Tbi essentials wsu

Traumatic Brain Injury (TBI)Essentials

Today’s Schedule• 8-8:30 Registration

• What is Traumatic Brain Injury & Screening for TBI-related deficits

• 10-10:15 Break

• How TBI Impacts Executive Functioning & Populations at Greater Risk for Brain Injury

• 12-1 Lunch

• Locating Community Supports and Services for Head Injured Clients

• 2:15-2:30 Break

• Counseling Brain Injury Survivors and Their Families• 3:45-4:00 Question and Answer

Overview

• Epidemiology• Mechanisms of Injury• Deficits Associated with TBI• Identification• Treatment• Special cases

#tbiwsu

EPIDEMIOLOGY

National prevalence rates of various disabilities

400,000 with Spinal Cord Injuries

500,000 with Cerebral Palsy

2.3 million with Epilepsy

3.0 million with Stroke-related Disabilities

4.0 million with Alzheimer’s Disease5.3 million with Traumatic Brain Injury

5.4 million with persistent Mental Illness

7.2 million with Mental Retardation

In the United States, at least1 million sustain a TBI each year

Incidence

Causes of TBI

Who is at Highest Risk for TBI?

• Males 1.5 times as likely as females to sustain a TBI

• Two age groups most at risk are 0-4 year olds and 15-19 year olds, and

• The elderly, frequently from falls• African Americans have the highest death rate

from TBI

Incidence of TBI x Age and Gender

MECHANISMS OF INJURY

Types of Brain Injuries

Acquired Brain Injuries

Traumatic Brain Injuries Other Brain Injuries:•Strokes•Hydrocephalus•Tumors•Demyelinating disorders•Infections•Toxic encephalopathy•Anoxic/hypoxic injury

Penetrating Closed Head Injury

Causes of TBI

Mechanisms of Injury

• Primary mechanisms of injury– Contusions– Small vessel disruption– Diffuse axonal injury

Coup-Contra Coup

Hematoma

Mechanisms of Injury

• Secondary mechanisms of injury– Edema– Evolving hematoma– Hydrocephalus

Normal ventricles

Managing intracranial pressure

Introduction to Neuroanatomy


What’s different about the brain?

Neuron

Synapse

Peripheral and Central Nervous System


• Front – back x

• Top – bottom

• Left - right

04/10/2023 © 2011 David D. Nowell, Ph.D. All rights reserved.

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what IS…


34

…what COULD BE


• Front – back

• Top – bottom

• Left – right x

Frontal Lobe

Temporal Lobe

Parietal Lobe

Occipital Lobe

Limbic System

Cerebellum

The Ventricles

Normal ventricles

DEFICITS ASSOCIATED WITH TBI

Medical• Physical stamina• Pain• Headaches• Seizures (within 2 years of injury)• Bowel/bladder continence

Motor Functioning

• Paresis or spasticity• Gross motor strength• Fine-motor speed and dexterity• Motor coordination and planning• Spatial-based movement• Oculomotor • Balance

Sensory-Perceptual Abilities

• Tactile, visual, and auditory modalities• Sometimes, olfaction

Attention

• Alertness and arousal.• Selective or focused attention.

– Modality specific• Sustained attention (vigilance).• Span of attention.• Hemi-neglect (ignoring one side of the body).

Receptive Language

• Word and phrase comprehension• Conflictual and comparative statements• Vocal tone and prosody• Speed of processing• Pragmatics (social meaning in language)

Expressive Language

• Fluency• Naming• Word and phrase repetition• Organization of output (e.g., spontaneous versus

confrontational speech)• Vocal tone and prosody• Pragmatics (social use of language)

Memory and Learning

The Executive Functions

X

Places

• San Jose• Aberdeen• Paris• Hattiesburg

Places

• San Jose• Aberdeen

• Paris• Hattiesburg

Boys’ Names

• Dante• Pete• Jordan• Elvis

Boys’ Names

• Dante• Pete

• Jordan• Elvis

“a healthy well-adjusted 26 year old”

