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The Changing VA Population:
Young, Active Duty and Brain
Injured
or
It’s A Co-Morbid World
Harriet Katz Zeiner, PhD
[email protected]
There’s a New Population in Town
And They Require Systemic
Change To Deal With Them
Effectively
Why?
How Big Is The Problem?
Why Won’t The Old Ways Work?
What Do I Have To Change To
Deal Effectively With Them?
• While 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.
• Improvised 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)
Of these injured military personnel,
60% have some degree of traumatic
brain injury
http://www.dvbic.org
If the War Ended Today:
• 30,000 WIA
• 65% of these are IED = 19,500
• 60% of IED injuries involve head injuries =
11,070
• 1500 combat-wounded polytrauma patients have been
treated at the 4 PRCs
Currently, 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
• 10,000 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 roles
• This is not a political issue—it is a major health
care problem in America, which the VA is
charged to deal with.
Occult (Hidden) Brain Injury
• How many people with TBI you find
depends on whether or not you are looking
• Degree to which you look is the degree to
which you find
• If 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
Clinical Reminder
Did the Vet serve in Operation Iraqi Freedom (OIF)
or Operation Enduring Freedom (OEF) after
Sept 11, 2001?
• Afghanistan
• Iraq
• Kuwait
• Saudi Arabia
• Turkey
• Other OIF services
PTSD Screen
• Have you had an experience in the past
month that was so frightening or upsetting
that you:
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Had nightmares or unwanted thoughts
Went out of your way to avoid reminders
Constantly on guard, watchful, or easily startled
Felt numb or detached from others
Brain Injury Screen
Did you have any injuries during your
deployment from:
• Fragments
• Bullets
• Vehicular crash including airplane
• Fall
• Blast (IED, RPG, grenade, land mine)
• Other injury
Brain Injury Screen
Did any injury result in:
• Being dazed, confused, seeing stars
• Not remembering the injury
• Losing consciousness for any amount of
time
• Concussion
• Head injury
Brain Injury Screen
Are you experiencing any of the following from a
head injury/concussion:
• Headaches
• Dizziness
• Memory problems
• Balance problems
• Ringing in the ears
• Irritability
• Sleep problems
• Other
Occult (Hidden) Brain Injury
• Half the patients with head injury will be
blast exposed
• Half will be the result of motor vehicle
accidents
• There are also a large number of post-combat
head injuries
• Look for an unusually large number of motor
vehicle accidents with head injuries in recentlyreturned Iraq/Afghanistan returnees—within 1
month of discharge and return home.
• The army reports a 70% increase in motor
vehicle accidents
Issues for Brain-Injured Active Duty/Vets:
Problems in memory
Problems in attention
Problems in problem solving
Problems in social appropriateness
Problems in organization
Problems in fatigue
Slowed speed of information processing
Anger outbursts
What Does BI Do to People?
• Unable to utilize the medical system as it
was constituted
• Difficulty in maintaining social roles,
marriages
• Difficulty holding jobs
• Difficulty in school/training
(vocational/college/WBRC)
The four Traumatic Brain Injury
Centers within the VA had already
treated a majority of the severely
combat injured requiring inpatient
rehabilitation
Since Desert Storm (Iraq 1) 1992
The VA reorganized the TBI lead centers
Polytrauma Rehabilitation Centers,
dividing the USA into 4 geographical
zones
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Palo Alto VAHCS, CA
Maguire VAMC, Richmond VA
James Haley VAMC, Tampa FL
Minneapolis VAMC, Minneapolis MN
VISN
VA integrated system network
Polytrauma Network Sites (PNS)
Each PNS Team consists of:
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Physiarist
Neuropsychologist
Occupational Therapist
Case Manager
Social Worker
Physical Therapist
Speech Pathologist
Prosthetist
The Mission of the Polytrauma
Center
• Provide comprehensive inpatient
rehabilitation services for individuals with
complex physical and mental health
sequelae of severe and disabling trauma
and provide support to their families.
