Behaviour management following traumatic brain injury (TBI)

Transcription

1 Behaviour management following traumatic brain injury (TBI) 24 March 2014 Jacqueline Woods Consultant Clinical Neuropsychologist Leeds Community Neurology Team Ph:

2 A familiar story Richard Hammond admits: 'I thought I was better after high speed crash - but I'm not'

3 A familiar story Eighteen months after the high-speed crash which almost killed him, Top Gear presenter Richard Hammond has revealed that he still suffers from emotional problems and memory loss. He said that returning to the BBC2 show only four months after the crash had been "much too early". "I thought I was better when I went back to work but now I don't remember going back. I was really having a bloody hard time. I had to evolve new strategies for coping. "I damaged all the complicated bits of the brain to do with processing and emotional control. I was prey to every single emotion that swept over me and I couldn't deal with it. I had to relearn things from scratch. "When I did a 24-hour race for Top Gear in September I was scared and nervous. It was making me argumentative, angry, thinking I wasn't good enough for the job, feeling awful. He added: "It's been a bloody long journey and it's still going. It's when I consider how far I've come since I was in hospital that I realise there was a lot more to fix than I thought.

4 The Human Brain

5 Frontal lobe or executive function symptoms (frequently overlooked at first) Absent mindedness Mental inertia Indecisiveness Immaturity Lack of spontaneity Poor planning Poor anticipation Poor insight Poor judgement Disinhibition Self-centred behaviour Verbal or physical aggression Lack of empathy Reduced initiation Poor social skills Unreliability Disorganised Fiscal impulsivity Inadequate planning Vocational unreliability Low motivation Inflexibility or being stubborn Dependence Poor self-monitoring Loss of emotional control Coldness and insensitivity Low frustration tolerance Irritability

6 Behaviour Management General strategies WHO IS THIS PERSON? Have a working hypothesis regarding the cause of the behaviour: Reactionary problem? Neuropsychologically mediated problem? Characterological problem?

7 Some of the common problems after acquired brain injury Impaired attention Impaired memory Impaired executive function Headache / Pain Irritability Impulsive anger Fatigue Anxiety Guilt re trauma/illness Substance abuse Alcohol sensitivity Post-traumatic stress Agitation Concreteness Labile affect Speech problems Poor auditory perception Post-traumatic epilepsy Adjustment problems

8 Behaviour Management General strategies Have a routine and provide as much structure as possible Have good communication- clear, direct, and often. Talk about behaviour and what to do about it Don t be vague- tell the person what behaviour you like/don t like Have clear limits/rules about behaviour- what is expected? What is appropriate/inappropriate?

9 Behaviour Management General strategies Give the person regular and consistent feedback about their behaviour Try to be consistent in how you respond to positive and negative behaviours Notice positive behaviour and reinforce it! Understand cognitive impairment and how it affects behaviour Use defusing and deescalating techniques when appropriate

10 Behaviour Management General strategies Use redirection, distraction and diversion to shift behaviour Keep a keen sense of humour Change the environment Obtain support for everyone involved A team approach works best Don t take it personally Have realistic expectations

11 INERTIA / REDUCED DRIVE Adynamia is heightened lethargy or an impaired motivational system. Although this is often incorrectly assumed to be characterlogical --it is a brainstem / frontal lobe symptom. Provide structure Use Premack principle Use written schedules Use check lists Use timers Set up salient reinforcers at task completion Develop a chores list Sometimes assistance in starting a task may be sufficient Set up a mentoring system Avoid the guilt trip For severe drive problems, 1:1 prompting may be needed.

12 IMPULSIVITY The tendency to act without forethought which is the result of impaired self-monitoring. Lack of selfregulation most often results in poor social adaptation or violations of social norms. This can also impact budgeting, work and appear manic. Provide immediate feedback calmly, outline the nature of the inappropriate behaviour. Bring attention to safety issues. Develop phrases such as STOP & THINK Develop a personal gesture as cue. Lavish praise. Provide written reminders. Avoid guilt trips.

13 DISINHIBITION Problems include tactlessness, excessive talkativeness, jocularity, childish behaviour, over familiarity, & sexual indiscretions. Calm but firm immediate feedback; quick and to the point. Use a consistent message such as, Stop and think, Bill Separate person from behaviour. Reinforce positive behaviours TOOTS (time-out on the spot) when possible. Avoid guilt trips. Offer alternative behaviours

14 AGITATION / IRRITABILITY Also conceptualised as low frustration tolerance. Behaviour is often disproportionate to the stressor. Anger is not the problem focus on the behaviour. A major contributor to social isolation. Catch agitation early in the cycle. Reinforce more appropriate behaviours. Avoid personalising anger separate the person from the behaviour Debrief about outburst with strategies (not just guilt) Focus on antecedents - triggers Develop distraction techniques Anger management -- just keep it simple Avoid guilt trips. Focus on deescalating before negotiating

15 Useful resources - Websites Headway- The Brain Injury Association Traumatic brain injury resource Good source of video content. National Resource Center for Traumatic Brain Injury Providing information for professionals, persons with brain injury, and family members. Also developing intervention programs, and assessment tools.

16 Useful resources - Websites TBI Resource Guide - **Excellent resource Canadian TBI resource guide

17 Useful resources - Books Head Injury A practical guide by Trevor Powell. Living with a Brain Injury by Phillip Fairclough. -Both can be purchased from Headway The Stroke Association and Headway produce booklets on common difficulties and ways to manage these. Headway Tel:

18 Reading list Durgin, C.J. (2000). Increasing community participation after brain injury: Strategies for identifying and reducing the risks. Journal of Head Trauma Rehabilitation, 15 (6), Sohlberg, M.M. & Mateer, C.A. (2001). Cognitive rehabilitation: An integrative neuropsychological perspective. NY: Guildford Press. Tate, R.L., Strettles, B. & Osoteo, T. (2003). Enhancing outcomes after traumatic brain injury: A social rehabilitation approach. In B.A. Wilson (Ed.), Neuropsychological rehabilitation: Theory and Practice (pp ). Lisse: Swets & Zeitlinger. Williams, W.H. & Evans, J.J. (Eds.) (2003). Biopsychosocial approaches in neurorehabilitation: Assessment and management of neuropsychiatric, mood and behavioural disorders. Hove, East Sussex: Psychology Press. Wood, R.L. & McMillan, T.M. (Eds.). (2001). Neurobehavioural disability and social handicap following traumatic brain injury. Hove, East Sussex: Psychology Press.