitive and social-emotional capacity to learn and adapt to current, new and emerging technologies, for example, staying safe online, handling online information and using the internet responsibly for communicating and socialising.
Participants completed 21 self-rated capacity items encompassing their knowledge, skill and confidence in supporting individuals with ABI regarding cyberscams. There were seven items for knowledge, for example, knowledge of potential red flags. Nine items for skill, for example, delivering interventions to help manage emotional impact of cyberscams. Five items related to confidence, for example, in identifying whether an individual with ABI is involved in a cyberscam. These were scored on a Likert scale (1 = none to 5 = high) and averaged for each capacity and total score.

Client characteristics
Participants with experience supporting a client affected by cyberscams provided unidentifiable information on the client's demographics (e.g. gender, age at time of scam, education) and ABI (e.g. cause, year sustained and severity).

Cyberscam details
Data was collected on the number, type and duration of the scam. Participants selected the platform used when the scam was initiated (e.g. online dating, social media, online marketplace). Participants rated their perceived confidence in online safety of the client (Likert rated from 1 = none to 5 = high), source of identification of the cyberscam (e.g. disclosure by the client, disclosure by family or support service, inferred by participant) and perceived level of awareness of the client that they had been scammed (recorded as a percentage, where 100% reflected complete scam awareness).

Perceived risk factors of clients and scam impact
Subjective reports of factors participants considered associated with increased vulnerability to cyberscams were explored across five areas and rated on a Likert scale (1 = very low to 5 = very high). Emotional and personality attributes such as depression, trust in others, kindness and addictive personality (Whitty, 2018) were measured across 15 items. Cognitive deficits encompassed attention, learning and memory, communication, fatigue and executive functions (e.g. insight, inflexibility, planning and problem-solving) across 10 items. Behavioural items were derived from the Overt Behaviour Scale categories (Kelly, Todd, Simpson, Kremer & Martin, 2006) as well as impulsivity (Whitty, 2019) and irritability (10 items). Social vulnerability factors included unemployment, reduced social and leisure activities, reduced study, increased computer use and accommodation change (seven items). Lack of supervision of online (computer and smartphone/tablet) and financial activities was the final area of vulnerability explored (three items), reflecting the guardianship (protection) aspect of the Routine Activity Theory of crime vulnerability most relevant to clinicians (Reyns, 2015). Participants also rated overall subjective confidence in their clients' online safety skills before and after a cyberscam event.
Checklists were used to identify psychological, financial and practical impacts of the scam (e.g. reduced trust in others, anger, depression, criminal charges) as well barriers to treatment due to the scam (e.g. disengagement, increased treatment length). Participants could rate overall psychological and practical impacts from Low to Extreme. The participants' emotional reactions to addressing the scam were collected via a checklist of 32 possible responses (e.g. angry, empathic, uncertain) derived from the qualitative study findings.

& 7. Perceived efficacy of prevention and treatment approaches
Participants rated their perceived self-efficacy in using cyberscam prevention techniques (11 items, e.g. education about staying safe online) and treatment approaches (25 items, e.g. cognitive behaviour therapy), both rated on a Likert scale (1 = very ineffective to 5 = very effective). These items were generated by the authors on the basis of the qualitative findings and clinical experience.

Data analysis
Data were entered and primarily analysed descriptively using Microsoft Excel 2016 and SPSS Version 25. Visual inspection of histograms of data analysed for each aim by author MC indicated normal distributions of scores and therefore assumptions of normality were met. No individual outliers were identified that significantly affected means or standard deviations. To address aim iii, t-tests were used to compare average scores between participants with and without exposure to cyberscam cases regarding prevention and treatment approaches.

Participants
In this paper, the term 'participants' refers to the neurorehabilitation clinicians and service providers who completed the survey, and 'clients' refers to the individuals with ABI described by the participants. As displayed in Table 1, the 101 participants were predominantly female neuropsychologists or occupational therapists in metropolitan community settings in Victoria and Tasmania, with an average of 10 years' experience working with individuals living with ABI. Demographic and occupational characteristics were broadly equivalent between those with and without experience with cyberscammed ABI clients.
Participants with experience supporting individuals with ABI who had been scammed Over half of the participants (n = 54, 53.46%) had a client with ABI affected by cyberscams.

