Hi, everybody. I am Wendy Ellmo. It is 10 Central, 11 Eastern. So we're going to go ahead and get started.

I hope you've enjoyed the bubbles. We are all about mindfulness and calm So I hope you were able to use the bubbles to come and it's kind of a an incentive to get here early.

And thank you all who did. So welcome to the second in our case studies series.

This one is going to focus on cognitive changes You don't have to have attended Jennifer Rayman's training last month, but it was 

Awesome. So if you'd like to go back and watch it.

You can do so at the webinar page that you signed up for this one at And I'm sure that'll be linked somewhere here. And you will get you will get a link to that at the very end of this to that page. And then you can go back and watch Jennifer's as well.

So our focus is going to be on addressing the cognitive changes. I am a speech language pathologist, so you kind of know where i'm coming from And I worked in the bulk of my career in a brain trauma center.

Working with people who had brain injuries. So a little bit about Brain Links. Brain Links is a grant funded program of the ACL at the federal level and at the Tennessee Department of Health Traumatic Brain Injury Program.

At the state level and we are a program of the Tennessee Disability Coalition.

So brain links is a statewide team of brain injury specialists, and it's our job to help the professionals across the state better serve people with traumatic brain injury by giving them trainings like this one. And by providing any materials that they might need,

And helping to develop those materials to fit what it is that they do. And really also, I think a huge part of our job is helping people to understand that brain injury is a much bigger deal than people think, and it is much more pervasive than people think.

And hopefully today I'm going to show you that We have lots and lots of educational materials on our website and you'll see that website link throughout here.

We have lots of brain health resources. That's a big focus of our work.

We have resources for returning to school and to work. We have toolkits. We have four of them now.

For healthcare providers, one for school nurses One for families and survivors and and one for service professionals, which was probably the one that would relate to most of you.

And we also run the Tennessee Brighter Futures Collaborative, and I'll talk about that more as we go and you are all welcome to join that and become a part of that.

Has some great resources. So if you have questions.

Please enter them in the Q&A. You can go ahead and ask them along the way.

I'm going to be talking for about an hour and 15 minutes.

So we'll probably save any questions that Jen can't answer or it's going to be a longer answer.

We'll save them probably until the end. But Jen, if there's something that really you think should be answered right away please go ahead and interrupt me. At the end, there is a survey for you to complete, it will take you about a minute.

And you'll get a certificate of attendance that hopefully you can use for continuing education units.

And then following the session, every material that I talk about, at least if it's a part of this program, if nobody prompts me to talk about something different.

You will have all of those materials linked in a document that'll be on the web page and you'll get that that link at the end after the the webinar ends.

So we're going to be talking about four case studies I'm going to highlight the clinical thinking along the way.

I'm going to show you a protocol for brain injury screening, cognitive and functional screening and strategy development I'm going to show you resources that work and how you can use them.

The case studies are going to be based on like two or more people so that we're protecting privacy And we've picked them so that we can address real issues that y'all face and highlight some key tools that you can use

And people are complicated. So they're not just a brain injury case It's brain injury and because usually brain injury goes along with different things.

Or if you're from one of those different service provider areas, we call them systems of support. You might hear me say that throughout then.

You have seen people with brain injury, whether you realize it or not. I'm going to talk as if it just happened if it's they really happened, even though it's a case of like two or more people I'll be saying things like, and then we did this and then we tried that and then and then i gave this

This resource. So just go along with me on that. Here's an important thing. I am not trying to be the expert in that other co-occurring area.

I would consider myself an expert in brain injury. Especially as it relates to language and cognition But I'm not an expert in homelessness. So when we come alongside folks in these other systems of support.

We're not trying to do their job we're going to let them give the resources and talk about the things that they know about we're not going to try to do that.

But… through our Tennessee Brighter Futures program, we have lots of great partners in all of the co-occurring areas So I'm going to direct you to the Tennessee Brighter Futures resource pages throughout.

They're going to give you some of those resources in the other areas.

And if you can't find what you're looking for there then go ahead and contact us and we'll try to put you in in contact with someone who can answer your question in that system of support.

Let's get started with James. James is 32 years old. We first meet him in a substance abuse program He says that he wants to get clean, but he doesn't always do what he says he's going to do.

He doesn't participate when he comes to group. He doesn't seem interested.

It's his third time in treatment, which is court ordered. He inconsistently shows up for appointments.

Child welfare is involved and he's in danger of losing visitation with his four-year-old son.

And James's employer is really trying to be supportive. He really likes James. James is a good guy.

But he's losing patience with him. So at this point, when I would get a case, I would get a file That's all you know. You know some basic information. In an ideal world, I had a neuropsych eval.

But at this point, you're kind of always thinking, well, what do i know now?

And what am I thinking about? Well, with James so far, we're thinking about that substance use.

We know that 50% of people in substance use treatment have a prior history I have a brain injury. 50%.

In criminal justice where he's not he's he's in recovery court but he's he's not in the prison system yet.

But in the prison system, we know that up to 80% of men in the justice system have a prior history of brain injury. That's a huge number.

We also know that for women in criminal justice, that's even higher. It's close to 100%.

So we got to be figuring that this brain injury it's got to be playing some role, especially in criminal justice.

In child welfare, we know that brain injuries impact relationships. It makes it harder.

And that it can impact a parent's ability to care for a child. We also know in the child welfare system.

There are parents who have had brain injuries, but there are also children that have had brain injuries.

And we know that brain injuries are often accompanied by long-term cognitive, emotional, and behavioral difficulties, sometimes physical difficulties as well.

We also know he's in a substance use treatment center We know that there's this new term called toxic brain injury, which is from either prolonged substance misuse or from a non-fatal overdose. We're calling that a toxic brain so We don't know if for sure if he has what we would call this toxic

Brain injury or not at this point. So this is the same list you saw a minute ago. And the highlighted things are kind of things that I'm listening for that suggest that there could be a cognitive component to it that

You know, he says he wants to get clean, but he doesn't do it. Well, why is that? Is that because he can't follow directions and things like that. So we're looking also for things like like that that suggests, well, maybe there's something going on here that is cognitive

May not be, might be from some other For some other reason, but it's kind of just how we want our brains to work on this.

So what are we going to do? Well, we're in the substance use treatment program setting.

We're going to screen for prior history of brain injury We're going to assess for cognitive and functional impairment We're going to educate the staff on brain injury. We're going to educate James about his brain injury.

