Samantha Grant - Arbias ABI Specialist Services - A Practical Guide to Supporting People with Cognitive & Behavioural Impairments after Acquired Brain Injury (ABI)

INTERACTIVE TRAINING - A PRACTICAL GUIDE TO SUPPORTING

PEOPLE WITH COGNITIVE AND BEHAVIOURAL IMPAIRMENTS AFTER

ACQUIRED BRAIN INJURY

Samantha Grant, arbias Ltd 2nd Annual National ABI Conference

Isn’t all training the same?

  Why develop more training on ABI?

  What is different about this training?

  Was this training effective?

  What made it that way?

Samantha Grant , arbias Ltd – 2nd Annual National ABI conference

Why address challenging behaviours?

  Prevalence of challenging behaviour among people with TBI known to rehabilitation services to be over 50% (Sabaz, 2012).

  For people with TBI, challenging behaviour is a major contributor to poor outcomes - ↓ participation, ↑levels of care and support need and demand on services, and ↓ levels of unmet need (Sabaz, 2012).


Why address challenging behaviours?

  A study of disability workers in Victoria - high exposure to challenging behaviour either directed at themselves or another (Koritsas, Iacono, Carling-Jenkins, & Chan, 2010).

  2/3 - exposure to physical aggression resulting in injury

  Up to 97% reported being exposed to other categories of challenging behaviour such as non-compliance


So what could we do differently?

  Address the lack of research on DSWs working with people with ABI

  Evaluate the effectiveness of the workshop developed

  Improve participants’ confidence and self-efficacy, knowledge and practice for working with ABI.


The formal training we offered

  2 day training for attendant care workers (and others)

  Delivered by an occupational therapist (Inbal Luft) and clinical psychologist (Samantha Grant)

  Designed for small-medium groups (up to 20 people)

  Intentionally practical to encourage people to learn and ‘think differently’

  Comprehensive training manual (approx 60 pages) Samantha Grant , arbias Ltd – 2nd Annual National ABI conference

Training content

 Day 1  Background to ABI, cognition, behaviour, rehab

team, types of assistance  Common cognitive impairments and strategies

 Day 2  Common behavioural impairments and strategies


Training Tools

-  Demonstrating a clear link between cognition and behaviour, and referring to this throughout the training

-  Clear lists of common impairments and then strategies

-  Practical activities that involved the participants actively engaging in support activities


Training Tools

-  Practical activities that challenged the participants own cognitive capacities

-  Visual examples of the issues they face, i.e. videoes

-  Opportunity to discuss relevant examples, and instant advice/feedback


Examples of Training Tools

  The next slides (11 – 25) are from the actual training slides and manual.


relationship between cognition and behaviour

Thoughts and feelings influence behaviour, e.g...   Reduced initiation not starting or completing activities

  Poor planning / problem solving impulsive behaviour, disinhibition, social /criminal issues, safety concerns / vulnerability

  Good insight increased frustration, depression

  Reduced insight increased risk taking / safety issues/ failure to achieve goals or succeed frustration

  Poor memory repetition of information social issues

  Cognitive communication issues frustration, irritability, aggression

A Practical Guide to Supporting People with Cognitive and Behavioural Impairments after Acquired Brain Injury | © Arbias Pty Ltd 2012

why is it different to work with people with cognitive impairments?

Example 1 – “Needs assistance with preparing meals”

Could mean:

 Physical Assistance

 Prompting (verbal, written, gestural)

 Set up of environment to provide cues

 Supervision

 Providing Feedback


why is it different to work with people with cognitive impairments?

Example 2 – “Needs assistance to complete personal care tasks (showering, dressing, grooming)”

Could mean:  Physical Assistance

 Prompting (verbal, written, gestural)

 Set up of environment to provide cues

 Supervision

 Providing Feedback A Practical Guide to Supporting People with Cognitive and Behavioural Impairments after Acquired Brain Injury | © Arbias Pty Ltd 2012

example of team approach

Person with ABI

GOALS

Rehab Team (including

carers)

Person is more

independent = less need for CARE


planning and organisational difficulties

Strategies:

•  Get organised

•  Timetable / Routine

•  Lists / Checklist (what’s next)

•  Written Instructions / Structure / Systems

•  Simplify

•  Alarms

•  Getting Ready

•  Assistance and prompting


planning and organisational difficulties

Common Difficulties:

