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I. An Overview of Acquired Brain Injury (ABI)

Acquired brain Injury (ABI) is damage to the brain that occurs after birth. *Damage that is causedby congenital or degenerative diseases is not included in this category. It may be caused by an external oran internal force. An external force is anything that directly causes damage to the brain that is not found

within the human body; an example of this is Traumatic Brain Injury. An internal force is anything withinthe human body that is the direct cause of damage to the brain; one example of this is CerebrovascularAccidents (Hibdard, Martin, & Cantor, 2006).

Common causes of ABI include:

1. Physical Injury2. Cerebrovascular Accidents (CVA)3. Tumors4. Infection

Physical Injury

E.g. Traumatic Brain Injury (TBI) *

Traumatic Brain Injury is injury to the brain that is caused when there is impact or rapidmovement of the head. This results in the brain slamming into the skull, causing bruising, bleeding,swelling, distortion, and or tearing of brain matter and neurons. Thousands of neurons can be damaged

(Farmer, Donders, & Warschausky, 2006; Donders, 2006). Neurons are one of the most important typesof brain matter; these are nerve cells that are responsible for processing and transferring information inthe brain (Carlson, 2005).

Activities that are associated with the acquisition and increased risk of TBI include:

Falls Motor Vehicle Accidents Physical Abuse Contact Sports

Baby Shaking

Cerebrovascular Accidents *

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There are two main types of Cerebrovascular Accidents (CVA): Ischemic and Hemorrhagic.

An Ischemic accident is damage to the brain that is caused when there is blockage of the bloodvessels that supply the brain tissue with blood. This results in tissue death due to the lack of oxygenation.Cholesterol plaques and blood clots are some common entities that cause the occlusion of blood vessels(Carlson, 2005; Gupta, R, & Stokes, T, 2002).

A hemorrhagic accident is damage to the brain that is caused when blood vessels in the brainrupture, damage is also caused when the brain is compressed by this blood that accumulates within the

brain tissue. High Blood Pressure is a leading factor in the rupture of blood vessels (Carlson, 2005).

A report from the Ministry of Health in Trinidad and Tobago noted that in 2004,965 residents of Trinidad and Tobago were hospitalized for CVAs(Ministry of Health, 2005).

Tumors

Brain Tumors *

Brain tumors are a mass of useless cells that grow out of control. Neuron cells do not form tumorsbecause they are unable to replicate in this manner; many of these cells originate outside of the brain.Tumors cause damage to the brain by compressing or infiltrating the tissue (Carlson, 2005; Sohlberg, M& Mateer, C, 2001).

The exact cause of this type of cell mutation is unknown but the following have been implicated:

Toxins Genetics Tobacco Radiation

The Trinidad and Tobago national Cancer Registry reported that Brain tumors were thesecond leading type of cancer among persons 0-14 years old, and in the top four for persons 15-24 yearsold for the period of 2000-2002 (Quamina, 2004).

Infections

Encephalitis *

Encephalitis is acute inflammation and irritation of the brain that may be caused by infectiveagents such as: viruses, toxins, bacteria (Sohlberg, M & Mateer, C, 2001).

Contentious Issues
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From the presenter's review of online public education websites that offer information on ABI, itwas noted that there were some inconsistencies in defining ABI. Some of these inconsistencies includedusing ABI and TBI interchangeably. Some sites have acknowledged this mistake and have sought toamend their definitions while others remain the same. This brings to mind some interesting questionswhich include:

How much does the general public really know about ABI? Should public education focus on ABI as opposed to focusing

separately on the individual causes of ABI? Could this integrative approach lead to better prevention measures?

II.

