Working with People with ABI : 2.WORKING WITH ABI : b) Injury - effect - behaviour

i) Injury - effect - behaviour - strategies

People with an ABI have a brain injury.
The injury has an effect on the working of the brain.
The working of their brain affects their behaviour.
People working with people with an ABI have to manage behaviours.

Rules of thumb

1. Understand:

What is the injury?
What is the effect?
How is the effect expressed in behaviour?
What are strategies for managing the behaviours?

2. Get to know the person

3. Get to know what strategies work for this person.

One worker said:

As a result of his accident he is left with his residual left sided weakness. He has chronic pain in his left knee and that's with – they have tried to address that with surgery but it is more to do with his brain injury as opposed to actually his knee. Obviously his speech is still affected and his behaviour. His behaviour is the biggest element. He can be quite oppositional, he can be threatening. We have had occasions where we have had to call the police out because he has threatened to hurt people. He just doesn't understand the consequences of those behaviours and he just thinks about the immediate gratification of needs.

ii) Clip 5. Gabby : Before and After (2min 30 sec)

Gabby describing how she was before the accident and how she is now .

Answer the following question:

What are some of the before and after differences for Gabby?

Check your answers here

Lot more relaxed with the future. I don't feel as stressed about am I going in the right directions.

Now focussed on small things. The small things are a big thing - switch off the light, open a cupboard door.

Don't feel a sense of loss - I think that is part of the brain injury.

Friends find not having a sense of loss strange to comprehend.

Learnt patience.

Mobility issues.

iii) Cognitive and behavioural changes - problems arising - support strategies

Screen 1 is an overview. Screens 2, 3 and 4 have specific examples.

SLIDES: To pause: Hover mouse over slide. To continue: move mouse off slide.
To go to a specific slide: Click on slide numbers below.

iv) Strategies for cognitive impairments

These are typical cognitive impairments, problems arising and management strategies.

There are also strategies for other changes e.g. mobility, communication, sexuality.

More strategies can be found in the following modules on the www.TBIStaffTraining web site:
These strategies would be appropriate for many types of ABI (in addition to TBI).

2: Communication
3: Promoting skills for independence
4: Understanding and managing cognitive changes following an TBI
5: Understanding and managing behaviour Changes following an TBI
6: Sexuality after an TBI : issues and strategies
9. Mobility

Cognitive Impairment	Problems arising	Management strategies
Attention and Concentration	have difficulty concentrating being distractible finding it hard to cope with more than one thing at once getting bored quickly switch off and appear not to listen not remembering what others have said not completing things they start changing the subject often	reduce distractions (e.g. noise, other people) use short, simple sentences encourage the person to stay with the activity for longer periods change activities when necessary when distracted, interrupt and bring back to task give reminders of next step keep to a routine
Speed of information processing	taking longer to complete tasks unable to keep track of lengthy conversations and instructions	make allowances and give the person extra time present information slowly present information in chunks present one thing at a time check that the person is keeping up
Fatigue	having an overall reduced ability to cope getting irritable and distressed having other problems exacerbated	encourage the person to take rest breaks schedule more demanding tasks when the person is at their best (often mornings)
Memory	finding it hard to remember new things forgetting appointments forgetting things people say frequently losing things	give reminders repeat information when necessary encourage person to rehearse and repeat information encourage use of external reminders, i.e. diaries, post-it notes structure a routine by breaking tasks into small steps keep belongings in regular places
Problem solving	reduced ability to find solutions to problems	train the person to approach new tasks in a systematic manner, e.g. break the task into small parts reduce the demands made on the person help educate the family and others about the person's problems avoid giving the person open-ended tasks
Planning and organisation	having difficulty working out the steps involved in a task not considering the end result of their actions having trouble organising their thoughts and explaining things to others	avoid becoming frustrated with the person give prompts for the following steps provide a written list which outlines the steps in order
Rigid and concrete thinking	taking statements literally insensitive and unable to consider feelings of others having a simplistic understanding of emotions being resistant to change keeping doing things incorrectly despite feedback	use simple and direct language, avoid abstract terms avoid using hints or sarcastic humour encourage person to imagine how they would feel in other situations explain any change in routine in advance, giving reasons
Disinhibition	being impulsive and act without thinking of consequences making rash decisions acting inappropriately toward people (including sexually) behaving in a silly, flippant or childish way disclosing personal information too freely	give immediate feedback, briefly asking person to stop behaviour and explain why provide appropriate external controls e.g. over finances remind person of the sensitive nature of some information, giving clear examples ignore the behaviour where possible
Reduced self-control	losing temper quickly being physically/verbally abusive having a lower frustration tolerance	distract or remove the person from anger-provoking situation withdraw attention when appropriate try not to escalate the situation by shouting back identify anger-provoking triggers and avoid when possible
Egocentricity and self-absorption	not considering consequences of their behaviour on others being unable to 'put themselves in someone else's shoes' appearing selfish to others not appreciating carers	try to explain situation from another's or your point of view try not to take offence, understand why the person is like that
Emotional lability	laughing and crying inappropriately changing moods quickly	try to identify triggers which result in mood swings be prepared for changes by having alternative plans
Perseveration	talking about the same topic repeatedly returning to the preferred topic when doing something else	remind person gently they've told you the information before distract the person back to the preferred activity ignore, as much as possible, future references to the topic try not to get into arguments, walk away if you're getting irritated
Reduced insight	being unaware of both cognitive and physical limitations having unrealistic goals, plans and expectations resisting efforts of carer/staff not realising that they have made errors because they haven't checked their work	gently remind person of deficits explain why proposed action is useful, reason through the steps point out possible negative consequences of person's unrealistic plans place external limitations where necessary (e.g. removal of driver's licence/access to car) gradually expose person to reality testing experiences
Poor self monitoring	not realising that they are 'hogging' conversations being verbose and keep talking when others are no longer interested	encourage them to check over their work use signals, agreed in advance, to let them know they're talking too much encourage turn-taking in conversation use external aids, e.g. graphs and tables to help the person monitor their behaviour
Reduced social skills	interacting poorly with others because of all the above problems losing their ability to relate well with others not picking up the usual social cues (e.g. looking at watch)	teach specific strategies like maintaining eye contact, asking questions of others, turn taking in conversation try to encourage awareness of others' reactions
Inertia	appearing to have no motivation and seem apathetic not acting until prompted not completing tasks knowing how to do something, but not doing it spontaneously	encourage person to commence activity prompt first step of the task try to find things that are most interesting for the person reward and encourage any self-initiated activity and persistence accept that the person may need less activity to keep them occupied and happy
Restlessness	complaining of boredom and be restless and agitated	remind person of activities they usually enjoy promote physical activity which may expend some energy

