Children

1
Children Brain Injury

• Anastasia Edmonston MS CRC
• TBI Projects Director
• Maryland Mental Hygiene Administration

2
What We Will Talk About

• The big picture
• What about concussion and kids?
• Strategies
• Prevention tips
• State, regional and national brain injury
  resources

3
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

4
IDEA Definition of TBIFederal Public Law
101-476, 1990

• ..an acquired injury to the brain caused by an
  external physical force resulting in total or
  partial functional disability or psychosocial
  impairment or both that adversely affects a
  childs educational performance..

5
The Big Picture
6
The Brain Injury Quiz

• How many pounds is the adult brain? a)
  7 lbs b) 3 lbs c) 1.5 lbs
• At what age is your brain fully mature?
  a) 16 b) 21 c) 25
• What is the last part of the brain to mature? a)
  temporal lobe b) brain stem c) frontal lobe
• Who has not had a traumatic brain injury? a)
  George Clooney b) Mike Wallace c) Jason Priestly
  d) Anne Hathaway

7
About 3.17 Million American civilians (more than
1.1 of population, live with the consequences of
traumatic brain injuryCDC in Journal of Head
Trauma Rehabilitation 2008 (Vol. 23, No. 6, pp
394-400)
8
Limitations of Study

• Does not include discharge records from military
  and veteran affairs hospitals
• Does not include children under 15 years of age
  (from SC data)
• Does not include persons treated and released
  from emergency department or other healthcare
  setting, and those not treated in any healthcare
  setting following a blow to the head

9
NATIONWIDE

• 1.4 million Americans sustain a brain injury each
  year
• 50,000 do not survive their injuries
• 235,000 are hospitalized
• 1.1 million are treated and released from our
  nations emergency departments following a brain
  injury
• Annual Incidence of TBI with disabilityAN
  ESTIMATED 124,000 American civilians

10
NATIONWIDE-children ages 0-14

• 2,685 deaths
• 37,000 hospitalizations
• 435,000 emergency department visits (accounting
  for over 90 of emergency department visits in
  children 0-14 years old)

11
Reframed, the numbers nauseate. In America
alone, so many people become permanently disabled
from a brain injury that each decade they could
fill a city the size of Detroit...
12
.Seven of these cities are filled already. A
third of their citizens are under fourteen years
of age.From Head Cases, Stories of Brain
Injury and its AftermathMichael Paul Mason2008
published by Farrar, Straus and Giroux
13
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 CDC 2006

14
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

15
Simplified Brain Behavior Relationships
Frontal Lobe Initiation Problem solving
Judgment Inhibition of behavior
Planning/anticipation Self-monitoring Motor
planning Personality/emotions Awareness of
abilities/limitations Organization
Attention/concentration Mental flexibility
Speaking (expressive language)
Parietal Lobe Sense of touch
Differentiation size, shape, color Spatial
perception Visual perception
Occipital Lobe Vision
Cerebellum Balance Coordination Skilled
motor activity
Temporal Lobe Memory Hearing Understanding
language (receptive language) Organization
and sequencing
Brain Stem Breathing Heart rate
Arousal/consciousness Sleep/wake functions
Attention/concentration
16
What happens in a TBI?

• Mechanism Acceleration/Deceleration
• Differential movement of partially tethered brain
  within the skull
• Results in
• Bruising of the brain surface
• against rough areas of the skull
• Stretching and twisting of nerve axons

17
Skull Anatomy Dr. Mary Pepping of the
University of Idahos presentation The Human
Brain Anatomy,Functions, and Injury
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.
The skull is a rounded layer of bone designed to
protect the brain from penetrating injuries.
Bony ridges
18
Brain SkullDr. Mary Pepping of the University
of Idahos presentation The Human Brain
Anatomy,Functions, and Injury
Injury to frontal lobe from contact with the skull
19
Diffuse Axon InjuryDr. Mary Pepping of the
University of Idahos presentation The Human
Brain Anatomy,Functions, and Injury Can
directly impact the major pathways of the brain.
20
RECAPThe 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

