Effective workplace communication with employees with acquired brain injury
- Implementation guide
- Acquired Brain Injury (ABI)
- Talking about talking and listening
- Talking about learning
- Talking about the job
- Talking about tools
- Talking about safety
- Talking about quality and quantity
- Talking about teams and workmates
- Talking about problems
- Talking about changes
- Talking about futures
Acquired Brain Injury (ABI)
An introduction to acquired brain injury (ABI).
Acquired Brain injury (ABI) is the term commonly used to describe damage that has occurred to the brain since birth. There is a large and growing number of people with acquired brain injury employed in disability employment services.
In general, people who are classified as having ABI have sustained injury to the brain through:
- Cerebro-vascular accidents (CVA). Commonly known as stroke, a CVA is a blockage or rupture of a blood vessel that has caused damage to the brain. A CVA usually occurs suddenly and the brain is damaged because its blood flow is interrupted. About 38,000 Australians each year have a CVA. It is the third most common cause of death after heart disease and cancer. Thrombosis is responsible for 40% of CVAs and although the incidence of CVA increases with age, it can occur at any age.
- Traumatic brain injuries (TBI). These are sometimes penetrating head wounds (like gunshot), but more usually a closed head injury, resulting from a blow to the head. Head injuries often result in more widespread damage to the brain than CVA. Moderate to severe TBIs affect around 6,000 Australians a year. Most of these people are under 30 years of age and the majority are male.
- Alcohol or drug related ABI occurs when use of these substances has led to brain damage. Alcohol related brain injury (ARBI) occurs when chronic overconsumption of alcohol causes dehydration and shrinkage of brain cells. Some 1.1% of the adult population suffers 'serious' ARBI, and around 500,000 people have mild or moderate degrees of this form of brain injury.
Brain injury can also be the result of illness, infections, tumors, or incidents when breathing has 'stopped' for significant periods of time.
There is a need to distinguish between people with acquired brain injury and people with intellectual disability. People with ABI often have cognitive impairments which lead, in turn, to them having 'intellectual problems'. So what's different?
In today's usage, people with intellectual disability refers to people who have a condition – usually resulting from a genetic disorder or accident of birth – of overall limited intellectual functioning. People who acquire a brain injury usually retain their intellectual abilities but have cognitive problems affecting specific areas of functioning.
For example, a person with ABI may still be able to play Scrabble at championship level, but may miss the title match because she can't remember what day and time it's being held.
These differences need to be taken into account when working with people with ABI.
The brain is a complex network which controls our every thought and action. The most complex organ in our bodies, it is an insignificant-looking greyish mass, weighing about 1,500 grams, that sits inside our skulls bathing in cerebro-spinalfluid. Certain functions are mediated by particular parts of the brain and these various parts and functions operate in an integrated way. The brain contains an average of 140 billion nerve cells called neurons, that transmit information by a combination of electrical and chemical activity.
Brain injury affects each person differently. The problems people experience will depend on which part of the brain has been affected, and the amount of damage sustained. The extent of some of these changes may not become apparent for some time after the injury has occurred.
Weakness or paralysis of muscles on one or both sides of the body is a common result of ABI. An individual may also lose their ability to coordinate their muscle movements (ataxia), resulting in difficulties eating, speaking and writing. Swallowing problems and incontinence of bladder or bowel may occur as short and long-term effects of ABI.
Speech can be impaired by injury to the nerves which control the speech-making apparatus. (More information about these effects is available in the section on communication.)
Changes in feeling, balance and sensation
People often experience dizziness and imbalance as a result of injury. Changes in feeling and sensation are often experienced, and there can be disturbances to taste and smell, orientation and touch.
Epilepsy and seizures
Following a brain injury, an individual can suffer seizures affecting movement, awareness or sensation.
Injury in which the frontal lobes have been affected can result in a disorder of motivation called adynamia. This condition will lead to a lack of drive and initiative in the person, leaving them indifferent to events and with very limited reserves of energy.
Some people will continue to have persistent pain after their injury.
Many people experience consistent or sporadic headaches as a result of brain injury.
Vision impairments, including double vision, field cuts, sector losses, rapid eye movement and near-sightedness are common, along with disturbances to eye movement and coordination.
Tinnitus (noises in the ears), hearing loss, and vertigo often follow head injuries. Some people may lose their ability to recognise non-verbal sounds; in other cases, the person to be extremely sensitive to certain noises or pitches.
Injury to the brain can affect a person's ability to fix and maintain attention. Common impacts include:
- reduced capacity to focus and maintain attention because of persistent fatigue
- reduced speed in processing information
- reduced capacity to process information leading to problems with handling complex information, or dealing with more than one thing at a time
- difficulties in screening our irrelevant detail.
A large number of people with ABI will have some impairment to how their memory functions.
There are two types of memory – short term and long term.
- Short term memory is where you store information that you need to remember and use again immediately (in the next few seconds, minutes or hours). This includes things like a message you have to pass on, or what you want to get out of the drawer you have just opened.
- Long term memory stores information that you want to retain because it is important to you in some way. Long term memory allows you to remember:
- things you've made a conscious effort to learn like family birthdays, or the words of the national anthem, or the names of the planets in the solar system, or how to stack cartons on a pallet (explicit memories)
- the steps in undertaking particular tasks or actions like tying your shoelaces, using a knife and fork, or how to drive (procedural memories).