Description of the Assessment and Diagnosis of ABI

In order to conclude that a person has been affected with an ABI there needs to be some type ofassessment to diagnose the problem. A team approach is often used with persons with ABI (Sohlberg, M& Mateer, C, 2001); an example of this is where neurological investigative test and neuropsychologicalassessments are used to complement each other (Bokde, Meaney, Sheehy, Reilly, Abrahams, & Doherly,2011)

Neurological Investigations

Neurological tests such as * Magnetic Resonance Imaging (MRI) and Single Photon EmissionComputerized Tomography (SPECT) are often used to assist the diagnosis of specific diseases, identifythe anatomical location of neural damage, and to track subtle changes in brain pathology. In addition, theyaid to add credibility to neuropsychological findings (Allen, 2002).

MRI

MRIs are one of the leading investigative tools that are used today in diagnostics. A MRI can

produce detailed images of the brains tissue, nerve cells and bones, by usingradioactive waves andmagnetic fields. It is frequently used in the diagnosis of tumors, infections, inflammation, and vascularabnormalities in the brain. This technique can assist in diagnosing all of the ABI that have been identifiedin this presentation (Allen, 2002).

SPECT

SPECTs are used to assess how the brain functions by using nuclear imaging to monitor cerebralblood flow. This test may be used to assist in the reporting of MRI findings in the diagnosis of tumors and

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inflammation. These images are fed into a computer which presents a three dimensional image of brainactivity and perfusion (Carlson, 2005; Bokde et al, 2011). Areas of damage usual show absent or reduced

perfusion.

Neuropsychological Assessment

Neuropsychological assessment can also be used to identify those changes in brain function whichmay indicate brain injury. Hence, referrals can be made to the relevant expert so that the appropriateneurological investigations can be done and a diagnosis given (Picard, & Stewart, 2007).

A comprehensive neuropsychological assessment is also conducted to indentify:

impairment in relation to the injury individual strengths and weaknesses coexisting disorders

and plan rehabilitation

The neuropsychological assessment is very comprehensive because it is based on the premise thatpsychological, social and biological factors have reciprocal relationships in client care. However, for thepurpose of this presentation the focus will be on some of the parts of testing that are more associated withassessing cognition (Picard, & Stewart, 2007).

The testing Process includes an interview, observations and practical testing.

The Interview

A detailed history from the client and relatives is collected (Picard, & Stewart, 2007). This historyincludes:

+ developmental milestones + childhood experiences

+ occupation + education

+ social + family

+ substance use + biographical information

+ medical + mental health

+ presenting problem

Behavioral Observations

These observations occur in a variety of settings and ways (Picard, & Stewart, 2007), including:

Open conversations Structured Conversations

Controlled Environments Uncontrolled Environments

Familiar Settings Unfamiliar Setting

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Neuropsychological Test

Neuropsychological test are based on a comparative foundation where the clients performance ona test is compared to that of persons his or her age, education, and or sex. One must bear in mind thatthese test have limitations, especially when being used on populations on which they have not beenstandardized. As a result the findings of the test need to be interpreted with caution and in conjunctionwith the other components of the neuropsychological assessment (Kaplan, 2009). Some researchers havequestioned the use of some of these tests because they have not been for use with the ABI population.

Some commonly used neuropsychological test and the associated functions that they assess arepresented in slide 18-19of the power point presentation.

There are no laws in Trinidad and Tobago to regulate who are involved in psychologicaltesting. In addition, Psychological assessment is often expensive, and the hope of obtaining publicservices remains an idea for many of the parents of children who are on the long waiting list, due to thelimited number of trained professionals who are employed in public service.

Contentious Issues

Considering the variety of ways that a person can become at risk for ABI, it is interesting toponder on its reality. Many people may be walking around and unaware that they are being affected by abrain injury that has occurred from being knocked in the head by books, balls, walls, and even dates. Dothe benefits of routine neuropsychological screening outweigh the costs? Or, what you do not knowcannot hurt you? Does the value of neuropsychological test overshadow issues with the validity andreliability of these tests? (Reliability- the consistency with which the tests measure and what it issupposed to measure. Validity- the extent to which it measures what it is to measure.)

