The Changing VA Population: Young, Active Duty and Brain Injured or It’s A Co-Morbid World Harriet...

The Changing VA Population:

Young, Active Duty and Brain Injured

orIt’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

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:

• 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 recently-returned 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 memoryProblems in attentionProblems in problem solvingProblems in social appropriatenessProblems in organizationProblems in fatigueSlowed speed of information processingAnger 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

• Palo Alto VAHCS, CA

• Maguire VAMC, Richmond VA

• James Haley VAMC, Tampa FL

• Minneapolis VAMC, Minneapolis MN

VISNVA integrated system network

Polytrauma Network Sites (PNS)

Each PNS Team consists of:

• 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

• 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


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


• 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 functioningProblems in memoryProblems in attentionProblems in problem solvingProblems in social appropriatenessProblems in organizationProblems in fatigueSlowed speed of information processingAnger 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/attention5. slowed information processing6. memory problems7. 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 laughingflighttearsanger

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)


Storage

Percent retention

Ability to abstract themes (relevant from irrelevant points


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


• Presence of procedural learning

• Presence of emotional learning

• Separation of verbal and motor learning

(Squire)

• Effect of proactive interference


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.


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


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.


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.



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



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.



Examples :

Psychologist: Went over the time period for the recovery from TBI and how you will continue to recover for 18 to 24 months.


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.


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

• 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 24/7• 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 Injurythat Your Departments Will Have To

Deal With

Inefficient memory: especially for appointments, episodic events

1. 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

Special TBI/PTSD Considerations

• Frontal Lobe as site of managing dysphoric affect and the ability to self-soothe

• 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

• Effects of slowed rate of info processing-

• Speak 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.

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 of Therapy

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

• 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.

• 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

http://main.uab.edu/show.asp?durki=49377



Cognitive Retraining

• 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:

• Clock

• Compass

• Left/right/above/below/next to/near

• Mental Rotation

Visuospatial Functioning

1. Scanning

2. Gestalt principles of form recognition

3. Figure ground

4. Transposition

5. Spatial relations between objects

6. Identification of object/surround in relation to self


Disorders of self/space relationship:

Hemispace

Surface of the body

Movement through space


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

• 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”.

• 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:

• Resilient one,

• Scarred, competent one,

• Wise one,

Metaphors

• 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

• 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

• 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

– 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.

The Changing VA Population: Young, Active Duty and Brain Injured or It’s A Co-Morbid World Harriet...

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