Traumatic Brain Injury by tlyaappjdlag

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									Traumatic Brain Injury:
 Challenging Behavior




    Anastasia Edmonston MS CRC
         TBI Projects Director
 Maryland Traumatic Brain Injury Project
  MD Mental Hygiene Administration
 What We will Cover Today

• Brain Anatomy-form and
  function
• Brain Injury-how many & who is
  affected
• Types of Brain Injury
 What We will Cover Today

• The Physical, Cognitive and
  Emotional/Behavioral Aftermath
  of Brain Injury
• TBI Screening Tool
• Brain Injury and Co-occurring
  disorders
 What We will Cover Today

• Strategies for Supporting
  Individuals with Brain Injuries
• Resources Available Statewide,
  Regionally and Nationally
                   Skull Anatomy
                                   The base of the skull is rough, with
The skull is a rounded layer       many bony protuberances.
of bone designed to protect
                                   These ridges can result in injury to
the brain from penetrating         the temporal and frontal lobes of the
injuries.                          brain during rapid acceleration.




                               Bony ridges
             Skull Anatomy




Injury to frontal lobe from contact with the skull
          Lobes of the Cerebrum


Frontal
lobe
               Parietal
               lobe                   Limbic
                                      Lobe




                          Occipital
                          lobe
   Temporal
   Lobe
               The Frontal Lobe
The frontal lobe is the area of
the brain responsible for our
“executive skills” - higher
cognitive functions.
These include:
• Problem solving
• Spontaneity
• Memory
• Language
• Motivation
• Judgment
• Impulse control
• Social and sexual
behavior.
             Frontal Lobe Injury
The frontal lobe of the brain can
be injured from direct impact on
the front of the head.
During impact, the brain tissue is
accelerated forward into the bony
skull. This can cause bruising of
the brain tissue and tearing of
blood vessels.
Frontal lobe injuries can cause
changes in personality, as well as
many different kinds of
disturbances in cognition and
memory.
         Prefrontal Cortex
The prefrontal cortex
is involved with
intellect, complex
learning, and
personality.
Injuries to the frontal
lobe can cause
mental and
personality changes.
     The Developing Brain
• Children‟s brains do not reach their
  adult weight of 3 pounds until they are
  12 years old
• The brain, and most importantly, the
  brain‟s frontal lobe region does not
  reach it‟s full cognitive maturity till
  individuals reach their mid twenties
     The Developing Brain
• The Frontal Lobe houses our executive
  skills, these include; judgement,
  problem solving, mental flexibility, etc.
• The Frontal Lobe is very vulnerable to
  injury
• Damage to the Frontal Lobe any where
  along the developmental continuum can
  impact executive skill functioning
               Temporal Lobe
The temporal lobe
plays a role in
emotions, and is also
responsible for
smelling, tasting,
perception, memory,
understanding music,
aggressiveness, and
sexual behavior.
The temporal lobe
also contains the
language area of the
brain.
 Temporal Lobe Injury
The temporal lobe of the brain is vulnerable to injury
from impacts of the front of the head.
The temporal lobe lies upon the bony ridges of the
inside of the skull, and rapid acceleration can cause the
brain tissue to smash into the bone, causing tissue
damage or bleeding.
               Parietal Lobe
The parietal lobe plays a
role in our sensations of
touch, smell, and taste. It
also processes sensory
and spatial awareness, and
is a key component in eye-
hand co-ordination and
arm movement.
The parietal lobe also
contains a specialized area
called Wernicke‟s area that
is responsible for matching
written words with the
sound of spoken speech.
         Side Impact Injuries
     May Impact the Parietal Lobe

Injuries to the right or left
side of the brain can
occur from injuries to the
side of the head.
Injuries to this part of the
brain can result in
language or speech
difficulties, and sensory
or motor problems.
             Occipital Lobe

The occipital lobe
is at the rear of the
brain and controls
vision and
recognition.
    Occipital Lobe Damage
Occipital lobe injuries
occur from blows to the
back of the head.
This can cause bruising
of the brain tissue and
tearing of blood
vessels.
These injuries can
result in vision
problems or even
blindness.
             The Limbic System
The limbic system is the
area of the brain that
regulates emotion and
memory. It directly connects
the lower and higher brain
functions.
       Coup-Contra Coup Injury
A French phrase that
describes bruises that
occur at two sites in the
brain.
When the head is struck,
the impact causes the
brain to bump the
opposite side of the
skull. Damage occurs at
the area of impact and
on the opposite side of
the brain.
         Diffuse Axonal Injury

Brain injury does not require a
direct head impact. During rapid
acceleration of the head, some
parts of the brain can move
separately from other parts. This
type of motion creates shear forces
that can destroy axons necessary
for brain functioning.
These shear forces can stretch the
nerve bundles of the brain.
       Diffuse Axon Injury
is a very serious injury, as it directly impacts
      the major pathways of the brain.
The Neuron


                     Dendrites:
                     Collects
                     information from
                     other neurons

         Cell Body



        Axon:
        Transmits information to
        other neurons.
          Definitions
• Traumatic Brain Injury is an insult to the
  brain caused by an external physical
  force
• Diffuse Axonal Injury the tearing and
  shearing of microscopic brain cells
• Acquired Brain Injury is an insult to the
  brain that has occurred after birth, for
  example; TBI, stroke, near suffocation,
  infections in the brain, anoxia
Incidence of TBI            CDC 2004




 In the United States, at
           least
 1.4 million sustain
    a TBI each year
    (That we know about)
What are the Costs of
      TBI?            CDC 2006


   Direct medical costs and indirect
   costs such as lost productivity of
 TBI totaled an estimated 60 billion in
  the United States in 2000. (That is
    equal to the cost of building the
    international space center or 60
      times the net worth of Oprah
  Winfrey )Jean Langlois of the CDC
      About 3.17 Million
  American civilians (more
  than 1.1% of population,
live with the consequences
   of traumatic brain injury
  CDC in Journal of Head Trauma
Rehabilitation 2008 (Vol. 23, No. 6, pp
               394-400)
What Might it Feel Like

         Handwriting
              &
     Processing Exercise
  Incidence of TBI Of   CDC 2004




      those 1.4 million..
• 51,000 die;
• 290,000 are hospitalized; and
• 1,224,000 million are treated
  an released from an
  emergency department
   “Reframed, the numbers
 nauseate. In America alone,
   so many people become
 permanently disabled from a
 brain injury that each decade
they could fill a city the size of
          Detroit……...
 ….Seven of these cities are
filled already. A third of their
 citizens are under fourteen
         years of age.”

