TBI-Focus on Behavior & Strategies

1. TBI-Focus on Behavior & Strategies Maryland 2014

2. Learning Objectives Understand the relationship between brain injury and behavioral regulation Describe interventions that may enhance the ability of individuals with brain injury to regulate their behavior Provide attendees with a variety of strategies that can be implemented at home and community by individuals living with brain injury Slide 1A.1

3. For most, Brain Injury is: • -A loss of Self • -A loss of future • -loss of possibilities

4. “I had a job, I had a girl, I had something going mister in this world…………” A 10 year survivor of a TBI quoting a Bruce Springsteen song when describing what he had lost because of his injury

5. A compromised brain can lead to compromised behavior, further adding to social isolation and social failureThe following slides 3 are adapted from Webcast: sponsored by the Health Resources and Services Administration’sFederal TBI Program Web castJuly 27, 2006

6. Speakers: • Harvey E. Jacobs, Ph.D., Licensed Clinical Psychologist/Behavioral Anaylist • Marty McMorrow, Director of National Business Dev., The MENTOR Network • Jane Hudson, JD., senior Staff Attorney, National Disability Rights Network

7. Behavioral Statistics Approximately 90% of all people who experience severe disability following brain injury experience some emotional or psychiatric distress 40% continue to demonstrate behavioral difficulty five years post injury Slide 1B.2

8. Behavioral Statistics • 25% experience behavior dysfunction that interferes with other activities of daily life • 3%-10% experience severe behavioral dysfunction that may require intensive professional and residential intervention (~3,000-9,000 new people per year)

9. Research findings regarding Behavior Problems after TBI “Aggressive behavior is associated with presence of major depression, frontal lobe lesions, poor premorbid social functioning and a history of alcohol and substance abuse” Tateno et.al J of Neuropsychiatry Clin. Neuroscience 2003

10. Research findings regarding Behavior Problems after TBI Research conducted by Wood and Liossi in 2006 reports “it is tentatively suggested that significant impairment in verbal memory and visuospatial abilities against a background of diminished executive-attention functioning is associated with the development of aggression after brain injury,especially when other risk factor such as low premorbid IQ, low socioeconomic status, and male gender are present” J of Neuropsychiatry Clin. Neuroscience

11. Research findings regarding Behavior Problems after TBI • “Impairments in recognizing the emotional state of others may underlie some of the problems in social relationships that these patients experience……TBI patients were found to be impaired on emotional recognition compared to the control patients both early after injury and one year later” Ietswaart et. al. Neuropsychologia, 2007

12. According to McMorrow, Jacobs and Hudson; HRSA Webcast July 27, 2006 “Almost all people who experience disability following brain injury are not inherently aggressive or assaultive. However, for some people, when challenges are not properly addressed this can result in…”

13. -Lack of responsiveness to requests-Property destruction-Verbal or physical aggression-Violation of personal or sexual boundaries-Wandering or flight-Self harm/self abuse/suicide

14. “Neurobehavioral Challenges” According to McMorrow, Jacobs and Hudson are caused by • Pre-injury history • Post-Injury learning and experiences • Inability to negotiate “difficult” situations • Others’ not recognizing the basic challenges to an individual with TBI, and • Not providing proper treatment

15. Strategies for Supporting Individuals with Behavioral ProblemsAdapted from Capuco and Freeman-Woolpert’s Strategies for Supporting an Individual with ABI

16. Environmental Triggers for Behavioral Problems • Too much stimulation • Rapid pacing • Lack of predictability and clear structure • Overwhelming physical and cognitive demands • Negative social input

17. TIP:If you manage the environment, you can prevent many problems And always practice a “Adult to Adult” Communication Style Bill Kerrigan of Sheppard Pratt

18. Guidelines for Behavior Management • Keep the environment simple. People with brain injuries are easily overstimulated • Decrease interruptions and distractions and surprises • Be consistent

19. Guidelines for Behavior Management • Keep instructions simple, concrete • If the person has problems processing language, try gesturing or cueing • Write things down • Give feedback and set goals • Feedback should be direct, caring, nonjudgmental, but not subtle • Avoid criticism

20. Guidelines for Behavior Management • Be calm, cool and friendly during an incident • This can reduce agitation • Avoids reinforcing misbehavior

21. Guidelines for Behavior Management • Redirection works. When the person is upset, agitated, aggressive, focus attention on some other topic, task, person • Provide choices

22. Expect the unexpected. People with brain injuries can have great variability from day to day. Mood swings are common. People with TBI are sensitive to changes, disruptions in routine, lack of sleep, alcohol, minor illnesses, fatigue and other stressors

23. Keep in Mind • Progress can be inconsistent and unpredictable • What works today may not work tomorrow, but may work the following day • Reduced stamina and fatigue may persist • Impairment of memory may hinder new learning • Transitions may be especially difficult

24. Prevention, Prevention, Prevention • Communicate expectations • Recognize internal and environmental triggers, plan strategies • Provide clear structure and predictable routines • Maintain realistic expectations • Help peers learn to alter interactions to avoid triggers

25. 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

26. Areas of Interpersonal Functioning that can be supported by Strategies Impulsivity Frustration tolerance Social skills Self esteem Building and maintaining relationships

27. Most of these Strategies address more than one cognitive and or behavioral deficit

28. Restoration Verses Compensation Spontaneous 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

29. Environmental & Internal Aides Creative cognitive strategies will employ both kinds of aids depending on individual need

30. Environmental, AKA Prosthetic external memory strategies and devices Changing or modifying the environment to support and/or compensate for a injury imposed deficit For Example: labeling kitchen cabinets

31. 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

32. Oftentimes a strategy can transition with practice from the external to the internal For 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”

33. 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

34. Examples of strategies-cheap tricks • Red lined index card and red stickers: Addresses visual neglect, attention and concentration • Reading guide: Addresses a number of visual problems including figure ground deficits, jerky eye movements (nystagmus) and impairment in the ability to smoothly move the eyes • Non-slip mats (“dycem”) holds books, plates, bowls, paper etc. in place if one hand/arm has no or limited functioning

35. 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 digital recorder/smart device

36. 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, smart device)

37. Strategies cont.…. • Use of PDA/hand held device (e.g. smart phone) • 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

38. 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 • Audio books, movies, keep the subtitles (for processing content in the case of memory and comprehension problems and increase awareness of nonverbal cues/communication)

39. 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

40. Memory StrategiesFollowing 6 slides adapted from:Parente & Herman in Retraining Cognition 1996 Aspen Publishers

41. 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?

42. 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

43. 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.

44. Problem Solving State 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”

45. 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.

46. Impulsivity Change Plan What change do I want to make?____________________ Why do I want to make the change?_________________ Change Not Changing ProsConsProsCons 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”

47. 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)

48. 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

49. 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

50. Minimize confusion/socially unacceptable behavior • Give useful and specific feedback about a behavior • Ask the individual for permission to coach him/her