Traumatic Brain Injury:
Physical, Cognitive
and Behavioral
Implications
Anastasia Edmonston MS CRC
TBI Projects Director
Maryland Mental Hygiene Administration
Training Agenda
• The incidence and
prevalence of TBI
• What is brain injury?
• What are the types of brain
injury?
Training Agenda
• Common cognitive, behavioral and
physical sequela of TBI
• Ideal rehabilitation pathways for
mild, moderate and severe TBI
• The TBI, mental health and
substance abuse connection
Training Agenda
• Why Screen?
• How to Screen for a history of a TBI
• Strategies to support individuals with
TBI
• Resources, medical, rehabilitation,
community supports and
employment
Incidence of TBI
CDC 2006
Worldwide, an estimated 10
million people incur a TBI
serious enough to result in
death or hospitalization each
year
Incidence of TBI
CDC 2004
In the United States, at
least
1.6 million sustain
a TBI each year
Incidence of TBI Of
CDC 2004
those 1.6 million..
• 51,000 die;
• 290,000 are hospitalized; and
• 1,224,000 million are treated an
released from an emergency
department
Annual Incidence of TBI with
Disability
AN ESTIMATED 124,000
American civilians
Cited by Jean Langlois ScD,MPH
NASHIA Conference 2007
Preliminary findings as analyzed
by Selassie, et. al
Returning Veterans
• As of 11.07 VA officials reported that of 61,285 veterans
screened since April 14, 2007 19% screened positive Honolulu
Star-Bulletin Nov. 4, 2007
• Pentagon reported as of September 20, 2007, 4,471 of 30,327
wounded troops sustained brain injuries.
• A September 2007 article in USA Today by Gregg Zoroya
looked at data from a variety of military sources put the number
as at least 5 times that much. (20,000)
• In that same USA Today article, Rep. Bill Pascrell is quoted as
saying more than 150,000 troops may have suffered brain injury
in combat
“Mild Traumatic Brain Injury in
U.S. Soldiers Returning from Iraq”
Hoge, McGurk, Thomas, et.al
NEJM Volume 358:453-463 January 31, 2008
• 1 in 6 returning troops have had at least one
concussion
• 4.9% reported injuries with LOC of those,
43.9% met criteria for PTSD (3xs the rate
found in those with other injuries)
• 10.3% reported altered mental status, of
those, 27.3% met criteria for PTSD
• TBI with LOC also associated with major
depression
Incidence of TBI
Maryland
2000 CDC Surveillance
• 5,229 Marylanders sustained
a moderate to severe TBI
• 13 people a day
• 5% of all hospitalizations TBI
related
Causes of TBI
Unknown,
9%
Suicide, 1%
Other Transport,
2%
Other, 7%
Falls, 28%
Pedal Cycle
(non MV), 3%
Assault, 11%
Motor VehicleTraffic, 20%
Struck
By/Against, 19%
CDC 2006
The Scope of the Problem
By Age
• Approximately 475,000 TBIs occur
among children ages 0-14
• ED visits account for more than 90%
of the TBIs in this age group
• Adults age 75 years or older have the
highest rates of TBI related
hospitalization and death CDC 2004
Why are the Numbers so
Big?
• 30 years ago, 50% of individuals with
TBI died, the number today is 22%
• due to:
• Improved medical technology and
techniques
• Safety features such as car seatbelts,
child safety seats and airbags
What are the Costs of
TBI?
CDC 2006
Direct medical costs and indirect
costs such as lost productivity of TBI
totaled an estimated 60 billion in the
United States in 2000. (That is equal
to the cost of building the international
space center or 60 times the net worth
of Oprah Winfrey )Jean Langlois of the
CDC
A Huge Public
Health
Issue…...
With Very Little Public Awareness or Funding
According to a 2000 Harris
Poll...
• 1 in 3 Americans interviewed were
not familiar with the term “brain
injury”
• 2 in 3 or 66% believe that TBI
occurs less frequently then breast
cancer
• 50% believe brain injuries happen
less frequently than AIDS
BIAA, 2000
In Fact…….
• TBI results in 1 1/2 times more
deaths each year then AIDS
• Each year 1.5 million people
sustain a TBI, that is 8 times the
number of individuals diagnosed
with breast cancer
Public Funding for Brain
Injury
Outlook Magazine 2005
• 900,000 living with HIV/AIDS, Per
person federally allocated $ = $18,111
• 4,557,000 living with MR/DD, Per
person federally allocated $ = $4,635
• 3,000,000 living with Breast Cancer, Per
person federally allocated $ = $295
• 5,3000,000 living with TBI, Per person
federally allocated $ = $2.55
What happens in a TBI?