From Head Cases, Stories of Brain
     Injury and its Aftermath
       Michael Paul Mason
2008 published by Farrar, Straus and Giroux
        Brain Injury and
           Children
• According to the BIAA, Brain Injury is
  the leading cause of death and disability
  among children
• Approximately 470,000 TBI‟s occur
  among children 0-14 years old a year
• Brain injuries account for over 90% of
  emergency department visits in children
  0-14 years old CDC Report “Traumatic Brain injury in the United States January
 2006
  Brain Injury and Concussion
           in Children
• In sports alone, 300,000 + concussions are
  “estimated” to occur annually
• For every 1 concussion in the NFL, there are
  5,650 youth injuries
• Sports associated with concussion: soccer,
  football, lacrosse, hockey, horseback riding,
  cheerleading…….. Gerard Gioia, Ph.D.,
  Children’s National Medical Center in remarks at the
  BIAMD conference 2005
Other potential Neurotoxins
 that may impact the brain
• Exposure to lead paint
• Regarding exposure to alcohol in utero,
  according to Dr. Jacobson of Wayne
  State University “We found more
  serious cognitive impairment in
  relation to alcohol than cocaine or other
  drugs, including marijuana and
  smoking” From “Fetal Brains Suffer Badly From
  Effects of Alcohol” NYT 11.4.03
        To Underscore
     The Developing Brain
• Children‟s brains do not reach their
  adult weight of 3 pounds until they are
  12 years old
• The brain, and most importantly, the
  brain‟s frontal lobe region does not
  reach it‟s full cognitive maturity till
  individuals reach their mid twenties
This is important to keep in
     mind because…..

  The Adult Consumer you
     are serving in your
     program may have
  suffered a brain injury as
           a child
        Causes of TBI                                          CDC 2006




      Suicide, 1%                  Unknown,
                                     9%
Other Transport,       Other, 7%
      2%
                                              Falls, 28%
 Pedal Cycle
(non MV), 3%

                    Assault, 11%

                                              Motor Vehicle-
                                               Traffic, 20%
                              Struck
                          By/Against, 19%
 Who is at the Highest Risk
         of TBI? 2005
• Males 1.5 times as likely as females to
  sustain a TBI
• Two age groups most at risk are 0-4
  year olds and 15-19 year olds
• The elderly, 75 and older from falls
• African Americans have the highest
  death rate from TBI
       What about those with
         unidentified TBI?
   Adapted from MCHB webcast, Wayne Gordan, Ph.D 5.21.08

• 425,000 people treated by MDs in office
  visits Langlois 2004
• 90,000 treated in other types of
  outpatient settings Langlois, 2004
• Uncounted injuries on the playground,
  on the playing fields, from falls in the
  home, assaults, domestic violence,
  returning veterans, etc. etc. etc…...
     The Scope of the Problem
• Distribution of Severity:

  – Mild injuries = 80%
    (LOC < 30 min, PTA ,1 hour)


  – Moderate = 10 - 13%
    (LOC 30 min-24 hours, PTA 1-24 hours)


  – Severe = 7 - 10%
    (LOC >24 hours, PTA >24 hours)
The Importance of Post
  Traumatic Amnesia

PTA is the period of time
   after injury when a
 person is unable to lay
       down new
memories…for example
“That first morning, wow, I didn‟t want
to move, I was thankful that nothing‟s
    broken, but my brain was all
     scrambled” Ryan Church, NYT 3/10/08
       “All he remembers from the
      collision with Anderson is the
     aftermath, being helped off the
    field by two people, although he
     said he did not know who they
    were until he saw a photograph
          later” Ben Shpigel NYT reporter
The Faces of Brain
      Injury
A short video by the Brain Injury Association of
                    Florida
    Possible Changes-Physical
•   Motor skills/Balance
•   Hearing
•   Vision
•   Spasticity/Tremors
•   Speech
•   Fatigue/Weakness
•   Seizures
•   Taste/Smell
    Possible Changes-Thinking
•   Memory              •   Executive skills
•   Attention           •   Problem solving
•   Concentration       •   Organization
•   Processing          •   Self-Perception
•   Aphasia/receptive   •   Perception
    and expressive      •   Inflexibility
    language            •   Persistence
    Possible Changes-Personality
           and Behavioral
•   Depression
•   Social skills problems
•   Mood swings
•   Problems with emotional control
•   Inappropriate behavior
•   Inability to inhibit remarks
•   Inability to recognize social cues
    Personality and Behavioral
              cont..
•   Problems with initiation
•   Reduced self-esteem
•   Difficulty relating to others
•   Difficulty maintaining relationships
•   Difficulty forming new relationships
•   Stress/anxiety/frustration and reduced
    frustration tolerance
  A memory deficit might look like
  trouble remembering or it might
            look like……
           (Capuco & Freeman-Woolpert)

• She frequently misses appointments-
  avoidance, irresponsibility (for example...)
• He says he‟ll do something but doesn‟t get
  around to it (for example...)
• She talks about the same thing or asks the
  same question over and over-annoying
  perservation
• He invents plausible sounding answers so you
  won‟t know he doesn‟t remember (for example…)
 An attention deficit might look
 like trouble paying attention or
        it might look like …
             (Capuco & Freeman-Woolpert)

• He keeps changing the subject
• She doesn‟t complete tasks
• He has a million things going on and
  none of them ever gets completed (for
 example…)

• When she tries to do two things at once
  she gets confused and upset
A deficit in executive skills might
look like the inability to plan and
 organize or it might look like...
       (Capuco & Freeman-Woolpert)

• Uncooperativeness,
  stubbornness
• Lack of follow through
• Laziness
• Irresponsibility
Unawareness might look like…
            (Capuco & Freeman-Woolpert)

• Insensitivity, rudeness
• Overconfidence
• Seems unconcerned about the extent of her
  problems
• Doesn‟t think she needs supports
• Covering up problems (“everything‟s fine…”)
• Big difference in what he thinks and what everyone
  else thinks about his behavior
• Blaming others for problems, making excuses
Lack of Awareness
A common and difficult to remediate
     hallmark of a brain injury
          Levels of Awareness
    Crossen et.al (1989) J Head Trauma Rehabilitation

• Intellectual Awareness-individual is able to understand at some
  level, that a particular function or functions is impaired. A greater
  level of intellectual awareness is required to recognize some
  common thread in the activities in which they have difficulty
• Emergent Awareness-individual is able to recognize a problem
  when it is actually happening. To do so, they must recognize a
  problem exists (intellectual awareness), and realize when it
  occurs
• Anticipatory Awareness-individual is able to anticipate a problem
  will occur and plan for the use of a particular strategy or
  compensation that will reduce the chances that a problem will
  occur, e.g. keep and refer to a calendar to support memory for
  daily schedule
   The Relationship
Between Brain Injury and
     Mental Health
             Depression
• Depression is the most common Axis I
  psychiatric disorder after TBI followed by alcohol
  abuse, panic disorder, specific phobia and
  psychotic disorders (Gordon et. al 2004)
• A 50 yr.. Follow-up of 1,198 WWII vets found that
  520 had incurred a TBI. 18.5% of vets with brain
  injuries had a life time prevalence of major
  depression verses 13.4% rate of depression
  among on brain injured vets (Holsinger et.al 2002)
    The Post -Concussive
  Syndrome and PTSD       Dr. Paul McClelland




• Increased startle response;
  especially to loud sounds
• Irritability
• Avoidance of many social events
• Intolerance of new situations
    Organic Personality Disorder &
       Anti-Social or Hysterical
       Personality Traits  Dr. Paul McClelland



