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Traumatic Brain Injury (TBI)Essentials
Today’s Schedule• 8-8:30 Registration• What is Traumatic Brain Injury & Screening  for TBI-related deficits• 10-10:15 Brea...
Overview•   Epidemiology•   Mechanisms of Injury•   Deficits Associated with TBI•   Identification•   Treatment•   Special...
#tbiwsu
EPIDEMIOLOGY
National prevalence rates of various               disabilities400,000 with Spinal Cord Injuries500,000 with Cerebral Pals...
Incidence  In the United States, at least1 million sustain a TBI each year
Causes of TBI
Who is at Highest Risk for TBI?• Males 1.5 times as likely as females to sustain  a TBI• Two age groups most at risk are 0...
Incidence of TBI x Age and Gender
MECHANISMS OF INJURY
Types of Brain Injuries                           Acquired Brain Injuries      Traumatic Brain Injuries                Oth...
Causes of TBI
Mechanisms of Injury• Primary mechanisms of injury  – Contusions  – Small vessel disruption  – Diffuse axonal injury
Coup-Contra Coup
Hematoma
Mechanisms of Injury• Secondary mechanisms of injury  – Edema  – Evolving hematoma  – Hydrocephalus
Normal ventricles
Managing intracranial pressure
Introduction to Neuroanatomy
Introduction to NeuroanatomyWhat’s different about the brain?
Neuron
Synapse
Peripheral and Central Nervous System
Introduction to Neuroanatomy• Front – back     x• Top – bottom• Left - right
what IS…            © 2011 David D. Nowell, Ph.D. All rights4/27/2012                                              33     ...
…what COULD BE            © 2011 David D. Nowell, Ph.D. All rights4/27/2012                                              3...
Introduction to Neuroanatomy• Front – back• Top – bottom• Left – right   x
?
Frontal Lobe
Temporal Lobe
Parietal Lobe
Occipital Lobe
Limbic System
Cerebellum
The Ventricles
Normal ventricles
DEFICITS ASSOCIATED WITH TBI
Medical•   Physical stamina•   Pain•   Headaches•   Seizures (within 2 years of injury)•   Bowel/bladder continence
Motor Functioning•   Paresis or spasticity•   Gross motor strength•   Fine-motor speed and dexterity•   Motor coordination...
Sensory-Perceptual Abilities• Tactile, visual, and auditory modalities• Sometimes, olfaction
Attention• Alertness and arousal.• Selective or focused attention.  – Modality specific• Sustained attention (vigilance).•...
Receptive Language•   Word and phrase comprehension•   Conflictual and comparative statements•   Vocal tone and prosody•  ...
Expressive Language• Fluency• Naming• Word and phrase repetition• Organization of output (e.g., spontaneous versus  confro...
Memory and Learning
The Executive FunctionsX
Places•   San Jose•   Aberdeen•   Paris•   Hattiesburg
Places• San Jose• Aberdeen• Paris• Hattiesburg
Boys’ Names•   Dante•   Pete•   Jordan•   Elvis
Boys’ Names• Dante• Pete• Jordan• Elvis
“a healthy well-adjusted 26 year old”
The Executive Functions•   Inhibition•   Shift•   Regulation•   Initiation•   Working memory•   Planning / organizing•   S...
The Executive Functions• Bridging the now with the past• Bridging the now with the future
© 2011 David D. Nowell, Ph.D. All rights4/27/2012                                              68                         ...
Preschool        1. 1-step errands        2. Chores with cues        3. Basic inhibition                         © 2011 Da...
Kindergarten -2nd Grade    1. 2-3 step directions    2. Bring papers home    3. 20-30 minute assignments    4. Simple spen...
3rd-5th Grade            1. Simple shopping list            2. Keep track of personal items            3. Longer homework ...
6th – 8th Grade        1. Complex chores        2. Babysitting        3. Organizing system        4. Complex schedule     ...
