A brief overview of an approach to risk assessment in those with head injury

1. Overview of Risk Assessment and
placement for those with brain
injury
Paul Fenton
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2. © Paul Fenton
Note
•
This brief primer/overview was designed and delivered to social workers within
a community social work setting in 2006, 2007 & 2008
•
Effective Risk Assessment involves clinical, cultural and community knowledge
experts who all contribute to a sound assessment of risk
•
Effective risk assessment usually takes place within a multidisciplinary
rehabilitation setting
•
Assessment of risk following brain injury is complex; this primer should not
replace professional advice and/or direction
•
This overview should be considered within the evolving body of
academic, clinical, cultural and community understandings of risk following
brain injury.
•
The following slides have been designed to use as notes for
viewers/readers.
2

3. © Paul Fenton
Overview
①
What is Risk?
②
Risk Assessment Assumptions
③
Traumatic Brain Injury (TBI)
a.
b.
Consequences
c.
Assessment
d.
Functional Neuroanatomy
e.
④
Overview
Facts
Risk Assessment (RA)
a.
b.
RA and Mental Illness
c.
Structure
d.
⑤
Basics
Special Cases
Placement Issues.
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4. © Paul Fenton
1. What is Risk?
 There are several definitions of the risk, Adams (1995)
defines risk as:
“the probability of an adverse future event multiplied
by its magnitude” (p.69)
 Risk by this definition involves two dimensions of
assessment:


Probability (how likely the event is to occur), and
Magnitude (the significance of the event)
 In short, how likely is this event, and how bad will it be?
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5. © Paul Fenton
1. What is Risk?
•
•
Risk does not only relate to self harm and/or harm to others
Risk also includes:
–
Risk of progression to illness (e.g. in cases of drug & alcohol
abuse)
–
Unintentional harm to self
–
Exploitation
–
Risk of abuse by others
–
Intentional or unintentional violence or fear-inducing behaviour
toward others
–
Risk of property destruction.
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6. © Paul Fenton
1. What is Risk?
Risk to self
• Safety
Risk to others
• Violence
• Health
• Quality of life
• Vulnerability
• Self-neglect
• Cultural/Spiritual
• Intimidation, threats
• Stalking
• Harassment
• Property damage
• Public nuisance
• Reckless behaviour
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7. © Paul Fenton
2. RA Assumptions
 The BEST predictor of future risk is PAST
behaviour
 Risk can be measured in some way
 Risk can be predicted
 Risk prediction is not 100% certain, but is based on
probability/liklihood of future risk
 Risk is not stable, but is variable
 Risk triggers can be both static and dynamic.
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8. © Paul Fenton
3a. TBI: Overview
 Traumatic Brain Injury (TBI) types:



Closed, Open, and Crush injuries
Mild, moderate, severe
Common injuries/events during TBI

Diffuse axonal injury (DAI) due to acceleration forces

Loss of consciousness

Coup and contré-coup injuries

Brain shaking

Bleeding and swelling (oedema), which places brain under physical pressure
due to the confined space of the skull

Other non-brain related injuries (this can mean that head injury may not be the
main focus of treatment).
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9. © Paul Fenton
3b. TBI: Consequences
 Isolation from family


Likely in majority of cases that the patient will be unsupported by whānau
(family) or friends after TBI
Neuropsychiatric & Neurobehavioural sequelae

i.e. Emotional effects, physical effects, etc. (see slide 11)
 TBI symptoms dependent on things such as:

The site of injury; severity; education level, and age at injury

Malingering may be an issue

Legitimacy of the impact/effects may be questioned

Specifically, in Mild TBI, long-term symptoms may be viewed with scepticism
by health professionals and family/friends.
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10. © Paul Fenton
3c. TBI: Assessment
•
Cognitive Function
–
–
–
–
–
Overall current functioning (verbal & non-verbal)
Verbal abilities
Visuospatial abilities
Processing speed
Memory (visual/verbal)
•
•
•
–
Attention and Working memory
Short-term
Long-term
Executive Functioning (potentially major consequences for Risk
Assessment).
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11. © Paul Fenton
3c. TBI: Assessment (con’t)

