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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
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Incidence of TBI CDC 2004
In the United States, at least
1.6 million sustain a TBI each year
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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
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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
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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
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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
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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%
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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
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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
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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
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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”
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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”
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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
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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
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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
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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)
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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
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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)
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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)
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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)
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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
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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
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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
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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
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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
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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
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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
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Coup-Contra Coup
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Diffuse Axonal InjuriesRotational forces on
the brain cause the
stretching, snapping and
shearing of axons
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Hematoma
Epidural Hematoma Hematoma or Blood Clot forms on top of the dura
Subdural Hematoma Hematoma or blood clot forms under the dura
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Secondary InjuriesHydrocephalus, (enlarged ventricles) Intracerebral Hemorrhage, Edema(swollen brain tissue)
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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)
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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)
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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””
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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
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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”
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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
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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
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Possible Changes-Thinking Memory Attention Concentration Processing Aphasia/receptive
and expressive language
Executive skills Problem solving Organization Self-Perception Perception Inflexibility Persistence
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Possible Changes-Physical Motor skills/Balance Hearing Vision Spasticity/Tremors Speech Fatigue/Weakness Seizures Taste/Smell
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Possible Changes-Personality and Behavioral
DepressionSocial skills problemsMood swingsProblems with emotional control Inappropriate behavior Inability to inhibit remarks Inability to recognize social cues
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Personality and Behavioral cont..Problems with initiationReduced self-esteemDifficulty relating to othersDifficulty maintaining relationshipsDifficulty forming new relationshipsStress/anxiety/frustration and reduced
frustration tolerance
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Lack of AwarenessA common and difficult to remediate hallmark of a brain injury
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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
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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
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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
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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
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Strategies cont…..Review schedule each dayPost signs on the wall etc.Try to “routinize” the day as much as
possible
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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
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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
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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
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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
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The Goal is to…...
Enhance the Predictability of the Daily Routine
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Why Screen for a History of Brain Injury?
What other screening efforts have found……...
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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
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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
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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
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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)
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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
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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
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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
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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
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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.
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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)
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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
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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.
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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
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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
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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
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What you are looking for…..Any reported or suspected functional
difficulties that are interfering with home, work or community activities
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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)
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Questions??
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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
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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. [email protected]
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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.
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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.