21
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

22
According to the USDE, in Maryland.

• Only 324 students out of 98,811with identified
  disabilities were receiving services under a TBI
  diagnosis in 2006. U.S. Department of Education,
  Office of Special Education Programs 7/17/06
  httpt//www.ideadata.org/tables29th/ar_1-3.xls

23
Why the Gaps in numbers?

• Not all children experience lasting effects
• The etiology of a students disability may be
  unidentified or misunderstood
• Student may be served under a 504 plan
• Effects of a early brain injury may not be
  expressed until the student is older
• When the effects do surface, they may diagnosed
  as having a learning disability, emotional
  disorder, or other disability
• Adapted from TBI and Educators Guide by the MD
  TBI Implementation Project and the BIAM 2003

24
Mild Traumatic Brain Injury (AKA concussion)

• Most common, 75-85 of all brain injuries are
  mild
• Individuals experience a brief (lt15 minutes)or NO
  loss of consciousness
• Post Traumatic Amnesia lt 1hour
• Normal neurological exam
• 90 of individuals recover within 6-8 weeks,
  often within hours or days

25
The American Academy of Neurology Concussion
is a trauma-induced alteration in mental status
that may or may not involve loss of
consciousness. Confusion and amnesia are
hallmarks of concussion http//search.aan.com/vi
visimo/cgi-bin/query-meta?input-formsimplev3Aso
urcesAANNewv3Aprojectaanqueryconcussion
26
Importance of Post Traumatic Amnesia

• PTA is the period of time after injury when a
  person is unable to lay down new memories
• For Example...

27
That first morning, wow, I didnt want to move,
I was thankful that nothings broken, but my
brain was all scrambled Ryan Church, NYT 3/10/08

• All he remembers from the collision with
  Anderson is the aftermath, being helped off the
  field by two people, although he said he did not
  know who they were until he saw a photograph
  later Ben Shpigel NYT reporter

28
Concussion and Kids-Sports

• In sports alone, 300,000 concussions are
  estimated to occur annually
• For every 1 concussion in the NFL, there are
  5,650 youth injuries
• Sports associated with concussion soccer,
  football, lacrosse, hockey, horseback riding,
  cheerleading.. Gerard Gioia, Ph.D., Childrens
  National Medical Center in remarks at the Brain
  Injury Association of MD conference 2005

29
Concussion and Kids-Sports

• Football has the highest rate of concussions in
  high school sports, girls soccer 2nd highest rate
  (New York Times 10.2.07)
• 29,167 concussions suffered by US high school
  girl soccer players, 20,929 concussions suffered
  by high school boy soccer players 2005-2006 (Time
  Magazine 2008)
• Female concussion rates in high school basketball
  were almost 3xs higher than among boys.
• In girls, symptoms take longer to resolve (NYT
  10.2.07)

30
Quoted in TimeDr. Joseph MaroonU of Pittsburgh
Medical Center

• More-developed necks allow boys to better absorb
  a blow to the head

31
Implications for Children

• Children who incur a brain injury are twice as
  likely as other children to have a second brain
  injury within 6 months.
• According to the researchers, factors included a
  complex interaction between children and their
  social environments (Pediatrics 2007 Eric
  Nagourney of the NY Times 4/3/07)

32
Implications for Children

• Concussion and repeated concussions can occur
  from falls and sports injuries
• Most soccer concussions are due to hard falls or
  player collisions
• Secondary impact syndrome, a rare but potentially
  fatal result of two concussions within a short
  period of time

33
The Faces of Brain InjuryA short video by the
Brain Injury Association of Florida
34
Brain Injurys Impact on Physical Functioning.
Adapted from BIA Utah BIA NJ

• Tired all the time/ Tires more quickly
• Continuing headache (maybe accompanied by
  nausea), may also be bothered by noise or light
• Less active
• Dizziness
• Ringing in the ears
• Slurred speech
• Changes in balance, difficulty grasping objects
• Bothered by light and noise
• Sleep changes (cant sleep, nightmares etc.)

