ISBN 978-0-9581040-2-9 Acquired B R A IN NJ UR Y: njury andChallengingBehaviours to AcquiredBrainInjury The practicalguidetounderstandingandresponding Edition (2013) Fourth Contents The FACTS ISBN 978-0-9581040-2-9 Synapse PO Box 3356 South Brisbane Q 4101 P: 61 7 3137 7400 Introduction F: 61 7 3137 7452 E: [email protected] 4 Acquired Brain 33 W: synapse.org.au 9 6 Communication problems 7 Understanding the brain Communication problems that result The FACTS is produced by Synapse and is 8 mental health issues and Acquired Brain Injury from a brain injury vary, and depend on proudly endorsed and supported by Brain 9 Children and Acquired Brain Injury many factors which include a person’s Injury Australia. personality, pre-injury abilities, and the Synapse is dedicated to improving the quality severity of the brain injury. of life of people living with and affected In the hospital by Acquired Brain Injury, or people whose behaviour challenges our understanding. 11 In the hospital Advertising rates are available on request. 12 Treatment and diagnosis 36 VISUAL DIFFICULTIES: Visit synapse.org.au 15 Why predictions of recovery are difficult to view online version which can be enlarged 16 Diagnostic tests and scans on screen. 17 Recovery from brain injury DISCLAIMER: While all care has been taken to ensure information is accurate, all information in this publication is only intended as a guide, and proper medical or professional support and information should be sought. Synapse will not be held responsible for any or damages that arise from following the information provided. Acquired Effects of acquired Carer issues and Rehabilitation In the Material within does not necessarily reflect brain injury challenging behaviours issues long-term the policies of Synapse or the staff and Brain Injury is Board of Management. References to other 19 Impact of Acquired Brain Injury 49 Changes in relationships 63 Rehabilitation tips 71 Potential future medical problems organisations and services do not imply an often called 22 problems 51 Issues for carers and family 64 The post-rehab slump 72 Accommodation options endorsement or guarantee by Synapse. the Invisible 23 and concentration issues 52 Domestic violence 66 Family guide to a low cost 74 Returning to work Synapse is partly funded by the Department 24 Fatigue and lack of motivation 53 Self-care strategies rehabilitation program 76 Advocacy of Communities, a joint Commonwealth and 68 Steps to a healthier brain State/Territory program providing funding and Disability. 26 Sleeping difficulties 55 Coping with serious drug issues 78 Returning to studies 70 Neuropsychological assessments assistance for Australians in need. 28 Depression after a brain injury 56 Sexual changes 30 Problems with organising 58 Challenging behaviours 80 Glossary Supported by financial assistance from 32 Problems with 61 Steps to independence 33 Communication problems 15 36 Impaired self-awareness 37 Hearing difficulties 38 39 Dizziness AUSTRALIAN NETWORK OF BRAIN INJURY ASSOCIATIONS 40 – loss of sense of smell 41 Epilepsy QLD Synapse VIC BrainLink Services WA Headwest 42 Sensory and perceptual skills Tel: 07 3137 7400 Tel: 03 9845 2950 Tel: 08 9330 6370 Email: [email protected] Email: [email protected] Email: [email protected] 43 Visual disorders Web: synapse.org.au Web: www.brainlink.org.au Web: www.headwest.asn.au 44 Self-centredness 46 AUS Brain Injury Australia TAS Brain Injury Association of Tasmania NT: Somerville 45 Stress Tel: 02 9808 9390 Tel: 03 6278 7299 Tel: 08 8920 4100 46 Headaches and other pains Email: [email protected] Email: [email protected] Email: [email protected] Web: www.braininjuryaustralia.org.au Web: www.biat.org.au Web: www.somerville.org.au

NSW Brain Injury Association of NSW SA Brain Injury Network of South Australia ACT National Brain Injury Foundation Tel: 02 9868 5261 Tel: 08 8217 7600 Tel: 02 6288 1117 Email: [email protected] Email: [email protected] Email: [email protected] Web: www.biansw.org.au Web: www.binsa.org Web: www.nbif.org.au In the immediate aftermath of brain injury, families Introduction are focused on survival. Introduction It is often not until much later that they hear the word “cognition”. This is the conscious process of the mind by which we are aware of thought and perception, including all aspects of perceiving, thinking and remembering. In general, cognition is knowledge – Acquired Brain Injury the way we learn and perceive the world around us. There is nothing The difficulties people with brain injuries face are easily ignored or misunderstood. simple about cognition, however. Often families are reassured when Even family members and friends may regard a person with Acquired Brain Injury who a family member awakens from a coma and recognises everyone. This exhibits cognitive problems or changed behaviour, as lazy or hard to get along with. initial recall of old learning lulls some families into a false sense of security, or moved violently there will be no loss using the exhaust of cars, but can also but a brain injury can involve impaired of consciousness and the person may occur in home or industrial accidents. here is very little understanding or Causes of brain injury to experience specific cognitive changes that cognition which can lead to a wide appear not to need medical attention. Carbon monoxide poisoning also knowledge in the community about The brain can be injured as a result of lead to difficulty in areas such as memory, range of problems that become Even so, there may be some mild damage appears to selectively damage areas T brain injury and the impact it has an accident, a stroke, alcohol or drug concentration, communication and behaviour. apparent over time. to the brain that can interfere with the of the brain such as the basal ganglia, on people and their families. Long-term person’s everyday living. The injury may caudate nucleus, putamen, globus abuse, tumours, poisoning, and While the outcome of the injury depends Excerpt from Cognition fact sheet at effects are difficult to predict and will be not be diagnosed but the person may be pallidus, and central white matter. These disease, near drowning, haemorrhage, largely on the nature, severity and location of synapse.org.au different for each person. Many people AIDS, and a number of other disorders the injury itself, appropriate rehabilitation and observed responding more slowly than brain areas are important for the control will experience increased fatigue, difficulty such as Parkinson’s disease, Multiple support will play a vital role in determining the usual or complaining about physical and of movement. with short-term memory and impaired mental problems. Symptoms of mild brain Sclerosis, and Alzheimer’s disease. level of recovery. Stagnant (ischaemic) anoxia is also concentration and retention skills. The terms Acquired Brain Injury (ABI) injury may include fatigue, headache, called hypoxic-ischaemic injury, or HII. There are five areas in which Acquired or acquired are used to dizziness, hearing loss, ringing in the with the sharp bony inner surface of the This type of injury causes general, diffuse Brain Injury may cause long-term describe all types of brain injury that Traumatic Brain Injury (TBI) is an Acquired ears, memory problems, sleep difficulties, skull. Focal lesions can occur at the site damage to the cerebral cortex and changes: occur after birth. The complications Brain Injury caused by a blow to the head irritability and short attention span. of impact inside the skull (coup injury) or cerebellum. Areas of the brain that are and difficulties that arise are varied and or by the head being forced to move rapidly • medical difficulties at a different site (contrecoup injury) which Hypoxic/Anoxic Brain Injury very sensitive to lack of oxygen include may include a range of hidden cognitive forward or backward, usually with some the (a region critical for • changes in physical and is typically, although not limited to, the Hypoxic/anoxic injuries result when there disabilities such as short-term memory loss of consciousness. As a result of this memory), border zone areas of the sensory abilities opposite side of the skull. is a substantial (hypoxic) or a complete loss, through to physical difficulties such blow or rapid movement, brain tissue may cerebral cortex (the parieto-occipital and • changes in the ability to think and learn (anoxic) lack of oxygen supplied to the as fatigue, paralysis and visual or hearing be torn, stretched, penetrated, bruised or Open fronto-parietal regions), cerebellum, basal • changes in behaviour and personality brain. Diminished oxygen supply to the impairment. Whatever the nature of the become swollen. Oxygen may not be able to An open head injury occurs when the skull ganglia, and spinal cord (thoracic region). • communication difficulties. brain may produce profound cognitive, eventual disabilities, the lives of people get through to the brain cells and there may and membrane lining of the brain have Perhaps the most common cause of physical, and emotional impairments The extent of some of these changes with Acquired Brain Injury change, as do be bleeding. been fractured, cracked or broken so that ischaemic anoxia is cardiac arrest. which may be slow to recover, if not (such as being more impulsive or getting the lives of those close to them. The effects of Traumatic Brain Injury can the brain is exposed or penetrated. When permanent. As a result, hypoxic/anoxic lost easily) may only become apparent as be temporary or permanent and range an open head injury occurs, pieces of Alcohol Related Brain Injury (ARBI) Acquired Brain Injury is not to be injury (HAI) can have a wider ranging time progresses. from mild injury, such as being momentarily bone or cerebrospinal fluid may enter the ARBI is a term used to describe the confused with . impact throughout the brain than stunned while playing football, to a very substance of the brain. Considerable local physical injury to the brain sustained as a People with an Acquired Brain Injury do Traumatic Brain Injury. not necessarily experience a decline in severe injury that may cause prolonged loss damage can occur in the area of the brain result of excessive alcohol consumption. their overall level of general intellectual of consciousness. for any period immediately below the impact area, as Anoxic anoxia occurs when there is not Other terms that are often used are functioning. Rather, they are more likely of time — however slight — can result in well as more widespread damage. enough oxygen in the air to be absorbed Wernike’s Syndrome and Korsokoff’s Acquired Brain Injury. While most people by the body and used e.g. high-altitude Syndrome. Alcohol has a toxic effect on Primary versus secondary effects make a good recovery, many are left with sickness. the central nervous system. It results in The direct application of physical changes to metabolism, heart functioning lasting effects that, even if mild, may have Anaemic anoxia occurs when there forces damaging nerve fibres, blood and blood supply. It interferes with the significant consequences for everyday living. is not enough blood carrying enough vessels and other brain tissue are absorption of thiamine (an important Closed head injury oxygen to the cells. This can occur due to commonly referred to as the “primary” nutrient in the brain). Alcohol is commonly loss of blood or insufficient oxygen being Closed head injury is the most common mechanisms of Traumatic Brain Injury. associated with poor nutrition. It can carried in the blood. Acute haemorrhage, cause of brain injury. It occurs when the head Further complications are often called cause dehydration which may lead to obstructed arteries, carbon monoxide is struck or moved violently but the skull and/ “secondary” mechanisms of brain wastage of brain cells. or membrane lining of the brain is not broken injury. A large number of secondary poisoning and chronic anaemia are The degree of brain injury resulting or penetrated. Such damage often involves complications may occur including: common causes of this type of injury. from excessive alcohol consumption “diffuse brain injury” via widespread shearing, haemorrhage (bleeding), haematoma Acute haemorrhages can occur due to depends on many factors, including the twisting and stretching of nerve fibres and (blood clot), raised intracranial pressure, open head injuries or a burst aneurysm. amount and pattern of consumption, bleeding due to the tearing of arteries and hypoxia (loss of oxygen), brain swelling Obstructions often occur due to clots, age, gender, and nutrition. ARBI may be veins throughout the brain. The forward and post-traumatic epilepsy. Such such as in a stroke. Chronic anaemia mild, moderate, severe or very severe. motion and rotation of the brain on the complications require close monitoring occurs when there are persistent low ARBI is associated with changes in relatively fixed brain stem is a common cause and medical management. red blood cells or haemoglobin, the cognition, difficulties with balance and of loss of consciousness and coma. chemical which carries oxygen and gives Mild brain injury blood its red colour. Carbon monoxide coordination and a range of medical and In addition to diffuse brain injury, focal lesions Sometimes, when the head is struck poisoning is seen in suicide attempts neurological disorders. and bruising may occur as the brain collides

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Stroke Understanding the brain A stroke is an interruption of blood supply to part of the brain. If arteries become The brain controls and coordinates everything we do: movements, feelings, thoughts, blocked, bleed or break, then the brain tissue that was being nourished deteriorates. breathing and bodily functions. The brain is made up of billions of nerve cells through which messages are transmitted by a combination of electrical and chemical activity. hen this lack of blood supply Treatment Recovery usually involves a lot of occurs to the heart it is called a Surgery, drugs, acute hospital care and relearning of activities such as walking he soft, jelly-like mass of the brain The motor strip at the back of the frontal Wheart attack. When it occurs in rehabilitation are all accepted stroke treatments and talking. This learning can be sits inside the skull, cushioned lobes controls movement. In the left the brain it is called a stroke. depending on the type of stroke. complicated by the fact that many Frontal lobe people have trouble concentrating after Tby cerebrospinal fluid. This fluid hemisphere the motor strip controls Types of stroke An example of surgery is a carotid a stroke. circulates around the brain and movement of the right side of the body Embolism is where an object, most endarterectomy to remove plaque if a neck through a series of cavities while in the right hemisphere the motor commonly a blood clot, blocks an artery. artery is blocked. Aspirin is a common drug called ventricles. strip controls movement of the left side of used for thinning the blood. Other medications Parietal lobe These clots can occur in other parts of The brain is divided into a the body. aim to dissolve clots that lead to stroke. New the body then break up and travel to number of parts, which techniques continue to arise, such as cerebral Temporal Lobes the brain where they lodge in the brain’s have specific functions angioplasty where balloons, stents and coils are smaller blood vessels. and are designed to work Temporal lobes are involved in receiving used to dilate small intracranial arteries. Thrombosis is where there is a gradual together. The more these and processing auditory information e.g. music and speech, language closure of a blood vessel. In a stroke, Recovery Occipital parts are coordinated and in tune with each comprehension, visual perception, this is most commonly fatty lipids called Generally speaking the brain does not lobe other, the better the organisation and categorisation of plaques building up on the walls of blood regenerate if brain tissue dies after an vessels and restricting blood flow. As a performance. information. A major function of the embolism or thrombosis. The individual may temporal lobes is memory and learning. result symptoms usually develop slowly regain some function after the pressure caused Left and Right The temporal lobes are also involved but may be rapid in some cases. by the bleeding (haemorrhage) has decreased. Temporal lobe Cerebellum Hemispheres in personality, and sexual Haemorrhage is severe bleeding. There Recovery after a stroke depends on are two kinds that can cause a stroke. An The largest part of the brain (the behaviour. a number of factors including the: cortex) is divided into two halves intracerebral haemorrhage is caused by a Brain stem Parietal Lobes ruptured artery leaking blood directly into • type and severity of the stroke called the left hemisphere and the right Parietal lobes are involved in monitoring the brain. A subarachnoid haemorrhage • part of the brain involved hemisphere. sensation and body position, occurs on the surface of the brain and the • extent and nature of the damage The left hemisphere is mainly involved understanding time, recognising objects, blood fills the space around the brain and • existing medical problems with speech and language (talking, reading, and judging the position of creates pressure. • type of treatment and comprehension, reading and writing) and the right hemisphere is mainly involved objects in the environment. Effects of stroke rehabilitation. with visual perception and interpretation Occipital Lobes The after effects of a stroke vary widely of nonverbal information, such as drawing Occipital lobes receive, integrate and for each stroke victim as different parts and spatial analysis. Each hemisphere is interpret visual information relating to of the brain are responsible for thought divided into four lobes. colour, size, shape and distance. processes, comprehension, movement Frontal Lobes and our senses. The extent of blood The Cerebellum shortage also determines the effect of the Frontal lobes are involved in problem- The cerebellum is located at the back and stroke. A stroke may result in paralysis, solving, planning, making judgments, below the main hemispheres of the brain. loss of feeling, communication difficulties, abstract thinking and regulating how It integrates movement signals to produce visual problems and many other issues people act upon their emotions and fine motor control for co-ordination, depending on which part of the brain impulses. Marked changes in a person’s precision, and accurate timing. is affected. personality and social skills can occur from damage to this area. The Brain Stem The brain stem connects the brain to the spinal cord and regulates wakefulness, breathing, body temperature and heart activity. Cranial nerves are located in the brain stem, which regulate a number of functions such as swallowing, speech and eye movement.

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Mental health issues and Acquired Brain Injury After a brain injury, mental health issues such as depression, anxiety and schizophrenia can greatly complicate rehabilitation and integrating back into the community.

ental illness and psychiatric euphoria or hopelessness. Functional employment or studies. A person can include problems associated with the Children disability are both terms used to impairment is the inability to perform have trouble — to a greater or lesser misuse of alcohol, nicotine, caffeine and Mdescribe abnormal brain function. certain routine or basic daily tasks, such degree — with one area, or all of them. illicit drugs. Because a brain injury changes brain as bathing or going to work. And there can be more than one type of Psychotic disorders: These disorders and Acquired function by changing brain structure, In mental illness, signs and symptoms can mental illness at the same time. impair your sense of reality. The most many of the symptoms of a mental illness appear as: notable example of this is schizophrenia, can look like the effects of a brain injury. What is psychiatric disability? • Behaviours e.g. repeated although other classes of disorders can As a result, it can be difficult for the Psychiatric disability is the term used be associated with psychosis at times. Brain Injury hand washing person — or their family — to realise a when a mental illness is debilitating • Feelings e.g. sadness Cognitive disorders: These affect your mental health issue exists. enough to require support for the • Thoughts e.g. delusions that the person. It is therefore possible to have ability to think and reason. They include A crucial difference for children and adults who Mental illness can occur at the same time television is controlling your mind a mental illness, but with the help of delirium, dementia and memory problems. as an Acquired Brain Injury: approximately • Physiological responses e.g. sweating. treatment, other people and/or learned Perhaps the most well-known of these acquire a brain injury is that a child’s brain is 40% of all people with an Acquired Brain coping strategies, to not have a disorders is Alzheimer’s disease. Injury also report having a psychiatric Signs, symptoms, and functional still developing. psychiatric disability. Developmental disorders: These cover disability. The difference between a brain impairments that mark specific mental a wide range of problems that usually injury and a mental illness is that when illnesses, are spelled out in detail in the The distinction is a question of how n children, the injury may disrupt the development of particular areas of first begin to make themselves known the brain is injured, we can see it on Diagnostic and Statistical Manual of severe the effect of the mental illness the brain and neural pathways which can lead to arrested or delayed is, not what the mental illness is. We in infancy, childhood or adolescence. a diagnostic scan. In a mental illness, Mental Disorders (DSM). This two-inch- development of specific skills and abilities. Damage to a young child’s brain They include Autism, Attention Deficit I will continue to use the term “mental we can’t, although an EEG may show thick book classifies and describes more may often affect the development of global abilities rather than producing illness” here. (Hyperactivity) Disorder and learning than 300 types of mental disorders, specific deficits. Previously acquired skills may also be lost due to substantial unusual patterns of electrical activity in disabilities. Just because they’re all and is used by mental health providers brain damage. It is important to remember, however, that there is significant the brain. What are the classes of grouped in this category, however, doesn’t to diagnose everything from anorexia variability in the rate at which children reach developmental milestones and So what is mental illness? mental illness? necessarily mean they share a common to voyeurism. every child is unique. Our evolving understanding of genetics cause or that there’s a relationship among Mental health and mental illness A mental health provider can evaluate and how the brain works may eventually the disorders. your signs and symptoms, then refer to Causes What is the difference between mental change how we classify mental illnesses. the DSM to diagnose your condition. Personality disorders: A personality The most likely causes of Acquired Brain Injury change over the life-span. In health and mental illness? If you are For now, we think of several main classes disorder is an enduring pattern of infants, shaken baby syndrome is by far the most common cause. Before the afraid of giving a speech in public, does of mental illness: What is mental illness? inner experience and behaviour that is age of two years, a baby’s head is relatively heavy compared to their body it mean you have a disease, or simply a Mental illness refers to all the different Mood disorders: These disorders dysfunctional and leads to distress or and their neck muscles too weak to provide full support. As infants become run-of-the-mill case of nerves? If you feel types of mental disorders, including change how you feel e.g. persistent impairment. Examples include borderline toddlers, falls and near drownings are become by far the most common sad, are you just experiencing a passing disorders of thought, mood or behaviour. sadness or feelings of euphoria. personality disorder and antisocial cause of brain injury. Other causes can include stroke, encephalitis, and case of the blues, or is it full-fledged To be classified as a mental illness, the They include major depression and personality disorder. meningitis, as young children have an immature immune system and also depression requiring medication? bipolar disorder. condition must cause distress, and Other disorders: These include can not communicate how sick they are feeling. Just what is “normal” mental health, result in a reduced ability to function Anxiety disorders: Anxiety is an disorders of impulse control, sleep, sexual anyway? Long-term consequences psychologically, socially, occupationally characterised by the anticipation of future functioning and eating. Also included Mental health providers define mental or interpersonally. danger or misfortune accompanied by are dissociative disorders, in which a The initial assessment following injury may not provide a very clear picture of disorders by signs, symptoms and This means that someone who has a a feeling of being ill at ease. Examples person’s sense of self is disrupted, and the long-term consequences for two reasons. One reason is that a relative functional impairments. Signs are what mental illness may have trouble coping include panic disorder, obsessive- somatoform disorders, in which there level of physical and cognitive recovery can be expected to occur over time. objective observers can document, such with emotions such as anger and stress, compulsive disorder, specific phobias and are physical symptoms in the absence The second reason is that specific areas of impairment may become more as agitation or rapid breathing. Symptoms and difficulties in handling daily activities, generalised anxiety disorder. of a clear physical cause, such as apparent when the child reaches a particular stage of development. are subjective, or what you feel, such as family responsibilities, relationships, Substance-related disorders: These hypochondriasis. Continued ...

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In the hospital It is important to become familiar with the hospital’s departments, wards and key staff providing treatment for Acquired Brain Injury.

n some hospitals, all patients with brain Advocacy must look after their own emotional and injury are admitted to the neurosurgical The best interests of patients and their physical health if they are to care for Iunit and cared for by the neurosurgeon. families are easily overlooked during the patient and other family members. Patients with multiple injuries may be times of stress. This can occur Support groups may be available at attended by a number of specialists. unintentionally as a result of a lack of the hospital or through the local Brain For example in cases of bone injury, an necessary resources, work overload or Injury Association. orthopaedic surgeon will be in charge. In poor communication. Most hospitals Coping strategies the Intensive Care Unit, a registered nurse provide support to obtain information and The following ideas are designed to (RN) is always available and assigned to make decisions. The person providing this help friends and relatives come to terms patients. support is often the social worker. with the traumatic experience of having Understanding medical Informing the patient someone sustain a brain injury. information At different stages of development children with Acquired Brain saying. Spoken or written language expression may be affected in With so much energy being put into • Acknowledge your personal reactions Injury may lag behind their peers in a number of functional areas terms of pronunciation, fluency, grammar, intelligibility or meaning Understanding medical terminology can the patient’s health, family members to stressful experiences be difficult, especially during times of unless intensive rehabilitation is provided. Such rehabilitation or and retrieval of words. are often reluctant to say anything that • Reduce sources of stress in your life stress. It is better, however, for people special education assistance may be required to address uneven may upset the injured person, especially • Accept support: whether it be talking to ask questions than to not understand development across functional areas. The most common long- Social, behavioural and emotional topics such as another person’s death. things over or getting help with what is happening. People often prefer term Effects of Acquired Brain Injury in childhood may be divided A child may experience difficulties relating to peers and siblings It is advisable to discuss these concerns the housework to direct such questions to a person with into these areas: and have difficulty joining group activities. They may appear with the appropriate hospital staff who whom they feel comfortable, such as a • Talk with other people about your very demanding of their parents’ or teachers’ attention and will provide guidance in this matter. It feelings and experiences as this can Sensory and motor changes member of the staff, a doctor or have difficulty following rules and instructions. A range of is usually preferable to tell patients any help you process what has happened an allied health professional. traumatic news (although they may forget) A child may lose some previously acquired skills or may have behavioural problems may arise after Acquired Brain Injury, such • Be aware other family members may It is common for hospitals to hold but be aware that due to the brain injury, difficulty learning new skills such as holding a pen, drawing, using as: depressed or anxious mood, hyperactivity, distractibility, deal with the situation very differently meetings with family members and their reaction may be different to what a computer keyboard, constructing and manipulating objects, impulsivity, poor judgment, reduced control of anger and to you various members of staff involved in the using cutlery, getting dressed, recognising objects, and a variety frustration, mood swings, aggression, sleep disturbance, and is expected. patient’s care. If you are not offered a • Maintain a sense of normality and of other eye-hand coordination activities. poor motivation and initiation. When social, behavioural and meeting, speak with the social worker to Adjusting to the experience make a routine for structure in your life Other problems may be balance, coordination or swallowing emotional problems are recognised early in recovery, a number of arrange one. These meetings provide a For family members and close friends, • Ring your local Brain Injury Association rehabilitation strategies may be employed in the school and home and speech difficulties. Professionals such as physiotherapists, good opportunity for relatives to direct this may be one of the most stressful for advice on community services and occupational therapists and speech pathologists play an environment. questions to specific professionals. It is and emotional times in their life. People support groups. important role in the assessment and rehabilitation of sensory The influence of age upon recovery often helpful if those attending prepare for and motor disorders. these meetings by writing down the most The relationship between a child’s age at the time of injury and Cognitive important points or questions they wish their long-term recovery is not well understood. One particular to raise. An Acquired Brain Injury may lead to a general decline in a theory suggests that younger children make a greater recovery number of intellectual abilities. However, similar to adults, than older children due to ‘neural plasticity’, or the ability of the a child may be within the normal range on measures of developing brain to reorganise itself to take over the functions intellectual functioning and yet display significant problems in performed by a damaged area. specific areas of attention, memory, language, visuo-spatial In general, research suggests that injuries acquired at an earlier and executive functioning. Deficits in these areas can affect a age are associated with lower levels of functional recovery or child’s development across all areas of school-based knowledge outcome across various skill domains. These findings support and socialisation. the view that long-term outcome is greater when basic functional Language and communication skills are developed prior to an Acquired Brain Injury. The influence of a child’s age upon level of recovery may prove less significant The necessary skills for reading, writing and oral communication than other factors, such as: the severity and type of brain injury, may be divided into language reception, comprehension and the child’s pre-injury skills and experiences, family functioning, expression. Many children experience receptive problems which involve difficulty processing different parts of spoken or written rehabilitation and support within the home and at school. information. Comprehension problems occur when a child cannot Go to synapse.org.au for a comprehensive range of fact sheets understand what he or she is reading or what another person is on children with a brain injury.

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Treatment and diagnosis When a brain injury occurs and medical attention is required, the initial place of treatment is likely to be the emergency department of a hospital. The priority of care is to make an initial diagnosis, stabilise the patient’s condition, and arrange for appropriate treatment.

tabilisation includes providing be disturbing or frightening for visitors to Brain Swelling respiration (breathing assistance view, but is standard practice in ICU. Brain swelling can occur after a significant Swhich may require the use of The patient is often heavily sedated head injury. Normally the brain fits ventilators) and maintaining blood for their own comfort and may be comfortably inside the skull but when it circulation. Medical staff will also attend unconscious. Pads may cover the eyes swells, cushioning space is reduced and to secondary problems that arise from the to keep them closed and to prevent the brain becomes compressed. This can injury, such as blood clotting, bleeding them from drying out. If an operation was cause further damage. Treatment for brain and brain swelling. They will ensure required, the patient’s hair may have been swelling is complex and includes drugs that the oxygen supply to the brain is partly shaved. The patient’s breathing to sedate the patient and a respirator to maintained. The treatment team caring for may be assisted by a ventilator, in which control breathing. the patient at this point can be expected case they will be unable to speak even if to involve emergency medical and nursing conscious. It is not known if the patient Coma staff including the neurosurgical registrar can hear or understand what is going on. Coma is a loss of consciousness in and neurosurgical consultant. Visitors are often unsure of how to behave which patients typically do not open their Tests but it is generally accepted that you eyes, do not speak and cannot follow should talk to the person and behave as if instructions. In the case of a mild brain X-rays, Computerised Axial Tomography they were conscious. injury, the loss of consciousness, or coma, (CT or CAT), Magnetic Resonance Imaging (MRI), and other tests may be performed to establish the nature and Glasgow Coma Scale extent of the patient’s injuries. The CT brain scan provides a series of X-rays at CRITERIA POINTS different levels of the brain and can be Open eyes Spontaneously 4 used to determine whether surgery is needed. Depending on the results of the To speech 3 scan the patient may be transferred to an To pain 2 operating room for surgery, intensive care None 1 unit (ICU) or a general surgical/medical ward. An MRI provides a more detailed Best verbal response Oriented 5 picture of the brain without using X-rays. Confused 4 Surgery Inappropriate 3 If surgery is required, it may involve Incomprehensible 2 removal of blood clots or bone fragments None 1 may last for one or two minutes, while referred to as being in a state of post- abilities. They may be able to use an eye from the brain; lifting the bone of a Best motor response Obeys commands 6 coma after a severe injury can continue coma unresponsiveness or persistent blinking response to communicate. fractured skull away from the brain; vegetative state. In this state the cerebral and/or insertion of a tube connected Localises pain 5 for days or even years. cortex of the brain is not functioning, Glasgow Coma Scale ranges to a pressure monitor to measure A person in a coma exhibits differing Withdraws to pain 4 and the person is unable to respond to A common tool used to measure coma is brain swelling. levels of responsiveness to touch, pain, Flexion to pain 3 things in the environment. Many people the Glasgow Coma Scale. It evaluates a Intensive Care and verbal commands. It is therefore can remain in this state for long periods person’s ability to open eyes, best verbal Extension to pain 2 better to talk about depth or levels of It may be necessary for the patient to go of time. response, and best movement response. It None 1 coma rather than thinking of coma as an to an intensive care unit (ICU) if special In the condition of locked-in syndrome, is used to monitor the level of coma and the all or none type of experience. drugs or assistance with breathing are A total score of 13 to 15 is classed as Mild Severity. the patient appears unresponsive and patient’s emergence from coma. It rates the required. Here the patient is attached to A total score of 9 to 12 is classed as Moderate Severity. The person who is in a wakeful state without the ability to move or verbally patient according to response to stimulation, A total score of 3 to 8 is classed as Severe Severity. a range of tubes and machines. This may but with profound nonresponsiveness is communicate, yet has full cognitive eye opening and ability to speak.