The Executive Functions• Inhibition

• Shift

• Regulation

• Initiation

• Working memory

• Planning / organizing

• Self-monitoring

The Executive Functions

• Bridging the now with the past

• Bridging the now with the future


68


69

1. 1-step errands

2. Chores with cues

3. Basic inhibition

Age-appropriate ExpectationsPreschool


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1. 2-3 step directions

2. Bring papers home

3. 20-30 minute assignments

4. Simple spending decisions

5. Follow rules/inhibit/no grabbing

Age-appropriate ExpectationsKindergarten -2nd Grade


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1. Simple shopping list

2. Keep track of personal items

3. Longer homework assignments

4. Simple project planning

5. Keep track of variable daily schedule

6. Save money

7. Inhibit and regulate even without teacher present

8. Manners

9. Simple delayed gratification (phone)

Age-appropriate Expectations3rd-5th Grade


72

1. Complex chores

2. Babysitting

3. Organizing system

4. Complex schedule

5. Longer term projects

6. Time management

7. Self soothe

8. Manage conflict

Age-appropriate Expectations6th – 8th Grade


73

1. Independent with assignments

2. Make adjustments based on feedback

3. Longer term goal setting

4. Manage leisure time

5. Inhibit reckless behavior

6. Easily walk away from provocation

7. Say “no” to fun activity if other plans already made

8. Take others’ perspective

Age-appropriate ExpectationsTeenage-mid 20’s

School and Vocational Outcomes• Problems initiating and completing work.• Slowed work pace.• Increased impulsivity.• Trouble navigating physical surroundings.• Decreased productivity.

School and Vocational Outcomes• Confusion and increased stress.• Resistance to change.• Trouble with generalization of new learning.• Distractible.• May resent special assistance.

Social-Behavioral Outcomes

• Loss of friends and social circles.• Decreased affective regulation.• Increased impulsivity.• Increased agitation.

Social-Behavioral Outcomes

• Poor perspective taking.• Comparison to preinjury level of functioning.• Poor understanding of TBI and recovery.• Premature return to school/work.• Unrealistic predictions.

Emotional

• Dependent behaviors / amotivation• Irritability / emotional lability / anger• Depression• Disinhibition• Denial/lack of insight• At risk for substance abuse

Who Gets Better? Predictors of Positive Outcome

x

Preinjury Predictors of Positive Outcome

• History of good academic achievement• Good social relationships• No history of learning, attention, or behavioral

difficulties• No history of substance abuse• No significant family problems


• Strong-willed and determined• Under 21 years of age• No previous neurological history (e.g., a prior

TBI)• Good self regulation skills


• No criminal history• Good relationships with family members• Warm and supportive family• No psychopathology

Behavioral Predictors of Positive Outcome

• Motivated and persistent• Optimistic• Has the capacity to recognize errors and self-

correct• Aware of behavioral deficits• Ambulatory

Behavioral Predictors of Positive Outcome

• Relatively independent with activities of daily living

• Initiates tasks with no/minimal assistance• Preserved perspective-taking capacity• Relatively preserved neurocognitive abilities

Environmental Predictors of Positive Outcome

• Individual treatment plans• Continuity and coordination of treatment

throughout the recovery process• Structure, consistency, and repetition in daily

activities• Good, stable resources (e.g., financial, family,

friends, community, etc.)

Environmental Predictors of Positive Outcome

• Presence of “key” person in the family• Family involved in the treatment plan• Family realistic about individual’s status• Presence of “key” person on team

Neurological Predictors of Positive Outcome

• Coma < 6 hours• PTA < 24 hours• GCS > 7• Normal EEG and MRI• Normal intracranial pressure• Normal ventricle size• No intracranial hematoma

Indices of Severity of TBI

• Intracranial Pressure• Retrograde Amnesia• Anterograde Amnesia/Post-traumatic Amnesia• Duration of Loss of Consciousness (LOC)• Glasgow Coma Scale score• Rancho Los Amigos Scale (1 to 10)

Indices of Severity of TBI

Mild injury0-30 minute loss of consciousness

Moderate injury

30 minutes to 24 hours LOC

Severe injury> 24 hours LOC

IDENTIFICATION OF TBI

Identification of TBI

• Obtain the medical records if possible• Interview family/friends for collaboration• Arrange for a neuropsychological evaluation• Refer to a neurologist or psychiatrist for medication

and behavioral consultation• Consider referral to a brain injury rehabilitation

program

Inquiry Regarding TBI

• Any history of concussion or head injury?• Ever been knocked out?• Note: this question may lead to discussion of

– Alcohol abuse– Domestic violence

• Postconcussive symptoms?• Return to work/school?

• When did you wake up from the head injury? Do you remember being transported to the hospital? Do you remember being in the trauma unit? Being transferred to the rehab unit?