Teenage-mid 20’s            1. Independent with assignments            2. Make adjustments based on feedback            3....
School and Vocational Outcomes•   Problems initiating and completing work.•   Slowed work pace.•   Increased impulsivity.•...
School and Vocational Outcomes•   Confusion and increased stress.•   Resistance to change.•   Trouble with generalization ...
Social-Behavioral Outcomes•   Loss of friends and social circles.•   Decreased affective regulation.•   Increased impulsiv...
Social-Behavioral Outcomes•   Poor perspective taking.•   Comparison to preinjury level of functioning.•   Poor understand...
Emotional•   Dependent behaviors / amotivation•   Irritability / emotional lability / anger•   Depression•   Disinhibition...
Who Gets Better? Predictors of         Positive Outcomex
Preinjury Predictors of Positive                Outcome• History of good academic achievement• Good social relationships• ...
Preinjury Predictors of Positive                Outcome• Strong-willed and determined• Under 21 years of age• No previous ...
Preinjury Predictors of Positive                 Outcome•   No criminal history•   Good relationships with family members•...
Behavioral Predictors of Positive               Outcome• Motivated and persistent• Optimistic• Has the capacity to recogni...
Behavioral Predictors of Positive               Outcome• Relatively independent with activities of daily  living• Initiate...
Environmental Predictors of Positive             Outcome• Individual treatment plans• Continuity and coordination of treat...
Environmental Predictors of Positive                Outcome•   Presence of “key” person in the family•   Family involved i...
Neurological Predictors of Positive                Outcome•   Coma < 6 hours•   PTA < 24 hours•   GCS > 7•   Normal EEG an...
Indices of Severity of TBI•   Intracranial Pressure•   Retrograde Amnesia•   Anterograde Amnesia/Post-traumatic Amnesia•  ...
Indices of Severity of TBI
Mild injury0-30 minute loss of consciousnessModerate injury30 minutes to 24 hours LOCSevere injury> 24 hours LOC
IDENTIFICATION OF TBI
Identification of TBI•   Obtain the medical records if possible•   Interview family/friends for collaboration•   Arrange f...
Inquiry Regarding TBI• Any history of concussion or head injury?• Ever been knocked out?• Note: this question may lead to ...
“Getting at” PTA in the clinical                interview• When did you wake up from the head injury? Do you  remember bei...
Comprehensive Mental Status           Examination• Behavior• Emotion• Cognition
ABC STAMPLICKER
ABC STAMPLICKER• appearance
ABC STAMPLICKER• behavior
ABC STAMPLICKER• cooperation
ABC STAMPLICKER• speech
ABC STAMPLICKER• thought –Form –Content
ABC STAMPLICKER• affect
ABC STAMPLICKER• mood
ABC STAMPLICKER• perception
TO ORIENT  To understand       one’srelationship to the   environment
ABC STAMPLICKER• level of arousal
ABC STAMPLICKER• insight
Judgment• The ability to weigh and compare the relative  values of different aspects of an issue.
ABC STAMPLICKER• cognition
ABC STAMPLICKER• knowledge
ABC STAMPLICKER• endings
Risk Assessment Protocol• Identify predisposing factors• Examine potentiating factors• Conduct a specific suicide inquiry ...
ABC STAMPLICKER• reliability
Diagnostic Issues• Cognitive Disorder NOS• Dementia Due to Head Trauma
Diagnostic Issues• Distinguishing psychiatric from TBI-related  impairment  – Insight/denial/anosagnosia  – Explosive beha...
TBI TREATMENT
Considerations in TBI Recovery•   What constitutes “recovery”•   Will he/she be 100%?•   It takes a year?•   “Plateaus”•  ...
Medical Management: Acute TBI•   Airway•   Close monitoring for edema•   Seizure control•   Close monitoring for increased...
