Traumatic Brain Injury:Traumatic Brain Injury: OverviewOverview

Anastasia Edmonston, TBI and Person Centered Planning Trainer-MHA

&Dawn Roher, Clinical

Resource Manager-BIAMD

MHA’s – Lead Agency in Maryland for Traumatic Brain Injury

Programs and initiatives:• Home and Community Based Services Waiver for Adults with

Traumatic brain injury.• Staff to the Maryland Traumatic Brain Injury Advisory Board. • Pilot program for transition age youth with brain injury.• Statewide TBI training to human service professionals. • MHA contracts with the Brain Injury Association of Maryland

to provide TBI resources and referral information to Marylanders with brain injury.

• Additional information about these programs and initiatives can be found at http://dhmh.maryland.gov/mha/SitePages/tbi.aspx

What We will Cover Today

• The Basic Brain• Who is affected?• Types of Brain Injury• How are people affected by Brain Injury?• Resources

What might it feel like to be living with a brain injury?

Writing and processing exercise

Incidence of TBI

CDC 2010, 2002-2006 dataIn the United States, at least

1.7 million sustain a TBI each year…

275,000 are hospitalized

TBI By Cause CDC 2010

• Falls-35.2% (young children & elderly)

• Unknown/Others-21%

• Motor Vehicle-Traffic-17.3%

• Struck by/against-16.5% (unintentionally by object or another person)

• Assault-10%

TBI in Maryland 2006-2010Data sources: Maryland Vital Statistics Administration and

Health Services Cost Review Commission 2012

• 15-24 year olds had highest percent of TBI related discharges (18%), followed by 45-54 year olds (13%), and 25-34 year olds (12%)

• One out of four TBI related discharges were caused by falls (27%), followed by MVAs (19%) and stuck by/against an object (7%)

The Scope of the Problem• Distribution of Severity:

– Mild injuries = 80%(Loss of consciousness < 30 min, Post traumatic amnesia < 1 hour)

– Moderate = 10 - 13%(LOC 30 min-24 hours, PTA 1-24 hours)

– Severe = 7 - 10%(LOC >24 hours, PTA >24 hours)

Skull Anatomy

The skull is a rounded layer of bone designed to protect the brain from penetrating injuries.

The base of the skull is rough, with many bony protuberances.

These ridges can result in injury to the temporal and frontal lobes of the brain during rapid acceleration.

Bony ridges

adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury

The Developing Brain

• Children’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 Brain

• Many of our adult thinking skills reside in the Frontal Lobe

• The Frontal Lobe is very vulnerable to injury

• If you have a frontal lobe injury as a child, you may “grow into your brain injury”

The Frontal LobeThe frontal lobe is the area of the brain responsible for our “executive skills” - higher cognitive functions.

These include:

• Problem solving• Spontaneity• Memory• Language• Motivation• Judgment• Impulse control• Social and sexual behavior.

adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury

Temporal LobeThe temporal lobe plays a role in emotions, and is also responsible for smelling, tasting, perception, memory, understanding music, aggressiveness, and sexual behavior.

The temporal lobe also contains the language area of the brain.

adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury

Symptoms and functional manifestations individuals

with brain injury or their family members may describe and MAPs

Resource Specialists may detect

Physical Challenges They May Report

• Dizziness, headaches

• Sleep problems• Diminished

taste/smell• Tremors/ataxia/poor

coordination• Speech problems

(reduced rate, slurring, stuttering)

• Seizures• Hearing impairment• Double vision, visual

field cut, tunnel vision

• Fatigue• Hemiparisis

Cognitive/Thinking Challenges They May Report

• Memory, especially for information recently read or heard

• Trouble organizing themselves, their day, their household

• Can’t multi-task anymore

• Have difficulty in social/work situations following the conversation if more than one person is talking

• Easily distracted (can’t read the paper if the TV is on)

Cognitive/Thinking Challenges You May Detect

• Difficulty staying on topic

• Vague, unclear language

• Perservation (repeating themselves)

• Confused

• Memory lapses• Very concrete in

their thinking (poor abstract thinking, doesn’t get jokes)

