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Traumatic Brain Injury: An Overview

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Title: Traumatic Brain Injury: An Overview


1
Traumatic Brain Injury An Overview
  • Helping Professionals Identify, Support and Treat
    Individuals with TBI in the Domestic Violence
    Treatment Setting
  • A Product of the Maryland Traumatic Brain Injury
    Partnership Implementation Project 2006-2009

2
Incidence of TBI CDC 2004
  • In the United States, at least
  • 1.6 million sustain a TBI each year

3
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

4
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

5
Who is at Highest Risk for TBI? CDC 2005
  • Males 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

6
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

7
Causes of TBI CDC 2006
8
How Does TBI Compare? www.biausa.org
  • 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

9
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

10
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

11
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

12
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

13
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

14
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

15
Focal frontal lobe disorders and violent behavior
Brower and Price 2001
  • Acquired sociopathydescribe 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

16
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)

17
From the Literature regarding Perpetrators of
ViolenceRosenbaum, 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

18
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 OLeary 1999)

19
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)

20
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)

21
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

22
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
  • Normal neurological exam
  • 90 of individuals recover within 6-8 weeks,
    often within hours or days

23
Signs of Concussion BIAA, Brain Injury Source
Summer 2000, Vol.4, Issue 2, 30-37
  • Late Signs
  • persistent headache
  • poor attention
  • irritability
  • ringing in the ears
  • restlessness
  • depressed mood
  • lightheadedness
  • memory
  • blurry vision
  • fatigue and anxiety
  • Early Signs
  • confusion
  • dizziness
  • vomiting
  • headache
  • nausea

24
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

25
Signs of Concussion BIAA, Brain Injury Source
Summer 2000, Vol.4, Issue 2, 30-37
  • Post Concussion Syndrome
  • headache
  • dizziness
  • personality changes
  • amnesia
  • reduced concentration
  • aggressiveness
  • depression
  • anxiety
  • hyperactivity
  • Second Impact Syndrome
  • collapse
  • respiratory failure
  • semicomatose
  • increased intercranial pressure
  • death can occur rapidly
  • survival with possible cognitive and behavioral
    deficits
  • dementia pugilistica

26
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

27
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

28
Coup-Contra Coup
29
Diffuse Axonal Injuries
  • Rotational forces on
  • the brain cause the
  • stretching, snapping and
  • shearing of axons

30
Hematoma
  • Epidural Hematoma Hematoma or Blood Clot forms on
    top of the dura
  • Subdural Hematoma Hematoma or blood clot forms
    under the dura

31
Secondary Injuries
  • Hydrocephalus, (enlarged ventricles)
    Intracerebral Hemorrhage, Edema
  • (swollen brain tissue)

32
Mechanism of Injury via DVBIAA, 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)

33
Mechanism of Injury via DVBIAA, 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)

34
Mechanism of Injury via DVBIAA, 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

35
Mechanism of Injury via DVBIAA, 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

36
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

37
Loss of Consciousness Verses Post Traumatic
Amnesia
  • PTA 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

38
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

39
Possible Changes-Thinking
  • Memory
  • Attention
  • Concentration
  • Processing
  • Aphasia/receptive and expressive language
  • Executive skills
  • Problem solving
  • Organization
  • Self-Perception
  • Perception
  • Inflexibility
  • Persistence

40
Possible Changes-Physical
  • Motor skills/Balance
  • Hearing
  • Vision
  • Spasticity/Tremors
  • Speech
  • Fatigue/Weakness
  • Seizures
  • Taste/Smell

41
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

42
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

43
Lack of Awareness
  • A common and difficult to remediate hallmark of a
    brain injury

44
Focus of Rehabilitation and Often Lifetime Support
  • Increase individuals 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

45
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

46
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

47
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

48
Strategies cont..
  • Review schedule each day
  • Post signs on the wall etc.
  • Try to routinize the day as much as possible

49
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

50
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

51
Minimize confusion/socially unacceptable behavior
  • Dont 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

52
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

53
The Goal is to...
  • Enhance the Predictability of the Daily Routine

54
Why Screen for a History of Brain Injury?
  • What other screening efforts have found...

55
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

56
Homelessness Brain InjuryA 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

57
Correlation between TBI Homelessness Hwang
et.al 10.7.08 Canadian Medical Journal
  • 904 homeless individuals surveyed
  • Lifetime Prevalence of TBI-53, more common among
    men than women surveyed
  • Rates 5 or more times greater than the 8.5
    lifetime prevalence in general population and
    consistent w/ prison studies

