General Strategies

• With the support of others around them, persons with a history of TBI should remain mindful of their strengths and limitations.
• Avoiding activities that exceed one’s ability level is important in minimizing frustration, which can aggravate existing cognitive weaknesses.

• Persons with TBI may be more vulnerable to the effects of fatigue, pain, and/or stress.
• Therefore, persons with TBI should limit involvement in more demanding activities (e.g., driving, cooking) when they are feeling physically or emotionally overwhelmed.

• Regardless of the specific cognitive weaknesses associated with a particular brain injury, planning ahead and allowing additional time for completion of tasks can minimize frustration for all involved and promote optimal performance by the person with the TBI.

Attention, Concentration, and Organization Difficulties

• Maintaining a predictable routine and structured environment that incorporates prioritized checklists and reminders (e.g., Post-Its) may enhance the person’s functioning.

• When completing tasks, the individual should try to focus on one task at a time and complete it in its entirety before moving on to the next task.

• The person may benefit from minimizing background distractions when he/she is working on complex tasks. For example, TV, radio or ongoing conversations in the background may hinder his/her ability to focus on the task at hand.

• The individual may benefit from taking regular breaks from tasks that require prolonged attention. In general, regular breaks from complex tasks can help prevent lapses in attention, which can result in errors.

• The person can outline the steps required to complete a task prior to beginning it, which can help ensure an organized approach. He/she can also use the outline to refer to throughout the task as a reminder of the steps he/she needs to complete.

• The person may benefit from alternating tasks of high and low interest. If arousal is an issue, less interesting tasks should be completed at the time of highest arousal.

• Those interacting with the person with TBI can make a point to praise/reward “on task” behavior while removing reinforcers for “off task” behaviors.

• Those interacting with the person with TBI should make sure the person is paying attention when he/she is being spoken to or beginning a task. Providing cues as needed may be helpful in cuing him/her to focus or refocus.

• In cases of compromised arousal, ensuring adequate sleep can be imperative and the individual may benefit from completing tasks in an upright position.

• Engagement in important activities (e.g., rehabilitative therapies) may be best scheduled at the time of day when the individual is most alert. In certain cases, medication (e.g., methylphenidate) may be indicated.

• For individuals with severe executive functioning difficulties, behavioral therapy with a rehabilitation psychologist/neuropsychologist/neuropsychologist[%1] may be helpful to address behavioral problems.

Initiation Problems

• Provision of environmental cues (e.g., visual signs, calendars, audible alarms) may be helpful in prompting the individual to complete tasks.

• Linking behaviors that “naturally” go together (e.g., taking medications with meals) may increase the likelihood of the target behavior (e.g., taking medications) occurring.

• For individuals whose lack of initiation is due to depression, initiation of antidepressant medications (e.g., SSRI) may be indicated. If this is suspected, consultation with a physician [%2]is needed.

• Individual and/or familial counseling may be helpful in developing realistic expectations, coping with stressors, and problem solving difficult situations.

Language Problems

• A person with speech difficulties can be encouraged to carry a card that lists emergency contact information that can be utilized in the event that family needs to be contacted and the person with TBI is unable to relay the necessary information.

• For those with significant communication difficulties, family members/friends/therapists may help the individual put together a “communication notebook,” in which he/she can put pictures of important items. Words describing each page can be printed under the pictures. The person can then use this notebook to facilitate communication with others in expressing her needs and wants, and to stimulate his/her use of language despite expressive difficulties. Some potential categories of items include:
• Important people (e.g., family members, friends)
• Commonly encountered items (e.g., foods, medications)
• Regular activities (e.g., going for walks, knitting)
• Facial expression of different moods (e.g., happy, sad, angry)
• Frequently visited locations (e.g., grocery store, friend’s home)

• Persons with speech difficulties may benefit from being asked questions in multiple choice or yes/no format (e.g., “Would you like to have peanut butter and jelly, leftover lasagna, or go out for dinner tonight?”)

• Provision of written templates in the home or workplace may be helpful in expediting communication; for example, “I am feeling __________ because __________.”

• The individual and those with whom he/she interacts are encouraged to remain patient when communicating. He/she can benefit from gentle cuing and in addition to writing responses as he/she is able.

• The person may benefit from utilizing technological assistance to compensate for speech difficulties. Some potential options that may be considered are noted on the NAA website: http://www.aphasia.org/naa_materials/books_cds_etc.html#commboard. See Assistive Technology section.

• For individuals with receptive language difficulties, it will be important for others to speak slowly, directly, and clearly. Information may need to be repeated or rephrased as needed. In medical or other important appointments, it may be helpful to have a trusted family member or friend present to take notes, ask questions, and gather information to later review with the person.

