traumatic brain injury:

Phoenix Area Integrated Behavioral Health Conference

August 17, 2016

tips for human service providers

Robin Hoskins, M.A., MAPC, BC-HSP, LAC

Faculty Associate, ASU, School of Social Work

Vicki Staples, MEd, CPRP

Associate Director for Clinical Initiatives

ASU Center for Applied Behavioral Health Policy

Acknowledgements & Disclaimer

These slides and associated materials were developed by:

Vicki Staples, MEd, CPRP

Associate Director of Clinical Initiatives

Center for Applied Behavioral Health Policy (CABHP)

College of Public Service and Community Solutions

Arizona State University

Robin Hoskins, M.A., MAPC, BC-HSP, LAC

Faculty Associate, ASU, School of Social Work

The presentation and associated materials may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior permission from CABHP.

defining tbi

causes

brain and behaviors

signs and symptoms

tips/interventions-challenging behaviors;

managing emotions; fatigue;

social skills; loss, mourning,

grief; coping with survival ; and

self care

motivational

interviewing

adolescents

screening

best practices

overview of this workshop

defining TBI

TBI comparison

Centers for Disease Control and Prevention. “Traumatic Brain Injury in the United States: A Report to Congress.” (January 16, 2001).

Traumatic brain injury is

now classified as a

“public health epidemic”

in America.

1,288

Deaths

6,943

Hospitalizations

43,369

Emergency Department Visits

???

Receiving Other Medical Care of No Care

Arizona Department of Health Services

Annual number of TBI’s in AZ

underestimation of the problem

number reported with TBI underestimates the

magnitude of the problem because the following

are not included in those estimates:

those treated by private physicians

those treated in private clinics, and urgent

care centers

individuals who did not seek medical care

what is TBI?

• A traumatic brain injury (TBI) is

caused by a blow or jolt to the

head or a penetrating head

injury that disrupts the normal

function of the brain. Not all

blows or jolts to the head result

in a TBI.

• The severity of a TBI may

range from “mild,” i.e., a brief

change in mental status or

consciousness to “severe,” i.e.,

an extended period of

unconsciousness or amnesia

after the injury.

types of brain injury

Congenital Brain Injury Acquired Brain Injury

Traumatic Brain Injury

Non-traumatic

Brain Injury

Closed

Head Injury

Open

Head Injury

Savage, 1991

Brain Injury Association

of America estimates

approximately

2.5 million Americans experience

a TBI every year

concussions – minor

and most common TBI

skull fracture – skull

cracks or breaks

depressed

penetrating

contusion – bruising or

bleeding of brain

hematoma – collection

of blood inside body

more about TBI

causes of TBI

Traumatic brain injuries accidents

20% due to violence

3% due to sports

injuries

50% associated alcohol

use associated

Non-traumatic brain injuries – not associated with trauma and typically involves entire brain loss of oxygen

drowning

toxic exposure to carbon monoxide

heart attack

stroke

causes

accidents - top causes

• falls 40%– 55% among children

are ages 0 – 14

– 81% among adults are 65 +

• unintentional blunt trauma– 15% - all age groups

– 24% among children ages 0 - 15

• vehicle crashes– 14% - all age groups

– Accounts for 26% of all TBI related deaths

• assaults– 10% - all age groups

– 75% assaults associated with TBI occur in ages

15 - 44

let’s break it down

men 3x as likely to die than women

rates are higher for ages 65 +

leading cause of TBI related

deaths by age: falls for ages 65 +

vehicle crashes for ages 55 – 24

assaults for ages 0 - 4

continued…

other and

unknownleading causes

19%

and there is the unknown

approximately 18% of all TBI-related emergency department visits involved children aged 0 to 4 years.

approximately 22% of all TBI-related hospitalizations involved adults aged 75 years and older.

males are more often diagnosed with a TBI (59%).

blasts are a leading cause of TBI for active duty military personnel in war zone

other vulnerable populations:

veterans

persons who are homeless

persons in jail or prison

DV survivors

who is at the highest risk?

behavioral health and TBI

73% of women in state prison have been

diagnosed with a mental health problem

research is showing that there is

a high prevalence of individuals

reporting TBI with co-occurring

substance disorder and severe

mental illness, one study reports

up to 72%

symptoms like paranoia,

obsessional disorder, depression

PTSD

suicide and TBI

people with TBI are 4 times as likely to

commit suicide

one study screened 172 participants with

TBI using the Beck Scale for Suicide

Ideation

35% had significant levels of

hopelessness

23% had suicide ideation

18% had made a suicide attempt

“TBI, mental illness, substance abuse, PTSD –they all go together like peanut butter and jelly.”

