Slide 1 - American Foundation for the Blind - Home Page · Web viewPassive vs. active learner (groups material) Fatigability (effect on accuracy) Over learning (repetitions to 100%,

Slide 1The Changing VA Population:Young, Active Duty and Brain InjuredorIt’s A Co-Morbid WorldHarriet Katz Zeiner, [email protected]

Slide 2There’s a New Population in Town And They Require Systemic Change To Deal With Them EffectivelyWhy?How Big Is The Problem?Why Won’t The Old Ways Work?What Do I Have To Change To Deal Effectively With Them?

Slide 3While serving in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), military service members are sustaining multiple severe injuries as a result of explosions and blasts.

Slide 4Improvised explosive devices, blasts, landmines and fragments account for 65% of combat injuries (Peake JB, N Engl J Med 2005 jan 20, 352 (3):219-222)

Slide 5Of these injured military personnel, 60% have some degree of traumatic brain injury http://www.dvbic.org

Slide 6If the War Ended Today:30,000 WIA65% of these are IED = 19,50060% of IED injuries involve head injuries = 11,0701500 combat-wounded polytrauma patients have been treated at the 4 PRCsCurrently, 10,200 people with head injury have been discharged home—and don’t know why they think, feel and behave differently* These numbers are from April 2008-Underestimate since only includes the wounded, not the exposed

Slide 710,000 people with undiagnosed mild TBI have been sent home.

Mild TBI refers to the time period of unconsciousness, not to the effects on the person’s life.Mild TBI can have MAJOR impact on marriages, jobs, relationships, children and rolesThis is not a political issue—it is a major health care problem in America, which the VA is charged to deal with.

Slide 8Occult (Hidden) Brain InjuryHow many people with TBI you find depends on whether or not you are lookingDegree to which you look is the degree to which you findIf your facility uses PTSD/BI screen, you will find them in the outpatient clinics—at a large VA the rate is 10 new cases per month

Slide 9Clinical ReminderDid the Vet serve in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) after Sept 11, 2001?AfghanistanIraqKuwaitSaudi ArabiaTurkeyOther OIF services

Slide 10PTSD ScreenHave you had an experience in the past month that was so frightening or upsetting that you:Had nightmares or unwanted thoughtsWent out of your way to avoid remindersConstantly on guard, watchful, or easily startledFelt numb or detached from others

Slide 11Brain Injury ScreenDid you have any injuries during your deployment from:FragmentsBulletsVehicular crash including airplaneFallBlast (IED, RPG, grenade, land mine)Other injury

Slide 12Brain Injury ScreenDid any injury result in:

Being dazed, confused, seeing starsNot remembering the injuryLosing consciousness for any amount of timeConcussionHead injury

Slide 13Brain Injury ScreenAre you experiencing any of the following from a head injury/concussion:HeadachesDizzinessMemory problemsBalance problemsRinging in the earsIrritabilitySleep problemsOther

Slide 14Occult (Hidden) Brain InjuryHalf the patients with head injury will be blast exposedHalf will be the result of motor vehicle accidents

Slide 15There are also a large number of post-combat head injuriesLook for an unusually large number of motor vehicle accidents with head injuries in recently-returned Iraq/Afghanistan returnees—within 1 month of discharge and return home. The army reports a 70% increase in motor vehicle accidents

Slide 16Issues for Brain-Injured Active Duty/Vets:Problems in memoryProblems in attentionProblems in problem solvingProblems in social appropriatenessProblems in organizationProblems in fatigueSlowed speed of information processingAnger outbursts

Slide 17What Does BI Do to People?Unable to utilize the medical system as it was constitutedDifficulty in maintaining social roles, marriagesDifficulty holding jobs

Difficulty in school/training (vocational/college/WBRC)

Slide 18The four Traumatic Brain Injury Centers within the VA had already treated a majority of the severely combat injured requiring inpatient rehabilitationSince Desert Storm (Iraq 1) 1992

Slide 19The VA reorganized the TBI lead centers Polytrauma Rehabilitation Centers, dividing the USA into 4 geographical zonesPalo Alto VAHCS, CAMaguire VAMC, Richmond VAJames Haley VAMC, Tampa FLMinneapolis VAMC, Minneapolis MN

Slide 20VISNVA integrated system network(Slide graphic)Map of the United States showing the network: 1 (ME, VT, NH, MA, CT), 2 (NY), 3 4 (PA, DE, WV,

Slide 21Polytrauma Network Sites (PNS)Each PNS Team consists of:PhysiaristNeuropsychologistOccupational TherapistCase ManagerSocial WorkerPhysical TherapistSpeech PathologistProsthetist

Slide 22The Mission of the Polytrauma CenterProvide comprehensive inpatient rehabilitation services for individuals with complex physical and mental health sequelae of severe and disabling trauma and provide support to their families.

