AccommodatingtheSymptomsofTBI

OhioValleyCenterforBrainInjuryPreventionandRehabilitationWithcontributionsfromMinnesotaDepartmentofHumanServicesStateOperatedServices

GoalsofTraining

¤ Serviceprovidersshouldbeableto:§ Recognizecommonsymptoms

ofTBI§ Incorporatecompensatory

strategiesintotheirpractices§ Increasetheoddsoftreatment

successforindividualswithTBI

¤ Thisinformationisnotintendedtobeusedinplaceofformaldiagnostictestingandtreatmentplanning

1

WhyshouldserviceprovidersbeawareofTBI?

¤AccordingtotheCDC,over1.7millionTBIsoccureachyear

¤Anestimated5.3millionindividualsintheUSlivewiththeeffectsofTBI

¤AhistoryofTBIoftengoesunrecognized

2

NeurocognitiveChangeswithTBI

¤Duetofrontallobedamage,TBIcanresultinchangesin:§ Memory§ Thinkingskills§ Behavior

3

NeedforServices

¤ NeurocognitivechangesfromTBIcommonlyresultin:§ Substanceuseproblems§ Disruptedrelationships§ Employmentissues§ Problemswithlearning

¤ Serviceprovidersarelikelytobe:§ TreatingindividualswithTBI§ TreatingindividualswithTBI

withoutevenknowingit

4

Whatdoesitmeanto“ACCOMMODATE”?

¤Accommodate: Provideservicesinamannerthattakesintoconsiderationthespecialneedsofanindividual

¤Providingaccommodationscreatesanopportunitytoaddresspotentialbarrierstotreatmentsuccess

5

NeurocognitiveChallengestoTreatmentSuccesswithTBI

6

¤ Problemswiththeregulationofthoughts,feelingsandbehavior

¤ Difficultybenefitingfromexperienceandrememberinginformationfromonesessiontothenext

¤ Intentionandbehaviormaybedisconnected

¤ Maynotfitwellwithothersandtheenvironmentbecauseofproblemsperceiving,understanding,andbehavingaccordingtosocialnorms

¤ Differencesincommunicationorlearningstylemakeparticipationindidactictrainingandgroupinterventionsmoredifficultandfrustratingfortheindividual

BarrierstoTreatmentSuccess

¤ LackofexperiencedstaffandreferralsourceswhounderstandhowtoadjusttheirapproachestohelpindividualswithTBI

¤ MisinterpretationofsymptomsofTBIbythetreatmentprovider(e.g.labelinganindividualas“noncompliant”or“resistant”),underminingthetreatmentrelationship

¤ Lackofaconsistentandrichenvironmenttoprovidestimulation,structure,andsupport

¤ Discontinuationoftreatmentbeforegoalsaremet

7

IdentifyingCommunicationandLearningStyles¤ Askhowwellthepersonreadsandwrites;or

observethroughsamples

¤ Findoutwhethertheindividualisabletocomprehendbothwrittenandspokenlanguage

¤ Ifsomeoneisnotabletospeak(orspeakeasily),inquireastoalternatemethodsofexpression(e.g.,writingorgestures)

¤ Askaboutandobserveaperson’sattentionspan;beattunedtowhetherattentionseemstochangeinbusyversusquietenvironments

¤ Askaboutandobserveaperson’sabilitytolearnnewideas,information,androutine;inquireastostrengthsandweaknessesorseekconsultationtodetermineoptimumapproaches

8

ContextualUnderstandingofPerson

¤ Whathasworkedinthepast,andhow?

¤ Whathasn’tworked,andwhy?

¤ Howinterestedisthepersoninworkingonthis?(e.g.onascalefrom1to10)

¤ Whatwouldtheyliketotry?§ Howcanwehelp?§ Comfortablewithtechnology?

¤ Whatcanwedotohelpiftheyarenotawareornotmotivated?

