The Role & Overlap of Brain Injury in Victims &...

The Role & Overlap of Brain Injury in

Victims & Offenders

Liz Gerdeman, MA, CBIS-T

Director of Professional Programs, BIAC

[email protected]

303.562.3298

© 2019 Brain Injury Alliance of Colorado

mailto:[email protected]

Acquired Brain Injury

Traumatic Brain Injury

External Forcesex: assault, fall,

blast injury, motor vehicle accident

Non Traumatic Brain Injury

Internal Event ex: stroke, tumor, lack of oxygen,

infection


Mechanism of Injury

Bony ridges Anoxia:

A loss of oxygen to the brain caused by

an airway obstruction due to choking,

strangulation, near drowning or drug

reactions.

Stroke:

Traumatic Brain Injury Non Traumatic Brain Injury


Classification of TBI Severity

Mild – Loss of consciousness 0-30 minutes

(Concussion)

Moderate – Loss of consciousness 30 minutes to 24hrs

Severe – Loss of consciousness for over 24 hours


• Children 0 to 4 years, older adolescents aged 15 to 19 years,

and adults 65 years+ are most at risk

• Males are almost twice as likely to sustain a TBI as females

• Falls are the leading cause of TBIs in the United States

(globally, motor vehicle accidents are #1)

TBI Statistics

In 2013, 2.8 million TBIs

occurred in the U.S.

47%

14%

11%

13%

15%

Falls

Motor Vehicle Traffic

Assault

Unknown/Other

Struck By/Against


Over 500,000 adults in Colorado have sustained a brain injury

• Colorado ranks 9th in the nation of fatalities and 13th in the nation of hospitalizations due to a TBI

• Almost 5,000 individuals are hospitalized and nearly 1,000 die due to a TBI in Colorado each year

• 23,500 emergency room visits each year are due to a TBI

• Males are twice as likely to sustain a TBI in Colorado as females

• The age groups with the highest risk of sustaining a TBI in Colorado are 15-24 and 65+

• Each year, 2,200 individuals continue to experience disability one year after hospitalization for a

TBI

The number of people with TBI who are not seen in an emergency department or who receive no care is

unknown.

Traumatic Brain Injury National Data Center

Colorado Data


“Mild” TBI: Complications

>75% of TBIs are mild. MTBI symptoms may appear mild, but can lead to significant,

life-long impairment affecting an individual’s ability to function physically, cognitively, and

psychologically

• Symptoms may be subtle

– 90% of concussions are not associated with a loss of consciousness

– Concussive symptoms may develop over days or even months later

• Treated in non-hospital setting, not in ED, or not treated at all

– 90% of mTBI may go unreported

– Often not visible on CT scan or MRI

• Brain Injury can mirror other disabilities

• Individuals with a history of concussion are at an increased risk of sustaining a subsequent concussion


Signs & Symptoms

Thinking/

Remembering

Difficulty thinking

clearly

Feeling slowed

down

Difficulty

concentrating

Difficulty

remember new

information

Physical Headache

Fuzzy or blurry

vision

Nausea or

vomiting (early

on)

Dizziness

Sensitivity to noise

or light

Balance problems

Feeling tired,

having no energy

Emotional/

Mood

Irritability Sadness More emotional Nervousness or

anxiety

Sleep Sleeping more than

usual

Sleeping less than

usual

Trouble falling

asleep

Difficulty

maintaining deep

sleep


• Rehabilitation– Physical Therapy

– Occupational Therapy

– Speech/Language Pathologist: Cognitive Therapy

• Independent Living Skills

• Medication– Pain management

– Physical symptoms (e.g., headaches, seizures, attention, fatigue)

– Mental health

• Complimentary and Alternative Modalities

How is brain injury “treated”?


• Functional abilities (physical, cognitive)

• Neurological changes: self awareness, cognition, communication, emotional regulation,

cognitive fatigue, hypersensitivity, executive functioning

• Life roles as worker, spouse, lover, friend, parent, sibling, authority figure, student…

• Responsibilities as bread winner, role model, support to others (emotional, work, home,

parenting, etc.), driving

• Social network of friends/family

• Self-esteem

• Intimacy

A Multitude of Loss

risk for homelessness

risk for substance abuse

risk for criminal activity

risk for mental health issues


Almost half of adults with TBI who have no pre-injury history of mental health problems develop

mental health problems after the TBI (Gould, Ponsford, Johnston, & Schonberger, 2011. Psychological Medicine, 41, 2099-2109.)

