Children

1
Children Adult Brain Injury OverviewImplicati
ons for Home, School and CommunityDRAFT

• Anastasia Edmonston MS CRC
• TBI Projects Director
• Maryland Mental Hygiene Administration

2
Workshop Agenda

• Incidence and prevalence of brain injury
• Physical, cognitive and behavioral implications
  of brain injury for children and adults
• Rehabilitation and educational treatment and
  support interventions
• State, regional and national brain injury
  resources

3
Nationwide UPDATED 9/6/07

• 51,000 die
• 290,000 are hospitalized and
• 1,224,000 million are treated an released from an
  emergency department Jean Langlois ScD,MPH
  Centers for Disease Control, 2007

4
Causes of TBI CDC 2006
5
Annual Incidence of TBI with DisabilityAN
ESTIMATED 124,000 American civilians

• Cited by Jean Langlois ScD,MPH NASHIA Conference
  2007
• Preliminary findings as analyzed by Selassie, et.
  al

6
For Children Nationwide Ages 0-14, TBI Results
in

• 2,685 deaths
• 37,000 hospitalizations
• 435,000 emergency department visits per year CDC
  2006

7
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 CDC 2006

8
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

9
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

10
Nationwide

• 5.3 million Americans with life-long or long-term
  needs as a result of a brain injury
• Direct medical costs and indirect costs such as
  lost productivity of brain injury estimated was
  estimated to be 60 billion in 2000. That is 6
  times the net worth of Oprah Winfrey!!! CDC 2006

11
Impact of Brain Injury

• 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
• TBI is the signature wound of the current
  conflicts in Iraq and Afghanistan
• Each year 1.5 million people sustain a TBI, that
  is 8 times the number of individuals diagnosed
  with breast cancer

12
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

13
A Huge Public Health Issue...

• With Very Little Public Awareness
• or funding.
• Federal dollars spent per person with brain
  injury per year, 2.55

14
Simplified Brain Behavior Relationships
Frontal 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)
Parietal Lobe Sense of touch
Differentiation size, shape, color Spatial
perception Visual perception
Occipital Lobe Vision
Cerebellum Balance Coordination Skilled
motor activity
Temporal Lobe Memory Hearing Understanding
language (receptive language) Organization
and sequencing
Brain Stem Breathing Heart rate
Arousal/consciousness Sleep/wake functions
Attention/concentration
15
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

16
Primary Injuries
Coup-Contra Coup
17
Primary Injuries
Diffuse Axonal Injuries
Rotational forces on the brain cause the
stretching, snapping and shearing of axons
18
Primary Injuries, also include.

• Epidural hemotoma-when a blood clot forms on top
  of the dura
• Subdural hemotoma-when a blood clot forms under
  the dura

19
Secondary Injuries
Intracerebral Hemorrhage
Hydrocephalus (enlarged ventricles)
Edema (swollen brain tissue)
20
The Developing Brain

• Childrens brains do not reach their adult weight
  of 3 pounds until they are 12 years old
• The brain, and most importantly, the brains
  frontal lobe region does not reach its full
  cognitive maturity till individuals reach their
  mid twenties

21
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

22
IDEA Definition of TBIFederal Public Law
101-476, 1990

• ..an acquired injury to the brain caused by an
  external physical force resulting in total or
  partial functional disability or psychosocial
  impairment or both that adversely affects a
  childs educational performance..

23
According to the USDE, in Maryland.

• Only 324 students out of 98,811with identified
  disabilities were receiving services under a TBI
  diagnosis in 2006. U.S. Department of Education,
  Office of Special Education Programs 7/17/06
  httpt//www.ideadata.org/tables29th/ar_1-3.xls

24
Why the Gaps in numbers?

• Not all children experience lasting effects
• The etiology of a students disability may be
  unidentified or misunderstood
• Student may be served under a 504 plan
• Effects of a early brain injury may not be
  expressed until the student is older
• When the effects do surface, they may diagnosed
  as having a learning disability, emotional
  disorder, or other disability
• Adapted from TBI and Educators Guide by the MD
  TBI Implementation Project and the BIAM 2003

25
Types of TBI-Mild (concussion)

• Most common, 75-85 of all brain injuries are
  mild
• Individuals experience a brief (lt15 minutes)or NO
  loss of consciousness
• Post Traumatic Amnesia lt 1hour
• Normal neurological exam
• 90 of individuals recover within 6-8 weeks,
  often within hours or days

