Traumatic Brain Injury Mental Health Practitioners Conference May 4, 2006

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Traumatic Brain InjuryMental Health
Practitioners Conference May 4, 2006

• Sponsored by
• USU Center for Persons with Disabilities
• Utah TBI Implementation Grant
• Cache County TBI Community Workgroup
• Northern Utah Area Health Education Center

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• David E. Nilsson, Ph.D., ABPP-CN
• The NeuroDevelopment Center
• 370 East South Temple, Suite 100
• Salt Lake City, UT 84111
• 801-532-1475
• 801-983-0111 (fax)
• dnilsson_at_NeuroDevCenter.com

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Introduction

• Myths of brain injury
• She doesnt look brain injured
• The brain-injury should be healed by now!
• No loss of consciousness
• Plasticity of the brain
• We use only 10 of our brain
• Psychological issues down the road

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Introduction

• Barriers to diagnosis and treatment of brain
  injury
• Silent Epidemic (1983)
• Social attitudes/perceptions
• Health care funding practices for brain injury
• Educational rules and guidelines

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Introduction

• Financial impact of brain injury upon funding
  priorities and the economy
• Brain injury population increasing
• Educational demands, decreasing resources
• SSI/other disability funding
• Brain injury/Criminal Justice System
• Workers Compensation issues/Vocational
  Rehabilitation

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Introduction

• Labeling vs. diagnostics
• Human nature prevails!
• If you can name it, you can fix it
• Brain injury is brain injury
• Diagnostic systems (DSM-IV, ICD-9/10)
• Logic (or lack of logic) of diagnostics
• What are we treating?

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Introduction

• Developmental/neurodevelopmental consequences of
  brain injury
• Earlier the injury, the worse the outcome
• Earlier the intervention, better the outcome
• Preemie study (Taylor, et al, 2002)
• Understanding the injury early is critical to
  life span interventions

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Introduction

• Unique challenge of this particular talk
• Just tell us what to do!
• Cannot be treated in isolation
• Invite questions and dialogue

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Goals of Presentation

• Increase awareness of functional capacity and
  characteristics of the brain
• Better understand consequences of brain injury as
  related to development and treatment
  considerations

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Goals of Presentation

• Identify individuals for whom brain injury is
  likely (or will be) a contributing disruption to
  health care/education/employment
• Recognize and initiate intervention strategies to
  optimize individual development, self-regulation,
  and functional capacity
  

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Overview of Presentation

• Presentation of neurodevelopment, and functional
  characteristics of the brain
• Presentation of mechanisms of brain injury, and
  consequences of such injury
• Presentation/discussion of intervention-specific
  strategies for individuals with history of brain
  injury

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What is Neuropsychology?

• Brain behavior relationships (science)
• Applications to individual patients (clinical)
• Individual learning differences (education)

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What is Neuropsychology?

• Brief History of Neuropsychology
• Phineas Gage
• Knowledge acquired through tragedy
• Early clinical applications in localization
• Integration of clinical/research applications
• Rehabilitation applications

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What is Neuropsychology?

• Psychology vs. Neuropsychology
• Mental health/physical health Freuds
  Folly
• Psychological issues
• ICD-9/10 vs. DSM-IV
• Diagnosis leads to treatment(?)
• Personal preference

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What is Neuropsychology?

• Neuropsychologist is a person who gives
  neuropsychological tests
• Neuroscience vs. psychiatric model
• Development neurodevelopmental focus
• Inside out or Top to bottom model

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Who is a Clinical Neuropsychologist?