Slide 23Intensive case management is essential to coordinate complex components of care for polytrauma patients and their familiesCoordination of care from combat theater to acute hospitalization to acute rehabilitation to his/her home community ultimately MUST OCCUR SEAMLESSLY

The treatment of brain injury sequelae needs to occur before or in conjunction with rehabilitation of other disabling conditions

Slide 24IED Mechanisms of Injury1. Dynamic pressure wave2. Shrapnel3. Acceleration / De-acceleration injury from hitting objects4. Crush injuries from collapsing buildings

Slide 25Polytrauma SequelaeAuditory: TM rupture, ossicular disruption, cochlear damage, foreign bodyEye, Orbit, Face: Perforated globe, foreign body, air embolism, fracturesRespiratory: Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, A-V fistulas (source of embolism), airway epithelial damage, aspiration pneumonitis, sepsis

Slide 26Digestive: Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric ischemia from air embolismCirculatory: Cardiac contusion, myocardial infarction from air embolism, shock, vasovagal hypertension, peripheral vascular injury, air embolism induced injury

Slide 27CNS injury: Concussion, closed and open brain injury, stroke, spinal cord injury, air embolism induced injury, anoxia, hypoxia

Slide 28Renal injury: Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and hypovolemiaExtremity injury: Traumatic amputation, fractures, crush injuries, compartment syndrome, burns, cuts, lacerations, acute arterial occlusion, air embolism induced injury

Slide 29Who Are The Head Injured?18-25 age groupActive duty ArmyMarines35-45 age groupNational GuardNational Reserve20% are womenFamily constellations are different

Slide 30

Culture Clash (Old VA vs New VA)Communication among patients who band together like birds in a flockThey Google you and everything you say.Get used to being challenged—it’s a sign of their involvement in the process.

Slide 31They are in the early stages of adult developmentIssues of late adolescence—separation, anger, appearance, jewelry, body piercing, make-up, clothes—in VA settingFirst job, beginning job skillsWorried about appearance, “date-ability”—developmental task is to find a partner

Slide 32Problems for women in the military:PregnancyFamily with childrenVocation (MOS)Friendly fire issuesSexual harassmentRape

Slide 33Problems for women who sustain brain injury in the militarySeen as insubordinateSeen as lazySeen as disorganizedSeen as passiveFrequently demoted or threatened with court martial—offered separation as an alternative

Slide 34Problems for women who sustain brain injury in the militarySeveral were offered separation for pregnancy—no mention of brain injuryC&P affectedNo service connection for brain injury

Slide 35Issues for Women Warriors on PolytraumaToo open and vulnerable for civilian worldDon’t read social or sexual cuesGive out wrong sexual cues—wrong means “unintended cues”Gum-balling—saying what you think

Slide 36Issues for Women Warriors on Polytrauma Failure to use birth controlFailure to self-protect during sex: STD, HIV

No memory of pregnancy No memory of infant daughter’s first milestones

Slide 37Issues for Women Warriors on Polytrauma Women Warriors are different in the abilities they bring to war—they are not simply “little men”Women Warriors are different in how they are treated in the military after they sustain an unrecognized head injuryWomen Warriors have different social issues and place in society, and their head injuries affect them in their roles and in their place in the family and society

Slide 38Training of StaffNot just clinical staff—all staff needs training in:Polytrauma/Co-morbidityTraumatic Brain Injury (TBI)Post Traumatic Stress Disorder (PTSD)Issues of late adolescenceMilitary vs civilian culture

Slide 39Issues for Brain-Injured Active Duty/Vets:Problems in Visuo spatial functioningProblems in memoryProblems in attentionProblems in problem solvingProblems in social appropriatenessProblems in organizationProblems in fatigueSlowed speed of information processingAnger outbursts

Slide 40One of the major difficulties inassessing BI is that symptoms of BI are not pathognomonic, and are often confused with psychiatric symptoms.

Slide 41This can have several negative effects: People may be placed on inappropriate medications that do not treat the symptomatology They can be inappropriately labeled with a psychiatric diagnosis

They have no understanding about the nature and course of the cognitive and emotional changes that have occurred

Slide 42For Community College/Educational Centers: This means the presence of students who have no idea what their learning and memory characteristics are.

