2. Today’s Schedule
• 8-8:30 Registration
• What is Traumatic Brain Injury & Screening
for TBI-related deficits
• 10-10:15 Break
• How TBI Impacts Executive Functioning &
Populations at Greater Risk for Brain Injury
• 12-1 Lunch
• Locating Community Supports and Services
for Head Injured Clients
• 2:15-2:30 Break
• Counseling Brain Injury Survivors and Their
Families
• 3:45-4:00 Question and Answer
3. Overview
• Epidemiology
• Mechanisms of Injury
• Deficits Associated with TBI
• Identification
• Treatment
• Special cases
6. National prevalence rates of various
disabilities
400,000 with Spinal Cord Injuries
500,000 with Cerebral Palsy
2.3 million with Epilepsy
3.0 million with Stroke-related Disabilities
4.0 million with Alzheimer’s Disease
5.3 million with Traumatic Brain Injury
5.4 million with persistent Mental Illness
7.2 million with Mental Retardation
7. Incidence
In the United States, at least
1 million sustain a TBI each year
9. Who is at Highest Risk for TBI?
• Males 1.5 times as likely as females to sustain
a TBI
• Two age groups most at risk are 0-4 year olds
and 15-19 year olds, and
• The elderly, frequently from falls
• African Americans have the highest death rate
from TBI
47. Medical
• Physical stamina
• Pain
• Headaches
• Seizures (within 2 years of injury)
• Bowel/bladder continence
48. Motor Functioning
• Paresis or spasticity
• Gross motor strength
• Fine-motor speed and dexterity
• Motor coordination and planning
• Spatial-based movement
• Oculomotor
• Balance
50. Attention
• Alertness and arousal.
• Selective or focused attention.
– Modality specific
• Sustained attention (vigilance).
• Span of attention.
• Hemi-neglect (ignoring one side of the body).
51. Receptive Language
• Word and phrase comprehension
• Conflictual and comparative statements
• Vocal tone and prosody
• Speed of processing
• Pragmatics (social meaning in language)
52. Expressive Language
• Fluency
• Naming
• Word and phrase repetition
• Organization of output (e.g., spontaneous versus
confrontational speech)
• Vocal tone and prosody
• Pragmatics (social use of language)
74. School and Vocational Outcomes
• Problems initiating and completing work.
• Slowed work pace.
• Increased impulsivity.
• Trouble navigating physical surroundings.
• Decreased productivity.
75. School and Vocational Outcomes
• Confusion and increased stress.
• Resistance to change.
• Trouble with generalization of new learning.
• Distractible.
• May resent special assistance.
76. Social-Behavioral Outcomes
• Loss of friends and social circles.
• Decreased affective regulation.
• Increased impulsivity.
• Increased agitation.
77. Social-Behavioral Outcomes
• Poor perspective taking.
• Comparison to preinjury level of functioning.
• Poor understanding of TBI and recovery.
• Premature return to school/work.
• Unrealistic predictions.
78. Emotional
• Dependent behaviors / amotivation
• Irritability / emotional lability / anger
• Depression
• Disinhibition
• Denial/lack of insight
• At risk for substance abuse
80. Preinjury Predictors of Positive
Outcome
• History of good academic achievement
• Good social relationships
• No history of learning, attention, or behavioral
difficulties
• No history of substance abuse
• No significant family problems
81. Preinjury Predictors of Positive
Outcome
• Strong-willed and determined
• Under 21 years of age
• No previous neurological history (e.g., a prior
TBI)
• Good self regulation skills
82. Preinjury Predictors of Positive
Outcome
• No criminal history
• Good relationships with family members
• Warm and supportive family
• No psychopathology
83. Behavioral Predictors of Positive
Outcome
• Motivated and persistent
• Optimistic
• Has the capacity to recognize errors and self-
correct
• Aware of behavioral deficits
• Ambulatory
84. Behavioral Predictors of Positive
Outcome
• Relatively independent with activities of daily
living
• Initiates tasks with no/minimal assistance
• Preserved perspective-taking capacity
• Relatively preserved neurocognitive abilities
85. Environmental Predictors of Positive
Outcome
• Individual treatment plans
• Continuity and coordination of treatment
throughout the recovery process
• Structure, consistency, and repetition in daily
activities
• Good, stable resources
(e.g., financial, family, friends, community, etc.