1/3 of TBI survivors experience emotional problems between 6 months and a year post injury

Patients who reported:

• Hopelessness 35%

• Suicidal ideation 23%

• Suicide attempts 18%

85% of survivor families report that emotional or behavioral problems have an impact on their function

Suicidal ideation can be 7x higher in people with TBI than in those without

• Attempts of suicide post-TBI can be at rates close to 17%

• Increased suicide risk persists up to 15 years post-injuryFazel, et al. 2014. JAMA Psychiatry, 71(3), 326-33.; Mackelprang et al., 2014. Am J Public Health, 104(7), e100; Simpson & Tate, 2007. Brain Inj., 21(13-14), 1335-51.

Mental Health Fallout


Brain Injury & Substance Use/Abuse

Why would TBI be association with substance abuse disorders?

1. Intoxication causes TBI

2. Early life TBI predispose to substance abuse

3. Structural damage from TBI changes behavioral control


Brain Injury & Violence

Violence is one of the leading causes of brain injury in the United States

• The CDC estimates that at least 150,000 brain injury deaths, hospitalizations,

and ED visits are related to assault annually.

• Of women reporting to emergency rooms for injuries associated with

domestic violence:

– 30% reported a loss of consciousness at least once

– 67% reported residual problems that were likely brain injury related (Corrigan, 2003)

• Another study polled 99 battered women:

– 75% reported sustaining at least 1 partner-related brain injury

– 50% sustained multiple (Valera, 2003)


Brain Injury & Violence

• Women experience about 4.8 million intimate partner-

related physical assaults and rapes every year

• Less than 20 percent of battered women sought

medical treatment following an injury

• Leaving an abuser: economic, emotional barriers and

BI can reduce planning, organizing, and memory skills

needed to leave


Brain Injury & Victimization

✓ Difficulty with anger management, which may prompt others to use undue physical

force or inappropriate medication

✓ Misperceptions may lead to treatment that is demeaning or abusive

✓ TBI outcomes affect others’ perceptions of a person’s ability to honestly and

accurately report an incident of victimization

✓ Persons with TBI or other disabilities may experience physical and sexual violence,

emotional abuse, or neglect by a caregiver

✓ A TBI can cause cognitive problems that reduce one’s ability to perceive,

remember, or understand risky situations that could lead to an incident of physical

or sexual violence

✓ May engage in at-risk drinking or drug use that place them in situations or

relationships that lead to episodes of victimization

✓ Uninhibited behaviors that lead to risky sexual engagement


Specific Challenges

Skills that may be needed

• Identifying that a plan to leave is needed

• Planning/remembering a sequence of actions

• Contacting community resources

• Finding a new place to stay

• Getting money needed

• Packing in secret

• Keeping plan a secret

• Making sure new place is safe

• Anticipating consequences

Skill deficits that are common

• Generativity can be impaired

• Ability to imagine other options

• Initiating and planning action sequences is impaired

• Initiating contact with resources

• Organization, prioritizing tasks

• Remembering details

• Impulse control

• Tendency to “blurt things out”

• Keeping secrets difficult

• Ability to infer others’ intentions

• Social judgment to assess safety

• Weighing benefits/risks impaired

• Depression and/or anxiety may immobilize the individual

• Difficulty with self initiation may prevent action steps needed

• Poor self awareness may limit the individual’s ability to change approach taken

• Cognitive difficulties serve to maintain depression/anxiety


Brain Injury & PTSD

• Brain injuries are often sustained during traumatic

experiences

• Range of co-morbidity that exist with both TBI and PTSD

(depression, chronic pain, etc.)

• Evidence that people can develop PTSD following severe

brain injury even when traumatic event can not be recalled

“The period of greatest psychological exposure is in reality the period of

greatest traumatic exposure” – Judith Herman


Brain Injury & Offenders

• Recent meta-analytic review found the prevalence of TBI in

the offender population to be 60.25% (Shiroma, Ferguson, &

Pickelsimer, 2010) vs. 8.5% general population report a history of

TBI (Wald, Helgeson, & Langlois, 2008)

• One meta-analysis found that approximately 30% of

juvenile offenders have sustained a previous brain injury (Vaughn, Salas-Wright, Delisi, & Perron, 2014)

• TBI is associated with higher impulsivity, aggressive

behavior and negative emotion ratings (Farrer, Frost, & Hedges,

2013)


Colorado Data

Childhood

Violence

Adult

Victimization

Suicide

Attempts

School

Suspensions

Substance

Abuse

Mental Health

60% 62% 39% 54% 93% 75%

• 4-year federal grant; screened over a thousand of offenders across 18

judicial sites

• Those that screened positive for history of brain injury & cognitive

impairment also had co-occurring diagnoses:


Encounters with authority can be made worse by…

• An invisible injury

• Stress

• Flooding

• Confabulation

• Symptoms that mirror intoxication


Sensory-

Motor

Attention

What does brain injury “look” like?

