Traumatic Brain Injury An Overview DRAFT

Traumatic Brain Injury: An Overview DRAFT Helping Professionals Identify, Support and Treat Individuals with TBI in the Domestic Violence Treatment Setting A Product of the Maryland TBI 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 (project #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. “ Incidence of TBI In the United States, at least CDC 2004 1.6 million sustain a TBI each year Nationwide  51,000 die;  290,000 are hospitalized; and  1,224,000 million are treated an released from an emergency department  Traumatic Brain Injury is the leading cause of death and disability for Americans under 45  Risk of TBI is higher for men then women 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 Traumatic Brain Injury in the Iraq and Afghanistan Conflicts “The toll of brain injury in this war is enormous. Almost 18,000 troops have been wounded according to the Department of Defense. The VA doctors say that two-thirds of them have been injured by IED blasts and two-thirds of those exposed to blasts suffer some brain injury-ranging from a mild concussion to permanent damage. Brain Injuries-thousands of them-could be the legacy of this war” MSNBC 4/26/06 cited by Langlois 9/6/07 Who is at Highest Risk for TBI? CDC 2005 1.5 times as likely as females to sustain a TBI  Two age groups most at risk are 0-4 year olds and 15-19 year olds  The elderly, frequently from falls  African Americans have the highest death rate from TBI  Males In Maryland……..  In 2000 there were 5,229 traumatic brain injuries  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 Causes of TBI Suicide, 1% Other Transport, 2% Pedal Cycle (non MV), 3% Assault, 11% Other, 7% Unknown, 9% CDC 2006 Falls, 28% Motor VehicleTraffic, 20% Struck By/Against, 19% 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 techniques  Safety features such as car seatbelts, child safety seats and airbags Definitions  Traumatic Brain Injury is an insult to the brain caused by an external physical force  Diffuse Axonal Injury the tearing and shearing of microscopic brain cells  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 Accidental vs. Inflicted Childhood Brain Injury One study found that children with inflicted (abuse related) brain injuries, had a higher rate of mortality, longer hospital stays, higher rates of subdural, subarachnoid, and retinal hemorrhages than children who incurred their injuries accidentally Reece, Sege (2000) In “Archives of Pediatrics and Adolescent Medicine” American Academy of Pediatrics-Committee on Child Abuse and Neglect Pediatrics 2001 “Physical Abuse is the leading cause of serious head injury in infants” “Head injuries are the leading cause of traumatic death and the leading cause of child abuse fatalities” “…95% of serious intercranial injuries and 64% of all head injuries in infants younger than 1 year were attributable to child abuse” The Developing Brain  Children’s brains do not reach their adult weight of 3 pounds until they are 12 years old  The brain, and most importantly, the brain’s frontal lobe region does not reach it’s full cognitive maturity till individuals reach their mid twenties The Developing Brain  The Frontal Lobe houses our executive skills, these include; judgement, problem solving, mental flexibility, etc.  The Frontal Lobe is very vulnerable to injury  Damage to the Frontal Lobe any where along the developmental continuum can impact executive skill functioning Focal frontal lobe disorders and violent behavior Brower and Price 2001 “Acquired sociopathy”describe in individuals with ventromedial prefrontal injuries in adulthood  Adults who incurred frontal lobe damage prior to age 8 exhibited recurrent impulsive and aggressive behavior  14% of subjects in Vietnam Head Injury Project with frontal lobe lesions engaged in fights or damaged property compared to 4% of controls without TBI  From the Literature regarding Perpetrators of Violence…...  Researchers at Indiana State University found that 83% of felons studied reported a head injury that predated their first encounter with the law (1998)  Batterers fared worse on three Neuropsychological indicators of cognitive functioning then a nonbatterer control group (Cohen et. al. 1999) From the Literature regarding Perpetrators of Violence……Rosenbaum, et. al., 1994  “a history of significant head injury increases marital aggression almost six-fold”  Almost all of the batterers’ head injuries occurred in childhood, with the most common causes being sports and falls From the Literature regarding Victims of Violence…..Adapted from The Alabama Department of Rehabilitation Services DV Training Greater than 90% of all injuries secondary to domestic violence occur to the head, neck or face region (Monahan & O’Leary 1999) From the Literature regarding Victims of Violence…..Adapted from The Alabama Department of Rehabilitation Services DV Training In 53 women living in a DV shelter… On average women experienced five brain injuries in the prior year Almost 30% reporting 10 brain injuries in the previous year. (Jackson & Phillips 1998) From the Literature regarding Victims of Violence…..Adapted from The Alabama Department of Rehabilitation Services DV Training Of the abused women with prior brain injuries, 81% reported cognitive, emotional, and physical complaints identical to individuals who have experienced a brain injury. (Ross 2002) From the Literature regarding Victims of Violence…..  