Accommodating the Symptoms of TBI€¦ · with TBI ¤Misinterpretation of symptoms of TBI by the...
Transcript of Accommodating the Symptoms of TBI€¦ · with TBI ¤Misinterpretation of symptoms of TBI by the...
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AccommodatingtheSymptomsofTBI
OhioValleyCenterforBrainInjuryPreventionandRehabilitationWithcontributionsfromMinnesotaDepartmentofHumanServicesStateOperatedServices
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GoalsofTraining
¤ Serviceprovidersshouldbeableto:§ Recognizecommonsymptoms
ofTBI§ Incorporatecompensatory
strategiesintotheirpractices§ Increasetheoddsoftreatment
successforindividualswithTBI
¤ Thisinformationisnotintendedtobeusedinplaceofformaldiagnostictestingandtreatmentplanning
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WhyshouldserviceprovidersbeawareofTBI?
¤AccordingtotheCDC,over1.7millionTBIsoccureachyear
¤Anestimated5.3millionindividualsintheUSlivewiththeeffectsofTBI
¤AhistoryofTBIoftengoesunrecognized
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NeurocognitiveChangeswithTBI
¤Duetofrontallobedamage,TBIcanresultinchangesin:§ Memory§ Thinkingskills§ Behavior
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NeedforServices
¤ NeurocognitivechangesfromTBIcommonlyresultin:§ Substanceuseproblems§ Disruptedrelationships§ Employmentissues§ Problemswithlearning
¤ Serviceprovidersarelikelytobe:§ TreatingindividualswithTBI§ TreatingindividualswithTBI
withoutevenknowingit
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Whatdoesitmeanto“ACCOMMODATE”?
¤Accommodate: Provideservicesinamannerthattakesintoconsiderationthespecialneedsofanindividual
¤Providingaccommodationscreatesanopportunitytoaddresspotentialbarrierstotreatmentsuccess
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NeurocognitiveChallengestoTreatmentSuccesswithTBI
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¤ Problemswiththeregulationofthoughts,feelingsandbehavior
¤ Difficultybenefitingfromexperienceandrememberinginformationfromonesessiontothenext
¤ Intentionandbehaviormaybedisconnected
¤ Maynotfitwellwithothersandtheenvironmentbecauseofproblemsperceiving,understanding,andbehavingaccordingtosocialnorms
¤ Differencesincommunicationorlearningstylemakeparticipationindidactictrainingandgroupinterventionsmoredifficultandfrustratingfortheindividual
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BarrierstoTreatmentSuccess
¤ LackofexperiencedstaffandreferralsourceswhounderstandhowtoadjusttheirapproachestohelpindividualswithTBI
¤ MisinterpretationofsymptomsofTBIbythetreatmentprovider(e.g.labelinganindividualas“noncompliant”or“resistant”),underminingthetreatmentrelationship
¤ Lackofaconsistentandrichenvironmenttoprovidestimulation,structure,andsupport
¤ Discontinuationoftreatmentbeforegoalsaremet
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IdentifyingCommunicationandLearningStyles¤ Askhowwellthepersonreadsandwrites;or
observethroughsamples
¤ Findoutwhethertheindividualisabletocomprehendbothwrittenandspokenlanguage
¤ Ifsomeoneisnotabletospeak(orspeakeasily),inquireastoalternatemethodsofexpression(e.g.,writingorgestures)
¤ Askaboutandobserveaperson’sattentionspan;beattunedtowhetherattentionseemstochangeinbusyversusquietenvironments
¤ Askaboutandobserveaperson’sabilitytolearnnewideas,information,androutine;inquireastostrengthsandweaknessesorseekconsultationtodetermineoptimumapproaches
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ContextualUnderstandingofPerson
¤ Whathasworkedinthepast,andhow?
¤ Whathasn’tworked,andwhy?
¤ Howinterestedisthepersoninworkingonthis?(e.g.onascalefrom1to10)
¤ Whatwouldtheyliketotry?§ Howcanwehelp?§ Comfortablewithtechnology?
¤ Whatcanwedotohelpiftheyarenotawareornotmotivated?