• Mechanism –
Acceleration/Deceleration
– Differential movement of partially
tethered brain within the skull
• Results in:
– Bruising of the brain surface
against rough areas of the skull
– Stretching and twisting of nerve
axons
Primary Injuries…
Coup-Contra Coup
Chuck Durgin 2007
Primary Injuries…
Diffuse Axonal
Injuries
Rotational forces on
the brain cause the
stretching, snapping
and
shearing of axons
…Primary Injuries
Hematoma
Epidural Hematoma
Dura
Hematoma or
Blood Clot forms
on top of the dura
Dura
…Primary Injuries
Subdural Hematoma
Dura
Hematoma or blood clot forms under
the dura
Secondary Injuries
Intracerebra
l
Hemorrhage
Hydrocephalus
(enlarged ventricles
Edema
(swollen brain tissue)
Definitions: How brain injury
may be defined in the Medical
Record
Traumatic Brain Injury is an insult to
the brain caused by an external physical
force
Acquired Brain Injury is an insult to the
brain that has occurred after birth, for
example; TBI, stroke, near suffocation,
infections in the brain, anoxia
Types of TBI
• Distribution of Severity:
– Mild injuries = 80%
(LOC < 30 min, PTA ,1 hour)
– Moderate = 10 - 13%
(LOC 30 min-24 hours, PTA 1-24 hours)
– Severe = 7 - 10%
(LOC >24 hours, PTA >24 hours)
Using Post-Traumatic Amnesia
(PTA) to Determine Severity of CHI
Dr. Paul McClelland
• When did you wake up from the head injury?
Do you remember being transported to the
hospital? Do you remember being in the
trauma unit? Being transferred to the rehab
unit?
• PTA: period of time after the CHI for which
the patient has no memory
Types of TBI-Mild
• Most common, 75%-85% of all brain
injuries are mild
• Individuals experience a brief (<15
minutes)or NO loss of consciousness
• Normal neurological exam
• 90% of individuals recover within 6-8
weeks, often within hours or days
2000 Epidemiological Study
of Mild TBI J. Silver of NYU, cited in WSJ by Thomas
Burton 1.29.08
http://online.wsj.com/article/SB120156672297223803.html?mod=googlenews_
• 5,000 interviewed
• 7.2% recalled a blow to the head
w/unconsciousness or period of
confusion
• Follow up testing found; 2x rate of
depression, drug and alcohol abuse
• Elevated rates of panic and and
obsessive-compulsive DO
“That first morning, wow, I didn’t want
to move, I was thankful that nothing’s
broken, but my brain was all
scrambled” Ryan Church, NYT 3/10/08
“All he remembers from the
collision with Anderson is the
aftermath, being helped off the
field by two people, although he
said he did not know who they
were until he saw a photograph
later” Ben Shpigel NYT reporter
Types of TBI-Moderate
• LOC/Coma between 20-30 minutes to 24
hours, followed by a few days or weeks of
confusion
• EEG/CAT/MRI are positive for brain injury
• 33-50% of individuals with moderate brain
injury have long term difficulties in one or
more areas of functioning
Types of TBI-Severe
• Almost always results in prolonged
consciousness or coma of days,weeks,
or longer
• 80% of individuals with severe brain
injury have multiple impairments in
functioning
Simplified Brain Behavior Relationships
Frontal Lobe
Parietal Lobe
• Initiation
• Problem solving
• Judgment
• Inhibition of behavior
• Planning/anticipation
• Self-monitoring
• Motor planning
• Personality/emotions
• Awareness of
abilities/limitations
• Organization
• Attention/concentration
• Mental flexibility
• Speaking
(expressive language)
• Sense of touch
• Differentiation:
size, shape, color
• Spatial perception
• Visual perception
Temporal Lobe
• Memory
• Hearing
• Understanding language
(receptive language)
• Organization and sequencing
Frontal
Lobe
Parietal Lobe
Occipital Lobe
Temporal Lobe
Occipital Lobe
• Vision
Cerebellum
Cerebellum
Brain Stem
• Balance
• Coordination
• Skilled motor activity
Brain Stem
• Breathing
• Heart rate
• Arousal/consciousness
• Sleep/wake functions
• Attention/concentration
Possible Changes-Physical
•
•
•
•
•
•
•
•
Motor skills/Balance
Hearing
Vision
Spasticity/Tremors
Speech
Fatigue/Weakness
Seizures
Taste/Smell
Possible Changes-Thinking
•
•
•
•
•
Memory
Attention
Concentration
Processing
Aphasia/receptive
and expressive
language
•
•
•
•
•
•
•
Executive skills
Problem solving
Organization
Self-Perception
Perception
Inflexibility
Persistence
Possible Changes-Personality
and Behavioral
•
•
•
•
•
•
•
Depression
Social skills problems
Mood swings
Problems with emotional control
Inappropriate behavior
Inability to inhibit remarks
Inability to recognize social cues
Personality and Behavioral
cont..