• Standards of Training
• Coursework/degree
• Theoretical foundations of neuroscience
• Post-doctoral fellowship
• Board Certification Process
• Educational credentials
• Peer review of work samples
• Examination (written/oral)

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Basic Neurologic Function

• Social perception
  Doesnt look brain injured?
• All or nothing model of injury
• Continuum model of diagnostics
• Realty-no two brain injuries the same
• Neurologic injury interacts with genetics,
  environment, life experience
• Oversimplification of brain function
• Timex watch model

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Basic Neurologic Function

• Neuron is basic unit of Central Nervous System
  (CNS)
• Born with all we have
• Billions of cells Trillions of interconnections
• Electrochemical processor

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Basic Neurologic Function

• Organized Functional Units of CNS
• Left Hemisphere / Right Hemisphere
• Frontal, Temporal, Parietal, Occipital Lobes
• Spinal Cord / Brain Stem
• What part of the brain does that?
• Localization of function
• Everything connected to everything else

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Basic Neurologic Function

• High-speed Internet Interconnections
• Projection Fibers
• Association Fibers
• Corpus Callosum

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Basic Neurologic Function

• Functions as an integrated unit
• Sum of its parts
• Heavily dependent upon interconnections
• Broad spectrum of functional deficits

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Basic Neurologic Function

• Global Functional Considerations
• Speed
• Conceptual integration
• Automaticity
• Self-regulation (e.g., hormones, mood, sleep)
• No down time/constant monitoring and processing
• Adjusts levels of arousal
• Decisions for directed and focused attention
• Plasticity?

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Common Disruptions to Neurologic Function

• Genetics
• Familial predispositions
• Genetic disorders
• Toxic exposures
• Fetal alcohol/drug exposure (FADE)
• Prescribed medications
• Smoking
• Chemotherapy
• Environmental toxins

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Common Disruptions to Neurologic Function

• Birth trauma
• Vascular events (e.g., stroke)
• Hypoxia
• Mechanical injury (e.g., forceps)
• Infectious/disease
• Viruses (e.g., Rubella, CMV, herpes)
• Encephalitis/meningitis

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Common Disruptions to Neurologic Function

• Physical Injury
• Shaken baby
• Head trauma (e.g., falls, MVA, blows to the head,
  penetrating wounds, MVA)
• Sports injuries
• Substance abuse (e.g., alcohol, drugs)
• Vascular events
• S_ _ _ happens
• Aging process

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Mechanisms of Brain Injury

• Vascular injury/changes
• Trauma bleeds (e.g., subdurals, epidurals)
• Blood Vessel injury (e.g., physical trauma,
  aging, genetic disorders)
• Decreased blood flow (e.g., hypoxia, nutrition)
• Physical trauma
• Blunt force trauma
• Penetrating wounds
• Shearing (whiplash)

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Mechanisms of Brain Injury

• Neurochemical changes
• Secondary to brain injury
• Sustained exposure to substances
• Chemotherapy

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Early Red Flags for Neurodevelopmental
Compromise (e.g., Brain Injury)

• Medical History Risk Factors
• Prematurity
• Prenatal/perinatal birth history
• Twin delivery
• Seizures
• Infectious diseases (e.g., encephalitis,
  meningitis, AIDS, viruses)
• Treatment of cancer
• History of acquired brain injury

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Early Red Flags for Neurodevelopmental
Compromise (e.g., Brain Injury)

• Neurodevelopmental/Neurobehavioral
  Characteristics
• Alertness/arousal
• Extreme sensory reactivity
• Developmental delays (e.g., speech, motor)
• Extreme sleep disorders

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Early Red Flags for Neurodevelopmental
Compromise (e.g., Brain Injury)

• Extreme irritability/reactivity
• Anxiety/depression
• Extreme aggression (e.g., biting, rage)
• Quick to react/slow to calm

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Early Red Flags for Neurodevelopmental
Compromise (e.g., Brain Injury)

• Poor self-calming ability
• No fear/boundaries
• Poor socialization
• Extreme hyperactivity

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Early Red Flags for Neurodevelopmental
Compromise (e.g., Brain Injury)

• Learning styles
• Extreme unevenness
• She should be able to
• Nonverbal Learning Disorder
• Math poorer than language skills
• Poor processing of visual language
• Poor perceptual-motor/visual-spatial skills
• Cant see the big picture
• Reading adequate to good/poor comprehension

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Early Red Flags for Neurodevelopmental
Compromise (e.g., Brain Injury)

• Poor social skills
• Rigid/inflexible style
• Poor executive function
• He just doesnt get it!

