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SCREENING &
STRATEGIES Supporting Individuals With a History of Brain
InjuryNational Conference on Ending
HomelessnessJuly 13, 2010
Goals for today…...• Brief discussion of “hidden” Traumatic Brain
Injury and the homeless• Introduce the HELPS Brain Injury Screening
Tool
• Equip professionals with functional and practical strategies that can be applied in the home, community and vocational setting
“Unidentified traumatic brain injury is an unrecognized
major source of social and vocational
failure”Wayne Gordon, Ph.D
Brain Injury Research Center Mount Sinai School of Medicine
Wall Street Journal 1.29.08
Why are so Many Brain Injuries “Hidden”?
• Individuals may not be admitted to a emergency room/hospital following a blow to the head
• Individuals may not be referred to rehabilitation services following discharge from the emergency room/hospital/trauma center
• Individuals may not be aware of the accumulative damage of multiple mild TBI and connect this damage to functional difficulties
Why are so Many Brain Injuries “Hidden”?
• Individuals may be unaware that they may benefit from referrals to treatment and thus don’t follow through with hospital/rehabilitation center recommendations
• Insurance funding has run out or is nonexistent
• Adults who have “grown” into their childhood brain injuries
Correlation between TBI & Homelessness
Hwang et.al 10.7.08 Canadian Medical Journal
• 904 homeless individuals surveyed• Lifetime Prevalence of TBI-53%, more
common among men than women surveyed
• 70% of the individuals surveyed incurred their brain injury prior to the onset of homelessness
• A history of TBI was associated with poorer health
Substance Abuse & Brain Injury
Analysis of the Literature (Corrigan 1995)
• Alcohol, the drug of choice-Corrigan and his colleagues report that for 70% of the individuals they work with who use substances, alcohol is the preferred substance
• Intoxication at time of injury-7 studies looked at incidence of intoxication (BAL equal or exceeding 100mg.dL)at time of injury. Intoxication ranged from 36% to 50%
• History of Substance Abuse-Findings suggest that for adolescents and adults in rehabilitation following a TBI, as much as 60% of this population have histories of alcohol use or dependence.
1994-2004- update (Parry-Jones
et.al 2006)
• Intoxication at time of injury: 37-51%
• Pre-TBI history of alcohol misuse:37-51%
• Outcome findings mixed with direction of outcomes trending poorer in neurological, medical and neuropsychological function for those w/pre-injury misuse
Impact of TBI in Adolescent Substance Abuse Treatment Programs 2005 study by Corrigan et.al
• 189 adolescents receiving residential SA tx were screened for a hx of brain injury
• TBI with Loss of Consciousness reported by 23% of residents
• 13% reported a moderate or severe TBI
“Having a TBI with loss of consciousness was significantly associated with being more likely
to be dependent on both alcohol and other drugs, to having experienced a drug overdose with loss of consciousness, being in special classes and having a seizure disorder. There were trends toward TBI with loss of consciousness being associated with having a learning disability,
having violence-related convictions, and receiving psychiatric outpatient services. Among
the later, persons with TBI were more likely to be treated for attention deficit hyperactivity
disorder, anger management and conduct disorders.”
John Corrigan Ph.D
TBI & Homelessness“For Veterans, A Weekend Pass From Homelessness”from the New York Times 7.26.09, Erick Eckholm
“….The ranks include young men like Kenneth Kunce, 26, who suffered a traumatic brain injury when his Humvee was hit by a roadside bomb in Iraq. The injury left him disorientated, jumpy and temperamental. When he came home he started using Ecstasy and alcohol, he said he
lost his wife and more than one job. He said he was grateful to the Veterans Affairs hospital for
providing speech and physical therapy, but added that he still had trouble coping with
noises and anger.Mr. Kunce, who sometimes lost his train of
thought as he spoke to this reporter, is living out of his car.”
The HELPS Brain Injury Screening Tool
(see handout)
The original HELPS tool developed by M. Picard, D. Scarisbrick, R. Paluck, 9.1991
Updated by the Michigan Department of Community Health
Additional comments and observations of the interviewer• Any visible scars?• Walks with a limp?• Uses a cane or walker?• Has a foot brace?
• Limited use of one hand?• Appears to have difficulty focusing vision?• Difficulty answering questions?• Answers are unorganized and/or rambling• Becomes easily distracted, agitated or is
emotionally labile
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
Restoration Verses
CompensationSpontaneous 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
devicesChanging or modifying the
environment to support and/or compensate for a injury imposed
deficit
For Example: labeling kitchen cabinets
Internal
The 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
internalFor 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
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 tape recorder
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, PDA)
Strategies cont.….
• Use of PDA/hand held device
• 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
• Books on tape, 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
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 SolvingState 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”
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
Recommended Viewing
• 2007 Miramax release, The Lookout, starring Joseph Gordon-Levitt, Jeff Daniels and Matthew Goode. Depicts the life of a young man four years after a moderate TBI. Excellent depiction of how strategies can be integrated at home, work and community.
• Beyond the Invisible: Living with Brain Injury. A production of the New York State Brain Injury. Go to www.bianys.org . This 30 minute film depicts the experiences of three Iraq veterans living with traumatic brain injuries incurred during deployment. The film can be watched via BIANYS website, or call the office for a free copy, 518-459-7911
Resources
• Health Organizer: https://tbi.mssm.edu/, a research project of the Mt. Sinai R & T Center. Website provides a way for individuals with TBI or MS to organize and track their medical information, users can participate interviews regarding their use of the health organizer if they chose (paid).
Resources
Care Pages
A website where individuals with brain injury and their families
share their stories
www.cms.carepages.com
Resources
• Http://www.abledata.com/, An online resource catalogue that lists different types of assistive technology available to help individuals with all types of disabilities
• http://www.biausa.org/Pages/AT/, Catalogue of assistive technology for people with cognitive impairments. The devices listed have been reviewed by experts in the field of brain injury. Product information, and information about manufacturers, and more offered in this catalogue
Resources staff training….
• http://www.webaim.org/simulations/cognitive - this is a site that can be used in staff training. It is a simulation of the effects of cognitive disabilities. You will be asked to complete simple tasks, but other tasks will get in the way.
• http://www.biausa.org/Pages/related_articles.html - links to many online articles, written not for professionals in the field, but for people learning about brain injury. The y cover all types of topics, from substance abuse and brain injury to cognition and brain injury. Written by various experts in the brain injury field.
• Certified Brain Injury Specialist (CBIS) Training offered through the American Academy for the Certification of Brain Injury Specialists, www.biausa.org
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
Recommended