• Intensive case management is essential to
coordinate complex components of care for
polytrauma patients and their families
• Coordination 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
IED Mechanisms of Injury
• 1. Dynamic pressure wave
• 2. Shrapnel
• 3. Acceleration / De-acceleration injury
from hitting objects
• 4. Crush injuries from collapsing buildings
Polytrauma Sequelae
Auditory: TM rupture, ossicular disruption,
cochlear damage, foreign body
Eye, Orbit, Face: Perforated globe,
foreign body, air embolism, fractures
Respiratory: Blast lung, hemothorax,
pneumothorax, pulmonary contusion
and hemorrhage, A-V fistulas (source of
embolism), airway epithelial damage,
aspiration pneumonitis, sepsis
• Digestive: Bowel perforation,
hemorrhage, ruptured liver or spleen,
sepsis, mesenteric ischemia from air
embolism
• Circulatory: Cardiac contusion,
myocardial infarction from air
embolism, shock, vasovagal
hypertension, peripheral vascular injury,
air embolism induced injury
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CNS injury: Concussion,
closed and open brain injury,
stroke, spinal cord injury, air
embolism induced injury,
anoxia, hypoxia
• Renal injury: Renal contusion,
laceration, acute renal failure due to
rhabdomyolysis, hypotension, and
hypovolemia
• Extremity injury: Traumatic amputation,
fractures, crush injuries, compartment
syndrome, burns, cuts, lacerations,
acute arterial occlusion, air embolism
induced injury
Who Are The Head Injured?
• 18-25 age group
– Active duty Army
– Marines
• 35-45 age group
– National Guard
– National Reserve
20% are women
Family constellations are different
Culture Clash (Old VA vs New VA)
• Communication among patients who band
together like birds in a flock
• They Google you and everything you say.
Get used to being challenged—it’s a sign
of their involvement in the process.
They are in the early stages of adult
development
• Issues of late adolescence—separation,
anger, appearance, jewelry, body piercing,
make-up, clothes—in VA setting
• First job, beginning job skills
• Worried about appearance, “date-ability”—
developmental task is to find a partner
Problems for women in the military:
Pregnancy
Family with children
Vocation (MOS)
Friendly fire issues
Sexual harassment
Rape
Problems for women who sustain brain injury
in the military
Seen as insubordinate
Seen as lazy
Seen as disorganized
Seen as passive
Frequently demoted or threatened with court
martial—offered separation as an
alternative
Problems for women who sustain brain injury
in the military
Several were offered separation for
pregnancy—no mention of brain injury
C&P affected
No service connection for brain injury
Issues for Women Warriors on Polytrauma
Too open and vulnerable for civilian world
Don’t read social or sexual cues
Give out wrong sexual cues—wrong means
“unintended cues”
Gum-balling—saying what you think
Issues for Women Warriors on Polytrauma
Failure to use birth control
Failure to self-protect during sex: STD, HIV
No memory of pregnancy
No memory of infant daughter’s first
milestones
Issues 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 injury
• Women 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
Training of Staff
Not just clinical staff—all staff needs training in:
• Polytrauma/Co-morbidity
• Traumatic Brain Injury (TBI)
• Post Traumatic Stress Disorder (PTSD)
• Issues of late adolescence
• Military vs civilian culture
Issues for Brain-Injured Active Duty/Vets:
Problems in Visuo spatial functioning
Problems in memory
Problems in attention
Problems in problem solving
Problems in social appropriateness
Problems in organization
Problems in fatigue
Slowed speed of information processing
Anger outbursts
One of the major difficulties in
assessing BI is that
symptoms of BI are not
pathognomonic,
and are often
confused with psychiatric
symptoms.
This 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
For Community College/Educational
Centers:
This means the presence of students who
have no idea what their learning and
memory characteristics are.
