Procedure for Assessing Awareness and Adjustment Following Brain Injury

Procedure for Assessing Awareness and Adjustment Following Brain Injury

Kit Malia, B.Ed., MPhil, CPCRT and Anne Brannagan, DIPCOT, MSc.

This rehabilitation manual for psychologists and therapists has a detailed protocol for assessing awareness and adjustment in adolescents and adults with a brain injury. It can be used in rehabilitation and community programs, and provides full instructions and scoresheets. By comparing the responses of survivors, therapists and family caregivers, the user gains information and insight into the complexity of self-awarenesss and its impact on rehabilitation participation and compliance with therapy programs.

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Full Description

This manual gives clinicians and caregivers a procedure with practical tools for assessing changes in awareness and adjustment in adults with brain injury. Using a methodical approach with step by step instructions, users are guided through 23 steps with 24 worksheets for assessing intellectual awareness, emergent awareness and anticipatory awareness. Once the levels of awareness and adjustment have been assessed, information is used to set short and long term goals for six domains of cognitive, executive, communication, physical, emotional and other. Accompanying the 71 page manual is a CD with PDF forms for all worksheets and scoresheets.

This manual provides methods for clinicians and caregivers who are working with clients in a variety of settings including inpatient and outpatient programs, community based programs and home settings. It includes methods for including families in the assessment process by gathering and comparing their observations and experience with that of direct-care staff.

  • This manual is included in the Cognitive Rehabilitation Tool Kit after TBI.
ISBN# 978-1-931117-47-0
Pages 72 pages, 8 ˝ x 11, perfect bound, softcover
Year 2008, second edition


Kit Malia, B.Ed., MPhil, CPCRT

Mr. Malia is the only Certified Cognitive Rehabilitation Therapist in the United Kingdom (via the Society for Cognitive Rehabilitation, USA). He holds a research degree in Neuropsychology. Initially trained as a teacher for people with learning disabilities, he has spent almost 19 years working as a cognitive rehabilitation therapist with adults who have acquired neurological injuries at The Defense Medical Rehabilitation Center, one of the largest brain injury rehabilitation units in the UK.

Mr. Malia has published scientific papers on cognitive and psychosocial rehabilitation, and clinical standards in brain injury rehabilitation. He is the primary author of Brainwave-R (an extensive collection of cognitive strategies and techniques for brain injury rehabilitation). He has also co-authored The Brain Injury Workbook with Dr Trevor Powell.

Mr. Malia has lectured at various conferences in Canada, USA, Sweden, Norway, Denmark, Finland, The Netherlands, Slovenia and the UK. He is also on the Board of Directors for the Society for Cognitive Rehabilitation, USA, and is the chairperson of the International Division for the SCR.

Anne Brannagan, DIPCOT, MSc.

Anne qualified as an Occupational Therapist in 1988 from the London School. She did a two year orthopedic rotation before specializing in Neurorehabilitation at the Defense Services Rehabilitation Center in Headley Court. She gained a research master's degree from Kings College in 1993.

Ms Brannagan is particularly interested in the cognitive and executive sequelae of acquired brain injury. She runs workshops with Kit Malia, training both professionals working in the field and caregivers of individuals with brain injury around the country. In addition, she has lectured on cognition at conferences in the UK, Sweden, Norway, Denmark, Finland, The Netherlands and the USA.

She is currently the membership chair of the Society for Cognitive Rehabilitation. She also is the chair of the National Executive Committee of NANOT and is deputy chair of the brain injury forum. Ms Brannagan has developed a number of rehabilitation activities, including a practical approach to the assessment of executive problems (The Brannagan Executive Functions Assessment) following brain injury and cognitive/psychosocial groups.


The Process

About the Authors
Intellectual Awareness (Steps 1 – 12)
Emergent Awareness (Steps 13 – 15)
Anticipatory Awareness (Steps 16 – 17)
Adjustment / Acceptance (Step 18)
Reporting the Findings (Steps 19 – 21)
Reinforcing the Message (Step 22)
Leading into Treatment (Step 23)

The Worksheets

Sheet #1 Changes since the Brain Injury (individuals)
Sheet #2 Problems since the Brain Injury (individuals)
Sheet #3 Funneling the Problems (individuals)
Sheet #4 Changes since the Brain Injury (relatives)
Sheet #5 Problems since the Brain Injury (relatives)
Sheet #6 Funneling the Problems (relatives)
Sheet #7 Summary of Average Scores by Domain
Sheet #8 Summary of Accuracy of Ratings by Domain
Sheet #9 Causes or Links between the Problems
Sheet #10 Anticipated Effects of Problems
Sheet #11 Summary Sheets for Intellectual Awareness
Sheet #12 Summary of Relevant Problems
Sheet #13 Questions to Keep in Mind to Assess Emergent Awareness
Sheet #14 Rating Actual Performance on a Task
Sheet #15 Identifying Problems and Devising Strategies
Sheet #16 Questions to Keep in Mind to Assess Anticipatory Awareness
Sheet #17 Predicting Performance on a Task
Sheet #18 Assessing Adjustment / Acceptance
Sheet #19 Model Profile
Sheet #20 Bar Chart Profile
Sheet #21 Reporting Sheet for Awareness and Adjustment
Sheet #22 Model of Awareness and Adjustment
Sheet #23 Setting Goals for Awareness and Adjustment
Sheet #24 Example Goals for Awareness



While there are some potential positive gains to having poor awareness following brain injury (e.g. unrealistic expectations may initially act as a buffer, protecting the patient from grim reality), it is generally agreed by therapists and families that a persisting lack of self awareness is a major obstacle to successful rehabilitation and reintegration. For instance, individuals who do not admit their problems may be cooperative and compliant in therapy but discontinue compensation strategies on leaving the rehabilitation center. As a result, their functional status will decrease. Even well learned compensation strategies are of little value to a person who is unaware of the deficits they are designed to compensate for.

“Patients who lack an awareness of their deficits or the functional implications of these deficits may, if compliant go through the motions of rehearsing a strategy but are clearly not engaged in the process. Consequently the likelihood of the patient’s learning or putting the strategy to functional use is minimal” (Ylvisaker et al, 1987).

It is therefore important to treat poor awareness as a matter of the highest priority within rehabilitation programs.

Owing to the artificial nature of the rehabilitation center, with its structure and expectations of therapists, the full extent of impaired self awareness is not always apparent unless specific assessments for this area are implemented by the team.

A distinction between awareness and adjustment/acceptance can be usefully made.

Stuss (1991) suggests that self awareness exists on 2 levels:

1) The objective knowledge of the existence of one’s deficits.

2) The associated understanding of the personal significance of those deficits.

The term awareness can be used when referring to the individual’s ability to perceive difficulties. The terms adjustment or acceptance can be used when referring to the individual’s ability to understand or internalize the problems.

The individuals who are able to list their problems, but in a detached way as though the problems have no personal meaning, are demonstrating only good awareness. They may be exhibiting knowledge but fail to use it or be unaware of the implications of that knowledge. The person who is able to demonstrate an understanding of how the problems will affect his/her life is demonstrating good awareness and acceptance.