(Cont’d)
In addition to (or instead of) neuropsychological evaluation, use your own behavior observations to understand what the injured individual is capable of doing. Watch him try tasks throughout the day and take notes on what you see. Ask other family members and friends to do the same. Get a good picture of what he does, when he does it, how he does it, and where he does it. Observe the impact your behavior has on his abilities. Don’t make assumptions about the meaning of what you are seeing; just make observations.
It is especially critical that you observe and understand the individual’s limitations in the broad area called “executive functions”: attention and concentration, distractibility, initiation, planning and sequencing. These are the skills which must be developed before you begin to address more specific areas such as memory, learning, and perception. You must discover how long he can attend to each specific type of task: you may observe that he is able to process verbal information for only 5 minutes but visual or motor information for 15 minutes. He may do well on certain activities if the room is quiet and he is well rested but totally lose that ability if the slightest noise occurs. You may observe that once he starts a task he can finish it easily but appears unable to get that first step going. Or you may observe that he consistently stops at the same step or leaves the same step out each time he tries a certain task.
Although it is relatively easy to understand the injured individual’s limitations in physical endurance, limitations in cognitive endurance are more difficult to observe and to understand. It is important that you keep track of time as well as activities as you observe the injured individual: how long the individual can work with words, with visual information, and on motor tasks and see how abilities in these areas deteriorate over time.
One of the hallmarks of head injury is performance variability: the individual can do something with apparent ease one day and appear totally confused and unable to do the same activity another day or at a different time the same day. In analyzing the individual’s abilities, therefore, it is important to understand the circumstances under which each ability is seen: (a) environment variables (e.g., who else was present, other activities occurring at the same time); (b) variables within the injured individual (e.g., fatigue level, how long the activity went on, what else the person has done earlier in the day, mood); (c) interpersonal variables (e.g., the mood of family members involved in the activity).
Memory problems are extremely common following head injury and account for a large percentage of the problems experienced by injured individuals and family members. Unfortunately, many people do not understand that attention and concentration must precede memory: if information didn’t get in the first place, you can’t remember it later on. We also tend to evaluate memory by verbal reports (i.e., what the person says) rather than behavioral observations (what the person does).
Generally the problems are in remembering information since the injury. It is important to observe what kinds of information the individual is able to remember and under what circumstances. Is he more able to remember something he did than something you told him? Does he remember things he heard better than things he saw or read? Does he remember things that happen in the morning better than things that happen at night? Have you observed him doing things even though he says he doesn’t remember how to do them? Can he remember things in one location and not another? If you understand the circumstances under which he is most likely to remember things, you have a good handle on how you can retrain his general ability to remember important information.