We're going to provide and teach accommodations and we're going to connect him with community resources.

Both brain injury ones And then any other system of support that he's involved in, like substance use.

Why is that protocol important? Well, we know that people with a traumatic brain injury have a harder time using the services and maintaining change within programs, whether it's substance use or mental health or any other if they don't receive

Needed accommodations and it could even be worse than that. They might be back in treatment again.

Or worse. So this is the screening that we used with him. The Ohio State TBI identification form This is a modified one that brings in not just traumatic brain injury.

But it brings in other types of brain injury. And we find that James did have some things that look like they could have been related to a concussion or some other level of brain injury.

He was dazed. He had a gap in memory He had balance and a headache. So what are we thinking at this point? Well, we know that If you've had a mild traumatic brain injury or concussion.

In childhood up to age 16 then by 21 age 21 to 25, we start seeing other things come into play.

Like substance abuse, committing violent offenses and property offenses So even though, and this is what a lot of the research is showing now that because just because someone has had, it was "only a concussion" or was "only an MTBI"

In childhood, but the young brain is this is, this is the old thinking, that the young brain is so resilient And it's like it never happened.

It happened. And the young brain is even more susceptible to it than an older brain is.

We're seeing all this research coming out about the problems people are having later on in life.

So he's had four football injuries.

And then there's um This bottom area, let me see if I can highlight it for you This bottom area is the modified part where it tells uh it's asking questions about other types of injuries you might have had like a stroke

Like a like an overdose. And we find out that James did indeed have an overdose And this, okay.

If your attention has strayed, bring it back for a sec.

Especially if you work with anybody who has had an overdose.

For every overdose death. There are approximately 50 overdose survivors, one death 50 survivors.

Okay, great. That's awesome. It is. But 90% of those people who survived become impaired because they had insufficient oxygen to their brain. They have an anoxic brain injury.

So we know that it's likely that from james's overdose he had an anoxic type injury from that.

That's a huge deal. We in the brain injury community usually use this number. I think it's about 2.8 million people a year.

Have a traumatic brain injury and that's that's big and bad by itself.

But now if we start looking at these other brain injury types like overdose death, that number just goes soaring. I think this number is about I think it works out to about 5 million, 4.9 million people a year have survive an overdose and have insufficient have had insufficient oxygen to the brain.

And that we know that using alcohol or drugs over time can lead to a toxic brain.

So next thing we're going to do, we found out that he did have a prior brain injury. We're going to assess for cognitive and functional impairment.

And we're going to use the adult symptom questionnaire, which I'm going to show you both the adult and the juvenile have a set of accommodations sometimes I might say strategies, I mean the same thing, accommodations and strategies. It's changes things that you do

A little bit differently to accommodate for the change that we're seeing.

It goes through all of these different areas it looks at these areas here and we're going to see what James acknowledged. These are things that james was aware of.

Memory he forgets meetings and appointments delayed processing. It takes too long to understand what someone's saying his attention, he's easily distracted.

Inhibition. He says things without thinking language, she has a hard time finding the right word. Sometimes that's just an attention problem.

Organization he has a hard time keeping up with time sensitive things like paying bills or some things at work that are time related And he didn't acknowledge anything in the areas of physical or sensory motor problems.

Mental flexibility or emotional problems except for being frustrated with his current circumstances which is pretty pretty normal.

And then from that, so he acknowledged certain areas. Now those areas we're going to go and find the strategy pages so First, they're going to give you information about that area And ignore the fact that they say community mental health, there's two different versions, I believe one is for

Mental health and criminal justice and another one is for another area, I believe.

But it doesn't matter. They're all the same. All the strategies are strategies.

No matter what environment you find yourself in.

And then you're going to start to see, you're going to see strategies below And then there's typically a second page and you'll see some more strategies So these are not absolutely use these it's figure out what's going to work for people and use this to jumpstart your brainstorming.

So James's strategies He met with a point person, someone that he really connected with each morning for about five minutes. And it was just okay james Show me your calendar, show me your notebook.

Do you have everything written down? What's going to happen today?

Do you have everything that you needed for those activities? And he has a notebook with sections with important areas of his life so they can go and Check those real quick if needed. He has areas for treatment.

For his son and child welfare for court and for work.

And we're all going electronic these days and all these days That's great. And we can use those tools where they work.

But often something physical that the person can outside of an electronic device, where if I need my calendar, I have to think about it go in and check if I had something there.

But if my notebook is there, I can just flip to the page. Obviously, I have to open that too.

But it's sitting there as a cue right there. And then he was we guided him to take brief notes when needed and they had to be brief, otherwise he wouldn't be able to pay attention to what he needed to pay attention to.

He was to review his calendar and notebook at the beginning and end of each day You can look at it as much as he needed to look at it Other than that but other than that you know kind of get grounded in the morning and then just make sure at the end of the day everything's been done

Because of the impulsivity, he needed to use a stop, think, go.

When planning something or before speaking just kind of taking a deep breath. We paired it with deep breaths just to give yourself that physiological pause And then he was to repeat information back ask people to slow down when talking

And to control the environment and be aware of visual and verbal distractions. So we increased his awareness of the fact that these visual things, so things in his environment and things that he could hear were distractions for him. And how does he start to control

For those. So we also got the treatment center, the substance use and the child welfare program to start changing the way they do things as well And you might think, well, you know, I don't want to change That's for brain injury. We don't see that many. Well, you do. You see more than you think you do.

But also the changes are going to become normal.

So they might seem like they take extra thought in the beginning they're going to become normal and then they're going to help lots of other people in the program too.

So they're going to help people with learning disabilities. They're going to help people with ACEs, with adverse childhood experiences, people who have experienced trauma. So even in domestic violence situations, anybody who's so they're going to just help overall. So they began to do things like trying to present information in as many modalities as possible so if they were

Talking about rules, they'd also have the rules written out in front of them. If the rule could have a picture.

That's helpful too. People had to summarize what was said or how it related to them, like in group situations When that's the norm it doesn't make someone first it helps everyone's processing and it's also not helping the person it's not making the person who

Who has to have that feel… like they're the only one and i don't want to I don't want to ask questions or I don't want to summarize something when nobody else needs it? Well.

Other people are going to need it too. So let's just make it a norm here.

They put a whiteboard in the room and someone would write down any important information that came up And that can be where you rotate it.