26
Concussion and Kids-Sports

• Football has the highest rate of concussions in
  high school sports, girls soccer 2nd highest rate
  (New York Times 10.2.07)
• 29,167 concussions suffered by US high school
  girl soccer players, 20,929 concussions suffered
  by high school boy soccer players 2005-2006 (Time
  Magazine 2008)
• Female concussion rates in high school basketball
  were almost 3xs higher than among boys.
• In girls symptoms take longer to resolve (NYT
  10.2.07)

27
Quoted in TimeDr. Joseph MaroonU of Pittsburgh
Medical Center

• More-developed necks allow boys to better absorb
  a blow to the head

28
Implications for Children

• Concussion and repeated concussions can occur
  from abuse
• Concussion and repeated concussions can occur
  from falls and sports injuries
• April 2007 edition of Pediatrics cites research
  suggesting children who suffer a brain injury are
  more likely to incur a second one within 6 months

29
Implications for Adults

• Concussion and repeat concussion can be the
  result of childhood abuse, injury
• Concussion and repeat concussion can be the
  result of assaults, domestic violence, MVAs
• Concussion and repeat concussion may contribute
  to social failure

30
NFL, Concussion Alzheimers Disease
(Guskiewicz et. al. 2005)

• 61 of the former players sustained at least one
  concussion in their career
• 24 sustained 3 or more concussions
• Retired players with 3 or more concussions had a
  fivefold prevalence of reported significant
  memory problems compared to players with no hx of
  concussion
• Researchers also observed an earlier onset of
  Alzheimer's disease in retirees than in general
  male population.

31
Implications for Adults

• Adults with a history of abuse and/or traumatic
  brain injury may have difficulty controlling
  their impulses and emotions
• Several studies have linked a history of a brain
  injury to subsequent acts of domestic battering
  and spousal aggression as well as other criminal
  behavior

32
Types of TBI-Moderate

• LOC/Coma between 20-30 minutes to 24 hours,
  followed by a few days or weeks of confusion
• Post Traumatic Amnesia 1-24 hours
• 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

33
Types of TBI-Severe

• Almost always results in prolonged consciousness
  or coma of days,weeks, or longer
• Post Traumatic Amnesia greater than 25 hours
• 80 of individuals with severe brain injury have
  multiple impairments in functioning

34
Brain Injurys Impact on Physical Functioning.

• Difficulty with walking, balance and movement
• Reduced fine and gross motor skills
• Speech impairments such as slow or slurred speech
• Seizure disorders
• Headaches or migraines
• Fatigue and/or pain

35
Brain Injurys Impact on Thinking..

• Memory, especially short-term memory
• Reduced flexibility of thinking
• Attention and Concentration difficulties
• Inability to plan or prioritize
• Multi-tasking or splitting and dividing ones
  attention can be very challenging

36
Emotional and Behavioral Consequences...

• Impulsivity
• Depression and mood swings
• Lack of self awareness and judgement
• Agitation and aggression
• Difficulty exercising good social judgement

37
Lack of Awareness A common and difficult to
remediate hallmark of a brain injury
38
A memory deficit might look like trouble
remembering or it might look like (Capuco
Freeman-Woolpert)

• She frequently misses appointments-avoidance,
  irresponsibility
• He says hell do something but doesnt 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
  wont know he doesnt remember

39
An attention deficit might look like trouble
paying attention or it might look like (Capuco
Freeman-Woolpert)

• He keeps changing the subject
• She doesnt 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

40
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

41
Unawareness might look like (Capuco
Freeman-Woolpert)

• Insensitivity, rudeness
• Overconfidence
• Seems unconcerned about the extent of her
  problems
• Doesnt think she needs supports
• Covering up problems (everythings fine)
• Big difference in what he thinks and what
  everyone else thinks about his behavior
• Blaming others for problems, making excuses

42
The Relationship Between Brain Injury and Mental
Health-Depression

• 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)
• Major depressive episodes occur in 20-30 of TBI
  patients in the first year. Depressive symptoms
  occur even more commonly.