Impaired AttentionThe ability to sustain focus on the information

necessary for learning or completing a task.

• Fidgets, squirms in seat, can’t sit

still

• Interrupts conversation

• Low frustration tolerance

• Talks Excessively

• Off topic

• Impulsivity

(inability

to inhibit)Memory

Sensory-

MotorInhibitionAttention

Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Impaired Attention

• Check to make sure there is good eye contact

• Be okay with redirecting

• Work on only one task at a time – check in regularly

• Keep instructions brief, simple, & to the point

• Have client participate in discussion & development of plan

• Reduce distractions, meet in quiet environment

• Use cue words to alert the client to pay attention (“look”,

“listen”)

• Establish nonverbal cueing system (eye contact, touch)


Delayed Processing SpeedHow quickly information is received, processed, and/or

outputted.

• Slow to respond to questions

• Appears to not be paying attention

• Looks confused

• Doesn’t follow instructions

MemorySensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Delayed Processing Speed

• Provide additional time to review information

• Speak slowly, making sure client understands – ask them to

rephrase back to you what they heard

• Offer assistance with completing forms

• Utilize checklists and a written schedule of routines

• Provide written cues for organizing (“first do this, then do

this”)


Short Term Memory LossThe mental ability to store and retrieve words, facts,

procedures, skills, concepts and experiences.

• Can’t remember more than one

thing at a time

• Can’t remember details

• Appears disorganized

• Appears to have an “attitude”

problem

• Appears

manipulative

MemorySensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Short Term Memory Loss

• Repeat information and summarize

• Provide written summary – cue them to record important

information (dates, action items)

• Review new information frequently

• Teach client to use reminder system like planner

• Teach “chunking” as a way to aid in retention

• Stick to routine as much as possible

• Keep information tangible and relevant

• Practice & reinforce strategies until they become automatic


Impaired Sensory Motor SkillsPerceiving and responding to what is seen, heard,

smelled, tasted, felt and touched.

• Appear overwhelmed

• Emotionally melt down

• Irritable, short fused

• May appear oppositional

• Shuts down

MemorySensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Impaired Sensory Motor

• Keep environment quiet

• Keep noise and lights to a minimum

• Keep sessions short to minimize onset of headaches and

fatigue

• Schedule rest periods and breaks from planned activities

• Consider time of day (mornings are often better)

• Ask client where in the room they’d prefer to sit or what

other accommodations they might need


Language (social pragmatics)Verbal and nonverbal rules of social language and

interactions.

• Do not interpret body language

• Use inappropriate eye contact

• May get in your space

• May either say too little or too

much

• Have little insight or

awareness of how their

behavior may

be inappropriateMemory

Sensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Social Pragmatics

• Provide direct, structured and concrete feedback

• Do not rely on body language to convey a message

• Role play

• Videotaping interactions


Language (Receptive)Ability to understand what is being said.

• Confused

• May say “huh” frequently

• Followers

• Struggle with abstract

language/sarcasm

• May withdraw

MemorySensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Receptive Language

• Be direct

• Avoid abstract humor, sarcasm, metaphors, colloquialisms,

etc.

• Allow wait time for person to process what has been said

• Provide instructions/directions slowly and one at a time

• Ask if it would be helpful to repeat or rephrase your

message

• Let the individual know that you value their input, thoughts,

and feelings


Language (Expressive)Ability to be understood.

• Poor grammar or immature speech

• Difficult to follow in conversation

• Difficulty staying on topic

• Difficulties navigating

social rules

• May withdraw

MemorySensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Expressive Language

• Redirect if the individual is off topic

• Provide opportunities to practice expression

• Role play common real life conversations

• Teach individual to rehearse silently before replying

• Be patient and allow person time to respond


Executive Function: InitiationAbility to start an action or activity

• Appears lazy or spacey

• Appears unmotivated

• Follower

• Needs constant cuing

• Lags in independent

living skills

MemorySensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Initiation Deficits

• Encourage client to focus on one step at a time

• Ask client to repeat instructions to ensure comprehension

• Use underlining and highlighting for significant parts of

directions. Checklists & calendars can help organize.

• Break complex directions into simple steps and assign

action items

• Utilize color-coding

• Help the person get started

• Repeat instructions or interventions multiple times in

different ways


Executive Function: Mental

FlexibilityAbility to easily shift from one idea, train of thought,

activity or way of looking at things to another.