• The purpose of this next section is:
• To present the most common
“complaints” regarding changes in
behavior, function, and personality
that result from TBI.
Teachers, family members , employers of
people with Mild TBI, often complain of
“personality” changes.
When questioned specifically, they mention:
1. fatigue
2. anger
3. emotional outbursts
4. problems with concentration/attention
5. slowed information processing
6. memory problems
7. Spatial perception problems
1. Why are people with TBI
so tired all the time?
Fatigue:
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.
All 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
• Concept of Energy Budget
1.
How 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.
2. Why are people with TBI
angry so much of the time?
Cognitive 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.
“Catastrophic reactions”
are emotional responses of neurologically
impaired people when the environment is
too complex for them cognitively.
There are four variants:
silly laughing
flight
tears
anger
Intervention:
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 person
4. Strike While the Iron Is Cold.
• Staff 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.
The 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).
For recording:
1. Consider recommending Sony Digital
Pro Duo recorders with Pro Duo card.
2. Puts lecture (audio) into MP3 file
3. Used in combination with Dragon
Naturally speaking- puts audio into text
form
4. Can transfer lectures onto IPod
5. Parrot Electronic Calendars
Other Sources of Anger
• Disability is So Unfair!
TBI often challenges people’s
assumptions about how the world
works. We all hold some false beliefs
about the world, such as:
° Life’s fair. This is untrue. In dealing with
unfairness, it helps to change the frame of
reference.
For 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.
Cognitive Disability
• Reduced efficiency, pace and persistence
of functioning
• Decreased effectiveness in the
performance of routine activities of daily
living (ADLs)
• Failure to adapt to novel or problematic
situations
• The Hallmark of Brain Injury is
Inconsistency, not Incapacity• Rather, the person is not reliable.
Swiss 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.
Changes in Learning and memory
Learning Changes
Learning/Memory: teaching new characteristics
Registration
• working span (no. of bits or chunks)
• effect of overage
• no. of verbal stage commands (1,2,3)
• Sawtooth learning curve of acquisition
• New limits of asymptote (not 100%)
• Massed vs. distributed practice
• What was premorbid learning style
• Passive vs. active learner (groups material)
• Fatigability (effect on accuracy)
• Over learning (repetitions to 100%, reps to over
learning)
Learning/Memory: teaching new characteristics
Storage
Percent retention
Ability to abstract themes (relevant from
irrelevant points
Learning/Memory: teaching new characteristics
Retrieval
• Spontaneous recall
• The role of association or context vs. rote
memorization
• Cueing effects- best modality, degree of
completeness
• Ability to recognize the correct answer
Learning/Memory: teaching new characteristics
• Presence of procedural learning
• Presence of emotional learning
• Separation of verbal and motor learning
(Squire)
• Effect of proactive interference
Learning/Memory: teaching new characteristics
Best Modality Route:
Visual, auditory,
Effect of writing
Modality of disturbance or distortion
Verification of accuracy
Qualitative Changes in Learning
• Underwhelm don’t overwhelm
• Too much means no learning
• Rest breaks, small sessions of distributed ,
not massed, practice.
• No cramming is possible!
Learning/Memory: Teaching New
Characteristics
The primary memory compensation:
1.
Student knows the characteristics of new memory
functioning and
2. That he/she needs to compensate for the changes.
3.
Primarily by requesting the world repeat, slow down, present
itself in smaller bites.
Learning/Memory: teaching new
characteristics
Use of a Memory book:
1. Used to record compensations and info
to remember- not a diary.
2. (2) Loose leafs with dividers
3. Size you will carry
4. Calendar: day at a glance or week at a
glance
Learning/Memory: teaching new
characteristics
Use of a Memory book:
5. Record appointments
6. Break down projects
7. Review Today and Tomorrow after every
meal
About Interventions
Whenever possible
• Tie a compensation to a physiological
response
Or
• a negative feeling that is a symptom of
overload.