• Decreased impulse control
• Labile and superficial affect
• Impaired insight and self awareness
• Decreased empathy and social
  awareness
• Impaired initiative (Depression?)
    Partial Seizures & Panic
 Attacks or Dissociative States
                  Dr. Paul McClelland


• Most common type of post-traumatic epilepsy
• Temporal lobe damage and complex partial
  seizures
• “Spells” starting suddenly & lasting a few
  minutes
• Olfactory (smell) or gustatory (taste)
  hallucinations
• Déjà vu or jamais vu
• Micropsia, macropsia and other symptoms
Obsessive-Compulsive Traits after TBI: Pre-
   Existing Conditions or Adaptation to
 Cognitive Deficits & Other Changes? Dr. Paul
                    McClelland


• Compulsive behaviors as adaptations
  for memory loss
• Temper tantrums and other adaptations
• Non-pharmacological management of
  brain-injured patients
     Other Mental Health
   Disorders Related to TBI
• PTSD is noted in some individuals
  following TBI even if there is no memory
  of the incidence (Klein, Caspi 2003)
• Rapid cycling bipolar is rare but noted in
  the literature for individuals with temporal
  lobe damage (Murai, Fujimoto 2003)
• Psychotic syndromes occur more
  frequently in individuals who have had a
  TBI then in the general population
  (McAllister, Ferrell 2002)
               TBI & Suicide
• “The risk of attempted or completed suicide in
  neurological illness is strongly related to
  depression, feelings of hopelessness or
  helplessness, and social isolation” (Arciniegas &
  Anderson, 2002)
• Simpson and Tate (2002) screened 172
  individuals for suicidal ideation and
  hopelessness. Findings using the Beck Suicide
  Ideation and Hopelessness Scales found 35%felt
  hopeless and 23%expressed suicide ideation.
  18% had attempted suicide post injury
   Individuals with or without a
history of brain injury often share
 identical risk factors for suicide
          Teasdale & Engberg 2001


• Young Adults
• Males
• Substance Abuse
• Other psychosocial
  disadvantages
Teasdale & Engberg‟s population
study of 145,440 Danes post TBI:
• Followed individuals with concussion, skull fractures
  and cerebral contusions or traumatic intracranial
  hemorrhages (lesions) for 15 years
• Incidence of suicide among all three groups higher
  compared to general population
• Presence of a co-occurring substance abuse
  diagnosis increased suicide rates among all three
  groups
• Significantly greater risk for suicide found among
  those with lesions than those with concussion or
  fracture
• Rate of suicide was 1% over a 15 year period
     Subsequent Studies…..
                Simpson & Tate

• A 2003 study found of 172 individuals post
  TBI, 17%attempted suicide over a period of 5
  years
• A 2005 study of 172 individuals with a hx of
  brain injury found that those with comorbid
  post injury history of psychiatric/emotional
  disturbance and substance abuse were 21
  times more likely to attempt suicide post
  injury
   Why Screen?



What other TBI Screening
  efforts have found
2000 Epidemiological Study
of Mild TBI J. Silver of NYU, cited in WSJ by Thomas
                             Burton 1.29.08
 http://online.wsj.com/article/SB120156672297223803.html?mod=googlenews_


• 5,000 interviewed
• 7.2% recalled a blow to the head
  w/unconsciousness or period of
  confusion
• Follow up testing found; 2x rate of
  depression, drug and alcohol abuse
• Elevated rates of panic and and
  obsessive-compulsive DO
Brain Injury in the Correctional
 Setting-Nationally CDC website 2008
• According to jail and prison studies,25-
  87% of inmates report having
  experienced a TBI-this compared with
  8.5% of the general population
• Prisoners with a history of TBI may also
  experience mental health disorders
  (including; severe depression, anxiety,
  substance abuse)
Brain Injury in the Correctional
       Setting-Nationally
             CDC website 2008

• Woman inmates who are convicted of a
  violent crime are more likely to have
  sustained a pre-crime TBI or some
  other form of physical abuse
• Women with substance abuse disorders
  have an increased risk for TBI
  compared with women in the general
  population
In Maryland- Screening Results
 from the MD TBI Post Demo II
         Project-2005
– Summary of TBI Incidence Among all Screened at 7
  public mental health agencies in Frederick and Anne
  Arundel counties
– N=190
– 39% no reported history of TBI (78)
– 58.94% of individuals with a history of TBI (112)
– 35.78% of individuals with a history of a single incidence of
  TBI (68)
– 23% of individuals with a history of 2 or more TBIs (44)
Details-County Detention
       Center 2005
– N=41
– Single TBI= 16
– 2 or more incidents of TBI= 14
– No history of TBI= 11
– 73% screened reported a history of TBI
County Detention Center
         2008
– N=25 (16 male, 9 female)
– 22 reported possible TBI(s)
– Single TBI=10
– 2 or more incidents of TBI= 12
– No History of TBI =3
– 88% screened reported a history of TBI
        TBI in a County Jail
             Population
             Slaughter et. al Brain Injury 2003
•   69 randomly selected inmates
•   60 (87%) reported TBI over their lifetime
•   25 (36%) reported TBI in the prior year
•   Later group had worse anger and
    aggression scores, trend towards
    poorer cognitive test results and higher
    prevalence of psychiatric DO then those
    w/out TBI in prior year
Brain Injury in the Correctional
       Setting-Nationally
               CDC website 2008

• According to jail and prison studies,25-
  87% of inmates report having
  experienced a TBI-this compared with
  8.5% of the general population
• Prisoners with a history of TBI may also
  experience mental health disorders
  (including; severe depression, anxiety,
  substance abuse)
Brain Injury in the Correctional
       Setting-Nationally
             CDC website 2008

• Woman inmates who are convicted of a
  violent crime are more likely to have
  sustained a pre-crime TBI or some
  other form of physical abuse
• Women with substance abuse disorders
  have an increased risk for TBI
  compared with women in the general
  population
     Brain Injury & Violence
                      Domestic Violence

• Greater than 90% of all injuries secondary to
  domestic violence occur to the head, neck or face
  region (Monahan & O’Leary 1999) Adapted from The
  Alabama Department of Rehabilitation Services DV Training

• Corrigan et.al., (2003) found that of 167 individuals
  treated for domestic violence related health issues,
  30% experienced a loss of consciousness on at least
  one occasion, 67% reported residual problems that
  were potentially TBI related
• Valera and Berenbaum, (2003) assessed 99 battered
  women. Of these, 57 had brain injured related
  symptomatology
  Homelessness & Brain Injury
    A little studied population,
             however…..
• A University of Miami study found that 80% of 60
  homeless individuals had high incidence of
  neuropsychological impairment
• Researchers in Milwaukee found possible cognitive
  impairment in 80% of 90 homeless men evaluated.
• Dr. LaVecchia of the MA Statewide Head Injury
  Program reported in 2006 that of 140 homeless
  individuals evaluated, 83.6% of males and 16.4% of
  females had an acquired brain injury
• Other studies in the UK and Australia show similar
  rates of brain injury among homeless individuals
        Correlation between TBI &
              Homelessness
  Hwang et.al 10.7.08 Canadian Medical
                  Journal
• 904 homeless individuals surveyed
• Lifetime Prevalence of TBI-53%, more
  common among men than women
  surveyed
• Rates 5 or more times greater than the
  8.5% lifetime prevalence in general
  population and consistent w/ prison
  studies
   TBI & Homelessness
“For Veterans, A Weekend
Pass From Homelessness”
from the New York Times 7.26.09, Erick Eckholm