)
86. Environmental Predictors of Positive
Outcome
• Presence of “key” person in the family
• Family involved in the treatment plan
• Family realistic about individual’s status
• Presence of “key” person on team
87. Neurological Predictors of Positive
Outcome
• Coma < 6 hours
• PTA < 24 hours
• GCS > 7
• Normal EEG and MRI
• Normal intracranial pressure
• Normal ventricle size
• No intracranial hematoma
88. Indices of Severity of TBI
• Intracranial Pressure
• Retrograde Amnesia
• Anterograde Amnesia/Post-traumatic Amnesia
• Duration of Loss of Consciousness (LOC)
• Glasgow Coma Scale score
• Rancho Los Amigos Scale (1 to 10)
92. Identification of TBI
• Obtain the medical records if possible
• Interview family/friends for collaboration
• Arrange for a neuropsychological evaluation
• Refer to a neurologist or psychiatrist for medication
and behavioral consultation
• Consider referral to a brain injury rehabilitation
program
93. Inquiry Regarding TBI
• Any history of concussion or head injury?
• Ever been knocked out?
• Note: this question may lead to discussion of
– Alcohol abuse
– Domestic violence
• Postconcussive symptoms?
• Return to work/school?
94. “Getting at” PTA in the clinical
interview
• When did you wake up from the head injury? Do you
remember being transported to the hospital? Do you
remember being in the trauma unit? Being
transferred to the rehab unit?
• PTA: period of time after the CHI for which the
patient has no memory
117. Considerations in TBI Recovery
• What constitutes “recovery”
• Will he/she be 100%?
• It takes a year?
• “Plateaus”
• The normal neurological evaluation
• Independence and modified independence
• No magic bullets
– Meds
– Rehab technologies
118. Medical Management: Acute TBI
• Airway
• Close monitoring for edema
• Seizure control
• Close monitoring for increased intracranial
pressure
125. Early Rehabilitation Efforts:
• Formal family meetings
• Use of an interdisciplinary team approach in
overall treatment
• Discharge planning by team
members, family, and community services
129. Referrals
• Case management
• Home modifications
• Transportation
• Cognitive rehabilitation
• Counseling
• Financial management
• Respite care
• Neuropsychological evaluation
130. Goals of Neuropsychological Assessment
• Determine spared versus impaired abilities.
• Understanding impact of injury and/or a
neurodevelopmental problem (e.g., LD).
• Assist in localization of function and
dysfunction.
131. Goals of Neuropsychological Assessment
• Assist in determining whether to remediate or
to compensate.
• Generate suggestions for remediation and
compensation.
• Suggestions for monitoring and tracking of
progress in school setting.
132. When to Consider a Referral to
Neuropsychology
• Documented brain injury/insult
• Suspected brain injury or insult
• Neurodevelopmental disorder
• Unusual psychological profile
• Positive neurological findings
• Severe behavior problems
• Treatment needs
158. The “Good-Fit” Personal Organizer for
the Client with Executive Dysfunction
• 2 pages per day
• 7 am to 9 pm
• Contains a master to-do list
• With the client at all times
• Use for work and home
• Have only one system
159. Use of the personal organizer or PDA
• Move it from your head to your calendar
• Break long term goals into action items
• The organizer is your budget – how you
“spend” your time
• Use your organizer for every part of your life
160. Use of the personal organizer or PDA
• Use your organizer for every part of your life
– Your to-do list should contain things you have to do, but
also things you want to do, or to be, or to have.
– You make appointments with your doctor or insurance
agent, because they’re important. You can make
appointments with yourself as well.
