q) A case studyNext E)

i) Case study

James is 28 years old and sustained a traumatic brain injury following an assault. He participated in a 3-month inpatient rehabilitation program at a Brain Injury Unit in a hospital. As a result of his injury, James has weakness down his left side, making it difficult for him to walk long distances or carry heavy objects. James also has difficulty planning and organising his time. Often on the ward in the hospital he became frustrated because he couldn't seem to get to his appointments on time.
It is now eight weeks since James's discharge. He has returned to live in his two-bedroom unit. He is living alone and receiving carer support for main meal preparation and heavy household cleaning tasks. James has been finding that he is tired all the time and that he is not managing to get on top of all the household chores. He is finding this very frustrating and is often having aggressive outbursts due to this frustration.

James also has difficulty remembering exactly what he has done during the week and what appointments he needs to attend. This often makes it difficult when James meets up with friends who inevitably ask, "what have you been doing lately?" It also means that he has to be extremely careful that he doesn't double-book himself.
James has parents and a sister who regularly keep in touch with him.


There are questions about this case study on each of the tabs.
Whatever your role try and answers the questions for all the other roles as well.
This will help provide a holistic view of the case and how to respond.      



ii) Information and referral workers questions

Answer the following question:

James rings your service up wanting additional support for cleaning in the home? How do you respond?
Check your answers here

The essence of approaching a good response is to:
a) not make assumptions and
b) ask specific questions to tease out what is happening and
c) gather more information at a later time and/or from others if necessary
d) pick things that you can work on

Ask specific questions. For example:
What's going wrong?
Have you got anyone coming now?
Who pays for them?

Discover why he is asking for additional support.

Don't make assumptions.
It may be that he is getting the cleaning but he is not letting them clean.
Just because the person thinks they need more workers doesn't mean that is the answer.
Question his assumption that this is the answer.
E.g. he may not be at home and so they don't come.

Get more information at a later time from him or another person.
What about you go away and write down what the problems are and ring me again.
Who lives with you? Can I talk to them about this?

Pick things that you can work on
If he has difficulty remembering appointments, is he using a diary? If not who could help him with this?


Answer the following question:

James' parents ring up wanting to know what services are available to help James with his frustration and anger? How do you respond?
Check your answers here

The essence of approaching a good response is also to
a) not make assumptions and
b) ask specific questions to tease out what is happening and
c) gather more information at a later time and/or from others if necessary
d) pick things in the case that you can work on

Ask specific questions:
When do these things happen?
What services are being provided?
What happens when he is frustrated?

Do not make assumptions:

It may be that James only experiences frustration at specific events, e.g. missing appointments.
If so the solution may be practical e.g. using a diary and a reminder in a mobile phone rather than psychological.

It may be that James experiences frustration in a wide range of different situations, he may need an assessment from a clinical psychologist. If so do they know if there has been an assessment done? Is he seeing a clinical psychologist? What is the history? This will help identify what the referral network was/needs to be.

It may be that the parents are having difficultly dealing with the frustration because they are tired, worn out and need some respite.

Pick the things in the case that you can work on.

He is missing appointments. He has a memory problem.
Has he got a diary or a weekly planner? Who can help him with this.

If the parents need respite, who can help with this?

iii) Support workers questions

Answer the following question:

1. Identify the skills and tasks that James has difficulty with.
    Check your answers here

1. Difficult for him to walk long distances or carry heavy objects.

2, Difficulty planning and organising his time.

3. He is tired all the time and that he is not managing to get on top of all the household chores.

4. He is having difficulty managing frustration.

5. James also has difficulty remembering what he has done and the appointments he has.


Answer the following question:

2. What are some of the strategies you might use to help James to manage these difficulties?
   Check your answers here

1. Difficult for him to walk long distances or carry heavy objects.

Use a small shopping trolly for carrying items (e.g. shopping) for smaller distances.
Plan ahead so that heavier items that must be moved can be moved by someone else (so frustration with things not being done is minimised).

2. Difficulty planning and organising his time.

Use a weekly planner on a white board
Provide specific lists of steps for specific tasks e.g. the steps to take for specific household chores.
Keep belongings and things he needs to work with in regular places

3. He is tired all the time and that he is not managing to get on top of all the household chores.

Schedule the chores into the weekly planner. Ensure there is not too much to do on any one day.

4. He is having difficulty managing frustration.

Identify what causes the frustration.
Put in place strategies to reduce the causes.

5. He has difficulty remembering what he has done and his appointments.

Use a white board for bigger events
Use a mobile phone to put in future events with an alarm before the event.
Use a diary to record what has happened at events
Use the calendar function in a mobile phone to record things that have been done.

iv) Program staff questions

Answer the following question:

5. James has started to attend your social activities program. He often misses his appointments. When he does come he gets frustrated easily and makes other participants uncomfortable. What do you do?
   Check your answers here:

Look at the referral information to see if it is adequate.
Adequate equals: this person has been referred to us because he has a brain injury and this is the effect of the injury on the person and strategies you may need to take to work with these effects.

Don't make assumptions

Ask specific questions of both him and his family members. E.g.

Is there something going wrong for you?
e.g. I don't like the person.
There is loud music in the background and I can't concentrate
I have this problem every time I go anywhere.