Memory Problems

• · Persons with TBI can benefit from using a memory/organizational notebook to keep important information, including calendars, phone directories, and to-do lists. The following guidelines may help people use of this strategy:
  • The individual with TBI may benefit from reminders to write information in organized sections of the planner/memory book.
  • Family/friends can remind the person to carry this organizer wherever he/she goes and can encourage him/her to add new information, such as his work schedule information or upcoming appointments.
  • A family member/friend can periodically go through the organizer to update and reorganize it, depending on how well the person with the TBI is keeping it up.
• The individual may benefit from regularly writing information down and making reminders for him/herself (e.g., notepad by the phone, use of Post-It notes, on a dry erase board set up in a central location in the home).

• For persons with motor limitations, a digital voice reminder that allows the user to instantly record and review short messages can be helpful. These devices can be readily found at office supply stores and in the electronics departments of larger stores. Family members, or other trusted persons, may be helpful in showing the individual with the TBI how to most effectively and efficiently use this device.

• The person with the TBI can set alarms (e.g., on a phone or PDA) to remind him/her of important events (e.g., to take medications, daily tasks, birthdays).

• For individuals who may have a tendency to lose important items, it can be helpful to set up a central location (e.g., a large bowl placed on an entryway table) where these items (e.g., keys, wallet) are always placed.

• Timers can be useful in providing cues regarding when it is time to take medications, check blood sugar/blood pressure, etc.
• Timers can range in complexity and expense (e.g., watches with timers, hand held planners or PDAs).

• Use of mnemonic (memory enhancing) strategies can also be helpful. Examples and explanations of some of these techniques can be found at the internet site, The Memory Page: www.thememorypage.net.

• Repetition (e.g., reciting the information to be remembered several times) is often helpful.

• Increasing the perceived relevance of material can be helpful for some individuals’ recall. As one example, this can be done by having a person restate information in his/her own words or discuss how it is relevant to his/her daily life.

• Labeling doors, drawers, cabinets, and dressers may be helpful in cuing the person about where to find items.

Slowed Speed of Processing

• The individual with TBI, and those with whom he/she interacts, should plan to allow additional time for the completion of projects. This will minimize frustration or errors that can result from experiencing time pressures.

• Cognitive efficiency may be compromised when information is presented too quickly or when too much material is presented at once. Therefore, information can be presented in smaller chunks, giving the person with TBI opportunities to repeat it to ensure it is understood and to promote memory for the information.

Termination Problems

• Respond directly to inappropriate statements or behaviors; for example, tell the individual, “What you just said was not OK,” or “Touching others that way is not acceptable”

• Cue and redirect the person from focusing on inappropriate topics, objects, etc.

• As with disorders of initiation, individual and/or familial counseling may be helpful in developing realistic expectations, coping with stressors, and problem solving difficult situations.

Visual-Spatial/Disorientation Difficulties

• If visual acuity is impaired, referral for a vision exam (e.g., by an optometrist, ophthalmologist, or neuro-ophthalmologist) may be needed to determine if corrective lenses or other devices are indicated.

• Magnifying lenses, enlarging materials on the copier or a computer, or changing the contrast level on computer monitors may help to address vision difficulties.

• Painting bright colors or applying bright tape in the corners or on the edges of objects (e.g., tables, chairs, stairs) may promote detection by the individual. Using solid, high contrast colors on walls and floors may be helpful in discriminating aspects of the environment.

• Reducing clutter in the individual’s environment can help to promote his/her detection of stimuli.

• Lighting adjustments (e.g., reducing glare with the use of yellow lights) can be helpful in promoting optimal visual acuity. In addition, use of motion detection lighting can help individuals with trouble finding or reaching light switches.

• If visual signs are in use in the person’s environment (e.g., as reminder cues), use of single words may be best to minimize visual demands.

• Educating the person about his/her vision disturbance (e.g., visual field cut) can be helpful in encouraging him/her to attend to all aspects of the environment (e.g., turning head to compensate for a visual field cut, patching one eye for double vision).

• Practicing utilization of other senses (e.g., hearing, touch) can be helpful in determining alternative methods for estimation the distance and location of objects.

• If left-right confusion is a problem, the person can wear a bracelet to assist in determining this orientation (e.g., a bracelet that says “LEFT” to be worn on the left wrist).

• The individual may benefit from investing in a global positioning system (GPS), which will facilitate navigation to given destinations and minimize anxiety associated with concern about becoming lost. Family members, or other trusted individuals, may be helpful in showing the individual how to operate this equipment.

For Students

• The academic support center/disability services office at educational institutions is typically responsible for working with students to provide accommodations when appropriate. Because a history of TBI may affect a student’s ability to learn and perform well in academic settings, accommodations may be helpful. Potential accommodations include the following:
• The provision of a tutor/assistant to help with organizing homework activities and completing out-of-class assignments.
• The provision of a quiet, nondistracting room for taking exams.
• Allowing a laptop or other word processing device for typing notes in class and/or the provision of a note taker.
• Allowing tape recording of lectures for further review.
• The provision of extra time for exams with writing emphases.
• Allowing use of calculator and computer programs (e.g., spell checker) to complete assigned projects and examinations.
• The provision of written handouts from professors, whenever feasible, to minimize the need to write and organize information visually.