Brain Injury in a behavioral health setting

1. Brain Injury in a behavioral health setting Presented by: Natasha McVey MSS, LCSW, CBIS Clinical Director of Mental Health Services Onward Behavioral Health The Light Program, Seeds of Hope, Life Counseling Services

2. Objectives • Brain Injury • Causes, Prevalence, & Common Effects • Clinical Cases • Screening Tools and Resources • Implications and Recommendations for Practice

3. How Big is the Problem?

4. Brain injury has a higher prevalence than HIV, breast cancer, and multiple sclerosis combined. Brain injury is also frequently undiagnosed and underreported.

5. Types of Brain Injury Acquired Brain Injury after birth process Traumatic Brain Injury external physical force Non-Traumatic Brain Injury Internal causes open head injury closed head injury

6. Non-Traumatic Brain Injury An insult to the brain resulting from internal causes Causes: • Stroke (hemorrhage or blood clots) • Infectious disease (encephalitis, meningitis) • Lack of oxygen to the brain (near drowning, overdose, airway obstruction, strangulation, cardiopulmonary arrest. hypoxia, anoxia) • Seizure disorder • Electric shock • Tumors (Surgery, radiation, chemo) • Toxic Exposures (substance abuse, ingestion of lead, inhalation of volatile agents) • Metabolic disorders (insulin shock, diabetic coma, liver and kidney disease) • Neurotoxic poisoning (carbon monoxide poisoning, inhalants, lead exposure)

7. Traumatic Brain Injury An insult to the brain caused by an external physical force • Causes: • Gunshot wounds • Falls • Assaults • Sports and recreational injuries • Shaken baby syndrome • Car accidents • Workplace injuries • Domestic Violence/child abuse • Military actions (blast injury)

8. Traumatic Brain Injury Closed Head Injuries Open Head Injuries Closed Head Injury

9. Severity of Injury Mild: Can have either brief or no loss of consciousness and its presentation may demonstrate vomiting, lethargy, dizziness, and inability to recall what just happened. Moderate: Will be marked by unconsciousness for any period of time up to 24 hrs. Will have neurological signs of brain trauma, including skull fractures with contusion or bleeding, and may have focal findings on an electroencephalograph (EEG)/computed tomography (CT) scan. Severe: Marked by a period of loss of consciousness of 24 hrs or greater.

10. What Age is most at Risk? 1. Adolescents/Young Adults age 15-24 and Adults 65 and older 2. Children Age 0-14 yrs old

11. Parts of the Brain and their Functions 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 Temporal Lobe• Memory• Hearing• Understanding language (receptive language)• Organization and sequencing Brain Stem• Breathing• Heart rate• Arousal/consciousness• Sleep/wake functions• Attention/concentration Cerebellum•Balance• Coordination• Skilled motor activity

12. Symptomology Following Brain Injury

13. Can Brain Injury Cause Psychiatric Disorders? • TBI relates to an increased risk for: • Depression • Bipolar Disorder • Panic Disorder • Generalized Anxiety Disorder • Schizophrenia • And more…. • TBI is associated with changes in personality and behavior • Other factors to consider: • Gender and genetic predisposition • Premorbid personality • Psychological resilience • Social support • Socioeconomic status When comparing TBI population to the general public, the rates for depression, panic disorder, phobic disorder, and generalized anxiety disorder were far greater along with an increase in suicide attempts, although frequently varied.

14. Case Study #1 • Client presented at assessment after a 4 day stay in-patient; Wife had requested divorce after finding sexting on his phone, and demanded that he get help. • He became suicidal at the thought of the marriage ending (prompted trip to hospital). • During assessment: he denied current intent or plan, and says he is committed to working on self and fixing marriage. • Started sexting in 2011. • No SA history. • Cancer in 2004. • HX of sexual abuse. • HX of self harming behaviors- in April 2018. • Mental Status exam showed full affect, Anxious/depressed mood, Clear speech, Logical thought process and normal Perception. Working Diagnosis?

15. TBI Case in the Media • Aaron Hernandez's brain tissue showed severe memory damage - YouTube • Convicted for the murder of Odin Lloyd- Gunshot • Indicted for double homicide of Daniel de Abreu and Safiro Furtado-was acquitted • 2007-2013 was investigated for various violent incidents. • Committed suicide in 2017 • Brain donated to science- Severe stage 3 CTE • Junior Seau- Shot self in chest- left paper in kitchen with lyrics he scribbled from a • song called “who I ain’t”. Describing a man who regrets the person he became. • Dave Duerson- Suicide note requested brain be studied for brain damage. • Andre Waters- Committed suicide in 2006. • All athletes with confirmed CTE.

16. Case Study #2 • Client age 56 presenting with wife at assessment; client reports depressive symptoms; does not want to get out of bed, extreme fatigue, loss of interest, does not attend work. • Wife reports that in summer symptoms get better. Also reports periods of increased energy, not needing sleep, Increased sex drive. • Mental Status exam showed depressed affect, Anxious/depressed mood, Clear speech, Logical thought process and normal Perception. Working Diagnosis?