• Talks too loud/too fast

• No first hand memory of injury

Other Clues to Cognitive/Thinking Challenges• Difficulty following

directions• Might have difficulty

with simple orientation questions

• Aggressive or hostile response to seemingly benign questions

• Delayed response time to your questions

• Tangential responses to your questions

• Confabulation (hard to determine at first interaction)

Personality and Behavioral Challenges They May

Report• Depression

• Anxiety

• Moody/Irritable

• Loss of/or strained relationships

• Insomnia

• Substance use/abuse

Personality and Behavioral Challenges You May Detect

• Impulsivity• Poor judgment• Flat affect

(noticeable in speech pattern)

• Sexually Disinhibited

• Emotionally labile • Substance

Use/Abuse• Aggression• Poor initiation

Lack of Awareness AKA

AnosognosiaA common and difficult to remediate hallmark of

a brain injury

“Emergence of Self Awareness is the Highest of all Integrated Activities of the

Brain” Stuss & Benson 1986

Commonly seen Scenarios

Growing into Brain Injury

• Great physical recovery, good initial cognitive recover

• Returns to school, behind peers

• Academically challenged

• Acts out behaviorally, if the injury several grades back, not recognized as TBI related

Continued….

• Drifts after graduation from high school

• Gets in with the “wrong” crowd

• At risk for mental health issues, substance abuse, criminal activity, burn out families and supports

Lack of Awareness X Impulsivity + Substance Abuse = Crisis

• Severe brain injury with excellent physical recovery

• Rejects outpatient therapy • Impulse control, memory problems, work

dries up• Drugs and Alcohol• Marriage on the rocks• Near tragic interaction with a state trooper• Resolution

“Unidentified traumatic brain injury is an unrecognized major source of social and vocational

failure”Wayne Gordon, Ph.D of the Brain Injury Research Center at

Mount Sinai School of MedicineQuoted in the Wall Street Journal 1.29.08

Individuals with Brain Injury are Overrepresented in the Following

Populations• Incarcerated individuals

• Homeless individuals

• Victims and perpetrators of domestic violence

• Individuals with behavioral health disorders (mental health and/or substance abuse)

• Service members returning from Iraq and Afghanistan

Treatment and Rehabilitation

Typical Course of Treatment for

a Severe Brain Injury

• Treatment at a Trauma Center • ICU/Acute Care• Inpatient Rehabilitation• Outpatient Rehabilitation• Other Community Services

Treatment Plan can include therapy and services from the following……

• Physical Therapy• Occupational Therapy• Speech Therapy• Cognitive Therapy• Social Work• Psychology• Recreation Therapy• Case Management• Nursing• Physician (rehab medicine, neurology)• Neuropsychology

Important Things to Remember:

A person with a brain injury is a unique individual first

No two brain injuries are exactly the same

The effects of a brain injury are complex and vary greatly fromperson to person

The effects of a brain injury depend on such factors as cause, location and severity

THUS…each person’s recovery and treatment process is unique to them

Factors that can determine the course of treatment:

• Family support• Finances• Insurance• Age• Co-occurring mental health and substance

abuse issues• Level of Education• Geographical location• Other resources and supports in the

community

When do people ask for help ?

• When the person is initially injured• When they hit a “bump in the road”• Further down the recovery curve, when they

are looking for services and never received them initially

• When they know something isn’t right and they are reaching out for education, validation, and support

• Aging parents with adult children with TBI

Who are the other sources of support and resources that complete this

picture?• Specialty clinics, i.e.-

concussion, mild TBI, sleep, etc.

• Neuropsychologists• Medical specialists—

headache, pain, neuro-opthamologists, physiatrists, neuropsychiatrists, neurologists, etc.

• Vocational counselors • State vocational

rehabilitation counselors (DORS)

• Attorneys

• Private case managers• Insurance case managers• Psychotherapists• Educators and school

personnel• Addictions Specialists• Other advocacy agencies-

C.I.L., MDLC, etc.• Pediatric resources• Developmental Disabilities

Administration• Support groups

Please refer to the Brain Injury Resource Handout for a additional

information and educational materials