SCREENING

1
SCREENING STRATEGIES Supporting Individuals
With a (often hidden) History of Brain Injury
A Product of the Maryland Traumatic Brain Injury
Partnership Implementation Project 2006-2009
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Goals for today...

• Overview of mild and often hidden brain injury
• 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

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Changes after Brain InjuryThings to remember

• A person with a brain injury is a person first
• The age at time of injury will impact development
• No two brain injuries are exactly the same
• Often symptoms of brain injury and psychiatric
  symptoms are similar
• The effects of a brain injury are complex and
  vary greatly from person to person
• The effects of a brain injury depend on such
  factors as cause, location and severity
• Preexisting skills will impact and be impacted by
  the brain injury(e.g. cognitive reserve)

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What is the most common type of traumatic injury?

• Mild Traumatic Brain Injury (AKA Concussion)
• Moderate Brain Injury
• Severe Brain Injury

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Answer Mild Traumatic Brain Injury,
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Mild TBI

• Most common type of brain injury, 75-85 of all
  brain injuries are mild
• Individuals experience a brief (lt15 minutes)or NO
  loss of consciousness (LOC)
• Post Traumatic Amnesia (PTA) lt 1hour
• Normal neurological exam
• 90 of individuals recover within 6-8 weeks,
  often within hours or days

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For approximately 10 of individuals who
experience mild traumatic brain injury,
difficulties can linger and can be exacerbated by
subsequent brain injuries It is also important
to note that individuals who experience a more
severe brain injury can make an excellent
physical recovery-leaving any residual cognitive
and behavioral difficulties hidden .
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Question If a person does not lose consciousness
after being struck on the head, can they still
experience brain injury related problems?

• Answer Yes, this is especially true for
  children and older adults who may seem just a bit
  dazed or confused after a blow to the head

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The Importance of Post Traumatic Amnesia

• PTA is the period of time after injury when a
  person is unable to lay down new memories
• (during this time they may appear dazed
  confused)

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FOR EXAMPLE...
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That first morning, wow, I didnt want to move,
I was thankful that nothings broken, but my
brain was all scrambled Ryan Church, NY Mets,
quoted in the New York Times 3/10/08

• All he remembers from the collision with
  Anderson is the aftermath, being helped off the
  field by two people, although he said he did not
  know who they were until he saw a photograph
  later
• Ben Shpigel NYT reporter

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The American Academy of Neurology defines
concussion as,Concussion is a trauma-induced
alteration in mental status that may or may not
involve loss of consciousness. Confusion and
amnesia are hallmarks of concussion
http//search.aan.com/vivisimo/cgi-bin/query-meta
?input-formsimplev3AsourcesAANNewv3Aproject
aanqueryconcussion
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The Developing Brain

• Childrens brains do not reach their adult weight
  of 3 pounds until they are 12 years old
• The brain, and most importantly, the brains
  frontal lobe region does not reach its full
  cognitive maturity till individuals reach their
  mid twenties

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This is important to keep in mind because..

• The Adult Consumer you are serving may have
  suffered a brain injury as a child
• and as a result are living with the consequences
  of a hidden brain injury

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Unidentified traumatic brain injury is an
unrecognized major source of social and
vocational failureWayne Gordon, Ph.DBrain
Injury Research Center Mount Sinai School of
MedicineWall Street Journal 1.29.08
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Examples of how an adult with a history of brain
injury, suffered in childhood or as a adult may
exhibit brain injury related cognitive and
behavioral problems
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A memory deficit might look like trouble
remembering or it might look like (Capuco
Freeman-Woolpert,)

• She frequently misses appointments-avoidance,
  irresponsibility
• He says hell do something but doesnt get around
  to it
• She talks about the same thing or asks the same
  question over and over-annoying perservation
• He invents plausible sounding answers so you
  wont know he doesnt remember (this is referred
  to as confabulation, the individual tries to
  fill in the blanks in their memory, it is not
  conscious lying)

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An attention deficit might look like trouble
paying attention or it might look like (Capuco
Freeman-Woolpert)