•
•
•
•
•
•
Problems with initiation
Reduced self-esteem
Difficulty relating to others
Difficulty maintaining relationships
Difficulty forming new relationships
Stress/anxiety/frustration and reduced
frustration tolerance
A memory deficit might look like
trouble remembering or it might
look like……
(Capuco & Freeman-Woolpert)
• She frequently misses appointmentsavoidance, irresponsibility
• He says he’ll do something but doesn’t get
around to it
• She talks about the same thing or asks the
same question over and over-annoying
perservation
• He invents plausible sounding answers so you
won’t know he doesn’t remember
An attention deficit might look
like trouble paying attention or
it might look like …
(Capuco & Freeman-Woolpert)
• He keeps changing the subject
• She doesn’t complete tasks
• He has a million things going on and
none of them ever gets completed
• When she tries to do two things at once
she gets confused and upset
A deficit in executive skills might
look like the inability to plan and
organize or it might look like...
(Capuco & Freeman-Woolpert)
• Uncooperativeness,
stubbornness
• Lack of follow through
• Laziness
• Irresponsibility
Unawareness might look like…
(Capuco & Freeman-Woolpert)
• Insensitivity, rudeness
• Overconfidence
• Seems unconcerned about the extent of her
problems
• Doesn’t think she needs supports
• Covering up problems (“everything’s fine…”)
• Big difference in what he thinks and what everyone
else thinks about his behavior
• Blaming others for problems, making excuses
Lack of Awareness
A common and difficult to
remediate hallmark of a brain
injury
Levels of Awareness
Crossen et.al (1989) J Head Trauma Rehabilitation
• Intellectual Awareness-individual is able to understand at some
level, that a particular function or functions is impaired. A
greater level of intellectual awareness is required to recognize
some common thread in the activities in which they have
difficulty
• Emergent Awareness-individual is able to recognize a problem
when it is actually happening. To do so, they must recognize a
problem exists (intellectual awareness), and realize when it
occurs
• Anticipatory Awareness-individual is able to anticipate a problem
will occur and plan for the use of a particular strategy or
compensation that will reduce the chances that a problem will
occur, e.g. keep and refer to a calendar to support memory for
daily schedule
Ideal Rehabilitation Pathway
for Mild TBI
• Diagnosed after injury and provided with
education and follow-up
• If they are of the approximately 10% of
mild TBI sufferers who continue to
experience difficulty functioning, there is
evidence of appropriate rehabilitation,
neurological/neuropsychiatric/neuropsych
ol-ogical treatment or consultation
Common and Less than
Ideal Pathway-Mild TBI
• Discharged and released from ER or
not even seen in ER
• Memory, emotional lability, visual,
vertigo, headaches and or fatigue
symptoms do not resolve after the first
few weeks following injury
• If subsequently seen by GP or in the ER
often told to just”take it easy”
Common and Less than Ideal
Pathway-Mild TBI, cont..
• Can’t function at work or home
• Spiral into depression and anxiety
• Family, friends and co-workers loose
patience
• If seen by a GP or neurologist may be
viewed as having a psychosomatic
reaction or be labeled a malingerinappropriately medicated
Common and Less than Ideal
Pathway-Mild TBI, cont..
•
•
•
•
•
Job loss
Mental Health Problems
Relationships and supports erode
At risk for Substance Abuse
At risk for entry into the criminal justice
system
Ideal Medical/Rehabilitation
Pathway-Moderate to Severe
TBI
• Acute care delivered at a trauma center (Shock
Trauma, Johns Hopkins)
• Inpatient rehabilitation at a CARF accredited brain
injury rehabilitation hospital(Sinai, Kernan, Maryland
General)
• Outpatient rehabilitation at a CARF accredited brain
injury rehabilitation center offering a community reentry program and individual therapies (Sinai,
Kernan, Total Rehab Care,Treatment and Learning
Centers)
Moderate to Severe TBI
Pathway cont.....
• Referral to a state vocational services
counselor with a TBI caseload
• Vocational services as appropriate can
include: vocational evaluation, work
adjustment training, vocational training,
job placement and job coaching
• Support services in the community-case
management and individual/family
therapy
Common and Less than
Ideal Pathway-Mod to
Severe TBI- Scenario I
• Discharged prematurely from Trauma or
Acute care to a nursing home
• Not followed for improvements, and
timing of rehabilitation intervention
• Suffer from behavioral outbursts, not
well managed by nursing home
personnel unfamiliar with TBI issues
Common and Less than Ideal
Pathway-Mod to Severe TBI
Scenario II
• Discharged from Trauma or Acute due to
good physical recovery
• Referrals not made for continuing
rehabilitation (cognitive therapy)
• Impulse control, memory problems affect
home, community, work and school
• Family is strained
• At risk for mental health problems, substance
abuse, criminal behavior, entry into a state
hospital
Common and Less than Ideal
Pathway-Mod to Severe TBI
Scenario III
• Injured as a child
• Go through ideal pathway thru
outpatient rehabilitation
• Return to school, behind peers
• Struggle academically
• Act out behaviorally, if the injury was
several grades back, not recognized as
TBI related
Common and Less than Ideal
Pathway-Mod to Severe TBI
Scenario III, cont.