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Why predictions of recovery are difficult WHO ARE ALL Predictions of recovery are difficult in the months following a brain injury, with the THESE HOSPITAL person and their family often frustrated by lack of knowledge about the future. PROFESSIONALS? There are many professionals who his uncertainty is common along the spectrum of brain injury. With Rehabilitation during a coma may form part of the medical team. a severe injury, doctors can make There are a limited number of rehabilitation interventions for Specific nurses are usually assigned to T their best estimates, yet they will have people during a coma. Limbs need to be moved to prevent a patient and are responsible for the immediate care of the patient. seen exceptions to the rule, with some tightening of the muscles. Patients need to be regularly moved patients never emerging from a coma to prevent ulcers and pressure sores from developing. There are A more senior member of the nursing staff usually while others defy all odds and returned to cases where people have emerged from a coma and claimed to coordinates the overall management of the ward work, albeit with cognitive problems. have heard what was said around them, so family and staff are including patient care, staff and support services. Doctors may predict a good recovery usually urged to be careful in their communications during the Medical specialists are involved in a patient’s care from mild brain injuries and , coma phase. depending on the type and extent of the injuries. Some yet some people may wind up with severe specialists you may encounter include: lifelong problems. POST TRAUMATIC Intensive Care Physician: a doctor who specialises in Why there aren’t accurate the management of patients who require the complex LENGTH OF PTA SEVERITY predictions? support available in an intensive care unit. Less than 5 minutes Very mild injury Physical injuries do not give an accurate Registrar: a senior doctor who directs the hospital unit picture of the degree of brain injury and post-traumatic amnesia, and has a effects is influenced by four factors: Between 5 to 60 minutes Mild injury team and patient management. The registrar may also sustained. The victim of a terrible car significant effect on the final outcome. • Personal assets and limitations before assist the specialist/consultant in caring for the patient. accident may have numerous fractures, Between 1 to 24 hours Moderate injury It should be noted that discharge from the injury Consultant: also known as Visiting Medical Officer or yet there can be less brain trauma than Greater than 24 hours Severe injury rehabilitation does not mean that recovery • The nature and severity of the injury VMO. A senior doctor subcontracted by the hospital someone who fell over in the bath tub. has finished. The person with a brain • The person’s reaction to the injury Greater than 7 days Very severe injury to provide oversight and mentorship for registrars The CT and MRI scans used to detect injury has hopefully learned the tools to • The support of significant others. and residents. brain injury are good at detecting bleeding continue with their own recovery. in the brain, yet fail to accurately show Of these four factors, it is the person’s Neurosurgeon: a surgeon who is a specialist in the Personal factors make a significant Post Traumatic Amnesia (PTA) trauma at the microscopic level. Brain reaction to his or her situation that is management of disorders of the nervous system, brain difference to the degree of recovery trauma can sever the connections recognised as the one that can most A person coming out of a coma doesn’t just wake up, but will go and spine. expected. For example, people who between brain neurons over areas of the likely be changed to improve future through a gradual process of regaining consciousness. This stage did well in the educational system and Neurologist: a medical specialist who has a high level brain yet this will not show in many tests. enjoyment and success in life. Self- of recovery is called Post Traumatic Amnesia (PTA) and may last those with very determined, motivated of expertise in diagnosis and treatment of disorders of The brain does have a limited ability to awareness, motivation, goal setting, for hours, days or weeks. In this stage, a person will not be able personalities usually perform very well the brain, brain stem and cranial nerves. heal itself. This process tends to occur coping strategies (use of memory aids to store continuous or recent memory, such as what happened in rehabilitation. just a few hours or even minutes ago. Patients in PTA are partially Neuropsychologist: a psychologist who is trained in over two years, with the most rapid etc.) and management of emotions are It is important for the person and the or fully awake, but are confused about the day and time, where understanding how the brain works and how it affects improvement in the first six months important reactions which influence family to be optimistic but realistic they are, what is happening and sometimes who they are. They behaviour, memory, learning and personality. as swelling and bruising of the brain long-term outcome following an acquired subside. This pace of healing usually about recovery and to develop a better brain injury. may be afraid, physically and verbally aggressive, disinhibited, : a therapist who has tapers off to the two year mark. This understanding of what is or isn’t possible. agitated and restless. If physically able, they may wander. They the expertise to improve or maintain independent is only a guideline as some will find Some families with a loved one in hospital Hard work and hope may have hallucinations and delusional beliefs such as an adult functioning in all aspects of daily living. improvement stops after a year, others have likened this to hoping for the best A brain injury is very different from other believing he or she is a child. Too much stimulation during this Physiotherapist: a therapist who deals with the may find gradual improvements two years while preparing for the worst. injuries where full recovery is the norm. time can compound the person’s confusion and distress. physical problems caused by the brain injury in order to afterwards. Generally, a slow rate of initial The brain is a complex and highly In conjunction with the Glasgow Coma Scale, length of PTA maximise physical functioning. improvement is associated with a greater Factors influencing long-term organised organ which can be extremely is frequently used as a guide to the severity of brain injury. A outcome Social Worker: a social worker provides a wide range chance of permanent disability. vulnerable. Even with a mild brain injury commonly used interpretation of the scale can be seen on this An injury to the brain can result in a lifelong cognitive effects can remain. The of social services including support, information, referral Importance of rehab page. A general finding is that if the PTA stage lasts for more and counselling to patients and families. number of impairments that may create good news is that faith, hope, hard work than one week, ongoing cognitive problems can be expected Proper rehabilitation is very important serious problems for the injured person. and a systematic approach can enhance in the long-term. once a patient has emerged from coma The ability of a person to cope with these the recovery process and life afterwards.

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Diagnostic tests and scans Recovery from a brain injury Neurological tests fall into three main groups: tests that examine the grey matter of the After acquiring a brain injury the most important issue is usually the degree of brain, ones that examine the white matter, and those examining the functioning. recovery expected.

he first group includes CTs and ecovery is usually rapid at first with improvements Community re-entry, or tertiary rehabilitation, focuses on the MRIs; the second group includes occurring as swelling and bruising of the brain subside. issues of everyday living and returning to previous community TDiffusion MRIs and HDFT; and the RImprovements continue as damaged cells heal, however activities such as work, study and leisure. It aims to help the third group includes EEGs, SPECTs, PETs, healing can be slow. The most significant improvements usually person and family find ways to adapt to, and compensate for, any fMRIs, and evoked potentials. occur in the first six months, however good gains can continue long-term problems or disabilities. for at least two years. Generally, a slow rate of initial improvement MRI and CT is associated with a greater chance of permanent disability. Managing Recovery Family members may need to make important decisions when MRI (Magnetic Resonance Imaging) Of every 1,000 people who survive a severe brain injury: and CT (Computed Tomography) scan they feel least in control. This will require them to be clear headed • 64% are expected to experience good recovery but may and well informed. Many find it useful to keep a diary in which the brain in cross sections to produce experience ongoing cognitive and/or behavioural problems they record medical, social and financial information. an image of the grey matter (neural cell • 25% are expected to have a moderate disability bodies). MRI does this with magnetic Medical information may include: • 10% are expected to have a severe disability fields; the CT scan uses X-rays. MRI has • Names of the doctors and areas of responsibility/titles • 1% are expected to remain in a permanent coma-like state. a higher degree of resolution than CT so • Dates and times of assessments trauma seen by MRI may go unseen by It is important for the person and the family to be optimistic • Key medical terms CT scan. The X-rays used in CT scans but realistic about recovery. Always try to develop a clear • Diagnosis and test results. understanding of what is or isn’t possible in rehabilitation. are better at detecting fresh blood while Social information may include: the MRI scan is better at detecting the Stages of Recovery • Person’s achievements remnants of old haemorrhaged blood. CT There are three broad stages of recovery following an Acquired • Visitors’ messages scans may be done frequently after the Brain Injury. The acute medical stage involves intensive medical injury to keep an eye on the amount of • Milestones (physical and cognitive recovery) treatment that may be needed for survival and preventing brain injury. A diary and a visitors’ book can also be helpful in retelling the further complications. history of what has happened. Diffusion MRI and HDFT The rehabilitation stage involves intensive therapy aimed at Financial information is important to assist if there are to be future PET, SPECT and fMRI placing wires on different parts of the helping the natural process of recovery and reducing the claims for compensation. It is important to keep all receipts Diffusion Magnetic Resonance Imaging Positron emission tomography (PET), scalp for different senses. likelihood of long-term disability. Emphasis is placed on the associated with caring for the injured person along with a diary and High Definition Fibre Tracking (HDFT) Single-Photon Emission Computed Lumbar Puncture person regaining previous skills and learning strategies to showing the time people have devoted to the personal care and are both used to detect white matter Tomography (SPECT), and functional A lumbar puncture is a diagnostic test overcome or compensate for ongoing problems. rehabilitation of the injured person. tracts (interactions between neural cell Magnetic Resonance Imaging (fMRI) are where cerebrospinal fluid is extracted for bodies) with HDFT showing the highest all used to detect levels of activity in the examination, and pressure of the spinal resolution image. This differs from MRI brain. PET does so by measuring the column is measured. It can often detect and CT which detect grey matter. In some use of glucose in brain cells and SPECT primary or metastatic brain or spinal cord brain injuries grey matter may be relatively and fMRI by measuring blood flow. PET neoplasm or cerebral haemorrhage. WHAT IS ? unharmed where white matter paths are is often used to map specific receptors Neurosurgeons specialise in treatment and surgery of the nervous system and damaged. This means that although the MRS and MRA in the brain where fMRI specialises in surrounding structures. cell bodies are living, they can no-longer being able to scan while presenting the Magnetic Resonance Spectroscopy is Their overall goal is to maintain blood flow compression decreases the blood flow brain damaged beyond recovery may be communicate with each other - creating subject with various stimuli. Both PET an imaging method of detecting and and oxygen to all parts of the brain, thus and oxygen to parts of the brain, which removed to increase chances of recovery a brain injury. These imaging techniques measuring activity at the cellular level. It and SPECT use radioisotopes to image minimising the damage and increasing the causes more swelling. for the healthy areas. therefore can detect brain injuries that may activity levels with PET’s radioisotopes provides chemical information and is often prospect of survival and recovery. One of the goals of the neurosurgeon is to The neurosurgeon is also responsible not be evident through MRI or CT. rapidly decaying allowing for a shorter used in conjunction with MRI. They operate on the brain, skull, scalp and break or diminish this cycle. This can be for the insertion of intracranial pressure window of capture. This also means a Magnetic Resonance Angiography is EEG spinal column. One of the most important done by removing any blood clots which monitoring devices which measure quicker scan, allowing for patients unable a type of MRI that produces extremely roles the neurosurgeon performs is in the are pressing on the brain and surgically the pressure and alert the medical An Electroencephalogram records the ever to be still for prolonged periods. detailed pictures of body tissues and prevention of further damage to the brain. repairing damaged blood vessels to stop team allowing them to intervene when changing tiny electrical signals coming organs without the need for x-rays. This is accomplished in several ways. any further bleeding. This gives the brain dangerous levels are reached. A from the brain using electrodes placed Evoked Potentials The quality is not the same as normal more room, increases blood flow, and ventricular drain may be used to drain off on the scalp. Slowing of electrical activity Every time we hear, see, touch or smell arteriography, but the patient is spared When the brain is injured, the brain will helps stem the cycle of compression and excess fluids or surgical intervention may may indicate a lesion or widespread our brain generates an electrical signal. swell. This swelling will cause parts of the the risks of catheterisation and allergic swelling. In severe cases, portions of the be called for. disturbance of brain function. Evoked potentials are recorded by reactions to the dye. brain to compress within the skull. This

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Further support and compensation Why rehabilitation makes At some stage it will be necessary to think about the financial impact a difference of the injury including loss of earnings, hospital expenses, rehabilitation Recent research indicates that the adult brain Impact of Acquired Brain Injury costs and long-term care expenses. Regardless of the situation it is can show experience-dependent recovery of recommended that legal advice be sought by a solicitor who is familiar neural circuits. This finding has three important with the issues and Effects of Acquired Brain Injury. The local Brain Injury implications, as follows: A brain injury is potentially one of the most devastating disabilities due to its Association can assist with the provision of educational information for • A lack of use and lack of stimulation of the legal advisors. brain, such as the absence of rehabilitation wide range of effects. opportunities or inactivity, may prevent Factors influencing long-term outcome experience-dependent recovery There are many different affects felt by the individual following a brain he number and severity of problems • If people reduce their activity and participation injury. Equally, for each person there are different factors that will influence resulting from a brain injury will differ in their world because of the effects of brain from person to person as each their speed of recovery, and the outcome of their injury. It is important to injury, they may develop secondary or additional T person’s brain injury varies in the extent consider the following when supporting someone through recovery: social, cognitive and behavioural disabilities and location of damage. The extent of • Individual’s personal assets and limitations before the injury • Depression and other emotional disorders, such some of these changes may only become • Location, nature and severity of the injury as anxiety and post-traumatic stress, can lead apparent as time progresses. • Individual’s reaction to the injury to poor motivation and may lower a person’s • Level of social support provided by friends and family. use of helpful coping strategies. Cognitive changes Often the easiest of these to influence is the individual’s reaction to the There are five common forms of recovery and Cognition is the conscious process of the injury and their situation. A positive attitude and good understanding adjustment following an Acquired Brain Injury. To mind by which we are aware of thought around how, why, and what has happened can often greatly improve the explain these forms of recovery and adjustment, and perception, including all aspects of outcome of rehabilitation. Also influencing long-term outcome is Self- the following sections use speech impairment as perceiving, thinking and remembering. In the example. awareness, motivation, goal setting, coping strategies and management general, cognition is the process by which of emotions. Remediation we acquire knowledge through perceiving Self-awareness Remediation involves relearning how to perform and learning about the world around us. tasks and skills in a similar way to pre-injury The ability to recognise personal strengths and limitations is particularly The nature of cognitive problems will performance, e.g. investing time and effort to important during rehabilitation when the person has the most opportunity vary over time depending on what the practice speech therapy exercises in order to for specialised support. There are three different levels of self-awareness. person with the injury is doing and where relearn and master language skills. Intellectual awareness is the ability to understand that a particular skill or they are. Some of them may not occur ability has changed following the injury. Emergent awareness is the ability Substitution or compensation at all. These changes may become to recognise and understand when a problem is actually occurring such This form of recovery involves using previously more obvious over time and can be very as noticing that concentration is poor when reading a book. Anticipatory acquired skills or learning new skills to perform frustrating because they can affect the awareness is the ability to anticipate that a problem is likely to occur tasks in a different way, e.g. learning alternative person’s ability to learn new things, to in future situations such as knowing a shopping list will be needed at means of communication such as writing work and to be involved socially. the supermarket. messages, using a communication board, Memory problems sign language or maximising non-verbal Research suggests that the development of intellectual awareness can One of the most common cognitive common following a Poor planning and problem-solving take up to twelve months following the injury, although some people will communication skills. deficits is poor memory. There may be brain injury. This can result in being People with a brain injury may have not develop a full awareness of their problems due to neurological or Accommodation problems in remembering people’s names easily distracted or it can result in being difficulty solving problems and planning psychological reasons. However, specialised rehabilitation programs can Accommodation involves the adjustment of or appointments, passing on messages or unable to stay on a task even without and organising things they have to do. assist the development of self-awareness. personal goals, expectations and priorities to phone calls, or remembering details read distractions. Hospital staff or family They may encounter trouble with open- A summary of long-term effects reflect the changed level of abilities, e.g. accepting in a book or newspaper. In therapy the members can often confuse this with ended decision-making and complex that the speech deficit is a long-term effect of People with an Acquired Brain Injury and their families often observe some person may forget what they are doing poor memory. tasks need to be broken down into a the injury and adjusting self-expectations about from one session to the next. Many are or many of the following long-term effects: Depression step-by-step fashion. speech abilities. able to remember things that happened • Poor attention and concentration Depression in a person with brain injury is Assimilation before the accident, but may have Communication • Memory problems a very common emotional consequence Assimilation involves modifying the environment difficulty remembering things that happen A broad range of social skills may be • Low motivation and poor initiation that usually comes some time after the or adjusting the expectations of other people, from day-to-day. The person may have affected by an Acquired Brain Injury • Difficulty carrying out plans injury. Signs of depression include lack e.g. selecting supportive environments or tasks problems learning new things. Memory including the ability to start or take turns of motivation, loss of sexual drive, sleep • Reduced ability to behave appropriately in social situations that match the person’s level of communication problems may resolve as the brain in conversation, interpret and respond disturbance and tearfulness. • Rapid changes in mood and difficulty controlling anger skills or educating other people to use alternative recovers but giving repeated practice of to social cues, show interest in others, memory tasks will not necessarily bring • Decreased ability to cope with stress and multiple demands means of communicating with the injured person. Lack of initiative use humour appropriately, shift between about recovery. It may be more effective • Depression and anxiety In spite of all good intentions, someone topics of conversation and regulate the Decompensation to develop compensatory strategies • Reduced number and quality of relationships with a brain injury may sit around at home volume and tone of voice. A person with Decompensation is often more problematic than and thereby minimise the impact of the • Social withdrawal and loneliness. brain injury often loses their listening skills, it is beneficial. It involves reducing the need to use problem on everyday life. all day long and watch TV. If the problem The long-term implications of Acquired Brain Injury can be difficult to a skill, e.g. avoiding or withdrawing from social is severe they may need prompting just and may talk excessively. Accompanying determine during the early stages of recovery as they may be disguised by interaction to reduce the need to communicate. Poor concentration to have a shower and get dressed or to memory problems may mean that they the impact of grief and loss and early swelling of the brain. Difficulty concentrating is another very participate in a conversation. often repeat topics.

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Lack of insight unreasonably suspicious and paranoid. Headaches number of reasons, both mechanical This is probably the most difficult problem There are multiple sources of head and and neurologic, particularly when the Socially inappropriate behaviour to deal with. People with a brain injury neck pain, both inside and outside the inner ear and/or temporal lobes have People with a brain injury may have have great difficulty seeing and accepting head. Headaches arising from a brain been damaged. Tinnitus is experienced difficulty judging how to behave in social changes to their thinking and behaviour. injury can be caused by displacement as noises which are commonly like a situations. They may walk up to strangers It is often beneficial to provide frequent, of intracranial structures, inflammation, buzzing, hissing or ringing in the ears. and start telling them about their accident, clear and simple explanations about why decreased blood flow, increased muscle Meniere’s syndrome is caused by they may be over familiar with therapists a problem is being treated or why the tone, inflammation of the thin layers of excessive pressure in the chambers of or they may make inappropriate sexual person is unable to do something. tissue coating the brain and increased the inner ear. Nerve filled membranes advances. This area can be incredibly intracranial pressure. stretch which can cause hearing loss, This is not to be confused with denial. A difficult for families or partners. In more ringing, vertigo, imbalance and a pressure person who lacks insight genuinely does severe cases these behaviours may place Visual problems not realise that their physical, sensory or sensation in the ear. the person at risk of becoming homeless Vision and visual functioning is often cognitive abilities have changed. This can or entering the correctional system. adversely affected by brain injury. Some Auditory is impaired recognition result in unreasonable expectations about of the more common visual systems of nonverbal sounds and noises but intact what they are able to do. Self-centredness problems include double vision, field cuts, language function. In some cases trauma People with a brain injury may appear Slowed responses sector losses, rapid eye movement and to the inner ear can cause the person to to be self-centred, and may be very be extremely sensitive to certain noises or The person with a brain injury may be nearsightedness. demanding and fail to see other people’s pitches and may not be able to tolerate slow to answer questions or to perform point of view. This can cause resentment Chronic pain many environments we take for granted. tasks and they may have difficulty keeping from family members, and it is a key This kind of pain persists beyond the up in conversation. Their capacity to cause of losing friends and having trouble expected healing time and continues Other problems respond quickly in an emergency may establishing new friendships. despite appropriate physical improvement So far only the more common issues have also be lost. The person can be helped in the affected area of the body. The by allowing them more time to respond Dependency been looked at. There are, however, many pain can emerge as headaches, neck and complete tasks. An understanding One of the possible consequences of effects that are less common but no less and shoulder pain, lower back pain and/ employer may be willing to modify the self-centredness is a tendency for some debilitating. For example, Heterotopic or pain in other body areas if trauma work situation. It is also vital that we people with a brain injury to become very Ossification is a secondary condition caused the brain injury. The pain may avoid letting the person get into situations dependent on others. The person may of ABI in which there is abnormal be so intense and bothersome that the where they may be at risk by virtue of their not like being left alone, and constantly bone growth in selected joints, most person withdraws from work, family and slowed responses. This is one reason why demand attention or affection. commonly in the hips, shoulders, knees social activities. many people with a brain injury are not and elbows - usually occurring within Emotional lability allowed to drive. There might also be a Paralysis the first nine months after injury. Chronic Just as some people with a brain injury neuroendocrine difficulties can occur need for careful supervision in the home. Differing degrees of paralysis can affect have difficulty controlling their behaviour, Dizziness and balance the brain are injured the rest must work in women some years post injury, with all parts of the body depending on which Inflexibility they may also have difficulty in controlling weight gain, thyroid disorders, changes These are very common complaints harder to compensate, and this results part of the brain has been injured. Effects People with a brain injury can be very their emotions. They may cry too much or in hair and skin texture, and perceived after acquiring a brain injury caused by in becoming cognitively and emotionally can include poor coordination, difficulty inflexible in their thinking. They can’t too often or laugh at inappropriate times. body temperature changes. Other people damage to the brain stem, blood pressure exhausted very quickly. This can lead to walking, visual difficulties or weakness on always change their train of thought, Alternatively they may suffer rapid mood fluctuations from damage to areas struggle with typographical disorientation, people becoming irritable or frustrated if one side of the body. so they may repeat themselves or have changes, crying one minute and laughing controlling the heart and blood flow or where they cannot remember how to trouble seeing other peoples’ points of the next. vertigo from damage to the inner ear. they do not carefully manage their limited Hearing problems navigate even well known environments, view. They may not cope very well with energy levels. Hearing problems can occur for a such as their own home or suburb. sudden changes in routine. Physical changes Epilepsy and Impulsivity Loss of taste and smell These are chronic medical conditions produced by temporary changes in the People with a brain injury may be very A blow to the head can cause anosmia electrical function of the brain, causing impulsive if they have lost the filtering by injury to the olfactory nerve. This system or control that makes them stop nerve sits between the frontal lobe and seizures which affect awareness, LONG-TERM SUPPORT NEEDS and think before jumping in. This can lead bony protrusions from the skull and is movement, or sensation. Medication to a wide range of behavioural issues and vulnerable to trauma. A blow to the head can usually control these conditions Community access is a priority support need for people with a brain injury. can also cause anosmia by damage well but some lives are devastated by problems with relationships and finances. It is important to assist a person’s orientation to the community relationships without direct support. These opportunities need to to smell processing cells in the orbito- frequent, uncontrollable seizures or (e.g. knowing one’s way around) and transportation. Support with be structured in a way that is minimally intrusive and acceptable Irritability frontal or anterior temporal lobes or by associated disabilities. to individuals. Further research is needed to develop and evaluate People with a brain injury tend to have a mechanical damage to nasal structures. community access, however, also helps to prevent loneliness low tolerance for frustration and can lose This loss of taste and smell often leads to Fatigue and social isolation. Although most people don’t want support interventions for enhancing natural support networks following their temper easily. If kept waiting for an either lack of appetite, or obesity as the Cognitive fatigue, or brain fatigue, is in forming and maintaining relationships, many desire an a brain injury. appointment they may become agitated person compensates with very salty or quite different to the physical fatigue that improvement in this aspect of their life. This suggests the need This is an extract from the Views on long-term support fact sheet and walk out. They may also become fatty foods. everyone is familiar with. When parts of to develop more naturalistic opportunities for people to develop available at synapse.org.au

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Memory problems Attention and While existing long-term often remain intact, an Acquired Brain Injury can significantly affect short-term memory. concentration issues Damage to the brain may reduce a person’s ability to concentrate, but the injured ommon everyday experiences can • Tape recorders or dictaphones become a nightmare of confusion • Electronic organisers person may not immediately recognise this. Cwithout strategies to manage or • Pill reminder boxes compensate for the effects of memory • Post-it notes In addition, there may not be any • Encourage them to withdraw from e.g. putting medication on the table with impairment. Problems may include • A memory book containing visible signs to alert other people that other people and avoid socialising every meal forgetting people’s names, losing a train historical events, personal a problem exists. This often leads to • Result in low levels of achievement. • Getting into a regular daily routine which of thought, getting lost at the shops, experiences and names. misunderstanding by members of the has a structure repeating or forgetting past conversations, Approaches to aid concentration Specific memory techniques community e.g incorrectly thinking a • Aiming for variety within an misplacing objects and difficulty learning Mobile phone technology can often Reassure the person that what is • Selecting and prioritising person with attention difficulties is lacking everyday routine new skills. integrate many of these aids (notebooks, happening to them is influenced by the key information intelligence or motivation. This problem • Scheduling demanding tasks when checklists, calendars, reminders, voice is of particular concern with children who damage to their brain. Encourage them Coping with Memory Problems • Repeating or rehearsing key levels of energy and alertness are recording). They are compact and easily return to the classroom after acquiring a to generate strategies from their own information using self-talk greatest Although there is no “wonder treatment” transportable, allowing for discretion. brain injury. Without support they may be past experiences. It is suggested that the to fix memory problems there are many • Using visual and verbal association to • Eating a healthy diet and sleeping well Developing routines to use memory seen as disinterested or lazy students. person be encouraged to identify specific effective strategies that a person can learn learn information and assist in recall situations where particular strategies may • Using self-talk to monitor thoughts aids People who have sustained a brain injury to improve the success of their memory. • Categorising information into groups. may: be effective. The following strategies may and actions It often takes time and effort for new skills • Become easily distracted be helpful: • Using a timer or electronic organiser. Organising the environment to become automatic. A routine itself The use of visual and verbal association • Have trouble keeping track of what is • Reducing all possible distractions in the The aim is to arrange surroundings so is a strategy for coping with memory techniques helps to put information into Monitoring success being said or done environment that less reliance or demand is placed problems. Sometimes a calendar or a meaningful context. When a person Encourage the person to practise different • Have difficulty doing more than one upon a person’s memory. Strategies a diary is a helpful way to reinforce a tries to recall such information later they • Taking regular rest breaks: having a strategies to work out which are most task at a time nap or a walk for organising the environment include routine. Using a memory aid involves a can use the associated visual and verbal effective in different situations using the the following: three-step routine, for example: information e.g. her name rhymed with • Experience information overload • Meditating, deep breathing and other following self-guided steps (WSTC): chess - visualise her as a queen on the • Be slower at taking in and making strategies for physical and mental W What is the problem? Ask ‘where is my • Using a notepad system beside 1 Writing in a diary information that will chess board (Jess). sense of information. relaxation, such as coffee breaks or attention letting me down?’ the phone be needed later A good way to remember numbers The effects of these difficulties on people’s talking to friends S Select a strategy. Ask ‘what are all the • Using a large notice board and 2 Checking the diary entries regularly everyday lives may: • Planning how to approach a task step- possible strategies I could use? Which making plans is by chunking. For example 4578 is 3 Acting on the information (performing remembered as forty-five, seventy eight. • Affect their ability to learn and by-step is the best strategy?’ • Having a special place to keep objects the tasks or attending appointments). Likewise, 502145 would be remembered remember information • Writing information down using notes T Try out the strategy. Ask: ‘what do I which tend to go missing (e.g. keys) Improving general well-being as half a century followed by the age • Cause them to feel frustrated with and keep them in specific places need to do to use this strategy?’ Do it! • Labelling or colour-coding cupboards Factors such as anxiety, stress (cognitive we get the key to the door and the themselves and other people (have a • Using a dictaphone to tape messages C Check out how the strategy worked. as a reminder of where things are kept that can be regularly played back and physical) and fatigue can have serious age a cousin has remained for the past ‘short fuse’) Ask ‘how successful was the strategy?’ • Tying objects to places e.g. a pen to effects on concentration and memory. five years. • Make them feel overwhelmed and • Using a white board to help organise, ‘Would I do it differently next time?’ the phone or a key to a belt. The improvement of a person’s emotional The PQRST strategy can be used to easily confused plan and store information Using external memory aids and physical well-being, therefore, improve reading and understanding of • Lead to fatigue, headaches and dizziness • Using ‘association’ techniques Everyone uses an external memory aid will most likely have benefits for their written material (practice this strategy of some type. When effectively used to mental alertness and ability to process using a newspaper article). store information, memory aids should information. Important considerations for The steps include: improving general well-being include: enable a person to focus upon learning P Preview (look over a newspaper article) PERSONAL ACCOUNTS OF BRAIN INJURY and recalling details for which a strategy • A balanced diet and appropriate Q Question: What is this article likely to cannot be used. Types of external A stroke three years ago has knocked me out of almost everything. supplements e.g. vitamins be about? aids include: • Sufficient restful sleep R Read the article carefully with the goal I am unable to work and described by fatigue. I’ve searched for some way of particularly uncomfortable, and I find it very • A diary for storing and planning • Regular exercise of answering the question the doctors as permanently disabled. I describing how I feel. The closest I’ve come difficult to stay upright for any length of time, • Notebooks • Relaxation and stress-reduction S Summarise or state the main points of still haven’t resolved many of the issues to is to say that it is like having malaria so tend to find my bed fairly quickly... • Lists and checklists strategies the article resulting from it all. without the fever. My eyes feel a long way We can learn from the experience of others. behind my face; I have headaches a lot, • Alarm clock/wristwatch alarms • Following prescribed medication T Test: try to recall the main points I still experience disorientation and Visit synapse.org.au to read personal stories and often have trouble finding my balance. • Calendars guidelines and medical advice immediately and after a short delay confusion, with memory impairments, and I by people with Acquired Brain Injuries, as Complicated conversations and noise are • Wall charts • Avoiding alcohol, cigarettes and drugs. (20 minutes). have troubles with concentration and well as their carers and family members.