17. Why is Screening for TBI Important? • Brain Injury is not always a visible disorder. • Some people may not know they have had a Brain Injury. • Documentation of a history of TBI may not be found in medical records.

18. Screening Questions • Have you ever been hit in the head? • Have you ever lost consciousness? • Have you ever had a concussion? • Do you, or did you ever, play contact sports? • Have you ever been in a car accident? • Have you ever been in a physical fight or a victim of violence? • Are you a veteran? Were you ever injured in service?

19. Screening Tools • OSU-TBI-ID • Purpose- Standardized procedure for eliciting lifetime exposure to brain injury • Population- Children and Adults • Published by Ohio State University- Free to use • Widely researched with over 66 references • HELPS Brain Injury Screening Tool • Purpose- Brief screening tool designed to be used by professionals who are not TBI experts • Population- Children and Adults • Published by International Center for the Disabled, TBI-NET U.S.- Free to use • Over 20 references

20. What does a positive screening mean? • Not all possible episodes of brain injury lead to cognitive impairment. • Certain episode characteristics are associated with a greater likelihood of long-lasting effects. • Neurocognitive testing can be used to look at the likely effects of brain injury.

21. Neurocognitive Assessment • Looks at Memory and Executive Functioning • Compares an individual’s performance to a sample of peers (same age, gender, education). • Short battery can take as little as 2 hours to administer; full batteries are often much longer. • Different from the typical psychological evaluation and/or IQ testing.

22. Why do those with brain injury need a different approach? These are neuropsychological functions, mediated by the brain, not always under willful control. • Executive dysfunction • Emotional dysregulation • Memory impairment • Variability of memory • Prospective memory The impact of Brain Injury may not be immediately evident given age-related demands

23. Quick Tips for Working With Individuals With Brain Injury • Provide simple written information, including summaries of what you are doing and what is next. • Have family involvement. Enlist them to reinforce goals of treatment. • Speak simply and ask direct questions. • Avoid long, complicated discussions. • Check the client’s understanding of the information presented, making sure to allow time for processing. • Offer breaks. • Provide appointment reminders. • Be careful with humor and your personal space.

24. Quick Tips Continued • Modify handouts to make them concise and to the point. Allow more time. • Paraphrase concepts and use concrete examples, incorporate visual aids. • Encourage the use of a planner; including a daily schedule. • Make sure homework assignments are written down. • After group sessions, meet individually to review main points. • Repeat, Review, Rehearse. • Do not presume that non-compliance arises from lack of motivation or resistance. • Be aware that unawareness of deficits can arise as a result of specific damage to the brain and may not always be due to denial. • Confrontation shuts down thinking and elicits rigidity; roll with resistance. • When appropriate do not discharge for non-compliance; follow-up and find out why someone has no-showed or otherwise not followed through.

25. Thoughts on How to Improve Practice in a Behavioral Health Setting? • Include screening tool in Intake Assessment. • Educate clinicians on Brain Injury and its effects. • Educate Families on Brain Injury. • Get staff certified as Brain Injury Specialists. • Tailor PHP and IOP structures to accommodate Quick Tips. • Know referral sources in your area.

26. Resources Available • BrainSTEPS- Assists students, schools and families in Pennsylvania following acquired brain injury. • Office of Vocational Rehabilitation (OVR)- Helps people with disabilities get back to work. Early reach coordinators can help youth aged 14-21.

27. Other Brain Injury Resources:Once someone is 21… • They may be qualified for PA Head Injury Program • Provides for $100,000 or 1 year of services if qualified • Services can be provided in community or in a facility • To apply: 1-866-412-4755

28. Medicaid Waivers • Provide funding for home and community-based services to qualified individuals. • Must be 18 years or older to receive services. • Application process is lengthy and requires at least 3 in-person meetings. • To apply: 1-877-550-4227 • By January 2019- National waiver through CHC; a Medicaid managed care program that will include physical health benefits and long-term services and supports.

29. Brain Injury Resource Line (BIRL) • Operated by BIAPA • Number to call if looking for resources. Anyone can call • Not a crisis line, but a place to learn about resources and • how to access them. • 1-800-444-6443

30. Other Resources • Brain Injury Support Groups www.biapa.org/support_groups • • Disabilities Rights of PA (DRP) https://www.disabilityrights.org/ • • Acquired Brain Injury Network of PA (ABIN-PA) http://www.abin-pa.org/

31. Information on Brain Injury: www.brainline.org https://www.cdc.gov/traumaticbraininjury/ http://www.biausa.org/ http://www.msktc.org/tbi/factsheets Systematic Approach to Social Work Practice: Working With Clients With Traumatic Brain Injuries:a downloadable 132-page manual completed with support from the National Institute on Disability and Rehabilitation Research

32. For further information www.biapa.orgwww.health.pa.gov Toll Free Brain Injury Resource Line 1-800-444-6443 PA Department of Health 1-717-772-2763

33. Local Programs

34. Local Programs