• He keeps changing the subject
• She doesnt complete tasks
• He has a million things going on and none of them
  ever gets completed
• When she tries to do two things at once she gets
  confused and upset

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A deficit in executive skills might look like the
inability to plan and organize or it might look
like... (Capuco Freeman-Woolpert)

• Uncooperativeness, stubbornness
• Lack of follow through
• Laziness
• Irresponsibility

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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 (e.g. athletes,
  service members)

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About multiple mild TBI NFL, Concussion
Alzheimers Disease (Guskiewicz et. al. 2005)

• 61 of the former players sustained at least one
  concussion in their career
• 24 sustained 3 or more concussions
• Retired players with 3 or more concussions had a
  fivefold prevalence of reported significant
  memory problems compared to players with no hx of
  concussion
• Researchers also observed an earlier onset of
  Alzheimer's disease in retirees than in general
  male population.

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The HELPS Brain Injury Screening Tool(see
handout)The original HELPS tool developed by M.
Picard, D. Scarisbrick, R. Paluck, 9.1991Updated
by the Michigan Department of Community Health
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HELPS

• Have you ever Hit your Head or been Hit on the
  Head?
• Prompt individual to think about TBI at any age,
  MVAs. Assaults, Sports injuries, Service related
  injuries, Shaken baby and/or adult

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HELPS

• Were you ever seen in the Emergency room,
  hospital, or by a doctor because of an injury to
  your head?
• Explore the possibility of unidentified
  traumatic brain injury many do not present in
  medical settings

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HELPS

• Did you ever Lose consciousness or experience a
  period of being dazed and confused because of an
  injury to your head?
• Remember, a LOC isnt required for someone to
  develop symptoms subsequent to a blow to the
  head. alteration of consciousness AKA post
  traumatic amnesia (PTA). At this point, the
  interviewer may consider asking the individual if
  they have had multiple mild TBI

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HELPS

• Do you experience any of these Problems in your
  daily life since you hit your head?
• You want to know when any problems began (or
  began to be noticed) Remember, lack of awareness
  is a hallmark of brain injury, you might ask if
  anyone close to the individual has made any
  observations regarding changes in function.

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HELPS

• Difficulty reading, writing, calculating
• Poor problem solving
• Difficulty performing your job/school work
• poor judgement (being fired from job, arrests,
  fights, relationships affected)

• Headaches
• Dizziness
• Anxiety
• Depression
• Difficulty concentrating
• Difficulty remembering

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HELPS

• Any significant Sickness?
• Acquired Brain Injury (ABI) can result in many of
  the same functional impairments as traumatic
  brain injury (TBI). For example, brain tumor,
  meningitis, West Nile virus, stroke, seizures,
  toxic shock syndrome, aneurysm, AV malformation,
  any history of anoxic injury, e.g. heart attack,
  near drowning, carbon monoxide poisoning can all
  result in multiple deficits

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Scoring the HELPS Positive for a possible Brain
Injury when the following three are identified

• An event the could have caused a brain injury
  (YES to H, E, or S), and
• A period of loss of consciousness or altered
  consciousness after the injury or another
  indication that the injury was severe (YES to L
  or E), and
• the presence of 2 or more chronic problems listed
  under P that were not present before the injury.

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Scoring the HELPS

• A positive screening is not sufficient to
  diagnose TBI as the reason for current symptoms
  and difficulties-other possible possible reasons
  need to be ruled out
• Some individuals could present exceptions to the
  screening results, such as people who do have
  TBI-related problems but answered no to some
  questions
• Consider positive responses within the context of
  the persons self-report and documentation of
  altered behavioral and/or cognitive functioning

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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

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What you are looking for..And Why

• Any reported or suspected functional difficulties
  that are interfering with home, work or community
  activities
• With the identification a history of brain
  injury, professionals can better support the
  individuals served and make informed referrals to
  brain injury specialists when appropriate

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In the absence of funding or resources for brain
injury specific services, human service
providers, individuals and family members can
implement strategies to improve functioning and
independence
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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

