›Rewarding and important part of our social interactions

›Maintains and develops close relationships

›Solve problems

›Work out personal issues

›Share our history

›Make sense of the present

›Plan for the future

Conversation

› Caused by a blow to the head or by the head being forced to move rapidly forward or backward, usually with some loss of consciousness

› Brain damage arises from being torn, stretched, penetrated, bruised and swelling can make the injury worse

› Alcohol associated with up to

half of all cases of TBI

› Car accidents, falls, assaults

sporting accidents

Traumatic brain injury

Most common in males aged 15-35 years and in people >75 yrs

In 2008, the total cost of TBI in Australia was $8.6 billion (Access Economics 2009)

Incidence and cost

Effects of a TBI

(Images courtesy of Professor Erin D. Bigler and Trevor Wu)

Medical difficulties

Changes in physical and sensory abilities

Changes in the ability to think and learn

Changes in behaviour and personality

Communication difficulties

Conversational skill difficulties

Slurred speech

Word finding difficulties

Consequences of TBI

Family strain, emotional distress, caregiver burden, and social isolation

A study of 273 caregivers across six Traumatic Brain Injury Centers in the USA, found that one-third of caregivers are at risk for depression, anxiety, or other forms of psychological distress

A main source of stress is difficulty communicating with the person with TBI

Impact on family

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Families can affect communication outcomes

Early work compared people with brain injury and their brothers without TBI interacting with a range of communication partners

Communication partners had significant positive and negative effects for person with TBI

- Negative effects: asking questions repeatedly, testing questions, not knowing what to do, talking to them like a teacher

- Suggestion: change communication partner behaviours and therefore provide an environment for people with TBI to communicate appropriately

› Participants were allocated to one of 3 groups:

1. Communication partner + person with TBI

2. Person with TBI alone

3. Delayed treatment – control group

› 44 participants with TBI (38 males, 6 females)

Average age = 36 years (range=18-68)

Average education = 12 years (range=7-20)

Average time post injury = 8 years (range=1-25)

Average PTA = 83.15 days (range=6-182)

NHMRC funded clinical trial (Togher, McDonald, Tate, Power and Rietdijk)

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Everyday communication partners

44 communication partners of person with TBI

Mean age = 50 years (range = 17-79)

Mean education = 13 years (range = 9-19)

80% were female

80% knew the person before the TBI

The majority were partners or parents, however siblings and friends also participated in the study

TBI Express Conversational skills training program

Group of 4-5 people with TBI & their communication partners

2.5 hr weekly group sessions (+ morning tea/social break)

1 hour weekly individual sessions for each pair

10 week program, with assessment of conversation before, immediately after and 6 months after treatment finished

TBI Express is available at

www.assbi.com from

ASSBI Resources

Three ways to have a good conversation

•Collaboration

•Elaboration

•Question asking

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How to collaborate in conversation

Collaborative

›Shares information

›Confirms partner’s contributions

›Shows enthusiasm

›Communicates respect

›Questions in a non demanding, supportive way

X Non collaborative

›Demands information

›Talks like a teacher

›Lack of enthusiasm

›Corrects the person

›Fails to acknowledge difficulties

›Quiz like questions

Being collaborative when planning a barbecue

Person with TBI says: “I want to have my BBQ at home”

Less collaborative

partner:

“No. We can’t have a big barbecue in our unit,

we’ll have it at a community centre”.

More collaborative

partner:

It would be nice to have the BBQ at home.

I was thinking though, we’ve got lots of people

coming and our place is pretty small…(see if

this cues an alternative)…

“Let’s think of bigger places we could have it”.

› I am going to help you organise and extend your thinking

›Elaboration of topics: I want to keep things going

›Elaborative organisation: I’ll help organise the conversation so we can talk in more detail

Elaboration

Elaborative

› Introduce topics of interest

› Add information to help develop topics

› Organises information

› Makes connections when topics change

› Reviews what has been said

X Non elaborative

› Introduces topics which are not interesting to the person

›Changes topic frequently

›Fails to make connections from one day to the next

Question asking

Good questions

›Open ended

›True questions

- About events where you were not present

- Feelings

- Opinions

X Poor questions

›Closed

›Testing, quiz like

- Question asker already knows the answer

- Testing performance, memory

›Yes!!

After treatment there were significant treatment effects found for

those who attended communication partner training

Person with TBI was judged to have better interactional skills

Communication partners improved in their ability to help the

person with TBI communicate effectively

Conversations were rated as being more rewarding, less effortful

and more interesting

Did the treatment work?

›Yes !!

Effect was maintained at 6 month follow up

i.e., The communication partner training group

improved relative to the other two groups

(Togher et al., 2012, 2013)

And was it maintained over time?

Research translation: manual, DVD, website

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Non collaborative behaviours › Giving him too many options without allowing him enough time to think

about the choices

› Asking him to rely on his memory without giving cues

› Testing his memory rather than helping the conversation to be interesting

or enjoyable

› Correcting him in a punishing manner while making his errors obvious

rather than giving a natural conversational response

› Talking to him like a teacher, including praising his ability to remember in a

condescending way

› Lecturing him on correct behaviour rather than showing understanding

› Taking a leadership role in conversation and stating her own plans rather

than allowing him to contribute.

Collaborative behaviours › Asks questions that include information which help him remember rather

than putting pressure on him to remember

› Gives cues in a conversational manner

› Gives correct information conversationally and connects his incorrect information to the correct answer to make his error less obvious

› She contributes her opinions so that they are sharing equally in the conversation

› Invites him to share his opinions without putting pressure on him

› Acknowledges his opinion even though she may not agree

› She communicates respect for his concerns

› She makes a suggestion about going to the shops but leaves it open for him to agree or disagree

› She guides him to organize his thinking and make a plan

Elaboration videos

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Summary

Training communication partners was more efficacious than

training the person with TBI alone

Communication training for families led to improved

engagement in social activities, increased independence for

some people with brain injury

Provided the first link in re-establishing the social network of

the person with TBI

Training everyday communication partners is an important

complementary treatment for people with TBI and their families

to facilitate and promote improved communication outcome

Telehealth – Assessment

and treatment using Skype

(Rachael Rietdijk)

Trialing the use of TBI Express

with people in outer urban, rural and remote areas

(Seeding funding from the Institute of Safety Compensation and Recovery Research (VIC)

Where to from here?

We are currently conducting a clinical trial of

communication partner based training: Comparing

Skype with in-person training

Participants need to:

• Be at least 6 months post-TBI

• Have significant social

communication problems

• Have a communication partner

• Have a computer with Internet

connection at home

• CONTACT:

Leanne.togher@sydney.edu.au

We are excluding participants who:

• Require an interpreter

• Are unable to participate in conversation (severe aphasia)

• Are unintelligible in conversation (severe dysarthria)

• Are unable to provide informed consent (severe amnesia)

• Have current drug or alcohol addiction or active psychosis

›Recovery after TBI can extend beyond 2 years

›Brain plasticity: rewiring of the brain occurs with repetition of specific tasks which are meaningful

›Treatment intensity is needed to create structural brain changes –practice practice practice

›Positive motivation and realistic goal setting are essential to success

Successful conversation is essential to all aspects of daily life and we can all improve our skills

Some take home messages