III. Identifying the Impact of ABI

Now that we know what ABI is and how to assess for ABI, lets examine how ABI affectthe individual. ABI can have far reaching effects, on the individual as well as their family. It can result in:

1) family problems, 2) loss of employment, 3) physical disability, 4) emotional instability, 5)
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psychosis, 6) social instability, 7) personality changes, 8) sensory alterations and 9) cognitivedefects. Any of these can impact on the other to produce additional changes in the individual, so all arerelevant to understanding the cognitive impact of ABI. However, because of time constraints this

presentation will focus on some of the common Cognitive effects of ABI.

Cognitive defect is any impairment in intellectual function. These include attention, memory loss,impaired concentration, altered perception, and problems processing information, difficulty with planning

and organization, and difficulty sequencing. These deficits are considered to be essential in determining ifthe individual can live independently and their readaptation in to society (Wesolowski, & Zenicus, 1993).The symptoms and signs that are manifested are determined by the cause, location, severity of braindamage as well as the persons age (Seynoe, Kara, & Hunt, 2007).

How ABI affects children may vary from how it affects adults because the childs brain is

immature and therefore at risk to more damage (Seynoe, Kara, & Hunt, 2007). In addition, abnormalitiesin children who are affected by ABI may not be evident until a developmental delay is noticed (Farmer,Donders, & Warschausky, 2006).

Memory loss is common with persons who have damage to the cerebral cortex of the brain.

Problems with memory range from deficits with long term or short term memory. These deficits may berelated to how the individual encodes, stores or retrieves information (Wesolowski, & Zenicus, 1993).

Frontal lobe damage is often associated with alterations in executive functions (planning, workingmemory, attention, problem solving, verbal reasoning, personal inhibition, mental flexibility, multi-tasking, task initiation and self monitoring) as well as narrative speech. Therefore, when it is damaged inchildhood there is longer disability than with adulthood. Strangely, researchers have noted that morecognitive defects are seen in the older age groups; the reason for this is unknown (Seynoe, Kara, & Hunt,2007)

Research has also shown, a link between the following cognitive functions and damage to theseareas of the brain:

Location of Damage Function Effected* Prefrontal abstract reasoning, feelings, personality

*(Answer for F)

Frontal Thalamic planning, motivation

Anterior temporal perception, learning, memory

Mild temporal/ Diencephalon learning, memory, personality

Tempo Parietal complex perception, comprehension

Deeper Parietal cognitive and perceptual integration

Occipital primary and secondary visual processes

Inferior Temporal memory, learning, visual discrimination

Posterior Temporal visiospatial, processing information, verbal

visiospatialBrain Stem/ Limbic system/Deep FrontalTemporal Connections

learning, memory, personality

Fiber Systems in Hemispheres slight subjective changes(Meier, Strauman, & Thompson, 1987)

These findings show that cognitive changes may not be localized to one specific area of the brain.Furthermore, they suggest that the neural connectivity and structural organization of the brain is such thatdamage to the brain can result in a complex set of results.

Case Presentation

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A well known case in the area of neuroscience is that of Phineas Gage. He was injured when asteel rod penetrated into his cheek, through his brain, and out through the top of his head. The Injurymostly caused physical damage that could be seen to the orbitofrontal cortex (Fleischman, 2007; Carlson,2005). However, one must bear in mind that the technological advances such as the MRI that is nowavailable today was not in the 1848 when this occurred. Therefore, possible damage to other areas of the

brain cannot be narrowed out; but the significance of this case is relevant to understanding the brain-behavior relationship.

Dr. Harlow, the doctor who took charge of the management of Gage, reported that Gage had lostthe ability to balance his intellectual capacity and his natural animal inclinations. In essence, the frontallobe damage caused by the external force resulted in problems with verbal reasoning, personal inhibition,

problem solving, mental flexibility, multi-tasking, task initiation, and self monitoring (Fleishman, 2007).The results from review of this case concur with the research findings.

On average, doctors at St Anns Hospital are visited by one person every three months, who hasa psychological impairment with a history of head injury (Marajah, K., 2011).