Human service professionals will be
seeing increasing numbers of returning
service members in need of services over
the next few years
 “….The ranks include young men like Kenneth
Kunce, 26, who suffered a traumatic brain injury
 when his Humvee was hit by a roadside bomb
 in Iraq. The injury left him disorientated, jumpy
  and temperamental. When he came home he
  started using Ecstasy and alcohol, he said he
lost his wife and more than one job. He said he
 was grateful to the Veterans Affairs hospital for
   providing speech and physical therapy, but
    added that he still had trouble coping with
                 noises and anger.
    Mr. Kunce, who sometimes lost his train of
thought as he spoke to this reporter, is living out
                     of his car.”
The HELPS Brain Injury
    Screening Tool
              (see handout)

The original HELPS tool developed by M. Picard, D.
           Scarisbrick, R. Paluck, 9.1991
Updated by the Michigan Department of Community
                       Health
            HELPS
• Have you ever Hit your Head or
  been Hit on the Head?
• Prompt individual to think about;
  TBI at any age, MVAs. Assaults,
  Sports injuries, Service related
  injuries, Shaken baby and/or adult
             HELPS
• Were you ever seen in the
  Emergency room, hospital, or by a
  doctor because of an injury to your
  head?
• Explore the possibility of
  “unidentified traumatic brain injury”
  many do not present in medical
  settings
                HELPS
• Did you ever Lose consciousness or
  experience a period of being dazed and
  confused because of an injury to your head?
• Remember, a LOC isn’t required for someone
  to develop symptoms subsequent to a blow to
  the head. “alteration of consciousness” AKA
  post traumatic amnesia (PTA). At this point,
  the interviewer may consider asking the
  individual if they have had multiple mild TBI
                HELPS
• Do you experience any of these Problems in
  your daily life since you hit your head?
• You want to know when any problems began
  (or began to be noticed) Remember, lack of
  awareness is a hallmark of brain injury, you
  might ask if anyone close to the individual
  has made any observations regarding
  changes in function.
                  HELPS
• Headaches          • Difficulty reading,
                       writing, calculating
• Dizziness
                     • Poor problem solving
• Anxiety
                     • Difficulty performing
• Depression
                       your job/school work
• Difficulty
                     • poor judgement (being
  concentrating
                       fired from job, arrests,
• Difficulty           fights, relationships
  remembering          affected)
                HELPS
• Any significant Sickness?
• Acquired Brain Injury (ABI) can result in many
  of the same functional impairments as
  traumatic brain injury (TBI). For example,
  brain tumor, meningitis, West Nile virus,
  stroke, seizures, toxic shock syndrome,
  aneurysm, AV malformation, any history of
  anoxic injury, e.g. heart attack, near
  drowning, carbon monoxide poisoning can all
  result in multiple deficits
   Scoring the HELPS
   Positive for a possible Brain Injury when the
          following three are identified:
• An event the could have caused a brain
  injury (YES to H, E, or S), and
• A period of loss of consciousness or
  altered consciousness after the injury or
  another indication that the injury was
  severe (YES to L or E), and
• the presence of 2 or more chronic
  problems listed under P that were not
  present before the injury.
     Scoring the HELPS
• A positive screening is not sufficient to diagnose
  TBI as the reason for current symptoms and
  difficulties-other possible possible reasons need to be
  ruled out
• Some individuals could present exceptions to the
  screening results, such as people who do have TBI-
  related problems but answered “no” to some
  questions
• Consider positive responses within the context of the
  person‟s self-report and documentation of altered
  behavioral and/or cognitive functioning
  Additional comments and
observations of the interviewer
•   Any visible scars?
•   Walks with a limp?
•   Uses a cane or walker?
•   Has a foot brace?
•   Limited use of one hand?
•   Appears to have difficulty focusing vision?
•   Difficulty answering questions?
•   Answers are unorganized and/or rambling
•   Becomes easily distracted, agitated or is
    emotionally labile
     What you are looking
       for…..And Why
• Any reported or suspected functional
  difficulties that are interfering with
  home, work or community activities
• With the identification a history of
  brain injury, professionals can better
  support the individuals served and
  make informed referrals to brain
  injury specialists when appropriate
Remember, for most, Brain
      Injury is:

• -A loss of Self
• -A loss of future
• -loss of possibilities
 “I had a job, I had a girl, I
had something going mister
   in this world…………”

     A 10 year survivor of a TBI
    quoting a Bruce Springsteen
   song when describing what he
    had lost because of his injury
A compromised brain can lead
  to compromised behavior,
    further adding to social
  isolation and social failure
The following slides 3 are adapted from
               Webcast:
sponsored by the Health Resources and
       Services Administration’s
   Federal TBI Program Web cast
             July 27, 2006
           Speakers:
• Harvey E. Jacobs, Ph.D., Licensed
  Clinical Psychologist/Behavioral
  Anaylist
• Marty McMorrow, Director of National
  Business Dev., The MENTOR Network
• Jane Hudson, JD., senior Staff Attorney,
  National Disability Rights Network
     Behavioral Statistics
• Approximately 90% of all people who
  experience severe disability following
  brain injury experience some emotional
  or psychiatric distress
• 40% continue to demonstrate
  behavioral difficulty five years post
  injury
     Behavioral Statistics
• 25% experience behavior dysfunction
  that interferes with other activities of
  daily life
• 3%-10% experience severe behavioral
  dysfunction that may require intensive
  professional and residential intervention
  (~3,000-9,000 new people per year)
Research findings regarding
Behavior Problems after TBI
• “Aggressive behavior is associated
  with presence of major depression,
  frontal lobe lesions, poor premorbid
  social functioning and a history of
  alcohol and substance abuse” Tateno
 et.al J of Neuropsychiatry Clin. Neuroscience 2003
Research findings regarding
Behavior Problems after TBI
• Research conducted by Wood and Liossi in
  2006 reports “it is tentatively suggested that
  significant impairment in verbal memory and
  visuospatial abilities against a background of
  diminished executive-attention functioning is
  associated with the development of aggression
  after brain injury,especially when other risk
  factor such as low premorbid IQ, low
  socioeconomic status, and male gender are
  present” J of Neuropsychiatry Clin. Neuroscience
Research findings regarding
Behavior Problems after TBI
• “Impairments in recognizing the
  emotional state of others may underlie
  some of the problems in social
  relationships that these patients
  experience……TBI patients were found
  to be impaired on emotional recognition
  compared to the control patients both
  early after injury and one year later”
 Ietswaart et. al. Neuropsychologia, 2007
  According to McMorrow,
  Jacobs and Hudson; HRSA
            Webcast July 27, 2006
  “Almost all people who experience
disability following brain injury are not
 inherently aggressive or assaultive.
   However, for some people, when
     challenges are not properly
    addressed this can result in…”
-Lack of responsiveness to
requests
-Property destruction
-Verbal or physical aggression
-Violation of personal or
    sexual boundaries
-Wandering or flight
-Self harm/self abuse/suicide
“Neurobehavioral Challenges”
    According to McMorrow, Jacobs and Hudson
                  are caused by:
• Pre-injury history
• Post-Injury learning and experiences
• Inability to negotiate “difficult” situations
• Others‟ not recognizing the basic
  challenges to an individual with TBI, and
• Not providing proper treatment
With the Proper Supports:

• -A renewed sense of self
• -A future can be imagined
• -New possibilities can be
  created
Strategies
  Attention is the ability to
 stay focused on a specific
topic or task. It is critical to
 successful participation in
     purposeful activity.