Do you want to do something about this?
What's the goal?
How do we work on this goal?

Is he being sent along because other people thought it was a good idea?
Does he like the activity?
What are his likes/wants/goals?

Is there something he would prefer to be doing?

If the specific issues are identified then explore strategies for how to address them.
If he can't concentrate: What support is needed for him to concentrate?
If there is one particular person he doesn't get on with: What can we do to minimise this an a problem
If needs support to do some of the activities and he is not getting it: How can we get him the additional support he needs?

Examine how what he is being asked to do matches with his skills and abilities.
If he is being asked to do things he does not have the skill to do: Are there alternative activities he cold do? Could he do the activity with support? What supports are needed? Where will they come from?

What support is needed to achieve the same outcomes as other people are achieving?

Has he attended other groups? What kinds of problems if any did he have with them?
What did they do for him to help him achieve things?

What strategies is he using to help with memory problems and missing appointments? Would other strategies be useful?
Does he have a white board weekly planner?
Does he have a mobile phone calendar and reminders?
If not would these be helpful to address the specific issue of missing appointments.
Could he, for example, get a text message reminder 2 hours before the activity?



v) Case managers questions

Answer the following question:

8. James' case has been referred to you. You are to work with James to develop a plan for the next 12 months. What are the sources of the information you need?
   Check your answers here

Agency reports

Obtain copies from family, hospitals, legal representatives

Discharge summaries - can be obtained from acute hospitals or rehabilitation services, Commonwealth Rehabilitation Service, private rehabilitation providers.

Neuropsychological reports – done by neuropsychologist or clinical psychologists. Usually focus on changes to cognitive function. Some assessments include I.Q. score, usually not very helpful as the overall score does not usually vary greatly from the preinjury score.

Rehabilitation/medical reports – done by rehabilitation specialists, physiotherapists, speech pathologists, social workers, rehabilitation counsellors.

Other therapist reports – include occupational therapy, physiotherapy, speech pathology, social work and rehabilitation counsellor reports.

Self report

Pre-morbid functioning vs. current status - It is important to get an idea of a person's ability before the injury and compare that with current functioning. Otherwise you can make any number of erroneous conclusions about the impact of the TBI.

Verbal vs functional ability - Some people are verbally articulate, but still have significant problems at a practical level that may be identified in an interview.

Difficulties with insight - Some people have reduced awareness about their needs, and may not fully understand the level of support being provided by key people in their lives.

Family report

Impact on the family - Families are often a key support for people with ABI. Information from families can provide valuable additional information in making an assessment.

Under reaction vs over-reaction - Family members sometimes minimise or over-emphasise the disabilities of their relative.


Other people may have valuable additional information - This may include agency/staff/friends/ employers, etc. The more sources of information, the better the quality of the assessment.

Where relevant sources of information are not available
Case managers may need to make arrangements to have a person with an ABI assessed appropriately.



Answer the following question:

11. What are likely to be some of the barriers to accessing services for James? What can you do about these potential barriers?
    Check your answers here

All of the following are common barriers if they are not present:

The service is available in the area. If the most appropriate service is not available then what are the alternatives? Would the service be suitable if James had support? Would the service be suitable if modified in some way?

Diagnosis - if James doesn't have a diagnosis he may find he doesn't get in to the service. Get a diagnosis if he doesn't have one.

The program aims and James needs matched: What is the program aiming to achieve? What are James goal? Do they match? If no, could the service be modified in some way to match James' goals?

There is adequate support for James to participate. What support does James need to participate in the program?
Maybe he needs a worker to facilitate interaction with other people.

Social inclusion - e.g. there may be a mens social group for Vietnamese people - but the problem for James in this mens group is he isn't social - so they many not want him to/ he many not want to continue coming.

Affordable - Can he afford any associated costs? Has get got the skills to manage the money?

Transport available - Is he able to get to the service?


vi) Managers questions

Answer the following question:

15. James' support staff are finding working with James difficult because of his anger outbursts? How will you deal with this?
Check your answers here

Have the support staff had appropriate orientation and training for working with people with acquired brain injury? If not, provide them with the orientation/ training e.g. Self-Study Module 1 : An Introduction to ABI

Work with the support staff on reinforcing key messages:

Uniqueness of the individual
Injury - effect - behaviour - behaviour management
You are part of a team
Be attuned to managing yourself, know what pushes your buttons and what you will do when it happens.
Stick to your role.

Analysing the problem behaviour:

  • When does it occur?
  • Where does it occur?
  • Who does the behaviour occur with?
  • Does it start suddenly or build up gradually?
  • How long does it last?
  • What is the history of the problem?
  • What solutions have been tried in the past?
  • How are people reacting?

Other factors to consider when analysing problem behaviour

  • Physical factors ie: excess noise, overcrowding, appropriateness of house or room.
  • Are they treated with respect?
  • Are they part of the decision making process/do they have choices?
  • Are they able to communicate effectively?
  • Will they benefit from being taught coping skills ie: relaxation etc

Develop strategies to specifically deal with the problem behaviour.

work with all the staff on agreeing on the specific strategies to be adopted - so there is consistency across all staff.

See: Understanding and Managing Behaviour Changes following a TBI  Although this resources is for traumatic brain injury much of it is relevant for most sudden onset ABIs.