Contentious Issue

Since, adults with ABI are more at risk than children for cognitive problems, should the public

resources that are available be more focused on providing care to adults? Is there benefit in providingmore money to conduct research on brain- behavior when so much research has been conducted alreadyand so many questions remain unanswered? Or could this money be better used by providing thoseaffected, with the necessary care?

IV. Theoretical Principles for Using Rehabilitation

Now that we know what ABI is, how to diagnose and assess it, as well as its impact; wemust now help the person to overcome this impact. However, before we arrive at the point where we takeaction, we must seek to find some type of theoretical principles or constructs to justify why we do, whatwe do.

Luria (1963) recognized that the Central Nervous System (CNS) spontaneously recovers afteracute injury. This recovery may extend from 1-2 years after injury. During this time it is said that there isfunctional reorganization and new neural pathways are generated to replace the ones that were damaged.In addition to these structural changes, functional changes also occur (Farmer, Donders, & Warschausky,2006). On the other hand, Seynoe, Kara, & Hunt (2007) reported that after injury the recovery process

reaches its peak at about 2-4 years. However, additional research has shown that even persons withchronic brain injury who are exposed to rehabilitation show improvement.

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The process and outcomes of the rehabilitative process have been addressed by three majortheories: Substitution, Compensation, and Relearning. The overreaching premise among these threetheories is that once there has been damage to the CNS, there will be some permanent and or irreversibledamage.

Substitution

Substitution, explains rehabilitative outcomes seen, when brain tissue that has been slightlydamaged or not damaged at all take over the roles of those tissues that have been damaged. One examplegiven was that by maintaining the environment the brain was able to bypass brain damaged areas and getanother part of the brain to solve the problem. * It suggests that the brain is flexible in the way that itcommunicates with its structures. Another premise is that the brain has reserve tissue that is either notutilized or underutilized. This tissue that is not utilized or underutilized is then able to take up the role ofthose areas of the brain that are lost (Ruff, & Baser, 1990).

Compensation

Compensation theory, proposes that parts of the brain that are responsible for lower levelfunctions take over higher levels of functioning when there is brain damage (Ruff, & Baser, 1990).

Relearning

Relearning theory, proposes that when individuals are exposed to activities and feedback is given,the person can learn new behaviors despite how severe the brain is injured. In addition, new ways ofdoing things can compensate for lost functions. This is the main principle behind rehabilitative treatment(Ruff, & Baser, 1990).

There is an absence of local research or compiled statistics that deals specifically withABI. There are no support groups for Trinidadians who are affected by cognitive deficits associated byABI.

Contentious Issue

* Theory supports the use of rehabilitative processes with person living with ABI. However, thereis limited documented empirical evidence to support some of the techniques that are used in

rehabilitation. Should professionals continued to use these methods, despite the obvious lack of empiricalevidence?

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V. Rehabilitation of Persons living With the Cognitive Effects of ABI

Finally, how does one go about rehabilitating an individual who has been cognitively affected byABI? One aspect of Rehabilitation from cognitive impairment is done primarily by exercising the brain.This may be done initially on an inpatient basis and then transition into a community process. Otheraspect of rehab focuses on improving the clientsquality of life by increasing independence, andfacilitating readjustment ( Sohberg, M, & Mateer, C, 2001).

Although cognitive deficits in people with brain injury are similar rehabilitative strategies must beindividualized. This is why there is a dire need for neuropsychological assessment, so that the individualsstrengths, weaknesses, and needs can be met (Farmer, Donders, & Warschausky, 2006; Seynoe, Kara, &Hunt, 2007).