• Perseverate

• Difficulties taking feedback

• Resistant

• Can appear stubborn or

argumentative

• May appear to

lack empathy

MemorySensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Mental Flexibility Deficits

• Suggest arriving at appointments/meetings early

• Develop and practice routines & plan ahead for changes in

routines

• Prepare for transitions

• Help develop alternative plans

• Assist in prioritizing goals, breaking them down into

smaller tangible tasks

• Provide respectful feedback to potential or obvious problem

areas


Executive Function: ReasoningDeliberate and controlled mental operations to solve

novel and on the spot problems.

• Concrete thinkers

• Can’t think of alternative solutions

• Difficulties answering open ended

questions

• Difficulties learning from

experience, cause and effect

MemorySensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Reasoning Deficits

• Point out possible consequences of decisions, short- & long-

term (“Is this a good idea? What might happen? Is this

consistent with your goals?”)

• Teach step by step approach to problem solving

• Avoid open-ended questions

• Speak concretely

• Be clear on expectations and consequences of risk taking

behaviors

• Be supportive and continually identify strengths


Emotional/BehavioralThe awareness of social, emotional and behavioral self-

regulation, control and monitoring.

• Over/under reaction

• Difficulties with anger management

• Melt down

• Can appear emotionally “flat”

• Difficulties making friends

• Can appear

argumentative

MemorySensory-


Processing

Speed

Language

Processes

Learning

Processes

Visual-

Spatial

Processes

Social

Emotional

Competency

Executive

Functions

Achievement/

Cognitive

Ability/

Reasoning

Accommodations for Emotional/Behavioral

Challenges

• Minimize anxiety with reassurance, education, and structure.

• Avoid focusing only on individual’s deficits

• Promote self awareness by stopping and addressing

undesired behavior immediately

• Don’t interpret lack of emotion as a sign of lack of interest.

• Suggest breaks if the individual becomes irritable or

agitated.

• Mindfulness exercises to aid clients in accurately identify

internal emotional states: progressive relaxation, body scans,

deep breathing exercises

• Practice positive social interactions. Provide alternative

comments or choices that could have been made

BIAColorado.org • (303) 355-9969

Skill vs. Will

Key Concepts

• Brain injury may present medically, but often, and more

importantly, behaviorally

• Accommodate and create simple strategies for the

behaviors (do not feel like you need to “treat” the injury)

• Consider first if the individual is capable of doing

something, as opposed questioning their willfulness


Screening and Identification

Importance of Screening for Brain Injury

One study found that 42% of persons who indicated they had incurred a TBI as defined by

the CDC did not seek medical attention (Corrigan & Bogner, 2007)

• Brain injury increases risk for problem behaviors & re-offending (Williams, Mewse, Tonks,

Mills, Burgess & Cordan, 2010)

• Clients may be eligible for support services (BIAC)

• Psychotherapies can be adapted for neurocognitive deficits. Examples:

• Minimize environmental distractions

• Educational therapies (e.g. CBT, DBT) should emphasize pacing, provide frequent

opportunities for clients to respond, generate feedback, and provide reinforcement to

maintain client engagement

• Written material/handouts where possible

• Repetition of key points

• Non-electronic devices might include checklists, pictures or icons, photograph cues, post-

it-notes, calendars, planners, and journals

• Therapies should be introduced with a simple rationale


Components of Screening

• Education / awareness

• Training regarding the sequelae of brain injury

• Important to have a foundational knowledge of brain injury

• Training should be provided to anyone conducting intake/screening

• Medical documentation

• Best practice

• Important to note that medical documentation only indicates an injury not impact

• Documentation should be from a clinician trained in diagnosing TBI

• Establishing credible history

• Assessing impact

• Modifying/generating novel interventions


Screening Tools

• Screening tools must be:

– Valid and reliable

– Sensitive to the population

– Appropriate to the setting

• Resources– Brain Check Survey (http://www.lobi.chhs.colostate.edu/survey.aspx)

– Brain Injury Screening Questionnaire

([email protected])

– OSU TBI-ID

(www.ohiovalley.org/informationeducation/screening/)



http://www.ohiovalley.org/informationeducation/screening/

Resources

• BIAColorado.org

• CraigHospital.org

• TBI Toolkit: http://www.mirecc.va.gov/visn19/tbi_toolkit/

• Brainline.org


Funds from surcharges on convictions of speeding tickets,

DUI, DWAI, & the children’s helmet law

Community

Grants

Research

GrantsServices

CO Department of Human Services

• Resource navigation for youth & adults with brain injury

• Specialized support & consultation about school-related

issues for children/youth with brain injury

• Brain injury specific classes and workshops

• Trainings to community providers about brain injury and

resources © 2019 Brain Injury Alliance of Colorado

Brain Injury Alliance of ColoradoThe go-to resource for help and services for survivors of an injury to the brain, their

families, and providers.