• PTA: period of time after the CHI for which the patient has no memory

“Getting at” PTA in the clinical interview

Comprehensive Mental Status Examination

• Behavior• Emotion• Cognition

ABC STAMPLICKER

ABC STAMPLICKER• appearance

ABC STAMPLICKER• behavior

ABC STAMPLICKER• cooperation

ABC STAMPLICKER• speech

ABC STAMPLICKER• thought

–Form–Content

ABC STAMPLICKER• affect

ABC STAMPLICKER• mood

ABC STAMPLICKER• perception

TO ORIENT

To understand one’s

relationship to theenvironment

ABC STAMPLICKER• level of arousal

ABC STAMPLICKER• insight

Judgment

• The ability to weigh and compare the relative values of different aspects of an issue.

ABC STAMPLICKER• cognition

ABC STAMPLICKER• knowledge

ABC STAMPLICKER• endings

Risk Assessment Protocol

• Identify predisposing factors• Examine potentiating factors• Conduct a specific suicide inquiry

Ideation?Plan?Intent?

• Determine level of intervention• Documentation

ABC STAMPLICKER• reliability

Diagnostic Issues

• Cognitive Disorder NOS• Dementia Due to Head Trauma

Diagnostic Issues

• Distinguishing psychiatric from TBI-related impairment– Insight/denial/anosagnosia– Explosive behavior disorders– Pseudodementia– “Acquired ADHD”?

TBI TREATMENT

Considerations in TBI Recovery

• What constitutes “recovery”• Will he/she be 100%?• It takes a year?• “Plateaus”• The normal neurological evaluation• Independence and modified independence• No magic bullets

– Meds– Rehab technologies

Medical Management: Acute TBI

• Airway• Close monitoring for edema• Seizure control• Close monitoring for increased intracranial

pressure

Normal ventricles

Increased intracranial pressure

ICP monitor

Pharmacological Treatments

• Amantadine x• Anti-seizure agents• Antipsychotics• Antidepressants • Stimulants

Early Rehabilitation Efforts:

• Formal family meetings• Use of an interdisciplinary team approach in

overall treatment• Discharge planning by team members, family,

and community services

Referrals

Referrals

Brain Injury and Statewide SpecializedCommunity Services

Referrals

• Assistive technologies• Independent living skills training• Speech therapy• Occupational therapy• Physical therapy• Neurology • Psychiatry• Physiatry• Substance abuse treatment

Referrals

• Case management• Home modifications• Transportation• Cognitive rehabilitation• Counseling• Financial management• Respite care• Neuropsychological evaluation

Goals of Neuropsychological Assessment

• Determine spared versus impaired abilities.• Understanding impact of injury and/or a

neurodevelopmental problem (e.g., LD).• Assist in localization of function and

dysfunction.

Goals of Neuropsychological Assessment

• Assist in determining whether to remediate or to compensate.

• Generate suggestions for remediation and compensation.

• Suggestions for monitoring and tracking of progress in school setting.

When to Consider a Referral to Neuropsychology

• Documented brain injury/insult• Suspected brain injury or insult• Neurodevelopmental disorder• Unusual psychological profile• Positive neurological findings• Severe behavior problems• Treatment needs

Cognitive Rehabilitation

• 4 ways our patients “get better”– Brain healing– Brain re-organization / plasticity– Compensatory skills– Restructuring the environment

Cognitive Rehabilitation:Specific Approaches

• Psychometric approach (healing/plasticity)• Stimulus-based approach (restructuring the

environment)• Developmental approach (plasticity and

compensatory)• Behavioral engineering approach

(compensatory skills)

Cognitive Rehabilitation

• Research challenges• Cognitive orthotics and prosthetics

Yoga / read

Staff meeting

Planningsession

Phone calls

billing

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Vc: kate re: brimfield

TC umass dermatology. Spoke w/ cindy 508 8564000

Learn French

Stop smoking

Be a better spouse

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Vc: kate re: brimfield

TC umass dermatology. Spoke w/ cindy 508 8564000

Learn French

Stop smoking

Be a better spouse

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Yoga / read

Staff meeting

Planningsession

Phone calls

billing

The “Good-Fit” Personal Organizer for the Client with Executive Dysfunction

• 2 pages per day• 7 am to 9 pm• Contains a master to-do list• With the client at all times• Use for work and home• Have only one system

Use of the personal organizer or PDA

• Move it from your head to your calendar• Break long term goals into action items• The organizer is your budget – how you

“spend” your time• Use your organizer for every part of your life

Use of the personal organizer or PDA

• Use your organizer for every part of your life– Your to-do list should contain things you have to do, but

also things you want to do, or to be, or to have.– You make appointments with your doctor or insurance

agent, because they’re important. You can make appointments with yourself as well.