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Areas of Interpersonal Functioning that can be
supported by Strategies

• Impulsivity
• Frustration tolerance
• Social skills
• self esteem
• Building and maintaining relationships

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Most of these Strategies address more than one
cognitive and or behavioral deficit
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Restoration VersesCompensationSpontaneous
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
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Environmental Internal AidesCreative
cognitive strategies will employ both kinds of
aids depending on individual need
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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

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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

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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

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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

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Cognitive Strategies are a key component of what
is often referred to as Cognitive Rehabilitation
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Definition of Cognitive Rehabilitation

• The application of techniques and procedures,
  and the implementation of supports to allow
  individuals with cognitive impairment to function
  as safely, productively, and independently as
  possible
• Mateer, CA (2005) in Fundamentals of Cognitive
  Rehabilitation. IN P. W. Halligan and D.T. Wade
  (Eds.), Effectiveness of Rehabilitation for
  Cognitive Deficits. Oxford Press
• Quoted 5.3.06 by Don MacLennan AVASLP conference

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Does it Work? Cicerone et. al review the
literature (Archives of Physical Medicine. 2005
Aug., 86 (8) 1681-92)

• There is substantial evidence to support
  cognitive rehabilitation for people with TBI,
  including strategy training for mild memory
  impairment, strategy training for post acute
  attention deficits, and interventions for
  functional communication deficits

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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

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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 is a color the eye is
  drawn to, even for those with visual field cuts
  related to their injury. Simply color one edge of
  an index card with a red marker and demonstrate
  how to use it to scan written material)
• Alarm watch

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Strategies cont..

• Use of a template for routine tasks, on the job,
  at home
• 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

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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)

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Strategies cont..

• Car Finder-low tech, install a longer radio
  antenna with a day-glow flag, high tech, Design
  Tech International by DAK Corp.
• 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

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Teach a variety of strategies for individuals to
incorporate into their daily routines Michelle
Rabinowitz OTR/L

• Safety checklist (e.g. for use of
  stove)reinforces attention
• Checklists- things to do before leaving the
  house (turn off all the appliances?, lock all
  the doors?, did I take my morning medications?
  turn down the heat/turn off the air conditioner?,
  do I have money or keys?, where am I going?, how
  will I get there? What time should I leave?
  Etc.) Very good for routine tasks, reinforces
  memory
• Place visual cues in the environment (cupboard
  labels, written directions, calendars, list of
  emergency phone numbers) reinforces memory

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Memory StrategiesAdapted fromParente Herman
in Retraining Cognition 1996 Aspen Publishers
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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?

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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

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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.

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Listening Skills

• L (L)ook at the person-focus on nonverbal
  aspects of communication
• I (I)nterest yourself in the conversation- use
  social fillers e.g I see, Tell me more
• S(S)peak less than half the time-decrease the
  chance of getting off topic

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Listening Skills continued

• T (T)ry not to interrupt or change the
  topic-stick to the topic at hand
• E (E)valuate what is being said. Question the
  content, do not blindly accept what is being said
• N (N)otice body language and facial
  expression-train this skill via use of pictures
  or scenes from movies, TV

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Try these techniques in groups or as focus of
individual sessions.During groups utilize a peer
feedback component
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More Thoughts on 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)

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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

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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

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Minimize confusion/socially unacceptable behavior

• Dont use the word inappropriate. Rather, give
  useful and specific feedback about a behavior (as
  soon as possible after the incident)
• Treat the individual like an adult in context,
  tone and body language
• Ask the individual for permission to coach
  him/her (regarding feedback, suggestions)

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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

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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

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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
66
Even for individuals with poor new learning
capacity, the three Rs ReviewRehearseRepeat
Can lead to mastery of tasks as they eventually
enter into memory, this is sometimes referred to
as procedural memory.
67
Keep in Mind Strategies used should play to an
individuals strengths

• A nonverbal individual who is computer savvy can
  utilize assistive technology to connect
  communicate

68
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
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Strategies for Injury Imposed Barriers

• Watch this scene from the 2007 Movie The Lookout,
  a Miramax release staring Joseph Gordon-Levitt
  and Jeff Daniels
• What are the characters barriers?
• What are the strategies he is using to compensate?

