3.3 Research on and Identification of Cognitive Impairments (Edmontson)

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

Most of these Strategies address more than one

cognitive and or behavioral deficit

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

Memory StrategiesAdapted from:

Parente & Herman in Retraining Cognition 1996 Aspen Publishers

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

Anastasia [email protected]

410-402-8478

Thank You