• Trouble making the transition to post
graduation roles and responsibilities
• Get in with the “wrong” crowd
• At risk for mental health issues,
substance abuse, criminal activity, burn
out families and supports
• May end up in one of the state hospitals
The Relationship Between
Brain Injury and Mental HealthDepression
• Depression is the most common Axis I
psychiatric disorder after TBI followed by alcohol
abuse, panic disorder, specific phobia and
psychotic disorders (Gordon et. al 2004)
• A 50 yr.. Follow-up of 1,198 WWII vets found that
520 had incurred a TBI. 18.5% of vets with brain
injuries had a life time prevalence of major
depression verses 13.4% rate of depression
among on brain injured vets (Holsinger et.al 2002)
The Post -Concussive
Syndrome and PTSD
Dr. Paul McClelland
• Increased startle response; especially to
loud sounds
• Irritability
• Avoidance of many social events
• Intolerance of new situations
Organic Personality Disorder &
Anti-Social or Hysterical
Personality Traits
Dr. Paul McClelland
•
•
•
•
Decreased impulse control
Labile and superficial affect
Impaired insight and self awareness
Decreased empathy and social
awareness
• Impaired initiative (Depression?)
Partial Seizures & Panic
Attacks or Dissociative States
Dr. Paul McClelland
• Most common type of post-traumatic epilepsy
• Temporal lobe damage and complex partial
seizures
• “Spells” starting suddenly & lasting a few
minutes
• Olfactory (smell) or gustatory (taste)
hallucinations
• Déjà vu or jamais vu
• Micropsia, macropsia and other symptoms
Obsessive-Compulsive Traits after TBI: PreExisting Conditions or Adaptation to
Cognitive Deficits & Other Changes? Dr. Paul
McClelland
• Compulsive behaviors as adaptations
for memory loss
• Temper tantrums and other adaptations
• Non-pharmacological management of
brain-injured patients
Other Mental Health
Disorders Related to TBI
• PTSD is noted in some individuals
following TBI even if there is no memory
of the incidence (Klein, Caspi 2003)
• Rapid cycling bipolar is rare but noted in
the literature for individuals with temporal
lobe damage (Murai, Fujimoto 2003)
• Psychotic syndromes occur more
frequently in individuals who have had a
TBI then in the general population
(McAllister, Ferrell 2002)
TBI & Suicide
• “The risk of attempted or completed suicide in
neurological illness is strongly related to
depression, feelings of hopelessness or
helplessness, and social isolation” (Arciniegas &
Anderson, 2002)
• Simpson and Tate (2002) screened 172
individuals for suicidal ideation and
hopelessness. Findings using the Beck Suicide
Ideation and Hopelessness Scales found 35%felt
hopeless and 23%expressed suicide ideation.
18% had attempted suicide post injury
Alcohol Use & TBI-Incidence
Analysis of the Literature (Corrigan
1995)
• Alcohol, the drug of choice-Corrigan and his colleagues report
that for 70% of the individuals they work with who use
substances, alcohol is the preferred substance
• Intoxication at time of injury-7 studies looked at incidence of
intoxication (BAL equal or exceeding 100mg.dL)at time of injury.
Intoxication ranged from 36% to 50%
• History of Substance Abuse-Findings suggest that for
adolescents and adults in rehabilitation following a TBI, as much
as 60% of this population have histories of alcohol use or
dependence.
Alcohol TBI-How does Incidence and
History Impact on Recovery &
Outcomes? Studies Suggest…..
• Alcohol may negatively affect the process of dendrite profusion
thus impede ability of the remaining neurons to compensate for
the neurons that have been damaged (Corrigan, NASHIA
webcast 2003)
• Alcohol use after brain injury may increase the risk of seizure
post TBI
• Increased brain atrophy observed in patients with a positive BAL
and or history of moderate to heavy pre-injury use (Bigler et al
1996 & Wilde et.al 2004)
• Performance on neuropsychological outcome variables by this
group was generally worse, though not statically significant
compared to other TBI groups (Wilde et.al 2004)
The “Honeymoon” Effect-The
Year Following Injury
• Bombardier reports (1997) that in comparison
with a separate medical patient sample,
individuals with a recent TBI were more
motivated to change their alcohol use.
Motivational Interviewing was utilized and of
50 post TBI patients, 84% fell into the
contemplation or action phases. Greater
willingness to change was noted in those with
alcohol involved injuries and higher daily
consumption pre-injury
The “Honeymoon” Effect-The
Year Following Injury
• In 197 individuals treated at a Level I trauma
center, alcohol use diminished in the first year
following TBI (Bombardier et.al 2003)
• Kreutzer and colleagues (1996)Followed the
pre-and post-injury patterns of alcohol and
illicit drug use of 87 individuals at 8 and 28
months post TBI. Decline in use was noted at
first follow-up. Use at second follow-up were
similar to pre-injury use
Honeymoon Factors
• Individual in an inpatient and/or highly structured
outpatient setting resulting in detoxification
• Physical and cognitive disabilities make access to
substances difficult
• Families are instructed to provide supervision due to
physical needs and judgement concerns
• Individual is remorseful over past use, related
behavior, blames self for accident and vows to
change
Subsequent Use-Risk
Factors
• Male
• Younger age
• History of substance abuse prior to
injury
• Diagnosis of depression since TBI
• fair/moderate mental health
• better physical functioning (Kreutzer 1996, Horner
et.al 2005)
Subsequent Use
• 10-20% of those with TBI develop substance
abuse problems after their injury (NASHIA
Webcast 2001)
• “A person with a preinjury history of two
drinks a day would not have had a reason to
seek alcohol-related treatment before his or
her accident. But once that same person
becomes brain-injured, the continuation of
that drinking pattern has the potential to
cause major problems” Robert Karol, Ph.D.