-- George

nationally…

1.7 million injured

50,000 die from a TBI

235,000 are hospitalized

1.1 million treated and released from ED

80,000 – 90,000 result in long-term disability

6.5 million Americans living with some effect

5.3 million with long-term, lifelong disability

3 main areas of impact

behavioral

physical

cognitive

6.5 million living

with some effect:

Native Americans/Alaska Natives

hospitalization rates highest

among all minority groups

age group

highest 15 – 24 years of

age

25 - 34 years of age

35 – 44 years of age

0 -14 years of age

compared to other

populations - TBI death

rates are greatest among

Native Americans/Alaska

Natives at any age

Native American summit on TBI

sponsored by the Health Resources and Services

Administration

Harold – “Living takes a lot of energy. We must find

the story that was given us and must not terrorize

ourselves with our thoughts.”

prayer, ceremonies, the earth, and elements must all

be incorporated into the care of an Indigenous

person with brain injury.

identify unique challenges

available services and gaps

provide information to agencies

completing tasks

gaining acceptance

game playing (child

to parent)

being institutionalized

coping with a lack of

understanding from

hospital workers and

police officials

“putting up with me”

overprotective family

letting go

no family support

top struggles for post-injury for

indigenous people

• unemployment rate as high as 75% in some areas

• alcohol and drug use is common

• 60% of people in general population experience depression after injury - within the Indigenous community, 60% is the depression rate pre-TBI

• violence, suicide attempts, accidents at the root of injury for Indigenous people

• telephone, transportation, education, comprehensive deficits cause Indigenous people to fall through the cracks

other considerations

brain and behavior. . .how it works

brain behavior relationships

different levels of TBI - mild

headaches

confusion

lightheadedness

dizziness

blurred vision

tired eyes

ringing in the ears

bad taste in mouth,

loss of smell, taste

attention

concentration

trouble with

memory

mood changes

change in sleep

patterns

trouble with

thinking

fatigue

trouble with speech

different levels of TBI – moderate/ssevere

may be similar to

those of mild TBI

headaches gets worse

and does not go away

repeated vomiting or

nausea

convulsions or

seizures

inability to awaken

from sleep

dilation of one or both

pupils

slurred speech

weakness or

numbness

loss of coordination

increased confusion

restlessness

agitation

signs and symptoms

remember this:

attention is the gateway to all

other functions

understanding and addressing

challenging behaviors

what you can do

organizing the living environment and planning your

approach as a helping professional can increase

opportunities for learning and decrease the chances of a

behavioral episode

behavioral challenges

no way to predict or know how long it will last

can interfere with all aspects of life

rate of recovery

safety issues

ability to socialize

types of challenges

typical problems include:

