TBI-Focus on Behavior &

StrategiesMaryland

2014

Learning Objectives Understand the relationship between

brain injury and behavioral regulation Describe interventions that may

enhance the ability of individuals with brain injury to regulate their behavior

Provide attendees with a variety of strategies that can be implemented at home and community by individuals living with brain injury

Slide 1A.1

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 failureThe following slides 3 are adapted

from Webcast: sponsored by the Health Resources

and Services Administration’sFederal 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

Slide 1B.2

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 TBIResearch 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

Strategies for Supporting Individuals with Behavioral Problems

Adapted from Capuco and Freeman-Woolpert’s Strategies for Supporting an Individual with ABI

Environmental Triggers for Behavioral Problems

Too much stimulation Rapid pacing Lack of predictability and clear structure Overwhelming physical and cognitive

demands Negative social input

TIP:If you manage the environment, you can prevent many problems

And always practice a “Adult to Adult” Communication Style

Bill Kerrigan of Sheppard Pratt

Guidelines for Behavior Management

Keep the environment simple. People with brain injuries are easily overstimulated

Decrease interruptions and distractions and surprises

Be consistent

Guidelines for Behavior Management

Keep instructions simple, concrete If the person has problems processing

language, try gesturing or cueing Write things down Give feedback and set goals Feedback should be direct, caring,

nonjudgmental, but not subtle Avoid criticism

Guidelines for Behavior Management

Be calm, cool and friendly during an incident

This can reduce agitation Avoids reinforcing misbehavior

Guidelines for Behavior Management

Redirection works. When the person is upset, agitated, aggressive, focus attention on some other topic, task, person

Provide choices

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 and 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

Areas of Cognitive Functioning that can be supported by Strategies

Attention Memory Decision making Sequencing Judgement Processing speed Problem solving

differences

Persistence Organization Self-Perception Inflexibility Self Monitoring Initiation

Areas of Interpersonal Functioning that can be supported by Strategies

•Impulsivity•Frustration tolerance•Social skills•Self esteem•Building and maintaining relationships

Most of these Strategies address more than one cognitive and or behavioral deficit

Restoration Verses Compensation

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

InternalThe 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

Examples of strategies-cheap tricks Red lined index card and red stickers:

Addresses visual neglect, attention and concentration

Reading guide: Addresses a number of visual problems including figure ground deficits, jerky eye movements (nystagmus) and impairment in the ability to smoothly move the eyes

Non-slip mats (“dycem”) holds books, plates, bowls, paper etc. in place if one hand/arm has no or limited functioning

Strategies Use of a journal/calendar Create a daily schedule “To do” lists and shopping lists Labeling items Learning to break tasks into small

manageable steps Use of a digital recorder/smart device

Strategies cont.…. Encourage use of rest and low activity

periods, naps are to be encouraged! Work on accepting feedback or coaching

from others, consult and collaborate with trusted individuals

Work on generalizing strategies to new situations

Use of a high lighter (RED) Alarms (on phone, watch, smart device)

Strategies cont.…. Use of PDA/hand held device (e.g. smart

phone) Use of a template for routine tasks, on the job,

at home, in the community 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 cont.…. 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

Audio books, movies, keep the subtitles (for processing content in the case of memory and comprehension problems and increase awareness of nonverbal cues/communication)

Strategies cont.….

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

Memory StrategiesFollowing 6 slides 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 EnvironmentConsistency, 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.

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:________________________________

_____________________________________

adapted from the Rhode Island BIA presentation “Brain Injury: A Practical Training for Caregivers”

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.

ImpulsivityChange 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?

adapted from the Rhode Island BIA presentation “Brain Injury: A Practical Training for Caregivers”

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)

Enhance Communication

Model how to paraphrase during conversations to maximize comprehension

Instruct how to reduce injury imposed tendency to be impulsive in word and/or action by using breaks and pauses

Speak in short, simple sentences and phrases

Communication….

Request that the individual jot down notes regarding discussions that he/she has with others and other important information

When giving instructions, do it verbally and in writing and when possible, physically model the task

Minimize confusion/socially unacceptable behavior

Give useful and specific feedback about a behavior

Ask the individual for permission to coach him/her

Behavior ….

Be clear on your expectations of the individual and his/her behavior

Give feedback immediately using the sandwich technique

Utilize positive reinforcement/feedback Formalize your expectations by negotiating a

written agreement, signed by all involved parties

Refer to the agreement frequently, update as needed

Keep in Mind…..

Talk slowly, use short sentences Eliminate distractions Accommodate individual needs and

learning styles Be flexible Write things down, provide directions Express ideas concretely

By Structuring the Environment, memory,

organization and attention are supported, enhancing

independence, reducing frustration, and freeing up

cognitive and psychological energy to tackle new

challenges at home, work and community

Even for individuals with poor new learning capacity, the three R’s

ReviewRehearse

&Repeat

Can lead to mastery of tasks as they eventually enter into memory

(AKA Procedural Learning)

Awareness is the key to sustained functional gains-For those whose degree of

damage does not allow them to take a self critical stance, they may always rely on the coaching or cueing of others

to employ strategies

Group Exercise

The Lookout

A 2007 Miramax release, starring Joseph Gordon-Levitt, Jeff Daniels and Matthew

Goode. Depicts the life of a young man four years after a moderate TBI.

Read the narrative summary

Break into groups of 4-5 people, after watching the scenes complete the handout

come back together to discuss

References

Retraining Cognition, Techniques and Applications (1996) Rick Parente and Douglas Herrmann. An Aspen Publication

Compensatory Memory Strategy Training: A Practical Approach for Managing Persistent Memory Problems (1985) Sandra B. Milton, Cognitive Rehabilitation

Treating Memory Impairments, A Memory Book and Other Strategies (1994) Vicki S. Dohrmann, M.A., CCC-SLP

Anastasia Edmonston MS CRCTBI Trainer, Maryland Mental Hygiene Administration 410-402-8478anastasia.edmonston@maryland.govProduct of the Maryland Mental Hygiene Administration’s TBI Projects 2014.

Thank You