Co-concurring with
Subsequent Use…..
•
•
•
•
Worse employment outcomes
More likely to be living alone & isolated
Greater criminal activity
Lower subjective well-being or life
satisfaction (NASHIA Webcast 2001)
Suggested Strategies for Professionals
Working with Individuals with TBI
• Review if available any neuropsychological or
neuropsychiatric records
• Attend 12-Step meetings with a “buddy” or staff
member, review meeting highlights
• “90 meetings in 90 days” may be too stimulating or
fatiguing after a TBI, balance so benefits of structure,
social group can be gained
• If the individual plans to share at a meeting, have
them jot down before hand what they want to say on
an index card
Suggested Strategies for Professionals
Working with Individuals with TBI
• Avoid approaches that are confrontational
(Sparadeo, NASHIA Webcast 2003)
• Insight oriented treatment approaches may
not work for individual’s whose thinking is
very concrete after a brain injury
• Offer “The Big Book” and other books with a
recovery or inspirational theme on tape
• “Where the body goes, the mind follows”,
“One day at a time” etc. powerful
Suggested Strategies for Professionals
Working with Individuals with TBI
• Use “Change Plan” & “Staying Clean, Staying
Sober” Worksheets
• Prepare for slip ups-”Emergency Plan”&
“Personal Emergency Plan: Lapse”
• Judicious use of drug testing
• For additional strategies, see hand out;
Substance Abuse Education and Intervention:
Tips and Tools for Clinicians Working with
Individuals with a History of Brain Injury
Why Screen?
What other TBI Screening
efforts have found
Findings from the
Literature…Criminal Justice
System
• Researchers at Indiana State University found
that 83% of felons studied reported a head injury
that predated their first encounter with the law
(1998)
• Adults who had frontal lobe damage prior to age
8 exhibited recurrent impulsive and aggressive
behavior
• 14% of the subjects in the Vietnam Head Injury
Project with frontal lobe lesions engaged in fights
or damaged property compared to 4% of controls
without TBI
Domestic Violence TBI
Findings
• Batterers fared worse on three neuropsychological
indicators of cognitive functioning then a nonbatterer
control group (Cohen et. Al 1999)
• Corrigan et.al., (2003) found that of 167 individuals treated
for domestic violence related health issues, 30%
experienced a loss of consciousness on at least one
occasion, 67% reported residual problems that were
potentially TBI related
• Valera and Berenbaum, (2003) assessed 99 battered
women. Of these, 57 had brain injured related
symptomatology
TBI Among Individuals with
Persistent Mental Illness
• Kathleen Torsney (2004) found in one
mental health treatment setting 13%
of individuals served had a history of
TBI
• These same individuals had been
treated in various mental health
settings but not received specific
brain injury treatment
Homelessness & Brain Injury
A little studied population,
however…..
• A University of Miami study found that 80% of 60
homeless individuals had high incidence of
neuropsychological impairment
• Researchers in Milwaukee found possible cognitive
impairment in 80% of 90 homeless men evaluated.
• Dr. LaVecchia of the MA Statewide Head Injury
Program reported in 2006 that of 140 homeless
individuals evaluated, 83.6% of males and 16.4% of
females had an acquired brain injury
• Other studies in the UK and Australia show similar
rates of brain injury among homeless individuals
In Maryland- Screening Results
from the MD TBI Post Demo II
Project-2005
– Summary of TBI Incidence Among all Screened at 7
public mental health agencies in Frederick and Anne
Arundel counties
– N=190
– 39% no reported history of TBI (78)
– 58.94% of individuals with a history of TBI (112)
– 35.78% of individuals with a history of a single incidence of
TBI (68)
– 23% of individuals with a history of 2 or more TBIs (44)
TBI Screening, Adapted
From:
Ohio Valley Center for Brain
Injury Prevention and
Rehabilitation
John Corrigan Ph.D
Have you ever been injured
following a blow to the
head?
• As a child?
• Playing sports?
• From a fall?
Have you ever been
hospitalized or treated in an
emergency room following an
injury?
• Treated and released?
• Evaluated by a neurologist?
• Had a CAT scan, MRI or EEG done
while in the emergency room?
Have you ever been
unconscious following an
accident or injury?
• Have no memory for the event?
• Felt dazed or confused?