Slide 43The purpose of this next section is:To present the most common “complaints” regarding changes in behavior, function, and personality that result from TBI.

Slide 44Teachers, family members, employers of people with Mild TBI, often complain of “personality” changes. When questioned specifically, they mention:fatigue anger emotional outbursts problems with concentration/attentionslowed information processingmemory problemsSpatial perception problems

Slide 451. Why are people with TBI so tired all the time?

Slide 46Fatigue:Many of the cognitive functions, which are automatic and reflexive for people without cognitive impairment, take 2-3 times the mental effort for people with TBI. This is due to the fact that people with TBI often have to think about, and do with conscious effort, what the rest of the world does automatically, without thinking.  

Slide 47All thinking requires some expenditure of mental energy:Paying attention, Switching attention to a new person, Keeping up with the topic of conversation, Organizing an answer to a question, Making a decision, Trying to decide what to do next, Organizing your day’s activities

Slide 48Concept of Energy Budget

Slide 49How to Compensate for the TBI Symptom of Fatigue.Make important decisions when the person has the greatest amount of mental energy, usually in the morning. Make as many activities as possible into a routine to minimize choice. This saves mental energy. Do not fill up the student’s day with scheduled activities.Do one important thing/day The use of an organizer, either written, taped or electronic is essential.

Slide 502. Why are people with TBI angry so much of the time?  Slide 51Cognitive deficits —slowed rate of information processing, reduced span of attention, loss of the ability to multitask (“Now I’m a one-trick pony”), memory problems for new information, visual-spatial difficulty in perceiving the environment — all serve to make the world seem a more difficult place to comprehend. The anger expressed by people with TBI is often a symptom of stimulus overload.  Slide 52“Catastrophic reactions” are emotional responses of neurologically impaired people when the environment is too complex for them cognitively. There are four variants: silly laughingflighttearsanger

Slide 53Intervention: 1. First, staff can point out the irritability, frustration, or anger when it occurs,2. suggest to the student with BI that too much is coming at them too fast. 3. Delay, Simplify, or Avoid. Discuss later with resource person4. Strike While the Iron Is Cold.

Slide 54Staff can be taught to speak with pauses(Speak as if you threw a handful of commas into your speech.) When you pause in parts of the sentence, the person with BI can “catch up” in information processing.

Slide 55The student can be asked to talk to people one-on-one rather than in groups speaking to two or more people places a strain on attentional mechanisms).

Slide 56For recording:1. Consider recommending Sony Digital Pro Duo recorders with Pro Duo card.2. Puts lecture (audio) into MP3 file3. Used in combination with Dragon Naturally speaking- puts audio into text form4. Can transfer lectures onto IPod5. Parrot Electronic Calendars

Slide 57Other Sources of AngerDisability is So Unfair!

Slide 58TBI often challenges people’s assumptions about how the world works. We all hold some false beliefs about the world, such as:

Slide 59Life’s fair. This is untrue. In dealing with unfairness, it helps to change the frame of reference.

Slide 60For example: Everyone who is alive today has beaten the odds. The odds are 100,000,000 to 1 that a particular sperm would fertilize the egg, which resulted in a particular individual. Those are the odds we all win at conception. After we are born, everything else is gratis, icing on the cake. This is offered as an alternative viewpoint for those who feel cheated of a fair share of good health and long life with any untoward events.

Slide 61Cognitive DisabilityReduced efficiency, pace and persistence of functioningDecreased effectiveness in the performance of routine activities of daily living (ADLs)Failure to adapt to novel or problematic situations

Slide 62The Hallmark of Brain Injury is Inconsistency, not Incapacity-Rather, the person is not reliable.

Slide 63Swiss Cheese Model

Loan function only in the “holes”.He/she who does the behavior is the one who gets “brain trained”.It’s not about efficiency, it’s about building new circuits.

