Traumatic Brain Injury An Overview

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					Traumatic Brain Injury: An
Helping Mental Health Professionals
    Identify, Support and Treat
       Individuals with TBI
              A Product of..
The Maryland TBI Post Demonstration Project
            This Presentation prepared by:

Maryland Department of Health and Mental Hygiene

  The Maryland TBI Post Demonstration Project

The Mental Health Management Agency of Frederick
                   County, Inc.

     “…supported in party by # 1H82 MC 00019-01 from the
  Department of Health and Human Services (DHHS) Health
  Resources and Services Administration, Maternal and Child
   Health Bureau. The contents are the sole responsibility of
   the authors and do not necessarily represent the views of
  DHHS. This is in the public domain. Please duplicate and
                     distribute widely. “
• 1.5 million Americans each year
• 80,000 each year experience long term
  disability following a brain injury
• Traumatic Brain Injury is the leading cause
  of death and disability for Americans under
• Risk of TBI is higher for men then women
          In Maryland……..
• In 2000 there were 5,229 traumatic brain
• 5% of all hospitalizations were TBI related
• 25% of all injury related deaths for ages 15-
  24 were TBI related
• 11% of all injuries to children 14 and under
  were TBI related
•   Transportation-44%
•   Falls-26%
•   Other/Unknown-13%
•   Non-Firearm Assaults-9%
•   Firearms-8%
      How Does TBI Compare?
• TBI results in 1 1/2 times more deaths each year
  then AIDS
• More Americans died as a result of TBI between
  1981 and 1993 then have been killed in all the
  wars in our history combined
• Each year 1.5 million people sustain a TBI, that is
  8 times the number of individuals diagnosed with
  breast cancer
   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
• Safety features such as car seatbelts, child
  safety seats and airbags
• 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-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
        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
        Types of TBI-Severe
• Almost always results in prolonged
  consciousness or coma of days,weeks, or

• 80% of individuals with severe brain injury
  have multiple impairments in functioning
      Possible Changes-Thinking
•   Memory                  •   Executive skills
•   Attention               •   Problem solving
•   Concentration           •   Organization
•   Processing              •   Self-Perception
•   Aphasia/receptive and   •   Perception
    expressive language     •   Inflexibility
                            •   Persistence
       Possible Changes-Physical
•   Motor skills/Balance
•   Hearing
•   Vision
•   Spasticity/Tremors
•   Speech
•   Fatigue/Weakness
•   Seizures
•   Taste/Smell
    Possible Changes-Personality and
•   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
    Lack of Awareness
A common and difficult to remediate
     hallmark of a brain injury
    Focus of Rehabilitation and
      Often Lifetime Support
• Increase individual’s awareness of injury
  imposed deficits
• Increase awareness of the the impact these
  deficits have on current functioning and
• Teach to anticipate how these deficits could
  affect future plans/activities
             Focus cont.….
• Teach the individual strategies for
  compensating for injury imposed deficits
• Treating therapists should conduct home
  visit to ensure strategies are meaningful in
  and carry over to the home environment
    Strategies for Remediation and
• Use of a journal/calendar
• Create a daily schedule
• “To do” 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
• 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
     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
• 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
• Treat the individual like an adult in context,
  tone and body language
• Ask the individual for permission to coach
                Behavior ….
• Be clear on your expectations of the individual
  and his/her behavior
• Give feedback immediately using the sandwich
• 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
   The Goal is to…...

Enhance the Predictability of the
        Daily Routine
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
• 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
• Heart Bypass
• Transplant
• Brain surgery to treat a tumor, aneurysm,
•   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…..
• Any reported or suspected functional
  difficulties that are interfering with home,
  work or community activities
    If you suspect an individual has
         had a brain injury…..
•   Obtain the medical records if possible
•   Interview family/friends for collaboration
•   Arrange for a Neuropsychological evaluation
•   Refer to a neuropsychiatrist for medication and
    behavioral consultation
• Consider referral to a brain injury rehabilitation
• Brain Injury Awareness Presentation-Brain Injury
  Association and the Brain Injury Association of Maryland,
• National Center for Injury Prevention and Control 2003
• Maryland Centers for Disease Control Surveillance 2003
• National Association of State Head Injury Administrators
• Brain Injury Association of America 703-
• Brain Injury Association of Maryland 410-
• Ohio Valley Center For Brain Injury
  Prevention and Rehabilitation, 614-293-
      Anastasia Edmonston
        Project Director
Maryland TBI Post Demonstration

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