(c) Copyright - See: Module 4: Understanding and managing cognitive changes following an TBI - www.TBIStaffTraining.info

v) Case study Questions

Read the following case study and then answer the questions below.

This 16-year-old male suffered a severe traumatic brain injury and facial fractures in a motor vehicle accident. His rehabilitation progressed well and he returned to live in the family home. A year after his injury he planned to return to school to do his HSC and eventually go to University, as he had always intended to do.

A review neuropsychological assessment was conducted around the same time.

On interview the young man complained that he forgets things he has been told, needs to go over and over information to remember it, needs to reread paragraphs to be able to understand what he is reading, and has difficulty following conversations.

The assessment found:

he had a very short span of attention
he could not divide attention (unable to follow more than one thing at a time)
his processing speed was slow
new learning was poor, information needed to be repeated
he did not recall much after a delay
he had difficulties remembering if his learning was interrupted by another task or different information
he was disorganised and did not plan how to work things out
some concrete reasoning
rapid fatigue when maintaining mental effort

He also demonstrated:

general problem solving skills at an appropriate level
excellent arithmetical ability
good adaptive skills, so could modify what he was doing to meet change and utilise feedback
he was able to recognise more information than he was able to recall
some insight towards his cognitive difficulties
an eagerness to get into University (which may be good or bad).

(c) Copyright - See: Module 4: Understanding and managing cognitive changes following an TBI - www.TBIStaffTraining.info

Questions

Answer the following questions:

What strategies could you suggest to assist this young man with managing his HSC studies?

Name three strategies for each of :

Strategies he could do himself,
Strategies the school might be able to provide, and
Strategies that are changes that may be needed at home

Check your answers: Strategies that he could do himself

Complete HSC studies over two to five years. Part-time study program at TAFE.
Write all important information down
Make use of a diary – aid with memory and organising self
Follow a weekly timetable – classes, breaks, study, travel, leisure time
Review small amounts of work/information often
Keep subject notes well organised
Ask questions
Study one subject at a time and have a break between changing topics
Prepare before classes, complete set readings
Limit distractions when trying to study (fatigue, hunger, drugs and alcohol).

Check your answers: Strategies that the school might provide

Sit at front of class to keep focus
Use a note taker or a tape recorder in classes (sometimes class notes are available)
Tutor to assist with interpreting assignments and developing a framework for generating and organising answers
Extra time during examinations to allow for slow processing or rest breaks
Possibly splitting up an exam over two sessions
Having a separate room for examinations so won't be interrupted.

Check your answers: Strategies that may be needed at home

Keep study space tidy and well organised
Have 'special places' for items (pens, rulers, keys, wallet, phone, diary)
Have a quiet place to study, somewhere interruptions are unlikely
Limit distractions when trying to study (TV, radio, other people, mobile phone).

b) Injury - effect - behaviour - behaviour support

i) Injury - effect - behaviour - strategies

Rules of thumb

ii) Clip 5. Gabby : Before and After (2min 30 sec)

iii) Cognitive and behavioural changes - problems arising - support strategies

iv) Strategies for cognitive impairments

Cognitive Impairment

Problems arising

Management strategies

Attention and Concentration

Speed of information processing

Fatigue

Memory

Problem solving

Planning and organisation

Rigid and concrete thinking

Disinhibition

Reduced self-control

Egocentricity and self-absorption

Emotional lability

Perseveration

Reduced insight

Poor self monitoring

Reduced social skills

Inertia

Restlessness

v) Case study Questions

Questions

Answer the following questions:

Planning and
organisation

Rigid and
concrete thinking

Egocentricity and
self-absorption

Reduced social
skills