– “Hi Cindy, this is David…..” (win friends and influence
people with your amazing phone log)
166. Psychotherapy with the brain-injured
client
• Mild TBI interventions
• Severe TBI interventions
167. Psychotherapeutic Interventions
Individual Therapy
• Permitting appropriate expression of
emotional reaction to TBI and loss
• Patient education
• Social skills training
• Family/spouse involvement
• Impact of memory problems and decreased
insight
168. Psychotherapeutic Interventions
Individual Therapy
• Critical for the therapist to be TBI-savvy
• Consider the environment in which the person
functions
• “Lieben und arbeiten”
181. Behavioral Therapies
• Very few people with TBI have fully lost the
ability to learn new behaviors
• Structure, consistency, and repetition
• Role of cognition in self regulation
• External feedback
182. Behavioral Strategies:
Defining the Problem
• This requires a measurable and precise
definition of the target behavior
– Always get specific examples
– Cross check across settings
– “Pick your battles”?
• Inquire about the antecedents and
consequences
183. Behavioral Strategies:
Identifying the Function
• Everybody’s doing the best he/she can
• Every behavior serves a function
• Every behavior problem is either
– A skills deficit, or
– A contingency problrm
184. Behavioral Strategies:
Identifying Resources
• Personal resources: Memory? Flexibility?
Persistence? Motivation?
• Social / family / peer resources
• Organizational resources
185. Behavioral Strategies:
Guidelines
• Skills
• Safety
• Least restrictive
• Managing the antecedent: Set me up for
success!
186. Examples of Behavioral Strategies
• Antecedents • Interventions
• Provide clear, concrete
• Does not understand instructions; notes
• Give prompts; reinforce
• Does not begin task initiative
• Simplify task; provide skill-
• Unable to do task based training
• Increase interest or
• Is not motivated relevance; reward for task
completion
187. Examples of Behavioral Strategies
Consequences Interventions
• Avoids failure by not Alternate difficulty
complying tasks with easy ones
• Gets out of work Premack principle
• Receives attention for Time out or ignoring;
not doing task reinforce for attention
• Gets to assert Offer choices when
independence/control appropriate
192. Behavior Management Strategies:
Apathy
• Give choices between doing one thing or
another; not between doing and not doing
• Activity scheduling, in advance
194. Behavior Management Strategies:
Denial/Lack of Insight
• Have ongoing discussions of “strengths and
needs”
• Create discrepancy
• This may be the most difficult problem to
address
196. Behavior Management Strategies:
Impulsivity/Disinhibition
• Structured and organized daily routine
• Rewarding/praising impulse control and
inquiring “how exactly did you do that?”
• “Talking stick”
198. Behavior Management Strategies:
Depression/Withdrawal
• Help students identify preserved abilities
and strengths - rather than focusing on
their deficits
• Keep TBI survivor involved in the present
rather than dwelling on the past
• Use active listening techniques, but focus
on positive feelings
210. Family Issues and Needs
• Family stress related to severity of TBI
• The family’s resilience may be key to a brain
injured child’s successful rehabilitation
• Divorce rates range from 15% to 54%
211. Sources of Family Stress
• Uncertainty about recovery
• Cognitive and personality changes
• Financial strain
• Transitions to “new” settings
• Lack of respite care
213. Family Issues and Needs
• Family’s adaptation may take years
• Any change may trigger emotional
response
• Watch for signs of grieving
214. Return to School
• Accommodations and Modifications
• IDEA and Section 504
215. IDEA Definition of TBI:
An acquired injury to the brain caused by
an external physical force resulting in
functional disability or psychosocial
impairment that adversely affects a
child’s educational performance.
216. School Re-Entry Issues
• Educational consultation should begin
before return to school
• Continuity of care between school and
rehabilitation services
• Prepare for multiple transitions
• Re-entry should include interdisciplinary
support
217. Percentage Referred for Services
Home Tutor 3.6
Special Ed. 1.8
Psych. services 2
Family counseling 2.8
Speech therapy 10.1
Ocupational
13.2
therapy
Physical therapy 23.7
218. Basic Criteria for School Re-Entry
• Attends to a task for 10 to 15 minutes
– Adjust for age
• Can tolerate 20 to 30 minutes of classroom
stimulation
• Can function adequately in a group of 2 or
more students
• Engages in meaningful communication
• Follows simple directions accurately
• Gives some evidence of learning potential
220. School Re-Entry Procedures
• Identify the best setting for intervention
– Outpatient counseling?