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ReflectiveRecommendations:Peopleastheirownexperts
q Ask“Whathelpsyouwith____?“§ Learningnewmaterial§ Rememberingnames§ Rememberingtodoassignments§ Finishingyourwork§ Stayingontrack§ Payingattention§ Rememberingthingsyouseeorhear§ Figuringouthowtodonewthings§ Makingchoicesthatkeepyou
healthyandsafe
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2Attention
3Processing
4Memory
5ExecutiveFunction
1Alertness
FlowofCognitiveProcesses
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Neurocognitive Functions
Attention
Memory
Processing
ExecutiveFunction
Initiation
Impulsivity
Planning&Organization
MentalFlexibility
Self-Awareness
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Problem=AttentionAsidefrombeingawakeandalert,oneofthemostimportantcognitiveabilitiesisbeingabletopayattentionorconcentrateonimportantthingshappeningaroundus.Attentionisoftenaffectedwhenfrontalregionsofthebrainarenotworkingproperly.Attentionisabasicthinkingabilitythatmaysetalimitonhowwellother“downstream”functionswork.
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Afterashortperiodis“checkedout”
Seemstonotpayattentiontowhatissaid
“Thrillseeking”orexcessiverisk-taking
Seekssensorystimulation(e.g.videogames)
Oftenappearsboredordisinterested
Lookfor:
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AccommodatingProblemswithAttention
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• Checktomakesurethereisgoodeyecontactandinitialattentionwhenbeginningataskoractivity
• Beginanactivitywithsomethingthatgetseveryone’sattentionorinvolvesactiveparticipationlikeanicebreaker,achallenge,ordemonstrationthatincludestheirparticipation
AttentionGrabber
• Keepinstructionsbrief,simple,andtothepoint• Boildowndiscussionstocriticalpointspresentedoneatatimeandorganizedfortheperson
BreakitDown
• Discussionsandimportantmeetingscanbeaccompaniedwithpracticeorrehearsaltokeepthepersonactivelyengaged
• Movementandtactileactivitiesenhanceenergyandattention
HandsOn
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Problem=ProcessingThetimeistakestothinkthroughandunderstandnewinformationorconceptscanbeaffectedwhenapersonhashadaTBI.Thisdoesnotmeantheycannotunderstand– theymayjustneedmoretimetounderstand.
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Onlypicksupaportionofinstructionsorconversations
Hasdifficultykeepingupwithaconversation
Maytireeasily
Mayappearto“zoneout”
Mayappearpassiveorunmotivated
Issometimesreferredtoas“lazy”
Lookfor:
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AccommodatingProblemswithProcessing
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• It’seasyforsomeonewithprocessingproblemstogetlostinaconversation.Simplifyinformationandprovideoneideaortaskatatime
Keepit
Simple
• Frequentlycheckforunderstandingbyaskingthepersontorepeatbackinstructionsorideas
CheckIn
•Makesuretoprovidesufficienttimeforthepersontoprocessandrespond.Countsilentlytoyourselfafteraskingaquestiontoallowextratimeforthepersontoprocessthequestion
SlowitDown
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Problem=MemoryEverydayourlivesarefilledwithactivitiesthatrequireustomakechoicesandresponsesbasedonpreviouslylearnedinformation,newlylearnedinformationandsometimesboth.PersonswithTBIcanhavetroublerecallingorrememberinginformation.Theyoftenhaveproblemsholdingseveralthoughtsatonceororganizingseveralpiecesofinformationintheirmindtomakeadecisionortakeaction.