Client characteristics
Participants provided information on 51 clients with ABI who had been cyberscammed. Clients were predominantly male (69.23%), with a mean age of 46 (SD = 18.18) and educated to high school. Most clients reportedly had moderate (n = 16), moderate-severe (n = 14), or severe (n = 16) ABI caused by a traumatic brain injury sustained on average 15.32 years (SD = 12.19) previously. Participants reported high levels of depression (58.82%) and anxiety (45.1%) in these clients.

Cyberscam details
An average of 1.3 (SD = 1.79, range 0-10) cyberscammed clients were reported per participant, with 33% of clients affected by multiple cyberscams. Only one participant provided detailed information on the second scam of their client, resulting in data regarding a total of 52 cyberscam events. Of the 52 cyberscam events, the majority were romance scams (48.08%), buying/selling scams (13.46%) and attempts to gain personal information (11.54%). Average cyberscam duration was 5.37 months (SD = 6.72, Range 1-30). Cyberscams were predominantly initiated over social media (n = 21), telephone calls (n = 12) and non-dating online chatrooms (n = 9).

Cyberscam identification
Participants rated only seven clients as 100% aware of the cyberscam, with the majority estimated as less than 50% aware (Mdn = 41.5%, IQR = 27.75 % to 68.25%). Most clients were made aware that they were being scammed by a clinician/service provider (31.37%) or a family member (23.53%) and only 21.57% self-identified the cyberscam according to the participants. Participants' most common cyberscam red flags were noticing their clients were infatuated with someone online, excessive internet use and reported financial loss (Fig 2).

Factors increasing vulnerability to cyberscams
Participants whose clients had been scammed rated cognitive, social, psychological, behavioural and supervision factors that were considered to increase their client's vulnerability to cyberscams (see Appendix). The highest ranked of these were cognitive factors, including lack of insight and awareness (M

Effectiveness of prevention and treatment strategies
Both participants with and without experience supporting an individual with ABI who had been cyberscammed provided their perspectives on intervention options. There were no highly effective prevention or treatment strategies identified by participants (Fig 3). Prevention strategies rated as having 'average' effectiveness were supervising computer use, partially limiting financial responsibilities and providing online safety tips. Treatment strategies rated as having 'average' effectiveness included referring the client to a psychologist, increasing participation in activities and supporting insight development. Compared with participants inexperienced with scams, participants with experience supporting a scammed client gave significantly lower ratings of prevention strategy effectiveness (  . The 10 most effective prevention and intervention strategies as rated by clinicians with and without experience of working with a person with ABI who had been cyberscammed. Note: Effectiveness was rated from 1 = very ineffective to 5 = very effective; P = Prevention strategy; I = Intervention treatment strategy.