V.1Pharmacological Intervention

Pharmacological interventions have been used as part of the rehabilitation process. Stimulantssuch as methyphenidate hydrochloride have been shown to improve concentration and behavior inchildren. Some professionals believe that pharmacological interventions are a significant part of therehabilitation process. For the financially challenged, it may be the most affordable option. Onedrawback is that a medication can have a range of side effects depending on its chemical composition.Other classes of medications are also used, but their use is dependent on the presenting problem (Farmer,Donders, & Warschausky, 2006). Below is a list of some of the types of medications and their use:

>Anxiolytic- anxiety >Hypnotics - insomnia

>Antidepressants- depression >Stimulants- concentration and impulsivity

V.2Social Worker Intervention

Another rehabilitation aspect for persons living with cognitive deficits may involve the access tofinancial and social support.Social workers are involved to assist the person in assessing social servicessuch as housing and finance. People need to meet their basic physiological needs, such as food, clothing,

and shelter, in order to recover and survive. Although this is not directly related to changing brainfunction, research has shown that when persons with cognitive defects are under stress, this increases theseverity of the cognitive symptoms.

V.3Occupational Therapy

Occupational therapy helps clients to improve their social skills, and assist to reintegrate clientsback into the community. This is an important part of rehabilitation. Memory loss may cause individualsto have to relearn how to be social (Sapezinskiene, L.,Svediene, L., &Guscinskiene J,2003).

V.4Family Therapy
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* Family therapy is a necessary part of the rehabilitative process for persons living with cognitivedefects. The family needs to resolve emotional issues, such as guilt, shame, and anger, so that they areable to offer the client a supportive and nurturing environment. In addition, the burden of caring for a

person with a cognitive deficit can be overwhelming. Having a supportive family unit or member can aidin the clients improvement because the client can be assisted with certain rehabilitative modalities, as wellas general support to reduce stress and improve the quality of life (Farmer, Donders, & Warschausky,2006).

V.5Biofeedback

This is a new method that is being used by psychologist who have specialist training in this area.It uses reinforcement to alter brain activity. The patient is given information about how his or her body isfunctioning. The person then uses this feedback to train their reaction (Glanz, Kwlawansky, & Chainer,1997). This can be used with clients with mild to moderate cognitive deficits who can understand the

procedure; it is especially useful for treating the physical effects of ABI.

V.6Individual and Group Psychotherapy

Persons living with ABImay be involved in a variety of psychotherapies. Therapy may beoffered on an individual level and or in a group structure. These therapies are usually focused onimproving cognitive functioning in areas such as: a) memory, b) orientation, c)attention, d) selfawareness, e) problem solving and f) planning. The type and structure of therapy are usually based on theindividualsneeds as well as the severity of the cognitive defect.

a. Methods to Improve Memory

Some methods that are used to improve memory are retraining and compensatory strategies(Wesolowski, & Zenicus, 1993).

a.1Retraining

Retraining methods include written and verbal rehearsal, acronym formation, visual imagery,chunking, association and rhyme formation.

-Rehearsal

In written rehearsal the client is taught to repeatedly write the information that he or she needs toremember. This is done as often as it is necessary for the person to remember. It cannot be used if theindividual has severe gross motor skill impairment, or is unable to read. Verbal rehearsal would be moreeffective for these persons (Wesolowski, & Zenicus, 1993).

Verbal rehearsal is done where the client repeatedly states, aloud or whispering, the informationthat he or she needs to remember. Clients who cannot self initiate may need family members to prompt

them. Verbal rehearsal has the benefit of being easier to implement than written rehearsal because theactivities are spoken. However, written rehearsal has the benefit of providing the client with cues.

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Both methods are also suitable for remembering a small number of daily activities, and moresuited for clients who can self initiate. Neither can be used effectively in severe cognitive impairment.

-Acronym Formation

The client is taught how to use letters to make codes for information that he or she needs toremember.

-Chunking

The client is taught how to group information together.

-Visual Imagery

Visual Imagery is one of the most widely researched and used strategies. The client is taught tomake mental pictures of the information that he or she need to remember. Information that is important,unusual, or humorous is easier to remember using this method. This takes a lot of time to implement andresearch had not shown that the client can use this method by themselves (Wesolowski, & Zenicus,1993).

-Association

This is a behavioral method that is used to link old or familiar information to information that theclient wants to remember. One limitation is that the client must remember to use it.

-Rhyme Formation

The client is instructed on how to make rhymes that are formulated from the information that theclient wants to remember.