9

ReflectiveRecommendations:Peopleastheirownexperts

q Ask“Whathelpsyouwith____?“§ Learningnewmaterial§ Rememberingnames§ Rememberingtodoassignments§ Finishingyourwork§ Stayingontrack§ Payingattention§ Rememberingthingsyouseeorhear§ Figuringouthowtodonewthings§ Makingchoicesthatkeepyou

healthyandsafe

10

11

2Attention

3Processing

4Memory

5ExecutiveFunction

1Alertness

FlowofCognitiveProcesses

Neurocognitive Functions

Attention

Memory

Processing

ExecutiveFunction

Initiation

Impulsivity

Planning&Organization

MentalFlexibility

Self-Awareness

12

Problem=AttentionAsidefrombeingawakeandalert,oneofthemostimportantcognitiveabilitiesisbeingabletopayattentionorconcentrateonimportantthingshappeningaroundus.Attentionisoftenaffectedwhenfrontalregionsofthebrainarenotworkingproperly.Attentionisabasicthinkingabilitythatmaysetalimitonhowwellother“downstream”functionswork.

13

Afterashortperiodis“checkedout”

Seemstonotpayattentiontowhatissaid

“Thrillseeking”orexcessiverisk-taking

Seekssensorystimulation(e.g.videogames)

Oftenappearsboredordisinterested

Lookfor:

AccommodatingProblemswithAttention

14

• Checktomakesurethereisgoodeyecontactandinitialattentionwhenbeginningataskoractivity

• Beginanactivitywithsomethingthatgetseveryone’sattentionorinvolvesactiveparticipationlikeanicebreaker,achallenge,ordemonstrationthatincludestheirparticipation

AttentionGrabber

• Keepinstructionsbrief,simple,andtothepoint• Boildowndiscussionstocriticalpointspresentedoneatatimeandorganizedfortheperson

BreakitDown

• Discussionsandimportantmeetingscanbeaccompaniedwithpracticeorrehearsaltokeepthepersonactivelyengaged

• Movementandtactileactivitiesenhanceenergyandattention

HandsOn

Problem=ProcessingThetimeistakestothinkthroughandunderstandnewinformationorconceptscanbeaffectedwhenapersonhashadaTBI.Thisdoesnotmeantheycannotunderstand– theymayjustneedmoretimetounderstand.

15

Onlypicksupaportionofinstructionsorconversations

Hasdifficultykeepingupwithaconversation

Maytireeasily

Mayappearto“zoneout”

Mayappearpassiveorunmotivated

Issometimesreferredtoas“lazy”

Lookfor:

AccommodatingProblemswithProcessing

16

• It’seasyforsomeonewithprocessingproblemstogetlostinaconversation.Simplifyinformationandprovideoneideaortaskatatime

Keepit

Simple

• Frequentlycheckforunderstandingbyaskingthepersontorepeatbackinstructionsorideas

CheckIn

•Makesuretoprovidesufficienttimeforthepersontoprocessandrespond.Countsilentlytoyourselfafteraskingaquestiontoallowextratimeforthepersontoprocessthequestion

SlowitDown

Problem=MemoryEverydayourlivesarefilledwithactivitiesthatrequireustomakechoicesandresponsesbasedonpreviouslylearnedinformation,newlylearnedinformationandsometimesboth.PersonswithTBIcanhavetroublerecallingorrememberinginformation.Theyoftenhaveproblemsholdingseveralthoughtsatonceororganizingseveralpiecesofinformationintheirmindtomakeadecisionortakeaction.

17

Inconsistentinperformanceoftasksordailyactivities

Hasdifficultyrecallingpreviouslylearnedinformation

Hasdifficultylearningnewinformation

Mayappearinattentive

Doesnotfollow-throughwithactivitiesorinstructions

Maybedescribedbyselforothersasforgetful

Lookfor:

AccommodatingProblemswithMemory

18

•Wheneverpossible,provideawrittensummaryofimportantinformation.Forexample,writedowntheirnextappointmentandanyactionitemsfortheweek.Iftheyareusinganorganizationalsystem,cuethemtorecordtheinformationintheircalendar

WriteitDown

•Reviewnewinformationfrequentlyandaskthemtorepeatbackwhattheylearnedintheirownwords.Thiscanhelpmaketheinformationmorerelevantandimproverecallofinformation

• Summarizeandsynthesizemultiplepointsintoonecoherentstatementtoreinforcelearning

Repeat

• It’simportanttoteachthepersonto“RemembertoRemember”.Teachcompensatorystrategiessuchascheckingacalendarattheendofasession,orwritinganamedownassoonastheymeetsomeone.Teachassociationsthatwillhelptriggerrecall(e.g.brushingteethisacuetotakemedication)

• Practiceandreinforcecompensatorystrategiesuntiltheybecomeautomatic

Remember

Problem=InitiationResponsibilitiesathomeorworkrequirethecompletionofasequenceoftasks.IndividualswithTBIcanhavedifficultygettingstartedorinitiatingaction.Sometimesapersoncantellyouwhatheorshewantstodobutcannotinitiatethestepsneededtoperformthatactivity.