Normal ventricles
Increased intracranial pressure
ICP monitor
Pharmacological Treatments•   Amantadine x•   Anti-seizure agents•   Antipsychotics•   Antidepressants•   Stimulants
Pharmacological Treatments•   Amantadine x•   Anti-seizure agents•   Antipsychotics•   Antidepressants•   Stimulants
Early Rehabilitation Efforts:• Formal family meetings• Use of an interdisciplinary team approach in  overall treatment• Di...
Referrals
ReferralsBrain Injury and Statewide SpecializedCommunity Services
Referrals•   Assistive technologies•   Independent living skills training•   Speech therapy•   Occupational therapy•   Phy...
Referrals•   Case management•   Home modifications•   Transportation•   Cognitive rehabilitation•   Counseling•   Financia...
Goals of Neuropsychological Assessment• Determine spared versus impaired abilities.• Understanding impact of injury and/or...
Goals of Neuropsychological Assessment• Assist in determining whether to remediate or  to compensate.• Generate suggestion...
When to Consider a Referral to            Neuropsychology•   Documented brain injury/insult•   Suspected brain injury or i...
Cognitive Rehabilitation• 4 ways our patients “get better”  – Brain healing  – Brain re-organization / plasticity  – Compe...
Cognitive Rehabilitation:          Specific Approaches• Psychometric approach (healing/plasticity)• Stimulus-based approac...
Cognitive Rehabilitation• Research challenges• Cognitive orthotics and prosthetics
Yoga / readPhone callsStaff meetingPlanningsession billing
Vh: jeff w/ puritan oilVc: kate re: brimfieldTC umass dermatology.Spoke w/ cindy 508 8564000
Learn FrenchBe a better spouseStop smoking
Vh: jeff w/ puritan oilVc: kate re: brimfieldTC umass dermatology.Spoke w/ cindy 508 8564000
Learn FrenchBe a better spouseStop smokingCall umass dermatolody- cindy 508 8564000
Yoga / readPhone callsStaff meetingPlanningsession billing
The “Good-Fit” Personal Organizer forthe Client with Executive Dysfunction•   2 pages per day•   7 am to 9 pm•   Contains ...
Use of the personal organizer or PDA• Move it from your head to your calendar• Break long term goals into action items• Th...
Use of the personal organizer or PDA• Use your organizer for every part of your life   – Your to-do list should contain th...
easy                                                    hard             © 2011 David D. Nowell, Ph.D. All rights 4/27/201...
“error-free learning”
© 2011 David D. Nowell, Ph.D. All rights4/27/2012                                              165                        ...
Psychotherapy with the brain-injured               client• Mild TBI interventions• Severe TBI interventions
Psychotherapeutic Interventions        Individual Therapy• Permitting appropriate expression of  emotional reaction to TBI...
Psychotherapeutic Interventions         Individual Therapy• Critical for the therapist to be TBI-savvy• Consider the envir...
Psychotherapy with the brain-injured               client• Develop routines• Energy conservation
Psychotherapy with the brain-injured               client• Values and motivators
© 2011 David D. Nowell, Ph.D. All rights4/27/2012                                              172                        ...
Psychotherapy with the brain-injured               client• Self-esteem
Self - esteem
Activity Scheduling
Psychotherapy with the brain-injured               client• Substance abuse and dependence
Psychotherapeutic Interventions            Group Therapy•   Modeling•   Problem solving•   Peer feedback•   Social skills ...
Behavioral Therapies• Very few people with TBI have fully lost the  ability to learn new behaviors• Structure, consistency...
Behavioral Strategies:         Defining the Problem• This requires a measurable and precise  definition of the target beha...
Behavioral Strategies:         Identifying the Function• Everybody’s doing the best he/she can• Every behavior serves a fu...
Behavioral Strategies:         Identifying Resources• Personal resources: Memory? Flexibility?  Persistence? Motivation?• ...
Behavioral Strategies:              Guidelines•   Skills•   Safety•   Least restrictive•   Managing the antecedent: Set me...
Examples of Behavioral Strategies    • Antecedents              • Interventions                        • Provide clear, co...