• Experienced a head ache, fatigue,
dizziness, or changes in vision?
Have you ever been injured
in a fight?
• Taken a direct blow to the head
• Experienced a violent shaking of the
head and neck?
Have you ever been injured
by a spouse or family
member?
•
•
•
•
Pushed
Punched
Shaken
Choked
Have you ever had any
major surgeries?
• Heart Bypass
• Transplant
• Brain surgery to treat a tumor,
aneurysm, stroke
Illnesses?
•
•
•
•
•
•
Toxic Shock Syndrome
Meningitis
Encephalitis
Hydrocephalous
Seizure disorder
Lead poisoning
Additional comments and
observations of the interviewer
•
•
•
•
•
•
•
•
•
Any visible scars?
Walks with a limp?
Uses a cane or walker?
Has a foot brace?
Limited use of one hand?
Appears to have difficulty focusing vision?
Difficulty answering questions?
Answers are unorganized and/or rambling
Becomes easily distracted, agitated or is
emotionally labile
What you are looking
for…..And Why
• Any reported or suspected functional
difficulties that are interfering with
home, work or community activities
• With the identification a history of
brain injury, professionals can better
support the individuals served and
make informed referrals to brain
injury specialists when appropriate
Strategies to
support
individuals with
TBI
Restoration
Verses
Compensation
Spontaneous restoration of functioning
occurs most rapidly and dramatically in
the first year following a brain injury.
Generally speaking, the greater the time
from the injury the more rehabilitation
efforts will focus on compensation
Environmental
&
Internal Aides
Creative cognitive
strategies will employ both
kinds of aides depending
on individual need
Environmental,
AKA Prosthetic external
memory strategies and
devices
Changing or modifying the
environment to support and/or
compensate for a injury imposed
deficit
For Example: labeling kitchen
cabinets
Internal
The strategy is “in your head”
For Example:
“I have to work the memory
muscle by counting everything,
like how many times I pedal when
I am on a bike”
Actor George Clooney discussing the use of internal memory strategies in The
London Sunday Times10. 23.05
Oftentimes a strategy can
transition with practice from
the external to the internal
For Example:
Preparing remarks on paper with
“pauses” written in to slow down
impulsive speech can eventually
segue into a internal strategy, “At
the end of every 2-3 sentences, I
will take a breath and check in with
my listener”
Strategies for Remediation
and Compensation
•
•
•
•
•
Use of a journal/calendar
Create a daily schedule
“To do” lists and shopping lists
Labeling items
Learning to break tasks into small
manageable steps
• Use of a tape recorder
Strategies cont.….
• Encourage use of rest and low activity
periods
• Work on accepting feedback or coaching
from others
• Work on generalizing strategies to new
situations
• Use of a high lighter
• Alarm watch
Strategies cont…..
• Review schedule each day
• Post signs on the wall etc.
• Try to “routinize” the day as much as
possible
Teach a variety of strategies for
individuals to incorporate into
their daily routines
• Safety checklist (e.g. for use of stove)reinforces
attention
• Checklists- “things to do before leaving the house”
(turn off all the appliances?, lock all the doors?, did I
take my morning medications? turn down the
heat/turn off the air conditioner?, do I have money or
keys?, where am I going?, how will I get there? What
time should I leave? Etc.) Very good for routine
tasks, reinforces memory
• Place visual cues in the environment (cupboard
labels, written directions, calendars, list of emergency
phone numbers) reinforces memory
Even for individuals with poor new
learning capacity, the three R’s
Review
Rehearse
&
Repeat
Can lead to mastery of tasks as
they eventually enter into memory
Memory Strategies
Adapted from:
Parente & Herman in Retraining Cognition 1996 Aspen Publishers
Memory Strategies
Adapted from:
Parente & Herman in Retraining Cognition 1996 Aspen Publishers
SOLVE Mnemonic
•
•
•
•
•
“S” (S)pecify the problem
“O” (O)options-what are they?
“L” (L)isten to advice from others
“V” (V)ary the solution
“E” (E)valuate the effect of the
solution, did it solve the problem?
Setting GOALS
Executive Skills Training
• “G” (G)o over your goals every day-helps
memory and awareness
• “O” (O)rder your goals-short and long term
• “A” (A)sk yourself two questions each day:
“what did I do today to achieve my goals?”
and “What could I have done differently to
achieve my goals”
• “L” (L)ook at your goals each day. Post goals
and progress on the wall, refrigerator etc.
The use of Prosthetic
external memory devices
• Car Finder-low tech, install a longer
radio antenna with a day-glow flag, high
tech, Design Tech International by DAK
Corp.
• Electronic pill boxes
• “Cheat sheet” or album of pictures of
family members and other important
individuals with their names
By Structuring the environment,
memory, organization, and
attention are supported,
enhancing independence,
reducing frustration, and freeing
up cognitive and psychological
energy to tackle new challenges
at home, work and community
Enhance Communication
• Model how to paraphrase during
conversations to maximize
comprehension
• Instruct how to reduce injury imposed
tendency to be impulsive in word and/or
action by using breaks and pauses
• Speak in short, simple sentences and
phrases
Communication….