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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).

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Resources

• Care Pages
• A website where individuals with brain injury and
  their families share their stories
• www.cms.carepages.com

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Resources, Voice Recorders, Watches Alarms, and
Radiopaging

• www.attainmentcompany.com-StepPad 29.00,
  Records up to 72 seconds for step by step
  directions
• www.olympus-global.com-Digital and Microcassette
  hand help recorders
• www.forgettingthepill.com- has alarm watches,
  pillbox organizers with timers, alarms
• www.timex.com-Watch that can keep appointment
  schedules, phone numbers, contacts 90.00
• www.watchminder.com-Watch with reminder
  functions, 30 alarm settings with viewable
  messages, 79.50

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Resources, Voice Recorders, Watches Alarms, and
Radiopaging

• www.dynamic-living.com-carries the Cadex Alarm
  watch (12 alarm settings) for 50.00, as well as
  low vision devices, key finders, and more
• www.neuropage.nhs.uk-Radiopaging system to send
  reminders of things to do. Monthly fee, arranged
  in conjunction with treating physician if
  medication involved

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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

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Resources. Central Maryland TAP, access to a
variety of adaptive devices, loans to consumers
availableWorkforce Technology Center2301
Argonne DriveBaltimore, MD 21218Voice (410)
554-9213Voice/TTY 1 [phone]TTY (410)
554-9204Fax [phone]http//www.mdtap.org
/loan.html
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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

77
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

78
Special thanks to New Hampshires Project
Response and John Capuco, Psy.D and Julia
Freeman-Woolpert M.Ed.
79
Glossary of Brain Injury Rehabilitation
Specialists

• Speech Therapist Speech therapists are trained
  in the evaluation and treatment of deficits in
  attention, organization, sequencing, thinking,
  problem solving, judgement, memory, writing and
  talking. They can teach and help individuals
  implement compensatory strategies. It is
  important to note that speech therapists working
  with individuals with brain injuries can and do
  address the mechanics of speech, e.g., breath
  control, volume and pitch, but also play a big
  role in addressing cognitive and functional
  skills. They can make visits to the home,
  community and workplace to help design and
  implement strategies.

80
TBI Rehabilitation Specialists continued..

• Occupational Therapist Occupational therapists
  address skills of daily living to enhance
  independence to include those skills necessary to
  bath, cook, and run a household. Occupational
  therapists address functional memory, visual
  perceptual and problem solving skills.
  Occupational therapists work to maintain
  flexibility of the arms and hands through
  exercise and custom made splints. They can make
  visits to the home, community and workplace to
  help individuals with the design and use of
  strategies to improve independence.

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TBI Rehabilitation Specialists continued..

• Social Worker These mental health professionals
  offer psychotherapy and counseling to individuals
  and their families to help them adjust and cope
  with the sequela of brain injury. Social workers
  can help families and individuals with brain
  injury integrate and reinforce the strategies and
  information provided by the medical and
  rehabilitation team. They also provide education
  on community resources as well as assistance in
  accessing them.

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Individuals With Brain Injuries May Also be Seen
by the Following Rehabilitation Specialists.

• Physiatrist
• Neurologist
• Neuropsychologist
• Neuropsychiatrist
• Special Educator
• Physical Therapist
• Vocational Rehabilitation Counselor
• Cognitive Therapist

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For more information regarding brain injury
resource coordination services and brain injury
training, contactAnastasia Edmonstonaedmonston_at_
dhmh.state.md.us410-402-8478
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A Product of the Maryland TBI Partnership
Implementation Project, a collaborative effort
between the Maryland Mental Hygiene
Administration, the Mental Health Management
Agency of Frederick County and the Howard County
Mental Health Authority2006-2009

• Support is provided in part by project
  H21MC06759 from the Maternal and Child Health
  Bureau (title V, Social Security Act), Health
  Resources and Services Administration, Department
  of Health and Human Service
• Please use and distribute widely