not being able to control temper

not being aware of proper social behavior

not obeying directions

restlessness

agitation

easily frustrated

things you can do

approaching and interacting

use a social greeting

introduce self each time

speak slowly and clearly

give time for person to

process if cognitive

processing slowed by TBI

be direct and brief

avoid repeatedly

disagreeing

not effective to

logically reason with

person who has

tendency to agitation

always explain your

intentions

redirect the attention of

person with TBI

formally end contact

managing the environment

hard to remain calm in

an active environment

stimulation can

increase restlessness

loud TV

loud conversations

crowds

create calm

environment

stay in control of your

behavior

use gentle physical

contact with permission

discuss use of physical

restraints with their

doctor if needed

medications

medications can help

helps the person stay in bed and go to sleep

better choice than restraints

be aware of side effects

affect person’s mental status

made worse if person already has memory loss

may make it difficult to participate in daily

activities – slowing the recovery process

treatment challenges

Arizona Department of Health Services

treatment challenges

determine what

activity is being

refused and why, if

possible

redirect the

attention

explain activities so

they know what to

expect

provide choices

bargaining

written goals

make the tasks

meaningful

provide feedback

temper outbursts

• gates fly open and emotions come out

• temper rises rapidly

• outbursts over relatively minor events

• unpredictable

• remain calm

• look for obvious reasons for the temper outburst

• do not try to reason or get into an argument

• nip it in the bud

• use a reinforcement program

• remember – it is a result of the injury and not personal

10 recommendations

1. increase rest time

2. keep environment

simple

3. keep instructions

simple

4. give feedback and

set goals

5. provide choices

6. decrease the

chance of failure

7. vary activities

8. over-plan

9. be calm

10.redirect the

person to task

managing emotions

Burnout is associated with stress and hassles involved in your work; it is very cumulative, is relatively predictable and frequently a vacation or change of job helps a great deal

emotions

anxiety feeling of fear or nervousness that is out of proportion

to the situation

can be harder to handle (being in crowds, being

rushed, or adjusting to sudden changes in plan)

cause of TBI replays over and over

too many demands (returning to work too soon, time

pressure)

overwhelmed (asked to make decisions)

situations that require a lot of attention (crowded

environments, heavy traffic, noisy children)

emotions

signs of depression are also

symptoms of TBI

more likely if they show up a

few months after the injury

rather than soon after the

injury

depression

feeling sad is a normal response after TBI

often appear in the later stages of recovery –

realization of long term impacts

if this becomes overwhelming or interfere with

recovery – depression may be the cause

tips for your clients on handling

emotions

stay in the moment

allow emotions to subside

or quiet

review and reflect

find someone you trust

consider the opposite

emotion

for families on handling

client’s emotions

remain clam and avoid reacting emotionally

yourself

take person to a quiet place

acknowledge feelings and give person a chance

to talk about it

provide gentle feedback once person gains

control

gently redirect attention to different topic or

activity

temper outbursts caused by several

factors

injury to parts of the brain controlling

emotional expression

frustration and dissatisfaction with changes

in life

feeling isolated, depressed, misunderstood

difficulty concentrating, remembering,

expressing oneself or following

conversations

tiring easily

pain

for families

• reducing stress and decreasing irritating situations

• self calming strategies, relaxation, better communication

methods

• try not to take it personally

• try not to argue with the person during the outburst

• do not try to calm them down be giving into their demands

• set rules for communication (not acceptable to threaten,

refuse to talk to the person when in a tantrum)

• afterward, talk about outburst and what might have led to it

• suggest outlets (leaving the room, taking a walk)

for families on forgiveness

consider how you would feel had you been the

cause of the injury. what does it mean to be truly

forgiven?

recognize the amount of effort you are putting into

resentment. what would it feel like if you could

use that energy for something else?

realize you are not able to move to acceptance of

the changes in the person if you continue to focus

on fault. how would it feel to be truly valued and

accepted?

tips on hope and gratitude• be realistic – the potential for recovery

is often underestimated

• recognize what is good already, notice

the person’s strength and resilience

• recognize the small successes

happening every day

• be thankful for what is rather than

what isn’t

this may help prepare the family for the

challenges ahead

66

what is fatigue?

feeling of exhaustion

tiredness

weariness

listlessness

feeling of not being

able to finish a task

overwhelms most

other feelings

can make it hard to

work physically and

mentally

sleep may not help

why is fatigue important?

you have less energy

makes it hard to care for yourself

impacts willingness to socialize

impacts ability to do things you enjoy

affects your mood

may keep people

with TBI from

going back to work

how common is fatigue?

