Brain Injury Functioning Issue #7

Executive Functions
Definition	The ability to reason, plan, problem solve, make inferences, and/or evaluate results of actions and decisions.
Signs and Symptoms of Problems	Poor Convergent Reasoning:  Hard to narrow down the key point or main idea of something.  Hard to choose the best possible solution to a problem. Poor Divergent Reasoning:  Hard to come up with more than one way of thinking about something.  Hard to see another point of view.  Difficulty with empathy.  Hard to think of multiple solutions to a problem, causing one to get stuck if one solution does not work.  Difficulty with Goal-Oriented Behavior:  Hard to set reasonable, attainable goals.  Difficulty thinking of all of the steps required to reach a goal.  Difficulty prioritizing what to do first.  Problems evaluating how your plan is going, fixing mistakes, and changing the plan as needed. Making Poor Decisions:  Acting on false or incomplete information.
Strategies for Survivors and Significant Others	Encourage use of all strategies required in hierarchy to this point Cue as needed to provide multiple alternatives to problems Avoid abstract language - be concrete and to the point Do not confuse stubbornness with decreased flexibility- a person may not see your point of view because he/she is unable to Write things down to increase concreteness Making pro/con lists to help with decision making Identify the relevant details and help to lead the person to a reasonable solution. Answer who, what, where, why, and how questions before making a decision to ensure all the essential information has been gathered first. Break directions down into sequential parts Provide set-up for tasks to assist participation Use written checklists for task steps Encourage the use of a planner Assist with set-up of filing system, notebook, etc. Take time to plan ahead Be consistent; establish structure Pre-plan activities to consider all aspects including amount of time, items needed, sequence of events, etc. Take the time needed to think of all the possible solutions to the problem at hand Verify that you are not missing a step in a sequence by stopping frequently and reviewing what has been done and what still needs to be completed. Ask questions Consider as many perspectives as possible before drawing  a conclusion

Brain Injury Functioning Issue #6

Memory
Definition	Taking in new information, holding on to information, and recalling information when needed.
Signs and Symptoms of Problems	Difficulty Retaining New Information:  Hard to hold on to even brief instructions or explanations.  Difficulty remembering what was said at the beginning of a conversation. Difficulty Storing New Information:  Information is not retained long enough to be permanently stored. Difficulty Retrieving Stored Information: Hard to recall the main point of a conversation, even if it just occurred.  May forget important things learned from experience, causing mistakes to be repeated.
Strategies for Survivors and Significant Others	Use external strategies (i.e. calendars, lists, planner, timers) Increase awareness of problems to increase use of strategies. Follow a daily structure/routine Allow repetition of new information or tasks to assist learning and recall Provide information in small pieces rather than lengthy ones Provide visual as well as verbal instruction of new tasks Help to develop associations/mnemonic devices to improve carry over of information learned  (associate old information with new) Determine strengths and weaknesses with memory, and use strengths as much as possible (i.e. verbal memory vs. visual memory vs. learning by doing). Write important information down in a consistent location and organized fashion Place items in a common location (i.e. keys in a bowl by front door, bills in tray) May need to rely on trusted others for memory Journal the day’s events as they occur

Brain Injury Functioning Issue #4

Information Processing
Definition	Taking environmental stimulation in through the five senses, interpreting it, and responding to it.
Signs and Symptoms of Problems	Thinking Speed is Slower:  It takes longer to understand sensory information and make sense of what is going on in a situation. Delay in Responding:  There may be a long pause before the person responds with words or behavior, and they may not be aware of this. Process only Fragments of Information:  Because of the slowed processing speed, parts of information heard or seen may be missed. Hard Time Being Concise:  It may be difficult to decide when enough has been said, and a person may continue to speak and lose their listeners’ attention.
Strategies for Survivors and Significant Others	Encourage organization of information given Verify written, read, and verbal information gathered. Encourage single task completion; rather than focusing on multiple tasks Concentrate on accuracy first and speed later Write information down to give to the individual as a means to allow extra time for better comprehension/understanding. Ask others to slow down or repeat information Reduce visual distraction, auditory distraction, and internal distractions Practice, Practice, Practice to improve efficiency of specific skill areas Improve word retrieval and thought organization through practice conversations Impose time restraints to improve concise speech