Examples of Behavioral Strategies Consequences              Interventions• Avoids failure by not     Alternate difficul...
Behavior Management Strategies:X
Behavior Management Strategies:    Agitation and Irritability
Behavior Management Strategies:         Agitation and Irritability•   Redirection•   Offer an alternative activity•   Rela...
Behavior Management Strategies:            Apathy
Behavior Management Strategies:               Apathy• Give choices between doing one thing or  another; not between doing ...
Behavior Management Strategies:     Denial/Lack of Insight
Behavior Management Strategies:        Denial/Lack of Insight• Have ongoing discussions of “strengths and  needs”• Create ...
Behavior Management Strategies:    Impulsivity/Disinhibition
Behavior Management Strategies:       Impulsivity/Disinhibition• Structured and organized daily routine• Rewarding/praisin...
Behavior Management Strategies:    Depression/Withdrawal
Behavior Management Strategies:      Depression/Withdrawal• Help students identify preserved abilities  and strengths - ra...
A                      B                             C    ANTECEDENTS                BEHAVIOR                      CONSEQU...
A                       B                             C  ANTECEDENT               BEHAVIOR                       CONSEQUEN...
A                B                                     C  ANTECEDENT       BEHAVIOR                               CONSEQUE...
A                                 B                      C            ANTECEDENTS                       BEHAVIOR          ...
© 2011 David D. Nowell, Ph.D. All rights4/27/2012                                              203                        ...
A                         B                             C  ANTECEDENT                 BEHAVIOR                       CONSE...
Beginning            Middle                            End            © 2011 David D. Nowell, Ph.D. All rights4/27/2012   ...
A                B                                     C  ANTECEDENT       BEHAVIOR                               CONSEQUE...
Treating Sensory Defensiveness
Addressing Visuomotor Problems with               Reading
What’s the kid’s deal?• Greene, Ross. The Explosive Child.
Family Issues and Needs• Family stress related to severity of TBI• The family’s resilience may be key to a brain  injured ...
Sources of Family Stress•   Uncertainty about recovery•   Cognitive and personality changes•   Financial strain•   Transit...
Family Definition of the Event
Family Issues and Needs• Family’s adaptation may take years• Any change may trigger emotional  response• Watch for signs o...
Return to School• Accommodations and Modifications• IDEA and Section 504
IDEA Definition of TBI:An acquired injury to the brain caused by  an external physical force resulting in  functional disa...
School Re-Entry Issues• Educational consultation should begin  before return to school• Continuity of care between school ...
Percentage Referred for Services     Home Tutor           3.6      Special Ed.   1.8  Psych. services   2Family counseling...
Basic Criteria for School Re-Entry• Attends to a task for 10 to 15 minutes  – Adjust for age• Can tolerate 20 to 30 minute...
School Re-Entry Procedures• Assess needs  –Adaptive domain  –Cognitive domain  –Communication domain  –Sensorimotor domain...
School Re-Entry Procedures• Identify the best setting for intervention   – Outpatient counseling?   – Home-based family in...
Developing IEP Goals• Focus on 2 or 3 priority issues• Identify metacognitive & organizational strategies• Write measurabl...
TBI Impact at School•   Problems initiating and completing work.•   Slowed work pace.•   Increased impulsivity.•   Topogra...
Classroom Management• Two key factors :  – Structure  – Motivation• Explicitly teach rules & expectations• Establish promp...
Classroom Management• Can students answer the following  questions:  – What do I have to do?  – How much do I have to do? ...
Classroom Management• Use repetition & feedback• Avoid multi-step instructions• Supplement verbal instructions with  nonve...
Classroom Management• To be motivating, a task must be interesting• Intersperse difficult or novel tasks with easy or  pre...
Specific Classroom Strategies:         Attentional Processes• Reward on-task behavior;• Use novel, unusual, relevant or st...
Specific Classroom Strategies:        Attentional Processes• Reduce the number of individual tasks on a  printed page• Red...