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Fatigue and lack of motivation Fatigue and a disorder of motivation called adynamia are very common outcomes following a brain injury.

atigue often results from having activities, attending to two conversations not appear to be interested in the diffuse damage throughout the brain. at once or conversing with background conversation, with dull responses to FIt is different to the yawning and noise. The huge effort involved for people or given situations. Social skills are sleepy feeling of normal fatigue. This type someone who has sustained a brain exactly that—skills. Because they become fogs the mind, drains all energy, dampens injury means they often need to sleep second nature for most adults, however, movement and sleep may do little to in the early afternoon due to the mental it is hard to accept that someone with a reduce it. exhaustion involved in getting through brain injury may be struggling. Its hard the morning. work to keep up with conversation, to pay Fatigue often goes hand in hand with attention, to provide appropriate visual adynamia, or lack of motivation - noted by Providing their sleep has not been cues, to analyse what was said, to think a loss of drive, indifference, and placidity. disturbed, the person often starts the day of a response, and to look interested - There is usually slowed mental function, a with some feeling of energy. Hours later especially for someone doing all of these marked decrease in ideas, and activity is (often they say its like a curtain falling things without automation. rarely self-initiated. There is often not only down) they find they are struggling to a verbal reminder needed to start a task, keep going, and can’t make sense of Lack of understanding what they’re doing. If they recognise this but further reminders required throughout Often a person will have no visible the task. It is easy to see how family warning and rest for an hour or two they may recover and be able to start again scarring from their brain injury, so all that members could get frustrated in these for another period. If they neglect the their employers, family and friends may situations unless they fully understand the warning and go on working until they can see is an apparently lazy person who impact of adynamia. cope no longer they bring on a state of enjoys an afternoon nap, gets upset Activities that were previously automatic severe fatigue which will stop them doing when you give them a few tasks and will often require increased effort after anything productive for the rest of the day. doesn’t give affection or take interest in the injury. These activities can be Often this can persist and prevent useful other people. concentrating, warding off distractions, work the next day, or even longer. The cruel irony of the situation is that reading for meaning, doing mental the person may never have worked this calculations, monitoring ongoing Trying to look interested hard to accomplish tasks, regain their performances, planning the day’s In social interactions the person may social skills or achieve the simplest of goals. When the injury is ‘invisible’ it friends can be relied upon to give you Should I tell other people? may be crucial for employers, family and their honest impression if you insist on In some cases it can be best to inform friends to be fully informed of adynamia your need for accurate feedback. This people about problems with fatigue. to begin the process of understanding its should give you an idea as to which Given the right information, family and devastating impact. Managing lack of motivation areas you need to work on, such as true friends should be concerned enough poor listening, or appearing vague or Managing fatigue to understand your difficulties and make Task analysis is one possible strategy to combat adynamia, or lack of motivation. uninterested. Some therapists can assist allowances. This also gives you the Learn where your limits are from in relearning skills through practice freedom to say you are getting fatigued Tasks are broken into individual sequenced steps and formed The ingredients for rebuilding these automatic habits are the experience. Even when you feel energetic, and repetition in functional situations. and need to take a break. When they into a checklist. Each step is then ticked as it is completed. In three P’s: Plan, Practice and Promotional attitude. The result take your usual breaks or naps. Overdoing Alternatively you could buy books on understand adynamia they should realise this way beginning, completing and following through on a task is is rehabilitation, or removing obstacles to independence, and it can lead to feeling exhausted for several effective communication and work on that it is not their conversation putting you much easier. systematic achievement of incremental goals in desirable days. Schedule pleasant relaxing activities life areas. these in day-to-day situations. to sleep! This reduces fatigue as it minimises the need to plan, organise, where needed — listening to music, In some ways the brain can be likened to Sometimes a brain injury can result in decide, prioritise, remember and put things in sequence. These Once you have goals in place, try building your motivation by: watching TV or reading if these are not a four lane freeway. The heavy traffic may difficulties in making social judgements. are only some of the cognitive issues required to say, cook an • Telling people about the goal to confirm personal commitment tiring. Make sure you eat properly, sleep well and avoid all drugs including alcohol, be moving along rapidly but close just one People can be too open and trusting omelette. The person with adynamia can be exhausted by these • Monitoring progress towards the goal by noting signs nicotine and caffeine. lane and suddenly there is a traffic jam. particularly after a frontal lobe injury. If tasks before they’ve even opened the kitchen door. of improvement The same can happen with your social you are wondering whether you should Task analysis re-establishes the routines in our activities of • Developing a system of external rewards to reinforce Social skills interaction. You may need to avoid group tell someone about your brain injury and daily living. With the use of checklists and lots of practice it personal effort A logical place to start here is to find out situations or distracting environments as how it has affected you, it may be best can eventually make a great improvement in terms of drive • Developing a routine which allocates time towards the goal how social interaction has been affected the ensuing ‘traffic jam’ will overload your to discuss it first with a trusted friend or and motivation. • Identifying people to provide support and encouragement. by adynamia. Usually family and close ability to communicate effectively. family member.

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Sleeping difficulties Sleeping disorders after a brain injury can be another problem you don’t need during your rehabilitation.

ack of sleep has a negative effect on awakened, sometimes dozens of times Negative thoughts whirring through the brain injury. Physicians may sometimes Practical steps to good snoozing members about respecting your need for our cognition, mood, energy levels a night. On top of this, they may find mind will usually make it very hard to fall use small doses of antidepressant Routine is vital for sound sleep. Go to bed a quiet environment. Land appetite. The average person themselves unable to sleep at all around asleep also. medications for patients with head injury. at exactly the same time every night— So what about naps during the day? needs eight hours of sleep a night or will 3am, despite being desperately tired. Typically, the medication is taken a half even on the weekend. Do not vary this by Some find that afternoon naps are Sleep your way to recovery suffer from decreased concentration, Sleep will usually be very light, so the hour before bedtime and assists with more than 15 minutes. That may sound essential due to the cognitive fatigue from energy and many other problems. These smallest noise brings the person instantly Sleep plays its part in not only helping the sleeping through the night. Sometimes extreme, but if you go to bed at the same a brain injury. Afternoon naps, however, effects are multiplied many times by awake. Research suggests a major cause brain to recover from injury, but in physical this medication works too well and people time and get up at the same time each can disrupt your night time sleeping so a brain injury. of disruptions or “sleep fragmentation” is healing as well. In a Traumatic Brain Injury, sleep for 12 to 15 hours for the first two day, your body will adjust to that pattern. it is important to experiment. It might a change in release of neurotransmitters there are often muscles damaged. During or three days. Some people report side Unfortunately, a brain injury can often lead Avoid caffeine and nicotine. These be better to lie down and rest without in the brain during sleep. active sleep, the brain stem secretes effects such as difficulty waking up in to a sleep disorder. This can be hard to stimulants have a negative effect on the allowing yourself to sleep. hormones that in effect paralyse our the mornings. Lowered sensitivity to detect as people with brain injuries can There can be a variety of other causes brain, and for some people may increase When stress, anxiety and negative some medications can also occur after also experience fatigue. Although some for disrupting sleep. Discomfort from muscles to prevent twitching. This can the likelihood of seizures. thoughts are involved, cognitive people may have problems with getting headache, neck pain or back pain will play a role in helping muscles to heal, but extended use - reducing medication behavioural therapy can also help. Speak Don’t get the body stimulated with too much sleep, the usual sleep disorder always make it hard to get to sleep. poor sleep will hinder this process. effectiveness. It is important to always with your GP about seeing a Psychologist exercise late in the evening. Make sure is trouble sleeping at night followed by Depression is a common feature after seek information from your doctor before or Neuropsychologist who can help you Medication and sleep your bedroom is at the right temperature feeling drowsy during the day. a brain injury and people may find they starting, stopping or changing any out with this. fall asleep easily but wake up several There are medications that can assist with medication. Only use medications as your and that the room is very dark. This can Causes of sleeping problems hours before dawn, unable to sleep sleep problems. Some medications are doctor prescribes, and always inform be very important because light plays a After a brain injury many find it not only again. Anxiety and inability to handle designed to promote sleep but they are them of any preexisting conditions (e.g. critical role in your sleep pattern. Make difficult to sleep, but they are very easily stress are other common problems. typically avoided by physicians who treat Brain Injury). sure it’s quiet as well. Talk with family

A positive approach to acquired brain injury

There are common elements about getting through traumatic even if improvement is painfully slow remember progress is situations in an emotionally and physically healthy manner. better than staying where you are. Set and prioritise goals, What are some of the forces at work that help people cope implement plans and make the most of support networks to with a brain injury? stay motivated. The half full glass A spiritual angle In any traumatic event, some will groan and feel it just confirms Many families and survivors say that spirituality helps them for them that the world is an unjust place full of misery. Others through the recovery process. Some families that have no will smile and say ‘what doesn’t kill you can only make you religious affiliation found that when faced with tragedy involving stronger’. It is the latter group who make the best recoveries a family member or friend, they found themselves praying, after a brain injury. They see negative situations as a time to meditating, or exploring other spiritual practices - possibly for grow and develop. They also tend to be more selfless and the first time. Taking a spiritual path can often assist people to concerned about others. make the most of learning from the experience. Laughter as medicine Whatever works for you There is certainly nothing funny about brain injury, but finding Choose to not give in to negativity, and find strategies that will reasons to smile each day is a factor in health and raises the help you do this. The “whatever works for you” strategy does level of optimism. Our attitudes and beliefs have a strong make you an active participant in the outcome. As Ronald E. influence on the body’s ability to heal itself. Osborn said, “Undertake something that is difficult; it will do you good. Unless you try to do something beyond what you Determination have already mastered - you never grow.” The good news is there is no limit to the extent of rehabilitation. - ‘Positive Approach to ABI’ Fact Sheet at synapse.org.au How far you get depends on how much you put in, and

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Depression after a brain injury TOPOGRAPHIC A number of factors influence a person’s level of depression following a brain injury. DISORIENTATION for being stared at while riding public to relieve depression by adjusting the transport: “People may stare at me chemical levels in the brain. Depression is This disorder means because they are naturally curious about often caused by an excess or a deficiency epression is a common outcome psychological support or other forms of Self-talk people will experience why I walk with a limp – that is part of of particular chemicals in the brain. Such following a brain injury. A person treatment from professionals. Self-talk is a useful technique for difficulty in finding human nature”. chemicals are created naturally within may be confronted with not their way in familiar D One of the most important factors to modifying inaccurate and upsetting our bodies and influence our moods, returning to work, cognitive deficits that consider when planning any treatment, thoughts. It requires the practised art surroundings. Peer support thinking, behaviour, sleep, energy levels, will never completely disappear, loss or evaluating the success of a treatment of replacing upsetting thoughts with Topographic disorientation (TD) Do not underestimate the importance appetite, concentration and other daily of friends, fatigue and difficulty with strategy, is whether or not the person constructive explanations. For example can be very disabling yet may go of social contact, and in particular peer functions. Medication can assist with managing anger and frustration. On top with depression feels as though they are instead of thinking, “I’m useless and I undetected. This inability to navigate support, for the maintenance of good balancing these chemicals when they of this they may have lost the strategies in control of their own life. A feeling of not never get anything right,” the person can through the environment usually mental health, including depression. become altered. used in the past to combat depression involves the person being unable to being in control can make depression replace their thoughts with a constructive Your local brain injury association or Most antidepressants take about two and these will need to be re-learned. learn routes in new environments as worse, or can lead to depression in an explanation such as, “My memory lets mental health association can put you in weeks before a person will notice any well. TD is generally viewed as an A number of factors influence a person’s otherwise healthy individual. me down, I will make better use of my touch with peer support groups for brain change in mental and physical state. impairment in spatial memory and level of depression following a brain injury. diary in future.” A variation of Self-talk injury or for depression. Medication needs to be trialled for at least Endogenous and exogenous has been given different names such It is important to consider life situation, is to prepare a rethink card. Rethink four to six weeks and should generally depression as visual disorientation, topographic Exercise level of traumatic stress experienced cards contain helpful coping statements be taken for approximately six to twelve amnesia and spatial disorientation. and the person’s perception of their life Although the treatment approaches are for particular situations. The card can For many people, exercise alleviates months even if the person feels better situation. usually similar, depression can be divided be carried around and read when the Making our way around our house the symptoms of depression. A major after a few months. People are advised to into exogenous (“reactive”) depression person notices unhelpful thoughts in depressive disorder can not be treated Other things to note are the personality or driving across the city is a see a general practitioner or psychiatrist and endogenous (“organic”) depression. certain situations e.g. a coping statement complex behaviour involving many by exercise alone, but every little bit and emotional well-being before the injury, to discuss issues relating to medication. Exogenous depression occurs when life components. TD varies from person helps. Particularly if you have an attack of the nature of the person’s brain injury and Electroconvulsive Therapy (ECT): events overwhelm your ability to avoid to person depending on the area of the blues - getting moving can not only the stage of recovery, and other health ECT is an extremely effective, very depression and maintain good mental the brain affected. For example one help you feel better but accelerate your conditions that may cause or exacerbate fast acting, antidepressant treatment health, and endogenous depression area of the brain acquires spatial rehabilitation. the symptoms of depression, e.g. heart with an extremely high efficacy. Where arises as a direct result of chemical information, another develops If you are currently recovering from disease or kidney failure other antidepressant medications processes in the brain. long-term representation of position physical injury or physical deficits as have failed, ECT is often effective at Signs and symptoms Exogenous depression can be helped while another will perceive relevant a result of a brain injury, discuss any landmarks on a journey. exercise program with your GP or reducing depressive episodes. The The common signs and symptoms of by anti-depressant medication, but rehabilitation team. disadvantages of this procedure are depression include changes in: addressing the causes through life A person may not even remember the cognitive side-effects that are changes or coping strategies will how to get around their home any • Mood e.g. extreme sadness, despair, Treatment approaches for consistently evidenced. The method remove the need for medications. more. Another may remember flat emotional reactions and irritability depression (voltage, length of administration, section Endogenous depression can be helped strategic landmarks but not be of brain administered to) directly affects • Thinking patterns e.g. a sense of It is common for some people to by life changes and coping strategies, able to compute their positional the cognitive deficits produced. It also hopelessness, pessimistic beliefs experience depression after a traumatic but medical intervention is often relationship to each other. Others directly affects the reduction of depressive • Behaviour patterns e.g. may remember well established event and require additional treatment necessary - sometimes life-long. to the strategies suggested. Treatment symptoms, whereby the most effective reduced attention to physical routes but be unable to learn a options can include the following: reduction occurs concurrently with the new one. The degree people are appearance, withdrawal Personal strategies for coping highest incidence of cognitive deficits. • Physical symptoms e.g. sleep with depression affected by TD depends on whether Psychological therapy: This form of treatment is usually most effective with ECT is used as a treatment of last resort – disturbance, appetite changes, The following strategies have been they can develop strategies that mild or moderate to severe forms of only when depression has not responded tiredness. suggested by people with Acquired Brain will compensate for the disorder. Some people can still make their depression. In general, people with very to other treatments. Always do your own Some of the changes described are Injury and may be useful. way around town by using maps severe forms of depression will require research, consult a doctor, and then common symptoms following an Acquired • Having a nap and constantly asking for directions. other interventions e.g. hospitalisation or decide. Brain Injury, which means it can be • Listening to music medication. After a person’s state of mind Some may benefit from the GPS Suicide difficult to recognise the development • Watching television satellite navigation units that can now has improved they may be more likely of depression. People’s experience of to benefit from psychological support to • Working on a personal project be fitted to cars which will give verbal Given the many difficulties faced by depression usually occurs on a continuum further reduce symptoms and provide someone who has survived a brain • Socialising instructions to reach destinations. ranging from very mild to very severe. The Small portable units are also available ongoing management. injury, it is possible for thoughts of • Walking or other exercise most important consideration is therefore and becoming cheaper each year. Antidepressant medication: Medication suicide to arise. It is crucial to look for the severity of the person’s depression • Mental stimulation support or see a doctor during this Condensed from the Topographic is often used in association with and how long it lasts. Many people are • Scheduling activities and making short- period as appropriate support will Disorientation fact sheet at psychological therapy for someone who able to self-manage their depression term plans normally assist in getting through deep synapse.org.au does not respond well to psychological using strategies. Other people require • Self-Talk or thought challenging. therapy alone. Medication may help depressive episodes.

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to work? It may be the sense of being productive, of being part of a team and feeling esteemed by peers. In this case Organising looking at volunteer work for a community your organisation may achieve these underlying needs. environment Achieving goals is a step by step Get a daily planner, process. It may seem too daunting at diary or electronic first but families can provide support organiser and write and assistance in a graduated way. The things down in the recovery process is more like a marathon order you are going to than a sprint. Both you and your family do them. need patience, positive attitudes and Get into the habit of checking plenty of loving support for each other. your schedule at the beginning of Goals should be adjusted to fit your every day or the night before. The learning style and what you enjoy. If you aim is to arrange surroundings so hate reading or writing then your goals that less reliance or demand is shouldn’t use written exercises or reading placed upon a person’s memory. of books. If you don’t mind writing then Strategies for organising the keeping a journal is an excellent way to environment include the following: record your progress, especially when • Using a note pad system you feel you aren’t getting anywhere. A beside the phone journal can keep track of the “three steps • Using a large notice board and forward, two back” that can sometimes making plans feature in recovery. • Having a special place to more control over your life. It pays to set Memory aids keep objects which tend to Problems with organising these out in writing and approach them go missing (e.g sunglasses) Memory is an important part of getting step-by-step. If your formal rehabilitation • Labelling or colour-coding organised. When effectively used to has finished, some goals may be to cupboards as a reminder of Many people find that following a brain injury they have difficulty getting organised. store information, memory aids should continue further work yourself. It is crucial where things are kept enable a person to focus upon learning to have an accurate idea of your strengths • Tying objects to places and recalling details for which a strategy and weaknesses. After sustaining a e.g. a pen to the phone cannot be used. Types of external he frontal lobe of the brain supplements e.g. vitamins the healthy lifestyle above. For example, brain injury, people often have unrealistic or a key to a belt. is responsible for the act of sleep can be properly regulated by aids include: • Sufficient restful sleep ideas here if their self-awareness has A To-Do List is a handy tool. organising our lives. Unfortunately always going to sleep and waking at • A diary for storing and planning T been affected, so the involvement of Get a whiteboard and put it up • Regular exercise it is very susceptible to injury and set times. Meal times should be at set rehabilitation professionals or family is a • Notebooks for various places somewhere in your house. Write some people with Acquired Brain Injury • Relaxation and stress-reduction times and never skipped. Work with good idea. • Lists and checklists on it the things that you have find great difficulty with prioritising, strategies family members to arrange a weekly One way to plan and organise a goal • Alarm clock, wristwatch alarm and to do and then erase them as sequencing, organising, initiating and • Following prescribed medication plan for visiting others, exercise and any involves designing a goal schedule timer you complete them. Sometimes completing tasks. guidelines and medical advice rehabilitation tasks. which may include some of the • Calendars and wall charts people will list 50 projects and Improve your lifestyle • Avoiding alcohol, cigarettes and drugs. Setting goals following sections: • Tape recorder. none of them will get done. If you have this problem, create a list of • Goal Factors such as anxiety, stress, multiple Structure We all have goals we have set out to Bringing it all together five projects that you want to do demands and fatigue can have serious achieve, often at a subconscious level. • Task/steps Structure allows us to put most of our All of these suggestions are and write them on the whiteboard. effects on your ability to organise. The Goals keep us focused on a purpose • Time frame lives on automatic pilot and reserve compensatory strategies—that is they Don’t add another project to the improvement of a person’s emotional and help us through difficult times when • Potential barriers creativity, memory, and novelty for more compensate for skills that your brain is not list until you have completed one and physical well-being, therefore, will important areas. After a brain injury many many others less motivated would give • Benefits of achieving the goal. as good at any more. The good news is of the five items. As you add one, you have to subtract one. You most likely have benefits for their mental find that they lose this structure to their up. A person who wants to get the most It is important to realise the underlying that the right strategies can go a long way may want to limit it to only three alertness and ability to plan and prioritise. day, particularly if they are not working. out of life often has a number of goals emotions or needs behind a goal. For to making up for a sluggish frontal lobe. projects if five is overwhelming. Important considerations for improving It is crucial to have well defined tasks for simmering at the same time. example, you may want to return to All it takes is commitment to getting these general well-being include: the day. By setting goals you can get out of work but find your cognitive deficits strategies into place and being patient • A balanced diet and appropriate Set a timetable each day that will ensure negative mind sets and help you gain prevent this. Why do you want to return with yourself!

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STOP - THINK Problems with anger Technique Communication problems A person notices the thoughts running Anger is a common reaction experienced when coming through their mind: Communication problems that result from a brain injury vary, and depend on many to terms with how a brain injury has changed one’s life. 1 Stop! And think before reacting factors which include a person’s personality, pre-injury abilities, and the severity of to the situation (are these thoughts accurate/helpful?) the brain damage. ollowing a brain injury, there is often Common causes of anger 2 Challenge the inaccurate or damage to the area of the brain that • Being confronted with tasks the person unhelpful thoughts controls our actions. This area usually ypical effects may include slow • Poor recognition of vocabulary • Making up stories F is no longer capable of doing 3 Create a new thought. controls impulses to shout or hurt others, or slurred speech, difficulty • Needing things to be repeated • Minimal responses when detail is • Other people’s behaviour e.g. driving, substituting for more appropriate actions. A plan can also be developed to help swallowing, drooling, or a nasal insensitive comments T • Difficulty with the speed, complexity or required in an answer a person avoid becoming angry when An individual with damage to this area can tone. Communication problems can amount of information said • Difficulty with abstract skills in sometimes loose this control and may • Inaccurate thinking e.g. falsely believing they plan to enter into a situation that be a mixture of both receptive and that people are laughing at them • Not paying attention in conversations understanding humour, puns, sarcasm experience rage in situations they used to has a history of triggering anger. An expressive problems. • Not understanding what is said and metaphors tolerate or ignore completely. • Unrealistic self-expectations example of a personal plan is using • Hyperverbal or rapid, non-stop talking • Barriers getting in the way of goals or the Stop - Think technique when Receptive skills • Difficulty remembering There can be an ‘on-off’ quality to this • Poor spelling and difficulty in learning routines e.g. queues approaching a shopping centre Indicators of receptive difficulties may instructions given. anger too. The person with the brain new words injury may be calm minutes later while • Build up of stress. situation that is known to trigger anger. include lack of understanding or attention, Expressive skills Identifying the cause of anger can be a problems with quickly given complex • Saying the same thing over and over those around are stunned by the angry My goal: improve my ability to cope The ability to use verbal or written skills to challenge. It is important to consider all information, and requests for repetition. It (perseveration) outburst and may feel hurt or shocked with anger when I am waiting in express oneself may appear unaffected, possible influences relating to: should be remembered that hearing loss • Trouble with writing long sentences. for hours, if not days, afterwards. Family long queues. but often there are subtle problems that members and partners often struggle to • Environment e.g. too much stimulation, can also occur following a brain injury and Typical angry thoughts: ‘The service emerge over time. Often communication Anomia - trouble with finding words understand these angry outbursts, with lack of structure, change of routine lead to the same effects. Ideally a hearing tests during rehabilitation will not detect People with a brain injury may talk resentment and bitterness often building here is so slack. Why can’t they hurry test by an audiologist should occur before • Physical state e.g. pain, tiredness problems as these formal testing normally; speech flows evenly and it’s up over time. Once they understand it up? I’m going to lose my cool any assessing receptive skills. • Mental state, e.g. frustration, confusion situations will not trigger many of these easy to understand. But some will have their loved one’s problem is in controlling moment now’. Stop thinking this! • Other’s responses/behaviours. Behaviours that may indicate problems subtle issues. Some of these can include: this very odd problem – they’ll know anger, and not directed at them, they can New calmer and helpful thoughts: with receptive language include: begin responding in ways that will help to Recommended Strategies for ‘Everyone is probably frustrated by the • Non-stop talking, rambling manage outbursts. Coping with Anger long line – even the person serving us. explanations or very rapid speech In some cases, the person with a brain Steps to successful self-management of I could come back another time, or, I • Difficulty remembering particular words injury can have problems with self- anger include: can wait here and think about pleasant • Incorrect use of language awareness. They may not be able to things such as going to see a movie’. • Talking about/interrupting about Becoming motivated acknowledge they have trouble with their unrelated topics The person identifies why they would anger, and will blame others for provoking • Not observing the usual norms and like to manage anger more successfully. them. Again, this can create enormous customs in social situations conflict within a family or relationship. It They identify what benefits they expect may take carefully phrased feedback, in everyday living from improving their anger management. Levels of anger and coping strategies changes in the family’s responses, and As the person becomes more aware of plenty of time for the person to gradually Self-awareness situations associated with anger they realise they have a problem at all. A person becomes more aware of can keep a record of events, triggers and The next step is for the person is to personal thoughts, behaviours and associated levels of anger. Different levels relearn anger management skills they physical states which are associated of anger can be explored (e.g. mildly used to take for granted. A good place with anger. This awareness is important annoyed, frustrated, irritated and higher to start is identifying a pattern in how in order to notice the early signs of levels of anger). the outbursts are related to specific becoming angry. They should be frustrations. Such triggers may originate encouraged to write down a list of Develop an anger management record from the environment, specific people or changes they notice as they begin to feel The person may keep a diary or chart internal thoughts. angry. of situations that trigger anger. List the situation, the level of anger on a scale It is important to have support from Awareness of situations of one to ten and the coping strategies families and loved-ones when attempting The person becomes more aware of that help to overcome or reduce feelings to change behaviour. Often family can the situations which are associated with of anger. feel that it is not their ‘problem’, however, them becoming angry. They may like simple changes in their response can to ask other people who know them to A simple and effective technique for often cause the situation to become far describe situations and behaviours they reducing levels of anger is the Stop – easier for all involved to manage. have noticed. Think technique.

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the word they want to say but just can’t the alphabet and try to get the first letter of speech Cognitive problems come up with it. This is called anomia, of the word. Or you can visualise spelling This is a condition in which strength and In some cases the person may not appear which means “can’t name”. Everyone the word – picture a blackboard and try coordination of the speech muscles are to have communication difficulties until they has an occasional anomia; those with a to “see” someone writing the word on unaffected but the person experiences are in stressful situations such as returning head injury can have it frequently. It can the blackboard. Then read the word off difficulty saying words correctly in a to work or study. These cognitive problems become frustrating if you are dealing with the blackboard. consistent way. For example, someone will usually stem from inability to maintain people all day long. It may result in poor may repeatedly stumble on the word Dysarthria attention, difficulty with abstract language, self-esteem when you’re just not sure of “yesterday” when asked to repeat it, but what you’re saying any more. poor organisation of language and a slower Dysarthria results in slow, slurred, then be able to say it in a statement such rate of processing information. A variation on this problem is that you say and difficult to understand speech as as, “I tried to say it yesterday.” the wrong word. Instead of saying, “pass the areas of the brain that control the The type of treatment depends on the How professionals can help me the spoon”, you might say “pass me muscles of the speech mechanism are severity of apraxia. In mild cases, therapy the noon.” Or, instead of using a similar damaged. A speech pathologist may help Following a brain injury, these cognitive may start by saying individual sounds sounding word, you may use an entirely with strengthening muscles, increasing issues can make it harder to learn and and contrasting them and thinking about wrong word. Instead of “pass me the movement of mouth and tongue, apply knowledge to specific situations. A how the lips and tongue should be spoon,” you may say, “pass me the car.” breathing exercises and slower rate of speech pathologist can assess and treat placed. Sometimes the timing of rhythm A speech/language pathologist is a speech. In extreme cases alternative communication problems, and provide of speech to tapping or clapping helps professional who commonly works with means of communicating may be advice to rehabilitation teams. They can to speak more clearly. Contrastive stress this type of problem. This person can looked at. help the person with a brain injury to teach you techniques to decrease this drills use the natural rhythm of speech to A person with dysarthria should cope in given social situations, using problem. For example, you can use increase intelligibility. In this exercise, the concentrate on slow clear speech with same sentence is repeated with a different compensatory strategies and treatment a technique called “circumlocution.” to help the person be more competent Basically, you “talk around” the word. frequent pauses. It may be an idea to stress patterns, changing the meaning of in social situations. Often the person can If you can’t come up with the word commence a topic with a single word first, the sentence. People with mild apraxia learn to compensate for a disability by “telephone,” you might say “you dial it, and to check frequently that the other can learn strategies to use to help them you can put a quarter in it, you can call person is understanding you. Try to limit produce the longer words that give them learning a new and different skill or by using people.” People eventually get what you or desist conversations if you become trouble. For the very severe apraxia, assistive technology such as a computer, were trying to say. Another technique that tired as speech often deteriorates quickly alternative and augmentative systems are calculator, hearing aid or augmentative people sometimes use is to go through with fatigue. often employed. communication device.

How families and friends can help BUILDING A CHILD’S SOCIAL SKILLS Families, coworkers, teachers and friends can play an important role in helping a person Young people learn their social skills from their day-to-day activities in the family, at school, improve communication skills or learn new compensatory strategies to reduce limitations. at play, and in the various groups and clubs they may be part of. This is particularly the case where they • Work with the person to find out what • Minimising a person’s feelings (“Its not Children and young people with a brain Some strategies for parents Think about when the difficulties happen. work together with the speech therapist techniques assist them to communicate that bad...”) injury may have difficulty with the social Understand your child’s strengths and Often you can improve things substantially to provide consistent support in the • Use open and non-judgmental • Pressuring the person beyond their skills that most of us take for granted. weaknesses in social skills, cognition and by adapting what you and your family do strategies being learned by the individual questions current ability An Acquired Brain Injury can cause language. Be prepared to alter some of and when you do it. with the brain injury. Family should ask • Allow people to take extra time to finish • Finishing sentences for people who lose children to interact in ways that aren’t the ways you do things. Think about how Try using ‘’ techniques (a questions and expect to be involved in the their sentence or to find a word track of what they were saying always socially appropriate – being poor you feel when your child behaves in ways simplified version if necessary) with your process of rehabilitation. • Speak clearly and simply when there is • Speaking excessively loudly or slowly at reading social cues, talking too much, that are socially difficult. Becoming angry child to find ways around difficulties. isn’t helpful so recognise your frustration, Approaches to USE when a receptive communication deficit • Arguing with a person or telling them interrupting, or seeing the world only from Help your child to rebuild social networks embarrassment, or anger. Set specific communicating with someone with a • Use paraphrasing and summarising to that they are being irrational their own point of view. Other social skills and friendships by asking other children rules and practise these skills many times, brain injury ensure understanding • Using technical jargon and lengthy may be lacking – simple things such as to your house, and talking to the school in a range of different situations. • Acknowledge the injury and • Simplify terms into everyday language. explanations that the person cannot using eye contact appropriately or they about building friendship networks. may be excessively friendly and accepting, be supportive understand or follow. Don’t draw attention to an inappropriate This is an extract from the Parents Approaches to AVOID hugging near-strangers and willing to trust behaviour by reacting strongly to it. Always • Prompt the person to evaluate their Guide range of fact sheets at • False reassurance and go with anybody. praise or reward the behaviours and skills own speech and be aware of issues synapse.org.au you are trying to encourage.