Slide 64Changes in Learning and memory

Slide 65Learning Changes

Slide 66Learning/Memory: teaching new characteristicsRegistrationworking span (no. of bits or chunks)effect of overageno. of verbal stage commands (1,2,3)Sawtooth learning curve of acquisitionNew limits of asymptote (not 100%)Massed vs. distributed practiceWhat was premorbid learning stylePassive vs. active learner (groups material)Fatigability (effect on accuracy)Over learning (repetitions to 100%, reps to over learning)

Slide 67Learning/Memory: teaching new characteristicsStoragePercent retentionAbility to abstract themes (relevant from irrelevant points

Slide 68Learning/Memory: teaching new characteristicsRetrievalSpontaneous recallThe role of association or context vs. rote memorizationCueing effects- best modality, degree of completenessAbility to recognize the correct answer

Slide 69Learning/Memory: teaching new characteristicsPresence of procedural learningPresence of emotional learningSeparation of verbal and motor learning (Squire)Effect of proactive interference

Slide 70Learning/Memory: teaching new characteristicsBest Modality Route:Visual, auditory, Effect of writingModality of disturbance or distortionVerification of accuracy

Slide 71Qualitative Changes in LearningUnderwhelm don’t overwhelmToo much means no learningRest breaks, small sessions of distributed , not massed, practice.No cramming is possible!

Slide 72Learning/Memory: Teaching New CharacteristicsThe primary memory compensation: 1. Student knows the characteristics of new memory functioning and2. That he/she needs to compensate for the changes.3. Primarily by requesting the world repeat, slow down, present itself in smaller bites.

Slide 73Learning/Memory: teaching new characteristicsUse of a Memory book: 1. Used to record compensations and info to remember- not a diary.2. (2) Loose leafs with dividers3. Size you will carry4. Calendar: day at a glance or week at a glance

Slide 74Learning/Memory: teaching new characteristicsUse of a Memory book: 5. Record appointments6. Break down projects7. Review Today and Tomorrow after every meal

Slide 75About InterventionsWhenever possibleTie a compensation to a physiological response Ora negative feeling that is a symptom of overload.This is what leads to generalization.

Slide 76

Learning/Memory: teaching new characteristicsMemory book: Use to record compensations.Examples:OT: Because your information processing is slow, you practiced writing your name as rapidly as possible, and we kept track of the times.

Slide 77Learning/Memory: teaching new characteristicsMemory book: Use to record compensations.Examples:PT: Because you learn best when information is given in three steps, we worked on theses three steps in doing transfers today: Step 1. Lock brakesStep 2. Shift to the strong sideStep 3. lean forward

Slide 78Learning/Memory: teaching new characteristicsMemory book: Use to record compensations.Examples:SPT: Because you have a leaky memory for the topic of conversation, you practiced saying, “Excuse me, could you refresh my memory? What were we talking about?” every time you had a memory lapse.

Slide 79Learning/Memory: teaching new characteristicsMemory book: Use to record compensations.Examples:Psychologist: Went over the time period for the recovery from TBI and how you will continue to recover for 18 to 24 months.

Slide 80Learning/Memory: teaching new characteristicsOther Memory Compensations:1. Needs a life routine so there is less to remember.2. Taping conversations, lectures, therapies.3. Wall lists.4. Beeping watch reminders, PDAs, Parrots, Cell phones with text message capacity.

Slide 81Learning/Memory: teaching new characteristicsTeach Verbal Compensations:I’m sorry, you are rushing ahead too fast for me. Please slow down.I didn’t catch that. Please repeat what you said.Because of my memory problem, I need to use my notebook.

Because of my leaky memory, I need to review today and tomorrow in my notebook calendar after each meal.

Slide 82Planning and Execution Assistant and Trainer- PEAT PEATPlanning and Execution Assistant and Trainer Increases independence and quality of life for people with cognitive disorders due to brain injury, stroke, MS, autism, Alzheimer's disease, ADHD, etc. Helps users complete more activities in the real-world:at home, school, work, around town.....or anywhere!A personal planning assistant that provides help 24/7Automatic cues to start and stop activities use customized voice recordings, sounds and pictures.Automatically monitors performance, and corrects schedule problems when necessary.Personalized scripts break large tasks into smaller steps, and guide users through multi-step procedures.Customized for individual needs and preferences

Slide 83

Slide 84Characteristics of Mild Brain Injurythat Your Departments Will Have To Deal WithInefficient memory: especially for appointments, episodic events1. 3 missed appointments, clinics drop them2. Need for memory prostheses and training (often too slow)3. Can’t come back later—they will disappear; solve the issue now4. Allow tape recording of information

Slide 85Special TBI/PTSD ConsiderationsFrontal Lobe as site of managing dysphoric affect and the ability to self-sootheExposure to traumatic stimulus- can’t come down from agitation

Slide 86TBI/PTSD with Frontal EffectsShift to relaxation, grounding, how to prevent overwhelming, catastrophic reaction first- when this is over learned, then introduce other techniquesWarning- watch relaxation relation to panic

Slide 87Caveat, possible harm to some from psychotherapyScott Lilienfeld on Psychological treatments that can cause harm