19

Hastroublegettingstartedwithatask

Appearspassiveorunmotivated

Needsconstantremindersorpromptingtocompleteatask

Abletoidentifyagoalbutcannotacttoachieveit

Oftenreferredtoas“lazy”

Lookfor:

AccommodatingProblemswithInitiation

20

•Breaklargeprojectsdownintosmall,moreachievablesteps(e.g.completingajobapplicationorselectingaplacetolive)

•Encouragethepersontofocusononestepatatime

Simplify

•Theuseofchecklistsandcalendarscanhelporganizeandpromptself-careactivitiesanddailyduties.

•Learningtorefertothechecklistwhen“stuck”canhelpthepersonmoveontothenextstep.

•Overtimethechecklistmaybeinternalizedasafamiliarroutine

Checkitoff

•Atimercanbeusedtohelpthepersongetstartedandlearntofocusonbeingproductiveforasetperiodoftime

•Analarmcanbeusedtoalertthepersontostartanactivity

• Timersoralarmscanbeassimpleasakitchenorstovetimertosomethingmorecomplexandportablelikeanappointmentfeatureonasmartphone

SetanAlarm

Problem=ImpulsivitySometimesitisdifficulttostartanactivity,andothertimesitishardtostopone.ProblemswithimpulsivityareverycommoninpersonswithTBI.

21

Maydoorsaythingswithoutthinking

Mayhavetroubleknowingwhentostopanactivity

Appearstodothingsquicklywithoutregardforsafety

Maynotfollowdirections

Maydominateconversationorinterrupt

Lookfor:

AccommodatingProblemswithImpulsivity

22

• Teaching“Stop,Think,Act”encouragesapersontoslowdownandthinkabouttheconsequencesofabehaviororactivitybeforedecidingtoact(e.g.Isthisagoodideaorabadidea?Whatmighthappen?Isthisconsistentwithmygoals?)

Stop,Think,Act

• Providingincentivesforshorter-termgoals(e.g.giftcardsforattendingappointments)mayimprovecomplianceintheshorttermwhenthepersonisunabletokeepalonger-termgoalinmind

ImmediateGratification

• Responddirectlytoinappropriatebehavior.Forexample,say,“WhatyoujustsaidwasnotOK.”

• Beclearwhensettingexpectations,limitsandconsequences

GiveFeedback

Problem=Planning&Organization

Busyschedulesrequireustokeeptrackofalotofinformation.ManypeoplewithTBIhavedifficultyplanningandorganizingdailyactivities,orneedassistancewithamethodofplanningandorganizingsuchtasks.

23

Isoftenlateforappointments

Hasdifficultyrememberingthingsthatneedtobedoneinthefuture

Oftenmissesimportantdeadlines

Givesupeasilyontasks

Appearstojumpfromactivitytoactivitywithoutcompletinganything

Lookfor:

AccommodatingProblemswithPlanning&Organization

24

• Encouragethepersontodevelopandmaintainconsistentroutinesthroughouttheday

• Identifyaplacetokeepimportantitemslikekeys,wallet/purse,glassesandcalendar

BePredictable

• Encouragetheuseofasystemfororganizingactivities,appointments,and“todo”liststhatmatchestheneedsandabilitiesoftheperson.Thesystemcanbeasimplecalendarorasmartphoneorelectronictabletwithadvancedfeatures

• Appsforsmartphonesandtabletshavebeendevelopedtohelpmeettheneedsofpeoplewithcognitiveproblems

• Prompttowritedownimportantorkeypointsofinformation

Planner

• Remindthepersonofthepurposeofasessionaswellaswhattoexpectalongthewaywithadescriptionofthefinaloutcomeandgoal

• Providedirectionsorinstructionsseveraltimes,andaskthepersontorepeattheinstructionsbacktoyou.Youcanask,“Nowyoutellmetheinstructionsinyourownwords”

SettheAgenda

Problem=MentalFlexibility

Everydayliferequiresustoswitchgearsandthinkonourfeet.Anewapproachmaybeneededwhencircumstanceschange.Whensomeonehasdifficultywithmentalflexibility,heorshehastroubleadjustingtochangingsituationsandunfamiliarcircumstances.