This is what leads to generalization.
Learning/Memory: teaching new
characteristics
Memory 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.
Learning/Memory: teaching new
characteristics
Memory 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 brakes
Step 2. Shift to the strong side
Step 3. lean forward
Learning/Memory: teaching new
characteristics
Memory 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.
Learning/Memory: teaching new
characteristics
Memory 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.
Learning/Memory: teaching new
characteristics
Other 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.
Learning/Memory: teaching new
characteristics
Teach 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.
Planning and Execution
Assistant and Trainer- PEAT
• PEAT
Planning 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 24/7
• Automatic 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
Artificial intelligence developed for NASA robots
compensates for
executive function impairments including initiation,
planning, and error correction.
PEAT now works on cellular phones!
The only therapeutic cueing product* that automatically reschedules activities as necessary
Characteristics of Mild Brain Injury
that Your Departments Will Have To
Deal With
Inefficient memory: especially for appointments,
episodic events
1. 3 missed appointments, clinics drop them
2. Need for memory prostheses and training (often
too slow)
3. Can’t come back later—they will disappear; solve
the issue now
4. Allow tape recording of information
Special TBI/PTSD Considerations
• Frontal Lobe as site of managing
dysphoric affect and the ability to selfsoothe
• Exposure to traumatic stimulus- can’t
come down from agitation
TBI/PTSD with Frontal Effects
• Shift to relaxation, grounding, how to
prevent overwhelming, catastrophic
reaction first- when this is over learned,
then introduce other techniques
• Warning- watch relaxation relation to panic
Caveat , possible harm to some
from psychotherapy
Scott 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)
Back To TBI
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Effects of slowed rate of info processingSpeak in groups with commas.
Get vet to ask for repetition
Recording
Second time through class
Pair group work with individual
Changes in mental flexibility/learning/abstraction affecting
5 column CBT technique:
1. Can recognize, not come up with countering
thought to a perception- be directive
2. Can drop “end of response”, make sure
beginning, middle, end of sequence in
perception, action, is followed.
3. How to interrupt perseveration- physical reset
• Consider The Alliance Model when dealing
with neurologically impaired individuals.
• Alliance 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.
Alliance Model of Therapy
The 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.
Alliance Model
1. Takes blame for symptoms off the person
2. 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 do
5. Use structure.
Teach the Family
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How 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.”
What To Do First In Treatment
Patient’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 community
3. Learn what is wrong-and what to do about it
4. Learn how to establish a daily routine
5. Periodically step briefly back into therapy when
out-of-routine events occur
What To Do First In Treatment
• Establish a day/night cycle
• Develop a daily routine for/with patient
Work with calendar in notebook/PDA\
– Review today/tomorrow in calendar after
meals
– How to break down tasks for calendar
– Practice use of resource people for problem
solving
(initially this looks a lot like case managing)
– Ask permission to correct,
– Permission to address a problem when it
occurs
Explain, Explain, Explain:
– symptoms of neurological impairment,
– what’s wrong,
– what to do about it
Transfer this knowledge from your head to patient’s
head
This is the “therapeutic agent of change”
• The UAB Home Stimulation Program provides activities for you to
use with individuals who have neurological impairment.
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These activities are designed to assist the individual in the recovery
of their thinking skill.
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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.
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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
Cognitive Retraining
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Attentional components
Visual-spatial functioning
Learning and memory
Problem solving-non interpersonal
Problem solving interpersonal
Why are Visual Spatial Abilities
Important in Blind Rehab?
• Many Techniques Require Intact Mental
Visual-spatial Cognitions:
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Clock
Compass
Left/right/above/below/next to/near
Mental Rotation
Visuospatial Functioning
1.
2.
3.
4.
5.
6.