But let's say there's some couple of people in the group that you know they're not going to be able to hear what's going on and write on the whiteboard or they're not going to be able to pull out the key things

Then just make it like it's a job like for maybe two people rotate and they do it.

And maybe other people have other other jobs. And they tried to keep regular appointment days and times so Wednesday at 10 was always the counselor. So wherever they could do that or the doctor whatever Other things they did was try to eliminate environmental distractors where they could, like quiet zones

Notepads were available. Now everybody should have everybody, maybe not everybody, but in our program, everybody had a notebook, but that was a cog rehab program.

And there were always though notepads available within these groups here so that they could write thoughts down instead of interrupting or capture something they wanted to remember And then mindfulness and deep breathing exercises were part of the program there were

Different like classes that worked on those things they would build in where needed if things started to get a little bit tough.

Build in mindfulness or deep breathing, they would just kind of stop and and do something.

Mindfulness changes your brain.

It will change it and make it calmer. At least in the the amygdala, which is that emotional area so It is great for changes other parts of the brain to helpful for memory.

But it'll quiet that trump where the trauma has really lit things up and then stop, think, act was encouraged throughout there were uh stoplights hung up.

Streetlights. Next thing we did was we educated the staff on brain injury. So obviously they had to be educated to do some of those changes that we just talked about. So we gave trainings though to The substance use treatment center to child welfare and also to the recovery court. We want to just get everybody brain injury informed.

Everybody was encouraged to adopt that protocol that we talked about.

And educational materials were shared. And we also talked about the service coordinators. And if you've heard me before, you've probably heard me say they're one of the best kept secrets for brain injury within the state there are seven free service coordinators across the state

Who can help with complex cases they can help if you don't know a provider. They might know where a provider is that you can get someone to.

A specialty provider You don't want to refer everyone in your program who you identify with a brain injury to them. We will overwhelm them. There are seven. And like I said, brain injury is a huge deal. We just want to refer to them, the people that we really need.

Extra help with. And then we want to educate the person about their brain injury. So in James's case he had lived with this with several brain injuries.

For years, but he didn't know that. So that can be really startling to hear.

In James's case uh he was he was kind of relieved to hear that. It made sense to him. It kind of put pieces together We gave all the strategy sheets that you saw earlier from this mind source.

And then James participated in giving modifications. He's like, I don't want to do it that way.

But I'd love to do it this way. Because that way it's really going to be much more personalized. We gave them educational materials. I'll show you some of those.

And he wanted information shared with his wife, but he didn't want information shared with his employer, at least not yet he didn't want to go in and be that guy with a brain injury but he did say but i'm

Going to show these things that I need to do differently And I think he's going to be fine with them. And we know that if it's a reasonable accommodation, the employer needs to provide that Anyway, and again, the employer was on James's side for sure

Turned out to be willing to let him use any of these strategies or accommodations.

We also went through the personal guide for everyday living after traumatic brain injury.

And this So this came from working in the brain trauma center And I found myself saying the same things over and over and over again to people and then finally put it down on paper.

And then modified it through the years. This top information we reviewed really deeply with James.

You'll notice that you'll notice that All of those things there will make your thinking worse too. So if you're tired enough.

You're going to have a hard time thinking. If you're emotional enough, including really excited.

Some people will say, well, I don't remember much about my wedding. It's because the the emotion was so high. If you're being under pressure, rushed, stressed, anxious, if you're drunk or even under the influence of prescription drugs, so non-prescription drugs.

Benadryl. If I have that.

I shouldn't be doing this. Being in pain or being sick.

And being sick can even start to throw you off before you have clinical symptoms your body is already under the weather. It's not functioning right. And a lot of our mild folks would come in and they'd say um Today's a bad day. I don't know what's wrong.

I can't think, I can't find my words. And then the next day they'd be out because they were sick. And we realized, ah, there's this kind of they're so sensitive. Their thinking is so sensitive to even beginning to get sick.

So we went through these things with James. It's really important that people, if people can understand and then control these things that's what the next section is about then they can maximize what they have for cognition.

Then we go through, we want them to understand the different types of attention because if they can get that Then… they can begin to take control of things. They can simplify tasks to make them sustainable.

Detention. So specifics about their life So sustained attention The example that we give is like reading a magazine, reading a book. There's a few there that people can understand. But then we say, okay.

How does this relate to your life? And in his program, it was like listening when someone's talking, just listening staying focused on them.

At work, it's listening to a customer for him. Simultaneous or divided attention, keeping your attention on two or more things at a time For James, it was putting an order in the computer while listening to the overhead speaker to hear if there was something that he needed

That was directed toward him. And then alternating attention is needing to switch your attention between two things.

So it's like working with a customer stopping to get on the phone and knowing where to get back to.

For james where he was. And then there are two more pages where we increase your awareness of distractors.

And we anticipate the distractors. Try to eliminate them wherever possible.

And then for James, we use old strategies. And for James, he used a lot of routines.

So we tried to build new things that he needed to remember.

Into your routine, either an old routine or if they were a whole group of new things then that kind of became its own routine where possible.

And then we shared community resources with James as well. So we told him about service coordinators. We told him that Holland was his But you don't need to contact her unless there's um there's a big issue that you're not able to handle. But we wanted him to have that information

And note that there's nothing here for substance use as community resources Because the substance use folks provided all of that.

So remember that these parts of the protocol that I told you about, I told you about the screening with the OSU.

I told you about assessing cognitive and functional impairment through this mind source tool. And then within that mind source tool, there are accommodations.

Well, I'm going to make it easier for you. Those are all found within the NASA obis and the obis is the online brain injury screening and support system.

And it's electronic. You can use it on paper, but it's easier. The whole point of this is to to do it electronically so you can electronically give someone a link, they can do it on their phone you can have them do it on a tablet on a computer

Whatever is going to work best all three of them are fine too so that you don't have to use staff time to do that unless someone needs that assistance You can give it to somebody if they are just doing

Prior history of brain injury, that'll take about 12 minutes. And then if they need to go on, it'll take a total of about 25 minutes. So not a lot of extra time and you're going to get some great information that you're going to need

To truly help this person. Some good resources that you can go to to learn more about dealing with behavioral health is this tool right here, ACL's Behavioral Health Guide. It also mentions mental health, substance use, criminal justice, domestic violence, and homelessness.

There's a great SAMHSA resource, Traumatic Brain Injury and Substance Use Disorder, making the connections and again you're going to have links to all of these.

And there is a child welfare one as well, best practice And Tennessee was co-chair on the development of this guide.