– “Hi Cindy, this is David…..” (win friends and influence people with your amazing phone log)


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easy hard

“error-free learning”


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Psychotherapy with the brain-injured client

• Mild TBI interventions• Severe TBI interventions

Psychotherapeutic InterventionsIndividual Therapy

• Permitting appropriate expression of emotional reaction to TBI and loss

• Patient education• Social skills training• Family/spouse involvement• Impact of memory problems and decreased

insight

Psychotherapeutic InterventionsIndividual Therapy

• Critical for the therapist to be TBI-savvy• Consider the environment in which the person

functions• “Lieben und arbeiten”


• Develop routines• Energy conservation


• Values and motivators


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• Self-esteem

Self - esteem

Activity Scheduling


• Substance abuse and dependence

Psychotherapeutic InterventionsGroup Therapy

• Modeling• Problem solving• Peer feedback• Social skills practice

Behavioral Therapies

• Very few people with TBI have fully lost the ability to learn new behaviors

• Structure, consistency, and repetition• Role of cognition in self regulation• External feedback

• This requires a measurable and precise definition of the target behavior– Always get specific examples– Cross check across settings– “Pick your battles”?

• Inquire about the antecedents and consequences

Behavioral Strategies:Defining the Problem

Behavioral Strategies:Identifying the Function

• Everybody’s doing the best he/she can• Every behavior serves a function• Every behavior problem is either

– A skills deficit, or– A contingency problrm

Behavioral Strategies:Identifying Resources

• Personal resources: Memory? Flexibility? Persistence? Motivation?

• Social / family / peer resources• Organizational resources

Behavioral Strategies:Guidelines

• Skills• Safety• Least restrictive• Managing the antecedent: Set me up for

success!

Examples of Behavioral Strategies• Antecedents

• Does not understand

• Does not begin task

• Unable to do task

• Is not motivated

• Interventions• Provide clear, concrete instructions; notes

• Give prompts; reinforce initiative

• Simplify task; provide skill-based training

• Increase interest or relevance; reward for task completion

Examples of Behavioral Strategies

Consequences• Avoids failure by not

complying• Gets out of work• Receives attention for

not doing task• Gets to assert

independence/control

InterventionsAlternate difficulty

tasks with easy onesPremack principleTime out or ignoring;

reinforce for attentionOffer choices when

appropriate

Behavior Management Strategies:

X

Behavior Management Strategies:Agitation and Irritability

Behavior Management Strategies:Agitation and Irritability

• Redirection• Offer an alternative activity • Relaxation strategies• Recognize antecedent conditions• Speak calmly• Use key familiar phrases

Behavior Management Strategies:Apathy

Behavior Management Strategies:Apathy

• Give choices between doing one thing or another; not between doing and not doing

• Activity scheduling, in advance

Behavior Management Strategies:Denial/Lack of Insight

Behavior Management Strategies:Denial/Lack of Insight

• Have ongoing discussions of “strengths and needs”

• Create discrepancy• This may be the most difficult problem to

address

Behavior Management Strategies:Impulsivity/Disinhibition

Behavior Management Strategies:Impulsivity/Disinhibition

• Structured and organized daily routine• Rewarding/praising impulse control and

inquiring “how exactly did you do that?”• “Talking stick”

Behavior Management Strategies:Depression/Withdrawal

Behavior Management Strategies:Depression/Withdrawal

• Help students identify preserved abilities and strengths - rather than focusing on their deficits

• Keep TBI survivor involved in the present rather than dwelling on the past

• Use active listening techniques, but focus on positive feelings


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metacognition


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Beginning Middle End


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BBEHAVIOR

CCONSEQUENCES

Treating Sensory Defensiveness

Addressing Visuomotor Problems with Reading

What’s the kid’s deal?

• Greene, Ross. The Explosive Child.