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Impaired self-awareness Hearing difficulties Lack of self awareness is a common outcome for people with frontal lobe injuries and A brain injury can damage both mechanical and neurological processes and result in is related to emotional and personality variables. a variety of hearing difficulties.

eople with a brain injury may be actions. If someone is unaware of their Our hearing process has two stages: the noise, can be a living hell for some people unable to recognise difficulties deficits they may actively seek to find mechanical and a neurological process. with a brain injury whose sensitivity to Pthey are having that are obvious to explanations elsewhere. A useful strategy The mechanical process is carried out sound has been affected. A few examples others, and insist they are back to normal. is encouraging them to look at situations by the ear which has three sections, the of difficult situations include dining out, In other cases they may not realise the from an outside viewpoint and analyse outer, middle, and inner ears. The outer taking a walk, washing the dishes, using extent of an issue and believe that others what happened. Ideally a problematic ear, consisting of the lobe and ear canal, a vacuum cleaner or listening to music. are exaggerating their impairments. They situation could be videotaped to aid protects the more fragile parts inside. Compounding the problem is that the can often exaggerate their own abilities this process. The hardest part of being The middle ear begins with the eardrum, disorder is often not diagnosed, and the in terms of social skills or emotional blamed for something is to not take it as a thin membrane which vibrates in person has trouble convincing others that control and have unrealistic ideas about a personal insult. Arguing will only worsen sympathy with any entering sound. The the problem exists. the future. the situation so it can be best to agree to motion of the eardrum is transferred Ear-plugs and ear-muffs can be a great disagree. A common response could be This lack of self-awareness is not denial. across the middle ear via three small help. Activities can be restructured “We both see this from different angles so Denial involves rejecting knowledge. bones to the inner ear where a tube called so that dining out or shopping can be Where there is lack of self-awareness, let’s leave it there”. If blame is a constant the cochlea is wound tightly like a snail done outside the peak hours, to avoid there is no knowledge to reject – the problem the whole family should look shell. From here the neurological process excessive noise. A commonsense person is, due to their brain injury, at adopting a consistent response and begins and the brain translates vibration approach to diet also helps. Avoiding simply incapable of understanding their seeking professional assistance. into electrical impulses. stimulants such as nicotine or caffeine true situation. Meniere’s syndrome Seeking professional help Trauma most commonly affects the reduces the body’s sensitivity to noise. A Not surprisingly this inability to recognise This syndrome is caused by excessive If lack of self-awareness is treated mechanical process. An eardrum may proper diet and exercise play their part deficits causes many problems for pressure in the chambers of the inner ear. professionally the first step is usually a in better overall health, which will impact rehabilitation. The need for rehabilitation rupture, any of the small bones could Nerve filled membranes stretch which neuropsychological assessment. This will indirectly on hyperacusis by reducing services will be questioned and the break or there could be bleeding or can cause hearing loss, ringing, vertigo, assess the person’s cognitive strengths stress. individual often has a complete lack of bruising of the middle ear. Sometimes imbalance and a pressure sensation in and weaknesses, evidence the impaired understanding of how their cognitive damage to the parietal or temporal lobes the ear. Although it can not be cured, As with many effects of brain injury, awareness, and suggest a treatment problems impact upon their relationships can disrupt the neurological process also. treatment can alleviate the symptoms hyperacusis is exacerbated by stress and plan. Usually the family will be included in with family and friends. People with a lack Thankfully many hearing difficulties are with medication such as diuretics or fatigue. Good sleep and avoiding stressful this process. of self awareness may go back to their The family takes the brunt not permanent and can be reduced or steroids, electrical stimulation or simply situations will maximise the ability to deal job and not understand why they struggle The impact on the family can be There are various psychotherapeutic eliminated with treatment. limiting movement. There are various with noise. in the workplace. They are often unable to immense. If they raise the issue with their techniques used to help increase a surgical procedures that may decrease Tinnitus The most effective solutions involve set achievable goals at work or evaluate family member there can often be an person’s self awareness. The therapist the pressure or remove or deaden the increasing the tolerance of noise, so the their own performance realistically. angry reaction. At times the family may first builds rapport then gently helps the Tinnitus is experienced as noises which nerves involved. person with a brain injury needs to walk Understandably this can affect one’s try to believe nothing is wrong - in their individual to see the discrepancy between are commonly like a buzzing, hissing or Auditory agnosia the fine line between protecting their ears vocational confidence. desire to see their loved one get well. their perceived level of performance ringing in the ears. It is usually caused by minimising discomfort, yet exposing This, however, could lead to dangerous and their actual level of functioning. The by damage to the mechanical process. This is impaired recognition of nonverbal themselves to sufficient noise to build up Three types of awareness situations e.g. an individual driving with next step is normally to help the person Because accurate diagnosis and sounds but intact language function. This impairment their ‘immunity’. Over-protection will only a visual impairment. A family should set anticipate and plan for the problems their treatment is needed a trip to the doctor rare outcome is normally from damage further increase the effect of hyperacusis. Impaired intellectual awareness is where specific goals with their loved one that deficits may bring about by teaching and possible referral to an audiologist to the temporal-parietal region of the Hearing clinics can provide therapy with a person is unable to understand that a have to be met before the family member strategies to deal with them. Treatment is required. brain which interferes with the cognitive deficit exists. The second type is impaired can forego treatment or supervision. methods will vary depending on the type process of hearing. There may be an a specially programmed hearing aid to Tinnitus can be exacerbated by exposure emergent awareness where a person Ideally this should happen with the of awareness impairment. inability to understand spoken language manage the hyperacusis. They may also to loud noises, excessive stress, caffeine, knows there is a problem but is unable to involvement of rehabilitation professionals while the ability to speak is preserved. provide a soft noise generator to be alcohol, nicotine, some illicit drugs realise when the problem is occurring so also. The long road to awareness Auditory agnosia often gradually resolves worn while awake for up to 18 months. and medications, and quinine found in is unable to compensate for the deficits. Lack of awareness can lead to poor itself over time. Long-term exposure to gentle sound at tonic water. The third type is impaired anticipatory It’s your fault, not mine recovery for people whose brain injury has a barely audible level can desensitise the awareness where the person is aware Another impact on the family is that resulted in this condition. Family members Some audiologists run clinics to help Sensitivity or Hyperacusis ears and improve both hyperacusis and of the deficit, can recognise when the external causes may be wrongly blamed should be on the lookout for this and seek manage tinnitus. Other treatments include Sometimes trauma to the inner ear tinnitus. This ‘white noise’ contains every problem is occurring, but is unable to for problems that develop. Linked treatment when required to enhance the hearing aids, tinnitus retraining therapy can cause certain noises or pitches to frequency audible to humans, and can anticipate the likely situations in which the with a lack of self awareness can quality of life for the family member with or cognitive behavioural therapy to become extremely loud or soft. Our be likened to the sound of distant surf or problem will occur. be a refusal to take responsibility for brain injury. alleviate distress. typical western lifestyle, with its barrage of wind. It can help up to 90% of sufferers.

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What you can do Impulsivity about hearing Dizziness problems Injury to the frontal lobes can affect the area of the brain If you are experiencing We have all experienced dizziness – dim vision, the room begins to spin and there that normally controls our impulses. auditory problems, see your may be slight nausea. It is also a very common occurrence after a brain injury. doctor, as there may be a treatable medical cause. njury to the frontal lobes of the brain can understand other people’s behaviour A referral may be needed to have your eople who say they feel ‘dizzy’ affect the area of the brain that normally or motives, and unable to empathise or hearing checked by an audiologist are usually referring to a sensation Icontrols our impulses. imagine how someone else is feeling. (hearing scientist) or you may be referred Pof turning round or whirling. to an ear/nose/throat specialist. Some Alternatively, dizziness may be used to This inability to control urges can lead Strategies for carers to impulsive — and often inappropriate audiologists run specialist clinics to help describe a swaying sensation, or a feeling — social behaviour. For example, a Impulsivity often arises in situations where manage some conditions and they fit of weakness, faintness, light-headedness previously shy person may become quite the person is confused or fearful. These hearing aids and/or therapeutic noise or unsteadiness. Occasionally, some extroverted and talkative if the brain injury can be minimised by a predictable daily generators if needed. people say they have blurred vision, schedule. Any outbursts should not be has led to mild disinhibition. When this Good quality and properly fitted hearing feelings of unreality, faints, blackouts or automatically written off as impulsivity and inability to control urges is more marked, aids reduce and even eliminate most even epileptic fits. Dizziness is a very ignored. They may be indicating a cause it may lead to a normally reserved, tinnitus associated with hearing loss. common complaint after acquiring a brain of fear or confusion that needs to be polite person making crude or sexually They take away the strain of listening injury for a number of reasons: addressed. inappropriate comments to strangers and distract from the tinnitus by • Brain stem damage following a brain injury. When lack of awareness is not an increasing sounds in the outside world. • Double vision issue, the person may apologise later. When other people do not understand Therapeutic noise generators are a • Blood pressure fluctuations from Try to be sensitive to this, despite any the reasons for this behaviour, it often hearing aid type device for people with damage to areas that control lingering anger or annoyance on your leads to rejection and criticism from no hearing loss that produces a blend heart / blood flow part. Prolonged complaints about the others. Impulsivity can therefore lead to of external sounds. This stimulates most • Damaged areas of the cerebellum may behaviour afterward are not likely to help, social isolation as the person alienates fibres of the hearing nerve to deviate lead to light-headedness or imbalance as usually the person’s lack of control was existing friendships and cannot make attention away from the tinnitus. not by choice on their part. • Vertigo from damage to the inner ear. new ones. Other inappropriate behaviours Tinnitus retraining therapy aims to may include: If the person engages in attention-seeking reduce and ultimately eliminate tinnitus The vestibular system behaviour such as yelling or interrupting, perception. It combines auditory therapy The vestibular system is the remarkably • Sexual promiscuity tell them this is not a good way to get (hearing aids/noise generator) and sensitive system which is responsible for • Acting without thinking your attention, and advise them on an counselling aimed to change negative our sense of motion. It helps to keep your • Inability to save money or alternative strategy. beliefs, distract from tinnitus and balance and focus your eyes in response regulate finances When managing impulsivity try to reduce stress. to motion. It is also easily disrupted, cause of your dizziness by checking your an attack. • Sharing personal details inappropriately recognise that challenging behaviours Cognitive behavioural therapy aims both by disease processes and trauma. ears and nervous system, taking your Some useful tips are: • Irritability have often arisen from a physiological to alleviate distress and producing Although dizziness, nausea and vertigo medical history, a blood pressure check • Angry outbursts cause – the frontal lobe injury, and are not adaptation to some conditions. Your are very common after a brain injury, they and a possible referral to other medical • Don’t use alcohol or other drugs • Over-familiarity with strangers ‘chosen’ by the individual. GP should be able to refer you to the are completely missed or ignored in many specialists. In some cases brain scans or • Get out of bed slowly in the morning • Asking personal questions of others Try to remember it is the impulsivity that necessary specialist, usually an ear/ cases. They can impose an extreme electrical recordings of the brain may be • Stop the moment dizziness starts and despite their discomfort. is at fault, not your loved one. In most nose/throat specialist. additional burden upon an injured brain. required to make the diagnosis. sit or lie down until it passes cases, they will not be speaking or acting The profound challenges that come with There are practical steps you can take to • Avoid or reduce problematic Lack of insight intentionally to annoy you or hurt your lessen many hearing problems: any sense of motion may leave people Treatment movements, or change your feelings. Separating the person from the with vestibular problems, literally unable to Another common outcome from a frontal • Avoid noisy environments There are many medications available behaviour can go a long way to coping move without severe problems. environment lobe injury is lack of awareness. This can where possible from over the counter motion sickness make it difficult to analyse one’s own with the situation. tablets to prescription only medications. • Sleep without a pillow to keep your • Tell others of your difficulty Diagnosis behaviour or to assess other people’s In serious cases, your local Brain Injury Therapy can treat balance and spatial neck and backbone perfectly straight • Use gentle music to cover constant reactions. This complicates the issue of Association will be able to put you in There is a difference between dizziness problems with exercises that can • Cut down on salt as this can increase noise caused by tinnitus impulsivity, as the person may refuse to touch with any specialists in behavioural and vertigo. Vertigo is triggered by make the vestibular system adapt the sensation of vertigo • Try to sleep well and avoid acknowledge that they have inappropriate issues who may exist in your State. In the head moving in different ways that to problematic movements. These stressful situations • Try to pinpoint times or conditions behaviour. They may be unable to suddenly make the room seem to spin. may include balance activities or eye some cases medication may play a useful where you are more likely to get dizzy. understand their own limitations, or the role. You should consult your rehabilitation • Cut down on salt if your problem Dizziness stems from light-headedness or movement exercises to help maximise the consequences of their actions. A person specialist or GP to see if medication involves fluid pressure in the ear a sense of imbalance and it will feel as if use of remaining vestibular function, sight, The good news is that dizziness is often lacking in insight is also often unable to could help. • Stop using drugs such as coffee, you are spinning, not the room. It is often and sensation in the feet. Some may find only a short-term problem after a brain cigarettes and alcohol. worse in the morning hours. that acupuncture can lessen dizziness by injury. Suitable and timely treatment can A doctor should be able to diagnose the using certain pressure points to diminish often lead to attenuation of symptoms.

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Effects of Acquired Brain Injury Effects of Acquired Brain Injury

Anosmia – loss of Panic sense of smell attacks Panic attacks are a possible outcome if Traumatic Brain Injury often damages the part of our a person experiences higher levels of anxiety. brain responsible for olfaction — our sense of smell. A small number of these people will go on to develop panic disorder, f the five senses, smell is often Weight loss or gain whereby panic attacks are intense considered to rank fourth in Our sense of food flavour is a mixture of and occur frequently. If left untreated, Oimportance for humans. Taste, both smell and taste perception. Since panic disorder can be a debilitating considered the fifth sense, is mostly the the ability to taste and enjoy food and condition, severely restricting the smell of food in the mouth. The sense of drink depends on our sense of smell, quality of life of the sufferer. smell originates from the olfactory nerves anosmia often leads to reduced appetite Panic attacks can occur at any time, which sit at the base of the brain’s frontal and weight loss. In some patients it leads repeatedly, and without warning. lobes, right behind the eyes and above to weight gain, because they eat food Mostly they last for a few minutes, the nose. After a brain injury, people may with a high salt and fat content to gain but on occasion may last for an hour experience a loss of taste and smell which any enjoyment. Approximately 30% of or more. In between attacks the is called anosmia. patients with anosmia know they have Epilepsy sufferer often feels intense anxiety, lost their sense of smell and taste before Why does it happen? worrying when and where the next being tested by the doctor. attack will occur. Panic attacks Epilepsy is a chronic condition in which seizures are produced by temporary changes An trauma to the head can cause are often accompanied by the Importance of testing anosmia by injury to the olfactory nerve. unpleasant physical symptoms of in the electrical function of the brain. This nerve sits between the frontal lobe It is a good idea to have suspected anxiety including heart palpitations, and bony protrusions from the skull and anosmia tested. Treatment will most hyperventilation, muscle pain, eizures affect awareness, repeat inappropriate words or phrases. Afterwards the person may be very sleepy is vulnerable to trauma. A damage to the often depend upon the cause of the dizziness and sweating, along with movement or sensation. Before a and confused and should be talked to brain via trauma, stroke, and many other anosmia. The cause may not be the brain the fear that the attack will lead to some may get a feeling of Treatment acquired brain injuries can also cause injury itself - it may be due to pressure death or a total loss of control. S in a calm and quiet manner. If a person anosmia by damaging smell processing on nerves as a side-effect of the injury unease called an aura. With medication, For most cases of epilepsy there is no has a partial seizure (petit mal), stay with cells in the orbito-frontal or anterior - or it may even be due to the effects of Why panic attacks occur many patients with epilepsy who are complete cure, however anticonvulsant them, talk calmly, and protect them from otherwise healthy are able to live full medications are the most common temporal lobes or by mechanical damage medications. Panic attacks are just extreme self-injury. Do not restrain them. They may and productive lives. Some patients’ treatment. Used correctly they can be to nasal structures. versions of normal bodily responses be able to respond to simple commands What can I do? lives, however, are devastated by very effective in treating seizures. to danger. Adrenaline being released such as “sit down”. After the seizure Will it go away? frequent, uncontrollable seizures or Find ways to make eating fun again. The into the blood stream causes the Keep track of the frequency of your explain where you are and what has associated disabilities. Not everyone If the sensory cortex has been bruised, texture of different foods becomes very heart to beat faster and the breathing seizures and notify the doctor or nurse happened. who experiences a seizure is diagnosed a gradual recovery of sensation may important, particularly how you combine rate to increase in order to supply of medication side effects in case the with epilepsy. Epilepsy is a long-term, be possible. One study of 66 subjects them. Mix half-cooked vegetables with major muscles with more oxygen. medication needs adjusting. Surgery may Living with epilepsy showed that 36% improved slightly, cooked ones for a texture comparison. ongoing, chronic disorder that causes be used to remove damaged regions of Having to cope with epilepsy as well as 45% had no change, and 18% worsened. Eat a hot meal with a cold salad for Treatments repeated seizures if it is not treated. It may the brain but is generally not performed other problems from a brain injury is not The presence of odour distortions, different temperature experiences. Try contribute to, or even cause, brain injury There are a number of treatments unless treatment with medication has easy. But there are steps you can take to however, (including phantom odours) spicy food from Eastern cuisines that for panic attacks with research but may also develop after a brain injury. failed. cause sensations on the tongue. have some control over the situation: decreased over time. showing cognitive behavioural There are two major types of seizures. • Take your medication on time and The object is to take some time to therapy to be best practice. Some The first type, a general seizure, begins on If someone else has a seizure make meals interesting and fun, so they people choose to combine a number both sides of the brain. Full convulsions For a grand mal seizure (convulsion) try avoid alcohol, coffee and other are still appealing to eat and you feel of treatment options. These can or brief staring episodes are often the to safely get the person laying down stimulants satisfied afterwards. include cognitive behavioural therapy result. The second type, known as a on one side. Place something soft • Sleep well and minimise stress If you have lost your sense of smell you (CBT), medication, complementary partial seizure, originates in one region of under the head. Loosen tight clothing. • Avoid conditions that trigger seizures may need to take some extra steps to therapies (herbs, vitamins and the brain. In a simple partial seizure, the Do not restrain the arms or legs. Do • Wear a Medic-Alert bracelet become safety conscious. Install plenty homeopathy), exercise and relaxation seizure related brain messages remain not put anything into the mouth. Be • Get medical advice before driving. of smoke detectors if you can’t smell techniques. For more information, localised so that one experiences a very careful whilst doing this, as the smoke in the house. Switch to electricity visit synapse.org.au for a fact sheet feeling, sensation, movement, or other person may be moving erratically and Inform your family and friends openly instead of gas. Read labels carefully in on Panic Attacks. symptom without any change in the could unintentionally cause you harm. about epilepsy. They will feel more case you are using strong chemicals that level of awareness. Some may suddenly The seizure itself should only last a comfortable around you and be able to need ventilation. become confused, fumble, wander or few minutes. assist if you have a seizure.

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Sensory and Visual disorders A brain injury can easily disrupt the sophisticated complex subsystems involving the perceptual skills flow and processing of information that allow us to see the world around us. Sensory and perceptual problems can arise from damage to the brain injury can lead to focusing right side of the brain or the parietal and occipital lobe region. problems, eye muscle coordination Adeficits, changes in eyeglass prescription, and peripheral vision he parietal and occipital lobes of known syndrome involves neglect: The changes. The type and extent of any the brain integrate the input from person fails to notice certain aspects on visual problem depends on the severity Tdifferent senses. For example, one side of the world in front of them, in the environment and location of the injury. Even when the senses involved in recognising an most typically the left hand side. For can be as simple as visual problems are diagnosed there is apple may include touch (firm, spongy example, a person with neglect may fail shifting furniture to often little vision rehabilitation offered. and smooth), sight (red or green, round, to notice food on the left side of a plate ensure greater space Some symptoms to look for are: spotty, large etc.), sound (crunching and when walking around or fail to copy aspects on the left side of • Headaches from visual tasks chewing), smell (fresh or rotting) and taste a picture. the house. The person (a granny smith versus a red delicious, may also learn to adjust • Blurred or double vision sweet or tangy). Management of visuo-spatial their expectations and • Sensitivity to light deficits • Inability to concentrate or focus The effects of brain injury may involve a educate other people about range of sensory and perceptual problems The presence of neglect may be their difficulties. • Reading or comprehension difficulties undiagnosed despite significant safety • Trouble judging distances which are often described according to Compensatory strategies the sensory perceptual system involved. issues. People with neglect are often • Sore eyes These systems include: unaware of their problems and tend to People often learn or may be • Loss of visual field. interfere with daily function. Double vision glasses because of low vision. Low vision use other explanations for the mistakes taught a range of strategies to can often be prevented without an eye aids include telescopic lenses for distance • Auditory (perception of sounds) If you find it difficult to process visual caused by the neglect. A key component compensate for visuo-spatial patch, through the use of prisms and vision and a range of magnifying aids for • Visual (perception of colour, shape, information you may be straining without of rehabilitation is therefore to educate problems. These strategies may vision therapy. size, depth and distance) realising it. A general sense of fatigue can reading and other fine tasks. the person and increase their awareness be something like a person learning • Tactile (the perception of touch relating arise from visual problems. Loss of visual field of the impact of the perceptual deficit in to turn their head or body to scan their Photosensitivity to pain, pressure and temperature) everyday living. Further components to environment, or moving objects into their Causes This loss can occur in any part of the Light sensitivity varies from person to • Olfactory (perception of smells) ideal position. A range of specialised visual field and is a common visual affect a program for managing visuo-spatial Trauma, stroke and other Acquired person. Some have no trouble but others • Gustatory (perception of taste). technology or equipment may also be following ABI. One example is loss of problems may include retraining skills, Brain Injuries (ABI) can cause damage to may find bright light painful. Solutions may changing the environment, changing available to fit into a person’s home or half of the field of vision in each eye. include tinted eye wear, or amber filters. A closer look at visuo-spatial skills parts of the brain responsible for visual People can frequently bump into objects, expectations, or compensatory strategies. assist with community access. Some information processing. Even if the head While deficits may occur within each and easily trip or fall over objects. They Hallucinations external prompts may include colour does not hit anything, whiplash can cause sensory system, the area of visuo-spatial Retraining skills may be afraid of leaving home and have Visual hallucinations may be formed stickers for object recognition, bright injury to the brain. Trauma may injure is often more dramatic. Visuo-spatial difficulty reading. Therapy can assist with One approach involves retraining until lights on the floor, musical or sound arteries, stretch nerves or damage the objects such as a person or figure or may deficits may include difficulties in the object detection and encourage constant the person regains, in varying degrees, prompts, hand rails, and other safety vertebral column itself. It can also create be unformed such as flashes of lights, following areas: scanning to compensate. the functional skill. Retraining typically devices. An example of a compensatory soft tissue damage that may cause eye stars or flickering distortions. • Drawing or copying objects involves repetitive and intensive exercises approach for object recognition involves muscle coordination problems. Reading difficulties Impaired visual memory • Recognising objects (agnosia) for a specific skill or task e.g. practise the person learning to rely more upon Common visual problems These may arise from blurred or double Memory is often impaired after stroke or • Telling left from right at drawing an object while receiving other senses such as touch, hearing and vision, jerky eye movements, or visual field smell. They may choose to shut their head injury. In rare cases very specific • Doing mathematics (discalculia) feedback. This approach tends to be Dry eyes loss. Treatment can involve aids such as more effective with specific skills. eyes to avoid inconsistent information types of memory processing are impaired. • Analysing and remembering visual This can result when nerves or muscles prisms or using a typoscope to focus on from the visual system. The rehabilitation A person may no longer be able to information of the eyelids are affected. Symptoms are individual sentences. After injury, it can Changing the environment or strategies described may be developed recognise faces, objects or letters. • Manipulating or constructing objects often relieved with the use of correct eye be hard to focus on a page due to nerve expectations by a neuropsychologist, occupational • Awareness of the body in space e.g. drops. In severe cases plugs placed in the damage that affects the eye’s refocusing. Vision rehabilitation A second approach involves modifying therapist or physiotherapist. The eventual Bifocal glasses can sometimes climbing stairs tear ducts can solve the problem. After a brain injury, some people the environment to provide more support goal of a rehabilitation program is often compensate. • Perception of the environment e.g. or reduce the demands of a particular greater independence and use of self- Double vision experience a natural recovery within following directions. skill. One example may involve building a management strategies. Family members, This condition may cause confusion and Low vision six months. Recovery can be assisted People may experience selective ramp or fitting a handrail for a person who friends and support workers can provide disorientation. People experiencing this Following a brain injury some people have by using the necessary prescription difficulties or several deficits depending finds it difficult to climb a flight of stairs valuable support and reinforcement of are often given an eye patch, although a normal field of view but can’t read print lenses, and speaking with your upon the nature of their injury. One well to their house. Sometimes, the change rehabilitation techniques also. this reduces the field of vision and can or watch television with conventional rehabilitation specialist.

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Visualisation Use your imagination (e.g. pleasant daydreams or memories) to will yourself into a relaxed state. Start by Self-centredness getting comfortable, scanning your Stress body for tension, and relaxing the muscles. Select a favourite place In some cases people with a brain injury which is real or imagined. Stress is part of everyday life and a natural reaction in can appear to become very self-centred Focus your imagination using all five adjusting to major life changes. senses, then use affirmations such as and display the egocentricity more normally repeating ‘I am letting go of tension’; associated with a young child or teenager. or ‘I am feeling peaceful’. Stress also occurs in response to ongoing and coping strategies they used to ease daily hassles such as traffic, noise or Practice using visualisation three the situation. The second step is to inconsiderate people. The body responds times a day for a few minutes or categorise different stressful situations to stress with the ‘flight or fight’ response longer. Eventually, with practice you as follows: in the central and peripheral nervous ndividuals may lose the ability to see the can use visualisation in everyday Controllable – Uncontrollable system. This involves a series of chemical world from another person’s perspective situations when feeling uptight. Iand have little or no self awareness changes which prepare the body for a Important – Unimportant about how their behaviour is impacting Slow breathing techniques stressful event. This can help a person to view it more on others. Proper breathing habits are essential Imagine the body’s reaction to the sound of clearly and objectively. for good mental and physical health. a loud siren late at night outside a person’s This inability to see another’s point of Useful Skills view can be very destructive as the family First, a person needs to focus upon home. During this stressful event the body often cannot understand how a previously their breathing pattern. They need to becomes mobilised into action via the To develop skills to manage stress focus identify whether they breathe mainly caring person now lives completely for brain’s messages. Changes may include on the following three things: Awareness, family is usually left as the only social hurt try to be assertive about what through the chest or through their themselves and has no insight into how increased heart rate and blood pressure, Acceptance, and Coping. Some may be network available. you require. stomach. Short, shallow and rapid they are affecting the family. sweating, dilated pupils and extra sensitive more useful in certain situations. Each skill In some cases, the person may be able Sometimes following a brain injury the breaths from the upper chest should senses such as hearing and vision. may be explained better using a situation be avoided. The aim is to breathe Why does it happen? to portray a cheerful, caring, seemingly family can also feel that they are being While the ‘flight or fight’ response is vital which people are often faced with after deeply and slowly through the nose. Although we take it for granted, the ability unchanged personality around their manipulated by the individual with the for survival, if this occurs too often to the brain injury. Let us use the example of to view the world from someone else’s old friends, but immediately revert to ABI. If the individual’s demands aren’t A person should feel greater body as a result of chronic stress, there a person who is stressed because they point of view is a very complex cognitive their self-centred behaviour when only met they may try various strategies to movement in the stomach than the can be negative effects such as reduced have an appointment. skill. This is just one of many sophisticated the family is around. This is particularly get what they want such as threats, chest as they inhale and exhale. protection from disease and infection, Awareness skills mental skills that occur in the frontal difficult, as these friends may not believe pleading, criticising lack of compassion, Practice breathing exercises everyday. hypertension, psychological disorders, and This is getting a clearer understanding lobes of the brain. Unfortunately this the family when they talk about the or forced silences. Family members are Learn to apply slow breathing as heart, liver and kidney conditions. of the situation and how it affects is a very common area to be affected difficulties of the new personality they often surprised that their loved one’s skills needed e.g. when feeling stressed, Stress exacerbated by ABI the person. in a Traumatic Brain Injury. This is why are facing. in this area are so effective when their angry or anxious. overall social skills have often dropped In the vast majority of cases people self-centredness frequently goes hand in Progressive muscle relaxation Example: The person can find out what a What the family can do significantly. In these cases it is vital for find it much harder to deal with stress hand with lack of self awareness, anger, A person learns to identify muscle appointment involves and the purpose of Often the hardest part for a family is the family to have agreed boundaries after a brain injury. Coping with stress depression, fatigue and reduced social groups and the difference between the appointment. accepting that the self-centredness is not for positive behaviour, and for all family uses many different cognitive functions skills. It is no wonder that families are tension and relaxation in the muscles. always going to go away. Some say that members to respond accordingly. such as: recognising the symptoms; Acceptance skills often brought to breaking point in the This can often assist as relaxing understanding that the brain injury has identifying causes; formulating a coping Acknowledging the stress and being months after the injury. If there is a support group for survivors of muscles can reduce tension related caused the self-centredness eventually strategy; maintaining control of emotions realistic about how it affects a person’s brain injury it may help for the person with to stress. Impact on the family brings them to a point where they can ABI and their family to attend. Sometimes appropriately; and remembering each lifestyle e.g. what aspects are controllable/ Focus upon 4 main muscle groups: Families are usually overjoyed when their accept the changes and enact strategies seeing similar behaviours and attitudes of these techniques. A brain injury can uncontrollable or important/unimportant. to manage the situations that arise. 1 Thighs, buttocks, calves and feet. dramatically affect these cognitive functions loved one survives the initial trauma of in others can bring about some level Example: Recognise that the appointment an Acquired Brain Injury (ABI). Following Sometimes the family unwittingly of self-awareness in the individual, and 2 Hands, forearms and biceps resulting in very little ability to cope with the normal stresses of everyday life. Family needs to be conducted and that it will discharge, a relieved family will often go to contributes to the problem. The family understanding in the family. 3 Chest, stomach and lower back members can find this hard to realise and probably be quite tiring and demanding. great lengths to help with the continuing may wish to cater to all of the individual’s Another possible way to increase a 4 Head, face, throat and shoulders believe a person is simply ‘whingeing’, rehabilitation process, usually making needs following the injury, in the hopes of Coping skills person’s awareness of their behaviours Therapists will suggest to start at the being over-emotional or immature. assisting with recovery. The individual with Prepare to cope with the stressful many sacrifices in time, money and effort can be through therapeutic sessions with feet, and work your way up to the top. on the road to recovery. the ABI may then become dependent on Understanding and situation by learning various strategies. a neuropsychologist. If an assessment Tense muscles for 5-7 seconds and As the months and years go by, families this treatment. Families need to be very indicates the person could benefit from Managing Stress Identify what changes a person can relax for 10-15 seconds. make to control the situation and reduce understandably become frustrated if none firm in setting boundaries, and realise that therapy, the neuropsychologist can The first step a person can take to reduce Note the physical, mental and stress levels. of their sacrifices are acknowledged. they must look after their own needs as gradually build rapport then explore and stress is to become aware of the major behavioural signs of stress each time Some are even criticised by their loved well as their loved one’s needs. challenge their beliefs and behaviours. sources of stress that exist in their life. Example: Using Self-Talk to develop a and try different strategies to see ones for not being supportive enough. Understand that your loved one may no With time this can gradually increase a The person may like to keep a stress helpful outlook towards the appointment which works best for you. Friends will be even less likely to longer be able to be concerned about person’s awareness and insight into how awareness diary for a few weeks that lists and writing down points if forgetfulness is tolerate self-centredness meaning the your rights and needs. Instead of feeling their behaviour impacts on others. the date, time, event, severity, symptoms, a worry.