Quality of Life and Daily Living


Day-to-day and qualitative impact of the injury
Psychiatric Functioning



Anxiety
Depression, etc.
Neurobehavioural Functioning (cognitive, emotional, behavioural and
physical effects) e.g.:

Memory

Somatic complaints

Affect/Mood

Aggression.
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12. © Paul Fenton
3d. TBI: Functional Neuroanatomy
The four lobes of the brain
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13. © Paul Fenton
3d. TBI: Functional Neuroanatomy
The left hemisphere is associated with verbal abilities, verbal memory, reading,
writing, logic, sequential analysis, mathematics: such as counting & measurement,
and music (in expert musicians). In 95% of people, important language functions are
„located‟ here such as: speech production & comprehension, grammar/words, and
patterns. Please Note: The left hemisphere is NOT the „dominant‟ hemisphere; BOTH
hemispheres MUST and DO work together 13 normal functioning.
for

14. © Paul Fenton
3d. TBI: Functional Neuroanatomy
The right hemisphere is associated with visuospatial abilities, visual
memory, pattern recognition, parallel processing, face recognition, and synthesis of
information. Important language functions are: intonation & prosody (making sense
of tone of voice and meaning), and contextual cues. The right hemisphere, once
viewed as “word deaf and word blind” makes a VITAL contribution to language and
social interaction, without which, we would not, for example, understand if someone
is speaking literally of figuratively, or even 14
when someone is making a joke.

15. © Paul Fenton
3d. TBI: Functional Neuroanatomy
The frontal lobe is associated with planning, sequencing, abstract
thought,
personality,
impulse
control,
intentional
behaviour,
problemsolving, monitoring and regulating behaviour. The frontal lobe is viewed by some as
the lobe that, if affected in some way, can have the most devastating consequences
on human functioning. As such, a person with frontal lobe damage may present
greater challenges for risk management15
than say a person with temporal lobe
impairments such as memory.

16. © Paul Fenton
3d. TBI: Functional Neuroanatomy
The temporal lobe is associated with memory and learning (the hippocampus is
located there), auditory processing, and language functions involved in speech
comprehension (Wernicke‟s area), visual pathways in the temporal lobe include the
ventromedial pathway involved in face recognition and shape/form and
categorical/orientation in visual recognition.
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17. © Paul Fenton
3d. TBI: Functional Neuroanatomy
The parietal lobe is associated with somatosensory system, and the dorsolateral
visual pathway involved in visual perceptual processes such as 3-d representation
of objects, and what is thought to be an disorder associated with attention called
“hemi-neglect” (ignoring (usually) the left side of space).
Please also note that the boundaries between the lobes is not as distinct as shown.
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18. © Paul Fenton
3d. TBI: Functional Neuroanatomy
The occipital lobe is where the primary visual cortex lies. Neural signals from the
eyes travel along the optic nerve via the thalamus and then radiate to the visual
cortex. Damage to this area affects vision possibly causing blind spots, tunnel vision
and affecting vision quality. The distinctions between the occipital and temporal and
occipital and parietal lobes are not clear cut and the occipital lobes play a role in
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object recognition, motion-detection, and shape discrimination.