58
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)

59
The HELPS Brain Injury Screening Tool(see
handout)The original HELPS tool developed by M.
Picard, D. Scarisbrick, R. Paluck, 9.1991Updated
by the Michigan Department of Community Health
60
HELPS
  • Have you ever Hit your Head or been Hit on the
    Head?
  • Prompt individual to think about TBI at any age,
    MVAs. Assaults, Sports injuries, Service related
    injuries, Shaken baby and/or adult

61
HELPS
  • Were you ever seen in the Emergency room,
    hospital, or by a doctor because of an injury to
    your head?
  • Explore the possibility of unidentified
    traumatic brain injury many do not present in
    medical settings

62
HELPS
  • Did you ever Lose consciousness or experience a
    period of being dazed and confused because of an
    injury to your head?
  • Remember, a LOC isnt required for someone to
    develop symptoms subsequent to a blow to the
    head. alteration of consciousness AKA post
    traumatic amnesia (PTA). At this point, the
    interviewer may consider asking the individual if
    they have had multiple mild TBI

63
HELPS
  • Do you experience any of these Problems in your
    daily life since you hit your head?
  • You want to know when any problems began (or
    began to be noticed) Remember, lack of awareness
    is a hallmark of brain injury, you might ask if
    anyone close to the individual has made any
    observations regarding changes in function.

64
HELPS
  • Headaches
  • Dizziness
  • Anxiety
  • Depression
  • Difficulty concentrating
  • Difficulty remembering
  • Difficulty reading, writing, calculating
  • Poor problem solving
  • Difficulty performing your job/school work
  • poor judgement (being fired from job, arrests,
    fights, relationships affected)

65
HELPS
  • Any significant Sickness?
  • Acquired Brain Injury (ABI) can result in many of
    the same functional impairments as traumatic
    brain injury (TBI). For example, brain tumor,
    meningitis, West Nile virus, stroke, seizures,
    toxic shock syndrome, aneurysm, AV malformation,
    any history of anoxic injury, e.g. heart attack,
    near drowning, carbon monoxide poisoning can all
    result in multiple deficits

66
Scoring the HELPS Positive for a possible Brain
Injury when the following three are identified
  • An event the could have caused a brain injury
    (YES to H, E, or S), and
  • A period of loss of consciousness or altered
    consciousness after the injury or another
    indication that the injury was severe (YES to L
    or E), and
  • the presence of 2 or more chronic problems listed
    under P that were not present before the injury.

67
Scoring the HELPS
  • A positive screening is not sufficient to
    diagnose TBI as the reason for current symptoms
    and difficulties-other possible possible reasons
    need to be ruled out
  • Some individuals could present exceptions to the
    screening results, such as people who do have
    TBI-related problems but answered no to some
    questions
  • Consider positive responses within the context of
    the persons self-report and documentation of
    altered behavioral and/or cognitive functioning

68
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

69
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

70
What you are looking for..
  • Any reported or suspected functional difficulties
    that are interfering with home, work or community
    activities

71
There are limits to what can be changed-Staff can
accommodate the injury related behaviors by
modifying the individuals environment, and their
own interpersonal interactions with the individual
  • Biological Limits to Behavioral Recovery
  • Farrell Hooper (1995)

72
Questions??
73
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

74
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_at_rehab.state.al.us

75
Resources
  • Brain Injury Association of America 703-236-6000,
    www.biausa.org
  • Brain Injury Association of Maryland
    410-448-2924, www.biamd.org
  • Ohio Valley Center For Brain Injury Prevention
    and Rehabilitation, 614-293-3802,
    www.ohiovalley.org.

76
Anastasia EdmonstonProject Directoraedmonston_at_d
hmh.state.md.us410-402-8478
77
A Product of the Maryland TBI Partnership
Implementation Project, a collaborative effort
between the Maryland Mental Hygiene
Administration, the Mental Health Management
Agency of Frederick County and the Howard County
Mental Health Authority2006-2009
  • Support is provided in part by project
    H21MC06759 from the Maternal and Child Health
    Bureau (title V, Social Security Act), Health
    Resources and Services Administration, Department
    of Health and Human Service This is in the
    public domain. Please duplicate and distribute
    widely.
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