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First Principle of Treatment Intervention

• Identify the individual in need
• Recognize need early
• By the inch its a cinch, by the yard it is hard

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The Second Principle of Treatment

• Recognize the individuals specific (and
  general) intervention needs
• The intervention request is seldom specific
• The constellation of behaviors is likely to be
  more productive

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The Third Principle of Treatment

• Recognize the need and plan to be a member of a
  treatment team
• All the kings horses and all the kings men
• Treatment in isolation is doomed to fail

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Diagnostic Tools

• Diagnostic testing
• Academic/educational measures
• Intellectual measures
• Neuropsychological testing
• Developmental/medical history
• Seldom available
• Understanding the big picture critical

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Diagnostic Tools

• Observation of behavior
• Mom
• School personnel
• Extreme behavior
• Few kids look neurologically compromised

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Functional Considerations for Intervention
Strategies

• Automaticity
• Speed of processing
• Conceptual organization
• Fatigue, decreased arousal
• Drive, initiative
• Neurodevelopmental status

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Basic Principles for Considering Intervention
Strategies

• Early intervention
• Adjust intervention to the individual
• Do not assume individual can perform task
• Developmental/neurodevelopmental monitoring
• Understand the logic of individual
• If you have seen one brain injury, you have seen
  one brain injury.

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Basic Principles for Considering Intervention
Strategies

• Optimize self-regulation
• Environment
• Behavioral/other therapy support
• NeuroFeedback
• Pharmacology
• Developmental Prophylaxis
• Give student boost for development
• Protect while recovering/catching up

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Intervention Strategies

• Teaching basic skills
• Do not understand cause-and-effect
• Cannot generate cognitive structure
• Limited automatic processing
• Shouldnt have to tell her.
• He has to learn by himself.
• Behavioral management strategies

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Intervention Strategies

• Reading/learning strategies
• Books-on-tape/CD
• Multi-sensory presentation
• Structured learning
• Writing strategies-speed consideration
• Reduce writing demands
• Notetaker/teacher outlines
• Word Processing/voice interactive computer
• Oral presentation (e.g., testing, papers)

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Intervention Strategies

• Testing environment
• Extended time
• Decreased stimulation
• Social skill development
• Intervene early
• Modeling, demonstration, role playing, etc.

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Intervention Strategies

• Behavior/therapy intervention
• High levels of reinforcement
• Provide specific feedback
• Environmental Engineering
• Noise management
• Reduce levels of stimulation

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Intervention Strategies

• Quieting the nervous system
• Disruption of immediate memory
• Behavioral interventions
• Medication, NeuroFeedback, etc.
• Managing fatigue
• Mental
• Physical

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Intervention/Treatment Environments

• Parenting skills
• Intervene at birth when appropriate
• Teach parents logic of behavior
• Nonconfrontive behavior management
• Provide increased level of feedback
• Environmental factors (anticipate behavior)
• Emphasize need to monitor

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Intervention/Treatment Environments

• School intervention considerations
• Limited ability to accommodate individual
• Based on model of repetition
  If you do it enough, you can learn it
• Limited recognition of organizational demands
• Remediate vs. adapt/accommodate

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Intervention/Treatment Environments

• Individual therapies
• Traditional therapies worthless
• Facilitate logic of symptoms
• Evaluate understanding of cause-and-effect
• Provide structure
• Increase level of awareness
• Teach self-monitoring/self-regulation
• Empower individual (e.g., self-advocacy)
• Coordinate services

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Intervention/Treatment Environments

• Program/agency intervention
• Mental health, Vocational Rehab, etc.
• Collaborate/communicate
• Generate a document of expectation (i.e., Who is
  doing what?)
• Generate potential Team list
• Long-term monitoring strategies
• Is it working?

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Audience Participation

• Language
• Self Regulation
• Service Plan
• Multi-Sensory
• Functional Capacity
• TBI / Criminal Justice
• Acquired Brain Injury (ABI)
• Research and Technology