– Home-based family interventions?
– School-based SLP / OT?
– Buddy system at school?
– In-service for school staff?
– Modified school day?
– In-school breaks?
– “Study halls” with resource teacher?
– Pre-vocational training?
• Regular re-evaluation for change over time
221. Developing IEP Goals
• Focus on 2 or 3 priority issues
• Identify metacognitive & organizational strategies
• Write measurable goals that incorporate the
strategies
• Include specific information about how the
strategy should be taught and implemented across
settings
• Write short-term goals that are truly short-term
222. TBI Impact at School
• Problems initiating and completing work.
• Slowed work pace.
• Increased impulsivity.
• Topographical disorientation
• Distractible
• Difficulty generalizing new learning
223. Classroom Management
• Two key factors :
– Structure
– Motivation
• Explicitly teach rules & expectations
• Establish prompts or cues, such as gestures
and reminder cards
224. Classroom Management
• Can students answer the following
questions:
– What do I have to do?
– How much do I have to do?
– When am I finished?
– What do I do next?
225. Classroom Management
• Use repetition & feedback
• Avoid multi-step instructions
• Supplement verbal instructions with
nonverbal / modeling
• Provide additional time for information
processing
• Assist with organization of materials and
schedule
226. Classroom Management
• To be motivating, a task must be interesting
• Intersperse difficult or novel tasks with easy or
previously learned ones
• Distinguish cognitive factors from other issues
(impact of headache, or depression)
227. Specific Classroom Strategies:
Attentional Processes
• Reward on-task behavior;
• Use novel, unusual, relevant or stimulating
activities
• Redirect
• Remove unneccessary distractors
• Explore a variety of cueing systems
– Verbal cues
– Physical prompts
– Gestural cues
228. Specific Classroom Strategies:
Attentional Processes
• Reduce the number of individual tasks on a
printed page
• Reduce the amount of copying from the board
• Provide a ruler or EZ-Reader to focus visual
attention
• Avoid asking a student to multi-task
• Chunking / Pomodoro
229. Specific Classroom Strategies:
Memory and Learning
• Enhance the saliency of material
• Regularly summarize information as it is
being taught
• Dry-erase board
• Use overlapping techniques, such as
repetition and rehearsal
230. Specific Classroom Strategies:
Memory and Learning
• Couple new information with previously
learned information
• Identify in advance the key information to be
learned
• Make use of over-learning
231. Specific Classroom Strategies:
Language
• Limit length and complexity of communication
• Do not use figurative speech
• Recognize the student may not understand
humor or sarcasm
232. Specific Classroom Strategies:
Language
• Reminders to start, end, or repair a
conversation
• Use question prompts to help the student
share more information, especially in
groups
• Allow for slowed information processing
234. Specific Classroom Strategies:
Visual Processing
• Provide longer viewing times or repeat
viewings when using visual instructional
materials
• Facilitate a systematic approach to reading
and math by covering parts of the page
• Provide support for orientation to building
and grounds
• Limit visual distractions (web
page, handouts, text, desk)
235. Specific Classroom Strategies:
Executive Functions
• Problem Solving Processes
• Develop a problem-solving guide to help student through the
stages of problem solving
– Identifying the problem
– Acquire relevant information
– Generate several possible solutions
– List pros and cons for each solution
– Identify best solution
– Create a plan of action
– Evaluate the effectiveness of the plan
– Encourage generalization
236. Specific Classroom Strategies:
Executive Functions
• Raise questions about alternatives and
consequences
• Provide ongoing, non-judgmental feedback
• Provide part of a sequence and have the
student finish it
• Frequent cues re: main topic vs. supporting
ideas
237. Specific Classroom Strategies:
Executive Functions
• Note impact of fatigue on cognition
• Note impact of some medications
• Consider reduced workload
• Consider note-taker
• “How exactly did you do that?”
