traumatic brain injury: an overview helping professionals identify, support and treat individuals...

Traumatic Brain Injury: An Overview

Helping Professionals Identify, Support and Treat Individuals with TBI in the Domestic Violence Treatment SettingA Product of the Maryland Traumatic Brain Injury Partnership Implementation Project 2006-2009

Incidence of TBI CDC 2004

In the United States, at least

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 DisabilityAN ESTIMATED 124,000 American civilians

Cited by Jean Langlois ScD,MPH NASHIA Conference 2007

Preliminary findings as analyzed by Selassie, et. al

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 fallsAfrican Americans have the highest

death rate from TBI

In Maryland…….. In 2000 there were 5,229 traumatic

brain injuries5% of all hospitalizations were TBI

related25% of all injury related deaths for ages

15-24 were TBI related11% of all injuries to children 14 and

under were TBI related

Causes of TBI CDC 2006

Falls, 28%

Motor Vehicle-Traffic, 20%

Struck By/Against, 19%

Assault, 11%

Unknown, 9%

Other, 7%

Pedal Cycle (non MV), 3%

Suicide, 1%

Other Transport, 2%

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

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

techniquesSafety features such as car seatbelts,

child safety seats and airbags

DefinitionsTraumatic Brain Injury is an insult to the

brain caused by an external physical forceDiffuse Axonal Injury the tearing and

shearing of microscopic brain cellsAcquired 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 accidentallyReece, 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 BrainChildren’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 BrainThe 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 yearAlmost 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/ConcussionMost common, 75%-85% of all brain

injuries are mild Individuals experience a brief (<15

minutes)or NO loss of consciousnessNormal neurological exam90% 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

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

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-SevereAlmost 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 InjuriesRotational 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 InjuriesHydrocephalus, (enlarged ventricles) Intracerebral Hemorrhage, Edema(swollen brain tissue)

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)

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)

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””

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

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

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 talkingLonger that period of time, the more

serious the potential impact of the injurye.g. NFL players

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

DepressionSocial skills problemsMood swingsProblems with emotional control Inappropriate behavior Inability to inhibit remarks Inability to recognize social cues

Personality and Behavioral cont..Problems with initiationReduced self-esteemDifficulty relating to othersDifficulty maintaining relationshipsDifficulty forming new relationshipsStress/anxiety/frustration and reduced

frustration tolerance

Lack of AwarenessA 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 deficitsTreating therapists should conduct

home visit to ensure strategies are meaningful in and carry over to the home environment

Strategies for Remediation and CompensationUse of a journal/calendarCreate a daily schedule “To do” listsLabeling itemsLearning to break tasks into small

manageable stepsUse 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 dayPost 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 behaviorGive feedback immediately using the

sandwich techniqueUtilize positive reinforcement/feedbackFormalize 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 IllnessKathleen 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 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

Correlation between TBI & Homelessness Hwang et.al 10.7.08 Canadian Medical Journal

904 homeless individuals surveyedLifetime 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

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)

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

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

HELPSWere 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

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 isn’t 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

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.

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)

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

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.

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 person’s self-report and documentation of altered behavioral and/or cognitive functioning

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 changed-Staff can accommodate the injury related behaviors by modifying the individual’s

environment, and their own interpersonal interactions with the individual

Biological Limits to Behavioral RecoveryFarrell & 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

ResourcesBrain Injury Association of America 703-

236-6000, www.biausa.orgBrain Injury Association of Maryland

410-448-2924, www.biamd.orgOhio Valley Center For Brain Injury

Prevention and Rehabilitation, 614-293-3802, www.ohiovalley.org.

Anastasia EdmonstonProject Director

aedmonston@dhmh.state.md.us410-402-8478

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

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