BIAC is a statewide nonprofit dedicated to helping all persons with a brain injury thrive in their community

– Core service is resource navigation for all ages – this is free, with no income or insurance eligibility criteria

– Brain injury specific conferences & workshops

– Online educational materials for survivors, family, & professionals

– Statewide brain injury professional networking groups

– Adaptive recreation programs, music & art therapy classes

– Emergency utility assistance through Energy Outreach Colorado

– Online resource directory specific to brain injury providers

– Statewide support groups

– Member of United States Brain Injury Alliance


Resource Navigation

Resource Navigation is our foundational support program

for survivors, family members, and caregivers. It is

intended to be quick and easy to access.

All ages can access this free support.

Examples of support:

•Finding medical providers

•Understanding brain injury

•Filling out paperwork

•Connecting to community-based resources

•Problem-solving

How to connect:

•Online Referral Form: https://biacolorado.org/referral/

•Email: [email protected]

•Phone: 303.355.9969, toll-free 1.800.955.2443


https://biacolorado.org/referral/


Self-management/Skill-building• Designed for survivors who want to invest time in improving their

skills in specific areas that can be challenging after a brain injury.

• BIAC Advisors work one-on-one with each participant to assess their

strengths & weaknesses, identify natural supports in their life, &

develop strategies for building specific skills with the goal of greater

self-sufficiency.

• Six-month program, average of 4 hours per month

• Participants will have regular homework outside of meetings with

their Advisor which will be reviewed each time they meet.

Areas of focus for Self-management:

• Communication

• Scheduling/Planning

• Prioritization/Organization

How to apply:

If you are a survivor interested in participating in the Self-management Program, please contact BIAC

to request an application: [email protected] or 303.355.9969, toll-free 1.800.955.2443© 2019 Brain Injury Alliance of Colorado


BIAC has a Youth Education Liaison specialist on staff who

provides free, statewide consultation and support services to

children and youth, aged 0-21, with a documented brain injury.

Examples of support:

• Providing parent/guardian education of services and

programming options available in schools

• Assisting in the partnership between parents and schools

• Educating parents and school teams on how a student has been

impacted by their brain injury

• Collaborating with schools on intervention planning

• Attending transition, IEP, MTSS, and other planning meetings

• Partnering with hospitals to help with transition to school

• Any other student specific educational

needs/concerns/questions

Education Consultation

How to apply:

If you are a parent or professional working with a child or youth with brain injury, please contact BIAC to request an

application for education consultation: [email protected] or 303.355.9969, toll-free 1.800.955.2443



The Power of Peer!

Have you ever been inspired to give back to other brain injury

survivors as someone who “has been there?” Have you ever

thought your life could improve by talking to someone that “really

understands because they know what it is like to have a brain

injury?”

The Peer Mentorship Program is looking for volunteers!

The program will span up to a year in duration, with weekly

phone or video conference contacts, and if possible a monthly

community activity (dependent upon proximity, transportation and

personal budgets). The program is designed to support survivors

explore resiliency, define what it means to thrive, and then to take

steps in this direction.

Peer Mentorship Program

If you are interested or would like to learn more, please contact:

Seija Curtin at [email protected] or 303-223-0731


https://biacolorado.org/referral/


Classes & WorkshopsThese activities are free, however space is limited and registration is required.

Clients in services with BIAC have priority access.

Classes

Art

Music Therapy

Adaptive Yoga

Cooking

Balance (fall prevention)

Workshops

Financial Health

Brain Injury Basics

Mindfulness


Recreation & Social Programs

Our camps are an opportunity to build friendships; gain confidence, accomplish physical feats you

did not think possible, earn field work credits and have more fun than you thought imaginable! Partial scholarship funding awarded based on needs and availability of funds.

Contact: Linda Heesch

[email protected]

303-562-0401

Multi Day Opportunities:

Winter Sports: March/April

Summer Camps: June through

August

Canoe Trip: September

Creative Activities September

Day Programs:

Obstacle Course – April

Rock Climbing – May

Paddle Sports – July

Zip Line – October

Social Activities:

Movies

Sporting events

Cultural activities



http://cokidswithbraininjury.com

Please see our website for more information:

BIAColorado.org

Thank you for your time!

Questions? Comments?

Feedback?

BIAColorado.org • (303) 355-9969


The Role & Overlap of Brain Injury in Victims &...

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