If a person's short term memory is impaired (as it is for many people with ABI) they may be unable to transfer new information into their long term memory and to access or retrieve the information that is already stored there. Hence ABI can leave marked differences in a person's capacity to remember events and skills learned before they were injured, and to learn and retain information since the injury.
Procedural memories are less likely to be impaired by brain injury. In other words a person may forget what a door handle is called (the explicit memory of a name) but they are less likely to forget how to use the handles to open or close the door (the procedural memory of how to do the task).
Impaired memory function has a profound impact on a person's capacity to learn because learning relies on memory functioning. There are three steps in memory:
|ACQUIRE||New information is received and goes into short term memory.|
|CONSOLIDATE||Information that is important is passed to the long term memory. You are more likely to store information that relates to information that is already in the long term memory (for example, information about wearing gloves when pruning roses if you remember hurting yourself on a thorn), or that is associated with your emotions (for examples, the words of a song that makes you happy, or your best friend’s favourite colour).|
|RETRIEVE||Getting the information back from your long term memory so you can use it again.|
Difficulties in planning and problem solving
Damage to the frontal lobes, the section of the brain that provides what is often called the 'executive' or 'management' function, will create severe difficulties in:
- planning ahead and using foresight
- organising information and behaviour
- controlling and regulating behaviour
- learning from errors and correcting behaviour
- generating ideas and alternatives
- initiative and motivation
- reasoning and thinking logically
- adapting to change or coping with new situations.
Difficulties in abstract thinking
The thinking of a person with cognitive impairments will often be confined to the actual and concrete, the here and now. Their ability to make mental calculations, estimate and evaluate things – including their own performance – will be limited. People with this problem will also find it very hard to see things from another person's viewpoint.
Some people with ABI will be unable to 'move' their attention from one thing to another, or to change their line of thought. They may repeat the same things over and over. Repetitive and continuous behaviour, speech or thinking produced by brain injury is called 'perseveration'. This can lead to a dependence on specific routines and patterns for doing things.
A person with ABI may show that they know about a task or understand an instruction but not be able to follow through the steps of the task, or correct an error. There is no association between thinking and action. This problem stems from impairment to the brain's ability to regulate thought processes and behaviours.
Lack of motivation and purpose
A person with ABI may talk about all the things they are going to do, but never actually get around to doing any of them without prompting and assistance. This lack of drive and initiative may extend to an inability to initiate any speech or action. It may come across as 'laziness' or passive aggression.
Our ability to think logically and purposefully allows us to consider and monitor our behaviour, so cognitive impairments can reduce our ability to control what we do. People with ABI can be very impulsive, and unable to stop and think about the consequences or effects of their behaviour.
Lack of insight
People with ABI often have very little awareness of their abilities and the way they appear to others.
A person with ABI may appear very self-centred. Damage to cognitive functioning can reduce the ability to acknowledge and understand the perspective and feelings of others.
One of the consequences of self-centredness may be a tendency for the person with acquired brain injury to become very demanding of attention from others, and very dependent on them.
Depression is a very common result of ABI. It may be demonstrated in a variety of ways including mood changes, pessimism, frequent self-criticism and criticism of others, self-pity, suicidal thinking, and social withdrawal.
Problems controlling anger are commonly experienced and are often key contributors to social, vocational and relationship problems for the person with ABI.
Loss of control of inhibition – or 'disinhibition'
Disinhibition stems from deficits in the ability to monitor and regulate behaviours and to perceive their impact on others. Disinhibition may result in irresponsible, impulsive behaviour, uncontrolled swearing or use of explicitly sexual language, or inappropriate sexual behaviour. People who are disinhibited will often stand too close, stare, or ask inappropriate questions.
A range of specific communication impairments may result from ABI. These include:
- problems understanding sounds, word meanings and sentence structures
- difficulties using words and grammatical structure, and controlling language use (for example, swearing)
- problems linking gestures or body language with what they mean (for example, that nodding means 'yes')
- difficulty recognising or understanding the written word (loss of literacy)
- difficulty writing sentences and words
- problems making the correct sounds and smooth transitions between words and sounds
- problems adapting or altering speech volume.
Communication problems may also occur as a result of impaired cognitive regulation of social functioning. The person may have problems:
- organising and moderating the tone of their speech
- organising the 'flow' of speech (there may be very long pauses, for example)
- using language accurately
- staying on a topic
- using or understanding 'abstract' language
- making 'small talk'
- taking turns in conversation
- following conversations in groups or if there are other distractions
- recalling what has been said before
- maintaining eye contact and personal space
- showing appropriate sensitivity to context and cues
- using appropriate gestures and facial expressions.
Any service that aims to assist people with ABI to build their work skills is involved in assisting them to learn, and people with disabilities resulting from ABI face significant communication and learning problems.
For support staff in employment services, the important issue is relevant information about the employee with ABI. Ensure you have all the information you need to carry out your support role effectively. It will help if you:
- are aware of the major physical and cognitive effects of the brain injury
- know the learning strategies that are likely to be effective for the particular person
- have details of other services currently received and other support sources available to the employee
- are clear on what the employee wants from you in the way of employment support
- use the best means by which to communicate with them
- remember that each person with ABI will be affected differently, and that you need to understand the specific needs of each person.