     The next 10 slides are from the
   Rhode Island BIA presentation “Brain
      Injury: A Practical Training for
                Caregivers”
                Attention
 Gain and encourage eye contact when
  appropriate.
 Use an opening statement such as “Are you
  ready to get started” to gain the consumer‟s
  attention before explaining an activity or giving
  directions.
 Be specific and clear. Avoid lengthy or vague
  explanations.
 Slow down when you speak. It is very difficult
  to listen carefully to someone who is talking at
  a fast pace.
 Limit interruptions when possible.
               Attention
 Minimize environmental distractions
  (competitive background noise, cluttered
  work areas and cluttered walls).
 Present information in an organized fashion.
 Pause to allow the consumer to process or to
  finish taking notes before moving to the next
  direction or to a new piece of information.
              Attention
 Encourage a steady work pace. Rushing can
  result in an increase in mistakes or in
  skipping an important step in an activity.
 Breakdown assignments into smaller more
  manageable portions.
 Provide a task breakdown or assist the
  consumer in developing a task breakdown for
  specific activities
               Attention
 Avoid overwhelming the consumer. Don‟t
  plan on covering large amounts of information
  in a single session.
 When assigning tasks that the consumer will
  be expected to complete independently,
  begin with simple activities. Progress to more
  difficult or complicated tasks if the consumer
  is successful with the simple activities.
                  Attention
 If you notice that the consumer is beginning to lose
  focus, give a cue to redirect to task, or ask if they
  need a short break.
 Provide positive feedback when the individual is
  performing well or requesting to use appropriate
  modifications or strategies during a session.
 When finishing an instructional session, help the
  consumer to review the material that was covered.
  Place emphasis on any follow up activities the
  consumer is supposed to complete independently.
             Attention
   To pay attention, we must be awake and
    alert, this is referred to as arousal level.
   Under normal circumstances our central
   nervous system automatically keeps the
 arousal level regulated. As a result of brain
   injury clients may experience lethargy or
 sluggishness referred to as a state of under
arousal. Or they may appear to be „hyper‟ or
   over stimulated known as a state of over
  arousal. In some cases the use of sensory
stimulation, relaxation or focusing techniques
 can be helpful. Responses to sensory input
        can vary from person to person.
                   Attention
 Use an appropriate volume and tone of voice for the
  individual consumer. A softer voice may be more
  tolerable to someone who is over stimulated. A
  louder voice with extra emphasis on key words may
  be helpful to someone who is under aroused.
 Determine if the use of white noise or environmental
  sound machines is helpful.
 Use high intensity white light or bright natural light for
  individuals who are under aroused, dimmed lighting
  for those who are over aroused.
                Attention
 Play background music that the individual
  finds helpful when paying attention to a
  particular activity, or for relaxation (soft
  soothing music, upbeat or rhythmic music).
 Include breaks into the daily schedule to
  listen to short guided meditation or relaxation
  tapes.
 Pause between activities or during lengthy
  activities to take a few deep breaths.
               Attention
 Movement such as gentle use of a rocking
  chair, or brisk movement can help to regulate
  arousal.
 Joint and muscle stimulation experienced
  during weight bearing or resistive exercises
  can also assist with regulation of arousal.
 Encourage participation in a regular exercise
  program or activity such as Yoga or Tai Chi
  when appropriate.
    The Benefits of Exercise
          Post Injury
 TBI Consumer Report # 2 TBI Central MT. Sinai Model Program
• Those who exercise had fewer physical, emotional and cognitive
  complaints. E.g. sleep problems, irritability, forgetting and being
  disorganized
• Non-exercisers complained of more cognitive problems or
  symptoms than those who exercise
• Exercisers with TBI were less depressed
• Exercisers viewed themselves as healthier
• Exercisers were often engaged in school, work, and “got
  around” the community more freely
• Exercisers had more severe brain injuries than the non-
  exercisers, suggesting that a severe injury does not prevent
  engaging in exercise
Memory functions are complicated
and sensitive. Memory is frequently
   the first function to be notably
    impaired and one of the last
  functions to be regained in the
          recovery process.
      The next 32 slides are
    adapted from the Rhode
     Island BIA presentation
    “Brain Injury: A Practical
    Training for Caregivers”
            Memory
   Memory Systems can significantly
    improve client follow through and
independence when used on a regular
      basis. When a new system is
  introduced a „repetitive training‟ and
   cueing period is recommended to
reinforce consistent use. Systems can
     be updated to accommodate for
     improvements in memory, or for
             changing needs.
                  Memory
• When designing a memory system:
 Define the goals or exact needs the system will be
  meeting.
 Designate separate sections based on specific
  needs.
 Use a format and style that the individual prefers.
 Encourage use of one system that is taken
  everywhere. (technology!) See Tony Gentry, Ph.D.
  OTR/L’s website:
  www.vcu.edu/partnership/pda/Jobcoach
                 Memory
 Timers, wrist watch alarms or talking watches
  can provide prompts.
 Use check off sheets (this allows the
  individual to self-monitor and reference back).
 Post simple reminder signs for prompts to
  turn off appliances, lights, etc.
 Label drawers and cupboard fronts indicating
  their contents.
                 Memory
 Post step by step directions for appliances
  such as the coffee maker, microwave etc.
 Post-it notes for extra reminders, for example
  place a post it note on the memory book as a
  reminder to check the „to do‟ list if there is a
  critical item on the schedule the next day.
 Provide written or picture based instructions
  in addition to verbal instructions.
                 Memory
 Color code folders, storage containers, or
  calendar entries to help with recall and
  identification.
 Use tape recorders to record meetings or
  appointments.
 Provide repetitive training or instruction when
  reintroducing functional activities into the
  daily schedule, and with all activities that
  require new learning.
 Encourage note taking at meetings,
  appointments, etc.
                 Memory
 Pocket “Voice it” recorders can be used to
  record reminders throughout the day.
 Use the home answering machine to leave
  “reminders to self”.
 Have a back up plan. For instance, in addition
  to strategies for remembering keys, have a
  contingency plan with extra keys available at
  accessible locations (neighbors, friends, etc.)
        Problem Solving
  Problem solving is used for completion of a
  wide range of activities throughout the day.
 Many activities are sequenced; performed by
   using a step by step approach. Cues can
  support consumer participation in activities
  Written or picture task breakdowns can be
   used during early training or as a prop for
independent task completion as the consumer
                  progresses.
    Strategies and approaches can also be
developed to help consumers with higher level
       or abstract problem solving skills.
  Problem Solving/Sequencing
                      example
• Squat Pivot Transfer
• 1)Park- at an angle along the mat, left front of the
  wheelchair touching the mat.
• 2)Lock both wheels
• 3)Check your locks
• 4)Flip up left arm rest
• 4)Scoot your bottom forward
• 5)Feet flat on the floor 8 -10 inches apart, left foot
  forward
• 6)Hands- Left hand on the mat, Right hand on the
  chair arm
• 7)Push on arms, lift up bottom, pivot onto the mat
        Problem Solving
State Problem:_________________________
 List 3 solutions: 1)_____________________
                    2)_____________________
                    3)_____________________