Pretty awesome. And then we used These Tennessee Brighter Futures resource pages and infographics to educate staff that we were dealing with. So everyone needed the brain injury ones.

And I should point out that infographic on the intersectionality and all of its brain injury and all of its intersectionalities So if you can see all of these little boxes Dennis, is the pointer showing up? Never mind. Let me just go to the, I'll go to the laser pointer.

So all of these boxes show all of these areas that brain injury intersects with.

That one is not quite finished yet. We're putting the final touches on it. So you'll have to come back to get that one, but you will have the link.

Will be there. Note that the criminal legal system, the criminal legal system folks didn't necessarily need those resource pages.

They needed the substance use ones. They needed the brain injury ones that you usually need If you're the expert in the area, you usually don't need yours. You usually need the other ones.

And I would suggest if you're a frontline provider. Download all of them, put them in a folder, or if you're like, I don't know if it's old fashioned, but I like paper paper.

I like to see things. I like to flip through. So I put all mine in a notebook.

So either is available for you. So let's move on to Aleea.

Aleea is in school full time. She was in school full time. She met a guy that she loved.

It was a little bit of controlling of her time but she thought he really That just meant he loved her. When she graduated, he wanted her to move across the country and she did.

At that point, he cut her off from everyone. He became abusive.

He strangled her multiple times and hit her in the head.

Too many times to count that could almost be in quotes because that's what you hear a lot.

Hit me too many times to count and she was thrown against the wall multiple times. She had a child and when he threatened the child, that's when she ultimately decided to leave.

She did press charges. She was trying to get on her feet in a shelter.

She misses appointments she has difficulty following the rules. And she can't tolerate the noise.

In the program. So what do we know? What are we thinking about at this point? Well, we know that as many as 20 million women each year could have a TBI caused by domestic violence.

Head, neck, and face are among the most common targets in intimate partner.

Assaults. So again, we're thinking that could that's a possible brain injury.

Women who are abused are more likely to have repeated injuries, not just one, but repeated injuries to the head and repeated stranglings.

And we know that the strangling can produce an anoxic injury. And what we know about anoxic injuries are that they really hit memory.

The hippocampus, which is the the key memory structure in the brain, really needs oxygen. So it gets hit hard when, And those people Often, if they have an anoxic injury,

Unless it produced some, it was bad enough to produce some physical change, you generally don't know it.

You would have to be interacting with them you'd have to see patterns of forgetting and things like that.

Maybe they don't remember you and it takes longer to learn your name and all that can often come from an anoxic injury.

We know that people with brain injuries are likely to experience difficulties with attention, concentration, memory, executive functioning.

Information processing And we know with the cognitive changes Especially when we're talking about domestic violence can make it harder to assess danger to make safety decisions to adapt to living in a shelter so you know you always hear, well, why didn't she just, or he, but why didn't she just leave

And this cognitive factor comes. So there's a complex answer there But this cognitive part comes into play too that it's Well, how do i how do I leave? When do I leave? Where do I go? What do I need?

All of that takes a lot of planning. And that's much, much harder to do.

After a brain injury. And we know that it's very likely that the perpetrator has a brain injury.

So in an ideal world, we want to get him or her help as well.

Here we have highlighted the things that suggest that Maybe there's something cognitive going on for cognitive going on Aleea. And then I have can't tolerate noise in green That can suggest that there's been a concussion But it can also suggest that it's a recent concussion. That tends to be

A symptom that we see within the early stages after concussion that they can't tolerate noise and sometimes they can't tolerate lights, bright lights. So it could be that there's something more recent going on. It can also be that it's more that

She can't tolerate the noise just because of concentration issues that she's having.

So it's not like a sensory sensitivity. It's more of a cognitive. So these are all things that are going through our mind at this point.

So what did we do? Well, we gave the OBISSS so we screened for prior history of brain injury. We screened for cognitive problems. We did all the same thing.

We've provided accommodations and strategies. And for Aaliyah.

We saw that she has memory problems she was given a notebook. She was given everything in writing along with the verbal. So it wasn't just here, you know, have this book, but we wanted her to hear it too.

House rules. Remember, she wasn't following rules House rules were posted in the front and reviewed regularly until she knew them.

So it could look like she's being obstinate. She just doesn't want to follow the rules. And in Aleea's case, it wasn't that at all. She just didn't know there were rules to be followed and we can say yeah we showed them to her. Well, yeah, you did but

They didn't stick. So let's get them to stick. The need for note-taking was reinforced in groups.

A schedule was posted in her room. So that she would get to appointments on time, all appointments were put in her phone with an alarm. So initially someone worked with her to do this and then she got to the point where she's like, oh, and a

An appointment, let me put it in my phone. Let me set an alarm.

Just note that some alarms are going to need to be set. Like when I'm sitting here at my desk and I want to know about an upcoming meeting.

10 minutes is enough. I'm sitting here anyway. But if it's something like a doctor's appointment, you might need to give enough time to get ready and get there.

So just note that. And she also worked on sleep hygiene. Her sleep was a mess. She was used to kind of you know just being real on alert And so she needed some work on sleep hygiene.

The staff slowed down. They checked in for understanding. And they paused between ideas.

To help her to get it. They taught her to become more aware of when she didn't understand something So we tend to go, well, she didn't ask me questions so She clearly understood me.

Folks aren't even sometimes processing to the level of understanding that they didn't get something.

So we have to do more, at least initially to be checking in And to ask them to be to we need to be slowing down Did you get that? What do you think about that?

And then distractions were minimized. They tried to keep noise levels down.

And there were some quiet zones, especially around rooms for inhibition, impulsivity, they implemented deep breathing.

And meditation. And again, becomes a part of the program Physiologically, you're physiologically changed when you're deep breathing.

Then meditation. You got to work people through the time where they say i I'm just sitting here. I'm just sitting here I'm not getting quiet. My brain is all over the place. That is a part of the process.

So we need to reassure people that you you may go through a while.

Of sitting but it's this practicing this calmness practicing labeling thoughts, saying, oh, I'm planning, oh, I'm worrying.

Not diving into the thought. The thought might come back. Oh, I'm worrying again.

Oh, I'm worrying again. And that might be what that meditation session looks like. That's great.

That's great. You are on your way. And you just do whatever you can do. If it's a minute, if it's five minutes.

Awesome. You're starting to make those changes in the brain. Obviously, counseling was a great, great resource for her She was told that she needed to let other people finish speaking.

