Issues in Developmental Disabilities Traumatic Brain Injury

1. Issues in Developmental DisabilitiesTraumatic Brain Injury Lecture Presenter: Donald L. Mickey, Ph.D.

2. Video of Don Mickey

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. Pathology of TBI • Micro pathology – Excitotoxic Injury, Shear injury • Coup/Contra Coup Injury • Diffuse Injury • Pharmacological Intervention – Timing is Critical • Mannitol

10. 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

11. 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

12. Acute Care Treatment & Course of Recovery Acute Care Treatment & Course of Recovery

13. Ideal Course of Recovery • Course of recovery -Coma -PTA (Post Traumatic Amnesia) Retrograde and Anterograde amnesia General Confusion Agitation • Hospital Rehabilitation • Post Acute Rehabilitation • Gradual Return to Community, and work, (with Supports) • Often Dependent on Insurance

14. 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

15. Neuropsychological & Radiological Assessment Neuropsychological & Radiological Assessment

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

17. Radiological Assessment • MRI • fMRI • PET scans • CT’s

18. Picture of Whole Brain

19. 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

20. Picture of Whole Brain

21. General Functions; Lobes • Parietal: Sensation, reading, listening, awareness of spatial relationships, and memory • Occipital: Visual perception

22. Picture of Whole Brain

23. Terminology, Injury and Manifestation Terminology, Injury and Manifestation

24. Specific terms (all caused by the injury) • Denial • Apathy • Emotional Liability • Impulsivity and Disinhibition

25. Specific terms (all caused by the injury) • Frustration and Intolerance • Lack of insight • Inflexibility • Confusion • Forgetting

26. 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

27. Manifestation of injury • Decreased alertness and arousal • Inadequate attention and concentration -Focused -Sustained -Selective -Alternating -Divided • Confusion and disorientation • Impaired memory of new information

28. 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

29. 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

30. 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)

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Ongoing Needs • Neuropsychological examination results • Community supports - are they coordinated? • “Family” supports • Specific information for care providers so they know how to assist individual

40. 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

41. 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