25

Hasdifficultythinkingonhisorherfeet

Getsstuckonanideaoronewayofthinking

Hasdifficultyadjustingtoneworunexpectedtasksandactivities

Maybeargumentativeandnotbeabletoseetheperspectiveofanotherpersonorconsideradifferentidea

Lookfor:

AccommodatingProblemswithMentalFlexibility

26

•Don’ttakeforgrantedthatsomethinglearnedinoneenvironmentwillgeneralizetoanother.Itisimportanttopracticestrategiesinmultipleenvironmentswithdifferentstafforsupportpersons.

Rehearse

•Personswithcognitiveproblemsoftencannotcomeupwithsolutionsoralternativestosituationsthatdon’thappenasplanned.Trytoplanforobstaclesandcomeupwitha“PlanB”.Forexample,identifyaleadormentorintheenvironmentwhocanserveasaresourcetouseifproblemsoccurintheprogramoronthejob.Practicegoingtothatpersonandaskingforassistance.

PlanB

•It’seasyforpersonswithcognitiveproblemstogetstuckonatopicoridea.Whenreviewingmaterial,announcethatyouaremovingontoanewsubjectandallowextratimeforthattransition.Providinghandoutsandanagendamayalsobehelpful.

MovingOn

Problem=Self-AwarenessWetakeforgrantedthatpeopleknowhowtheyarebeingperceivedorhowtheyarecomingacross.IndividualswithTBIoftenhaveproblemswiththeirbehaviorandmaynotbeawareofhowtheyarebeingperceivedbyothers.

27

Underestimatesproblemsormaynotbeawarethataproblemexists

Oftensetsunrealisticgoals

Isunabletoidentifyoralterinappropriatebehaviors

Maysaythingsotherpeoplemightbethinkingbutwouldnotsayaloud

Mayuselanguagethatisnotappropriateforthesituationoraudience

Maydominateinteractionswithothers

Lookfor:

AccommodatingProblemswithSelf-Awareness

28

• Planaheadforsituationsthatmaybringaboutpoorjudgmentandtalkaboutpotentialobstacles

Plan

• Practicepositivesocialinteractionsaheadoftime

• CueforcompensatorystrategiesPractice

• Promotepositivebehaviorbystoppingandaddressingundesiredbehaviorimmediately.

• Providealternativecommentsorchoicesthatcouldhavemade

Promote

q Identifyspecificproblemsthatarepotentialbarrierstotreatmentsuccess

q Developclearstrategiestoaccommodateproblems,takingintoaccountaperson’suniquecommunicationandlearningstyles

q Providedirectfeedbackregardinginappropriatebehavior

q KeepinmindthatnoncompliantbehaviormaybeasymptomofTBI

q Bepatient!AnindividualwithTBIwillneedextratimeandpracticetoachievehisorhergoals

29

Remember

Resources

¤OhioValleyCenterforBrainInjuryPreventionandRehabilitationhttp://ohiovalley.org

30

CustomizedforuseinNebraskawithpermissionfromOhioValleyCenterforBrainInjuryPreventionandRehabilitation

¤ NebraskaBrainInjuryAdvisoryCouncil

¤ www.braininjury.nebraska.gov

¤ 308-865-5012

31

DevelopedinpartwithsupportofagrantfromtheUSDepartmentofHealthandHumanServices,HealthResourcesandServicesAdministration(HRSA)toOhioRehabilitationServicesCommission andTheOhioStateUniversity(2013).

Reprintsaresupported,inpartbygrantnumber90TBSG0013-01-00,fromtheU.S.AdministrationforCommunityLiving,DepartmentofHealthandHumanServices,Washington,D.C.20201. Granteesundertakingprojectsundergovernmentsponsorshipareencouragedtoexpressfreelytheirfindingsandconclusions. Pointsofvieworopinionsdonot,therefore,necessarilyrepresentofficialAdministrationforCommunityLivingpolicy.