35
Brain Injurys Impact on Thinking.. Adapted from
BIA Utah

• Memory, especially short-term memory
• Difficulty learning new information
• Trouble paying attention staying on task
• Misses instructions
• Multi-tasking or splitting and dividing ones
  attention (aka executive skills) can be very
  challenging

36
Emotional and Behavioral Consequences Adapted
from BIA Utah and NIA NJ

• Impulsive
• worried and moody
• flat affect or little change in emotion
• Spends more time alone
• Easily upset (teary, agitated, aggressive)
• Self-centered of finding it hard to take
  anothers point of view
• Difficulty exercising good social judgement
• Difficulty following daily routine at school
  and/or home

37
Possible Changes-Personality and Behavioral ...MD
TBI Project

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

38
Possible Changes-Personality and Behavioral

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

39
Children Grow into Their Brain
Injuries(Gioia)as children grow, more is
expected, children with a history of brain injury
may not be able to meet the demands.Impact of
an injury may not become apparent till years post
injury andnot be attributed to an earlier blow
to the head
40
Recommended Supports and Services-The Ideal
Pathway Following Concussion or Mild Brain
Injury-Childhood Injury

• Family and child is educated about the possible
  symptoms of concussion
• If symptoms emerge or persist following a
  concussion, appropriate referrals are made to a
  neurologist, pediatric neuropsychologist.
  Appropriate interventions and supports including
  outpatient speech, occupational and physical
  therapy are provided and coordinated with school
  personnel
• Exposure to situations where a second impact is a
  possibility is minimized

41
If Symptoms Persist and are Left Untreated.in
children

• Teachers and family may notice irritability
• Schoolwork suffers
• Behaviors attributed to factors other than the
  brain injury (family/peer problems, adolescence)
• Child continues to experience problems, becomes
  depressed/may begin to act out
• Is at risk for academic/social difficulties
• Is at risk for a subsequent brain injury,
  exacerbating the above

42
If Symptoms Persist and are Left Untreated.in
adults

• Job loss
• Mental Health Problems
• Relationships and supports erode
• At risk for Substance Abuse
• At risk for entry into the criminal justice system

43
Why Screen?What other TBI Screening efforts have
found
44
2000 Epidemiological Study of Mild TBI J. Silver
of NYU, cited in WSJ by Thomas Burton 1.29.08
http//online.wsj.com/article/SB120156672297223803
.html?modgooglenews_ wsj

• 5,000 interviewed
• 7.2 recalled a blow to the head
  w/unconsciousness or period of confusion
• Follow up testing found 2x rate of depression,
  drug and alcohol abuse
• Elevated rates of panic and and
  obsessive-compulsive disorder

45
Findings from the LiteratureCriminal Justice
System

• Researchers at Indiana State University found
  that 83 of felons studied reported a head injury
  that predated their first encounter with the law
  (1998)
• Adults who had frontal lobe damage prior to age 8
  exhibited recurrent impulsive and aggressive
  behavior
• 14 of the subjects in the Vietnam Head Injury
  Project with frontal lobe lesions engaged in
  fights or damaged property compared to 4 of
  controls without TBI

46
Domestic Violence TBI Findings

• Batterers fared worse on three neuropsychological
  indicators of cognitive functioning then a
  nonbatterer control group (Cohen et. Al 1999)
• 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

47
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

48
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)

49
TBI Screening

• 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

50
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

51
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

52
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

53
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.

54
HELPS

• Difficulty reading, writing, calculating
• Poor problem solving
• Difficulty performing your job/school work
• poor judgement (being fired from job, arrests,
  fights, relationships affected)

• Headaches
• Dizziness
• Anxiety
• Depression
• Difficulty concentrating
• Difficulty remembering

55
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

56
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.