Often people will feel like They have a right to interrupt because if I don't, I'm going to forget you really don't have that right to interrupt because you're going to throw off the person who is speaking it's rude. So we're going to work on strategies that allow you to not have to interrupt. So writing down

A key word was really helpful for Aleea. And then stopping and thinking.

Before she ran to do anything. She also had a decision-making template to help her. Now, it didn't look like this. It was on paper.

And it was kind of just each, it can be stepwise or it can be columns however works for that person.

But it had these components. What is your problem that you're trying to solve?

What are possible solutions? What are pros and cons of that?

And then what is the solution that you're going to choose?

And maybe a why, why you chose that. The possible solutions is one of the most important parts.

Because often people don't make They make the wrong decision because they never got to even listing the right one.

So we want to slow people down here and say. What are all of the possible solutions and you can even say Even if they're ridiculous.

Because that's going to get your brain working on generation. And that's really important.

So we also advocated for screening for Aleea's abuser.

We were able to train the court and the prison system. And so you'll remember that I said in the beginning that these are these are, to some degree fake cases where we put people together. So this is the ideal world. In the ideal world, we want everybody trained. So we want to get in there.

With the court system, with the prison system. And in the recovery courts that we've worked with, we find that they know that our people, brain injured folks, are in there.

So they have been very, very receptive. So get in there for training wherever possible.

We got strategies implemented for the abuser and we got the court to implement the protocol.

So connecting Aleea with community resources we also explained the service coordinators to her and that Fredda was hers if needed But really the shelter might be, and the folks at the shelter set her up with might, depending on what our issue is, might be

The best resource for her to go back to. So changes that the shelter made, they try to present information as as many modalities as possible. They had people summarize what was said or how it related to them.

And you might be going at this point, well, this sounds really familiar for the changes that James made.

They are because they are. It's we're dealing with the same sorts of things. So the same sorts of things can be helpful.

Which makes it really easy. But there might be some tweaks. Rules were posted in each common room in each room common spaces, regular appointments were made whenever possible.

Mindfulness and breathing were were put into play Stop, Think, Act was encouraged.

And the decision making template was reinforced for everybody because again a lot of these things They're just good things that can help Everyone. And the hope is that Over time, these strategies are going to become much more automatic for both the staff and for

The person using them and sometimes they could an external thing can become internal. So I can get better at visualizing and holding on to my my schedule, but I just need time to kind of be getting more organized and getting my cognition kind of

Under control overall and then getting rid of all those conditions that we talked about.

Being tired, being in pain. So the recovery court also made changes. Everything was given in writing when possible.

More processing time was given when the person needed to respond to a question, they were given time to think.

They weren't pressed. Notepads were given out to write thoughts down. The lawyers summarized the proceedings.

Anytime there was a break, anytime there was at the end.

And they also had a pad between them and the person where they could just write key things that were happening that the person could see.

And then this is a hard one. The lawyer slowed down when speaking.

All people entering the system were screened for prior history of brain injury and everybody was given strategies.

Here are some great domestic violence resources. They come from the Ohio Domestic Violence Network. They have some great resources.

That you can check out. And then the resource pages that were relevant here were the brain injury ones, the criminal legal system.

And domestic violence. So let's talk about John.

John is… 24 years old. He was recently released from prison He had a brain injury in middle school playing football.

He started shoplifting. And he went to a juvenile detention center at that point where he sustained another injury. And we hear that a lot.

Once someone gets into the juvenile system they'll often It's just the nature of the system that they'll often have another injury.

He fell in with a bad crowd. After that, he started stealing cars for joy rides.

And he works for his uncle now as an auto mechanic and he loves that.

And he has a very high ACE score, Adverse Childhood Experiences.

So what do we know at this point? What are we thinking about? Well, we're thinking about that high ACE score.

That makes it more so if you have a lot of adverse childhood experiences you are more likely to have a TBI later on in life not not that it's absolutely going to happen.

But we also know that that's also that's trauma and that is going to impact the way that you think.

It's going to make you more emotionally responding and emotionally responding more impulsive generally.

The juvenile justice system, we know that 40 to 50% have a history of brain injury.

Likely to sustain more over time and the criminal justice system, like I said, comes into play for john as well has 50 to 80% have a prior history of brain injury.

Again, we know that people with traumatic brain injury have attention, can have attention concentration, memory.

Executive functioning and problems processing information. And they often have executive functioning changes and these are also going to go along with the high a score, making poor decisions, poor judgment and more impulsive that's because so executive functioning is a frontal lobe

Function, why people with ACEs tend to have difficulty is because their amygdala or the emotional part of their brain is so fired up.

That it overpowers, it doesn't have great connections to the frontal lobe. So it's overpowering what the frontal lobe can step in and do.

So we need to be calm enough to be able to assess a situation calmly and go, okay, here's what I'm going to choose.

So what did we do? We used the OBS. We did all those sections and with sections with John, we found high inhibition scores that he was aware of.

Saying things without thinking, doing things without thinking, not following directions.

Dominating conversations, interrupting others. When others were speaking. Now, keep in mind that anything that you get, this is a self-report measure. So anything that you get from this the person is aware of.

You may see things over time and it may be a whole separate section.

That the person never doesn't know that they're doing. So we may also need to be stepping in and going, "Hey.

You know, I'm noticing this thing with memory. Are you noticing that?"

Or whatever it is. So he's he's seeing these inhibition.

Issues. The strategies that we used were, again, deep breathing meditation let's change the brain. That makes something like the stop -think - act easier to use because the brain is is operating. When I say slower, that's a good thing.

We're quieting the amygdala we're lighting up. We're making the frontal lobe more active.

Counseling was really helpful for him too And he was counseled also to help let others finish speaking, write a note.

One word, if you can, if that will work for you.

To let them finish and then you can continue. He also needed the decision making template has looked a little bit different but the key areas were still the same.

We educated him about his brain injury as well. Well, again, this startling revelation for some people. For John, it was really, I don't want to overstate this, but it can be life-changing for some people.

For someone like John, what he was starting to realize was "Do you mean that this means I'm not a bad person?"

I'm like, "Yeah, you're not a bad person. Your brain is operating in a way that made you not think about what you were doing. You didn't evaluate who you were hanging out with you just you just - boom, acted."