Family Issues and Needs

• Family stress related to severity of TBI• The family’s resilience may be key to a brain

injured child’s successful rehabilitation• Divorce rates range from 15% to 54%

Sources of Family Stress

• Uncertainty about recovery• Cognitive and personality changes• Financial strain• Transitions to “new” settings• Lack of respite care

Family Definition of the Event

Family Issues and Needs• Family’s adaptation may take years• Any change may trigger emotional

response• Watch for signs of grieving

Return to School

• Accommodations and Modifications• IDEA and Section 504

IDEA Definition of TBI:

An acquired injury to the brain caused by an external physical force resulting in functional disability or psychosocial impairment that adversely affects a child’s educational performance.

School Re-Entry Issues

• Educational consultation should begin before return to school

• Continuity of care between school and rehabilitation services

• Prepare for multiple transitions• Re-entry should include interdisciplinary

support

Percentage Referred for Services

23.7

13.2

10.1

2.8

2

1.8

3.6

Physical therapy

Ocupationaltherapy

Speech therapy

Family counseling

Psych. services

Special Ed.

Home Tutor

Basic Criteria for School Re-Entry

• Attends to a task for 10 to 15 minutes– Adjust for age

• Can tolerate 20 to 30 minutes of classroom stimulation

• Can function adequately in a group of 2 or more students

• Engages in meaningful communication• Follows simple directions accurately• Gives some evidence of learning potential

School Re-Entry Procedures

• Assess needs–Adaptive domain–Cognitive domain –Communication domain–Sensorimotor domain –Social-emotional-behavioral domain–Transportation needs–Family needs

School Re-Entry Procedures• Identify the best setting for intervention

– Outpatient counseling?– Home-based family interventions?– School-based SLP / OT?– Buddy system at school?– In-service for school staff?– Modified school day?– In-school breaks?– “Study halls” with resource teacher?– Pre-vocational training?

• Regular re-evaluation for change over time

Developing IEP Goals

• Focus on 2 or 3 priority issues• Identify metacognitive & organizational strategies• Write measurable goals that incorporate the

strategies• Include specific information about how the

strategy should be taught and implemented across settings

• Write short-term goals that are truly short-term

TBI Impact at School

• Problems initiating and completing work.• Slowed work pace.• Increased impulsivity.• Topographical disorientation• Distractible• Difficulty generalizing new learning

Classroom Management

• Two key factors :– Structure – Motivation

• Explicitly teach rules & expectations• Establish prompts or cues, such as gestures

and reminder cards


• Can students answer the following questions:– What do I have to do?– How much do I have to do?– When am I finished?– What do I do next?


• Use repetition & feedback• Avoid multi-step instructions• Supplement verbal instructions with

nonverbal / modeling• Provide additional time for information

processing• Assist with organization of materials and

schedule


• To be motivating, a task must be interesting• Intersperse difficult or novel tasks with easy or

previously learned ones• Distinguish cognitive factors from other issues

(impact of headache, or depression)

Specific Classroom Strategies:Attentional Processes

• Reward on-task behavior;• Use novel, unusual, relevant or stimulating

activities• Redirect• Remove unneccessary distractors• Explore a variety of cueing systems

– Verbal cues– Physical prompts– Gestural cues

Specific Classroom Strategies:Attentional Processes

• Reduce the number of individual tasks on a printed page

• Reduce the amount of copying from the board• Provide a ruler or EZ-Reader to focus visual

attention• Avoid asking a student to multi-task• Chunking / Pomodoro

Specific Classroom Strategies:Memory and Learning

• Enhance the saliency of material• Regularly summarize information as it is

being taught• Dry-erase board• Use overlapping techniques, such as

repetition and rehearsal

Specific Classroom Strategies:Memory and Learning

• Couple new information with previously learned information

• Identify in advance the key information to be learned

• Make use of over-learning

Specific Classroom Strategies:Language

• Limit length and complexity of communication• Do not use figurative speech• Recognize the student may not understand

humor or sarcasm


• Reminders to start, end, or repair a conversation

• Use question prompts to help the student share more information, especially in groups

• Allow for slowed information processing


• Speak slowly• Reduce background noise

Specific Classroom Strategies:Visual Processing

• Provide longer viewing times or repeat viewings when using visual instructional materials

• Facilitate a systematic approach to reading and math by covering parts of the page

• Provide support for orientation to building and grounds

• Limit visual distractions (web page, handouts, text, desk)

Specific Classroom Strategies:Executive Functions

• Problem Solving Processes• Develop a problem-solving guide to help student through the

stages of problem solving– Identifying the problem– Acquire relevant information– Generate several possible solutions– List pros and cons for each solution– Identify best solution– Create a plan of action– Evaluate the effectiveness of the plan– Encourage generalization


• Raise questions about alternatives and consequences

• Provide ongoing, non-judgmental feedback• Provide part of a sequence and have the

student finish it• Frequent cues re: main topic vs. supporting

ideas


• Note impact of fatigue on cognition• Note impact of some medications• Consider reduced workload• Consider note-taker• “How exactly did you do that?”

