Traumatic Brain Injury: An Overview

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Traumatic Brain Injury An Overview

• Helping Professionals Identify, Support and Treat
  Individuals with TBI in the Domestic Violence
  Treatment Setting
• A 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 falls
• African Americans have the highest death rate
  from TBI

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In Maryland..

• In 2000 there were 5,229 traumatic brain injuries
• 5 of all hospitalizations were TBI related
• 25 of all injury related deaths for ages 15-24
  were TBI related
• 11 of all injuries to children 14 and under were
  TBI related

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Causes of TBI CDC 2006
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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 techniques
• Safety features such as car seatbelts, child
  safety seats and airbags

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Definitions

• Traumatic Brain Injury is an insult to the brain
  caused by an external physical force
• Diffuse Axonal Injury the tearing and shearing of
  microscopic brain cells
• Acquired 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 accidentally
• Reece, 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 Brain

• Childrens brains do not reach their adult weight
  of 3 pounds until they are 12 years old
• The brain, and most importantly, the brains
  frontal lobe region does not reach its full
  cognitive maturity till individuals reach their
  mid twenties

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The Developing Brain

• The 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 sociopathydescribe 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
ViolenceRosenbaum, 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 OLeary 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 year
• Almost 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/Concussion

• Most common, 75-85 of all brain injuries are
  mild
• Individuals experience a brief (lt15 minutes)or NO
  loss of consciousness
• Normal neurological exam
• 90 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

• Late Signs
• persistent headache
• poor attention
• irritability
• ringing in the ears
• restlessness
• depressed mood
• lightheadedness
• memory
• blurry vision
• fatigue and anxiety

• Early Signs
• confusion
• dizziness
• vomiting
• headache
• nausea

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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-Severe

• Almost 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 Injuries

• Rotational 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 Injuries

• Hydrocephalus, (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 talking
• Longer that period of time, the more serious the
  potential impact of the injury
• e.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

• Depression
• Social skills problems
• Mood swings
• Problems with emotional control
• Inappropriate behavior
• Inability to inhibit remarks
• Inability to recognize social cues

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Personality and Behavioral cont..

• Problems with initiation
• Reduced self-esteem
• Difficulty relating to others
• Difficulty maintaining relationships
• Difficulty forming new relationships
• Stress/anxiety/frustration and reduced
  frustration tolerance

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Lack of Awareness

• A common and difficult to remediate hallmark of a
  brain injury

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Focus of Rehabilitation and Often Lifetime Support

• Increase individuals 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 deficits
• Treating 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 Compensation

• Use of a journal/calendar
• Create a daily schedule
• To do lists
• Labeling items
• Learning to break tasks into small manageable
  steps
• Use 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 day
• Post 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

• Dont 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 behavior
• Give feedback immediately using the sandwich
  technique
• Utilize positive reinforcement/feedback
• Formalize 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
Illness

• Kathleen 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 surveyed
• Lifetime 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
• N190
• 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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HELPS

• Were 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 isnt 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 persons 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 individuals environment, and their
own interpersonal interactions with the individual

• Biological Limits to Behavioral Recovery
• Farrell 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.
  Mcrowley_at_rehab.state.al.us

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Resources

• Brain Injury Association of America 703-236-6000,
  www.biausa.org
• Brain Injury Association of Maryland
  410-448-2924, www.biamd.org
• Ohio Valley Center For Brain Injury Prevention
  and Rehabilitation, 614-293-3802,
  www.ohiovalley.org.

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Anastasia EdmonstonProject Directoraedmonston_at_d
hmh.state.md.us410-402-8478
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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.