19. © Paul Fenton
3e. TBI: Facts
 TBI may cause decades-lasting vulnerability to psychiatric
illness in some individuals
 It may cause new illness in those with no prior history
 It may exacerbate existing illness
 TBI seems to make people susceptible to depressive
episodes, delusional disorder, and personality disturbances
 Mild Head Injury may cause long-lasting neurobehavioural
impairment (see previous slide)
 Alcohol abuse and illegal drugs are forbidden for those with
head injury
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20. © Paul Fenton
3e. TBI: Facts (con’t)
 In comparison to the general population, higher
proportions of those with TBI develop psychiatric
illness
 Usually depression, anxiety and panic disorder
 History of prior psychiatric illness associated with:
 Lower Glasgow Outcome Scale scores, lower MiniMental State Exam scores, and fewer years of formal
education.
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21. © Paul Fenton
3e. TBI: Facts (con’t)
•
In relation to RA, focal prefrontal lobe damage is associated with an
impulsive subtype of aggressive behaviour
•
But, general frontal lobe dysfunction is linked to aggressive dyscontrol, but
the increased risk of violence is less than widely presumed
–
•
i.e. we don’t know what brain areas are predictive of violence.
Also, temporal lobe structures are implicated in psychopathy –
antisocial/sociopathic characteristics1
1.
This term refers to people of average or superior intelligence, free from psychosis, who are cold and
callous, domination-seeking, emotionally-detached, abnormally aggressive and irresponsible, and are unable to
make enduring relationships or learn from experience.
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22. © Paul Fenton
4a. RA Basics

Usually, the best predictor of future behaviour is usually past behaviour


But, this might pose a problems with TBI as they have no history to go on,
barring review of prior function and multi-deminsional assessment
Assessment is a combination of:


Knowledge of Actuarial Methods (Statistics e.g. car stats for youth…)

Knowledge of Literature

Knowledge of Culture & Environment


Clinical expertise & judgement
Collaboration with professionals and whānau (family)
Assessment should be multi-dimensional.
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23. © Paul Fenton
4a. RA Basics (con’t)
 Must include Strengths, Coping and Protective Factors
 This ensures comprehensive understanding of the individual
and capabilities, rather than weaknesses only (avoid deficit
thinking)
 Assess multiple domains (“ABCDEF”)






Affect (emotions/feelings)
Behaviour
Cognition
Drugs
Education
Family.
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24. © Paul Fenton
4b. RA and Mental Illness
 Mental illness does not necessarily predispose people to
greater risk
 Greater majority of those with mental illness pose no greater
risk to general population
 Best predictors of risk are offending and previous history of
risk
 Risk posed by severely ill is only increased when in actively
psychotic phase
 Risk of violence increased in those who have active
symptoms and misuse drugs/alcohol
 Challenge mental health misperceptions.
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25. © Paul Fenton
4c. RA Structure
1. Characteristics of risk
a.
Risk fluctuates (regularly assess)
b.
Degree of risk occurs at all ages
c.
Prediction of risk is <100% accurate; at best, it’s a
short-term predictor
d.
Good clinical judgment is the best way to minimise
risk
e.
Don’t rely on actuarial factors alone (e.g. age &
gender, etc.).
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26. © Paul Fenton
4c. RA Structure (con’t)
2. Assessment of risk
a. Assess constantly, especially after:
i.
First contact with service
ii. Changes in care
iii. Changes in life events
iv. Significant Changes in mental state
v. Discharged to less-restrictive environments
vi. Diagnosed with chronic illness.
b. Assess regularly and note any changes
c. Based on Collateral Information (see point “d” overleaf).
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27. © Paul Fenton
4c. RA Structure (con’t)
2. Assessment of risk (con‟t)
d. Assessment is based on:
i. Patient history
ii. Self-report when interviewed
iii. Discrepancy in verbal accounts
iv. Psychological and Physiological tests
v. Relevant statistics
vi. Actuarial indicators.
All of the above taken together = Clinical judgment
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28. © Paul Fenton
4c. RA Structure (con’t)
3.
A. Risk Assessment Information sources:
i.
Factual information
ii.
Informed opinion
iii.
Actuarial information
iv.
Weight given to those who know the individual well.
B. Risk Assessment Information Considerations:
i.
Don’t rely on distorted summary reports
ii.
Look for Objective, Verifiable data sources
iii.
Use first-hand sources if possible
iv.
You might use family to corroborate/validate information – within reason (use judgment)
v.
Lack of insight and denial may be present in those with TBI (both are neurological
conditions, not necessarily psychological conditions).
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29. © Paul Fenton
4c. RA Structure (con’t)
4. Formulation of risk – the why
a. Summarises risk data, sets out
management plan
b. Checks adequate assessment
done
c. Ensures we THINK about the risk.
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30. © Paul Fenton
4c. RA Structure (con’t)
4.
Formulation of risk (con‟t) – the how
a.
Background:
Relevant demographics; culture; history of violence/self-harm/other; psychiatric history; and
behaviour
b.
Current situation:
Current mental state; sources of stress; precipitating events; and stressors &
circumstances
c.
Risk Factors:
ID relevant risk factors (e.g. “SAD PERSONAS, SLAP” - see slide 35); and prioritisation of
risk factors
d.
Risk Statement:
Nature and magnitude of likely event; probability; Precipitating factors/circumstances; how
long assessment valid for; and when next assessment due.
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31. © Paul Fenton
4c. RA Structure (con’t)
5. Managing risk
a. Aim to ID actions and implement them
b. Evaluate outcomes of risk management plan
i.
Immediate risks
ii. Ongoing management
iii. Preventive actions
iv. Contingency plans.
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32. © Paul Fenton
4c. RA Structure (con’t)
6. Balancing risks
a.
b.
7.
Sometimes necessary to take risks for therapeutic benefit
Total risk avoidance can be restrictive.
Harm to others
a.
Remember mental illness poses no greater risk
b.
But, watch those
hallucinations, etc.)
c.
Also, watch those who abuse alcohol and drugs or go off medication
d.
Also, watch those with history of conduct disorder/antisocial disorder
and substance abuse
e.
Also, watch those with untreated symptoms.
in
active
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psychotic
stages
(command