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doctor should ask you questions about migraine features fairly responsive to anti- duration. It has a readily seen cause and the injury. migraine medications, the other without reduces with treatment. On the other such features. hand, chronic pain lasts beyond the Major types of headaches Neuralgic Pain Syndrome tends to expected duration and it may continue The major types of headaches following occur when large nerves in the scalp are beyond the physical healing of the body trauma include musculoskeletal injured following trauma. This type of pain region involved. headache, tension-type headache and tends to be a shooting, stabbing type in neuralgic (e.g. migraine) headache. Other Pain and rehabilitation the front and side of the head, sometimes rare causes of headache including seizure with pain around or behind the eye. The difficulties a person with brain injury disorders and pneumocephalus (air in faces can be even greater when pain is the head). Migraine headache can last from involved. The pain may be so intense and four hours to three days. They have Musculoskeletal headache is the bothersome that the person withdraws perhaps the clearest diagnosis of any most common type, and also the most from work, family and social activities. of the categories of headache, using overlooked. There can be musculoskeletal the acronym POUNDing: Pulsating Pain may prevent individuals from pain from the neck and structures in the headache for between 4 and 72 hOurs, attempting to return to everyday head — a very common cause of this Unilateral (one-sided), Nauseating and activities. This not only serves to lengthen is whip lash injuries. These headaches Disabling. Treatment should include significantly the time before returning to often worsen with stooping, bending or reduction of triggers such as stress, activities, but it also may contribute to exertion and may be associated with foods that may elicit an allergic reaction, hesitancy and reduced self-confidence dizziness, sensitivity to light, sensitivity to sleep inconsistency, and other allergies. when later attempting to resume activities. sound and even imbalance. Manipulative Hormonal fluxes can also cause In contrast to people with mild brain injury, therapy can be effective to assist in migraines, and hormone replacement people with moderate to severe brain resetting bony structures. Other treatment therapy has been effective at controlling injury may deny or minimise the effects of may focus on strengthening weak spinal migraines in many cases. The most their deficits. For these people, pain may musculature, improvement of posture, effective control is often awareness – reduce both awareness of their deficits anti-inflammatory medications and muscle people who are susceptible to migraines and their incentive to work on improving relaxants, or the use of splints. often have an “aura” that signals the these deficits by causing them to focus Cervical Sympathetic Nerve Syndrome approach of a migraine, and may too much on their pain. is, unfortunately, one instance in which be able to prevent it by immediately headaches resulting from whiplash cannot stopping stressful activities and/or taking Medication be cured. This syndrome occurs when pain‑killers. Pain management in brain injury is often the cervical spinal column — the length Appropriate medication could difficult as medications may work against of spinal column in the neck itself — is include tryptamines, ergotamine or recovery. Many painkillers work against damaged. Symptoms can include (apart corticosteroids. Relaxation training and the re-emergence of the person’s mental from a headache) uncontrollable spasms biofeedback could also be considered. and physical systems. Narcotics could over the body, painful pins and needles Newer techniques including the use of also become a problem because of Headaches and other pains all over the body, vertigo, facial pain, botulinum toxin injection into pericranial their potential for and sinus congestion, fatigue, and more. This musculature can also be explored. their negative side effects on the ability condition has also been known as Barre- Pain is a frequent symptom after a brain injury, although its persistence is usually not There are many other types of headaches think clearly. Lieou Syndrome, after the doctors who which can be diagnosed with tests such independently discovered it. Although it Anti-inflammatory agents are related to the severity of injury. as MRI scans of the brain, X-rays and is possible to treat this condition if there appropriate for musculoskeletal pain, magnetic resonance angiography. is pressure upon the nerves but no actual though doctors must stay alert for n some cases, particularly severe Headaches arise from problems with symptom of an underlying disorder. Often damage, it is vital that treatment be within Other types of pain possible gastric problems. Patients with brain injury, surgical intervention may a number of different structures both a doctor may make this diagnosis, and 72 hours of the injury or permanent brain injury and spinal cord injury tend to Apart from headaches, there are Ibe required to relieve pressure upon inside and outside the head. Those inside no further investigation is made of the damage becomes almost inevitable. have high acid content in the stomach numerous other sources of potential pain nerves or within the skull. Appropriate the head can be the dura, the venous problems causing the pain. The headache and are susceptible to stomach ulcers Tension headaches are reported by after a brain injury, such as abscesses, clinical examination and diagnostic sinuses, blood vessels and cranial nerves. which can be increased by these agents. may be treated as a neurovascular or most people to feel like a diffuse vice-like skin sores, cervical or spine injuries, Those outside the head can be the skin, tests are needed to assess the form of migraine headache, when the great pressure throughout the head. An attack fractures, heterotopic ossification (bony Antidepressants can be effective in treatment required. muscles, nerves, arteries, joint capsules, majority are not primarily migraine-type can last from 30 minutes to a week. overgrowth), kidney stones, bladder controlling some headache and nerve cavities within the head, nerves and the problems. There are different types Tension type headache may be chronic , and constipation. pain. These are not sedating except Causes of headaches periosteum. of injuries that may create the pain or episodic depending on frequency. There are two kinds of pain—acute and in high doses, and don’t depress the The brain itself is not a source of pain. A post-traumatic headache is only a generators of headache. Ideally your There appear to be two types - one with chronic. Acute pain is relatively short in respiratory cycle.

46 Synapse | © Brain Injury Association of Queensland | synapse.org.au synapse.org.au | © Brain Injury Association of Queensland | The FACTS 47 CHRONIC PAIN SYNDROME Effects of Acquired Brain Injury Chronic pain can lead to depression, Carer issues and challenging behaviours anger and anxiety disorders as sufferers may have many other negative events and stressors to deal with. With chronic pain, people may feel the pain is increasing even though there is no medical evidence for this. In these cases other factors are at play including: Changes in relationships • Emotional functioning • Personality traits • Past learning experiences The impact of a brain injury has often been likened to throwing a pebble in a pond, the • The way others respond to the person’s behaviour. effects go far beyond just the person who has acquired the injury, including partners, Sleep and appetite disturbances can intensify the disability that results from chronic pain. As time goes by, friends, family, carers and work colleagues. the person may become depressed and preoccupied with normal changes in bodily functioning and may worry about experiencing new illnesses. he issues and needs of partners and family members will vary according The person can develop a tendency to view all activities to the stages of the recovery in terms of how much pain will be experienced. This T process. Each stage will bring its own can lead to a cycle of helplessness and despair, often joys, challenges, hopes and needs. Old accompanied by anger toward professionals who ‘never coping methods may remain helpful for seem to be able to cure the pain’. In turn, professionals some; for others, new methods will need can lose patience with the person with persistent pain Always speak with your doctor about possible courses of action, to be developed. who may appear to have limited medical justification for however, and make sure to research emerging therapies. these complaints. Resentment, anger, despair, grief and numbness may be emotions encountered. Managing Chronic Pain Your task in the process of recovery is to Pain management strategies are usually based on one sort out what you are feeling, and seek SUICIDE AND ultimate and constant objective—the reduction of pain, out help and support for yourself. not its total elimination. If the person experiencing the ACQUIRED BRAIN pain and all of the professionals who treat the person Acute stage do not make this the goal, frustration will grow, resulting In the acute stage, the physical trauma INJURY in failure to coordinate treatment efforts in a successful to your loved one is often life threatening. manner. Reasonable outcomes would include: No one wants to leave the hospital; Depression is very common at different • Decreased medication use everyone’s focus is on the patient. stages of the recovery process and suicide Your focus at this time is on your loved can OFTEN be a risk. • Fewer physician visits • Fewer hospitalisations one who has been injured; your own Families and carers are often well placed to be able to look • Improved flexibility and endurance needs right now hardly seem to matter. out for the first signs of potential suicidal tendencies. There Your friends often want to help; this is the • Increased strength is often a gradual lead up to suicide, with a typical process time to let them. The rest of your “outside- • Improved functioning at home involving planning, organising the means then enacting. of-the-hospital” life still needs tending to, • Improved social interaction exhausted and out-of-sorts. This is part Some possible warning signs can be: the person becoming and your friends can relieve that worry Community re-entry stage • Return to employment. of the natural letdown of the initial trauma. withdrawn and very depressed; expressing a desire to die by taking care of the house, children, car In the community re-entry phase, the This can be a time when you realise that and talking about suicide; or even suddenly becoming very Research has shown that having realistic, helpful thoughts pooling, shopping, and so forth. Beyond person with a brain injury moves back into you have been (and are) tired and worried. cheerful or tidying up affairs, such as paying bills or saying is an important part of pain management. Cognitive attending to day-to-day tasks, some may family life and begins to renegotiate his or You may not feel like talking to, or being goodbye to old friends. These can all indicate an individual behavioural psychologists can help chronic pain sufferers want to offer emotional support as well. her social world. You, as care giver, begin with, your friends right now. You may be may have made a decision to suicide. to change their negative thoughts about their pain, its You may have conflicting feelings about to redefine your world as well. effects, and other sources of stress. this. Your good friends will understand preoccupied by your own concerns. You A vital way to combat this is to let the person know that When a loved one returns home, and be there for your needs, whatever may not want to talk constantly about the others do care about them. This may involve just spending One approach that views pain as a learned behaviour everything initially readjusts around that they are. You might find it helpful to name injury and burden your friends, but you time with the person even if no talking occurs, or arranging is administered by a psychologist or neuropsychologist. person. Your friendship needs will often one or two of them as coordinators. may not really want to talk about anything for others to spend time with them. Listening can play a Other approaches help the person to identify change again. You may find it difficult to They can return phone calls for you, offer else, either. strong part in prevention too. It is tempting to tell the person inappropriate and unhealthy beliefs about pain and leave your loved one and go out. You apologies and thanks to others, and do You may want to be with your friends why they shouldn’t kill themselves and give advice, when provide strategies to deal more effectively with pain may want a friend or two to visit, but even whatever else needs to be done. – but then won’t want to. This is a simply listening to how they feel can help much more. behaviour. Techniques may include relaxation training, that may feel like it is too much, because hypnosis, stress management, attention-diversion perfectly natural reaction even if it feels Depression can respond well to medication so make Post-acute stage of the extra work that now goes on in strategies and neurofeedback. disconcerting to you. Ask your friends your world. sure the person is in touch with their GP about the In the post-acute stage, the patient is for their patience and grant yourself the depressive episode. Where to get help medically safe and has been moved to same. You may find more comfort being Some friends may be comfortable When there is a high risk of suicide, there are different There are support groups and medical facilities set up a rehabilitation centre. At this point, you with other families in the rehabilitation with what has happened, and with the strategies that can assist, including counselling, referral to help people cope with chronic pain. Ring your local can relax a bit and start to put order back unit who are going through what you are, difference they observe in your loved one to a psychiatrist, medication, a hospital stay and case doctor or Brain Injury Association to get the contact into your world outside of the hospital. than being with your old friends. Take – and perhaps in you. management. For more information, go to synapse.org.au details in your State. Part of this may include offering multiple advantage of the support if it is what One of the first ways to address their fears for the fact sheet Suicide and brain injury. thank you’s to your friends. You may feel you need. or discomforts may be to educate these

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Issues for carers and family friends about the injury. With information, plans may be put on hold to take care Children Carers can often feel that their life is not their own. They have very they can become more comfortable with of their loved one. They often have to The person with the injury may have had the situation. cope with dramatic personality and children before or after their accident or little time alone to pursue their own interests and social life, Many at this stage will themselves behavioural changes. Some of the illness. From a child’s point of view it can and carers often have to do everything around the house. feeling anger and resentment at friends’ most distressing changes can involve be more difficult to have known their happiness. You may feel isolated, with aggression, rapid changes in mood, parent before the injury. In this situation no way to share these feelings with old self-centredness, impulsivity, sexual and the child has to come to terms with why rior to the injury they may have friends. You may wish to seek out support social disinhibition, poor motivation and their parent has changed so dramatically Emotions relied upon their loved one’s support groups of other caregivers, who are lack of empathy. Friends of the family after coming home from hospital. All carers respond to the demands of for everyday chores, but now the feeling just as you are; these groups can often distance themselves over time and After the accident it can be extremely P caring for their loved one in their own workload increases and there is often provide a good social support. Contact can become quite bitter unless they have difficult for a child to understand why way. Feelings are always individual and reduced support to help the carer cope. your local Brain Injury Association for a good understanding about why this their parent needs care, walks or talks everyone will react differently. Some of information on how to access these. behaviour occurs. strangely, never remembers anything, Carers may have difficulties accessing the feelings that carers often say that therapy for intensive rehabilitation and even Above all, remember that it is time now to Partners gets upset so easily and why they no they experience are feeling overwhelmed, act as case managers to ensure that their give your own needs priority. You do need The rate of marital and relationship longer want to play with them. confused and shocked by the diagnosis to go out, to take time for yourself. loved one receives much needed care. to stress because of the demands breakdown is very high following Acquired Children may display increased acting- of brain injury, or realising the changes that caring will bring into their lives. of caring. In the long-term Brain Injury. The pressures on a spouse or out behaviours, emotional problems, Personality and behavioural partner can be immense. They may have or relationship difficulties. Negative changes Given the many ways a brain injury can Sometimes being a carer can feel like an Family to take over the running of the house, parenting such as yelling, ignoring impact on a family, it is not surprising endless grind and result in depressive Families may be confronted with child-like One of the common issues that families become the sole wage earner, increase or or being impatient by both injured that carers will encounter a wide range symptoms. You may find you are behaviour, self-centredness, tactlessness, face is their son or daughter with an decrease their hours of work, make most and uninjured parents is reported in of emotions. There are no right or wrong sleeping too much, or waking early or reduced emotional sensitivity and lack of injury returning to the family home of the decisions and provide support to most families. Most families report feelings. These feelings are a natural and during the night. You might feel worthless gratitude. The person with a brain injury despite having lived away from home the person with the injury. Finances may substantial breakdowns in relationships normal reaction to caring. or agitated most of the time, and have prior to the injury. For the person with become a major concern due to medical may show marked changes in their social between children and their injured Guilt can be a common feeling. Carers difficulty making decisions. the injury this can represent a huge bills and loss of income. A change in the skills and self-care. Impaired executive parent when it is the father who is may feel responsible for the brain injury Family members also experience loss of independence and self-reliance. sexual relationship of a couple can also functioning may be displayed in a number injured. Most non-injured parents report occurring, not wanting to be a carer, grief, often feeling they have lost their For the family, they now have someone be a very distressing and sensitive issue. of ways including impulsivity, verbal and substantial depression, which correlated losing their temper or being embarrassed loved one but being unable to say who is either fully dependent or semi- These changes can also involve either a physical aggression, alcohol and drug significantly with negative behaviour by the person being cared for. Carers goodbye. For some, the caring duties independent. Family members’ lives reduced sexual drive (hyposexuality) or abuse, poor stress tolerance, and a lack in children. should not feel guilty about taking a break have overwhelmed their life to the can change significantly. Their future increased sexual drive (hypersexuality). of mental flexibility. Common emotional Friends difficulties such as depression and anxiety from caring or placing the person in point they feel they have also lost their A very common statement made by may lead to challenging behaviours such residential care. former lifestyle. people with Acquired Brain Injury is ‘you as withdrawal and avoidance. Increased Anger can arise when someone is the Stress find out who your real friends are’ after dependency may also lead to increasing sole carer or others in the family don’t It is typically the day-to-day stresses Major issues for couples the injury. Unfortunately, friends can demands for attention from caregivers. do their fair share. They may become which take a greater toll on a person’s disappear at the time when the person When self-awareness has been affected, frustrated with the person they are caring Both men and women with brain injuries find the loss of physical and mental health. When most needs their support. It is also this places further stress on family as the for if they regularly face challenging autonomy and independence is their biggest problem, and people experience a major life change, common for people who have spent loved one may refuse to believe they are behaviours, angry outbursts, or both mention personality changes and memory deficits they are more likely to recognise the a long time in hospital to feel that they acting inappropriately and may respond self‑centredness. as significant. have missed out on a lot of experiences need for support and use various angrily to feedback. Resentment can arise from lack of Among married couples, wives identify their personality changes and cognitive with their friends and that they now coping strategies. Carers may initially support when friends don’t make contact deficits in their husband with a brain injury as primary problems. have trouble relating to their friends and Lack of understanding seek support after the brain injury has any more, support services don’t provide Husbands, by contrast, place loss of autonomy and mood swings in wives with a sharing their interests. People who are somewhat distanced occurred, but often they don’t seek help enough help, and the focus always is on years down the track as the day-to- brain injury at the top of their lists. Families in which husbands had sustained brain Supportive friends learn to adjust from the person with the injury often have the person with the brain injury. day stress of caring can gradually wear injuries place higher importance on job loss and income change than do families in their expectations of the person with little understanding of what they are going Concerns about the future can result in them down. which wives were injured. Women with brain injuries and non-disabled wives value the injury and seek new activities for through. The person with the injury may , wondering how well the loved one support groups and other emotional support methods as coping strategies, whereas spending time together e.g. watching be able to act ‘normally’ for short periods fear Physical signs of stress may include will recover, what will happen if you don’t the men stressed problem-focused and goal-orientated strategies. a game of sport instead of going to in front of visitors or publicly, so that many a lowered immune system, breathing cope or who will take up the caring role if People with a brain injury who experience higher ratings of cognitive and social a nightclub. Alternatively, the person won’t believe the difficult home situation difficulties, fatigue, sleep disturbance you can no longer do so. dysfunction are more likely to be depressed and anxious. Non-injured spouses also may wish to meet other people with as described by the family. Rather than and muscular tension. Carers may also show increased anxiety and depression, with wives more affected than husbands. a brain injury by joining a specialised offer support, friends or members of the Caring can mean being cut off from others find themselves feeling out of touch group rehabilitation program or a less extended family may make judgements and facing high stress over a very long with reality, forgetful, or not looking structured brain injury social group. about how a person cares for their relative. period of time. Carers are very vulnerable after themselves.

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Domestic violence Challenging behaviours after a brain injury may lead to domestic violence in families.

t is possible that people with an The following are some examples of Have a family meeting whereby all Acquired Brain Injury (ABI) may develop abuse a family may encounter: members are trained to treat family abuse Ibehaviours that lead to domestic • Grandfather yells constantly at his niece in a consistent manner to keep the person violence. Many of us were raised to he adored prior to his accident from learning to use family abuse as a method of manipulation. believe that we should stand by our family • The husband constantly accuses his members no matter what. This stance is wife of having an affair Join a support group in your area so that put to the test when threatened or actual • A husband hits his wife the moment you can find out how others have handled violence occurs. Choosing to ignore the she doesn’t agree with him on an issue. this problem. Do not allow yourself to live behaviour can mean your family member in a ‘reign of terror’. If problems persist, does not get constructive feedback on the Management techniques you may need to consider professional negative behaviour - which can lead to a Do not allow a pattern of family abuse support with a program geared at cycle of violence. to become established in your home. behavioural management. Your local Brain One of the most aggravating things a You will need to make some allowances Injury Association may be able to refer you family can experience is that the person for changes brought on by a brain injury to specialists in this area. with Acquired Brain Injury can be the but continued abuse and violence is not The last resort picture of politeness when speaking to the acceptable. When the person still retains rehabilitation nurse or a visitor. There are self-awareness, they will need to relearn Your State Brain Injury Association should different explanations for this, that may not communication skills, anger management, be able to link you with services who make challenging behaviour or aggression and relaxation techniques to manage their can advise you on legalities, emergency easier to tolerate, but they do provide a anger and tendencies towards violence. accommodation and restraining orders. framework for understanding. Unfortunately there will be cases where Reasons for violent behaviour a lack of self-awareness means that a person cannot relearn these skills. In Self-care strategies We all tend to let our hair down with these cases, it is necessary to develop family, as opposed to strangers or a behaviour management program to acquaintances. Of course, after a brain minimise or prevent violent outbursts. Carers and family members often find themselves at the breaking point. Use these injury a person’s interpretation of letting Do not take the abuse personally – strategies to spoil yourself and make sure you care for yourself as well. their hair down may be well beyond this will only interfere with your ability what most would consider acceptable, to implement effective behaviour particularly if their self-awareness has management. It pays to look at what the carer needs to be aware of the organisation can help to reduce stressors, feelings will go. It is normal to feel as if been affected. They may justify their triggers were in each case, however, and cumulative effects of daily stressors create time for enjoyable activities and you are going crazy at times, and it does violence by saying that others provoked see if these can be minimised. Aand use strategies to reduce maintain social support. not help to try to suppress or deny what them, not realising that the brain injury has the impact of stress. Too much stress you are feeling. There is a reason you are Treat each occurrence as an isolated increased their sensitivity to stress and can have a negative impact on health, Respite care feeling this way, and this will lessen when incident. A person with a brain injury may decreased their ability to handle it. so carers (like everyone else) need to Long-term carers find that surviving is a your body is ready. not remember their abusive The frontal lobe is often damaged in brain maintain regular exercise, a balanced matter of taking time out for themselves. outburst yesterday. The best way to deal with your feelings injury. This area of the brain is involved in Try to find out what diet, regular sleep and rest and relaxation. Respite care is an essential part of the is to accept them, but make sure reasoning, problem solving and controlling the triggers were and Other useful strategies to work on overall support that families often need. you can talk about your feelings with our more basic instincts such as anger. minimise these in include problem-solving on major issues, It can be provided in the client’s home or someone who understands, whether it A person who has sustained a brain injury future where possible. investigating and altering irrational beliefs, in a variety of out of home settings. Since is a family member, friend, counsellor or has often lost these skills and therefore stress-reducing self-talk and meditation. not all families have the same needs, support group. Keep in contact with may have trouble controlling anger respite care is usually flexible to fit in with your support systems – Always seek professional assistance if you and violent outbursts. In many cases Dealing with stress a family’s requirements. you need to have people with feel you can’t get past these issues. individuals with ABI often lose some of A balanced life can go a long way to whom you can discuss problems their social judgement capabilities. reducing stress. To last the long haul, Dealing with difficult feelings Reasonable expectations of family abuse. Overall, a family’s patience can be quite carers need to balance their needs along Guilt, anger, resentment, fear, stress, of yourself worn after months of care. What makes with those of their loved one, developing anxiety, depression and grief are some Avoid the superhero attitude! You may matters worse is that the individual with a lifestyle that balances caring with of the emotions that will be encountered try to undertake all the caring whilst ABI may have little insight into their family, hobbies, socialising and work. while caring for someone with a brain being a model of patience, courage, impact on the family. Time management, goal setting and injury. With time, the worst of these understanding and support and sacrificing

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yourself in the process. Be prepared for Counselling have the right to expect appropriate times when you feel like quitting, yelling, Counselling involves talking to someone support and treatment, and should be Coping with serious drug issues leaving and breaking down. The caring who understands and can work with you assertive in claiming what you want. There role is similar to running a marathon – you are grievance procedures and appeal to give you the encouragement, support need to pace yourself for the long haul. processes in most cases. Your Brain Some people will try an illicit drug once then move on. Others will use them and ideas to improve your situation. It Trying too hard in the early stages may Injury Association may be able to assist, can be a way to assist with the many occasionally, or stick to a level of regular use that avoids physical dependency. mean you lose all your energy further or link you with advocacy organisations. changes in your relationships and roles, down the track when your caring may be as well as dealing with the strong feelings more crucial. Keeping friendships and interests associated with caring. Your local Brain nfortunately, a small percentage result in being kicked out of the house. No has developed a high level of dependency Try to relax and enjoy yourself. Maintain Injury Association can put you in touch of people develop a major money will be handed to the person using on an illicit drug. This is usually best Support groups an identity of your own separate from the with support groups or organisations Udependency that can seriously illicit drugs, though some outstanding bills done with an experienced counsellor, Why join a support group? You can meet person you care for. Try to keep your links who can provide counselling or other disrupt their lives, and those around may be paid. who can provide relevant information and others in a similar position, have a break, to the world outside caring. Absorbing psychological assistance. them as well. People with a brain injury Setting boundaries is part of an approach possible approaches. There are many get information and get support from interests, having fun and relaxation are all are more likely to fall into the latter issues to be looked at such as dealing others who have a shared experience. good for your physical and mental health. that has been called ‘tough love’, which Planning for health category due to depression, boredom, argues that protecting a person from the with inappropriate behaviours, how much Sharing ideas, feelings, worries, Regular exercise, rest and nutritious food Be aware that some friends may tire of social isolation, impulsivity or lack of consequences of their actions means they support to provide and responses to information and problems can help you are all necessary in order to withstand you talking about the hassles of being a self-awareness. Everyone will have a are less likely to do something about it. various situations that may arise. It may feel less isolated. Sometimes family and stress. Try to plan your day so you get carer. Some carers can become resentful different definition of exactly what a drug help to link in with other parents through friends don’t understand the condition of all three. Walking, swimming, yoga, and lose friends by expecting them to ‘problem’ is, but usually it will involve Formulating a plan support groups to get experienced the person you are caring for. People in gardening or dancing are good ways provide more support than they are willing an ongoing disruption to family life, Family members need to agree on a information from others who are further the support group will often understand. to get some gentle exercise. Learning to give. relationships, school or employment, consistent approach when a loved one down the track. Support groups bring together carers to relax by listening to pleasant music, Where possible, seek support from other health and finances. in local areas, sometimes under meditating or doing specific relaxation carers and don’t expect too much from Looking after yourself the guidance of a facilitator who is exercises can help you sleep better. friends - even if it means pretending to be experienced in supporting carers. Often interested in things other than your own Families will frequently find that they SHOULD A PERSON DRINK AFTER A other carers or workers are invited to Self-advocacy problems as a carer. seem to completely revolve around the BRAIN INJURY? present information and training. Your At some point, carers may find person with a serious drug problem. It is Brain Injury Association can help put you themselves unhappy with the level of important that boundaries are set so that A common question asked is whether the use of alcohol in touch with carer support groups in support from a particular hospital, health everyone’s lives are not overly disrupted. and other drugs after an injury can cause further brain your area. professional or welfare association. You This not only protects your lifestyle, but complications. can assist the user as well. If the family is Studies have suggested that the use of even ‘normal’ not overly protective, the person will have amounts of alcohol for people with a mild brain to start facing more consequences of injury may be associated with poor neurological their actions. outcomes as indicated by brain scans, performance COPING WITH GRIEF AND LOSS It helps to link up with an experienced on neuropsychological tests and increased drug counsellor who can help you keep a Carers often don’t have time for their own personal grief. behavioural problems. balanced view on the situation. Many specialists recommend that people abstain from The losses involved may include the return, people can experience a sense of Try to continue seeing your loved one as alcohol for at least one year after their injury. If people personality changes in their loved one, hopelessness and despair. a family member, not just seeing the drug decide to have some alcohol it is suggested that they only friends becoming distant, loss of career Adaptation or reorganisation – energy is problem. Try to separate the issue from drink a very small amount until they become aware of opportunities, less freedom or personal spent establishing a new way of life with the person - you will both appreciate the how alcohol now affects them and learn to recognise their time and loss of financial security. potential for satisfaction and achieving difference this makes. personal limit, or the level that may be consumed without Grief is an ongoing process in which new goals. Talk about your feelings with someone any risks or negative consequences, such as coordination problems, becoming who understands the situation - don’t let people may move forwards, backwards or Ultimately, it is important for carers to aggressive or socially disinhibited. It may be beneficial to ask a close friend or family things build up inside you. miss different stages. One model has the retain a sense of normality in their daily member to provide tactful feedback on what they observe. Alcohol use can often following stages: routine regardless of the extreme stress Try to continue the everyday things you become a sensitive issue, however, where a person may not appreciate being told Shock – Numbness and refusal to believe they may be under. People need to do, particularly enjoyable activities. You how much they should drink or whether they should drink at all. in the reality of the loss. The shock is remember that they are experiencing may feel guilty taking ‘time out’ but it will Some people are strongly advised not to drink or take drugs at all after their greatest when the loss is not expected. normal reactions to abnormal and give you a fresh outlook when you return. injury due to particular medical conditions or the use of prescribed medication Yearning and searching – Effort is traumatic life events. Each person’s Tough love e.g. alcohol can lower the seizure threshold for a person with epilepsy. For safety devoted to trying to undo the loss despite reaction is unique and it is important to considerations people are encouraged to ask their doctor for advice on alcohol and The family needs to agree on what is, some awareness that it may not be allow for delayed reactions or reactions drug use. Additionally, people may require an intervention or program from alcohol and isn’t acceptable, and what the possible. People may continue to search that are different to your own. and drug support services. consequences are. For example, it for signs that the loss has returned (e.g. Remember that alcohol can dampen recovery, and cause problems with If you would like more information on may be agreed that hurling abuse is the person’s memory is getting better). coordination, impulsivity, concentration, depression and seizures. the grief and loss process, go to not acceptable. Continued stealing of Disorganisation and despair – As synapse.org.au to read the Emotional household items to finance drug use will it becomes clear that the loss will not stages in recovery fact sheet.

