Brain Injury

1. Brain Injury Calista Nabors, LMSW Sedrick Jackson, LCSW

2. What is Brain Injury • Injury to brain tissue that temporary or permanently impairs brain function “Brain injury is not an event or an outcome. It is the start of a misdiagnosed, misunderstood, under-funded neurological disease.” -Brain Injury Association of America

3. Disability Prevalence • Why is this important? • Depression • Stroke • Epilepsy • The “Silent Epidemic”

4. Incidence • Annual Rates • 1.7 Million per year (CDC) • 50,000 Deaths • 235,000 Hospitalizations • 1,100,000 ED visits

5. Comparison • Incidence of Select Health Problems in the U.S

6. Traumatic Brain Injury Act of 1996 • Passed July 29th, 1996 • Acknowledged the incidence and prevalence of brain injury nationally • “to expand efforts to identify methods of preventing traumatic brain injury; expand biomedical research efforts or minimize the severity of dysfunctions a result of such an injury; and to improve the delivery and qualify of services through State Demonstration Projects”

7. Funding • Private Insurance • Department of Defense/Veterans Administration • Some Federal grants for TBI-No feveral money for ABI • Private Pau • Non-Profit support- Scholarships given from community fundraising • Medicaid • After hospitalization • Only 5% of individuals with severe brain injuries have adequate funding for long term treatment

8. Cost • Staggering • Life-long costs • Year 2000 • $60 Billion • Lifetime cost • $406 Billion • Neurological Rehab starts at approx $30,000 per month

9. No two brain injuries are exactly the same • The effects of a brain injury are complex and vary greatly from person to person • The effects of a brain injury depend on such factors as cause, location, and severity

10. Types of Brain Injury • Traumatic Brain Injury (TBI) • Penetrating: foreign objects enters the brain • Example: bullet • Closed Head: blow to the head • Example: car accident • Acquired Brain Injury (ABI) • occurred after birth, but is not related to congenital defect or degenerative disease

11. Causes TBI • Falls • Motor Vehicle-Traffic Accidents • Struck by/against • Assaults • Blasts- Leading cause of TBI for active military in war zones. ABI • Hypoxia • Illness • Infection • Stroke • Substance abuse • Toxic exposure • Tumor

12. Severity • Mild Brain Injury • Loss of consciousness for less than 30 minutes (or no loss) • Glasgow Coma Scale of 13-15 • Post-Traumatic amnesia less than 24 hours • Temporary or permanently altered mental state • Post-concussion symptoms

13. Severity • Moderate • Coma more than 20-30 minutes but less than 24 hours • Glasgow Coma Scale of 9-12 • Skull fractures may be present • Signs on EEG, CT or MRI • Long term problems in one or more areas of life

14. Severity • Severe • Coma longer than 24 hours • Glasgow Coma Scale of 3-8 • Bruising, bleeding in brain • Signs on EEG, CT or MRI • Long term impairments in one or more areas of life.

15. Brain and Behavior Relationships

16. Brain Stem • Breathing • Heart Rate • Arousal/Consciousness • Sleep/Wake funtions • Attention/Concentration

17. Cerebellum Occipital Lobe Vision • Balance • Coordination • Skilled motor activity

18. Temporal Lope • Memory • Hearing • Understanding language • Organization & sequencing

19. Frontal Lobe • Initiation • Problem-solving • Judgment • Inhibition of behavior • Planning/Anticipation • Self-monitoring • Motor planning • Personality/Emotions • Awareness of abilities/Limits • Organization • Attention/Concentration • Mental Flexibility • Speaking

20. Common Disabilities • Problems with cognition • thinking, memory, and reasoning • Sensory processing • sight, hearing, touch, taste, and smell • Communication • expression and understanding • Behavior or mental health • depression, anxiety, personality changes, aggression, acting out, and social inappropriateness • More serious injuries my result in unresponsiveness with periods of alertness; a persistent vegetative state

21. Substance Abuse • 58% of individuals with acquired brain injury had a history of alcohol abuse or dependence prior to injury (Kreutzer, Dougherty, &Harris, et al., 1990 • Post Injury • As many as 50% of individuals with an acquired brain injury will return to using drugs and alcohol post-injury. (Sparadeo, Strauss &Barth, 1990)

22. Treatment • Initial • Little can be done to reverse the initial brain damage, medical personnel try to stabilize an individual and focus on preventing further injury • Mild injury • Mild traumatic brain injuries usually require no treatment other than rest and over-the-counter pain relievers to treat a headache. • Moderate to severe cases • Rehabilitation that involves individually tailored treatment programs in the areas of physical therapy, occupational therapy, speech/language therapy, physiatry (physical medicine), psychology/psychiatry, and social support.

23. Medication Therapy • Depakote and Tegretol –work well for aggression • Desyrel (sedating property) • Anti- Depressants • No MAOI’s- due to dietary constraints • Inderal and Clonidine (antihypertensive medications) • Antipsychotics- impair recovery, memory, learning, and lower seizure threshold.