• Request that the individual jot down
notes regarding discussions that he/she
has with others and other important
information
• When giving instructions, do it verbally
and in writing and when possible,
physically model the task
Minimize confusion/socially
unacceptable behavior
• Don’t use the word inappropriate.
Rather, give useful and specific
feedback about a behavior
• Treat the individual like an adult in
context, tone and body language
• Ask the individual for permission to
coach him/her
Behavior ….
• Be clear on your expectations of the
individual and his/her behavior
• Give feedback immediately using the
sandwich technique
• Utilize positive reinforcement/feedback
• Formalize your expectations by negotiating a
written contract, signed by all involved parties
• Refer to the contract frequently, update as
needed
Strategies for Supporting
Individuals with
Behavioral Problems
Adapted from Capuco and Freeman-Woolpert’s Strategies for
Supporting an Individual with ABD
Environmental Triggers for
Behavioral Problems
•
•
•
•
Too much stimulation
Rapid pacing
Lack of predictability and clear structure
Overwhelming physical and cognitive
demands
• Negative social input
TIP:
If you manage the
environment, you can
prevent many problems
And always practice a “Adult to
Adult” Communication Style
Bill Kerrigan, Humanim
Guidelines for Behavior
Management
• Increase rest time. Fatigue is a
common problem
• People have limited coping
skills, reduce stress
Guidelines for Behavior
Management
• Keep the environment simple.
People with brain injuries are easily
overstimulated
• Decrease interruptions and
distractions
• Be consistent
• Decrease surprises
Guidelines for Behavior
Management
• Keep instructions simple,
concrete
• If the person has problems
processing language, try
gesturing or cueing
• Write things down
Guidelines for Behavior
Management
• Give feedback and set goals
• Feedback should be direct,
caring, nonjudgmental, but not
subtle
• Avoid criticism
• Give supportive encouragement
• Have a positive attitude
Guidelines for Behavior
Management
• Be calm, cool and friendly
during an incident
• This can reduce agitation
• Avoids reinforcing misbehavior
Guidelines for Behavior
Management
• Redirection works. When the
person is upset, agitated,
aggressive, focus attention on
some other topic, task, person
• Provide choices
Guidelines for Behavior
Management
• Decrease chance of failure
• Keep success rate above
80%
• Watch for frustration and
Behavioral momentum
Guidelines for Behavior
Management
Expect the unexpected. People
with brain injuries can have great
variability from day to day. Mood
swings are common. People with
TBI are sensitive to changes,
disruptions in routine, lack of
sleep, alcohol, minor illnesses,
fatigue and other stressors
Keep in Mind
• Progress can be inconsistent and
unpredictable
• What works today may not work tomorrow,
but may work the following day
• Reduced stamina and fatigue may persist
• Impairment of memory may hinder new
learning
• Transitions may be especially difficult
The Goal is to…...
• Enhance the Predictability of the Daily
Routine
There are limits to what can be changed-Staff
can accommodate the injury related
behaviors by modifying the individual’s
environment, and their own interpersonal
interactions with the individual
Biological Limits to
Behavioral Recovery
Farrell & Hooper (1995)
Glossary of Brain Injury
Rehabilitation Specialists
Speech Therapist: Speech therapists
are trained in the evaluation and treatment of deficits
in attention, organization, sequencing, thinking,
problem solving, judgement, memory, writing and
talking. They can teach and help individuals
implement compensatory strategies. It is important to
note that speech therapists working with individuals
with brain injuries can and do address the mechanics
of speech, e.g., breath control, volume and pitch, but
also play a big role in addressing cognitive and
functional skills. They can make visits to the home,
community and workplace to help design and
implement strategies.
TBI Rehabilitation Specialists
continued……..
Occupational Therapist:
Occupational therapists address skills of daily
living to enhance independence to include those
skills necessary to bath, cook, and run a
household. Occupational therapists address
functional memory, visual perceptual and
problem solving skills. Occupational therapists
work to maintain flexibility of the arms and
hands through exercise and custom made
splints. They can make visits to the home,
community and workplace to help individuals
with the design and use of strategies to improve
independence.
Individuals With Brain Injuries May
Also be Seen by the Following
Rehabilitation Specialists…….
•
•
•
•
•
Physiatrist
Neurologist
Neuropsychologist
Neuropsychiatrist
Special Educator
• Physical Therapist
• Vocational
Rehabilitation
Counselor
• Cognitive Therapist
• Social Worker
Resource Coordination
Services provided by MHA’s Brain
Injury Project in the following counties
• Frederick and Washington CountiesCharlotte Wisner 301-682-6017
• Montgomery County-Catherine
Rinehart Mello 301-586-0900 X159
• Baltimore and Howard CountiesLauren Dorsey 301-529-1508
Training: for professionals
provided by MHA’s Brain Injury Project
•
•
•
•
Overview of Brain Injury
Mental Health and Brain Injury
Substance Abuse and Brain Injury
Traumatic Brain Injury: causes, Impact, and
Implications for the Criminal Justice System
• Vocational Issues and Brain Injury: How to
Support Individuals with Brain Injury in the
Workplace
• Brain Injury: An Overview of the Problem and
Supports and Strategies for Educators
Resources
• Brain Injury Association of America 703-2366000, www.biausa.org
• Brain Injury Association of Maryland 410-4482924, www.biamd.org
• Ohio Valley Center For Brain Injury
Prevention and Rehabilitation, 614-293-3802,
www.ohiovalley.org.