Specific Classroom Strategies:       Memory and Learning• Enhance the saliency of material• Regularly summarize informatio...
Specific Classroom Strategies:        Memory and Learning• Couple new information with previously  learned information• Id...
Specific Classroom Strategies:                Language• Limit length and complexity of communication• Do not use figurativ...
Specific Classroom Strategies:               Language• Reminders to start, end, or repair a  conversation• Use question pr...
Specific Classroom Strategies:               Language• Speak slowly• Reduce background noise
Specific Classroom Strategies:           Visual Processing• Provide longer viewing times or repeat  viewings when using vi...
Specific Classroom Strategies:          Executive Functions                  • Problem Solving Processes• Develop a proble...
Specific Classroom Strategies:        Executive Functions• Raise questions about alternatives and  consequences• Provide o...
Specific Classroom Strategies:           Executive Functions•   Note impact of fatigue on cognition•   Note impact of some...
SPECIAL CASES
•   Domestic violence•   Shaken baby syndrome•   Combat trauma•   Alcohol abuse/dependence•   Mild TBISPECIAL CASES
• Domestic violence SPECIAL CASES
In women reporting to ERs for injuries        associated with DV:• 30% of battered women reported a loss of  consciousness...
Domestic Violence…Greater than 90% of all injuries secondaryto domestic violence occur to thehead, neck or face region.   ...
• Shaken baby syndromeSPECIAL CASES
American Academy of Pediatrics-Committee on  Child Abuse and Neglect Pediatrics 2001 “ …95% of serious intercranial injuri...
Shaken Baby Syndrome
Shaken Baby Syndrome• Rotational, acceleration, deceleration forces• There may or may not be impact trauma• Brain rotates ...
Shaken Baby SyndromeKirschner & Wilson’s “dirty dozen”• 1. Child fell from a low height• 2. Child fell and struck head on ...
Shaken Baby SyndromeKirschner & Wilson’s “dirty dozen”• 5. Child suddenly turned blue or stopped  breathing, and was then ...
Shaken Baby SyndromeKirschner & Wilson’s “dirty dozen”• 9. Caretaker tripped or slipped while carrying  child• 10. Injury ...
Shaken Baby SyndromeSymptoms• Apnea• Listlessness• Lethargy• Poor feeding• Irritability• Vomiting• Seizures
• Combat traumaSPECIAL CASES
Combat Trauma• TBI as “signature wound” of Iraqi conflict                      • USA Today 9/07
Combat Trauma• Iraq characterized by different kind of  weaponry: explosive munitions.• 15% of soldiers returning from Ira...
Combat Trauma•   Comorbid PTSD•   Headache•   Sensory impairment•   Alcohol use
• Alcohol abuse/dependency SPECIAL CASES
Alcohol Abuse• May increase morbidity of MVA-related TBI  (Cunningham et al 2002)• Although low amounts may be protective•...
• Mild TBI SPECIAL CASES
TBI Severity: Mild TBI (mTBI)• Concussion signs and symptoms include ANY changes in  behavior such as:   – Cognitive impai...
TBI Severity: Mild TBI (mTBI)• Persistent symptoms following the concussion is often  referred to as Post-Concussive Syndr...
TBI Severity: Mild TBI (mTBI)• Chronic traumatic encephalopathy
Psychotherapy with the persistent          post-concussive client•   Perfectionistic tendencies•   Somatic focus•   Poigna...
The “Big 5” (plus 1)• The “Big 5”  – Daily planner  – Daily organization time  – Movement  – Nutrition  – Connection  – Sl...
Let’s stay in touch! Join my e-newsletter list:   Fill out a card today and drop it in the box.   Text to join: text DN...