         Solution 1          Solution 2
                  Solution 3
 Pros    Cons        Pros Cons          Pros
                    Cons

Describe the most logical and effective solution
                based on the
above:________________________________
_____________________________________
         Impulsivity
 Impulsivity is often a consequence of
       injury to the frontal lobes.
Impulsivity can have a negative impact
   on independent living, particularly
when life changing decisions are made
    without carefully thinking things
                 through.
             Impulsivity
                    Change Plan
What change do I want to make?____________________
Why do I want to make the change?_________________

          Change                    Not Changing
   Pros            Cons        Pros          Cons

                   List step for
    change:1)________________2)______________
3)________________4)________________5)___________
                        ___

                 Who could help
      me?_________________________________
           What might interfere with my
           change?___________________
           How would I evaluate success?
            _______________________
            Initiation
 Poor initiation, a decreased ability to
  initiate or begin activities, can be a
 consequence of brain injury. Initiation
    deficits are often misinterpreted,
caregivers may assume the consumer
     doesn‟t care or that they aren‟t
   motivated. Damage to any one of
 several different areas of the anterior
part of the brain can result in deficits in
                 this area.
                    Initiation
 Many individuals respond well to structure and
  consistent routines.
 When preparing daily and weekly schedules be
  specific. Designate specific times for activities to be
  performed. In addition to using a general concept
  such as clean-up the kitchen, indicate specific tasks
  for example: put dishes in the dishwasher, wipe off
  the table, wash the counter.
 Begin with lighter demands that promote success.
  The difficulty of demands can be increased when the
  consumer demonstrates consistent follow through
  with the easier activities.
                 Initiation
 Encourage consumer participation when
  developing schedules.
 Provide training and cues when introducing a
  new or updated schedule.
 Accept close approximations of the desired
  behavior when changes are initially instituted.
 Use positive reinforcement for all successful
  follow through.
 Engage the consumer in a problem solving
  approach when addressing areas of difficulty.
       Communication
 Communication is very complex and
involves processing of both verbal and
nonverbal information. Individuals may
     have receptive deficits, difficulty
 understanding specific words or with
the way in which words are presented.
  They may have expressive deficits,
 difficulty remembering a word, or with
   pronouncing words correctly when
                speaking
           Communication
 Receptive Deficits:
• Slow your rate of speech
• Simplify sentence structure, be clear and
  concise
• Pause between sentences or topics to allow
  for processing
• Repeat key words or concepts
• Rephrase as needed
• Summarize information frequently
             Communication
 Expressive Deficits:
 Do not expect an immediate response to a question
  or statement. Pause to allow the individual time to
  prepare their response.
• Accept gestures and pantomime in addition to verbal
  speech.
• Ask yes/no questions, avoid questions that require
  lengthy or detailed answers.
• Provide extra time for consumers who are using
  augmentative communication devices.
• Accept written answers or drawings.
   Hearing/Central Auditory
         Processing
 When there is trauma to the temporal lobe area,
  individuals may experience a change in the ability to
  hear sound or in the ability to process auditory
  (sound) input. Once sound is detected by the ear, the
  brain processes what was heard on multiple levels.
  Individuals with central auditory processing deficits
  may have difficulty with:
 Filtering out competitive background noise
 Noticing the differences between similar sounds or
  words
 Maintaining attention on a speaker who is giving a
  presentation on complicated information or when
  listening to a long presentation.
 Remembering information as it is processed.
   Hearing/Central Auditory
         Processing
 Reduce or eliminate background noise.
 Instruct the client to directly face the speaker to
  maximize on visual speech cues.
 Increase the volume of the speaker‟s voice in relation
  to the surrounding background noise at presentations
  or meetings. Provide a speaker microphone or
  assisted listening device.
 Speakers should avoid covering their mouth,
  shouting or over-enunciating words.
 Consider referring for an audiological evaluation to
  determine if hearing aides or specialized alerting
  devices would be beneficial.
                 Vision
  Vision is an extremely important source of
  sensory information. The eyes send many
    messages to the brain, the brain must
interpret all of the incoming messages. There
       can be problems with coordinated
movements of the eyes and/or with the brains
  ability to process and interpret information
  accurately. Deficits can range from mild to
  severe. Even subtle deficits can affect the
individuals ability to work on visual tasks and
              should be addressed.
                    Vision
 Use enlarged print.
 Print on yellow instead of white paper or use
  a yellow acetate overlay on documents to
  increase contrast.
 A book mark or ruler can be used to help with
  staying on the line when reading or scanning
  for information.
 Change florescent lights to high intensity
  white lights, or increase natural light.
 Simplify forms; determine if extra spacing,
  grid lines, bold print or bold lines are helpful.
                      Vision
 Use a cut out guide to isolate sentences or words.
 When consumers are working on near vision tasks
  for long periods, have them take short breaks to shift
  their gaze to distant objects to decrease eye fatigue.
 Refer to a vision care professional trained in working
  with acquired brain injury for thorough assessment of
  vision related complaints.
 Refer for adaptive technology assessment for
  computer modification or low vision technology when
  appropriate.
      Activity Tolerance
  Fatigue is a common complaint after brain
 injury. It is more difficult for individuals with
 brain injury to compensate for their deficits
             when they are over tired.
Consumers may need more sleep than they
did before they were injured. They may not
be able to tolerate a very busy schedule. It is
  important to consider energy conservation
and work simplification when preparing daily
              and weekly schedules.
     In some cases they may have sleep
    disturbances; the physician should be
 consulted if a consumer is unable to get to
 sleep or stay asleep during the appropriate
                      hours.
    Activity Tolerance
 When developing a plan to manage fatigue:
 Carefully review the current schedule with
                the consumer.
 Make a list of the most important activities,
those that must be done on a daily or weekly
 basis, and plug them into the new schedule
 (Some activities may need to be eliminated
         when revising a schedule).
Schedule activities that are more difficult or
   demanding throughout the week. Don‟t
 schedule all heavy or difficult activities on a
                   single day.
      Activity Tolerance
  Alternate between light or low demand
  activities and high demand more difficult
       activities on the daily schedule.

Determine if there are certain times during
 the day that the consumer is at his or her
 „best‟ try to schedule important or priority
           activities at those times.

   Determine what times of the day the
consumer is usually more fatigued, schedule
  only light activities or rest periods during
                  these times.
            Activity Tolerance
 Encourage consumers to increase their use of
  accommodations and strategies or provide extra
  supports during the times of day that they are usually
  more fatigued.