• www.headinjury.com. Good resource for
memory aides and tips
Resources
• Http://www.jan.wvu.edu/media/BrainInjury.html. The
Job Accomodation Network offers useful articles
about working with individuals with brain injury on the
job, and simple accommodations that can be used to
maximize success on the job
• Http://www.neuro.pmr.vcu.edu/ National Resource
Center for Traumatic Brain Injury, developed by the
Medical College of Virginia and Virginia
Commonwealth University. Offers useful articles that
are very user friendly, and a catalogue of nicely
priced resources for working with people with brain
injury
Resources, Voice Recorders,
Watches Alarms, and
Radiopaging
• www.attainmentcompany.com-”StepPad” $29.00,
Records up to 72 seconds for step by step directions
• www.olympus-global.com-Digital and Microcassette
hand help recorders
• www.forgettingthepill.com- has alarm watches, pillbox
organizers with timers, alarms
• www.timex.com-Watch that can keep appointment
schedules, phone numbers, contacts $90.00
• www.watchminder.com-Watch with reminder
functions, 30 alarm settings with viewable messages,
$79.50
Resources, Voice Recorders,
Watches Alarms, and
Radiopaging
• www.dynamic-living.com-carries the Cadex
Alarm watch (12 alarm settings) for $50.00,
as well as low vision devices, key finders,
and more
• www.neuropage.nhs.uk-Radiopaging
system to send reminders of things to do.
Monthly fee, arranged in conjunction with
treating physician if medication involved
Resources
• Http://www.abledata.com/, An online resource
catalogue that lists different types of assistive
technology available to help individuals with all types
of disabilities
• http://www.biausa.org/Pages/AT/, Catalogue of
assistive technology for people with cognitive
impairments. The devices listed have been reviewed
by experts in the field of brain injury. Product
information, and information about manufacturers,
and more offered in this catalogue
Resources….
Central Maryland TAP, access to a variety of
adaptive devices, loans to consumers available
Contact Susan Levi
Workforce Technology Center
2301 Argonne Drive
Baltimore, MD 21218
Voice: (410) 554-9213
Voice/TTY: 1 (800) 832-4827
TTY: (410) 554-9204
Fax: (443) 260-0833
EMAIL: slevi@charm.net
http://www.mdtap.org/loan.html
Resources
The University of Alabama Traumatic Brain Injury
Model System has created the UAB Home Stimulation
Program. This program offers many activities for use
by individuals with brain injuries, their families and
the professionals who work with them. The activities
are designed to help support cognitive skills and can
be done in the home setting. The Home Stimulation
Program can be accessed from the Internet at
htt://main.uab.edu/show.asp?durki=49377. For
further information contact: Research Services, Dept.
of Physical Medicine and Rehabilitation, University of
Alabama at Birmingham, 619 19th St. S SRC 529,
Birmingham, AL 35249-7330/ 206-934-3283.
Tbi@uab.edu.
The Michigan Department of
Community Health
Web-Based Brain Injury Training
for Professionals
www.mitbitraining.org
This free training consists of 4 module that
take an estimated 30 minutes each to
complete. The purpose of the training is
twofold, to “ensure service providers
understand the range of outcomes” following
brain injury and to “improve the ability of
service providers to identify and deliver
appropriate services for persons with TBI”
More on staff training….
As of April 2004, the Defense and Veterans Brain Injury Center at
Walter Reed Army Medical Center is offering an online learning course
on traumatic brain injury through the Veterans Health Initiative. For
more information
contact:http://www1.va.gov/vhi/docs/TBIfinal_www.pdf
http://www.webaim.org/simulations/cognitive - this is a site that can be
used in staff training. It is a simulation of the effects of cognitive
disabilities. You will be asked to complete simple tasks, but other
tasks will get in the way.
http://www.biausa.org/Pages/related_articles.html - links to many
online articles, written not for professionals in the field, but for people
learning about brain injury. The y cover all types of topics, from
substance abuse and brain injury to cognition and brain injury. Written
by various experts in the brain injury field.
Certified Brain Injury Specialist (CBIS) Training offered through the
American Academy for the Certification of Brain Injury Specialists,
www.biausa.org
Acknowledgments
This presentation is based on
training materials developed by
the staff and consultants of the
Maryland TBI Projects
2003-present
Thank You
Anastasia Edmonston
aedmonston@dhmh.state.md.us
410-402-8478