57
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

58
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

59
What you are looking for..And Why

• 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 ramblingBecomes easily
  distracted, agitated or is emotionally labile

60
Strategies for supporting children with
persistent symptoms
61
Strategies to enhance learning are included in a
childs IEP or in a 504 planSome examples to
support those with brain injury related
challenges include with or with out an IEP or 504
plan... (For more information on IDEA 504
plans go to resource section of this handout)
62
Strategies-Physical-for Children

• Visual aides (large print, screen adapters,
  scanning aides)
• Built in rest periods in daily schedule
• Structure and simplify the classroom environment
  (predictable schedule, reduced clutter,
  consistent cues, written classroom rules)
• Tailor assignments and homework (3 ten minute
  verses one half hour assignments)
• Adapted from TBI and Educators Guide by the MD
  TBI Implementation Project and the BIAM 2003
  BIA Utah

63
Strategies-Cognitive

• Calendar/keep schedule predictable
• Planner vs. loose paper
• Laptop/computer
• Tape recorder
• Timer/timer watches
• Untimed testing
• Alternative testing

• Use of a reader or note taker (buddy)
• Highlighter
• Books on tape/film adaptation
• Strategic scheduling
• Break tasks/assignments into steps

64
Strategies Continued

• Encourage active listening strategies e.g
  paraphrasing back to speaker the information,
  especially when it is novel
• Special seating
• Place visual cues in environment (calendars etc.)

• Use of an FM system (headphones that directly
  link child to the teacher to screen out
  distractions)
• Text reader programs
• Retention in long term memory is enhanced by the
  three Rs Repeat, Rehearse, and Review
• Checklists

65
Uses of Strategies at Home and When Navigating
the CommunityWatch this clip from the movie The
LookoutWhat are the strategies he uses to
compensate for memory, organization, etc.
66
The Only Cure for Brain Injury is Prevention
67
Strategies for Prevention
68
Prevention

• Car safety
• Helmet use
• Sports
• Violence reduction

69
Car Safety

• Parents and caregivers-DRIVE THE POSTED SPEED
  LIMIT
• Drivers-insist all adult passengers wear their
  seatbelts. An unrestrained adult in the event of
  an accident can be transformed into an unguided
  missile that can injure or kill a child passenger
  (same goes for dogs, buckle them up too!)
• Dont drink and drive, reaction time can
  deteriorate after only two drinks

70
Car Safety for Child Passengers

• Children up to 14 years of age or younger need to
  sit in the back seat and properly restrained for
  their age, weight and height.
• Children 40-80 pounds should sit in a booster
  seat. This enables the belt to sit properly, low
  and tight across the top of the thighs Kids in
  Safety Seats website

71
Car Safety for Child Passengers

• Although car manufacturers recommend not to place
  children 12 or under in the front seat with an
  air bag, research suggests that no child under 14
  should sit in the front seat with an airbag.
  (Pediatrics 2005)
• At 14, the maturation of the bones and muscles is
  sufficient to tolerate the impact of a deployed
  airbag

72
The Good News!

• Because of increased use of seat belts, and
  placement of children in the backseat, it is
  estimated that from 1995-2001, 1,700 lives were
  saved!
• Report by the Air Bag and Seat Belt Safety
  Campaign 2005

73
Helmets Sports

• Brain injuries cause more deaths than any other
  sports injury
• Research shows that 85 of bicyclists head
  injuries can be prevented by a bicycle helmet
• Always wear a helmet when biking, playing,
  football, baseball (at bat), horseback riding,
  in-line skating, ice skating, roller skating,
  avoid heading the ball when playing soccer
  (Brain Injury of America website www.biausa.org)

74
Violence Prevention

• Keep guns unloaded and locked up
• Keep bullets locked up in a separate location
• Explain to children the difference between the
  violence they may see on TV and the real harm
  that guns can do (BIAA website, www.biausa.org.)
• Teach children to walk away from conflict

75
Resources

• Brain Injury Association of America
• 1-800-444-06443
• www.biausa.org

76
Resources

• Brain Injury Association of Maryland
• 410-448-2924
• www.biamd.org

77
Resources Centers for Disease ControlWonderful,
free tool kits

• Heads Up Concussion in high school sports- a
  tool kit for for coaches, parents and athletes
  http//www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm
• Head Up Concussion in Youth Sports Tool Kit
  http//www.cdc.gov/ConcussionInYouthSports/default
  .htm