So that was eye-opening for him. It was really important two four for his uncle, to John, for his uncle to know that. He wanted his uncle. He felt like everybody around him that had loved him or still loved him

Felt like he was a bad person. and he wanted them to understand that, yeah, you made bad choices.

But um it was all because of this. Again, that's not an excuse, but it is a reason. All of the strategy sheets that came from the mind source were reviewed with him.

The educational, and the thing about the OBISSS, is that if you use the OBISSS versus this on the right-hand side, the mind source pages, they will be electronically sent the relevant ones to the whoever is assigned the counselor. Whoever it is, the staff,

and to John. So you're both getting them, which is a nice a nice quick thing. All of educational materials were shared with him. I'll show you those and we talked with his uncle to help him understand the issues that he

having and how he could support him. We went through the five types of concussion with John. Because we just wanted him to really understand more about that there really was, there really were some concussions that he had. And that there are different types that come with different symptoms so

He was able to say, ah, "The first one I had more of these symptoms. The second one, I had more of these symptoms." 

And then we want people to understand the two modifying factors that sleep and neck issues can drastically change the cognition. So if you can get the sleep under control and any neck pain that the person might be having, just getting that neck in alignment, sometimes you take away the concussion symptoms. They weren't truly concussion. And sometimes you minimize them so much because sometimes there was this,

You know, this overriding factor that was making it so much harder. So those are two, this is a great resource to be using with folks. And then we use the personal guide with him too, just a great educational resource. We went all through all the stuff that you already know

And then for him, his sustained attention was just staying focused on working on a car, not getting on his phone, not getting distracted by internal thoughts not leaving and going and grabbing something and coming back.

But his divided attention having a conversation while trying to take a note that was difficult.

And then alternating attention, his thoughts interrupting. Him working He's checking his phone, interrupting.

So internal distractors were things that we needed to work on with him. Again, the meditation will help with that.

But again, that is not a fix. That is not a quick fix. It is a fix, not a quick one.

We need to be doing some other things. We had him write his distractor down.

And then you need to decide, does he need to do it? Can it wait? And then if it's a big enough thing just use the decision-making template later to figure out what you need to do.

With it so key documents for the justice system are the Criminal Justice and Juvenile Justice Practice guide and a Guide to Resources to Address TBI within Juvenile Justice.

Systems. Disability Rights of North Carolina has a great database that has 30 years of stuff in it. And you can go in and you can search it by, you only want juvenile justice information you only want you only want

CIT, crisis intervention training stuff in it. You only want it related to domestic violence.

Great resource. And the resource pages from Tennessee Brighter Futures that we used were the Brain Injury, the Criminal Legal again, and the Adverse Childhood Experiences. And this also has information on Positive Childhood Experiences to help counteract things.

And you might notice that the these infographics have a lot of similarities to them.

And that's because this protocol that i have I told you about now for each of the is universal.

It goes through all of the systems. And so it's repeated on everyone where it's brain injury in the criminal legal system. Okay, do these things.

You're working in a domestic violence system do these same things.

Maybe some tweaks, but same things. Now let's move on to our final case. This is Rudy.

Rudy is 27 years old right now.

He's homeless. He knows he had a severe brain injury when he was 12.

It was from a car accident, but he didn't know much about it.

So luckily the shelter that he went to was brain trauma informed. And so they tried the step. They tried the OBISSS.

But um Rudy was not a good self-reporter. It really wasn't helpful for him wasn't going to work. So they were able to find his mom.

And find that he had a severe car accident when he was 12. He was right about that.

It was a family member that was driving, so it was rarely talked about It happened over the summer.

And he was in the hospital five days. His mom says there were tubes everywhere. It was a big deal.

He recovered well and he was discharged to home with no follow-up.

It was a big deal it was a rollover accident. His mom described Rudy as like this big teddy bear or really when he was little, he was a little teddy bear before his injury, he was lovable and fun and funny and he had lots of

Friends. The school was never notified because no one thought it was a big deal. The doctor was really pleased with his recovery.

But his mom says that thinking back. His grades slowly dropped that year by the end of the year. So this happened over the summer.

He goes into that school year. They can look good Initially, because you're often building on, you often have old learning at the start of the school year that then gets built on.

Especially at the beginning of the year. And then it takes time to see where new learning isn't happening. So we often see change in schools later on.

A year later, the end of the school year. So his grades dropped that year and he was starting to get into trouble for wandering. He was just wandering around the classroom And he was bothering other kids. He wasn't finishing his work.

He was getting into trouble in the lunchroom and in recess.

And the kind of the light bulbs go off for us there because those are unstructured times.

So it is more likely that the rules are less clear and we see trouble in a lot of kids in that area. And at that point, really his behavior became the focus Not his school work or the grades because then he was being like

Starting to become labeled as this behavior kid, this trouble kid. By ninth grade, he seemed to be alone a lot. Again, this is all the mom.

Telling us this, he stopped liking school by high school. He dropped out in 11th grade. His mom said he became too much to handle. They got into lots of fights.

And he left home six months later and she lost track of him.

The caseworker at the homeless shelter got Rudy into a group home. He was finally ready to do that.

The caseworker scheduled a neuropsychological exam, but like many of you probably encounter, it was four months out. It was not going to be easy. They're not going to get quick information.

Neuropsychological evals are the gold standard for brain injury. They are.

So they went with the next best option, which is to have an evaluation by a speech language pathologist who is trained in neurological disorders so someone who can do a cognitive linguistic evaluation and they're going to get a lot of good information. They're going to be able to infer

a lot from a lot from the language, what they're seeing through that.

Again, neuropsych eval is the gold standard, but if you can get to a cognitive linguistic evaluation by an SLP.

That's a very, very good kind of substitute. And then if you still need and want that that neuropsychological evaluation later, that's great.

Do it. They used that SLP information along with staff observation so all the information that you have from any source the mom any reports that you might have on other people that if you're dealing with a different case bring all of that information together.

You can put it into this Brainstorming Solutions Tool. So this was a tool that was developed when we were working with the Department of Intellectual and Developmental Disabilities. And we realized that there were folks that were working in group homes

And in community settings with people who were very significantly, had significant impairments in cognition, sometimes in behavior. And they weren't trained in it.

And so we kind of, this is like a a core dump of what a cognitive therapist would be looking for and what would be thinking about.

So all of the information that you have goes here and we're going to focus on the cognitive parts. We're going to skip anything psychosocial and behavioral and hold that for the next webinar.

So maybe that served as a little tease if it did I don't apologize for it.