43
Other Mental Health Disorders Related to TBI

• Anxiety, seems to go hand in hand with
  depression. Those with depression or anxiety
  perceive their injury and cognitive impairment as
  more severe then nondepressed individuals with
  TBI (Fann et.al 1995)
• Oquendo and colleagues (2004) found that males
  with mild TBI with a hx of substance abuse
  coupled problems of aggression and hostility were
  more likely to attempt suicide then non injured
  males

44
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 than in the
  general population (McAllister, Ferrell 2002)

45
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 35felt hopeless and 23expressed
  suicide ideation. 18 had attempted suicide post
  injury

46
Alcohol Use TBI-IncidenceAnalysis 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.

47
Recommended Supports and Services-The Ideal
Pathway Following Concussion or Mild Brain
Injury-Childhood Injury

• Family and child is educated about the possible
  symptoms of concussion
• If symptoms emerge or persist following a
  concussion, appropriate referrals are made to a
  neurologist, pediatric neuropsychologist.
  Appropriate interventions and supports including
  outpatient speech, occupational and physical
  therapy are provided and coordinated with school
  personnel
• Exposure to situations where a second impact is a
  possibility is minimized

48
Less than Ideal Pathway Following Concussion/Mild
TBI

• Hit on the head while playing, or riding a bike,
  horse, playing football, soccer, cheerleading,
  etc.
• May or may not experience a loss of consciousness
  lt15 minutes, PTA, post traumatic amnesia
• Return to normal activities without being
  evaluated by a health professional

49
Less than Ideal Pathway Following Concussion/Mild
TBI

• Feel tired, lethargic, experience headaches
• Teachers and family may notice irritability
• Schoolwork suffers
• Behaviors attributed to factors other than the
  brain injury (family/peer problems, adolescence)
• Child continues to experience problems, becomes
  depressed/may begin to act out
• Is at risk for academic/social difficulties
• Is at risk for a subsequent brain injury,
  exacerbating the above

50
Recommended Supports and Services-The Ideal
Pathway For Childhood Moderate to Severe TBI

• Specialized TBI medical rehabilitation services
• Neuropsychological evaluation and follow-up
• IEP that reflects recommendations of therapists
  and neuropsychologist and teachers
• A transition plan is written by age 14, DORS and
  DDA referrals in place
• Individual and family therapy
• TBI Support group
• Case management and resource coordination

51
Common and Less than Ideal Pathway-Mod to Severe
TBI

• Go through ideal pathway through outpatient
  rehabilitation
• Return to school, behind peers
• Struggle academically
• Act out behaviorally, if the injury several
  grades back, not recognized as TBI related

52
Common and Less than Ideal Pathway-Mod to Severe
TBI

• 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

53
Ideal Rehabilitation Pathway for Mild TBI-Adults

• 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, the individual is referred to
  appropriate treatment,(neurological/neuropsychiatr
  ic/ neuropsychological treatment or consultation)

54
Common and Less than Ideal Pathway-Mild TBI-Adult

• 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 justtake it easy

55
Common and Less than Ideal Pathway-Mild TBI,
cont..

• Cant 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
  malinger-inappropriately medicated

56
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

57
Ideal Medical/Rehabilitation Pathway-Moderate to
Severe TBI-Adult

• 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 re-entry program and individual
  therapies (Sinai, Kernan, Humanim, Total Rehab
  Care, Sky Neurorehabilitation)

58
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

59
Common and Less than Ideal Pathway-Mod to Severe
TBI

• 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

60
Without Appropriate Services, Individuals with
TBI are at Risk for...

• Long-Term Unemployment
• Alcohol and or Drug Use and Abuse
• Social Isolation
• Higher risk of subsequent brain injuries than
  individuals who have never incurred a brain injury

61
Why Screen?

• What other TBI Screening efforts have found

62
Findings from the LiteratureCriminal 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

63
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

64
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

65
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?modgooglenews_ wsj

• 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

66
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
• N190
• 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)

67
TBI Screening, Adapted From

• Ohio Valley Center for Brain Injury Prevention
  and Rehabilitation John Corrigan
  Ph.D

68
Have you ever been injured following a blow to
the head?

• As a child?
• Playing sports?
• From a fall?

69
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?

70
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?

71
Have you ever been injured in a fight?

• Taken a direct blow to the head
• Experienced a violent shaking of the head and
  neck?

