Traumatic Brain Injury

1. Traumatic Brain InjuryPlease stay on the line. The webinar will begin shortly. To download this presentation and other materials, go to: http://soarworks.prainc.com/article/soar-webinar-tbiUse your phone to hear audio:Toll Free Number: 1-855-749-4750Access code:663 518 165Unique Attendee ID: Found under the “Event Info” tab aboveContact lguerin@prainc.com if you experience technical difficulties.This webinar is being recorded and will be available for viewing within 1 week of this presentation.

2. Traumatic Brain Injury Presented BY: SAMHSA SOAR Technical Assistance Center Policy Research Associates, Inc. Under Contract TO: Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services

3. Welcome! Kristin Lupfer, Project Director SOAR Technical Assistance Center Policy Research associates, Inc. Delmar, New York

4. Webinar Instructions • Muting • Recording availability • Downloading documents • Evaluation • http://soarworks.prainc.com/article/soar-webinar-tbi

5. Learning Objectives • Understand the  prevalence and causes of TBI among Veterans and others who experience homelessness or at risk of homelessness • Understand the challenges interviewing SOAR applicants with TBI, by sharing practice tips and an assessment tool to overcome them • Learn the major methods of evaluating a TBI andthe evidence required to evaluate a claim involving TBI

6. Agenda Traumatic Brain Injury Prevalence and Practice Tips for Engaging & Interviewing SOAR Applicants • Anastasia Edmonston, MS, CRC, Trainer, Maryland Behavioral Health Administration, Catonsville, Maryland Evaluating Traumatic Brain Injury for Disability Determination • E. Caroline Mason, Medical Relations Director, Maryland Disability Determination Services, Timonium, Maryland • Dr. Carla Sarno, M.D., Chief Psychiatric Consultant, Maryland Disability Determination Services, Timonium, Maryland Questions & Answers

7. Poll Question #1 How familiar are you with a Traumatic Brain Injury (TBI) impairment? a. Not familiar with TBI diagnosis, signs, symptoms and functional limitations. b. Basic understanding of TBI diagnosis, signs, symptoms and functional limitations, but unsure how DDS evaluates c. Basic understanding of TBI diagnosis, signs, symptoms, functional limitations and how DDS evaluates d. Good understanding of TBI and success with representing applicants with TBI diagnosis for SSI/SSDI benefits

8. Traumatic Brain Injury: An Often Hidden Disability Anastasia EdmonstOn, Trainer, Maryland Behavioral Health Administration, Catonsville, Maryland

9. We Will Discuss Today • What are TBI and ABI? • Who and how many are affected? • How a history of brain injury can create barriers to behavioral health and success in the community, workplace and in making and maintaining relationships • Supporting the functional impact of brain injury via documentation and prescriptive assessment

10. Definitions • Traumatic Brain Injury (TBI) is an insult to the brain caused by an external physical force, for example; fall, MVA, assault, sports related, IED explosion. • Both mechanisms of injury can result in chronic disability that may get worse with age* Acquired Brain Injury (ABI) is an insult to the brain that has occurred after birth for example; stroke, near suffocation, infections in the brain, anoxia

11. Incidence of TBI In the United States, at least1.7 million sustain a TBI each year…275,000 are hospitalized CDC 2010, 2002-2006 dates

12. TBI By Cause • Falls-35.2% (young children & elderly) • Unknown/Others-21% • Motor Vehicle-Traffic-17.3% • Struck by/against-16.5% (unintentionally by object or another person) • Assault-10% • CDC 2010

13. Who may have a TBI? • People who are incarcerated • People experiencing homelessness • Victims and Perpetrators of Domestic Violence • Individuals with behavioral health disorders • Returning military service members

14. The TBI & Homelessness Connection • 2008CMJ- 904 individuals surveyed • 53% lifetime prevalence of TBI Hwang et.al • 2014 CMJ- 111 men screened • 45% screened positive for history of TBI • 73% had 1st TBI before adulthood • For 87% the injury predated homelessness. • Mechanism of injury: assault, sports/recreation, MVA, fall • Positive screen (+) associated with history of arrest or mental illness and parental history of substance abuse . Topolovec-Vranic et. al

15. The TBI & Homelessness Connection • 2015 Journal of Health Care for Poor & Underserved • Of 229 veterans seeking homeless services, nearly all (83%) had sustained at least 1 TBI prior to first episode of homelessness. • 43% sustained at least 1 TBI following first episode of homelessness. • Median lifetime # of TBI’s incurred was three. • 30% of individuals sustained injuries with severity levels that would be expected to be associated with ongoing TBI-related deficits Barnes et. al.