VERY common

responsible to for approximately 7 million

visits to the doctor’s office

more than 1 billion spent annually trying to

evaluate or treat fatigue

people with TBI - as many as 70%

complain of mental fatigue no matter

how severe the TBI

other populations at risk

women

people who:

have other kinds of

neurological

problems

live alone

have chronic pain

have stressful, low

paying, or boring

jobs

have psychological or

psychiatric conditions

abuse alcohol or

drugs

take certain kinds of

medications

types of fatigue

physical - “I’m tired

and I need to rest. I’m

dragging today.”

psychological - “I

just can’t get motivated to

do anything. Being

depressed wears me out; I

just don’t feel like doing

anything.”

mental - “After awhile, I

just can’t concentrate

anymore. It’s hard to stay

focused.”

what type of fatigue

have you noticed in

your clients/service

recipients?

physical fatigue

muscle weakness

worker harder to do

things post TBI

dressing

working around the

house

walking

worse in evenings

after busy day

better in morning after

good sleep/rest

gets better as client

becomes more

active/stronger

psychological fatigue

depression

anxiety

gets worse with stress

sleep may not help

may be worse in the

morning

must find the cause of

the fatigue to help

client

medications may help

mental fatigue

make it hard to

concentrate

the more you have to

concentrate the more

fatigue

may cause irritability

forces client to

concentrate harder to

do tasks that were

used to be easier

the type of fatigue we

know the least about

social skills

social opportunities

problems with speech

self concept and emotions

self centeredness

awareness and social

perception

navigating social situations

(mobility, coordination and

endurance)

challenges for social skills

take the shame out of a problem situation

focus on practical and actual (not emotional)

emphasize positive over negative

build skills in less demanding situations first

role play or practice skills

help the person use his/her words and actions (not

yours)

practice sending and receiving skills

videotape for review

find a mentor to help cue them

tips

loss, mourning and grief

loss, mourning, grief

physical death

non-physical death

divorce

separation

illness

injury

transitions (loss of employment, empty-nest

syndrome, geographical moves)

grief and mourning

grieving = internal

response to loss

how one feels on the

inside

sad

angry

confused

afraid

alone

mourning =

external response

to the loss

how one

expresses

feelings about the

loss

funerals

ceremonies

rituals

talking

writing

primary and secondary loss

primary

impact on the

person’s life can be

staggering

day to day challenges

life altering changes

secondary

comes after the

primary loss

can be

physical

emotional

spiritual

financial

social

grief is a process

can be ongoing for

months, years

it is Unpredictable

not a step by step

process

the familiar is no longer

familiar

wide range of

responses

shock

numbness

disbelief

disorganization

disbelief

confusion

searching for

meaning

hello - goodbye - hello

goal is not to get over the pain and loss

the goal is to reconcile, heal, integrate loss into

one’s life

saying goodbye to the life they once had so they

can embrace the life they have now

tips for your clients

be gentle with yourself

your loss is real

take time to work through your feelings

recognize secondary losses

recognize your family is also experiencing grief

find appropriate ways to express your grief

take time to reflect (past, present, future)

ask for help

keep life in perspective

tips for families

recognize your personal loss

find someone to share your grief

have courage

allow yourself to seek respite or relief

ask for help

keep life in perspective

tips for the helper

S H A R E

Support

Hope

Acknowledge

Reflection

Engage in Life

self care for the helper and families

caused by the neurological disruption, not a personal issue

they are not purposefully misbehaving

eliminating the behavior is not realistic

knowing this can help you understand the behavior and lessen your concern, anxiety

manage your own behavior not that of the other person

work to minimize challenging and/or inappropriate behavior

key concepts for your own self care

as a helper

MI and TBI

adapted from Miller & Rollnick, 2002 and Rollnick, Miller, & Butler, 2008

adapted from Miller & Rollnick, 2002 and Rollnick, Miller, & Butler, 2008

children andadolescents

children and adolescents

about 4 out of every 100

boys and 2.5 of every 100

girls have a traumatic

brain injury by age 16

5 out of 8 adolescents

have sustained a head

injury (male and female)

brain development

develops from the

inside out

frontal lobe fully

develops in mid 20’s

(2+ years later in

males)

orbito- frontal cortex

last area to mature

and develop

highest level of

thinking and

reasoning occurs in

the OFC

OFC is most

vulnerable to impact

emotional regulation

and interpretation of

reward and

punishment , and

planning

brain development

injury in childhood can

result in key stages of

brain development being

altered

interrupted

halted

abilities that are just developing or have not yet

emerged are the most sensitive and more likely to be

disrupted

impacts of TBI may become more complex as the

child matures

screening

screening

adapted from the Ohio

Valley Center for Brain

Injury Prevention and

Rehabilitation

John Corrigan, Ph.D.

