A Day in the Life

A Day in the Life

R. E. is a 13 year old male with an extensive history of psychiatric disorder including diagnosis of depression and schizoaffective disorder who sustained traumatic brain injury on 10/6/97 as the result of being hit by a car while riding on his bicycle. On admission to Del Ray Medical Center he was noted to have right rib fractures, right pneumothorax , a left femur fracture, a pelvic fracture, and an ankle fracture. Skin grafts were required on the right. Reports indicate that he had a Glasgow Coma score of VII on admission, although follow-up information was not provided. Antidotal reports from the family suggest that he may have been in a coma for approximately two days. He was transferred to Health south-Sunrise hospital on 10/29/97 where he was noted to be medically stable yet agitated, restless, and screaming. Since then he has been involved in a variety of therapeutic activities although compliance has apparently been quite poor. Records reviewed included neuropsychological consultation completed prior to this most recent brain injury with notations of significantly reduced executive and adaptive performance skills. He was referred for admission to the Florida Institute with specific goals of improving his overall performance so that he can transition home with a minimum of complications. As part of the referral process, R.E. was interviewed, along with his family, by Cheryl Levine of our staff. Various medical records were also obtained for review.Based on information available to date, R.E. is appropriate for admission to the Florida Institute. The general goal will be to continue rehabilitation while working to improve his ability to comply with necessary therapeutic procedures to ensure best possible outcome. We anticipate that he will be discharged to home under the care of his parents although this is preliminary in nature. As described above, R.E. has apparently had multiple residential psychiatric placements prior to injury, thus the discharge plan and overall outcome are subject to change as we gather more information and the initial 30 day period. With the conclusion of this, we will generate specific functional outcomes and communicate them to all concerned parties.

As noted above the rehabilitation program will be directed toward improving general self control and behavioral functioning. In general it is likely that his program will include:

Intensive behavioral supervision, monitoring, and teaching. Information from Health south indicates that he is non- compliant with treatment, hostile, aggressive, and at times quite agitated attempting to kick or otherwise strike therapy and other staff. His family notes that he had difficulty in self control and impulse control prior to injury, however they note that he has seemed to become somewhat more aggressive as directed toward people as opposed to objects and property. The most important area for initial intervention will focus on compliance, with clear and supportive, yet firm intervention in this area. Very simple steps and procedures will be outlined with R.E. and frequent practice will occur. He will also be involved in an overall facility wide contingency management program that stresses increasing performance and compliance on a day to day basis. As this is occurring, other areas such as accepting "no," following instructions, acknowledging and appropriately following the requests of others, demonstrating alternatives to verbal and physical aggression, and increasing general control of impulses will be stressed.
Complete evaluation of medical, psychiatric, and Neurologic status will also occur. We will evaluate his performance on current medications in light of brain injury and make recommendations for change as indicated. Ongoing monitoring will occur to ensure compliance as well as maintaining an ongoing source of data and information for medical review. It is likely that R.E. will be evaluated by our neurologist, neuropsychiatrist, and internal medicine physicians to ensure best possible functioning in this area.
Complete evaluation of emotional and behavioral status. R.E. has apparently had difficulties with depression in the past and at least claims to have had several suicide attempts. Recently his family has apparently noted changes in behavior, mood, and temperament that suggest reemergence of depression or other problems that have been historically very difficult for him. Observation and assessment will be used to determine his current emotional status with particular respect to prior levels of functioning and corrective strategies to be implemented. Generally individuals within our programs tend to improve in these areas simply through positive association with others in a success oriented environment although other treatment options such as individual follow-up will be considered.
Evaluation and treatment of residual problems in physical status including alterations in endurance, strength, and mobility particularly with respect to ensuring adequate healing of fractures and redevelopment of active physical skills.
Evaluation of cognitive and language functioning. It has been noted that R.E. demonstrates difficulty in speaking although it is not entirely clear whether he simply chooses to not speak or this may reflect additional complications of Neurologic impairment. Similarly he is noted to have increased difficulty in memory with very reduced attention, organization ability, and ability to anticipate events in the future. We will evaluate and provide a number of corrective strategies and treatments in these areas to both continue redevelopment of old skills and hopefully promote more positive change. An additional area of emphasis within this general cluster of difficulties includes notably poor judgment, again with historic roots, that it seems are much worse since injury. Our approach here will be similar to that in behavioral issues with frequent practice, review and teaching of alternative strategies and compensatory routines.
Evaluate the overall impact of injury on R.E.'s ability to complete a variety of routine acts including daily self care skills. Although reported to be capable of this activity prior to injury, compliance was a significant difficulty that reduced performance. It is not clear now that current performance problems are due to continuation of compliance problems or whether these difficulties reflect new problems associated with brain trauma.
Assist the family in understanding the implications of R.E.'s current injury and developing proactive strategies to deal with likely future problems. We will assist them in developing and delivering the type of support structure and supervision he needs in the home, as possible through teaching and training in behavior management strategies and skills. Should it appear that a return to home is not practical, we will assist them in developing other options.R. E. was discharged from the Florida Institute for Neurologic Rehabilitation in March of 1998 and had made significant gains in all aspects of the rehabilitation continuum. He had attended Ridge Learning Center in Palm Beach where his behavior, attendance and academics were reported to be good. Friction however was beginning to develop at home between he and his sibling and his parents. The following year during the advent of his puberty the client transitioned to high school and a special classroom self contained for the emotionally handicapped. His behaviors became inappropriate and disinhibited and attendance in school worsened. He has had recent police interventions for reported domestic violence and disturbances in his home including burglary, pyromania and driving without a license. He also has been threatening suicide.