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Inconsistentinperformanceoftasksordailyactivities
Hasdifficultyrecallingpreviouslylearnedinformation
Hasdifficultylearningnewinformation
Mayappearinattentive
Doesnotfollow-throughwithactivitiesorinstructions
Maybedescribedbyselforothersasforgetful
Lookfor:
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AccommodatingProblemswithMemory
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•Wheneverpossible,provideawrittensummaryofimportantinformation.Forexample,writedowntheirnextappointmentandanyactionitemsfortheweek.Iftheyareusinganorganizationalsystem,cuethemtorecordtheinformationintheircalendar
WriteitDown
•Reviewnewinformationfrequentlyandaskthemtorepeatbackwhattheylearnedintheirownwords.Thiscanhelpmaketheinformationmorerelevantandimproverecallofinformation
• Summarizeandsynthesizemultiplepointsintoonecoherentstatementtoreinforcelearning
Repeat
• It’simportanttoteachthepersonto“RemembertoRemember”.Teachcompensatorystrategiessuchascheckingacalendarattheendofasession,orwritinganamedownassoonastheymeetsomeone.Teachassociationsthatwillhelptriggerrecall(e.g.brushingteethisacuetotakemedication)
• Practiceandreinforcecompensatorystrategiesuntiltheybecomeautomatic
Remember
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Problem=InitiationResponsibilitiesathomeorworkrequirethecompletionofasequenceoftasks.IndividualswithTBIcanhavedifficultygettingstartedorinitiatingaction.Sometimesapersoncantellyouwhatheorshewantstodobutcannotinitiatethestepsneededtoperformthatactivity.
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Hastroublegettingstartedwithatask
Appearspassiveorunmotivated
Needsconstantremindersorpromptingtocompleteatask
Abletoidentifyagoalbutcannotacttoachieveit
Oftenreferredtoas“lazy”
Lookfor:
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AccommodatingProblemswithInitiation
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•Breaklargeprojectsdownintosmall,moreachievablesteps(e.g.completingajobapplicationorselectingaplacetolive)
•Encouragethepersontofocusononestepatatime
Simplify
•Theuseofchecklistsandcalendarscanhelporganizeandpromptself-careactivitiesanddailyduties.
•Learningtorefertothechecklistwhen“stuck”canhelpthepersonmoveontothenextstep.
•Overtimethechecklistmaybeinternalizedasafamiliarroutine
Checkitoff
•Atimercanbeusedtohelpthepersongetstartedandlearntofocusonbeingproductiveforasetperiodoftime
•Analarmcanbeusedtoalertthepersontostartanactivity
• Timersoralarmscanbeassimpleasakitchenorstovetimertosomethingmorecomplexandportablelikeanappointmentfeatureonasmartphone
SetanAlarm
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Problem=ImpulsivitySometimesitisdifficulttostartanactivity,andothertimesitishardtostopone.ProblemswithimpulsivityareverycommoninpersonswithTBI.
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Maydoorsaythingswithoutthinking
Mayhavetroubleknowingwhentostopanactivity
Appearstodothingsquicklywithoutregardforsafety
Maynotfollowdirections
Maydominateconversationorinterrupt
Lookfor:
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AccommodatingProblemswithImpulsivity
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• 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
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Problem=Planning&Organization
Busyschedulesrequireustokeeptrackofalotofinformation.ManypeoplewithTBIhavedifficultyplanningandorganizingdailyactivities,orneedassistancewithamethodofplanningandorganizingsuchtasks.
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Isoftenlateforappointments
Hasdifficultyrememberingthingsthatneedtobedoneinthefuture
Oftenmissesimportantdeadlines
Givesupeasilyontasks
Appearstojumpfromactivitytoactivitywithoutcompletinganything
Lookfor:
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AccommodatingProblemswithPlanning&Organization
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• Encouragethepersontodevelopandmaintainconsistentroutinesthroughouttheday
• Identifyaplacetokeepimportantitemslikekeys,wallet/purse,glassesandcalendar
BePredictable
• Encouragetheuseofasystemfororganizingactivities,appointments,and“todo”liststhatmatchestheneedsandabilitiesoftheperson.Thesystemcanbeasimplecalendarorasmartphoneorelectronictabletwithadvancedfeatures
• Appsforsmartphonesandtabletshavebeendevelopedtohelpmeettheneedsofpeoplewithcognitiveproblems
• Prompttowritedownimportantorkeypointsofinformation
Planner
• Remindthepersonofthepurposeofasessionaswellaswhattoexpectalongthewaywithadescriptionofthefinaloutcomeandgoal
• Providedirectionsorinstructionsseveraltimes,andaskthepersontorepeattheinstructionsbacktoyou.Youcanask,“Nowyoutellmetheinstructionsinyourownwords”
SettheAgenda
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Problem=MentalFlexibility
Everydayliferequiresustoswitchgearsandthinkonourfeet.Anewapproachmaybeneededwhencircumstanceschange.Whensomeonehasdifficultywithmentalflexibility,heorshehastroubleadjustingtochangingsituationsandunfamiliarcircumstances.