Hopefully you'll come and you'll be there. We call it the BST, the Brainstorming Solutions Tool, BST for Rudy. I'm going to blow it up a little bit for you.

So they saw problems with attention. He starts doing something else during a conversation. Or when you're trying to give him instructions, he loses track of what he's doing. Processing speed, they see that he doesn't respond right away. He seems confused sometimes.

Memory he forgets instructions. He's forgetting his chores and he needs to do his chores.

He forgets what we've talked about. And I love this because you can see where they are assigning things that might otherwise get attributed to "doesn't want to," "won't." They're assigning it to cognitive things. They may or may not be right but

The fact that you're approaching it from a, "What's the cognitive? What could be happening cognitively?" is a great approach. So maybe he's just forgetting to do his choice. Maybe it's not that he's being I'll rebel about it. And often if you say to somebody, "Well, why didn't you do your chores?"

They might say, "I don't want to." Because… the feeling of saying I forgot feels really bad and they don't want to be that person that has a bad memory They'd rather be the person that's like the rebel the the bad kid, especially if they've kind of been that before.

Initiation, so starting things, the ability to start things They don't know if he's forgetting.

Or if he isn't initiating. So again, I love this this clinical thinking that's starting to happen just by using the tool.

Awareness, they say he's not really sure what's going on. And we kind of saw that with the the trying to do the OBISSS that he does not have a good awareness.

He just knows "things don't come easy to me. This is just how I am." He doesn't know why, but this is just how he is.

But we also, I love that they wrote this too. "I don't like it when people treat me like I'm stupid."

So he knows they're doing something different for him. So then continuing on that, we also see impulse control. He gets angry quickly. So this is good information.

We're attributing it. We're looking at it through a cognitive lens. But we're also being able to put down some behavioral things here, which is going to be great for the next time on April 3rd when we talk about psychosocial and behavioral changes and what do we do about that.

So he gets angry quickly. He yells. Sometimes he throws something at somebody but he says something He's not trying to hurt anyone. It's almost like this impulse. "I'm just mad all of a sudden." And then he says, "I'm bad sometimes."  So he's attributing it to

You know like who he is, "I'm bad." They notice that he has difficulty understanding when it's too fast, too complex.

And he speaks very simply. Organization-wise, they say he's messy especially his room, but he also leaves things around common areas they're not sure about planning. And here's a really good thing too. They're noticing though when they when they have then they're forced to think about

Planning.  "Well, he does sit a lot and he watches TV a lot." Is that because he's not planning something else?

To be doing or you can't plan it. Problem solving, he often thinks of one solution and he acts on that.

His judgment seems good. His vision seems good? He doesn't say he can't.

But I love the question mark. They're questioning it. Motor ability, they can see that. So they can see that it does seem good And then we're going to talk about social the next webinar.

And they said emotionally he seems sad sometimes and he seems angry sometimes.

And they know that the environment that works best is quiet.

And he does get distracted with noise or lots of movement and or people so we got some good information from here and then the SLP, this will get filled out even more information and then the neuropsychological about you'd get even more information.

What I love about both of those evals too is they will come with recommendations. So here are some strategies that might help with those things.

So you don't have to do a lot of problem solving.

So let me let you enjoy that while I tell you that we provided lots and lots of education to Rudy because he was not aware. We needed to increase his awareness first.  It's hard to get someone

To change something, to do something different, like use a strategy when they don't understand why they're doing it. We did do this guide with him as well.

Filled it out for him. I'm going faster just because you've seen these things already.

Now, this is a guide to possible changes after brain injury.

This, we would love in an ideal world that this gets handed out every time someone is discharged from the hospital when they've had a brain injury.

Or might have had a brain injury when they are discharged after brain surgery, when they get discharged from a a cognitive rehab unit. Because we know that just because someone has gone through treatment does not, we know that Medicaid

or Medicare has now just designated designated brain injury as a chronic a chronic issue, meaning that we know that people have issues for a very long time for life for some people.

So this is just something for them to hang on to. We really gave it to him and to his the people more than anything because of this part here where it has all of these symptoms that are listed.

Right in here. And so you can find your symptom and then know who to go to.

For that. So if something comes up now we're teaching everybody to know lots about strategies.

It doesn't mean that you have to go there. But if you need extra help.

Then that could be really helpful. And then the final page has brain health information prevention and resources.

We also trained everyone, including Rudy, about brain health you know that there's this wonderful idea of person-centered care, which is what the person wants to do But that really needs to be informed.

I want to eat hot pockets all day long. Well, Hot Pockets are terrible for me.

That would not be my voice of choice that just came to mind. Maybe Rudy likes those.

But what about, what are you doing to yourself long term? So what can we be doing better in all of these areas.

And this is an evidence-based document that we have that you can use to educate people, to leave with people. We also have a brain injury, a Brain Health training that is on our YouTube channel. And Jen, that's one I didn't put on our

Didn't expect to say that. That's not on the sheets, but our YouTube channel.

I might have it on her from the first webinar. That Brainstorming Solutions Tool, or the BST, has this kind of sister document that goes along with it, the Strategies and Accommodations Tool. or the SAT. and it has for every area on the BST,

It has a corresponding area where you can see strategies. Now, again, this also is not the be all end all for strategies, but you can put it together with the mind source, you can put it together with any other ones.

Any other tools for strategies, you can Google "strategies for memory issues."

But it's to be kind of a tickler and it's also to help you to see. If you see the initials like here under initiation, you see SLP and NP. That's a speech language pathologist might be able to help you with that or a neuropsychologist.

Might be able to help you with that. The really important thing is we need to have input from Rudy.

The team's going to brainstorm. Well, Rudy's going to be a part of that. We may do some of the brainstorming behind the scenes. But then Rudy gets to go.

"That's not going to work for me. I need to do that differently. No, I do not want you cueing me by saying that it that way.

Because you're going to make me feel stupid. And that's not good. That's not going to work.

I want you to say this instead." And anytime I can get someone else's word their own words to tell me how to queue that's what I want. And let's say that because Rudy is predisposed to feel stupid,

When he's given feedback maybe you have an agreement and the first time you give that or second time or whatever you say it to him.

And he has a big reaction that's a trigger for him.

I usually do really well saying, "Oh, Rudy, no problem. That was what you had said that I could say to you to remind you that this was happening.

If you don't want me to say it that way, I won't say it that way." And that will often really just diffuse it and they realize you're just there to help.