R.E will be readmitted to the Florida Institute of Neurological Rehabilitation for 30-60 day intensive neurobehavioral restoration evaluation and treatment program. It is the opinion of the staff that the patient has begun to severely decompensate due to a number of salient factors including physical and emotional changes as a result of puberty, school and classroom change creating less structure and therefore more opportunity to become bored and inattentive. In addition, the surroundings of high school and a new peer group of older students creates more temptation to act out and follow in order to be accepted, as well as changes in family dynamics creating a less secure home environment. The family also needs a time out to regroup and work with the FINR facility on new strategies for generalization of skills acquired to these new environments, and a strong emphasis will be placed on readjustment of behavior protocols, medications and collaboration through the IEP process with the new school environment in order to create the right programming and structure for the client.

The Florida Institutes's neurologist and neuropsychiatrist will evaluate and chart R.E.'s progress during his stay. A neuropsychological evaluation was conducted on 10/15/99, nevertheless, the neuropsychologist will review records in aim of treatment recommendations. R.E. will be enrolled in the school program where a behavioral protocol will be developed to increase his self-control and promote the acquisition of social skills and gain insight into his behavior. He will be evaluated by occupational, physical and speech and language pathology for a possible treatment plan. The nurse liaison will coordinate record correspondence necessary for his treatment at FINR.

Health. R.E. has full bladder and bowel management and does not use equipment for bladder control. He is able to chew and swallow without risk of choking. He is prescribed Desyrel, Luvox, and Wellbutrin.
Personal and self-care. R.E. is able to feed himself using utensils and his grooming and hygiene is adequate with supervision. He needs prompting and cueing to initiate self-care tasks and to satisfactorily complete his personal hygiene and grooming. He is able to select his clothing and dress without assistance.
Physical functioning and mobility. R.E. does not use adaptive equipment for transfers or ambulation. Instead he is independent for locomotion and negotiating inclines and stairs and transferring in and out of the bathtub.
Cognitive skills. R.E. is currently in the 9th grade in public school where his attendance has been poor and unproductive. He recently had a neuropsychological on 10/15/99, and his results should be forthcoming. His ability for producing reasonable and safe decisions regarding his social, financial and personal matters is impoverished and in need of supervision. His ability to maintain cognitive control over his affectivity and impulsively is moderately impaired and will need behavioral intervention. Treatment staff will discuss methods for self-control, including recognizing stimuli that triggers impulsiveness and strategies to preempt maladaptive responses. The behavioral specialist will develop a protocol to increase cognitive control over his impulse and urges.The neuropsychological test will focus on his abilities to utilize abstract reasoning, sophisticated problem-solving, concept formation and cognitive shifting. Neuropsychological testing will be needed to explain his abilities for processing auditory and visual information as well as storing and retrieving information.
Community integration. With minimal assistance R.E. is able to initiate recreation and entertainment. He is able to manage small amounts of money for snacks and entertainment yet cannot reasonably possess large sums of money. Occupational therapy will help him develop a budget consonant with his age. He is able to use the telephone and access emergency services. He is able, with assistance, to plan and prepare snacks and simple meals. He needs to learn to cleanup and care for his personal items and clothing. He is able to identify household hazards and danger. Occupational therapy will develop a treatment plan to increase his independence in daily living activities.
Communication. R.E. is able to comprehend conversations and communicate his needs and interests. He is able to read and write and his speech is coherent and goal-directed. He can be tangential at times but can be redirected when he digresses in conversation. His speech is clearly articulated.
Behavioral adjustment. R.E. will be enrolled in FINR's school program where his academic skills will be assessed and a program geared to his level of achievement will be implemented. He will be rewarded for his attendance, participation and work completion. He is manipulative and will attempt to curtail school assignments. He is easily frustrated and cannot delay gratification. He argues, whines and complains unless he is engaged in all pleasurable tasks. He is sexually inappropriate and will need a behavioral program to decrease the frequency of inappropriate masturbation and urinating in public. Additionally, he will be rewarded for inhibiting impulse and discussing his anger and desires.
Psychosocial. R.E. has severe difficulty with social interaction. He has disagreements with peers and reports that he is being "bothered by other kids." He threatened the bus driver for not intervening. Treatment staff will reward R.E. for discussing strategies to improve social relationships. He will be included in group therapy to learn to handle social issues. Also his depression over not "fitting in" with peers will be handled in group therapy. He has limited insight as to how he impacts others socially. Treatment staff will reinforce him for discussing his cognitive deficits, especially his lack of frustration tolerance and inability to delay gratification as it relates to social impingement.
Discharge. R.E. will return home once he has achieved his goals. His family will be included in family education sessions at FINR and to continue assisting the client in generalization of new behavior strategies.