24. Social Workers Role • Social workers play a very meaningful role. • LMSW: facilitates access to service agencies, assists with care decisions and planning, and facilitates communication among various professionals, care providers and family members • LCSW: continue support services to families and client. Facilitate support groups and provide individual therapy for the client and family members • Advocacy • Currently one of the hottest medical topics • Funding for treatment and placement is very limited • Medicaid does not pay for neurological rehabilitation

25. Common Therapy Models • Cognitive Behavioral Therapy (CBT) • Mild/Moderate • Cognitive Rehabilitation Therapy (CRT) • Mild/ Moderate • Dialectical behavior therapy (DBT) • Moderate/Severe • Behavioral Therapy • Mild/ Moderate/Severe

26. Cognitive Behavioral Therapy • CBT- Mild to Moderate • Cognitive-behavioral therapy focuses on altering thoughts or perceptions that are causing psychological distress • For those with moderate brain injury • Therapist train the client to continuously ask questions about strong emotional response • Example: What is it that's really making me angry? Did it always make me angry? Did it always make me this angry? • Computer-based cognitive therapy programs have helped many individuals suffering from brain injuries • Fun way to exercise each the brain with card games, mystery games etc. that can improve each area of the brain.

27. Cognitive Rehabilitation Therapy CRT • patient-specific and goal-oriented • increase their ability to process and interpret information • Its goal is to help the client enhance his or her ability to move through daily life by recovering or compensating for damaged cognitive functions • CRT involves a variety of treatments and often involves the participation of family or caregivers • CRT interventions are promising, however the Department of Defense recommends an investment in research to further define, standardize, and assess the outcomes of CRT interventions.

28. Dialectical Behavior Therapy DBT • Multi-treatment approach • Individual Therapy • Coaching • Structure • Managing Crises • Multiple stages • Connection between borderline personality disorder and brain injury • Certain brain mechanisms underlying the impulsivity, mood instability and negative emotions are responsible for maladaptive behaviors • The amygdala, which normally regulates arousal and emotions, may be involved in the disruption of normal emotional responses due to injury

29. Behavioral Therapy • Clients with moderate to severe brain injury's may not be able to cognitively process actions • Severe brain injury may leave someone intellectually inept • Behavioral Therapy • Reward and punishment systems • Operant conditioning • Positive reinforcement

30. Treatment Plan • Break it down! • Outcomes: the big idea • Goals: break the general outcome down • Objectives: no ambiguity, clearly defined • Person Centered • Supportive • Simple • Consistency • Positive • Daily Planner: Slowly adjusting daily plan.

31. Adjustment for All 6 stages of adjustment for the family • 1)Shock, Hope, Denial • 2)Recognition and Helplessness • 3) Annoyance, Expectations, Reality, Seeking information • 4)Realism, Exhausted, Pulling away, Bereavement • 5) Sadness, grief, mourn • 6) Understanding, acceptance, family unit • PTSD for entire family: acute or delayed anxiety

32. Change • Identifying events in environment: ABCs • Antecedent • Behavior • Consequence • Positive reinforcement • Yes or No questions • Stay Calm • Maintain a Sense of Humor • Avoid Arguments • Don’t Take things personally • Redirection

33. Quiz • What part of the brain causes the most change in personality when injured? • True or False: CBT is the best treatment for all clients with Brain Injury • Are open ended questions appropriate for brain injured clients? • True or false: all brain injuries are the same? • What are the two types of brain injury? • True or false: All brain injuries are the same. • True or False: Punishment for bad behavior is good practice? • How many stages of adjustment are their? • True or False: Medicaid covers brain injured individuals long term care • What is the 3rd most prevalent disability seen in the United States?

34. References • American Speech Language Hearing Association; Traumatic Brain Injuryhttp://www.asha.org/public/speech/disorders/TBI.htm • Brain Injury Association of America; http://www.biausa.org/living-with-brain-injury.htm • Brain Injury Resource Center; http://www.headinjury.com/rehabcognitive.html • Centers for Disease Control and Prevention; http://www.cdc.gov/TraumaticBrainInjury/index.html • Institute of Medicine; http://www.iom.edu/Reports/2011/Cognitive-Rehabilitation-Therapy-for-Traumatic-Brain-Injury-Evaluating-the-Evidence.aspx • The Gale Group Inc., Gale…. Gale Encyclopedia of Alternative Medicine • Mayo Clinic; http://www.mayoclinic.com/health/traumatic-brain-injury/DS00552/TAB=indepth • National Institute of Health; NINDS Traumatic Brain Injury • National Institute of Mental Health: Borderline Personality Disorder • PsycCentral;http://psychcentral.com/news/2011/10/13/cognitive-rehabilitation-therapy-for-traumatic-brain-injury-tbi-does-it-work/30325.html • Texas Health and Human Services Commission; office of Acquired Brain Injury; http://www.hhsc.state.tx.us/hhsc_projects/abj/index.shtml • The Bridge of Central Massachusetts: DBT for Individuals with Intellectual Disabilities • Kreutzer, JS Dougherty DR, and Harris AZ. Et al (1990). Alcohol use among persons with traumatic brain injury. Journal of Head Trauma Rehabilitation 5:9-20 • Sparadeo, FR, Strauss D &Barth, JT(1990). The incidence, impact and treatment of substance abuse in head trauma rehabilitation. Journal of Head Trauma Rehabilitation 5 (3), 1-8 • The Essential Brain Injury Guide Academy of Certified Brain Injury Specialists, Brain Injury Association of America.