Common limitations of many of these methods are that clients may be unable to self initiatetechniques and so family members may have to prompt them, they do not facilitate remembering largesets of information. Learning occurs but clients may not be able to apply it to other situations. Clients

with sever deficits fail to learn from these methods (Wesolowski, & Zenicus, 1993).

a.2 Compensatory

Compensatory methods aid to eliminate some of the limitations of the rehearsal strategies and aremore suited for person with severe memory deficits.

External memory sources or aids help to supplement deficits in memory (Sohlberg, M & Mateer,C, 2001). People with ABI who have been thought retraining strategies tend to prefer the use ofcompensatory strategies such as lists, appointment books and diaries. In addition, the training for using

aids is simpler than that for retraining. It was noted that because the use of memory aids are moregeneralized it makes it easier for the client to transfer the learning to other situations. The long term resultis the learning of problem solving as well as increased memory (Wesolowski, & Zenicus, 1993).

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There are three main types of compensatory strategies: 1) storage devices such as checklists,memory notebooks, calculators and computers 2) cueing devices such as clocks, bells, alarms, and timers3) restructured environment such as the use of labels and rearrangement of furniture.

a.2.1Storage Devices

-Written Checklist

These are used to outline steps, tasks, and skills that are necessary to complete a particular task.Checklists have three main components that make them effective:

1)A Column for information that is to be remembered2)A blank column for crossing off completed items3)A title and date at the top

The therapist models the use of the checklist, checking off each step after its completion. Then theclient practices the process. The reliance on the checklist can be gradually faded out by removing one stepat a time; at the end the skill is acquired.

-Memory Notebooks

The first step in using this technique is to explain why the technique is being used. The next stepis to model the use of the notebook and have sessions to review how to use it. The client is givenfeedback and praise on his or her use of the technique. One disadvantage of this technique is that theclient has to remember to use the notebook. However, it is suitable for remembering large quantities of

information (Wesolowski, & Zenicus, 1993). The therapist must motivate and reinforce the use of thenotebook, help the client to organize and practice using it, and teach how to use the device. The client istaught how to rely on the device by being given homework that calls for the use of the device. The clientmust be aware of what is in the notebook. One disadvantage is that this cannot be used with people whocannot read.

a.2.2Cueing Devices

-Visual Cues

Visual cues can be written or graphical objects such as pictures or maps. They signal to the clientto remember information. Some common ones include labels. This has been effectively used by Burke(1990) to reduce the use of profanity with a patient with ABI.

a.2.3Restructured Environment

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-Environmental Restructuring

The environment is restructured so that it prompts the client to react in a certain way. Changes canbe made to the clientsphysical environment or schedule. Examples of this include grouping specificdaily activities. This is effective when it is used in a familiar environment (Farmer, Donders, &

Warschausky, 2006; Sohlberg, M & Mateer, C, 2001).

b. Orientation Methods

b.1Orientation Groups

Daily orientation groups may be facilitated by occupational therapist. This is suited for theinstitutional setting and is usually the first session on the day. Clients are oriented, and the daily

scheduled is reviewed. The first step is to assess the clientsorientation and schedule by asking the clientto write it down, the clients share their responses and feedback is given (Wesolowski, & Zenicus, 1993).

b.2Individual Orientation

Individual orientation is used on a one on one basis when there is sever disorientation. Thismethod allows for more material to be covered, and the giving of immediate feedback. The therapist asksabout one aspect at a time. The client is given about three seconds to reply. If the reply is incorrect or sheor he does not answer, the therapist provides the cues and another 3 seconds is given. If it is incorrect or

unanswered the therapist provides the correct answer and then asks the client to repeat the correctresponse. Appropriate reinforcement is given for correct answer (Wesolowski, & Zenicus, 1993). s. Thisis done until the client is oriented.

