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Traumatic Brain Injury:Traumatic Brain Injury: OverviewOverview
Anastasia Edmonston, TBI and Person Centered Planning Trainer-MHA
&Dawn Roher, Clinical
Resource Manager-BIAMD
MHA’s – Lead Agency in Maryland for Traumatic Brain Injury
Programs and initiatives:• Home and Community Based Services Waiver for Adults with
Traumatic brain injury.• Staff to the Maryland Traumatic Brain Injury Advisory Board. • Pilot program for transition age youth with brain injury.• Statewide TBI training to human service professionals. • MHA contracts with the Brain Injury Association of Maryland
to provide TBI resources and referral information to Marylanders with brain injury.
• Additional information about these programs and initiatives can be found at http://dhmh.maryland.gov/mha/SitePages/tbi.aspx
What We will Cover Today
• The Basic Brain• Who is affected?• Types of Brain Injury• How are people affected by Brain Injury?• Resources
What might it feel like to be living with a brain injury?
Writing and processing exercise
Incidence of TBI
CDC 2010, 2002-2006 dataIn the United States, at least
1.7 million sustain a TBI each year…
275,000 are hospitalized
TBI By Cause CDC 2010
• 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%
TBI in Maryland 2006-2010Data sources: Maryland Vital Statistics Administration and
Health Services Cost Review Commission 2012
• 15-24 year olds had highest percent of TBI related discharges (18%), followed by 45-54 year olds (13%), and 25-34 year olds (12%)
• One out of four TBI related discharges were caused by falls (27%), followed by MVAs (19%) and stuck by/against an object (7%)
The Scope of the Problem• Distribution of Severity:
– Mild injuries = 80%(Loss of consciousness < 30 min, Post traumatic amnesia < 1 hour)
– Moderate = 10 - 13%(LOC 30 min-24 hours, PTA 1-24 hours)
– Severe = 7 - 10%(LOC >24 hours, PTA >24 hours)
Skull Anatomy
The skull is a rounded layer of bone designed to protect the brain from penetrating injuries.
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.
Bony ridges
adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury
The Developing Brain
• Children’s brains do not reach their adult weight of 3 pounds until they are 12 years old
• The brain, and most importantly, the brain’s frontal lobe region does not reach it’s full cognitive maturity till individuals reach their mid twenties
The Developing Brain
• Many of our adult thinking skills reside in the Frontal Lobe
• The Frontal Lobe is very vulnerable to injury
• If you have a frontal lobe injury as a child, you may “grow into your brain injury”
The Frontal LobeThe frontal lobe is the area of the brain responsible for our “executive skills” - higher cognitive functions.
These include:
• Problem solving• Spontaneity• Memory• Language• Motivation• Judgment• Impulse control• Social and sexual behavior.
adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury
Temporal LobeThe temporal lobe plays a role in emotions, and is also responsible for smelling, tasting, perception, memory, understanding music, aggressiveness, and sexual behavior.
The temporal lobe also contains the language area of the brain.
adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury
Symptoms and functional manifestations individuals
with brain injury or their family members may describe and MAPs
Resource Specialists may detect
Physical Challenges They May Report
• Dizziness, headaches
• Sleep problems• Diminished
taste/smell• Tremors/ataxia/poor
coordination• Speech problems
(reduced rate, slurring, stuttering)
• Seizures• Hearing impairment• Double vision, visual
field cut, tunnel vision
• Fatigue• Hemiparisis
Cognitive/Thinking Challenges They May Report
• Memory, especially for information recently read or heard
• Trouble organizing themselves, their day, their household
• Can’t multi-task anymore
• Have difficulty in social/work situations following the conversation if more than one person is talking
• Easily distracted (can’t read the paper if the TV is on)
Cognitive/Thinking Challenges You May Detect
• Difficulty staying on topic
• Vague, unclear language
• Perservation (repeating themselves)
• Confused
• Memory lapses• Very concrete in
their thinking (poor abstract thinking, doesn’t get jokes)
• Talks too loud/too fast
• No first hand memory of injury
Other Clues to Cognitive/Thinking Challenges• Difficulty following
directions• Might have difficulty
with simple orientation questions
• Aggressive or hostile response to seemingly benign questions
• Delayed response time to your questions
• Tangential responses to your questions
• Confabulation (hard to determine at first interaction)
Personality and Behavioral Challenges They May
Report• Depression
• Anxiety
• Moody/Irritable
• Loss of/or strained relationships
• Insomnia
• Substance use/abuse
Personality and Behavioral Challenges You May Detect
• Impulsivity• Poor judgment• Flat affect
(noticeable in speech pattern)
• Sexually Disinhibited
• Emotionally labile • Substance
Use/Abuse• Aggression• Poor initiation
Lack of Awareness AKA
AnosognosiaA common and difficult to remediate hallmark of
a brain injury
“Emergence of Self Awareness is the Highest of all Integrated Activities of the
Brain” Stuss & Benson 1986
Commonly seen Scenarios
Growing into Brain Injury
• Great physical recovery, good initial cognitive recover
• Returns to school, behind peers
• Academically challenged
• Acts out behaviorally, if the injury several grades back, not recognized as TBI related
Continued….
• Drifts after graduation from high school
• Gets in with the “wrong” crowd
• At risk for mental health issues, substance abuse, criminal activity, burn out families and supports
Lack of Awareness X Impulsivity + Substance Abuse = Crisis
• Severe brain injury with excellent physical recovery
• Rejects outpatient therapy • Impulse control, memory problems, work
dries up• Drugs and Alcohol• Marriage on the rocks• Near tragic interaction with a state trooper• Resolution
“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
Individuals with Brain Injury are Overrepresented in the Following
Populations• Incarcerated individuals
• Homeless individuals
• Victims and perpetrators of domestic violence
• Individuals with behavioral health disorders (mental health and/or substance abuse)
• Service members returning from Iraq and Afghanistan
Treatment and Rehabilitation
Typical Course of Treatment for
a Severe Brain Injury
• Treatment at a Trauma Center • ICU/Acute Care• Inpatient Rehabilitation• Outpatient Rehabilitation• Other Community Services
Treatment Plan can include therapy and services from the following……
• Physical Therapy• Occupational Therapy• Speech Therapy• Cognitive Therapy• Social Work• Psychology• Recreation Therapy• Case Management• Nursing• Physician (rehab medicine, neurology)• Neuropsychology
Important Things to Remember:
A person with a brain injury is a unique individual first
No two brain injuries are exactly the same
The effects of a brain injury are complex and vary greatly fromperson to person
The effects of a brain injury depend on such factors as cause, location and severity
THUS…each person’s recovery and treatment process is unique to them
Factors that can determine the course of treatment:
• Family support• Finances• Insurance• Age• Co-occurring mental health and substance
abuse issues• Level of Education• Geographical location• Other resources and supports in the
community
When do people ask for help ?
• When the person is initially injured• When they hit a “bump in the road”• Further down the recovery curve, when they
are looking for services and never received them initially
• When they know something isn’t right and they are reaching out for education, validation, and support
• Aging parents with adult children with TBI
Who are the other sources of support and resources that complete this
picture?• Specialty clinics, i.e.-
concussion, mild TBI, sleep, etc.
• Neuropsychologists• Medical specialists—
headache, pain, neuro-opthamologists, physiatrists, neuropsychiatrists, neurologists, etc.
• Vocational counselors • State vocational
rehabilitation counselors (DORS)
• Attorneys
• Private case managers• Insurance case managers• Psychotherapists• Educators and school
personnel• Addictions Specialists• Other advocacy agencies-
C.I.L., MDLC, etc.• Pediatric resources• Developmental Disabilities
Administration• Support groups
Please refer to the Brain Injury Resource Handout for a additional
information and educational materials