72
Have you ever been injured by a spouse or family
member?

• Pushed
• Punched
• Shaken
• Choked

73
Have you ever had any major surgeries?

• Heart Bypass
• Transplant
• Brain surgery to treat a tumor, aneurysm, stroke

74
Illnesses?

• Toxic Shock Syndrome
• Meningitis
• Encephalitis
• Hydrocephalous
• Seizure disorder
• Lead poisoning

75
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

76
What you are looking for..

• Any reported or suspected functional difficulties
  that are interfering with home, work or community
  activities

77
Strategies-Physical-for Children

• Visual aides (large print, screen adapters,
  scanning aides)
• Tutoring in one handed typing techniques
  (especially for middle and high school students)
• Built in rest periods in daily schedule
• Anticipate accommodations (classrooms accessible,
  augmentative devices obtained, etc.) Adapted from
  TBI and Educators Guide by the MD TBI
  Implementation Project and the BIAM 2003

78
Strategies-Physical-for

• Return to work gradually, part-time adjust
  medications as needed (adults)
• Rest periods as needed
• Accommodations for visual perceptual deficits,
  red highlighter etc.
• Modify home and work to accommodate mobility and
  coordination limitations

79
Strategies-Cognitive-Adults Children

• Calendar/keep schedule predictable
• Planner vs. loose paper
• Laptop/computer
• Tape recorder
• Timer/timer watches
• Untimed testing
• Alternative testing

• Use of a reader or note taker (buddy)
• Highlighter
• Books on tape/film adaptation
• Strategic scheduling
• Break tasks/assignments into steps

80
Strategies Continued

• Encourage active listening strategies e.g
  paraphrasing back to speaker the information,
  especially when it is novel
• Place visual cues in environment (labels,
  emergency contacts, calendars)

• Retention in long term memory is enhanced by the
  three Rs Repeat, Rehearse, and Review
• Safety checklist for use of stove etc.
• Checklists
• Alarm watch

81
Resources

• Brain Injury Association of America
• 1-800-444-06443
• www.biausa.org

82
Resources

• Brain Injury Association of Maryland
• 410-448-2924
• www.biamd.org

83
Resources continued...

• National Safe Kids Campaign
• www.safekids.org
• 1301 Pennsylvania Ave., N. W.
• Washington D.C. 20004-1707
• 202-662-0600

84
Resources continued...

• Kids in Safety Seats
• Kiss_at_dhmh.state.md.us
• 1-800-370-SEAT, call for information as well as
  for a car seat safety check

85
Resources continued...

• The Safe Concussion Outcome Recovery Education
  Program(SCORE)
• At the Childrens National Medical Center
• Washington DC
• 202-884-2429

86
National Center on Secondary Education and
Transition

• www.ncset.org

87
Resources

• Specialized Health Needs Interagency
  Collaboration (SHNIC)
• Kennedy Krieger Institute
• 410-502-8419

88
Lash and Associates Publishing/Training
www.lapublishing.com

• Information and ReferralBrain Injury in Children
  and Adults
• Books, pamphlets and tip sheets on various
  aspects of brain injury can be purchased, the
  website also offers many articles that can be
  downloaded for free

89
National Dissemination Center for Children with
Disabilities

• www.nichcy.org/pubs/factshe/fs18txt.htm

90
Publications Available from Lash Associates

• Pay Attention! Attention Training for Children
  Ages 4-10. 2nd edition, Jennifer Thomson and
  Kimberly Kerns. Resource for professionals and
  families working with children following TBI,
  brain tumors, and ADHD
• Getting A-Head of Concussion. Phil Hossler and
  Ron Savage. For school nurses, parents,
  pediatricians, and coaches. Discusses the signs
  of concussion and how to monitor at home and in
  the classroom

91
Resources

• Catherine Rinehart Mello 301-682-6017
• The Project provides free resource coordination
  services to individuals with brain injury (18 and
  older).

92
Brain Injury Training

• Available free of charge for human service
  professionals and agencies in
• Frederick
• Washington
• Montgomery
• Baltimore
• Howard
• Anne Arundel County
• All counties on Marylands Eastern Shore
• Contact Anastasia Edmonston 410-402-8478

93
Contact Information

• Anastasia Edmonston
• 410-402-8478
• aedmonston_at_dhmh.state.md.us