2009

proposed questions

1. have you ever been injured following a blow

to the head? as a child?

playing sports?

from tbi – a fall, motor vehicle incident, interpersonal

violence?

2. have you ever been hospitalized or treated in

an emergency room following an injury? treated and released?

evaluated by a neurologist?

had a cat scan, mri or eeg done while in the er?

proposed questions

3. have you ever been unconscious following

an accident or injury? have no memory for the event?

felt dazed or confused?

experienced a violent shaking of the head and neck?

4. have you ever been injured in a fight? taken a direct blow to the head?

experienced a headache, fatigue, dizziness, or changes in

vision?

proposed questions

5. have you ever been injured by a spouse or

family member? pushed

punched

shaken

choked

6. have you ever had any major surgeries?

heart bypass

transplant

brain surgery to treat a tumor, aneurysm, stroke

proposed questions

7. illnesses? toxic shock syndrome

meningitis

encephalitis

hydrocephalous

seizure disorder

lead poisoning

exposure to chemotherapy (especially as a child)

proposed questions

8. additional comments and observations of

the interviewer any visible scars?

walks with a limp?

uses a cane or walker?

has a foot brace?

limited use of one hand?

appears to have difficulty focusing vision?

difficulty Answering questions?

answers are unorganized and/or rambling?

becomes easily distracted, agitated or is emotionally

labile?

what you are looking for……

any reported or suspected functional difficulties that are

interfering with home, work, or community activities.

red flags

red flags when screening

you intuition or professional sense are alarmed

obvious physical symptoms are present

individuals’ or family’s disclosure of injury

post-concussive complaints are offered

when typical interventions or strategies prove ineffective

individual’s behavior is not a logical expected response

to an auditory or visual request

when affective and emotional responses are not parallel

to stimuli or environmental influences

when medication regiments prove ineffective or the

person exhibits effects different from those expected

best practices

Best Practices

conduct comprehensive developmental screening upon

admission to school/district

collect in-depth social-developmental histories for all

clients experiencing referral

asking brain injury questions in multiple ways at multiple

times (Corrigan’s screening ?’s)

question/observe upon return to school/work/therapy

after extended absences

have heightened awareness of the signs of brain injury

inform others about TBI, its signs and impacts

screening requires action

documentation

referral

follow-up

offer interactions that are

respectful and take into

account the limitations

and impairments that

have resulted from the

brain injury

Ideal Brain Injury Rehabilitation

physical therapy

occupational therapy

speech therapy/cognitive

retraining

neuropsychology

neuro-psychiatry

social work

recreational therapy

physiatry

neurology

references• Brain Injury Association of Arizona, www.biaaz.org

• Centers for Disease Control and Prevention.

www.cdc.gov/traumaticbraininjury/

• Corrigan, J. (2009). Screening Questions. Ohio Valley Center for Brain

Injury Prevention and Rehabilitation

• Department of Health and Human Services. HHS.gov Health Resources

and Services Administration

• Hospital, C. (2008). Brainline. www.brainline.org

• Medley, A. and Powell (2010). Motivational interviewing to promote self-

awareness and engagement in rehabilitation for following acquired brain

injury: A conceptional review. Neuropsychological Rehabilitation 20(4), 481-

508.

• Moss, M.B. (2010). Understanding the Frontal Lobes: Emotional Regulation,

Social Intelligence and Motivation. Institute for Brain Potential

• Novack, T. (2002). TBI Inform – Managing Behavioral Problems after a TBI.

Traumatic Brain Injury Model System

• Wolf, S (2010). Brain Injury: Understanding TBI and Dysexecutive

Functioning. Wattle and Daub Research