by Kit Malia, B.Ed., MPhil, CPCRT and Anne Brannagan, DIPCOT, MSc.
Brain injury rehabilitation manual on assessing awareness and adjustment in adolescents and adults with brain injury for therapists and clinicians in rehabilitation and community programmes.
This manual gives clinicians and caregivers a procedure with practical tools for assessing changes in awareness and adjustment in adults with brain injury. Using a methodical approach with step by step instructions, users are guided through 23 steps with 24 worksheets for assessing intellectual awareness, emergent awareness and anticipatory awareness. Once the levels of awareness and adjustment have been assessed, information is used to set short and long term goals for six domains of cognitive, executive, communication, physical, emotional and other. Accompanying the 71 page manual is a CD with PDF forms for all worksheets and scoresheets.
This manual provides methods for clinicians and caregivers who are working with clients in a variety of settings including inpatient and outpatient programmes, community based programmes and home settings. It includes methods for including families in the assessment process by gathering and comparing their observations and experience with that of direct care staff.
Intellectual Awareness (Steps 1 – 12)
Emergent Awareness (Steps 13 – 15)
Anticipatory Awareness (Steps 16 – 17)
Adjustment / Acceptance (Step 18)
Reporting the Findings (Steps 19 – 21)
Reinforcing the Message (Step 22)
Leading into Treatment (Step 23)
Sheet #1 Changes since the Brain Injury (individuals)
Sheet #2 Problems since the Brain Injury (individuals)
Sheet #3 Funnelling the Problems (individuals)
Sheet #4 Changes since the Brain Injury (relatives)
Sheet #5 Problems since the Brain Injury (relatives)
Sheet #6 Funnelling the Problems (relatives)
Sheet #7 Summary of Average Scores by Domain
Sheet #8 Summary of Accuracy of Ratings by Domain
Sheet #9 Causes or Links between the Problems
Sheet #10 Anticipated Effects of Problems
Sheet #11 Summary Sheets for Intellectual Awareness
Sheet #12 Summary of Relevant Problems
Sheet #13 Questions to Keep in Mind to Assess Emergent Awareness
Sheet #14 Rating Actual Performance on a Task
Sheet #15 Identifying Problems and Devising Strategies
Sheet #16 Questions to Keep in Mind to Assess Anticipatory Awareness
Sheet #17 Predicting Performance on a Task
Sheet #18 Assessing Adjustment / Acceptance
Sheet #19 Model Profile
Sheet #20 Bar Chart Profile
Sheet #21 Reporting Sheet for Awareness and Adjustment
Sheet #22 Model of Awareness and Adjustment
Sheet #23 Setting Goals for Awareness and Adjustment
Sheet #24 Example Goals for Awareness
While there are some potential positive gains to having poor awareness following brain injury (e.g. unrealistic expectations may initially act as a buffer, protecting the patient from grim reality), it is generally agreed by therapists and families that a persisting lack of self awareness is a major obstacle to successful rehabilitation and reintegration. For instance, individuals who do not admit their problems may be cooperative and compliant in therapy but discontinue compensation strategies on leaving the rehabilitation center. As a result, their functional status will decrease. Even well learned compensation strategies are of little value to a person who is unaware of the deficits they are designed to compensate for.
“Patients who lack an awareness of their deficits or the functional implications of these deficits may, if compliant go through the motions of rehearsing a strategy but are clearly not engaged in the process. Consequently the likelihood of the patient’s learning or putting the strategy to functional use is minimal” (Ylvisaker et al, 1987).
It is therefore important to treat poor awareness as a matter of the highest priority within rehabilitation programmes.
Owing to the artificial nature of the rehabilitation center, with its structure and expectations of therapists, the full extent of impaired self awareness is not always apparent unless specific assessments for this area are implemented by the team.
A distinction between awareness and adjustment/acceptance can be usefully made.
Stuss (1991) suggests that self awareness exists on 2 levels:
1) The objective knowledge of the existence of one’s deficits.
2) The associated understanding of the personal significance of those deficits.
The term awareness can be used when referring to the individual’s ability to perceive difficulties. The terms adjustment or acceptance can be used when referring to the individual’s ability to understand or internalise the problems.
The individuals who are able to list their problems, but in a detached way as though the problems have no personal meaning, are demonstrating only good awareness. They may be exhibiting knowledge but fail to use it or be unaware of the implications of that knowledge. The person who is able to demonstrate an understanding of how the problems will affect his/her life is demonstrating good awareness and acceptance