Scanning
Gestalt principles of form recognition
Figure ground
Transposition
Spatial relations between objects
Identification of object/surround in
relation to self
Visuospatial Functioning
Disorders of self/space relationship:
Hemispace
Surface of the body
Movement through space
Visuospatial Functioning
Cognitive maps (only developmental
sequence):
Egocentric
Landmarks
Coordinate referents
Issue of Acceptance of Disability in
Brain Injury
Re-inventing the Self
• To include disability, but not only disability
• A self of accretion
Aging to Sage- ing Model
Zalman Schacter Shalomi
Wrote Age-ing To Sage-ing
I’m suggesting that we see neurological
impairment as premature aging- not just
physically, but developmentally
American Model For Aging
• Physical Decline
• Social Irrelevance
• Death
• Therefore, successful aging in America
means staying middle-aged forever.
• Schacter-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
person
• To ones family, friends, fellow professionals
People who have survived disability are
more mature- they are sages in ways their
peers are not.
Combat experience makes you different
from peers who haven’t been in combat.
Older, more experienced—this is an
identity “in addition” to disability.
What are Vets with BI experienced
or wise in?
• To survive neurological impairment
• To struggle to reach competency-again
• To achieve a meaningful life when all is not
perfect
• To learn to cope with adversity and
reduced life expectations
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For 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”.
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The task for the Vet with BI is to be the
scarred, competent, resilient one. Battle
scars, accident scars, experience scars,
facial and body scars.
Techniques/Themes/Interventions to Use
with Survivors of Brain Injury
• Whenever 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.
Use of positive metaphors:
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Resilient one,
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Scarred, competent one,
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Wise one,
Metaphors
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Survivor
Positive Pathfinder
Mending Mentor
Strong Spirit
Calm Soul
Proud Turtle (slower)
Sound, Solid Survivor
Hope Handler
Peaceful Pacemaker
Laid-back leader
Focus Finder
Diplomatic Diva
"Swiss Cheese" Expert
Resilient Roadrunner
Resilient Rebel
Easy Going Elder
Easy Flow Expert
Mind Minder
Military Mind Bender
Wise Warrior
Freedom Fighter
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Family /Caregivers
Gentle Guide
Positive Pal
Caring Cheerleader
Caring Comrade
Family Farmer
Family Framer
Supportive Sibling
Grand Supporter
Peaceful Pacemaker
Perfect Partner
Patient Partner
Caring Communicator
Resilience Roadie
Coping Connector
Family Fighter
Timeline Teacher
Mind Lender
Mind Mentor
• Use 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.
The 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.
Strong role of the Disability
Coordinator
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Contain the uncontained
Give active choices to help students
articulate what they think and feel but
cannot organize themselves to express.
Loan cognitive function
Provide a safe container to learn
• Help 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.
**the 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)
What Every Educator/Counselor
Needs to Know
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What is the behavioral problem
How to contain the problem
Correct balance between
appreciation/correction
That 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)
Some Neuropsych Tips Caregivers
Should Know
• They cannot multitask-now a one trick
pony
• Inside/ outside line moved (gum-balling,
seems rude, hurtful)
• Lack ideas
• Initiation difficulty (broken ignition, broken
starter)
• Establish a day/night cycle
• Establish a daily routine
• Teach what the problem is, and how to get
around it
• What is the learning span- stay at or lower
• Periodically step back into checking with an
expert when out of routine events occur
• Use a PDA/Calendar
• Review today/tomorrow after each meal
• Break down events in calendar
• Ask permission to correct
• Permission to correct a behavior when it
occurs
• Explain, explain, explain
• Symptoms of head injury and what to do
about it
• Loan the patient part of your cognition
• Swiss cheese metaphor
• Teach Partial functions if full functions not possible
(example parenting-love, nurture, teach, protect)
• Fairness fantasy
• Catastrophic reaction- how not to be overwhelmed in the
world
• Gumballing
• The line between an inside versus an outside thought
• Probably consider that students with BI may need
periodic therapy tune ups, life-long, due to out-of-routine
events.