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 Types of TBI-Mild/Concussion  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 Signs of Concussion BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30-37  Early Signs  confusion  dizziness  vomiting  headache  nausea   Late Signs persistent headache  poor attention  irritability  ringing in the ears  restlessness  depressed mood  lightheadedness  memory  blurry vision  fatigue and anxiety Signs of Concussion BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30-37  Behavioral  Changes blank staring  decreased response time for directions, answering questions  confusion  distractibility  difficulty with ADLs  slurred speech  disorientation  extreme range of emotion's  impaired memory  LOC Signs of Concussion BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30-37   Post Concussion Syndrome   Second Impact Syndrome headache  dizziness  personality changes  amnesia  reduced concentration  aggressiveness  depression  anxiety  hyperactivity collapse  respiratory failure  semicomatose  increased intercranial pressure  death can occur rapidly  survival with possible cognitive and behavioral deficits  dementia pugilistica 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 Coup-Contra Coup Diffuse Axonal Injuries Rotational forces on the brain cause the stretching, snapping and shearing of axons Hematoma Epidural Hematoma Hematoma or Blood Clot forms on top of the dura Subdural Hematoma Hematoma or blood clot forms under the dura Secondary Injuries Hydrocephalus, (enlarged ventricles) Intracerebral Hemorrhage, Edema (swollen brain tissue) Mechanism of Injury via DV BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30-37      Closed head injury: punched with fist or object, head slammed onto a surface Open head injury: skull is fractured or is displaced by external force Anoxia: from near drowning, strangulation or loss of blood due to open lesions, e.g. stab wounds, impingement of carotid artery, thrombosis Penetrating injuries: gunshot wounds. Handguns weapons most often used. Results in a 91% death rate. (National Center for Injury Prevention and Control) Firearms are the single largest cause of death from TBI (Fontanarosa 1995, Harrison et.al 1998) Mechanism of Injury via DV BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30-37 Chronic Stress and Depression can lead to neurotoxic levels of glucocorticoid which in turn leads to cell death or “cell suicide” Increase in cortisol levels can lead to a reduction in the size of the hippocampus (part of the brain responsible for sorting information into memories) Mechanism of Injury via DV BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30-37 “Researchers indicate a boxer wearing a six to eight ounce glove can generate an impact force of more than half a ton” “…gloves are used to “soften the blow”” Mechanism of Injury via DV BIAA, Brain Injury Source Summer 2000, Vol.4, Issue 2, 30-37 “An “uppercut” is a blow to that causes the head to turn with a rotational acceleration, increasing the force of the blow” Resulting in DAI. This also occurs with violent shaking. Muhammad Ali verses George Forman Mechanism of Injury via DV(Sadovsky 1999, cited in Quality Matters Spring 2004 edition) “ Women with injuries resulting from assault were 13 times more likely than those with unintentional injuries to have sustained injuries to the head” Loss of Consciousness Verses Post Traumatic Amnesia the period of time after a blow to the head when the brain cannot process and lay down new memories  May be walking and talking  Longer that period of time, the more serious the potential impact of the injury  e.g. NFL players  PTA= 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 Possible Changes-Thinking  Memory  Attention  Concentration  Processing  Aphasia/receptive and expressive language  Executive skills  Problem solving  Organization  Self-Perception  Perception  Inflexibility  Persistence Possible Changes-Physical  Motor skills/Balance  Hearing  Vision  Spasticity/Tremors  Speech  Fatigue/Weakness  Seizures  Taste/Smell 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 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 activities  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 Compensation  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 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 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  Refer to the contract frequently The Goal is to…... Enhance the Predictability of the Daily Routine Why Screen for a History of Brain Injury? What other screening efforts have found……... 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? sports?  Playing  From a fall? Have you ever been hospitalized or treated in an emergency room following an injury? and released?  Evaluated by a neurologist?  Had a CAT scan, MRI or EEG done while in the emergency room?  Treated 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 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 program What you are looking for…..  Any reported or suspected functional difficulties that are interfering with home, work or community activities There are limits to what can be changedStaff 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) Questions?? References     Brain Injury Awareness Presentation-Brain Injury Association and the Brain Injury Association of Maryland, 2000. National Center for Injury Prevention and Control 2003 Maryland Centers for Disease Control Surveillance 2003 National Association of State Head Injury Administrators 2003 References  Increasing Awareness about Possible Neurological Alterations in Brain Status Secondary to Intimate Violence (2000) Dr. Mary Carr author, published in Brain Injury Source Volume 4 Issue 2, 30-37., a publication of the Brain Injury Association of America  Traumatic Brain Injury & Domestic Violence Materials from the Alabama Department of Rehabilitation Services, TBI Project, Maria Crowley, Project Director 2004. Mcrowley@rehab.state.al.us Resources  Brain Injury Association of America 703236-6000, www.biausa.org  Brain Injury Association of Maryland 410-448-2924, www.biamd.org  Ohio Valley Center For Brain Injury Prevention and Rehabilitation, 614-2933802, www.ohiovalley.org. Anastasia Edmonston Project Director Maryland TBI Demonstration Project aedmonston@dhmh.state.md.us 410-402-8478