Brain Injury Functioning Issues #3

Disinhibition
Definition	A syndrome marked by difficulty properly directing and controlling energy and emotions.
Signs and Symptoms of Problems	Impulsivity:  Doing or saying things without considering the consequences.  Making decisions before thinking about all of the information. Feelings or behaviors come on too strong and/or too fast:  Feelings come to the surface and are hard to hold back.  Reacting to small things with too much emotion.  Talking too loud or too fast when the topic is emotional.  Restlessness:  Hard to keep still.  Intense and frequent need to move or fidget. Irritable and Easily Frustrated:  Hard to forget even small irritations.  Brooding.  Often require others to help calm down. Emotional Flooding:  Can become easily overwhelmed when feeling challenged socially or cognitively.  Mind “goes blank.”  Once flooded, it is temporarily impossible to think clearly or act purposefully.
Strategies for Survivors and Significant Others	Visually/verbally cue the person to slow down.  Build in delays.  Establish automatic “pauses” between each task.  Use a stopwatch if needed. Ask the individual if they would do better if they put more thought in to a decision.  Consult a coach or family member before acting and gather further feedback Use this sequence “Stop, Think, Act, and Evaluate” and analyze how they did afterward Use self-talk strategies (i.e. Could I go slower? Did I think about this long enough? ). Be direct in response to inappropriate behaviors (i.e. interruptions, inappropriate remarks, tone of voice, awkward facial expressions) Teach relaxation strategies In a tactful way, let the person know how they are coming across (i.e. “when you say I do this, it makes me feel…”). Ask permission to videotape an interaction with the person and later analyze with the person Verify what was really seen, heard, or felt to know if feelings are justified Encourage use of breaks to relax, calm down, and re-attempt communication when ready Seek coaching Ask the other person to slow down if they are making you irritated. Excuse self from current situation if too upset “SAVE” strategy (Stop, Ask, Verify, Evaluate)
Attention/Concentration
Definition	Staying awake, alert and ready, focusing, and keeping a train of thought.
Signs and Symptoms of Problems	Hard to Stay Alert:  Not enough mental energy to engage fully in the environment. Hard to Focus Attention:  Easily distracted by noises and things around you.  Distracted by personal thoughts, feelings, and worries. Lose “Train of Thought:” Once able to focus, a person may lose “train of thought” or concentration if distracted.  It may be hard for a person to make a point without getting off track and “rambling.”
Strategies for Survivors and Significant Others	Allow extra time for task completion Limit distractions during task completion Provide cues as needed to sustain task focus.  Set timers/use alarms to remind to re-focus.  Verify performance for accuracy Direct person back to the current topic when conversation becomes unfocused Encourage eye contact and participation during conversation (asking questions, nodding/shaking head) Reduce environmental distractions (i.e. closing doors, reducing glares) Teach strategies such as using a line guide to reduce amount of information to attend to on a page Improve visual attention by scanning left to right and top to bottom while using finger to anchor               eyes Repeated verbal/visual cues to “slow down and pay attention to details”

Brain Injury Functioning Issues #2

Adynamia
Definition	Low mental energy or apparent lack of will.  Not “dynamic.”
Signs and Symptoms of Problems	Trouble Initiating:  Hard to get started on things.  Difficulty Generating Thoughts/Ideas:  Run out of ideas quickly.  Do not give a lot of details in communication. Lack of Spontaneity:   Loss of “spirit.”  Others think you are not interested or are just “going through the motions.”  Face often does not show emotion.  “Poker Faced”
Strategies for Survivors and Significant Others	Do not tell the person that they are “lazy”-understand they most likely know what needs to be done, but they have difficulty getting started.  Offer support to get started. Establish “accountability contracts” with supportive others to help initiate activities Become aware of facial expression, posture, eye contact Over exaggerate emotions Provide written checklists to encourage participation Cue as needed to begin tasks, verbally or with timers/alarms Use a routine to encourage increased task anticipation
Strategies for Survivors and Significant Others	Help to break large tasks into manageable chunks Schedule tasks and encourage sticking to the scheduled due date Speak louder (reduces monotone) Prepare by using notes to help initiate conversation Use to-do lists, timers, watches, beepers, and other adaptive devices to improve ability to self-initiate tasks

One of My Main Problems In Relation to Functioning Issues Since My Brain Injury

Neurofatigue
Definition	Fatigue that is organically based and NOT due to excessive activity or abnormal sleep patterns.  It can emerge suddenly without warning, or after engaging in a cognitively demanding task.
Signs and Symptoms of Problems	Lack of Energy to Engage: Difficulty engaging in activities of daily living, communicating with others, or social activities. Low Arousal:  Difficulty waking up and staying awake throughout the day.  It may require auditory and tactile cueing to wake from sleep.  It may be hard to open the eyes.  Decreased Alertness:  Decreased ability to maintain mental awareness of surroundings, leading to decreased response to them.
Strategies for Survivors and Significant Others	Need to build awareness of the causes & effects of neurofatigue Help to identify early signs of fatigue (yawning, slow motion, in a “fog”, etc.). Trust others when they offer feedback about your apparent fatigue levels. Encourage conservation of energy and establish set times for rest throughout the day.  Assure the person that taking “time out” is needed and is okay. Establish a routine for bedtime/wake times. Help to break large tasks into manageable chunks-use a checklist. Do not schedule too much in one day.  Spread activities out throughout the week. Have patience and “do what you can and don’t worry about the rest” Minimize stimulation in the environment when a survivor is completing tasks.  Manage the “flood” of input (i.e. limit the number of people interacting with the individual). Consult physician to inquire about side effects of medications.  Could possibly induce drowsiness and be prescribed for later in the day. Adjust diet and exercise to facilitate a healthy lifestyle and to promote healing.  Increase water intake.