16. 2000 Epidemiological Study of Mild TBI • 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 obsessive-compulsive disorder By J. Silver of NYU, cited in WSJ by Thomas Burton 1.29.08 http://online.wsj.com/article/SB120156672297223803.html?mod=googlenews_

17. Christchurch, New ZealandBirth Cohort Study (2014) • Compared with non-injured individuals, inpatients (at least 1 night in hospital) , those injured between 0-5 &16-21 were more likely to have symptoms consistent with drug dependence • All inpatient groups had increased risk of arrest, with the age group 0-5 & 6-15 more likely to be involved in violent offenses McKinlay et. al, Journal of Head Trauma 2014

18. Why is it so important to screen for a history of TBI? Often, individuals are unaware of how a prior history of brain injury or brain injuries is contributing to difficulty at home, work, school and problems with relationships with others AS WELL as difficulty accessing/participating in and benefiting from mental health and/or substance abuse services

19. “Unidentified traumatic brain injury is an unrecognized major source of social and vocational failure.” Wayne Gordon, Ph.D. of the Brain Injury Research Center at Mount Sinai School of MedicineQuoted in the Wall Street Journal 1.29.08

20. Possible Physical Changes

21. Possible Changes in Thinking aka Cognitive Skills

22. Possible Changes in Personality & Behavior *

23. Functional Clues to a Possible History of TBI • Does the individual need reminders to perform basic ADLs? • Does the individual need reminders to perform higher level ADLs such as cooking & community activities and/or are they a safety risk if they use a stove etc. • Does the individual need assistance to remember appointments , do they lose their way in the community? • Does the individual have a history of losing jobs? • Do you note any attempt by the individual to use strategies to support memory, attention, processing etc.? • Are they orientated X3?

24. Other Considerations • Did the individual experience abuse as a child, did the individual’s mother drink during pregnancy? • Does the individual report they received special education services in school? • Does the individual have a history of losing jobs? • Do the professionals working with the individual report that they often feel like they are starting from square one in each session/appointment (e.g. little or no follow through on between session assignments such as collecting/completing paperwork)

25. Obtaining Supporting Data for a History of Brain Injury

26. Obtain a snap shot of “before” TBI Keep in mind for some individuals, who grow up in chaotic environments, there may be no clear cut “before” in terms of their functional status. Was there a dramatic loss of functioning at home, work and community post the TBI? Did the individual… • Have a stable employment history? • Have no or an insignificant legal history? • Graduate from high school, attend college or trade/vocational training? • Manage any or all of the above despite other health or behavioral health issues? * • Have social ties, including; family, volunteering, church, hobbies etc.

27. Conduct the OSU TBI-ID http://ohiovalley.org/tbi-id-method/ This short tutorial via text and video walks the viewer through the administration of the screening tool

28. “What if There is a Traumatic Brain Injury?” A Product of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation John Corrigan PhD Director, Ohio Valley Center for Brain Injury Prevention and Rehabilitation, The Ohio State University; Columbus, Ohio. http://ohiovalley.org/informationeducation/whatif/index.cfm

29. Tips Regarding Supporting Documentation • Be mindful that a standard psychological assessment may not provide information regarding the ability to learn new information and/or ability to apply information in novel situations (executive functioning) • Obtaining a full neuropsychological evaluation may not be feasible, however there are alternative ways to gather information regarding executive functioning skills that can support your observations and the individual’s self-report in addition to the OSU TBI-ID

30. Language from a Support Letter for VA benefits: TBI & PTSD * “A few years following the shooting at Fort X ( ) chose not to reenlist and left the Army. He felt returning to civilian life would open up a variety of educational and career opportunities not available to him in the service. However, the army provided something that was critical to his successful functioning day to day following his injuries, and that is structure. While in the military the expectations were laid out for him, literally day to day he knew exactly what to do. In the civilian world, we are expected to impose structure on our lives, make decisions that are in our best interest and follow through with our responsibilities. The ability to multitask and make thoughtful, measured decisions are high level cognitive skills that most of us take for granted. For individuals who receive a blow or blows to the temporal/frontal regions of their brain, this skill can be compromised. Although it is related to organic brain damage, the behavioral manifestations of the damage often looks to the casual observer as if the person is unmotivated, lazy, self-centered, disorganized and impulsive.”

31. Alternative Tests • Wisconsin Card Sorting Test- • Trail Making A & B • Wechsler Adult Intelligence Scale IV • Wechsler Memory Scale IV

32. Language from a Support Letter for SSDI benefits * • Cognitively, ( ) brain injury has resulted in some right side weakness and some cognitive deficits. She has moderate deficits in attention and immediate memory but her speech is within normal limits. She has continued to make progress in these areas. She has residual impairments in verbal fluency, visual motor tracking, verbal memory and construction. Secondary to ( ) brain injury, her cognitive impairments limit her attention, insight, judgment, and ability to make informed decisions. ( ) demonstrates significant problems with mood regulation and impulsivity. ( ) presents as social and alert. When asked direct questions, she is able to verbalize her responses on topic. ( ) is oriented to time, place and person. She can follow When given a simple three step command, she can successfully complete three steps, however, she breaks down if there are more than 4 or 5 steps, especially if the information is novel. “

33. 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. Excellent SA TX resource & information • www.brainline.org , wealth of information and supports available for individuals with brain injury, their families and professionals.