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Traumatic Brain Injury (TBI) Essentials: workshop at Worcester State University

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  • 5 MINUTE OVERVIEW
  • EVERY 21 SECONDS, ONE PERSONIN THE U.S. SUSTAINS A BRAIN INJURYAs aconsequence of these injuries:– 50,000 people die– 230,000 people are hospitalized and survive– 80,000 to 90,000 people experience the onset of longtermdisability
  • ? source
  • • An estimated 5.3 million Americans—a littlemore than 2% of the U.S. population—currentlylive with disabilities resulting from brain injury.• It is estimated that one million people are treatedfor TBI and released from hospital emergencyrooms every year.• After one brain injury, the risk for a second injuryis three times greater; after the second injury, therisk for a third injury is eight times greater.• Falls are the leading cause of TBI for persons age65 and older; transportation-related injuries leadamong the 5-64 population
  • ? source
  • • An estimated 5.3 million Americans—a littlemore than 2% of the U.S. population—currentlylive with disabilities resulting from brain injury.• It is estimated that one million people are treatedfor TBI and released from hospital emergencyrooms every year.• After one brain injury, the risk for a second injuryis three times greater; after the second injury, therisk for a third injury is eight times greater.• Falls are the leading cause of TBI for persons age65 and older; transportation-related injuries leadamong the 5-64 population
  • Gray white junction
  • • An estimated 5.3 million Americans—a littlemore than 2% of the U.S. population—currentlylive with disabilities resulting from brain injury.• It is estimated that one million people are treatedfor TBI and released from hospital emergencyrooms every year.• After one brain injury, the risk for a second injuryis three times greater; after the second injury, therisk for a third injury is eight times greater.• Falls are the leading cause of TBI for persons age65 and older; transportation-related injuries leadamong the 5-64 population
  • Rancho Los Amigos Scale I. No ResponseA person at this level will:not respond to sounds, sights, touch or movement. II. Generalized ResponseA person at this level will:begin to respond to sounds, sights, touch or movement; respond slowly, inconsistently, or after a delay; responds in the same way to what he hears, sees or feels. Responses may include chewing, sweating, breathing faster, moaning, moving and/or increasing blood pressure. III. Localized ResponseA person at this level will:be awake on and off during the day; make more movements than before; react more specifically to what he sees, hears or feels. For example, he may turn towards a sound, withdraw from pain, and attempt to watch a person move around the room; react slowly and inconsistently; begin to recognize family and friends; follow some simple directions suck as &quot;Look at me&quot; or &quot;squeeze my hand&quot;; begin to respond inconsistently to simple questions with &quot;yes&quot; or &quot;no&quot; head nods. IV. Confused-AgitatedA person at this level will:be very confused and frightened; not understand what he feels, or what is happening around him; overreact to what he sees, hears or feels by hitting, screaming, using abusive language, or thrashing about. This is because of the confusion; be restrained so he doesn&apos;t hurt himself; be highly focused on his basic needs; ie., eating, relieving pain, going back to bed, going to the bathroom, or going home; may not understand that people are trying to help him; not pay attention or be able to concentrate for a few seconds; have difficulty following directions; recognize family/friends some of the time; with help, be able to do simple routine activities such as feeding himself, dressing or talking. V. Confused-Inappropriate, Non-AgitatedA person at this level will:be able to pay attention for only a few minutes; be confused and have difficulty making sense of things outside himself; not know the date, where he is or why he is in the hospital; not be able to start or complete everyday activities, such as brushing his teeth, even when physically able. He may need step-by-step instructions; become overloaded and restless when tired or when there are too many people around; have a very poor memory, he will remember past events from before the accident better than his daily routine or information he has been told since the injury; try to fill in gaps in memory by making things up; (confabulation) may get stuck on an idea or activity (perseveration) and need help switching to the next