33. © Paul Fenton
4d. RA Special Cases
 Violence Risk Assessment
 Also assess aggression/threats
 Predictors:
 Previous history
 Gender – male 18-30
 Psychiatric patients – BUT only when:




In coercive situations
In active phase of psychosis
Alcohol/Drug use
Psychopathy (see slide 21).
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34. © Paul Fenton
4d. RA Special Cases (con’t)
 Violence Risk Assessment






Clinical history
History of risk-taking behaviours
Escalation of risk
Victim ID and Profile
Early warning
Interventions.
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35. © Paul Fenton
4d. RA Special Cases (con’t)
 Suicide Risk Assessment
 Risk factors: Sex, Age, Depression, Previous
Attempts, Excess Alcohol, Rational thought
gone,
Support,
Organised,
No
spouse, Abuse, Sickness (“SAD PERSONAS”)
 Severity, Lethality, Availability, Proximity to Help
(“SLAP”).
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36. © Paul Fenton
5. Placement Issues
 Placement is based on outcome of the
RA, rather than desire to place a person in
secure care regardless of outcome
 However, prevailing mental health belief and
prejudice might suggest otherwise
 In this case, we must minimise risk as best as
possible (see overleaf and slide 31 – Managing Risk).
 Balance between what is best for patient and
what is best for family/community.
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37. © Paul Fenton
5. Placement Issues (con’t)
 Where to place? (this can minimise risk)

Secure facility option

Semi-secure facility option

Open facility/Home/Hostel option
 How to minimise risk? (see slide 31 also)

Monitor risk

Ensure ongoing support – use family support/monitoring too, if possible

Ongoing management

Take Preventive actions

Have contingency plans.

Documentation and tracking is important.
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38. © Paul Fenton
5. Placement Issues (con’t)
Will we get it wrong at times?
 Yes, sadly
 This may be more a matter of “if”, but
“when”, for mental health and allied
professionals
 Assessment is not 100% accurate
 Supervision and support is important
here.
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39. © Paul Fenton
FINISH
 The key to Risk Assessment is to support and confer
with one another
 Work in a community of best practice professionals
and community experts
 Look for examples of best practice
 If in doubt, seek expert advice.
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