c.Attention Methods

Attention methods center on thepersonsability to focus on stimulus, task or situation. It iscomprised of three components: alertness, vigilance/ capacity, and selection (Wesolowski, & Zenicus,1993). . Alertness is apersonsreadiness to react to a stimulus. Vigilance is the amount of mental effort.While selection is focused on what the person attends to. Attention training strategies include: 1)environmental restructuring, 2) salience of target stimuli, 3) checklists, 4) self monitoring, 5) self talk, 6)overlearning, 7) altering consequences, 8) feedback, and 9) cueing devices.

c.1Environmental Restructuring

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The environment is manipulated by increasing, decreasing, or totally eliminating stimuli. Thisfacilitates behavior change and adaptation. Some examples include reducing noise and or lighting,changing colors, and reducing the number of people in a room (Farmer, Donders, & Warschausky, 2006).

c.2Salience of Target Stimuli

This involves changing the location or color of an object or item on a list.

c.3Checklists was previously covered.

c.4Self Monitoring

The client learns to monitor their own behavior. It is believed that when people monitor their ownbehavior their behavior changes. The client is taught to note when he or she is attending to their ownbehavior by placing a tick in the appropriate chart, when the cue is presented. Bells, timers and recorded

messages can be used as cues (Wesolowski, & Zenicus, 1993).

c.5Self Talk

The client observes his or her own behavior and then talks aloud or whispers to themselves. Thiscan be used with self monitoring. The client asks themselves questions, as well as gives the answers aloudto themselves (Farmer, J Donders, & Warschausky, 2006).

c.6Over learning

The client repeats the task over and over, after it has been demonstrated. The client must showsome capacity to learn in order to use this method.

c.7Altering Consequences

Task completion and positive behavior, is reinforced and the opposite is reprimanded. Thestimulus that is given must be reinforcing for this to be effective and the one used for failure of the task

should reduce the number of times that the task is not completed.

c.8Feedback

Feedback can be given in a written or verbal form. The therapist makes positive contact, and thenfeedback is given.

c.9Cueing Devices

Cueing devices are those which prompt the client to react. These devices include clock, bells andtimers. The client is trained how to use the device and given frequent opportunities to practice it.

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d.Self Awareness

Self awareness strategies include education, personal adjustment groups, team integration, goaland journal groups, natural consequences and video therapy (Wesolowski, & Zenicus, 1993).

-Video Therapy

In video therapy clients learn by watching video recording of themselves in a variety of situations.

-Natural Consequences

The client is allowed to experience the natural response to the effects of his or her behavior. Thisaids people to be aware of unrealistic goals.

-Personal Adjustment Groups

The individual is given feedback from the group, on his or her abilities and limitations.

e.Problem Solving Strategies

Problem solving strategies include problem solving groups, problem solving vignettes, flowsheets, current event groups, and scheduled problem (Wesolowski, & Zenicus, 1993).

-Scheduled Problems

Scheduled problems allows the client to problem solve in a structures and controlled environment.The client is trained as to how to respond if he does not know how and is given feedback. This strategy issuitable for training a person for a new environment.

-Current Event groups

Current event groups are involved in reviewing current events via the television, newspaper ordocumentaries. They then go through the problem solving process of identifying the problem, looking atthe advantages and disadvantages, and the selecting the best possible options (Wesolowski, & Zenicus,1993).

-Flow Sheet

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A flow sheet is a tangible reminder that gives steps for resolving a problem. The rationale forusing this method is given to the client, then the therapist models the activity, after which the client triesit, and the necessary feedback is given.

-Problem Solving Groups

The therapist takes a small group, of not more than five people, through the problem solvingprocess. Then they apply it to real situations.

f.Planning Disorders

Planning disorder strategies include planning groups, planning checklists, repeated exposure andcurrent event groups (Wesolowski, & Zenicus, 1993). . These methods involve identifying the problem,gathering the relevant information, exploring possible solutions and then structuring a plan.

-Current Event Groups

Current event group are used to formulate plans for specific problems.

-Repeated Exposure

The individual is given the opportunity to be repeatedly exposed to planning. The procedure ispracticed repeatedly and feedback is given by the therapist.