Example- Conditioned relaxation techniques possibly increasing panic attacks for patients with panic disorder dx. (Adler, Craske, and Barlow, 1987; Lynn, Martin & Frauman 1996)

Slide 88Back To TBIEffects of slowed rate of info processing-Speak in groups with commas.Get vet to ask for repetitionRecording Second time through classPair group work with individual

Slide 89Changes in mental flexibility/learning/abstraction affecting 5 column CBT technique:1. Can recognize, not come up with countering thought to a perception- be directive2. Can drop “end of response”, make sure beginning, middle, end of sequence in perception, action, is followed.3. How to interrupt perseveration- physical reset

Slide 90Consider The Alliance Model when dealing with neurologically impaired individuals.

Slide 91Alliance model is based on redirected anger. Anger is always generated when loss is experienced. It is adaptive, Anger creates energy to prevent collapsing in despair, and fuels the need to change. It is always present. It is natural part of the history of recovery. It is not pathological or delusional.

Slide 92Alliance Model of TherapyThe optimal condition for rehabilitation of neurologically impaired patients is created when the patient, family and staff are allied against “demon” brain injury. This is the triangulation necessary for optimum recovery.

Slide 93Alliance Model1. Takes blame for symptoms off the person2. Still invested in reducing the impact of demon Brain Injury on my life.3. Tie compensations to physiological need or a negative symptom/feeling (like anger, tears, flight)4. Teach a compensation-a construct that suggests what to do5. Use structure.

Slide 94Teach the FamilyHow to talk to the patient (handful of commas). How to frame criticism. Example “If you want me to feel close to you, speak in a quiet voice.” (do not say “stop yelling” rather, end on a positive behavior or patient only remembers “yelling”).Or“Tell me that you appreciate all that I do.”

Slide 95What To Do First In TreatmentPatient’s Goals of Therapy:1. Patients can navigate the medical system more effectively (better access to services)2. Reach higher level of function in the home and/or community3. Learn what is wrong-and what to do about it4. Learn how to establish a daily routine 5. Periodically step briefly back into therapy when out-of-routine events occur

Slide 96What To Do First In TreatmentEstablish a day/night cycle

Slide 97Develop a daily routine for/with patient

Slide 98Work with calendar in notebook/PDA Review today/tomorrow in calendar after meals How to break down tasks for calendar

Slide 99 Practice use of resource people for problem solving (initially this looks a lot like case managing)

Slide 100 Ask permission to correct, Permission to address a problem when it occurs

Slide 101Explain, Explain, Explain: symptoms of neurological impairment, what’s wrong, what to do about itTransfer this knowledge from your head to patient’s headThis is the “therapeutic agent of change”

Slide 102The UAB Home Stimulation Program provides activities for you to use with individuals who have neurological impairment. These activities are designed to assist the individual in the recovery of their thinking skill. Each activity provides a group of tasks listed by their level of difficulty. The tasks range from the least challenging, Level 1 to higher levels that are progressively more challenging. Select activities that you feel might be appropriate and follow the directions, increasing the level of difficulty as the progress warrants. Work on several tasks each day and shift tasks after a few days to provide variety. The tasks are offered to provide some guidance and structure to people with brain disorders and their families.You may print any part of it for use at home. The entire program is also found on the Internet at http://main.uab.edu/show.asp?durki=49377

Slide 103Cognitive RetrainingAttentional componentsVisual-spatial functioningLearning and memoryProblem solving-non interpersonalProblem solving interpersonal

Slide 104Why are Visual Spatial Abilities Important in Blind Rehab?

Slide 105Many Techniques Require Intact Mental Visual-spatial Cognitions:ClockCompassLeft/right/above/below/next to/nearMental Rotation

Slide 106Visuospatial Functioning1. Scanning2. Gestalt principles of form recognition3. Figure ground4. Transposition5. Spatial relations between objects6. Identification of object/surround in relation to self

Slide 107Visuospatial FunctioningDisorders of self/space relationship:Hemispace

Surface of the bodyMovement through space

Slide 108Visuospatial FunctioningCognitive maps (only developmental sequence):EgocentricLandmarksCoordinate referents

Slide 109Issue of Acceptance of Disability in Brain Injury

Slide 110Re-inventing the SelfTo include disability, but not only disabilityA self of accretion

Slide 111Aging to Sage-ing Model

Slide 112Zalman Schacter ShalomiWrote Age-ing To Sage-ing I’m suggesting that we see neurological impairment as premature aging- not just physically, but developmentally

Slide 113American Model For AgingPhysical DeclineSocial IrrelevanceDeathTherefore, successful aging in America means staying middle-aged forever.

