Arnie H. Zencius

Improving executive function disorders in brain-injured clients

In 1983, Lezak described executive functioning as the ability to engage in independent, purposeful, self-directive and self-serving behaviour. Self initiation, problem-solving and self-monitoring or regulation of behaviour are important components of executive functioning. This paper presents the results of efforts to improve executive functioning in three areas: problem solving, self-initiation and self-regulation.

Managing hypersexual disorders in brain-injured clients

Three case studies involving hypersexuality in brain-injured clients are illustrated. Two cases involved the inappropriate touching of the opposite sex, and the third case involved exhibitionism. In one case of touching, feedback was used to decrease inappropriate touching. In the other case of touching, scheduled massage was used to shift stimulus control to an appropriate setting. In the case of exhibitionism, a combination of self-monitoring, private self-stimulation and dating-skills training were used to suppress the behaviour.

A comparison of four memory strategies with traumatically brain-injured clients

Six traumatically brain-injured clients were trained in four memory improvement strategies. These were written rehearsal, verbal rehearsal, acronym formation, and memory notebook logging. This study showed that only memory notebook logging was effective in increasing recall of classroom material.

Memory notebook training with traumatically brain-injured clients

Four brain-injured clients continually demonstrated short-term memory deficits including difficulty learning new material and forgetting appointments. Training in the use of memory notebooks improved performance of homework assignments and keeping appointments.

Comparing motivational systems with two non-compliant head-injured adolescents

Behavioural contracting, point systems and point systems plus response costs were compared to determine their effectiveness in increasing the attendance of two head-injured adolescents at class and therapy sessions. All of the motivational systems increased attendance, although the point system plus response cost seemed slightly more effective for one client.

Assessing and treating non-compliance in brain-injured clients

Assessment of non-compliance has been discussed. This included exploration of reinforcement contingencies, age appropriateness, cultural background and social background. Several perspectives on this have been addressed. Memory deficits are also critical when assessing non-compliance. Specifically, when the TBI person has severe memory deficits. Consequence management and antecedent control techniques have shown to be highly effective in promoting participation. Additionally, non-compliance should not necessarily be viewed as non-desirable, in fact, the client may be communicating preferred and non-preferred interests. It is important to recognize individual talents, interests and preferences. This is a significant point when you consider that TBI survivors had pre-injury lifestyles, i.e. full-time employment, a working social network, and preferred interests and activities.

Mini-breaks: the use of escape on a fixed-time schedule to reduce unauthorized breaks from vocational training sites for individuals with brain injury

This study evaluated mini-breaks with three individuals who were traumatically brain injured and engaged in unauthorized breaks. The vocational instructors reported that the three participants were having problems staying at their scheduled vocational training sites (walking away without permission). Following baseline, participants were placed on mini-breaks; that is, participants were given a ten-minute mini-break every hour. Thus, mini-breaks were given without regard to unauthorized breaks. Unauthorized breaks decreased to zero levels for all three participants when mini-breaks commenced. Following 1 month of the mini-breaks, two of the participants were put back on a regular break schedule (one 15-minute AM break and one 15-minute PM break and a 30-minute lunch break). The third participant was placed in supported work. The effects of the mini-breaks were maintained. Copyright

The Role of the Family

Therapists should include the family members in planning rehabilitation. Family members’ concerns and expectations must be addressed for long-term success (Livingston & Brooks, 1988). The brain-injured individual is a member of an interdependent system (the family) and changes in any member affect that system (Guth, Lasseter, & Harward, 1988a). Many family members attempt to deal with injury or disability by either increasing the rigidity of existing roles or creating new roles for members. These changes in patterns of interaction, role definitions, and allocations of resources can either promote or interfere with successful family functioning.

The Daily Routine

The teaching and learning of behavior are taking place around us all the time, and we usually do not notice them. Thus, it appears that people learn to behave without outside influences. Although most of us do not realize that we are teaching and learning, the process is going on almost continuously in the social interactions within various environments. Not all the behaviors are those that you would call “socially desirable.” Bad habits are learned and taught just as readily as good ones. This can be particularly true in certain families and rehabilitation environments.

Developing the Rehabilitation Plan

Rehabilitation planning for individuals following a traumatic brain injury is a goal-oriented, client-centered process with its foundations in functional, integrated, and comprehensive assessment (Guare, Samson, Guth, Warren, & Burke, 1988). The emphasis on client-centered assessment relates to the extreme variation in skill performance even among individuals with similar brain injuries. In more specific terms, rehabilitation planning following brain injury is defined as a process of identifying a desired outcome; specifying current performance abilities and inabilities (those skills needed to function in the desired community, educational, and vocational domains); and defining the necessary interventions, services, and environments that will assist an individual in achieving the desired objectives.