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Hasdifficultythinkingonhisorherfeet
Getsstuckonanideaoronewayofthinking
Hasdifficultyadjustingtoneworunexpectedtasksandactivities
Maybeargumentativeandnotbeabletoseetheperspectiveofanotherpersonorconsideradifferentidea
Lookfor:
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AccommodatingProblemswithMentalFlexibility
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•Don’ttakeforgrantedthatsomethinglearnedinoneenvironmentwillgeneralizetoanother.Itisimportanttopracticestrategiesinmultipleenvironmentswithdifferentstafforsupportpersons.
Rehearse
•Personswithcognitiveproblemsoftencannotcomeupwithsolutionsoralternativestosituationsthatdon’thappenasplanned.Trytoplanforobstaclesandcomeupwitha“PlanB”.Forexample,identifyaleadormentorintheenvironmentwhocanserveasaresourcetouseifproblemsoccurintheprogramoronthejob.Practicegoingtothatpersonandaskingforassistance.
PlanB
•It’seasyforpersonswithcognitiveproblemstogetstuckonatopicoridea.Whenreviewingmaterial,announcethatyouaremovingontoanewsubjectandallowextratimeforthattransition.Providinghandoutsandanagendamayalsobehelpful.
MovingOn
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Problem=Self-AwarenessWetakeforgrantedthatpeopleknowhowtheyarebeingperceivedorhowtheyarecomingacross.IndividualswithTBIoftenhaveproblemswiththeirbehaviorandmaynotbeawareofhowtheyarebeingperceivedbyothers.
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Underestimatesproblemsormaynotbeawarethataproblemexists
Oftensetsunrealisticgoals
Isunabletoidentifyoralterinappropriatebehaviors
Maysaythingsotherpeoplemightbethinkingbutwouldnotsayaloud
Mayuselanguagethatisnotappropriateforthesituationoraudience
Maydominateinteractionswithothers
Lookfor:
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AccommodatingProblemswithSelf-Awareness
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• Planaheadforsituationsthatmaybringaboutpoorjudgmentandtalkaboutpotentialobstacles
Plan
• Practicepositivesocialinteractionsaheadoftime
• CueforcompensatorystrategiesPractice
• Promotepositivebehaviorbystoppingandaddressingundesiredbehaviorimmediately.
• Providealternativecommentsorchoicesthatcouldhavemade
Promote
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q Identifyspecificproblemsthatarepotentialbarrierstotreatmentsuccess
q Developclearstrategiestoaccommodateproblems,takingintoaccountaperson’suniquecommunicationandlearningstyles
q Providedirectfeedbackregardinginappropriatebehavior
q KeepinmindthatnoncompliantbehaviormaybeasymptomofTBI
q Bepatient!AnindividualwithTBIwillneedextratimeandpracticetoachievehisorhergoals
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Remember
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Resources
¤OhioValleyCenterforBrainInjuryPreventionandRehabilitationhttp://ohiovalley.org
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CustomizedforuseinNebraskawithpermissionfromOhioValleyCenterforBrainInjuryPreventionandRehabilitation
¤ NebraskaBrainInjuryAdvisoryCouncil
¤ www.braininjury.nebraska.gov
¤ 308-865-5012
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DevelopedinpartwithsupportofagrantfromtheUSDepartmentofHealthandHumanServices,HealthResourcesandServicesAdministration(HRSA)toOhioRehabilitationServicesCommission andTheOhioStateUniversity(2013).
Reprintsaresupported,inpartbygrantnumber90TBSG0013-01-00,fromtheU.S.AdministrationforCommunityLiving,DepartmentofHealthandHumanServices,Washington,D.C.20201. Granteesundertakingprojectsundergovernmentsponsorshipareencouragedtoexpressfreelytheirfindingsandconclusions. Pointsofvieworopinionsdonot,therefore,necessarilyrepresentofficialAdministrationforCommunityLivingpolicy.