Slide 114Schacter-Shalomi argues that in more mature cultures, each human age has a developmental task, and the task for older adults is:To become a Sage, a Mentor, A Wise personTo one’s family, friends, fellow professionals

Slide 115People who have survived disability are more mature- they are sages in ways their peers are not.

Slide 116

Combat experience makes you different from peers who haven’t been in combat. Older, more experienced—this is an identity “in addition” to disability.

Slide 117What are Vets with BI experienced or wise in?To survive neurological impairmentTo struggle to reach competency-againTo achieve a meaningful life when all is not perfectTo learn to cope with adversity and reduced life expectations

Slide 118For those with brain injury, “resilience” is the model.Resilience is defined as “I use the latest/best compensation most effectively.” “I cope effectively but not perfectly, to all that I encounter”This is also the goal of the educator- to foster “resilience”.

Slide 119The task for the Vet with BI is to be the scarred, competent, resilient one. Battle scars, accident scars, experience scars, facial and body scars.

Slide 120Techniques/Themes/Interventions to Use with Survivors of Brain InjuryWhenever possible, go to the meta level, give the “big picture”, over and over again. Tell them where you want to go,What you are trying to do, What success looks like.

Slide 121Use of positive metaphors: Resilient one, Scarred, competent one, Wise one,

Slide 122MetaphorsSurvivorPositive PathfinderMending MentorStrong SpiritCalm SoulProud Turtle (slower)Sound, Solid SurvivorHope HandlerPeaceful PacemakerLaid-back leaderFocus Finder

Diplomatic Diva"Swiss Cheese" ExpertResilient RoadrunnerResilient RebelEasy Going ElderEasy Flow ExpertMind MinderMilitary Mind BenderWise WarriorFreedom Fighter

Slide 123Family /CaregiversGentle GuidePositive PalCaring CheerleaderCaring ComradeFamily FarmerFamily FramerSupportive SiblingGrand SupporterPeaceful PacemakerPerfect PartnerPatient PartnerCaring CommunicatorResilience RoadieCoping ConnectorFamily FighterTimeline TeacherMind LenderMind Mentor

Slide 124Use the Alliance model to redirect anger. Anger is always generated when loss is experienced. It is adaptive, anger creates energy to prevent collapsing in despair, and fuels the need to change. It is always present. It is natural part of the history of recovery. It is not pathological or delusional.

Slide 125The optimal condition for education is created when the Student with BI and college staff are allied against “demon” brain injury. This is the triangulation necessary for optimum achievement.

Slide 126Strong role of the Disability Coordinator

Contain the uncontainedGive active choices to help students articulate what they think and feel but cannot organize themselves to express.Loan cognitive functionProvide a safe container to learn

Slide 127Help everyone agree on what constitutes improvement. In the alliance of student with TBI/educational staff- articulate what is the problem and what is the next step.

Slide 128the optimum environment for the student with TBI is the matching of the correct level of learning to the student’s current learning capacity level.Fantasy that “more is better”(learning and number of bits- too much means no learning)

Slide 129What Every Educator/Counselor Needs to KnowWhat is the behavioral problemHow to contain the problemCorrect balance between appreciation/correctionThat compensation use is never 100%- rather, how to increase the frequency of positive behaviors or decrease the frequency of a particular behavior that reduces others’ closeness.How to set goals (small steps)

Slide 130Some Neuropsych Tips Caregivers Should KnowThey cannot multitask-now a one trick ponyInside/ outside line moved (gum-balling, seems rude, hurtful)Lack ideasInitiation difficulty (broken ignition, broken starter)

Slide 131Establish a day/night cycleEstablish a daily routineTeach what the problem is, and how to get around itWhat is the learning span- stay at or lowerPeriodically step back into checking with an expert when out of routine events occurUse a PDA/CalendarReview today/tomorrow after each mealBreak down events in calendar

Slide 132Ask permission to correct

Permission to correct a behavior when it occursExplain, explain, explainSymptoms of head injury and what to do about itLoan the patient part of your cognitionSwiss cheese metaphor

Slide 133Teach Partial functions if full functions not possible (example parenting-love, nurture, teach, protect)Fairness fantasyCatastrophic reaction- how not to be overwhelmed in the worldGumballingThe line between an inside versus an outside thoughtProbably consider that students with BI may need periodic therapy tune ups, life-long, due to out-of-routine events.