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MEDICATION NON-COMPLIANCE Sexual changes A refusal to take prescribed medication is a common A brain injury can have consequences for a problem families face after an ACQUIRED brain injury. person’s sexual functioning. People who reject medications do so for a variety of reasons. Knowing which n the hospital phase, impulsivity, hand, others may encounter premature • Alter expectations and negotiate about Masturbation Specific forms of treatment may include reasons will put the family in the best disinhibition and lack of awareness ejaculation or increased sex drive along how often, how long and the type of psychological support, medical and position to respond effectively. Imay lead to rehabilitation staff with sexual disinhibition. A family member may need to be told sexual activity the person may desire surgical approaches. getting unwanted sexual attention Such changes may be a direct result that masturbation is an appropriate way Denial • Be assertive and sensitively from the individual with the Acquired of damage occurring to particular brain to deal with sexual urges, but in the Psychological support Non-acceptance of having an Acquired communicate personal views Brain Injury (ABI). The medical team, structures underlying sexual functioning privacy of their own room. It is important A psychologist or social worker can Brain Injury can be a reason for refusing • Make changes to lifestyle and routines family and friends need to have a or inhibition. Other biological causes to establish ground rules to protect the provide sexual and marital counselling to medication, or the person may believe that improve quality time together. common response to inappropriate of sexual dysfunction may include rights and privacy of others, so when, couples to enhance their understanding that he or she is now well enough not to sexual behaviour that will assist the damage to genital organs, muscles Another important issue is the increased where and how need to be discussed. of sexual changes, communication skills, need it. patient to regain control over very and bones, spinal cord and peripheral vulnerability that people may experience In some cases, a partner or spouse may problem-solving, conflict resolution and Side effects basic impulses when placed in close nerve damage, medical conditions, due to cognitive impairment and continue in a caring role but no longer caring behaviours. Professionals may also Unpleasant side effects can be a proximity to a person of the opposite hormonal disturbance and side effects emotional distress. In particular, the wish to maintain a sexual relationship. In provide literature, audio-visual aids and strong disincentive — they can induce sex. This behaviour can particularly of medication and drugs. person may not sense when they are at these cases, it needs to be stated clearly advice on sexual positions, techniques be a problem for males from their late risk. They may not know how to cope and consistently that masturbation will be and aids. A psychiatrist may prescribe drowsiness, nausea, weight gain, muscle Assessment rigidity and other undesirable symptoms. teens to mid-twenties when their sexual with unwanted sexual advances or may the only option to sexual urges. medication for either psychological or urges are strongest. Some of this Seeking professional advice can be not understand the consequences of physical problems. Influential friend behaviour may include fantasising, lewd an embarrassing and sensitive issue their actions. Family members and friends Treatment for Sexual Problems Medical and surgical approaches Some people with the best intentions verbal responses, disrobing and/or for many people as sex is usually a need to be aware of these issues and Professionals can help people cope with give bad advice. If someone the person masturbating in public, impulsiveness, very personal and private aspect of discuss any concerns with a professional. a variety of physical and psychosocial The medical management of sexual respects believes that medication or drugs and touching others. life. People are often more likely to changes. Following assessment, specific problems is usually most applicable for are ‘bad’ then they could convince the discuss sexual issues with their general treatment of sexual problems may musculoskeletal, neurochemical and person to refuse medication. Understanding by the family practitioner during a visit for other health involve education, learning new skills vascular disorders. Some examples include Families and partners can have trouble reasons. Assessment of sexual issues and behavioural techniques, physical hormonal replacement, new medication Power play understanding these sexual changes can be a vital first step in learning to rehabilitation, aids and medical treatment. (e.g. anti-spasticity drugs) or a change As in all families, there can be a clash of and can react negatively. A good manage or discover treatment options. of current medication, neurosurgical and wills between two or more people. If the understanding should be gained of Assessment may involve an interview, orthopaedic procedures. person with an illness refuses medication, how impulsivity, disinhibition and lack questionnaires, physical examination, they know the caregiver will do whatever of awareness have caused changes in and neurological and medical tests. they can to gain compliance. They may sexual behaviour. In addition to a general practitioner, try negotiation or even manipulation to get psychologists and psychiatrists may be their way. The individual with ABI must be encouraged to take control over involved in the assessment and treatment Forgetfulness aspects of their life, when there is a of sexual issues. Remembering to keep to a regular regime reasonable expectation for responsible Management of Sexual Changes of medication can be difficult, especially if behaviour. When sexual behaviour is your thought processes are affected. inappropriate, steps need to be taken Reactions of partners and family Sometimes no matter how hard a carer to learn better ways for managing members tries or pleads, the person may refuse or compensating for the lapses in Partners and family members play a to take medication. Taking medication is social skills. significant role in influencing the person’s a personal decision. This doesn’t mean adjustment to physical and psychosocial that the reason for refusing medication is Common changes changes that affect their sex life. Partners valid or reasonable, and if noncompliance Sexual changes are common after a and family members may consider the continues with adverse effects brain injury. Although we are all sexual following forms of coping: professional advice should be sought. in nature, there is a great deal of social • Develop greater understanding by For more information, go to stigma around sexual behaviour in the seeking information on how to support synapse.org.au to read the Medication wrong place or time. the person noncompliance fact sheet. Some common changes following • Learn different techniques and an ABI include a loss of sexual drive, compensatory strategies e.g. different inability to achieve or maintain erection ways of giving and receiving pleasure or inability to orgasm. On the other with the person

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Challenging behaviours Challenging behaviours are those behaviours that threaten the safety • Direct any disapproval away from the person and onto the behaviour. of the self or others, or limit access to the community. While the exact causes of challenging behaviour are not well understood, the two main causes of behavioural changes that ndividuals and communities have a self‑centredness, tactlessness, reduced themselves. As people gradually develop follow an ABI often stem from: tendency to judge people by their emotional sensitivity and lack of gratitude. higher levels of self-awareness into the Ibehaviour. Anyone who acts outside People may show marked changes in impact of their post-injury changes, the • A learned response - reinforced for the the acceptable boundaries is then in their social skills and self-care. Impaired most common reactions include depression person in their environment danger of being excluded. People with an control may be displayed in a number and anxiety. Some people can experience • The inability of many to control their Acquired Brain Injury (ABI) may ‘break the of ways including impulsivity (acting first a catastrophic reaction to their losses such behaviour due to the direct effects of rules’ associated with: and thinking later), verbal and physical as anger, fear, helplessness, suspiciousness their injury. • How close to stand to other people aggression, increased/decreased libido, and paranoia. Some people with ABI may financial irresponsibility, alcohol and lack trust in other people and become Responding to Challenging Behaviour • When it is appropriate to interrupt drug abuse, poor frustration and stress suspicious about their actions and ideas. In Effective responses to challenging behaviour another person who is speaking tolerance, impatience, restlessness, and a some cases, this leads to the development rarely happen by chance. A successful • When and how to show emotions lack of mental flexibility with the need for a of paranoid tendencies in which the person strategy will require a disciplined approach • How to interpret and respond to highly structured and routine environment. has fixed beliefs and acts in a guarded and that coordinates and implements a number nonverbal communication Common emotional difficulties, such secretive manner. of steps. The steps for responding to • What parts of a person’s body may be as depression and anxiety may lead How others respond to these behaviours challenging behaviour require the people seen naked or touched to challenging behaviours such as will be an important factor in the successful involved to: • When to speak and how to get a withdrawal and avoidance. Increased rehabilitation of the person, as well as • Observe and measure behaviour point across. dependency, which may be related influencing the quality of life of family and • Identify the causes of behaviour to emotional problems, may also lead friends. It is important when challenged by In the early stages of recovery these • Develop realistic expectations about to increasing demands for attention a person whose behaviour has changed problems may not be obvious. Long-term change and how to measure the results from caregivers. as a result of an ABI, to keep the emphasis irreversible brain damage sometimes • Identify and evaluate possible approaches It is not uncommon for people with ABI on behaviour rather than personality. This occurs, however, resulting in specific and strategies for change problem behaviours. to experience a lack of insight into the helps to: • Develop a behaviour management program nature and effects of their injury. This may • Maintain a greater sense that change Types of Challenging Behaviours lead to feelings of frustration; particularly is possible • Implement the program consistently Impaired social behaviour is often if they are forced to rely on others to • Specify what is happening in clear and • Monitor progress and review evidenced by childlike behaviour, do things they might normally do for concrete terms • Maintain gains and make further progress.

‘Stages of change’ model in drug dependency Decision stage requires constant attention and vigilance from the person. In this stage the person has made the decision, to change, and You can support them by working with them on plans to minimise People experiencing drug problems typically go through a series of stages in dealing with is considering how they should go about it. They need to develop risk of relapse and expressing your faith in them to manage their their use. By recognising what stage someone is in, we can respond in a way that is most an action plan and prepare for how they are going to carry it out. own life. Recognise and support the other important areas of their appropriate to that stage. You can help by talking to them about what they want to do and lives as well – work, studies, hobbies, relationships and so on. exploring the different options available. Pre-contemplation Contemplation Relapse The person does not want to change or won’t accept they have The person is thinking about making changes to their drug use. Action This is where the person falls back into an earlier pattern of drug a problem. Because someone in this stage has no intention In this stage, someone is in the early stages of uncertainty, and This is the stage where they carry out their action plan. This plan use behaviour. This can be very discouraging for family members, of changing their drug use, threats, ultimatums and external they are starting to be torn between the desire to change and the could involve entering into treatment, changing their environment, but patience is needed. On average, illicit drug users go around pressure to change not only have no effect, but can also result desire to stay the same. They are weighing up the pros and cons, or reducing or ceasing their drug use. Their action plan may not this cycle seven times before finally making a lasting change! A in reactiveness (digging their heels in and becoming even more and start to consider change. necessarily mean abstinence from drug use. Helpful responses brain injury with impulse issues, of course, makes relapse even determined to keep using). You can help them to explore more fully their thoughts on their can be to recognise any action as being positive, don’t focus more likely. Helpful responses can be keeping communication open, but drug use, but try not to indicate one way or the other your on the negative if they slip back, and encourage their belief that You can support your loved one by not panicking. See relapse not discussing the need for change. It can pay to focus on harm preferred choice for them. Acknowledge that just starting to change is possible and well within their capabilities. as a short-term obstacle, not a waste of so much hard work. minimisation with their existing drug use – if they’re going to use, consider change is a positive step and reinforce this. Maintenance Encourage the person to see this as a mistake that can be how can they do it most safely? Contact your local Brain Injury Association for referral to agencies who can help with information The person now has to work to maintain the changes to their life, learned from, not a sign that this situation is impossible. Focus on on harm reduction. and avoid slipping back into the “old way” of doing things. This the positive changes already made.

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questions to ask when formulating brain injury, the people around them, Steps to independence a response to behaviour and the environment. Some of the most commonly used and successful • What are the different challenging behaviours displayed by the person? approaches are outlined as follows: As one reaches adulthood, independence is a natural goal. However, to resume an • Which behaviours will be focused upon initially? • Modify the environment or routine independent lifestyle safely after a brain injury, independence should be approached • What pattern has been observed for each target behaviour? • Give feedback about the behaviour • What seems to cause or contribute to the behaviour? • Motivate the person to change in stages and based on the person’s recovered physical and cognitive abilities. • What are the expectations of change (individuals versus family member or carer)? • Reward and acknowledge desired • How will change be measured? behaviour or some people with severe monitor and assist the person. • What are the possible approaches and strategies for change? Neuropsychological assessment • Change expectations and demands cognitive deficits, achieving • What level of control and participation can the person with a brain injury have? A neuropsychological assessment is a Recreational activities are good for • Teach new skills and behaviours complete independence may be an F task-oriented assessment of cognitive reestablishing community involvement. • How will progress be measured and what outcome measures may be used? • Change how others react unrealistic goal. functioning and the key piece of Whatever services your family member • How will gains be maintained and generalised over time? • Psychological support Determining when it is safe to let go after information that will help determine the decides to participate in, ensure the • Can further progress be made by extending the program to different behaviours? • Medication. brain injury can be a heart-wrenching extent of assistance a person may need persons in charge know the person’s impairments and the extent of help he/she Develop a behaviour management decision for families. All too frequently, to function in society. Many people injured will need to participate effectively. Your local program families expect that discharge from a as a result of acceleration/deceleration Brain Injury Association should be able to Key questions in developing a behaviour hospital or completion of a rehabilitation forces experience damage to the frontal put you in contact with these services. Observe and measure the behaviour identifying immediate and delayed management program include: program indicates the person is “well” lobes. Damage in this area usually results reactions following the behaviour or “cured”, however most people will in a reduction or loss of ability to: exercise During this initial assessment stage the • What are the behaviours to address? The importance of appropriate main aim is to get a clear understanding from both other people and experience some ongoing problems good judgment; reason things through; • What is the pattern of behaviour? identification of the specific behaviours that cause the environment. ‘What outcome is with cognition. There is a delicate problem-solve; inhibit inappropriate With each step toward independence, it concern. Each challenging behaviour may achieved by the behaviour’ • What is the goal for change? balance between protecting a person behaviours; organise and structure • Which steps will achieve the goal? time; control impulsiveness; and becomes more important for the person require a different strategy. It is important Develop realistic expectations and from potential harm and promoting an • How will change be monitored? follow through with tasks. to prioritise which category of behaviours measure results opportunity to attempt independent will be addressed first. Measuring the • Which approach(es) will be effective? Setting realistic goals for change involves: actions and learn from the results of If a neuropsychological behaviour involves questions such as how • How can the person with the Acquired their efforts. assessment was not • The degree to which the behaviour/s often and where does it occur, how long Brain Injury have as much control and completed in conjunction may be eliminated, reduced, increased does it last and how do people react to it? participation in decision-making, as Involve family in rehabilitation with a rehabilitation program, or influenced their capabilities will allow? It is helpful for family members to witness school systems, vocational Identify causes and influences of • How long the behaviour has been first-hand how deficits impact on the rehabilitation agencies challenging behaviour • Who will implement the plan? present (before and after the injury) person’s ability to perform certain tasks. and other state-supported The causes or influences of challenging For all carers and family members • The person’s capacity to control the It also prepares the family to assume programs may be a good place behaviour may be divided into individual involved in the program, a consistent behaviour their role as the support system once to start looking for ways to obtain factors, environmental factors and factors approach is often the most significant • The person’s level of insight rehabilitation is completed. this information. related to people. Severe behavioural factor influencing success. The • The person’s level of motivation difficulties may require assessments expectations of behavioural change also People with a brain injury often function Watch for increased awareness • The environment conducted by professionals. These need to be clearly defined and realistic. best within a structured environment. and gradually let go • The ability and willingness of others to It may not be possible to change all It is important for everyone with whom assessments will help provide insight Some people with frontal lobe damage assist with strategies behaviours at once, or in all situations. the person interacts to be aware of into the person’s level of cognitive and lack awareness about their own • The ability and willingness of the psychosocial functioning, the effects compensation strategies used for deficits, impairments and may take unnecessary person to cooperate with other people. The Right to Stay the Same of the brain injury, the impact of the as well as the need to reinforce those risks affecting safety. Over time this It is important not to lose sight of the environment and the influence that mental Behaviour should be measured prior to strategies on a consistent basis. Ideally, may change and increased insight may illness may have upon the behaviour. To the intervention to provide a ‘baseline’ person’s rights. In spite of all the best the person should not use stimulants intentions, the person concerned may not create a negative reaction to the new make sense of what causes or influences against which progress can be compared. or depressive agents after a brain injury self. Although this change in awareness the behaviour, the antecedent, behaviour, The period of time spent measuring the want to alter their behaviour. If this is the due to the exaggerated effect these case, then they have the right to behave can be a positive sign of improvement, and consequence (ABC) model can behaviour needs to be long enough to substances have on the injured brain. It in a way that challenges the norms of the dealing with it emotionally can be quite be used: provide a representative view. is much easier to monitor and prevent community. People cannot be punished challenging. Families must be alert to these the use of addictive substances than to • Antecedent - examines what usually Identify and evaluate possible for their behaviour unless it is by the law. changes to prevent self-injury, disruption deal with them after they have become a happens before the behaviour, and approaches and strategies for change Neither can they be restrained against of cooperation and/or increased demands troubling issue. particular triggers or events that may There are many different approaches their will or forced to conform to another for independence. set off the behaviour and strategies to encourage people to person’s rules without consent. The Additionally, family members should It is helpful to gradually establish some • Behaviour - examines what happens change their behaviour. The suitability excuse ‘It is for their own good’ is not consider the need for guardianship safe activities for the person to manage during an incident and effectiveness of each option will sufficient reason to deprive another citizen and familiarise themselves with these independently like a program at a local • Consequence - analysis involves vary according to the person with a of their rights under the law. protective tools. gym where there are staff trained to

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rehabilitation tips to carry proper identification at all times. on a stationary bike. After the person has to interdependence and, for many, With rehabilitation being so important after a brain injury, are there ways to In the event of seizures, ensure that the been evaluated getting on and off safely, complete independence. Focusing on person has information in the form of a allow him/her to progress to a two-wheel what a person does well is an enriching maximise the amount of recovery possible? bracelet, necklace and/or wallet card bicycle and — using good protective experience for all family members. When that accesses medical instructions. If the equipment such as elbow pads and letting go is a safety issue, it often is hile there is no cure for brain gentle encouragement the theme to similar problems, and together solutions person could become lost then maps or helmets —allow him/her to practice skills best to err on the side of caution rather injury, the brain does have some home rehabilitation. are often found. The person also feels a record of the address should be carried in a relatively “safe” area with footpaths than relinquish too much control too capacity to repair itself and less alone – a sense of belonging is very at all times. and grass in the event the rider falls. early. It is important to keep in mind W Memory prompts that independence is not a virtue and rehabilitation is crucial to recovery from – important to those whose lives have been Plan failures when applicable Conclusion dependence is not a vice. it uses both your body’s natural healing If the person is constantly faced with dramatically changed. They also greatly abilities and your brain’s ability to relearn. situations in which they have no recall and influence the carer’s ability to support the Sometimes it can be helpful to support Finding the proper balance between It is easier for the family to be in a position Rehabilitation also means learning new those around are constantly mentioning individual often increasing understanding control by the family and gradual the person in an activity where there is of control at the onset of the community ways to compensate for abilities that have this lack of memory, it may eventually and providing an outlet for frustration. relinquishing of control are the stepping concern about safety. Denial — whether re-entry phase of recovery rather than permanently changed due to brain injury. cause an erosion of self-esteem. Create organic denial or lack of awareness of experience a sense of failure when the stones to greater independence, with some strategies to compensate for this Get involved one’s deficits — can be a persistent person with an Acquired Brain Injury is many families finding the journey can be Attitude problem by developing lists, post-it notes, During the rehabilitation process, try to be a satisfying partnership. problem. Sometimes it is useful to take unable to resume his/her exact pre-injury Those who make the most of their or cue cards. These strategies can help as involved as possible, ask questions, risks to reach a goal. For example, a lifestyle. Gradual re-entry can provide a Permission to adapt this article has recoveries tend to have an optimistic the individual feel more independent, less attend family conferences and learn all person with balance problems who measure of safety and protection that been kindly granted by the Brain Injury outlook, are usually more giving and likely to make mistakes, or feel nagged or you can while your family member is in a wants to ride a bike again can start off can move the person from dependence Association of America. selfless, and don’t tend to give up easily. scolded. structured setting. You know your needs Even if this isn’t your natural personality, Familiar settings best. Your rehabilitation team needs to hear this is the perfect time to develop these your opinions and concerns. A brain injury often creates difficulty traits! Those who do the best usually look learning new information and generalising Make sure you are provided with a sound upon negative experiences as a chance to SHOULD I LEAVE MY PARTNER? new skills from one environment to and realistic discharge plan. Once home, grow and develop themselves further. don’t sit back and assume everything Partners can be the unseen victims as they struggle to cope with the effects of their loved another. The most effective rehabilitation People with a brain injury often say occurs in the home setting where old will automatically fall into place. Establish one’s brain injury — struggling with anger, dependency, grief, overly direct communication, a routine (structured environment), egocentricity, or simply the stress of looking after the kids and their partner. rehabilitation is the biggest challenge of learning is maximised. When injured their lives. While you may never get back people are transported to another city or consistently enforce the discharge plan, So often, underlying these issues lurks the It’s still no good! to ‘normal’, the good news is there is no state, much of what they learn cannot and make sure that your family member has question of whether they should stay or People rarely make the decision to end limit to the extent of your rehabilitation. be applied when they return home. The control over those aspects of their life that go. It pays to see if you have tried all the a relationship flippantly. It usually only How far you get depends on how much familiar cues which facilitated recall in the are safely manageable. treatment setting disappear and the new strategies available to make it work. comes after agonising guilt, depression, you put in, and even if improvement is Injury prevention frustration and having tried every option painfully slow remember progress is better behaviour cannot be elicited. Strategies worth trying One brain injury can make you much more to make it work. When confronted by than staying where you are. Never underestimate the impact of Feedback on behaviour susceptible to further ones. Some of these constant aggression, the decision may be relationship counselling, especially when Structure People with a brain injury have enough added traumas occur because of the relatively easy. Often the individual with both people acknowledge there is a problems without increasing their burden cognitive and behavioural deficits following the brain injury is apologetic, however, Most of us lead highly structured lives: we problem and want to do something about by accepting any and all behaviour. If the original injury. The impulsive person who trying the best they can to improve - awake, sleep and work at the same times it. Unfortunately, self-awareness is often a family members tolerate behaviour which has poor judgment may repeatedly place although the relationship may still not each day. This kind of structure allows casualty following an injury. If your partner drives others away, the injured person himself in dangerous situations and then work any more. us to put most of our lives on automatic does not acknowledge the cognitive pilot and reserve creativity, memory, and may become increasingly isolated from be unable to cope. Apart from supervision human contact and the burden on the effects of the brain injury, counselling But what about my partner? novelty for more important areas. After another useful tip is to avoid: caregiver can increase. Try to provide will probably only help you to learn When a partner leaves, the person with a brain injury, a person’s life often has • Exposure to toxic materials accurate and realistic feedback on adaptive strategies. the brain injury may react in a number no structure. Tight structure reduces the • Alcohol behaviour and its consequences. Try to see how you are part of the of ways. In some cases, there may be need to continually make decisions, vastly • Nicotine problem. Remember it takes two to choosing to make life difficult for you. threats or physical violence which cannot increases capabilities and significantly Support groups • Stimulants and other recreational drugs You must adjust your expectations of your be tolerated in any circumstances — you tango! Even though you may be doing it reduces the demands placed upon Support groups play a vital role in the Hopefully this information has been useful may need to obtain a restraining order. tough, some of your reactions could be partner for this neurological disability, as the caregiver. lives of people with brain injuries and their to you and you will begin to think about contributing to the problems. Relationship you would for a physical disability such as A point to remember is that there are Upon discharge, try to develop a families. This will be especially so when rehabilitation in terms of cognition and issues usually trigger our own insecurities cerebral palsy. always options available. Some may schedule that includes as much activity the person completes rehabilitation and behaviour rather than medical and physical and you may need to look within yourself Get support. Use respite services. Get continue to live with their partners to as your loved one can handle without finds that life is changed in ways that problems. People who have sustained at how you need to change too. into a support group and talk to others. provide support, but make it clear that becoming too tired. Remember that the person and the family find puzzling head injuries have a great deal to offer to Get educated on the effects of brain Call your local Brain Injury Association for the sexual and romantic relationship fatigue, initiation and motivation are often or difficult to manage. Groups enable family, friends, and society if they are given injury. Remember, your partner is not further information about support groups. is finished. big problems after an injury, so make the person to identify with others with a chance.

62 Synapse | © Brain Injury Association of Queensland | synapse.org.au synapse.org.au | © Brain Injury Association of Queensland | The FACTS 63 Rehabilitation issues “I know I should Rehabilitation issues be happy. I'm one of the lucky ones. A mild brain injury, “The crash came three years later. I'd always a big recovery and been a really positive person and I threw I'm even back at myself into rehab. The doctors were amazed work, my family is at how well I did. Even after two years I kept The post-rehab slump supportive and most working on new strategies, although my brain of my friends still had ceased to improve at that point. Then hang around. But suddenly I couldn't be bothered any more”. People with a brain injury often make excellent recoveries through positive attitude, hard I've lost big parts of me forever. A year work and family support. Once formal rehabilitation is over, however, there may be a after discharge the slump, leaving them trapped in a spiral of depression, despair and suicidal thoughts. loss hit me and “I tried to kill myself last year, and my family I've lost the plot got me to counselling. I don't think it's helped since then”. – there's just no point really if I can't work or have friends. During my rehabilitation I was he major reason for the post-rehab this is the point where the limitations of progress. Some describe the new self pretty positive about the future but there's slump is often psychological. the injury are often apparent. as a stranger living in their skin, and nothing now. This is it. No more improvement”. TThe person with the brain injury knowing that this will not change can be is told that a positive commitment to Where to from here? hard to accept. The brain injury itself can rehabilitation will maximise results. This No matter what the new goal is, it will add to the impact of this disappointment is a clear goal, and more importantly it is often be limited by the effects of the brain as anger, depression and intolerance of usually easy to see the progress resulting injury. Employment may not be possible, stress are often much harder to handle from hard work. or only on a drastically reduced level. Any post-injury. big project may prove difficult due to the The brain does its best to heal itself to impaired ability to plan, concentrate and Accepting the new self a limited extent for a year or two after remember. Goals involving social activities Those who have done well in their the injury, which contributes to a sense may be hampered by reduced self- recovery can find this plateau phase of progress. Even beyond this point, confidence, social skills and energy levels. difficult to accept. In a way this is the improvement can still be made by working final stage of rehabilitation and often the the roses'. Wrestling with depression A spiritual approach or commitment to What the family can do on strategies that will compensate for Who is this stranger? hardest. Coming to grips with a new gives an insight into the pain and suffering self-improvement may be the key for Families can help their loved one by putting cognitive deficits – memory prompts, Particularly for those who have done well identity and even learning to appreciate it of others. others. Each cognitive deficit is seen as strategies in place to avoid or lessen the anger management, pacing and relaxation is a very difficult step, and many people an opportunity for self-growth and further in their rehabilitation, this new self can Some survivors have made sense of their post-rehabilitation slump. Work with them techniques. be very difficult to accept. Despite being are unable to make it. development, not just as a disability. experience by seeing how they can help on developing new goals and activities Inevitably there comes a point where told things will never be the same again, Remarkably, people often find that before rehabilitation tapers off. Contact For some, the answer is focusing on others. They may attend or even initiate a visible progress tapers off, and it is there is still the secret hope that possibly a positive attitude. Cognitive deficits even many years post-injury, they still your State Brain Injury Association for support group where they can share their apparent that this is as good as it gets. enough hard work during rehabilitation are viewed in a different way to see the gradually improve in some areas with this support groups and activities that may exist hard-won lessons with others, or write The survivor has been focusing so much may make good things happen. Being strengths that can arise. An inability to approach. Some even come to appreciate in your area. A counsellor can also help the of their experiences. For those who can of their time and energy on this goal of confronted by the reality of this new self work means opportunities to develop how a brain injury has made them a more individual with ABI with their new identity. recovery, and now it has been reached. can then be a crushing disappointment hobbies such as art or gardening. Lack of work, an option is sometimes casual work thoughtful, stronger person because of As one person put it, "For survival we must The logical step is to set a new goal, and after many months of measurable energy means taking more time to 'smell supporting others with a brain injury. the many challenges they have faced. let go of what was, in order to become what we will be".