  Planning activities / tasks   Disorganised

  Incomplete tasks

  Incorrect sequencing   Allowing enough time

  Unstructured time   Miss appointments / events at

scheduled time

  Inappropriate clothing for weather

  Community access difficulties (plan how to get somewhere)

  Run out of food/medication

  Poor multitasking   Judgement / decision making

  Budgeting /money management issues


rigid thinking / inflexibility


  Rigid / inflexible thinking

  Fixated

  Difficulty changing train of thought / perseveration

  Can’t see other points of view

  Find change challenging

  Reasoning / Decision Making Issues


rigid thinking / inflexibility

Strategies:

•  Don’t argue

•  Acknowledge and redirect

•  Manage Change

•  Use clear, direct language


meaning of behaviour

Why do you do the things you do?


on the footy field


on stage


in the name of entertainment


reinforcement


impulsiveness / disinhibition / reduced self control


  Filtering system in brain doesn’t work

  Act without thinking or can’t stop themselves

  Say inappropriate things (may know it’s inappropriate but can’t stop themselves)

  Safety issues

  Social issues (may be partly pre-morbid)



Examples:


“I think you’re really hot and would be great in bed”


Strategies:

•  STOP-THINK-DO

•  Immediate feedback

•  Praise / Reward


video: A18


So what did we find?


1. Help ACWs understand their clients

  We achieved this through:  Education about common impairments after ABI  Teaching about the relationship between cognition

and behaviour  Explaining what “person centered” means? (e.g.

ask clients what they want. Don’t assume they have been asked)

 Reinforcing that people with ABI may not have the skills to do certain things (e.g. regulate their behaviour) due to cognitive and behavioural impairments


Evidence of the need and impact: 1

  ACWs and others may lack ‘basic’ knowledge: I used to think… the person understands or don’t… a sandwich short of a picnic… didn’t you get an education… now… you can’t just label them as dimwits… maybe you can help ‘em (P90)

  Training addresses specific knowledge gaps:


Cognitive Psychological / Behavioural Memory impairment Slowed info processing Difficulty with new learning Planning and organisation

Reduced insight/awareness Irritability / Agitation Aggression Depression Socially inappropriate behav.

2. Give ACWs new strategies to use

  We achieved this by:  Getting people to think about what strategies they use

 Highlighting the concept of different types of assistance (not just physical)

 Conveying how providing assistance may in fact be limiting someone from developing their skills

 Emphasising the environment = many factors, including people within it



  They need practical strategies they can’t get from written material (esp. the internet)

I've just basically said to the staff … go to the ABI info website… in the past it was fumbling around…


3. Apply multiple teaching techniques

  We included in our training:  Case examples (videos, experience)

 Discussion and generation of ideas (they are also experts)

 Role play

 Written supports (workbook)



  Everyone said that these were the best   They remembered the videos and activities   They drew on knowledge from analogies   They referred to the workbook repeatedly

It increased their confidence and self-efficacy!


4. Make it accessible

  We did this by:  Using simplified terminology to cut through jargon

(e.g. goals = what people want)

 Talking about context of support / care provision as being within the rehab team

 Conveying understanding of the role of all rehab team members and where to turn for support / clarification when issues arise



  Most have not worked with a rehab team, and only a minority have worked with an OT

  In many cases you cannot assume prior – even basic – training and information Whilst, like I said, I had a very practical knowledge previously, this gives me the, the right words to use for certain professions. (P78)

  Support arrangements can be complex and inadequate, if they exist at all – particularly if there are multiple agencies involved


Acknowledgements

  The wonderful people who have provided their experiences to us, including those who agreed to be filmed

  Inbal Luft, Occupational Therapist, Vanessa Aird, Speech Pathologist and the arbias Case Managers

  Jennie Brentnall, Occupational Therapist and Researcher

  LTCS   The participants who wanted to learn more!


For more on the formal training…

A Practical Guide to Supporting People with Cognitive and Behavioural Impairments After

Acquired Brain Injury

Contact: Samantha Grant arbias NSW 02 9644 2869 [email protected]


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Samantha Grant - Arbias ABI Specialist Services - A Practical Guide to Supporting People with Cognitive & Behavioural Impairments after Acquired Brain Injury (ABI)