78
Resources/References

• "Brain Injury Partners Navigating the School
  Systema collaboration of the National Institute
  of Child Health and Development and the Brain
  Injury Association of America.
• Brain Injury A Guide for Families About School
  Published by the BIA of New Jersey, includes an
  excellent discussion on how the IEP and 504
  plans can support students with brain injury
  http//www.bianj.org/publications-on-brain-injury
• Slides 17-19 adapted from Dr. Mary Pepping of
  the University of Idahos presentation The Human
  Brain Anatomy,Functions, and Injury

79
Resources/References

• http//www.bianys.org/learnet/. A website full of
  information on strategies for children, teachers
  and clinicians on how to problem solve around
  various brain injury related issues. Created by
  the NIA of New York State
• Brain Injury Resource and Information Network of
  Tennessee www.tndisability.org/brain
• Brower MC, Price BH. Neuropsychiatry of frontal
  lobe dysfunction in violent and criminal
  behavior a critical review. Journal of
  Neurological and Neurosurgery Psychiatry
  200171720-726.

80
Resources continued...

• National Safe Kids Campaign
• www.safekids.org
• 1301 Pennsylvania Ave., N. W.
• Washington D.C. 20004-1707
• 202-662-0600

81
Resources continued...

• Kids in Safety Seats
• Kiss_at_dhmh.state.md.us
• 1-800-370-SEAT, call for information as well as
  for a car seat safety check

82
Resources continued...

• The Safe Concussion Outcome Recovery Education
  Program(SCORE)
• At the Childrens National Medical Center
• Washington DC
• 202-884-2429

83
National Center on Secondary Education and
Transition

• www.ncset.org

84
Resources

• Specialized Health Needs Interagency
  Collaboration (SHNIC)
• Kennedy Krieger Institute
• 410-502-8419

85
Lash and Associates Publishing/Training
www.lapublishing.com

• Information and ReferralBrain Injury in Children
  and Adults
• Books, pamphlets and tip sheets on various
  aspects of brain injury can be purchased, the
  website also offers many articles that can be
  downloaded for free

86
National Dissemination Center for Children with
Disabilities

• www.nichcy.org/pubs/factshe/fs18txt.htm

87
Publications Available from Lash Associates

• Pay Attention! Attention Training for Children
  Ages 4-10. 2nd edition, Jennifer Thomson and
  Kimberly Kerns. Resource for professionals and
  families working with children following TBI,
  brain tumors, and ADHD
• Getting A-Head of Concussion. Phil Hossler and
  Ron Savage. For school nurses, parents,
  pediatricians, and coaches. Discusses the signs
  of concussion and how to monitor at home and in
  the classroom

88
Recommended Reading

• I am the Central Park Jogger A Story of Hope and
  Possibility by Trisha Meili, 2003
• Every Good Boy Does Fine A Novel by Tim
  Laskowski, 2003
• Over My Head A Doctors Own Story of Head Injury
  from the Inside Looking Out by Claudia Osborn,
  2000

89
Recommended Viewing

• Film released by Miramax in 2007
• The Lookout
• Starring Joseph Gordon-Levitt, Jeff Daniels,
  Matthew Goode and Isla Fisher
• Aside from being a great bank heist movie, this
  movie realistically depicts the struggles of a
  young man living with the aftermath of a
  traumatic brain injury he suffered as a high
  school senior
• Appropriate movie to share with teenagers, brings
  home the message of brain injury prevention
  without preaching

90
Brain Injury Training

• Available free of charge for human service
  professionals, agencies and advocacy groups in
• Frederick
• Washington
• Montgomery
• Baltimore
• Howard
• Anne Arundel County
• All counties on Marylands Eastern Shore
• Contact Anastasia Edmonston 410-402-8478

91
Contact Information

• Anastasia Edmonston
• 410-402-8478
• aedmonston_at_dhmh.state.md.us

Thank you!
92
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 Please Copy and Distribute Widely