ALTERNATIVE MEDICINES and healing. Examples of Alternative Therapies can include, for use with children who have ADHD; all free from the negative but are not limited to: Meditation, hypnosis, spiritual healing, side-effects often resulting from conventional medicine (e.g. Alternative Medicine is exactly as it sounds: an massage, chiropractic, herbal supplements, homeopathy, cardiovascular issues, psychiatric symptoms, and even cancer). alternative to conventional medicine. naturopathy and acupuncture. Alternative Therapies can also This doesn’t mean there are no side-effects, however, so always While conventional medicine is supported by scientists and pharmaceutical include widely accepted practices such as nutrition, exercise, research. Is important to assess the potential risks of the therapy companies, alternative medicine (also referred to as “Complementary and and relaxation. objectively, to ensure the safety of the individual. Alternative Medicine” (CAM) or Alternative Therapies) is not endorsed in the Alternative medicine can often be misunderstood on initial Claims of a miraculous cure should also be viewed with same way. Most Alternative Therapies have existed for thousands of years, and presentation. The statement “Tai Chi cures illness” is controversial caution. They have been known to occur, however usually as many have been passed down from cultural groups the world over. and unbelievable initially. When you look, however, at the fact that a result of enormous amounts of time, effort, money, or unique Many treatments that were once classed as/or considered alternative have Tai Chi is a very effective way to improve balance, coordination, circumstances. now become ‘mainstream’. Putting mouldy bread on wounds was once just strength, flexibility and cardiovascular fitness - you can a housewife’s remedy until the antibiotic penicillin was identified. Vitamins understand how it may now affect illness. Having a healthy body It is very difficult for science to evaluate quality of life. Even when were found to cure scurvy and other previously unexplained illnesses, and the improves the immune system which in turn fights off illness - so there is a limited medical benefit from a therapy there may be acidophilus cultures commonly in supermarket yoghurt are now recognised as Tai Chi then affects illness in an holistic way. a very real benefit to the patient from the sense of purpose, a major component for intestinal health. The main benefit of Alternative Medicine/ Therapies is often the satisfaction, or hope that the treatment can provide. So proceed People who seek Alternative Medicine are often those who are opposed to lack of potential negative side effects. Massage and “green” or with caution, but don’t discredit something before you think synthetic pharmaceuticals, and who prefer a more natural approach to health nature therapy are examples of effective Alternative Therapies about what it can do for you and your family.

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Family guide to a low cost

Commonwealth Rehabilitation Service can rehabilitation program assist in exploring vocational options and getting back into the work force. Your family member is discharged from hospital and you are ready to continue their Step 3: Monitor progress and update as needed rehabilitation. The steps listed below may serve as a guide if you wish to develop a As the program progresses, you should find that the person’s cognitive and program using free or low-cost resources which exist in your community. to ensure that behavioural goals are practices, and including your family and physical endurance, performance speed, not all negative, e.g. designed to stop loved one in their group. This can take and skills are steadily improving while range of community services, many of the community each day. behaviours. You must balance behaviours time and education sessions (speak Step 1: Obtain detailed the demands on your time are steadily which are paid for by your tax dollars, to be stopped with those you wish to to your local Brain Injury Association), objective information Basic cognitive goals: People who have decreasing. You must be able to fade are available in most communities and see started so that the person is not left however may be more advantageous in sustained brain injuries are frequently yourself from the picture at appropriate The injured person: Since research are appropriate for people who have with a behaviour void. Your behaviour the long-term. extremely distractible and can often have times, even when you are not completely has clearly demonstrated that the most sustained brain injuries. Most of these management program should utilise limited ability to attend to and concentrate Academic goals: Some people with a sure the person can perform the activity disabling consequences of brain injury agencies do not advertise; many are appropriate rewards to encourage the on tasks. Until attention and concentration brain injury may be able to successfully without your help. As the person’s are cognitive and behavioural, information not aware of the special needs of those person to behave in more positive ways. are improved, community-based activities enrol in academic programs once their skills improve, you must make certain about the person’s current level of who sustain brain injuries and how their may be problematic. At this point in time (if you are not basic cognitive and behavioural deficits that your expectations rise so they are functioning in these areas is essential if agency’s services might be utilised by already doing so) you should begin to have been remediated or despite commensurate with his new abilities. a realistic program is to be developed. this population. Think outside the box Initial cognitive retraining activities should give honest, objective feedback to the remaining deficits. The line between When indicated, set goals at higher levels. You need specific information on things and don’t be afraid to approach these probably be conducted within the home injured person on specific maladaptive rehabilitation and education begins to blur The myth of the plateau, which suggests such as how much can be learnt, what community services for assistance. setting. Appropriate activities might behaviours and your reactions to them. at this point, especially when the courses that people who sustain brain injuries is the best way to learn, what activities include working on craft projects from Step 2: Develop and implement books in the public library, playing simple Although such direct oral feedback is not or subject areas had not been attempted reach a certain point in their recovery and are most likely to present problems, what customarily given in most social settings, prior to the injury. then stop making progress despite the limitations there may be perceptually, and your program board or card games, or playing simple video games. Since pre-injury information the injured person may not understand If you are considering including a formal best rehabilitation efforts, must also be how you can set things up to maximise Now you are ready to set specific and skills are frequently relatively intact, why he fails to make friends unless he is academic component, you should challenged as your program progresses. abilities. Your rehabilitation program rehabilitation goals. Since you are the person may be able to play games provided with such information. determine whether the person can keep When progress appears to be levelling off, must also take physical limitations into designing your own program, you are it may be useful to think of that time as a which were learned pre-injury (such as Social/recreational goals: One of the track of class times, take notes, study for account. In addition to general information free to include only those activities which period of consolidation of newly-acquired checkers or poker) without having to learn most frequent complaints voiced by an examination, and learn the information about the person’s medical status and you feel will be helpful to the injured skills, a time for the repeated practice new rules. At this stage, the ability to learn presented. Also to be considered is physical abilities, thorough evaluation person and for which you have the time, people with a brain injury is the lack of having to deal with transportation to the which is required to integrate the new of both visual and auditory systems resources and energy to follow through. is not being addressed, only the ability to friends and social opportunities. The campus, locating a specific classroom or information and skills with the old until should be completed. Management of attend and concentrate. reasons for this are varied but physical Certain problems occur often enough dealing with distractions in the classroom. they become as routine as possible. medical needs must be an integral part While such activities may initially require limitations, behaviour control issues, that the broad areas which must be Speak with the campus’s disability At some point in time the injured person of the rehabilitation program. Adaptive a quiet distraction-free environment, the decreased cognitive capacity and poor addressed can be identified even though service. Most will have one and they can and/or family members decide that they equipment such as a wheelchair, braces, amount and type of distractors should be social skills are often major culprits. In specific activities must be decided by generally offer services such as note- no longer wish to pursue rehabilitation. and communication devices, must be increased as attention and concentration many cases, the person may lack insight family members. Among these common taking, recorded lectures and one-on-one On rare occasions this occurs because appropriate to the person’s current needs improve. The amount of consecutive time into the nature, range, severity or even the areas, and in chronological order of tutorials to assist. all goals have been met; usually other and in good repair. existence of deficits following the brain importance, are: devoted to such activities can also be injury and may seem generally unable Vocational goals: Some people with factors such as extremely slow progress, Your support system: Family members gradually increased until the person is Survival skills goals: Those activities or unwilling to modify his/her behaviour. brain injuries may recover sufficiently to the wish to pursue other activities, or must objectively decide how much time, able to continue at the task for a realistic which have the highest survival value This could be the case even in the face return to either sheltered or competitive burnout account for this decision. The money and emotional energy they will amount of time. (daily routines such as showering, of interpersonal cues which are not at employment; others will be able to fact that a structured rehabilitation be able to commit and how long they grooming, toileting, dressing, sleeping Basic behavioural goals: When the all subtle. Once the person’s behaviour contribute to their communities in program is no longer in place does not will be able to do so. This includes such and eating) should receive concentrated person is able, at least at minimal levels, is positively altered in the home setting, volunteer positions. Many people necessarily mean that the injured person factors as who will provide transportation attention in the initial phase. Goals should to attend and concentrate, to learn, and community recreation activities are often will be unable to pursue vocational will stop acquiring or refining skills, or that to activities, supervision in both the deterioration will occur, although both are address the mechanics of completing to remember, behavioural contracts can introduced in the rehabilitation program. goals because their salary would not home and the community, and what certainly possible. The long-term success the task as well as the amount of time be used to reduce the frequency and Your local brain injury association should compensate for government or private materials will be needed. An organised of your program may be contingent upon required. Goals in this area have been severity of specific targeted behaviour have a list of recreation programs set sources of disability income and/or program requires the effort of more than continued effort on the part of all family accomplished when the person is able to problems such as verbal aggression, up for people with disabilities. Don’t be benefits. People who are not eligible one person - unless it is undertaken in members, especially the injured person. awaken on his/her own, independently perseveration, or social skill issues. limited by disability programs, however. If for benefits may have to attempt to extremely small and manageable steps. complete his/her morning hygiene routine, Information about behaviour management you feel able, reach out to other recreation return to work if they wish to live above Many thanks to Judith Falconer Ph.D. for Community resources: This is definitely and prepare and clean up after eating; strategies can be obtained from your programs in your community - try your bare subsistence levels. If and when permission to adapt this article from her the time to start ringing around. A wide they should be dressed as if going out in brain injury association. It is critical hand at opening their eyes to inclusive re-employment is a realistic goal, the website at: brain-train.com.

66 Synapse | © Brain Injury Association of Queensland | synapse.org.au synapse.org.au | © Brain Injury Association of Queensland | The FACTS 67 DOES HOMER HAVE A BRAIN?

Homer Simpson is Rehabilitation issues possibly the world’s Rehabilitation issues best known cartoon character. He is also the most likely to be suffering from acquired brain injury. He has been hit in the head with Steps to a countless objects, landed on his head repeatedly as he fell down a ravine (twice!) and became a boxer when it was discovered he healthier brain could be repeatedly punched in the head without being knocked out, winning by default as his opponents wore themselves out and collapsed. It doesn’t take a neuropsychological assessment to fatigue and immune suppression, along to see that Homer exhibits most with memory, concentration and mood of the classic symptoms of a disorders. Optimal learning cannot take brain injury. There are the anger place against a background of poor sleep. issues as he is constantly choking his son, Bart. He has a raging What can you do if you can’t get to sleep? alcohol problem, with too much The most common causes of difficulty are time spent at Moe’s tavern, and not being able to shut off the anxieties impulsivity with his tendency to and worries of the day and preparing for do anything to get his hands on tomorrow’s problems. One useful strategy is donuts. preparing for sleep: What about his memory problems • Don’t take one last look at email - always forgetting they have a messages third child, Maggie? Or lack of • No phone calls or activities after 9 pm attention as he repeatedly ignores • Don’t go to bed until you feel sleepy Exercise and challenge your brain Nourish your brain with a or afternoon, eating a snack containing are much more susceptible to acquiring danger alarms as safety inspector • Don’t have caffeine after 12 noon. sugar, such as fruit, can solve the problem. another one. at the nuclear power plant? What Like our body the brain needs exercise. healthy diet of his rapid changes in mood, Blood pressure, diabetes and Practising skills leads to better Like any high-performance machine, the As a general rule, good nutrition for the Manage anxiety, stress inability to cope with multiple cholesterol performance whereas unused skills often brain needs top quality fuel – a well- body is good nutrition for the brain. and depression demands, low motivation and If you have diabetes and high cholesterol, deteriorate or are forgotten. Ongoing balanced, low cholesterol, low saturated Enjoy physical activity Anxiety increases heart rate and blood inappropriate social behaviour you have 4 times the risk of stroke. If you mental stimulation has been shown to (animal-fat) diet. Timing is significant Exercise daily if possible by setting exercise pressure which can lead to stroke. and hypersexuality? have only diabetes you have twice the risk provide some protection against mental as studies have demonstrated the priorities and sticking to them. Regular Acute stress, such as the “flight or fight The strange thing is he still has of stroke. Experiencing many mini- decline. Challenge the brain by trying importance of a good breakfast. exercise reduces depression and reduces reaction”, is normal and short-lived. plenty of friends, despite his can lead to dementia in later life. things you don’t already do, such as Not all fats are bad for you in the right cardiovascular risk factors, even a simple There is increasing evidence that many issues. Unfortunately, the studying a new language. Challenging quantities. Unsaturated fat and protein are Avoid alcohol and other drugs if walk lets you think freely. stress actually damages the brain. The Springfield community does tend creates new pathways that can sometimes especially important for developing brains. to show a lot more understanding possible Some exercise states may produce hormones linked to stress can actually kill become alternate routes when neurones Fish, a rich source of both, is sometimes and compassion for Homer’s Alcohol and other drugs affect the central euphoria, but even 12 minute bouts nerve cells in animals and are thought to die off in middle and old age. Just called brain food. Your body converts eccentricities than the real nervous system and in varying degrees, of exercise (to 85% maximum heart do the same in humans. remember if you have a brain injury to long strings of amino acids in the protein world does for people with a impair a person’s ability to think clearly and rate) release serotonin, dopamine, The steps you take to reduce stress are take on tasks that are realistic. If you have you eat to individual amino acids that your brain injury... control emotions and behaviour. These and noradrenaline that can act like likely to preserve nerve cells and help trouble with judgment you may need to brain converts to the specific proteins abilities are often impaired by an Acquired antidepressant medications. maintain mental abilities which is crucial if discuss it with others first. it needs. Brain Injury and therefore when people Exercise in the evening after a stressful day. you already have a brain injury. So how can you exercise and challenge Your brain needs vitamins and minerals • Ensure a balance of work and use drugs and alcohol they are likely to Take exercise opportunities like using stairs One of the toughest stresses is your brain to reap the benefits? that only come from a balanced diet. In recreation experience even greater problems with particular research suggests the anti- instead of elevators. depression. It affects memory, slows brain alertness, memory, problem-solving and Exercising the brain is doing anything • Take time out for yourself oxidant vitamins E and C can protect metabolism and can lead to some degree controlling their behaviour and emotions. that makes you think, such as “what Make “safety first” a priority Visit your general practitioner if problems the brain. of brain damage. Some strategies for did I do last Saturday?” Many thanks to Brain Foundation for their Brain trauma is the invisible disability. coping with stress are: persist past this. Avoid excess food. Reducing calories kind permission to condense an article Some possibilities are: The major causes of adult head trauma • Meditation can help slow age-related brain changes. are motor vehicle accidents, on-the-job Relax and sleep well from Brainwaves, Newsletter of the Brain • Avoid using calculators If you must smoke, or drink caffeine and accidents, falls, assaults and sports injuries. • Relaxing by actively tensing then During deep sleep, the brain repairs itself Foundation, Autumn 2003. You can visit • Swap TV for mind games or a book alcohol, do so in moderation. Take common-sense safety precautions relaxing individual muscle groups and boosts the immune system. During their website at: http://www.brainaustralia. • Play games that involve memory (bridge) Glucose is the fuel needed to keep the including wearing seat belts and sports • Channelling internal stress into external rapid eye movement (REM) sleep, the org to read the complete article and a wide or thinking ahead (chess) cells alive and functioning. When your safety helmets as appropriate. Remember action through exercise brain consolidates information learned range of other information at • Take up a new hobby. concentration wanes in the late morning that if you have an existing brain injury you • Let go of things outside your control during the previous day. Poor sleep leads [email protected].

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Neuropsychological Potential future assessments medical problems A person with a brain injury will usually Carers and family members are in a unique position to spot undergo a neuropsychological assessment medical problems that may emerge after leaving hospital at some stage of rehabilitation.

The neuropsychological assessment is an amilies need to be alert to various evaluation of various areas of functioning problems and changes that may and is a standard tool used in evaluating Findicate the need for re-evaluation or rehabilitation in a hospital or a workplace. follow-up treatment. Problems developing It relies upon the use of standardised after the person is home and no longer testing methods to evaluate areas such as: involved in medical or rehabilitation settings may not be as readily recognised • Perceptual sensory and motor functions as a result of brain injury. Valuable • Concentration and attention treatment time can be lost if caregivers • Memory, planning and organisation are unaware of some possible medical • Emotions, personality and behaviour consequences of brain injury. • Language, hearing and sight Heterotopic Ossification (HO) • Problem solving The neuropsychologist will usually look at This is a secondary condition in which there is abnormal bone growth in selected case histories, hospital records and talk joints, most commonly in the hips, to family members to find out about the shoulders, knees and elbows. It usually person’s pre-injury personality and skills. conference can be very valuable for other tasks”). This important information can occurs within the first nine months of these functions may have been monitored How an assessment can help members of the family unable to attend help the family more effectively guide injury and is most often discovered by the Visual system changes physical therapist when limited or painful well in the acute phase of recovery, the A range of psychological tests is used the conference. and support the person and assist with Vision and visual functioning is often range of motion is seen. participants report five or more years later to objectively measure brain functions, activities that utilise the preserved abilities adversely affected by brain injury. A written report should be provided that they were experiencing problems including evaluations of language, and reinforce strategies that compensate Medication can slow the growth of the Families, vigilant at the bedside, are often following completion of the assessment such as weight gain, thyroid disorders, attention span, orientation, spatial for deficits. excess bone. HO, along with changes in the first to notice changes in the eyes, that can be shared with everyone involved changes in hair and skin texture and perception, memory, concentration, musculoskeletal system problems, such such as redness, watering and other in the support of the individual. The report Knowing your family member’s difficulties perceived body temperature changes. new learning, mathematical reasoning, as various forms of arthritis, osteoporosis, signs of a problem. A consultation is should cover case history and current can increase your effectiveness as a The women additionally complained of abstract and organisational thinking, and worsening spasticity (involuntary usually arranged with an ophthalmologist issues, the various tests conducted, caregiver and decrease the discord that chronic sleep disturbances, difficulty problem solving, social judgment, motor muscle stiffness) and dystonias (muscle and with treatment, the problem can be observations, assessment results and often develops when the family is not controlling blood pressure, a reduction abilities, self‑awareness and emotional problems causing movement disorders) brought under control. recommendations. aware of ways the injury has affected the Traditionally the occupational therapist in levels of immunity to infections and characteristics. warns of future problems that must be cognitive abilities of a family member. addressed. evaluates visual perceptual functioning arthritic complaints. Indications are that Possibly the most important outcome Benefits for the family These tests can be quite expensive due and teaches methods for compensating damage in the hypothalamus, limbic of this testing is the interpretation of The neuropsychologist should explain the Hearing loss to the time involved. Universities offering for any perceptual deficits. In addition, it system and pituitary may play a role in the results which are used not only person’s abilities that remain unchanged programs in neuropsychology often Hearing problems can occur for a is important that visual processing and these disturbances. as the basis of the treatment plan for as well as areas of the brain that are provide evaluations at low cost or sliding number of reasons, both mechanical visuomotor ability be evaluated. Some Most people with a brain injury are therapists but even more importantly adversely affected by the injury and how scale as part of their student training. and neurologic, particularly when the of the more common visual systems expected to experience a normal life for the person and their family. Once these deficits are expected to impact inner ear and/or temporal lobes have problems include double vision, field cuts, span, barring unforeseen circumstances; the neuropsychologist has completed upon the person’s life. It is helpful for Ideally a neuropsychological assessment been damaged. All patients should have sector losses, rapid eye movement and families can play a crucial role by keeping the scoring and the narrative portion of the neuropsychologist to be very clear should explain how damage in the brain an otoscopic examination and hearing nearsightedness. an eye out for any further medical the assessment, a meeting should be and informative about ways the injury affects the way a person with a brain screening followed by behavioural problems arising post-injury. scheduled with the person and family to will affect the day-to-day existence of injury thinks, acts and deals with life in testing. External bleeding in the ear canal, Neuroendocrine disorders discuss the findings. It is helpful to ask the person (e.g. “damage to the frontal general, in a way that can fully maximise middle ear damage, cochlear injury, Research suggests that chronic Thanks to the Brain Injury Association that the conference be recorded or bring lobes of the brain is expected to create the survivor's recovery and participation in and/or temporal lobe lesions can cause neuroendocrine difficulties can occur in of America for permission to adapt this a tape recorder with you. Taping the difficulties in planning and organising family, work and the community. auditory dysfunction. women some years post injury. Although article from their site at www.biausa.org.

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Brain Injury Association can give you laundry services and medication If money is available, it is possible to hire information on what is available. supervision. Many hostels cater for people lifestyle support workers to provide the with a mental illness and have psychiatric necessary support which may enable Long-term facilities support specialists visiting on a regular a person to live in their own home (or Most States will have facilities that care basis. There are few hostels set up provide carer respite). for people with a severe brain injury on a specifically for people with a brain injury There may be community health services long-term basis. In most cases, there are so they are frequently unsuitable or a who can provide free support through very long waiting lists and strict criteria compromise at best. The cost will usually personal care attendants, but there is a involved. An indication of the chronic be around 80% of the person’s pension long waiting list in most cases. shortage is that many younger people or benefit. with a brain injury wind up spending their Call your local Brain Injury Association to lives in nursing homes due to a lack of Public housing find out about lifestyle support workers, other options. Waiting lists for public housing are community nursing services or Home and generally long but may be worthwhile Community Care services in your State. Group homes for those with a permanent disability The most common examples of these who can live independently. The options Hope for the future are the homes set up in the community usually range from detached houses to Synapse has a range of Accommodation for people with a disability - with round duplex, town houses, and apartments Projects for people with Acquired Brain Accommodation options the clock staff supervising residents. or sometimes shared living. The relevant Injuries and Complex and Challenging Unfortunately they usually are not set up government department may be able Behaviours. These establish a continuum The lack of support and services for people with a brain injury is probably most for people with a brain injury. There may to provide help with rental bonds, rental of accommodation options from intensive be group homes that provide a basic subsidies and help with the cost of support in behaviour response units, to evident in the lack of accommodation options. level of support for elderly people which moving. There may be rental assistance small group homes, to individual units may suit people with a mild brain injury and other supports available for people with drop‑in support. who only need minimal support to live with a disability, as well as an application Synapse supports six small group homes independently. list specifically for accessable housing. brain injury can result in a range of • A single mother who can no longer danger of being evicted as he/she and a transitional complex consisting of accommodation issues. Frequent cope with her teenager’s behaviours can’t budget well enough to pay Hostels Own home with support a shared hub and four independent living Ascenarios include: and needs him/her to move out the rent. skills units. We are developing another Hostels are typically large houses divided Each State government will have its • Elderly parents can no longer act as • Parents unable to look after their Unfortunately, these scenarios are into small bedrooms which may be own eligibility criteria and application complex in cairns also, to facilitate full time carers due to health problems son/daughter who is about to be extremely common and in most states shared or single. There are usually on-site processes for people with disabilities. accommodation options for rural and • An individual with a brain injury with discharged and needs ‘round-the- there are very few options available. Any managers who provide differing levels Usually there is little money available and remote people in need. no support, about to be discharged clock’ medical care that do exist are usually in huge demand of supervision. Some will provide meals, people with a brain injury may find the For more information, click the supported from prison • A person with a mild brain injury in with very long waiting lists. Your local supervision of challenging behaviours, process difficult and unrewarding. accommodation link at synapse.org.au

YOUNGER PEOPLE WITH A BRAIN INJURY IN NURSING HOMES ACQUIRED BRAIN INJURY

Often, younger people with a brain injury are placed into aged care facilities as there are very Dave was hit by a car while riding a bicycle when he was five applicant, either during the trial or the sentencing proceedings”. few appropriate facilities available. years old. Three days later he was discharged from hospital. Dave’s disability was dismissed despite the neuropsychological assessment. Younger people with a severe brain injury may still be physically of residents with a brain injury. Challenging behaviours such His behaviour subsequently deteriorated. He found it difficult to fit, but are psychologically and socially debilitated with unique as disinhibition, verbal or physical aggression are often evident concentrate and keep up with his peers at school and was often Unfortunately Dave’s story is a common one. There is an over- and individual care needs that are not met by generic disability or following a Brain Injury and staff ate aged care facilities are often reprimanded for fighting, leading to suspension from school representation of people with Acquired Brain Injury in criminal aged care services. untrained in management of these. at age 15. At age 20, he received a sentence for a serious justice systems throughout Australia. Poor community and assault charge. There are many reasons why aged care is not suitable for younger There is a need for redress in the attitudes of society and service government recognition of this disability is replicated in criminal people with an Acquired Brain Injury. There is often a lack of planning provision for people below the age of 65 years with a Dave was introduced to illicit drugs and acquired drug justice systems to the detriment of people with Acquired Brain peer interaction for younger residents who may have nothing brain injury requiring long-term high level care. Further research is dependency problems which, in addition to excessive alcohol Injuries. As with the wider community, the justice system has little in common with other residents. Younger residents are usually needed on the views and experiences of younger people with an consumption, further exacerbated his anger management understanding of the devastating nature of Acquired Brain Injury more physically fit and stronger, and would benefit from intensive Acquired Brain Injury residing in aged care facilities and the views problems. At age 29, he was assessed and diagnosed with a as a disability. physical rehabilitation which is not available in an aged care and experiences of their families. brain injury. The Crown opposed applications to appeal against Advocacy services across Australia are working hard to make facility. Staff often identify difficulties with providing supervision, Adapted from Younger people with ABI in nursing homes at conviction and sentence on the grounds that there was no sure Dave’s case isn’t the norm. Speak to your local Brain Injury communicating with, and managing the emotions and moods synapse.org.au evidence of “psychological cognitive difficulties exhibited by the Association to find an advocacy service near you.

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INFORMATION FOR EMPLOYERS Returning to work Some employers have the One of the main hopes and expectations people have misconception that people who have disabilities are when leaving hospital is that they will return to the work Reasonable adjustments expensive to accommodate. or study they were involved in prior to the injury. Employers need to make a reasonable adjustment to the needs of a person This is not necessarily true. Adapting the workplace and introducing changes are with a disability. This means the employer must examine the physical and typically low cost and easy to implement. t is very common, however, for a strengths and deficits to provide organisational barriers which may prevent Simple modifications such as a handrail person to feel that they are ready to guidelines regarding employment the employment, limit the performance or reducing background noise can allow return to their previous position well potential. Sometimes a meeting can be I or curtail the advancement of people a person with a brain injury to manage before everyone else thinks they are. organised between the person who was with disability. their work environment better. When The individual’s unrealistic expectations injured, family members, the employer considering modifications for someone are often due to poor self-awareness or and rehabilitation professionals to discuss Wherever it is possible, necessary with a brain injury, it is important to denial. If a neuropsychological assessment a gradual return to work plan. A work trial and reasonable to do so, employers remember that this process must be took place during rehabilitation, this can may be organised to assess how well Some common recommendations for synapse.org.au, Information for are required to make modifications or conducted on a case by case basis - with provide some indications about the areas the person can cope with the demands returning to work include having plenty Employers, providing tips for employers in adjustments to the workplace to meet input from the individual. An Acquired of difficulty that will need to be addressed of different tasks. On-the-job training of rest periods, a routine and structure supporting employees with a brain injury. the particular needs of the person with Brain Injury may result in a combination of in returning to work. provides the opportunity for people to to tasks, flexibility, reduced hours, a disability. disabilities. The limitations resulting from Legal issues The ability to hold a job is one of the relearn previously acquired skills or learn supervision and support. Some individual Exceptions are only made if this causes each of these disabilities may need to be strongest measures of community new skills. characteristics that may influence level If a person returns to work after a brain unreasonable disruption or creates individually accommodated for. of achievement include self-awareness, injury they will often find that cognitive a health or safety risk. Examples of integration. The single most important Strategies for managing motivation, determination and adaptability. impairments can make this a difficult reasonable adjustment include changes Examples factor in predicting return to work is impairments experience. The Disability Discrimination to work practices or job design, A police officer, returning to work active participation in rehabilitation and in Volunteer work following surgery for a brain aneurysm the therapeutic community. The second Understanding the different forms of Act specifies that people with a modifications to equipment or premises, had partial paralysis to the left side and best predictor is the injured person’s recovery and adjustment becomes People who are assessed as not disability have equal opportunity to gain and training or other assistance. could no longer use both hands for word self-awareness. The ability to manage particularly important when people return being ready for work may wish to employment and that their disability Whenever it is necessary, possible and processing. Transferring to a vacant emotions is also a signifcant factor to work after their injury. It is often helpful pursue volunteer work (e.g. at a charity should only be taken into consideration reasonable, employers should take into position that involved computer research in employability. to consider which area of impairment organisation) to improve their skills, when it is fair to do so. The Act also states account an individual’s needs and make accommodated him and he was provided might benefit from which form of recovery awareness of personal capabilities, and that employers should make reasonable appropriate adjustments to the work a one handed keyboard. Potential barriers and adjustment. level of experience. Paid employment adjustments to accommodate the needs environment to accommodate people A therapist who developed short-term Some barriers in returning to work are: Remediation may not be a realistic long-term option of someone with a disability. with a disability. for many people after Acquired Brain memory deficits had difficulty writing • An person’s desire to work being This involves relearning skills with practice Two types of discrimination The first step is to identify the essential case notes from counselling sessions. Injury. Accepting this situation can be very functions of the job. Marginal or peripheral greater than their actual readiness until a certain level has been achieved Discrimination can be defined as treating Modification suggestions included: distressing for people who have often functions of the position are not included • Accessing support e.g. linking with the e.g. practising typing speed. people less favourably than others allowing the therapist to tape record spent most of their lives building a career. as the job can be modified or these right employment support agency because of some real or imagined sessions and replay them before dictating Substitution It is hoped that people can pursue other tasks given to others. Prospective and • Cognitive impairment characteristic. Direct discrimination is notes, to schedule 15 minutes at the end Substitution requires maximising previous avenues for achievement, satisfaction and current staff with disabilities in any • A lack of opportunities for people to treating a person less favourably (because of each session to write up hand written skills or learning a new skill to overcome productive use of their leisure time. type of employment can qualify for demonstrate what they are capable of of his or her disability) than a person notes and to schedule fewer counselling a difficulty e.g. using self-instruction to reasonable adjustment. sessions per day. • Poor control over emotions improve concentration skills. Managing fatigue without that disability in the same or • Fatigue and other physical problems Fatigue is a very common outcome similar circumstances. Unjustifiable hardship A labourer working in a noisy factory Accommodation had difficulty concentrating on job tasks. e.g. dizziness and headaches after a brain injury, and it has a serious Indirect discrimination occurs when An employer can claim unjustifiable This is when a person adjusts their goals Modification suggestions included: • Experiencing a loss of self-confidence impact on someone’s ability to resume a ‘condition’ prevents a person with a hardship in making adjustments for an and expectations to match their level erecting sound absorbing barriers around after unsuccessful attempts work, especially in jobs needing intense disability, or an associate of a person with employee with a disability. The employer of capability e.g. aiming for a position his work station, moving unnecessary • Loss of motivation. concentration or fast paced decision a disability, from doing something due to is responsible for thoroughly assessing equipment from the area to reduce traffic with less responsibility and a reduced making. Often survivors can manage a physical barriers, policies, procedures, the applicant’s request for work related and allowing the employee to wear a Support work load. workload if they can approach one task practices, selection or admission criteria, adjustments before claiming ‘unjustifiable headset or ear plugs. Employment support agencies and Assimilation at a time, work in a quiet environment rules or requirements. hardship’. This assessment includes Excerpt from the Information for employers rehabilitation services often provide Assimilation is modifying the environment without distractions, and have a flexible An employer cannot discriminate against areas such as direct costs, any offsetting of a person with ABI fact sheet at programs that may focus upon the person and expectations of other people e.g. schedule for rest breaks if needed. The someone on the basis of disability. If a tax, subsidy or other financial benefits synapse.org.au returning to their previous position. This introducing specialised equipment, problem, of course, is that many work person is able to carry out the ‘essential available, indirect costs and/or benefits. is usually not possible straight away. supportive work environments and environments won’t allow some, or activities’ of a job despite their disability, Contact your local disability employment The results of different assessments can educating employers and colleagues possibly any, of these to happen. they must be given the same opportunity service to find out more about what is gather information about the person’s about the nature of support required. There is a related fact sheet at to do that job as everyone else has. available to you.

