Issues in Developmental Disabilities

Traumatic Brain Injury

Lecture Presenter:

Donald L. Mickey, Ph.D. QuickTime™ and a

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ORGANIC VERSUS PATHOLOGICAL? (Keep In Mind)

What is the causal agent for the behavior and problems that we see exhibited?

We must be aware that each individual is different and each person had a life, which they may be able to remember, prior to the brain injury

Definition

Sudden insult to the brain which may or may not involve loss of consciousness (LOC)

Causes

Major: Assaults, falls, car accidents, gun shots

May also include stroke, anoxia, carbon monoxide poisoning, infections, toxic exposure

Add-Blasts as additional cause due to the war

Prevalence-Risk Groups

Males 1.5 times as likely as females to sustain a TBI

Two age groups most likely 0-4 year olds, 15-19 year olds, and over 75

Now-Military

Prevalence TBI results in 1.5 more deaths a year than

AIDS Each year 230,000 individuals are

hospitalized with TBI and survive 4th leading cause of death overall Each day 5,500 individuals sustain a TBI Approximately 1 in every 10 individuals are

touched by TBI 80,000-90,000 people experience onset of

long term consequences of TBI

Prevalence-Scope

400,000 Americans with spinal cord injury

500,000 with Cerebral Palsy 4 million with Alzheimer’s disease 5 million with persistent mental illness 5.3 million with TBI disability

Pathology of TBI

Micro pathology – Excitotoxic Injury, Shear injury

Coup/Contra Coup Injury Diffuse Injury Pharmacological Intervention – Timing

is Critical Mannitol

Outcomes of TBI-Basic Elements

Extent and Location of Gross Damage Extent of Microscopic Damage Pre Morbid Brain Factors Response to Post injury Therapies GCS within 24 hours post injury

Neuropathology and Neurotransmission – Vulnerable Areas

White Matter- Shear Injury Affects Corpus Callosum and Basal Ganglia

Coup/Contra Coup Injury- Affects Frontal, Temporal, and Occasionally Occipital Structures

Chronic Injuries – May Alter the Homeostasis of Neural Transmission

Acute Care Treatment & Course of Recovery

Acute Care Treatment & Course of Recovery

Ideal Course of Recovery Course of recovery

-Coma-PTA (Post Traumatic Amnesia)

Retrograde and Anterograde amnesia General ConfusionAgitation

Hospital Rehabilitation Post Acute Rehabilitation Gradual Return to Community, and work, (with

Supports) Often Dependent on Insurance

The Other Course of Recovery

Hospital Management at Acute Level Return to Community with Limited

Outpatient Therapy Patient and/or Family is Left to Figure

Out What is Next

Neuropsychological & Radiological Assessment

Neuropsychological & Radiological Assessment

Neuropsychological Assessment Attention/concentration and orientation Memory Behavioral observation Language ability Visual spatial/visual constructive Motor performance Executive functioning Motivation Personality factors Summary Recommendations

Radiological Assessment

MRI fMRI PET scans CT’s

Picture of Whole Brain

General Functions; Lobes

Frontal, left vs right: Emotional control center and highest intellective area of the brain; includes language, creative thought, problem solving, initiation of movement, judgment, and impulse control

Temporal: Memory, language, sequencing, musical ability

Picture of Whole Brain

General Functions; Lobes

Parietal: Sensation, reading, listening, awareness of spatial relationships, and memory

Occipital: Visual perception

Picture of Whole Brain

Terminology, Injury and Manifestation

Terminology, Injury and Manifestation

Specific terms (all caused by the injury)

Denial Apathy Emotional Liability Impulsivity and Disinhibition

Specific terms (all caused by the injury)

Frustration and Intolerance Lack of insight Inflexibility Confusion Forgetting

Specific terms (all caused by the injury)

Verbosity Perseveration Confabulation Lack of Initiation and Follow-Through Slow and Inefficient Thinking Poor Judgment and Reasoning Social imperception Fatigue

Manifestation of injury Decreased alertness and arousal Inadequate attention and concentration

-Focused-Sustained-Selective-Alternating-Divided

Confusion and disorientation Impaired memory of new information

Manifestation of injury Impaired sequential memory of past

information Expressive language problems Receptive language problems Agitation and irritability Catastrophic reaction and reactive

depression Exacerbation or decrease of pre-injury

mental health issues

Manifestation of injury

Impaired adaptive behavior = Executive functioning-Difficulty in planning a course of action-Planning, organizing, and following through on any goal orientated task at home or work

Inconsistencies for the Individual Everyone says you look good and are

doing well Mirror says I look good No retrograde amnesia so I can

remember all the things I have done and can do

Impairments block understanding of self information (right hemisphere injury)

Inconsistencies for the Individual

The effect of fatigue compounds the effects of the injury

“Can’t walk and chew gum”! Frontal lobe problems - too many

choices and decisions Simple definition - no auto pilot now,

must always be alert

Inconsistencies for the Individual Higher functioning individuals who use

cognitive processes are more aware of even small short comings, which in turn magnifies the impairments

Major memory impairment and adequate intellectual capacity often has impairment as focus of treatment versus use of preserved skills

Minor memory impairments often are ignored as not important

Community Issues Lack of understanding of the

functional deficits, or too much understanding of the “deficits” blocks community success

“Normal” verbal abilities and/or normal “IQ” often has support people down playing the impairments or ignoring the impairments as not important

Community Issues

What does brain injury mean to you? Individuals often select one or two cases as their idea of brain injury - this may not represent the current case

Underlying or pre-existing mental health and/or life style issues are ignored or become focus

Community Issues

Unawareness of how to treat the brain injured individual, i.e. can I set limits, what should I say when happens, we don’t want him to get upset, etc.

One size does not fit all

Needs Awareness of injury deficits in a

functional sense - how does a right frontal lobe injury affect the person in the environment?

This has to be an ongoing educational process with supports available following failures to process what happened

Functional and verifiable knowledge of strengths and weaknesses

Needs

Energy Output-How much-How Long-Crashes/recovery

Risk taking to develop new skills or verify existing skills

Planned failure in the community setting to assist the learning process

Problems and Changes How can we expect individuals to

change if they don’t know what is wrong?

When you know, it is easier to take responsibility for your self versus listening to others tell you what and why you need to change

Planned failure and community challenges

Ongoing Needs

Neuropsychological examination results

Community supports - are they coordinated?

“Family” supports Specific information for care providers

so they know how to assist individual

Questions and Ideas Importance of survival in the

community -RISK TAKING-

Psychological impact of accepting change

Need to adapt everything to a “real world” environment - importance for care providers

Caveat

Always remember what you are dealing with a WHOLE system (person) that had a life prior to becoming a brain injured “patient or client”

Always be aware that systems function together and may not always fit neatly into specialty areas