241. In women reporting to ERs for injuries
associated with DV:
• 30% of battered women reported a loss of
consciousness at least once.
• 67% reported residual problems that were
potentially head-injury related.
(Corrigan 2003)
242. Domestic Violence…
Greater than 90% of all injuries secondary
to domestic violence occur to the
head, neck or face region.
(Monahan & O’Leary 1999)
244. American Academy of Pediatrics-Committee on
Child Abuse and Neglect Pediatrics 2001
“ …95% of serious intercranial injuries and 64% of
all head injuries in infants younger than 1 year were
attributable to child abuse”
Pediatrics, 2001
246. Shaken Baby Syndrome
• Rotational, acceleration, deceleration forces
• There may or may not be impact trauma
• Brain rotates inside the skull
• Bridging veins in the brain may be stretched or
torn
• Subdural hematoma may develop
247. Shaken Baby Syndrome
Kirschner & Wilson’s “dirty dozen”
• 1. Child fell from a low height
• 2. Child fell and struck head on floor or
furniture, or hard object fell on child
• 3. Child unexpectedly found dead (age and/or
circumstances not appropriate for SIDS)
• 4. Child choked while eating and was
therefore shaken or struck on back
248. Shaken Baby Syndrome
Kirschner & Wilson’s “dirty dozen”
• 5. Child suddenly turned blue or stopped
breathing, and was then shaken
• 6.Sudden seizure activity
• 7. Aggressive or inexperienced resuscitation
• 8. Alleged traumatic event one day or more
before death
249. Shaken Baby Syndrome
Kirschner & Wilson’s “dirty dozen”
• 9. Caretaker tripped or slipped while carrying
child
• 10. Injury inflicted by sibling
• 11. Child left in dangerous situation (e.g.
bathtub) for just a few moments
• 12. Child fell down stairs
252. Combat Trauma
• TBI as “signature wound” of Iraqi conflict
• USA Today 9/07
253. Combat Trauma
• Iraq characterized by different kind of
weaponry: explosive munitions.
• 15% of soldiers returning from Iraq may have
sustained at least mild TBI (Hoge et al 2008)
• 36% may have been exposed to blasts
(Maguen et al 2012)
256. Alcohol Abuse
• May increase morbidity of MVA-related TBI
(Cunningham et al 2002)
• Although low amounts may be protective
• Chronic alcohol abuse associated with
falls, assaults, multiple head injuries
• Overlay of alcohol-related impairment
259. TBI Severity: Mild TBI (mTBI)
• Concussion signs and symptoms include ANY changes in
behavior such as:
– Cognitive impairments
– Physical symptoms (e.g., headaches, blurry
vision, diplopia, dizziness)
– Emotional symptoms (e.g., irritability, volatility)
– Sleep difficulties
– Not “feeling like themselves.”
260. TBI Severity: Mild TBI (mTBI)
• Persistent symptoms following the concussion is often
referred to as Post-Concussive Syndrome.
• Cumulative effect
262. Psychotherapy with the persistent
post-concussive client
• Perfectionistic tendencies
• Somatic focus
• Poignancy
• Secondary gain
• “old me / new me”
• Check to see whether you are working at
cross-purposes
263. The “Big 5” (plus 1)
• The “Big 5”