SPECIAL CASES

SPECIAL CASES

• Domestic violence• Shaken baby syndrome• Combat trauma• Alcohol abuse/dependence• Mild TBI

SPECIAL CASES

• Domestic violence

In women reporting to ERs for injuries associated with DV:

• 30% of battered women reported a loss of consciousness at least once.

• 67% reported residual problems that were potentially head-injury related.

(Corrigan 2003)

Domestic Violence…

Greater than 90% of all injuries secondary to domestic violence occur to the head, neck or face region.

(Monahan & O’Leary 1999)

SPECIAL CASES

• Shaken baby syndrome

American Academy of Pediatrics-Committee on Child Abuse and Neglect Pediatrics 2001

“ …95% of serious intercranial injuries and 64% of all head injuries in infants younger than 1 year were

attributable to child abuse”

Pediatrics, 2001

Shaken Baby Syndrome


• Rotational, acceleration, deceleration forces• There may or may not be impact trauma• Brain rotates inside the skull• Bridging veins in the brain may be stretched or

torn• Subdural hematoma may develop


Kirschner & Wilson’s “dirty dozen”• 1. Child fell from a low height • 2. Child fell and struck head on floor or

furniture, or hard object fell on child• 3. Child unexpectedly found dead (age and/or

circumstances not appropriate for SIDS)• 4. Child choked while eating and was

therefore shaken or struck on back


Kirschner & Wilson’s “dirty dozen”• 5. Child suddenly turned blue or stopped

breathing, and was then shaken• 6.Sudden seizure activity• 7. Aggressive or inexperienced resuscitation• 8. Alleged traumatic event one day or morebefore death


Kirschner & Wilson’s “dirty dozen”• 9. Caretaker tripped or slipped while carrying

child• 10. Injury inflicted by sibling• 11. Child left in dangerous situation (e.g.

bathtub) for just a few moments• 12. Child fell down stairs


Symptoms• Apnea • Listlessness• Lethargy• Poor feeding• Irritability• Vomiting• Seizures

SPECIAL CASES

• Combat trauma

Combat Trauma

• TBI as “signature wound” of Iraqi conflict• USA Today 9/07

Combat Trauma

• Iraq characterized by different kind of weaponry: explosive munitions.

• 15% of soldiers returning from Iraq may have sustained at least mild TBI (Hoge et al 2008)

• 36% may have been exposed to blasts (Maguen et al 2012)

Combat Trauma

• Comorbid PTSD • Headache• Sensory impairment• Alcohol use

SPECIAL CASES

• Alcohol abuse/dependency

Alcohol Abuse

• May increase morbidity of MVA-related TBI (Cunningham et al 2002)

• Although low amounts may be protective• Chronic alcohol abuse associated with falls,

assaults, multiple head injuries• Overlay of alcohol-related impairment

SPECIAL CASES

• Mild TBI

TBI Severity: Mild TBI (mTBI)

• Concussion signs and symptoms include ANY changes in behavior such as:– Cognitive impairments – Physical symptoms (e.g., headaches, blurry vision,

diplopia, dizziness)– Emotional symptoms (e.g., irritability, volatility)– Sleep difficulties – Not “feeling like themselves.”


• Persistent symptoms following the concussion is often referred to as Post-Concussive Syndrome.

• Cumulative effect


• Chronic traumatic encephalopathy

Psychotherapy with the persistent post-concussive client

• Perfectionistic tendencies• Somatic focus• Poignancy• Secondary gain• “old me / new me”• Check to see whether you are working at

cross-purposes

The “Big 5” (plus 1)

• The “Big 5”– Daily planner– Daily organization time– Movement– Nutrition– Connection– Sleep

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Tbi essentials wsu

Health & Medicine

Transcript of Tbi essentials wsu