Discussion
Cyberscams represent a growing worldwide threat to which people with ABI may be particularly vulnerable. This potentially represents an important clinical issue for ABI rehabilitation providers. This scoping study surveyed 101 Australasian clinicians and service providers to determined their experiences in identifying and treating cyberscams in adults with ABI. Approximately half of the participants had identified at least one client with ABI who had been cyberscammed, suggesting that this is of relevance to neurorehabilitation. Participants subjectively appraised that awareness of the scam by clients with ABI was low and it was generally someone in the client's support network who recognised that the cyberscam had occurred. Accordingly, there may be cyberscam cases which remain undetected by clinicians and service providers or unreported by the person with ABI due to their lack of scam awareness. In the general community, cybercrimes may not be formally reported by up to two thirds of victims due to shame, concern about being blamed and pessimism regarding the outcome of reporting (Cross, Richards & Smith, 2016;Smith, 2008). In the case of romance scams, acknowledging the scam has occurred not only entails accepting that they were deceived and the improbability of recouping finances losses, but also the loss of the relationship with someone with whom they have developed a deep emotional attachment, called a "double-hit" (Buchanan & Whitty, 2014). Cyberscam warning signs frequently reported by participants included noticing infatuation in an online relationship, excessive internet use and financial losses. To a certain extent, these observations represent clinically helpful indicators of cyberscam victimisation. However, by the time these behaviours are recognised, the scam may have substantially progressed, rendering intervention more difficult. Rather than being acute events, the reported cyberscams were generally protracted, with the average duration more than five months and some as long as two and a half years. During this time, romance scammers may engage in grooming, enticing the person with declarations of love and detailed dramatic stories, to which the person being scammed can heroically respond by providing financial assistance. This grooming and sharing of seemingly personal stories renders disengaging more difficult (Kopp, Layton, Sillitoe & Gondal, 2016;Whitty, 2013). Based on the finding of low self-rated capacity, clinicians and service providers may benefit from efforts to increase their knowledge, skills and confidence in identifying cyberscam vulnerability and warning signs. The development of validated screening tools for susceptibility to cyberscams currently being undertaken by our team may provide a practical means of earlier scam identification and enable timely instigation of preventative approaches such as conversations about online safety.
The majority of cyberscams reported by participants that impacted people with ABI in this study were romance and dating scams. Whilst acknowledging the secondary source of this finding, it is noted that this is in contrast with the most frequently reported scams in Australia, namely phishing, threats to life or arrest and identity theft (ACCC, 2019). Whether this reflects a difference in scam profiles between these populations would require larger, representative data sets using validated measures. Consistent with the greater proportion of romance scams, seeking out companionship and loneliness were identified by participants in the current study as factors that reportedly increased vulnerability to scams in their clients with ABI. Rather than loneliness representing a specific vulnerability to being scammed, it may be the impetus for desiring a relationship, with online daters in a large European sample noted to be lonely, regardless of whether or not they were scammed. (Buchanan & Whitty, 2014). Social isolation and relationship breakdown are common after ABI, with loss of employment, rejection by peers, fractured families and reduced leisure activities all more prevalent than in the general community and contributing to feelings of loneliness (Hawthorne, Gruen & Kaye, 2009). According to Williams, Beardmore & Joinson (2017), social isolation and loneliness create vulnerability to online grooming, and this need for attention is exploited by offenders. Resisting influence to potential scams is a cognitively effortful task (Williams et al., 2017), potentially compounded by ABI-related attentional difficulties. For people with ABI, the combination of wanting a relationship, loneliness, reduced attention and cognitive fatigue may explain increased vulnerability specifically to romance scams. Further research is required to verify this contention. Understanding the mechanisms of vulnerability to romance scams for people with ABI is also needed in order to design interventions addressing these factors.
In addition to the natural desire for a relationship, increased susceptibility to cyberscams was reported by participants in this study to be associated with executive impairments and impulsivity in their clients. Whilst we did not have direct evidence of cognitive impairments in these predominantly moderate to severely injured clients, executive dysfunction due to ABI commonly results in errors in judgement, decision-making and impulsivity (Cotrena et al., 2014). Indeed, cognitive impairments, albeit relating to reduced speed and episodic memory, were found in scamsusceptible adults with MCI (Han et al., 2016). Similarly, longer response time when deciding whether an online dating profile was genuine or fraudulent was associated with poorer accuracy in a UK sample of 261 adults (Whitty, 2019). Conversely, greater self-reported impulsive behaviour was associated with better scam detection accuracy, with Whitty suggesting that following one's initial instincts of distrust may be beneficial, rather than ignoring these feelings or directly challenging the scammer. To address the cognitive-executive and psychological factors in individuals with ABI associated with online risk-taking behaviour, clinicians and service providers may consider preventative approaches which improve online safety skills, normalise open discussion of potential scams and promote least restrictive approaches to computer independence and financial responsibilities such as supervising or limiting access to potentially hazardous online sites.
Despite romance scams being the most frequently documented cyberscam type, participants in this study endorsed social media as the most common means of scam initiation for their clients rather than online dating platforms. Accordingly, individuals with ABI may be at risk of online dating scams even if they do not formally use internet dating sites. Furthermore, individuals with ABI commonly use social media (Baker-Sparr et al., 2018) and many report that they initiate and use social media without support from rehabilitation professionals, instead relying on a "trial and error" approach (Brunner et al., 2019). Taken together, neurorehabilitation professionals should ensure that online activities, and social media competencies in particular, are routinely assessed.
In this study, clinicians considered that most clients with ABI who were scammed experienced a range of negative psychological and practical impacts of the cyberscam including depression, anxiety, agitation and irritability, family and relationship conflict, self-blame and financial distress. Whilst these issues are similar to those experienced by scam victims in the general population (Whitty, 2018;Whitty & Buchanan, 2012), for people with ABI they may occurr against a background of concurrent ABI-related difficulties, further compounding their psychosocial challenges. Furthermore, some clinicians reported that the scam interfered with treatment goals, duration and engagement. This may have financial implications due to increased therapy costs and potentially additional burden on natural support networks.
Participants had low confidence in the cybersafety skills of their clients with ABI and did not identify any preventative or treatment strategies deemed to be highly effective. Prevention strategies considered to have average effectiveness included supervising computer use, partially limiting financial responsibilities and providing online safety tips. Interestingly, and contrary to our hypothesis, participants with actual clinical experience were more guarded in their endorsement of these prevention approaches than participants without experience on which to base their ratings. Whether this finding reflects disapproval of the specific prevention approaches suggested, or a more generalised pessimism towards risk reduction, is unclear. Additional qualitative investigation may shed some light on the reasons for low ratings of commonly available approaches and may support the need for the creation of tailored prevention programmes.
The Australian government recently established several agencies to improve cybersafety through community awareness and online resources (e.g. Australian Cyber Security Centre, eSafety Commissioner, StaySmartOnline). Recognising that training designed for school-aged children, seniors and adults in the workforce may not be appropriate for adults with disabilities such as ABI, existing digital citizenship education programmes could be adapted or created specifically to compensate for common brain-injury-related deficits such as attention, memory and executive impairments. Although tailored prevention resources are now emerging for people with disability (Gould & Brokenshire, 2017;ThinkUKnow, 2019), their effectiveness requires evaluation. Whilst the evidence base is developing, potential interim cybersafety prevention approaches for neurorehabilitation professionals could include routinely discussing online risks to increase awareness and normalisation, discussing risk tolerance with the individual and their support network, providing hands-on and practical support for the specific social media and online activities relevant to the individual, encouraging and praising exhibited cybersafety behaviours and establishing trusted support people to assist if difficulties are encountered (Gould et al., 2021;Third, Forrest-Lawrence & Collier, 2014). As well as increasing the cybersafety of the individuals with ABI, clinicians and carers are akin to teachers in school settings who act as online safety role models, and as such also require early and ongoing cybersafety skill development (Walsh, Wallace, Ayling & Sondergeld, 2020). For individuals with ABI who become victim to a scam, treatment approaches recommended by experienced clinicians to have average likely effectiveness were referral to psychology, increased participation and increase insight and awareness. As described in the case of Colin, it remains challenging to identify specific, psychological approaches to help someone recognise and recover from a cyberscam. The lack of evidence-based interventions and guidelines for psychological recovery from cyberscams highlights a need for further clinical research in this field.