– Daily planner
– Daily organization time
– Movement
– Nutrition
– Connection
– Sleep
264. Let’s stay in touch!
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davidnowell David Nowell Seminars
Editor's Notes
5 MINUTE OVERVIEW
EVERY 21 SECONDS, ONE PERSONIN THE U.S. SUSTAINS A BRAIN INJURYAs aconsequence of these injuries:– 50,000 people die– 230,000 people are hospitalized and survive– 80,000 to 90,000 people experience the onset of longtermdisability
? source
• An estimated 5.3 million Americans—a littlemore than 2% of the U.S. population—currentlylive with disabilities resulting from brain injury.• It is estimated that one million people are treatedfor TBI and released from hospital emergencyrooms every year.• After one brain injury, the risk for a second injuryis three times greater; after the second injury, therisk for a third injury is eight times greater.• Falls are the leading cause of TBI for persons age65 and older; transportation-related injuries leadamong the 5-64 population
? source
• An estimated 5.3 million Americans—a littlemore than 2% of the U.S. population—currentlylive with disabilities resulting from brain injury.• It is estimated that one million people are treatedfor TBI and released from hospital emergencyrooms every year.• After one brain injury, the risk for a second injuryis three times greater; after the second injury, therisk for a third injury is eight times greater.• Falls are the leading cause of TBI for persons age65 and older; transportation-related injuries leadamong the 5-64 population
Gray white junction
• An estimated 5.3 million Americans—a littlemore than 2% of the U.S. population—currentlylive with disabilities resulting from brain injury.• It is estimated that one million people are treatedfor TBI and released from hospital emergencyrooms every year.• After one brain injury, the risk for a second injuryis three times greater; after the second injury, therisk for a third injury is eight times greater.• Falls are the leading cause of TBI for persons age65 and older; transportation-related injuries leadamong the 5-64 population
APPENDIX L p.a13: LAST TXGIVING HOLIDAY: ON SCALE FROM 1-10 HOW GOOD WAS IT FOR U AND YR FAMILY? HOW COULD IT BE A (+1)?MAIN RELATIONSHIP…MOST IMP RELATIONSHIP: WHAT WOULD MAKE IT 10% BETTER? WHAT COULD I DO THIS WK’END TO MAKE THAT HAPPEN?
APPENDIX L p.a13: LAST TXGIVING HOLIDAY: ON SCALE FROM 1-10 HOW GOOD WAS IT FOR U AND YR FAMILY? HOW COULD IT BE A (+1)?MAIN RELATIONSHIP…MOST IMP RELATIONSHIP: WHAT WOULD MAKE IT 10% BETTER? WHAT COULD I DO THIS WK’END TO MAKE THAT HAPPEN?
PLACE NAMES WHICH ARE ALSO PEOPLE’S NAMES:MADISONGEORGIACHARLOTTEINDIAPARISKENYAARIZONAADELAIDESYDNEYDALLASHOUSTONOLYMPIAJORDANBETHANY
Certain aspects of memory / learning
FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
Accurate?Oriented to purpose?GuardedDefensiveseductive
Fluency of speechThe initiation and flow of languageComprehension/Receptive languageNaming Close head injuries or dementia may cause an inability to name objects. ProsodyVariations in the rate, rhythm and stress in speech.Quality of speechLoudness, pitch, spontaneity, articulation.
d/o’s of perception:Ah/vhDepersonalization, derealization
Must use physical findingsNeurologic deteriorationUnilaterally dilated pupilHemiparesisPosturing
Def. of terms; spontaneous recovery; generalization
Def. of terms; spontaneous recovery; generalization
197”
Make task shorter, build in breaks, use salient r+ for afterwards, make steps more explicit, make task more appealing (beat the clock, write steps down on slips of paper, in jar)
242”
TBI ct: independence and power
We use our senses to interface with world around us, retreating from “too much” or “too tight” or “too loud” and seeking lights and sound and movement when we’re understimulated
We use our senses to interface with world around us, retreating from “too much” or “too tight” or “too loud” and seeking lights and sound and movement when we’re understimulated
Dx approach
Texts which are visually cluttered or demanding.
Victim and perp more likely to be male
!Nerves in brain may be destroyed or damaged!Seizures may occur!Brain may swell following the injury, resulting in permanent brain damage or death!Retinal hemorrhages!Fractures of the endplates of the long bones!Fractured ribs
MYSTERY BOXHAVE ST / VP PUT NAMES OF ATTENDEES IN HATAPPENDIX A p. a2: TO DO