34. Resources • Rehabilitation Research and Training Center on Traumatic Brain Injury Interventions & New York Traumatic Brain Injury Model System • at Mount Sinai School of Medicine and the Mount Sinai Rehabilitation Research and Training Center • www.mssm.edu/tbinet

36. Contact Information • Anastasia Edmonston MS CRCanastasia.edmonston@maryland.gov410-402-8478ACKNOWLEDGEMENT Dawn Roher of the Maryland Brain Injury Association roher@biamd.org410-448-2924

37. Poll Question #2 True or False? The behavioral manifestations of the TBI often looks to the casual observer as if the person is unmotivated, lazy, self-centered, disorganized and impulsive. a. True b. False

38. Disability Determination Services: Evaluating Traumatic Brain Injury (TBI) E. CAROLINE MASON, MEDICAL RELATIONS DIRECTOR, MARYLAND DISABILITY DETERMINATION SERVICES, TIMONIUM, MD DR. CARLA SARNO, M.D., CHIEF PSYCHIATRIC CONSULTANT, MARYLAND DISABILITY DETERMINATION SERVICES, TIMONIUM, MD

39. Social Security Definition of Disability The inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. • Substantial Gainful Activity (SGA) • Medically Determinable Impairment (MDI) • Duration

40. Sequential Evaluation Process • Is the individual engaging in SGA? • Does the individual have a severe impairment? • Does the individual have an impairment which meets or equals the listing? • Does the impairment preclude the ability to perform past relevant work? • Does the impairment preclude the ability to perform other work?

41. Evaluation of Traumatic Brain Injury • Neurological and mental impairments, wide variety of posttraumatic symptoms and signs • Recovery highly variable – long term outcomes difficult to predict first few months post injury • Medical hold 3-6 months • Determine stabilization with improvement or worsening

42. Medical Listings - Physical • Disability Evaluation Under Social Security • Listing of Impairments • 11.00 Neurological – Adult • 11.18 Cerebral trauma • 11.02 Epilepsy – convulsive epilepsy • 11.03 Epilepsy – nonconvulsive epilepsy • 11.04 Central nervous system vascular accident

43. Medical Listings - Mental • 12.00 Mental Disorders – Adult • 12.02 Organic mental disorders: Psychological or behavioral abnormalities associated with a dysfunction of the brain. History and physical examination or laboratory tests demonstrate the presence of a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities. • The required level of severity for these disorders is met when the requirements in both A and B are satisfied, or when the requirements in C are satisfied.

44. Medical Listings – A Criteria • A. Demonstration of a loss of specific cognitive abilities or affective changes and the medically documented persistence of at least one of the following: • Disorientation to time and place; or • Memory impairment, either short-term, intermediate, or long-term; or • Perceptual or thinking disturbances; or • Change in personality; or • Disturbance in mood; • Emotional lability and impairment in impulse control; or • Loss of measured intellectual ability of at least 15 IQ points from premorbid levels or overall impairment index clearly within the severely impaired range on neuropsychological testing

45. Medical Listings – B Criteria • B. Resulting in at least two of the following: • 1. Marked restriction of activities of daily living; or • 2. Marked restriction in maintaining social functioning; or • 3. Marked difficulties in maintaining concentration, persistence, or pace; or • 4. Repeated episodes of decompensation, each of an extended duration; or

46. Medical Listings – C Criteria • C. Medically documented history of a chronic organic mental disorder of at least 2 years duration that has caused more than a minimal limitation of ability to do basic work activities, with symptoms or signs currently attenuated by medication or psychosocial support, and one of the following: • Repeated episodes of decompensation, each of extended duration; or • A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate; or • Current history of 1 or more years inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement.

47. Mild TBI Symptoms • Physical symptoms • Loss of consciousness – few seconds to few minutes • State of being dazed, confused, or disoriented (no LOC) • Headache • Nausea or vomiting • Fatigue or drowsiness • Difficulty sleeping • Sleeping more than usual • Dizziness or loss of balance

48. Mild TBI Symptoms • Sensory symptoms • Blurred vision • Ringing in ears • Bad taste in mouth • Changes in ability to smell • Sensitivity to light or sound • Cognitive or mental symptoms • Memory or concentration problems • Mood changes or swings • Feeling depressed or anxious

49. Moderate to Severe TBI Symptoms Moderate to severe TBI can include any of the signs and symptoms of mild injury, as well as, the following symptoms that may appear within the first hours to days after a head injury: • Physical symptoms • Loss of consciousness from several minutes to hours • Persistent headache or headache that worsens • Repeated vomiting or nausea • Convulsions or seizures • Dilation of one or both pupils of the eyes • Clear fluids draining from the nose or ears • Inability to awaken from sleep • Weakness or numbness in fingers and toes • Loss of coordination

50. Moderate to Severe TBI Symptoms cont. • Cognitive or mental symptoms • Profound confusion • Agitation, combativeness or other unusual behavior • Slurred speech • Coma and other disorders of consciousness