 Avoid rushing, schedule enough time for each activity
  to be performed at a steady and reasonable pace.

 Remember that cognitive activities can be very tiring
  for some consumers. You will need to observe how
  each individual responds to different activities.
    Considerations for Plan
        Development
 Each plan must be developed on a case by case
  basis to meet the individuals needs.
 Always include the client in development of the plan
  when possible.
 Each consumer may present with a wide variety of
  strengths and challenges.
 Individuals may have deficits in multiple areas.
 Because a consumer does do well in some areas
  does not mean they should automatically be
  expected to do well in all areas.
    Considerations for Plan
        Development
 Limitations in each deficit area may require specific
  accommodations.
 Some deficits may not be obvious when your first
  meet the consumer.
 Recovery can vary greatly from individual to
  individual. Consumers may need extra support to
  realize they can‟t compare their recovery with that of
  other brain injury survivors.
 Because recovery can continue for some time the
  plan may need to be changed and updated on a
  regular basis to meet the consumer‟s changing
  needs.
  Additional Considerations
 It is important that consumer is motivated to work on
  the goals that have been developed.
 Always consider the consumer‟s input when
  developing goals.
 If the team has developed goals that are different from
  the consumer‟s, be sure to explain what the purpose
  and potential value of working on those goals might be.
  Discuss how the goals developed by the team may
  compliment or support the consumer‟s personal short
  and long term goals.
 Keep the discussion focused on identifying goals and
  activities that offer the opportunity for success.
Potential Disruptive Behaviors
     Not all brain injury survivors will
     experience difficulty with social
  behavior. However, TBI survivors who
  have had severe frontal lobe injury or
  who have been more recently injured
  may exhibit disruptive behaviors. You
               may observe:
         •Social judgment errors
         •Threatening comments
    •Inappropriate sexual comments or
                 advances
Potential Disruptive Behaviors
  In most cases these behaviors are
  not intentional but rather the result
    of poor inhibition and judgment.
       These behaviors, although
  upsetting are not usually meant to
  be harmful, and can be addressed
       by using a consistent team
               approach.
The next 10 slides are
adapted from the New
  Hampshire Project
Response presentation
 “Changes After Brain
       Injury”
    Environmental Triggers for
      Behavioral Problems
• Too much stimulation
• Rapid pacing
• Lack of predictability and clear structure
• Overwhelming physical and cognitive
  demands
• Negative social input
Note: if you manage the
 environment, you can
prevent many problems
  Guidelines For Behavior
       Management
• Increase rest time. Fatigue is a
  common problem.
• People have limited coping skills.
  Reduce stress.
   Guidelines For Behavior
        Management
• Keep the environment simple. People
  with brain injuries are easily
  overstimulated
• Decrease interruptions and distractions
• Be consistent
• Decrease surprises
   Guidelines For Behavior
        Management

• Keep instructions simple, concrete.
• If the person has problems processing
  language, try gesturing or cueing.
• Write things down.
   Guidelines For Behavior
        Management
• Give feedback and set goals
• Feedback should be direct, caring,
  nonjudgmental, but not subtle
• Avoid criticism
• Give supportive encouragement
• Have a positive attitude
• Use the “feedback” sandwich
    Guidelines For Behavior
         Management

• Be calm, cool, and friendly during an incident
• This can reduce agitation
• Avoids reinforcing misbehavior
• Redirection works. When the person is upset,
  agitated, aggressive, focus attention on some
  other topic, task, person.
• Provide choices
     Guidelines For Behavior
          Management
•   Decrease chance of failure
•   Keep success rate above 80%
•   Watch for frustration
•   Behavioral momentum
•   Expect the unexpected. People with brain injuries can
    have great variability from day to day. Mood swings
    are common. People with TBI are sensitive to
    changes, disruptions in routine, lack of sleep, alcohol,
    minor illnesses, fatigue, other stressors.
         KEEP IN MIND…
Progress can be inconsistent and
  unpredictable
     • What works today may not work
       tomorrow, but may work the following
       day
  – Reduced stamina and fatigue may persist
  – Impairment of memory may hinder new
    learning
  – Transitions may be especially difficult
   Prevention, Prevention,
        Prevention
• Communicate expectations
• Recognize internal and environmental
  triggers, plan strategies
• Provide clear structure and predictable
  routines
• Maintain realistic expectations
• Help peers learn to alter interactions to
  avoid triggers
Additional Strategies


  From the MD TBI Project
Most Strategies address
more than one cognitive
and or behavioral deficit
           Strategies

Spontaneous restoration of functioning
occurs most rapidly and dramatically in
 the first year following a brain injury.
  Generally speaking, the greater the
     time from the injury the more
   rehabilitation efforts will focus on
             compensation
        Environmental
              &
        Internal Aides

  Creative cognitive strategies will
employ both kinds of aids depending
         on individual need
   Environmental,
AKA Prosthetic external
memory strategies and
       devices
  Changing or modifying the
 environment to support and/or
compensate for a injury imposed
            deficit
 For Example: labeling kitchen
          cabinets
                      Internal
   The strategy is “in your head”
           For Example:
    “I have to work the memory
  muscle by counting everything,
like how many times I pedal when
          I am on a bike”
Actor George Clooney discussing the use of internal memory strategies in The
                     London Sunday Times10. 23.05
  Oftentimes a strategy can
transition with practice from
 the external to the internal
              For Example:
  Preparing remarks on paper with
   “pauses” written in to slow down
  impulsive speech can eventually
  segue into a internal strategy, “At
  the end of every 2-3 sentences, I
    will take a breath and check in
            with my listener”
    Strategies can help
individuals compensate for
   the physical barriers
 imposed by a brain injury