Limitations and strengths
Several methodological limitations of this study require acknowledgement. Relying on the perspective of clinicians and service providers limited direct inferences about the experiences of people with ABI, and as such the findings regarding the factors which increase vulnerability and the impacts should be interpreted with caution. Nevertheless, this methodology did enable investigation of clinicians' awareness of the occurrence and impact of scams within their clients, their management approaches and their training needs. The study methodology prohibited generation of prevalence data of cyberscams within the ABI population due to potential recruitment bias, whereby people with an a priori interest in scams could be more likely to participate. The findings are also tempered by the modest sample size, reliance on secondary sources of information; subjective ratings of cognitive impairment; lack of construct and criterion validity analyses; 50% incomplete surveys, and possible overlap in cases between clinicians. A potential recruitment bias is exemplified by the high response rates in Victoria and Tasmania, where the authors and our collaborators have been conducting awareness raising campaigns in the ABI sector. Whilst the response rate was not able to be estimated due to the recruitment method of convenience via snowballing, participants represented a broad range of disciplines and professional settings, half of whom did not identify any scams within their clients. First-person prevalence studies, validated self-report and objective measures of cyberscam vulnerability, and representative data collection protocols are needed to address these shortcomings.
Strengths of this scoping study included the investigation of a novel clinical practice issue to increase awareness, provide an introductory understanding and guide the direction of future targeted studies in cyberscams after ABI. These findings will inform the development of planned quantitative and qualitative studies to investigate cyberscam vulnerability and impact from the perspectives of people with ABI and their close others, as well as the development of tailored intervention programmes. A further strength of this study was the piloting of a new survey measure.

Conclusions
This study found that cyberscam vulnerability and victimisation is of relevance to neurorehabilitation clinicians, with half of respondents identifying cyberscamming of their clients with ABI, particularly romance scams. Cyberscams were reported to interfere with treatment provision, and participants lacked effective prevention and intervention strategies, experiencing personal distress and concern about their scammed clients. The findings suggest that clinicians would benefit from education and evidence-based resources to assist them in identifying vulnerable clients, and access to tailored interventions which help clients avoid, disengage and psychologically recover from cyberscams. These initial scoping findings call for further methodologically rigorous research and validated self-report measures to quantify the frequency and vulnerabilities of cyberscams in the ABI population.