Many of the rehabilitative services are not covered or inadequately covered by insurancecompanies in Trinidad, and so persons are often unable to bare the cost of such services. A session withan Occupational Therapist in Trinidad starts at $200 TT, while the price for neuropsychological testingcan be thousands of dollars (Garcia, L., Edwards, R., Green, R., & Sthepens, S, 2007).

Contentious Issue

Do the benefits of rehabilitation outweigh the cost, considering that that there is no guaranteethat the individual will return to a higher level of functioning? It is better to be cost effective and stickwith pharmacological methods which are much more reasonably priced?

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Overreaching Contentious Issues

Should private service providers lower their cost so that more people can afford to access

their services? Is the quantity of money that these professionals are asking for on par with the standardof service that they provide?

Main Interaction Between Components

Each of the components contains information that is necessary to know in order to plan, andimplement appropriate individualized rehabilitative care for clients living with ABI. The first

component explains what ABI is and gives detailed examples of ABI. However, to be certain that aperson has ABI, he or she must be diagnosed, and so part of the second component leads to making adiagnosis of ABI. One you know what you are looking for and how to find it then you need tounderstand how effected the individual as a person. The second part of component two, the

Neuropsychological assessment aids one to identify how ABI has effected the individual. This is asignificant step in identifying strengths and weaknesses and individualizing therapy; everyone withABI will not be affected the same way. As long as we know how the individual is affected, we areguided by theory or empirical evidence (Component iv) in deciding what types of rehabilitationtechniques (Component v) should be more effective. In addition, once the information in componentsone to four is available a client oriented rehabilitation program can be implemented.

References

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Donders, J. (2006). Traumatic Brain Injury. In Farmer, J., Donders, J., & Warschausky, S. TreatingNeurodevelopemntal Disabilities: Clinical Research and Practice. Guildford Press: London.

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Goldstein & McNeil (Eds.). (2004). Clinical Neuropsychology: A Practical Guide to Assessment andManagement for Clinicians. Wiley.

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Rehabilitation. Guildford Press: New York.

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The Six Multiple Choice Questions

A) Examples of Acquired Brain Injury include all the following except:

1. Encephalitis

2. Cerebrovascular Accidents

3. Traumatic Brain Injury

4. Alzieimers Disease *

5. Brain Tumors

The answer can be found in slide number 2 with supporting evidence in slide 3, 4, 6, 8. They havealso been identified in *yellow in this handout.

B) Examples of Neurological Investigations include:

1) Magnetic Resonance Imaging and

2) Myelograph and Single Photon Emission Computerized Tomography and

3) Single Photon Emission Computerized Tomography and Magnetic Resonance Imaging *

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4) Mediastinoscopy and Amniocentesis

5) Thoracentesis and Mediastinoscopy

The answer can be found in slide number 13 and had also been identified in *green in the handout.

C) Most Rehabilitative strategies:

1) Can produce 100% recovery

2) Are easy to access in Trinidads Public Health System

3) Are available at a reasonable cost

4) Are based on sound empirical evidence

5) lack of empirical evidence *

The answer can be found in slide number 33 and had also been identified in *red in the handout.

D) Family therapy:

1) Is not important in rehabilitation

2) is a necessary part of the rehabilitative process *

3) Can only benefit persons with mild cognitive impairments

4) Ss

5) Ss

The answer can be found in slide number 39 and had also been identified in *pink in the handout.

E) The substitution theory of rehabilitation explains that the brain is:

1) Flexible and has unutilized tissue *

2) Incapable of alerting the way that it communicates

3) Able to regenerate new cells

4) Minimize injury by increasing blood flow

5) Resistive to change

The answer can be found in slide number 29 and had also been identified in *grey in the handout.

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F) Injury to the prefrontal cortex of the brain has been associated with changes in:

1) Comprehension, learning, visual discrimination

2) Complex perception, learning, memory

3) Memory, perceptual integration, personality

4) Abstract reasoning, feelings, personality *

5) Visual discrimination, comprehension, planning

The answer can be found in slide number 25 and had also been identified in *blue in the handout.

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