             For Example:
  Prism glasses may be prescribed
    to address double vision after
       injury just as bifocals are
  prescribed for many after age 40
               Strategies
• Use of a template for routine tasks, on the
  job, at home
• Use of a high lighter (RED)
• Use of ear plugs to increase attention, screen
  out distractions (Parente & Herman 1996)
• Partitions/cubicles, at work, quiet space at
  home
• Model tasks e.g. turning on a computer and
  accessing email
                Strategies
• Use of pictures, for faces/names, basic
  information, for step-by-step procedures, e.g.
  making coffee
• Use of a timer, to track breaks at work, the
  time minimum technique, allocated time to
  puzzle over a problem or vent a frustration
• Books on tape, movies, keep the subtitles (for
  processing content in the case of memory and
  comprehension problems and increase
  awareness of nonverbal cues/communication)
               Strategies
• Car Finder-low tech, install a longer radio
  antenna with a day-glow flag, high tech,
  Design Tech International by DAK Corp.
• Electronic pill boxes/blister packs with day of
  the week labels
• Review schedule each day
• Post signs on the wall etc. (use
  pictures/symbols for low literacy skills)
• Try to “routinize” the day as much as possible
     Teach a variety of strategies for
   individuals to incorporate into their
              daily routines
                 Michelle Rabinowitz OTR/L
• Safety checklist (e.g. for use of stove)reinforces
  attention
• Checklists- “things to do before leaving the house”
  (turn off all the appliances?, lock all the doors?, did I
  take my morning medications? turn down the
  heat/turn off the air conditioner?, do I have money or
  keys?, where am I going?, how will I get there? What
  time should I leave? Etc.) Very good for routine
  tasks, reinforces memory
• Place visual cues in the environment (cupboard
  labels, written directions, calendars, list of emergency
  phone numbers) reinforces memory
     Memory Strategies
                     Adapted from:
Parente & Herman in Retraining Cognition 1996 Aspen Publishers
         SOLVE Mnemonic
•   “S” (S)pecify the problem
•   “O” (O)options-what are they?
•   “L” (L)isten to advice from others
•   “V” (V)ary the solution
•   “E” (E)valuate the effect of the
    solution, did it solve the problem?
Organizing the Environment
   Consistency, accessibility, separation,
           grouping, proximity
• Consistency-put things in the same place,
  keys, wallet etc.
• Accessibility-things that are commonly
  used, keep them physically close, in the
  kitchen, in the office
• Separation-put things in logically distinct
  locations. Clothes, mail
• Grouping-put things that are used together in
  the same area, raincoat & umbrella
• Proximity-cooking utensils near the stove
           Setting GOALS
        Executive Skills Training
• G” (G)o over your goals every day-helps
  memory and awareness
• “O” (O)rder your goals-short and long term
• “A” (A)sk yourself two questions each day:
  “what did I do today to achieve my goals?”
  and “What could I have done differently to
  achieve my goals”
• “L” (L)ook at your goals each day. Post goals
  and progress on the wall, refrigerator etc.
        Listening Skills
• “L” (L)ook at the person-focus on
  nonverbal aspects of communication
• “I” (I)nterest yourself in the
  conversation- use “social fillers” e.g “I
  see”, “Tell me more”
• “S”(S)peak less than half the time-
  decrease the chance of getting off topic
 Listening Skills continued
• “T” (T)ry not to interrupt or change the
  topic-stick to the topic at hand
• “E” (E)valuate what is being said.
  Question the content, do not blindly
  accept what is being said
• “N” (N)otice body language and facial
  expression-train this skill via use of
  pictures or scenes from movies, TV
 Try these techniques in
  groups or as focus of
    individual sessions.
During groups utilize a peer
   feedback component
More Thoughts on Listening
         Skills
• An area where reduced cognitive skills can
  be misinterpreted as poor interpersonal skills
• No one likes a “noisy listener”
• Poor listening skills can be impacted by
  anxiety (about memory, social skills etc.)
• Relaxation techniques can be helpful (breath
  in slowly over 7 breaths, hold for 4-7 counts,
  exhale over 7, repeat as necessary)
Strategies for Injury
 Imposed Barriers
Watch this scene from the 2007
     Movie The Lookout
 What are the character’s
           barriers?
What are the strategies he is
   using to compensate?
        Brain Injury
the Long Term Consequences
 Follow the injury and recovery of Iraq
 veteran, “Toggle”, a character in the
      Doonesbury comic strip. Gary
    Trudeau accurately depicts blast
  injury, living with motor, visual, and
      speech and language deficits
    (especially aphasia) and PTSD as
   Toggle picks up his life post injury.

   http://www.doonesbury.com/strip/dailydose/
                   References
• Slides 3-21 adapted from Dr. Mary Pepping of the University of
  Idaho‟s presentation The Human Brain: Anatomy,Functions, and
  Injury
• Corrigan JD. (1995). Substance Abuse as a Mediating Factor in
  Outcome from Traumatic Brain Injury. Archives of Physical
  Medicine and Rehabilitation Vol. 76, April: 302-309
• Bombardier, CH., Temkin, NR., Machamer, J., Dikmen
  SS.(2003), The Natural History of Drinking and Alcohol-Related
  Problems After Traumatic Brain Injury Archives of Physical
  Medicine and Rehabilitation Feb;84(2):185-91.
• Bombardier C., Davis, C. (2001). Screening for Alcohol
  Problems Among Persons with TBI. Brain Injury Source. Fall 16-
  19.
• Corrigan J., et. al (1998) Utilities for Community Professionals.
  Ohio Valley Center for Brain Injury Prevention and Rehabilitation
  Resource Coordination in
         Maryland
• Charlotte Wisner, Resource Coordinator for Frederick
  & Washington Counties, call 301-682-6017
• Lauren Dorsey, Resource Coordinator for Baltimore
  & Howard Counties, call 301-529-1508
• Catherine Reinhart Mello, Resource Coordinator for
  Montgomery County, call 301-586-0900
• Any questions regarding resource coordinator or free
  training on brain injury related topics, call Anastasia
  Edmonston, Project Director 410-402-8478
            RESOURCES
• Brain Injury Association of America 703-236-
  6000, www.biausa.org
• Brain Injury Association of Maryland 410-448-
  2924, www.biamd.org
• Ohio Valley Center For Brain Injury
  Prevention and Rehabilitation, 614-293-3802,
  www.ohiovalley.org. Excellent SA TX
  resource & information
• www.headinjury.com. Good resource for
  memory aides and tips
   The Michigan Department of
       Community Health
Web-Based Brain Injury Training for
         Professionals
           www.mitbitraining.org
   This free training consists of 4 module that
     take an estimated 30 minutes each to
    complete. The purpose of the training is
      twofold, to “ensure service providers
  understand the range of outcomes” following
    brain injury and to “improve the ability of
    service providers to identify and deliver
   appropriate services for persons with TBI”
           Resources
  The University of Alabama Traumatic Brain Injury
Model System has created the UAB Home Stimulation
Program. This program offers many activities for use
 by individuals with brain injuries, their families and
the professionals who work with them. The activities
 are designed to help support cognitive skills and can
 be done in the home setting. The Home Stimulation
     Program can be accessed from the Internet at
   htt://main.uab.edu/show.asp?durki=49377. For
further information contact: Research Services, Dept.
of Physical Medicine and Rehabilitation, University of
  Alabama at Birmingham, 619 19th St. S SRC 529,
    Birmingham, AL 35249-7330/ 206-934-3283.
                     Tbi@uab.edu.
       Resources
Rehabilitation Research and Training
  Center on Traumatic Brain Injury
Interventions & New York Traumatic
  Brain Injury Model System at the
Mount Sinai School of Medicine and
   the Mount Sinai Rehabilitation
   Research and Training Center
       www.mssm.edu/tbinet
   Recommended Reading
• I am the Central Park Jogger: A Story of
  Hope and Possibility by Trisha Meili,
  2003
• Every Good Boy Does Fine: A Novel by
  Tim Laskowski, 2003
• Over My Head: A Doctor’s Own Story of
  Head Injury from the Inside Looking Out
  by Claudia Osborn, 2000
 A Product of the Maryland TBI Partnership
Implementation Project, a collaborative effort
   between the Maryland Mental Hygiene
     Administration, the Mental Health
                Management
Agency of Frederick County and the Howard
      County Mental Health Authority
                 2006-2009
 Support is provided in part by project H21MC06759 from
  the Maternal and Child Health Bureau (title V, Social
     Security Act), Health Resources and Services
Administration, Department of Health and Human Service


 This is in the public domain. Please use
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