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Advocacy As anyone with a disability knows, health services, employers, and society in general, are not always inclusive when a disability is involved. Advocacy is concerned with speaking out about fundamental human needs and rights — about justice and equity for all people regardless of disabilities such as a brain injury. SELF ADVOCACY PLANNER PETS AS PART OF Advocacy usually addresses constitution or funding criteria may not Though the following plan is not specific to any particular situations where: permit it. For others, it is a lack of funding type of advocacy, these techniques are based on educating REHABILITATION • Others (service providers) have as individual advocacy is usually quite rather than directing. Work through each step as they are expensive to provide. Systemic Advocacy presented before moving on to the next one. Remember, this The inclusion of pets into hospital and rehabilitation an obligation to you that they environments has long been considered very therapeutic. are not fulfilling is about changing attitudes and ideas is only a guide, so use your best judgement when planning to of systems and organisations in view of self-advocate. Pets can continue to be an important part of life long after • Your rights are ignored or violated “Our son has a severe changing those systems for the benefit of rehabilitation has ended. • You have a responsibility that is STEP 1 What do you want to advocate for? brain injury, and the many individuals. Most welfare agencies In addition to filling lonely hours with companionship, pets particularly difficult for you to carry out hospital says he must be use their limited funding to provide a Identify your goals so that you have something to work can be trained, much like the more familiar Guide Dogs, to towards. Gather as much information about the issue as • You are being misunderstood or are moved to a nursing home measure of systemic advocacy which perform tasks and assist persons with disabilities in many having trouble understanding others. possible then develop a strategy. now. That isn’t the right can make a difference to outcomes in the different ways. The responsibility for pet care can enhance long-term. cognitive functioning in ways that are more subtle and So why is advocacy important? place for him, but we STEP 2 Who do you need to speak to? If you are seeking an advocate, contact Remember, you must always give the service provider or enjoyable than traditional therapies. Fun activities often Advocacy is important because you are aren’t sure how to stop your local Brain Injury Association to see organisation a reasonable opportunity to resolve the issue. It stimulate people with low motivation in ways that are not important. Despite society’s progress the hospital doing this.” if there is an agency providing individual will be helpful to become familiar with the complaint process often achieved by sitting in front of a television set for hours in the way it supports people with a advocacy services in your area. of the organisation you are dealing with. Remember to make on end. disability, there is still a lot of unfairness, “I think Centrelink are going notes of the names of people you speak with, what you Pets must be cared for, otherwise they fail to thrive. The exclusion and general misunderstanding Self-advocacy spoke about, and the date you spoke with them. needs of the pet can be motivating for a person who may within the community. In many instances, to take me off the pension. Self-advocacy can be defined as the otherwise resist or refuse to actively engage with others. people with a disability still do not have The doctor assessing me STEP 3 What do I say? act of pleading or arguing in favour of Naturally a responsible adult should intervene if the pet’s access to various buildings, services and doesn’t seem to be aware something, such as a cause, idea, policy State clearly the issue you are talking about and indicate health or well-being is adversely affected. When limitations community associations. of mild brain injuries and or active support, for oneself. By self- what action you think should be taken to resolve it. Make it arising from the brain injury are barriers to independently clear that you are giving the service provider or organisation a Where are all the advocates? their effects. He doesn’t advocating you are providing yourself caring for a pet of choice, talk with the person about chance to fix a mistake or omission if that is the issue. Where strategies that will enable more independence and determine Many welfare organisations engage in think it really affects my with not only the opportunity to resolve possible provide solutions - not just criticism. what duties will be managed by whom so responsibilities can systemic advocacy, which is primarily ability to work. I get so your issue, but to learn more about be monitored. concerned with influencing and stressed about it, I have service providers, other people, and STEP 4 What if I need someone else to assist me most importantly yourself. Trying to bring to advocate? changing the ‘system’ in general (such no idea how to fight this. I People with severe brain injury and other impairing conditions about positive change for yourself can Don’t feel bad if you wanted to advocate on you own but you often have little control over their lives. Owning a pet can as legislation, policy and practices) in have trouble even filling out ways that will benefit people with a sometimes feel like an ongoing struggle had to involve someone else, sometimes it is the only way to provide an opportunity for controlling at least one facet of disability as a group. Systemic advocates the normal forms, let alone that requires considerable time, energy, resolve an issue. their lives - their pet! Pets always have time for sharing with will encourage overall changes to the complaining.” and commitment. Seek assistance where their owners and their loyalty is indisputable. possible, and try to speak with others in STEP 5 How do I make contact? law, service policies, government, and Pet therapy is a well-established routine in many hospitals, a similar situation - it may give you some Methods you can use to self-advocate include phone, email, community attitudes. “I’ve returned to work nursing homes and rehabilitation centres. Anecdotal perspective and add another voice to letter, fax, or the media. Choose the method that best suits accounts tell of the benefits of pets being in the presence Individual advocacy after the car accident, your cause. you, or the one you feel most comfortable with. It is often but I’m having trouble easier to advocate via email, as tracking is in-built, and there of people in all stages of recovery, rehabilitation and even Individual advocacy is when the advocate can be little discrepancy. end-stage illnesses. The comforting and calming affect concentrates effort on only one person learning the new systems of stroking a furry animal often elicits more relaxing facial or a family. The advocate could be a staff they’ve brought in. The STEP 6 Where can I get help? expressions and/or postures in persons even thought to be member of an organisation, a carer, family boss says he won’t pay There are several ways you can receive assistance with self- in minimally-responsive states. Nonverbal people generally member, friend or volunteer. This type for training, so I either advocacy planning: respond with contented smiles when pets are introduced into of advocacy is focused on the specific shape up or get sacked. • Call your local Advocacy Service for advice or assistance their environment. Almost all people with disabilities can take needs or situation surrounding the person • Speak to a friend or peer about your thoughts some responsibility for the care of an animal, even if it’s no Can he do this? What are with a disability. • Talk to your local ombudsman about your rights more than a daily stroking or play session. my rights?” Most welfare organisations do not provide • Contact a lawyer or research online to understand the Many thanks to the Brain Injury Association of America at individual advocacy. For some, their laws around what you’re advocating www.biausa.org for permission to adapt this article.

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Returning to studies • Treat steps as self-contained goals and undesirable behaviour can be replaced tackle them one at a time with an agreed alternative. It is also helpful Survivors of Acquired Brain Injury (ABI) who have done very well in their recovery still • As each step is completed, reinforce it to agree on a signal that the teacher can face a major hurdle in returning to their studies. BRAIN as an achievement of success give as a sign for the student to stop • Create a break between each step if and think about what they are doing. SURGERY IN needed It could be a word, or a sign (e.g. arm • Review each preceding step before up in the air). In time it will become an THE STONE moving onto the next. automatic process. Surgery has been around a Short-term memory problems Allowances long time. Even 12 000 years Students may lose books and equipment, All educational institutions now have ago, people had holes cut forget appointments and arrangements, policies that make allowances for people in their skulls in many ask the same questions again and with disabilities in terms of tests and different cultures. again, or forget which classroom they assignments. These institutions are Even more surprisingly, they are supposed to be in. Fortunately, there often unaware of the multiple impacts occasionally survived. In the 19th are ways to assist memory and it can be on a student’s abilities such as short- century, Fijians were using this surgical an exciting challenge to work out new term memory difficulties, fatigue, lack of technique, ‘Trephination’, to treat brain avenues to compensate for problems. concentration, susceptibility to stress and injuries. Students with memory issues may lowered organisational ability. Students should contact their Disabilities Officer to When someone’s skull was cracked, need to become familiar with using make suitable arrangements for tests and Trephination was used to reduce memory aids and may need constant assignments. the pressure from brain swelling reinforcement by teachers, who should and reduce the risk of death and be informed of how to respond. Try to Many schools and universities will help permanent brain injury. The most think laterally and come up with a way to you learn new material if you let them remarkable fact was that the Fijians incorporate aids into everyday living - like know that you have a disability. There is achieved a 70% success rate while by using a mobile phone. This can make still little awareness of brain injury in many London surgeons at that time only individuals more likely to use them. organisations so you may need to present this information to them to acquaint them had a 25% success rate! Stress, frustration and anger The Fijian’s trick was largely one of with this particular disability. It may help if A common trigger to personal stress is a hygiene. They would wash their hands your doctor or neuropsychologist writes feeling of helplessness or being trapped in and the injury repeatedly in coconut a letter to document that you have a a situation over which we have no control. milk which is remarkably similar in valid disability. Disciplined or authoritarian environments chemistry to our body fluids (it has You will need to explain the can add to a student’s belief that they even been used for transfusions when accommodations or special help you are being deprived of alternatives. The blood products have run out in war require, such as: number of factors following an attention and concentration. It will be responses to gradually improve insight, student should be able to choose from a zones!) Scalpel and tweezers were ABI may make this difficult. First necessary to gradually build up tolerance if possible. number of options in dealing with these • Extra time for assignments and exams made of bamboo for cutting and Aof all, loss of short-term memory for concentration daily but this is not emotions. • Exams in a quiet room removing bone and damaged brain will make it very hard to learn. Second, as simple as it sounds. Keep periods Lack of organisational skills • Copies of teacher’s notes if tissue. After sewing up the wound, it The triggers for these emotions should be school has a fair amount of fatigue of concentration short by allowing Planning and organisational skills can concentration is affected. would be checked a few days later for identified, and where possible, avoided. associated with it. With a brain injury, regular breaks. Start with ten minutes sometimes be impaired to the extent infection which would be cleaned out When this isn’t possible, relaxation and people can have limited energy and may and build up gradually with a few extra that the student knows what he or she Some study strategies again with coconut milk. meditation can act as good insurance be good in the morning, but fade early in minutes daily. wants to do, but has difficulty getting policies. When high levels of anger or Organising yourself will be crucial. Some As you would have guessed, the main the afternoon. Third, returning to school started. This means that the person will aggression are imminent, the student useful suggestions to try are: Lack of insight problem for the English surgeons or university involves a social dimension need a very clear plan of how to go about should be able to take time-out, having • A good diet, regular sleep and exercise was a lack of hygiene in badly — people very desperately want to fit in Many students with an Acquired Brain carrying out a task. The first step will be planned for this already with teachers. overcrowded hospitals. Things have • Avoiding alcohol, cigarettes and drugs with their peers. For some people, having Injury have a lack of insight regarding their to stop and think – he or she will need This needs to be seen as an opportunity improved somewhat so thankfully • Structure your days and week some friends they can hang out with is level of ability and are unable to recognise time and support to work out a plan by to restore balance and perspective, that their performance and capabilities there is no need to bring on the • Use memory prompts such as their number one priority. identifying the task, keeping it simple and not punishment. are functioning at a reduced level. They coconuts and bamboo today. notepads, alarms and a notice board addressing one task at a time: Common problems and strategies may respond to negative feedback by “Brain Surgery in the South Pacific”, Impulsive behaviour • Experiment on study times and find An injured brain may never be restored believing that teachers are against them, • Write down all the steps required to Medical Observer, 17 March 1995, Behaviours displayed are often a genuine when you’re most alert to pre-injury capabilities but performance or other ways that allow them to believe complete the task pp. 74-75. case of innocently doing what seemed • Structure your study times and try to can generally be improved. Difficulties their performance is still normal. Teachers • Sort out the list of steps in the order to be a good idea at the time. Strategies stick to them are often experienced in the areas of should be informed of appropriate they are to be achieved should be discussed with teachers so that • Join study groups

78 Synapse | © Brain Injury Association of Queensland | synapse.org.au synapse.org.au | © Brain Injury Association of Queensland | The FACTS 79 Glossary Glossary This glossary covers many of the basic terms used in the context of Acquired Brain Injury, both in the hospital stage and during rehabilitation.

A creating dreams, which may include the Burr hole: A 10-20mm surgical drill hole a segment of bone, which is usually E Hemianopia: Blindness in the same sides medio-basal forebrain, inferior parietal made through the skull. replaced. This allows access to the brain of both eyes which can follow damage to Acquired Brain Injury/ABI: This is any cortex, medial temporal lobe or occipito- and its coverings. Echolalia: Imitation of sounds or words the brain. This can cause an inability to see organic damage to the brain occurring without comprehension. This is a normal temporal cortex. C CSF: on the left or right side. after birth. ABI can have a number of see Cerebrospinal Fluid. stage of language development in infants Anosmia: Loss of the sense of smell by CAT Scan: Computerised Axial but is abnormal in adults. Hemiparesis: Weakness, partial paralysis causes including (but not limited to) CT Scan: see CAT Scan. either mechanical damage to the olfactory Tomography, also known as Computerised or loss of movement that only affects one Trauma (TBI), Stroke, Degenerative EEG: EEG or Electroencephalogram is a nerve or damage to areas in the anterior Tomography or CT Scan. A scanning Chronic Traumatic (CTE): side of the body. Diseases (like Alzheimer’s), Hypoxia and test used to record any changes in the temporal or oribito-frontal lobes that technique that uses a rotating X-ray A progressive degenerative disease of the Alcohol & other Drugs. electrical activity of the brain. An EEG is Hemiplegia: Paralysis of one side of the process the sense of smell. machine to record slices of your body. brain often found in athletes (e.g., boxers, often used in the testing of epilepsy. body. May be associated with spasticity - ADHD: Attention Deficit Hyperactivity football players) with a history of repetitive Anoxia: No oxygen in cells of the body. Catheter: A tube which is inserted into any increased muscle tension and spasms. Disorder (sometimes ADD or Attention brain trauma, including symptomatic Embolism: Blood clots are the clumps If prolonged, will cause cell death. Can body part to withdraw or introduce fluids. Deficit Disorder) usually manifests in concussions as well as asymptomatic sub- that result from coagulation of the blood Heterotopic Ossification: Abnormal be due to no oxygen reaching the blood, childhood or adolescence, and tends to Cerebellum: concussive hits to the head (i.e., injuries (blood hardens from liquid to solid). A deposits of bone in muscle. e.g. through strangulation or suffocation, The portion of the brain linger through adulthood. Behaviours can (located at the back) which helps without symptoms). blood clot that forms in a blood vessel or can be due to no blood reaching the Homeostasis: The ability of the body to include difficulty maintaining attention, coordinate movement. Damage may result or within the heart and remains there is cells, e.g. through the heart stopping or maintain a stable internal environment, hypersensitivity to stimuli, incessant in ataxia. called a thrombus. A thrombus that travels blood flow being stopped in one area by D talking, impulsivity, incessant movement, to another location in the body is called e.g. temperature, breathing, blood- an embolism. Cerebral: ignoring or tuning out, anxiety, frustration Concerning the brain. Dementia: Includes, but is not limited to, an embolus. The disorder is called an sugar levels. Mainly controlled by the Alzheimer’s Disease, Dementia following embolism. For example, an embolus that Autonomic Nervous System through the and irritability. : Difficulty understanding or Cerebral Angiogram: X-ray picture of the Head Injury, Parkinson’s Disease, occurs in the brain is called a cerebral hypothalamus. Adynamia: expressing language as a result of damage blood vessels inside the head. A drug is A lack of motivation after Dementia following HIV, and Substance- embolism. to the brain. injected via the groin artery which outlines Hydrocephalus: Enlargement of the trauma to the frontal lobes. Characterised Induced Dementia. Dementia was formerly these cerebral vessels. Embolus: See ‘Embolism’. ventricles due to an increase of fluid (CSF) by difficulty initiating activities or Apraxia: Inability to voluntarily perform used in the DSM to define a disorder on the brain. Often due to a blockage completing tasks. Gives the appearance skilled movements. Cerebral Cortex: The outer layer of the that presents with memory impairment Emotional lability: Repeated, rapid, abrupt in the ventricles preventing them from of lethargy. brain, responsible for cognitive processes and multiple cognitive deficits. See shifts in emotion that are not related to Arterial line: A thin tube (catheter) inserted draining into the nervous system. Can including reasoning, mood, perception of Neurocognitive Disorder. external stimuli. Affect: Your experience of an emotion, and into an artery to allow direct measurement cause ABI. stimuli and other thought processes. Epilepsy: the behaviour that arises from it. of the blood pressure, amounts of oxygen Diagnostic Statistic Manual for Mental A chronic condition caused Hypertension: Abnormally high blood and carbon dioxide in the blood. Cerebrospinal Fluid (CSF): Liquid which Health (DSM): This is the guide by which by temporary changes in the electrical Agnosia: A disorder of recognition pressure. fills the ventricles of the brain and supplies Psychologists and Neuropsychologists function of the brain, causing seizures from injury to higher order information Asymptomatic: Without symptoms. If which can affect awareness, movement the brain and spinal cord with nutrients. categorise and diagnose mental health Hypotension: Abnormally low blood processing cells which can result in an someone is asymptomatic, they have no and sensation. disorders. pressure. inability to recognise or distinguish faces symptoms that are evident. Chronic: In medicine, this means lasting Executive Function: Range of abilities or objects. consistently for a long time. A ‘Chronic’ Diffuse Axonal Injury: This is widespread Hypothalamus: Small region of the brain at Ataxia: Abnormal movements due to the to plan, monitor oneself, learn from condition lasts for 3 months or more. damage to the Axons in the brain that the top of the brain stem which regulates Agraphia: Inability to write that can arise loss of coordination of muscles. experience and accomplish steps to This is in contrast to acute (abrupt/sharp/ deliver signals between cell bodies. the Autonomic Nervous System. from damage to areas of brain responsible reach a goal. Executive functions include Autism: Developmental disorder of the brief) and subacute (between acute and for cognitive or motor skills necessary to Diffuse Brain Injury: Injury to cells in attention, concentration, planning, initia__ Hypoxia: An insufficient supply of oxygen brain that may lead to lack of social chronic). write. many areas of the brain rather than in one tion, and problem solving. to cells of the body. May result in cell response, inability to cope with change, Cognitive: The function of the mind by specific location. Focal Brain Injury: death if severe. Can be through not Alculia: A disorder characterised by an and ritualised behaviours. Injury restricted to one which we become aware of all aspects of enough oxygen reaching the blood, e.g. inability to comprehend or write numbers Disinhibition: Loss of control over region (as opposed to diffuse). Autonomic Nervous System: This is the perceiving, thinking and remembering. due to drowning or carbon monoxide or perform arithmetic operations. impulses due to frontal lobe trauma. Frontal Lobes: The region of the brain part of the Peripheral Nervous System Coma: poisoning, or not enough blood reaching The state of not being responsive directly behind the forehead. Responsible Alexia: Inability to read due to brain that controls functioning mostly below Dysarthria: Speech impairment resulting the cells, e.g. due to bleeding or or able to be aroused. Person does not for Executive Functions, a variety of damage causing cognitive or visual the level of consciousness. e.g. heart from damage to the nerves and areas of constricted blood vessels such as a blood open their eyes, follow commands or “higher cognitive functions”, and motor rate, digestion, respiratory rate, salivation, clot causing a stroke. problems. speak. the brain that control the muscles used in control. Damage can cause changes perspiration etc. forming words. Alzheimer’s disease: Degenerative Concussion: Disruption of brain function to personality, dysexecutive syndrome, problems with spoken language, impaired I disorder of the brain with cognitive decline Axon: The long slender projection of usually from a blunt impact to the head Dysautonomia: A malfunctioning of the social skills, and paralysis. due to appearance of plaques followed by a nerve cell that allows it to conduct causing the brain to bounce inside the autonomic nervous system, presenting ICP/Intracranial Pressure Monitor: is development of neurofibrillary tangles in electrical impulses and deliver them to skull. primarily as ineffective temperature a monitoring device to determine the the cells of the brain. other cells - allowing for communication. regulation and ineffective regulation of G pressure within the brain. It consists of a Contrecoup: Bruising of the brain tissue heart-rate and breathing. Glasgow Coma Scale: small tube (catheter) in contact with the Amnesia: Inability to remember learned on the side opposite to where the blow Measures the B pulsating brain or the fluid cavity within information. Acquired Brain Injury can was struck. Dysexecutive Syndrome: Impaired degree of disturbed consciousness arising from trauma. it. ICP is measured by means of a metal cause retrograde amnesia (loss of recall Blood clot: A solidified localised collection executive functioning, usually resulting Contusion: Another name for a Bruise, screw or a plastic catheter connected to of events right before the trauma) and/ of blood. from damage to the frontal lobes. caused when blood vessels are damaged an electronic measuring device. or (loss of recall of H Brain stem: The lower extension of the or broken often as a result of trauma. Dysphagia: Difficulty with swallowing. events for some period of time after the Haematoma: A collection of blood in an Impulsivity: A tendency to rush into brain where it extends to the spinal cord. trauma). Another term for anterograde Craniectomy: Surgical removal of a Dysphasia: See Aphasia. Dysphasia is a organ, space, or tissue, due to a break in something without thinking or reflecting Neurological functions located in the brain amnesia is post-traumatic amnesia or PTA. section of the skull. milder form of Aphasia. the wall of a blood vessel. first. stem include those necessary for survival Anoneiria: Inability to dream due to trauma (breathing, heart rate) and for arousal Craniotomy: The making of a surgical Dyspraxia: See Apraxia. Dyspraxia is a Hard Collar: Stiff plastic collar worn to Intra-Cerebral Haematoma: A blood clot of the areas of the brain responsible for (being awake and alert). opening through the skull, by removing milder form of Apraxia. support the neck. in the brain.

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M manipulation, voluntary movements, and Subarachnoid: Beneath the Arachnoid the integration of different senses. Damage Mater. This is in between the Arachnoid Meninges: The three membranes that can cause difficulty with identifying or and the Pia Mater, the inner two meninges cover the central nervous system. From naming objects, difficulty with writing or covering the Brain and Spinal cord. outermost to innermost: Dura Mater, mathematics and difficulty with motor Subdural: Arachnoid Mater, Pia Mater. coordination or being aware of space Below the Dura, the outermost and distance. menix. Most often in between the Dura Meningitis: An inflammation of the and the Arachnoid layers. meninges. PEG Tube: Short for “Percutaneous Symptom: Endoscopic Gastrostomy” tube. A tube Evidence of an illness or injury Migraine: Severe headache often inserted into the stomach through the e.g., anything that the patient experiences associated with sensitivity to light or noise. abdominal wall to provide food or other as a result of that illness or injury. May emerge after acquiring a brain injury. nutrients when eating by mouth is not Synapse: Neurons communicate with one- Minimally Responsive State/MRS: A state possible. Commonly used for patients in a another via synapses. This is where the of consciousness following a coma in coma or PVS. axon and dendrites of cells join together which the patient appears to be awake but Perseveration: Persistence of a to facilitate communication and hence is unable to respond to their environment response in a current task which may brain function. and can only make reflex movements. have been appropriate for a former task. Previously known as Persistent Vegetative Perseverations may be verbal or motoric. T State or PVS. Persistent Vegetative State/PVS: Tachycardia: Excessively rapid heartbeat. MRI (Magnetic Resonance): See Imaging Minimally Responsive State (MRS). Usually refers to a heartbeat of greater enables detailed pictures of the brain to than 100 beats per minute (BPM). be acquired using a scanning machine. It Post-Traumatic Amnesia/PTA: This refers uses a strong magnet rather than X-rays. to the period following brain trauma when Temporal Lobes: Located at about the victim is unable to effectively imprint the level of the ears. Responsible for N and retain a stable, continuous memory of interpreting and understanding sounds, events. See also Amnesia. categorisation of objects, some visual Neurons: Nerve cells in the brain, processing and short and long term Premorbid: spinal cord, and peripheral ganglia that Existing before the injury. This memory. Damage can result in impaired communicate via electrical signals. The can refer to attitudes, interests, personality memory, hearing and recognition cells most often comprise of a cell body, traits or medical conditions. of objects. axon and dendrites. Proprioception: The sensory awareness of Thermoregulation: The maintenance Neuropsychologist: A psychologist the position of body parts with or without of a stable body temperature. with further studies in brain function, movement. Thermoregulation can be impaired through personality and behaviour. damage to the brain stem, particularly the S Hypothalamus. Neurocognitive Disorder: The DSM- Seizure: 5 has moved towards this as a new An uncontrolled discharge of Thrombus: Blood clots are the clumps categorisation of disorders attributable nerve cells, usually lasting only a few that result from coagulation of the blood to changes in brain structure, function, minutes. It may be associated with loss of (blood hardens from liquid to solid). A or chemistry. The core or primary deficit consciousness, loss of bowel and bladder blood clot that forms in a blood vessel or is cognitive, and the deficit represents a control, and tremors. within the heart and remains there is called decline from a previously attained level of Sequelae: Pathological condition occuring a thrombus. See also Embolism. functioning. ABI, Dementia, Stroke and as a result of an illness or injury, typically Tracheostomy (Trachy): This is a breathing Parkinson’s are now able to be defined as chronic. e.g. A loss in short-term memory ‘Neurocognitive Disorders’. tube inserted through the middle of the following a brain injury. neck just below the voice box. Through O Shunt: An apparatus designed to remove this tube an adequate air passage can be excessive fluid from the brain. A surgically maintained. It may be necessary to leave Occipital Lobes: Region in the back of the placed tube which transfers fluid into the tube in the windpipe for a prolonged brain which processes visual information. either the abdominal cavity, heart or large period. Damage to this lobe can cause visual veins of the neck. deficits. V Spasticity: An involuntary increase in Oedema: Increased fluid content in the muscle tone (tension). Ventilator: This is a machine that does brain causing swelling. the breathing work for the unresponsive SPECT: Single Photon Emission patient. It delivers moistened (humidified) P Computed Tomography. A diagnostic air with the appropriate percentage of scan that uses a small, safe amount of a oxygen and at the appropriate rate and Parietal Lobes: Located in the middle radioactive drug to measure blood flow pressure. and top of the brain. Responsible for inside the brain. Not as sensitive as a visual attention and processing, spatial PET scan, but more useful for examining Ventricles: Cavities (spaces) inside the awareness, touch perception and seizure activity. brain which contain cerebrospinal fluid.

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Brain Injury Australia Brain Injury Association of Tasmania HeadWest Freecall: 1800 BRAIN1 (1800 272 461) Phone: 03 6278 7299 Phone: 08 9330 6370 Email: [email protected] Fax: 03 6228 0855 Fax: 08 9317 2264 Website: www.braininjuryaustralia.org.au Website: www.biat.org.au Email: [email protected] Location: Email: [email protected] Website: www.headwest.asn.au Weemala Flat, Building 27, Location: Location: Royal Rehabiltation Centre, Sport & Recreation House 645 Canning Highway 227 Morrison Road, Selfs Point Road Alfred Cove WA 6154 Ryde NSW 2112 Cornelian Bay TAS 7008

Brain Injury Network of South Australia National Brain Injury Foundation Phone: 08 8217 7600 Ph / fax: 02 6288 1117 Fax: 08 8211 8164 Email: [email protected] Brain Injury Association of NSW The under 18’s got Website: www.binsa.org Website: www.nbif.org.au Phone: 02 9868 5261 Email: [email protected] Location: Fax: 02 9868 5619 Location: PO Box 5542 Website: www.biansw.org.au 70 Light Square Hughes ACT 2605 the premiership... Email: [email protected] Adelaide SA 5000 Location: Suite 102, Level 1 and two brain injuries. 3 Carlingford Road Epping NSW 2121

BrainLink Toll free: 1800 677 579 Telephone: 03 9845 2950 Integrated Disability Action Email: [email protected] Phone: 08 8948 5400 Website: brainlink.org.au Fax: 08 8948 5409 It stuns a worrying number of people to learn that a simple game of footy Location: Email: [email protected] 54 Railway Road, Website: www.idainc.org.au can result in someone suffering an Acquired Brain Injury (ABI). At Synapse, Location: Blackburn VIC 3130 we’re dedicated to improving the awareness of ABI. Without your help Unit 4, Nightcliff Community Centre however, we could not hope to achieve the level of awareness required to 18 Bauhinia Street, reduce the devastating effects of brain injury. For some 1.6 million Australians Nightcliff NT 0810 and their families, life will never be the same again. Don’t let it be unbearable.

Your support, no matter how small, will help us reconnect their lives.

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At Synapse we’re dedicated to improving The ultimate goal being self sufficiency the quality of life of those living with, or and a return to the community. Without affected by Acquired Brain Injury (ABI). your help, we could not achieve the level One of the biggest issues facing people of support demanded by the 1.6 million with ABI is finding a place to live. Through Australian currently suffering an ABI. our accomodation services we can help Your support, no matter how small, will those affected to lead a more fulfilling life. help us, help them reconnect their lives. Connect ... synapse.org.au Information, strategies and supports to ensure that people with a brain injury, their families and carers can make the most out of life. synapse.org.au