So we can either change it at that point or usually at that point folks will tell me.

"No, that's fine. That's fine." And then we modify as needed. Sometimes modify because the person is making improvements and we need to lessen the strategy system. Strategies for Rudy and communication we needed to do a lot of it. We needed to slow down when talking.

Shortened sentences. And the information. We needed to be careful not to talk down to Rudy.

And over time, we really got a sense of what that was for Rudy, what made him feel that way.

Use visuals whenever possible. Demonstrate things. And then Rudy's job was to be asking questions. Again, we recognized that he wasn't always going to ask us a question when he didn't understand because he wasn't processing that deeply enough to realize he didn't understand.

He was listening to us, so he thought he had it.

But he didn't. But that was his job to get was to get better at asking questions.

For chores, because he wasn't doing his chores, and really being a part of a living community he needed to.

We hung up a chore chart. For him. There was color coding involved.

We put the chores on his calendar. That he used so that he could he had all of his chores, but then they were also listed in a calendar telling him when to do which ones.

They were put in his phone with a reminder alarm. And for messiness, we set up systems for where things need to go. So if you think about the executive functioning issues that somebody has problems developing a plan Well, imagine if you've ever walked into maybe you have children and you've walked into

Their room and you tell them to go clean it up.

It's overwhelming because they don't have the skills for that either.

So for Rudy, what we did was we set up systems where there were different bins held labeled bins held different things. He had pictures of sometimes what each bin looked like or what the closet should look like when it's good. And then when things were categorized, that was helpful for him.

So that can be a great tool. So it wasn't that he wanted to be messy. It wasn't that he was trying to be dirty or anything like that.

But it was an executive function task that was too much for him.

For planning, he had a calendar and then he was involved in developing the steps. So just because the chore was written down didn't mean that Rudy could break that down.

So we put steps for it and where we could, we put pictures Rudy had a volunteer job at the food bank and first he was able to start by making boxes and that making boxes station had pictures And it had general steps written.

By each picture of what he needed to do. He got real good at that. He didn't need that anymore. It was there but he didn't need to use it anymore. It just became kind of a motor memory thing And then he was able to restock the boxes for the sorters. When the sorters ran out, the food sorters.

He put them in a taped off. So he knew right where they went when that was empty or close to empty. And then again, he just got better at that.

Then he was able to use the pallet jack to move the loaded boxes.

Where they needed to go. And so we really saw as he masters one job he can add another And still remember the first one. And it was best if we could kind of be cycling him through the things So that he would always be remembering.

And then the goal really is for him to get a paid job at the food bank.

A good tool that you can look at for more information about homelessness is this adapting your practice by the National Health Care for the Homeless Council?

And the resource pages were Brain Injury, Homelessness and Minority Health.

And that's Rudy. Well, there's more to Rudy. Join us next time. We'll finish out Rudy and do another case as well.

Focusing on psychosocial and behavioral changes. And that's on April 3rd.

So time now for your questions. And I'm going to flip the screen.

While you're typing those in. To the survey. So please take this one minute survey and you will get a certificate of attendance.

Afterwards. So hopefully you can use that for CEUs and this is being recorded. It will be posted to our our website and the materials will be there as well.

If you have any other colleagues that could benefit from this information or from getting continuing education credits and can get it by using a certificate as I can.

Please refer them there. Jen, any questions?

Yes, yes. Just one moment here. I'm trying to also, I'm getting there are um I want to put our link in there for people who maybe are not using the QR code too, although it looks like it's working well.

Right.

Bear with me, it's happening.

It's hard to be doing a two things at once. I learned that too.

We've had a quiet group and it's still sometimes a little hard to see everything. Okay.

Hmm.

So we have one great question and it might spur some more questions.

And I did answer it online, but I want you to be able to answer it too, because it's really good. And it's funny because I think that this especially this last case with Rudy was a perfect segue into this question.

I will read it. This is from our good friend Kelly B.

And Kelly, feel free to um put something in the chat if you want for me to unmute you so that you can speak if I'm not if we don't answer it fully, but Just let me know. Kelly said, "Do you find that strategies are most often needed for a lifetime

Along with a need for strategies to change over the course of time

versus ending strategies?"

Great question. It's going to depend, yes. Sometimes they will be needed for a lifetime.

Uh huh.

Sometimes they can kind of be faded out especially if the issue is more mild.

And they kind of just needed to kind of get it almost feels like there's reorganization that's going on in the brain So, um.

Or the steps become more more to the forefront of our awareness. I think schools don't do don't always do a great job of helping children and then later in college and all helping us learn how to learn or helping us to learn how we

So sometimes the strategy is kind of telling you how you think.

You know it's it's it's filling in some of those blanks like, oh, categories are good. Oh, here's my planning strategy i know no Aleea may not need to use that that decision-making template for the rest of her life Because they become internalized. And she's like, okay, this, this, this. Okay, I'm going to do that

And yes, they can need to be changed depending on, so they might need to be simplified and pieces need to be taken out as people get better. They might also change based on You know, Rudy wasn't working and now he is working. Okay, now we need new strategies. Sometimes

they'll go from environment to environment and sometimes they won't. So that's a great time when someone is changing environments to pull in support again or for support to kind of if support is to become more involved and then be able to back

Out. Hopefully that Answered.

Kelly.

Oh, Kelly has a response. "It feels that there are times when individuals feel that they're doing better so they stop using the strategies."

Yes. Yes.

It's the strategies that allow them to do it well. She said, thank you. This is wonderful information.

Yes. Yes. So I always used to talk about, and I would have people that would all the time say this is in therapy. So we're still in that early phase. They'd say, well.

I don't want to use a strategy because I want my brain to get better at it more like The way I always explained it is It's a safety net. The strategy is a safety net.

So you may or may not need it, but you have it.

You want to learn it so that you can use it when it's needed. And we want in this beginning time to be using it to help your brain sort of reorganize and and get better and get better to think about how it does things.

So maybe later we'll take it away. And then I'd always have people that would say.

No, I don't want to use a planner. Because I want to I'm going to remember it on my own. I'm not going to use the planner.

And I'm like, did you use a planner before you were injured?

Yeah, I did. Okay. The brain injury didn't make it better.

So let's still use every strategy that you used before. We're going to use them still.

There was a reason he used them then. They worked. And then when you can normalize strategies to say.

You know a lot of people do this. A lot of people use calendars. It's a normal thing. It's not because just because you've had a brain injury.