part of the activity; focus on basic needs such as eating, relieving pain, going back to bed, going to the bathroom, or going home. VI. Confused-AppropriateA person at this level will:be somewhat confused because of memory and thinking problems, he will remember the main points from a conversation, but forget and confuse the details. For example, he may remember he had visitors in the morning, but forget what they talked about; follow a schedule with some assistance, but becomes confused by changes in the routine; know the month and year, unless there is a serious memory problem; pay attention for about 30 minutes, but has trouble concentrating when it is noisy or when the activity involves many steps. For example, at an intersection, he may be unable to step off the curb, watch for cars, watch the traffic light, walk, and talk at the same time; brush his teeth, get dressed, feed himself etc., with help; know when he needs to use the bathroom; do or say things too fast, without thinking first; know that he is hospitalized because of an injury, but will not understand all the problems he is having; be more aware of physical problems than thinking problems; associate his problems with being in the hospital and think he will be fine as soon as he goes home. VII. Automatic-AppropriateA person at this level will:follow a set schedule be able to do routine self care without help, if physically able. For example, he can dress or feed himself independently; have problems in new situations and may become frustrated or act without thinking first; have problems planning, starting, and following through with activities; have trouble paying attention in distracting or stressful situations. For example, family gatherings, work, school, church, or sports events; not realize how his thinking and memory problems may affect future plans and goals. Therefore, he may expect to return to his previous lifestyle or work; continue to need supervision because of decreased safety awareness and judgement. He still does not fully understand the impact of his physical or thinking problems; think slower in stressful situations; be inflexible or rigid, and he may be stubborn. However, his behaviors are realted to his brain injury; be able to talk about doing something, but will have problems actually doing it. VIII. Purposeful-AppropriateA person at this level will:realize that he has a problem in his thinking and memory; begin to compensate for his problems; be more flexible and less rigid in his thinking. For example, he may be able to come up with several solutions to a problem; be ready for driving or job training evaluation; be able to learn new things at a slower rate; still become overloaded with difficult, stressful or emergency situations; show poor judgement in new situations and may require assistance; need some guidance making decisions; have thinking problems that may not be noticeable to people who did not know the person before the injury. © Los Amigos Research and Educational Institute (LAREI), 1990
  • APPENDIX L p.a13: LAST TXGIVING HOLIDAY: ON SCALE FROM 1-10 HOW GOOD WAS IT FOR U AND YR FAMILY? HOW COULD IT BE A (+1)?MAIN RELATIONSHIP…MOST IMP RELATIONSHIP: WHAT WOULD MAKE IT 10% BETTER? WHAT COULD I DO THIS WK’END TO MAKE THAT HAPPEN?
  • APPENDIX L p.a13: LAST TXGIVING HOLIDAY: ON SCALE FROM 1-10 HOW GOOD WAS IT FOR U AND YR FAMILY? HOW COULD IT BE A (+1)?MAIN RELATIONSHIP…MOST IMP RELATIONSHIP: WHAT WOULD MAKE IT 10% BETTER? WHAT COULD I DO THIS WK’END TO MAKE THAT HAPPEN?
  • CingulategyrusFornixAnterior thalamic nucleiHypothalamusAmygdaloid nucleusHippocampus
  • PLACE NAMES WHICH ARE ALSO PEOPLE’S NAMES:MADISONGEORGIACHARLOTTEINDIAPARISKENYAARIZONAADELAIDESYDNEYDALLASHOUSTONOLYMPIAJORDANBETHANY
  • Certain aspects of memory / learning
  • FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
  • FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
  • FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
  • FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
  • FIGHTING NUN IN MYSTERY BOX: WHY IS THIS FUNNY? WE HAVE EXPECTATIONS BASED ON AGE, STATUS, ETC.Preschool Run simple errands (e.g., “Get your shoes from thebedroom”). Tidy bedroom or playroom with assistance. Perform simple chores and self-help tasks withreminders (e.g., clear dishes from table, brush teeth,get dressed). Inhibit behaviors: don’t touch a hot stove; don’t runinto the street; don’t grab a toy from another child;don’t hit, bite, push, etc.
  • Rancho Los Amigos Scale I. No ResponseA person at this level will:not respond to sounds, sights, touch or movement. II. Generalized ResponseA person at this level will:begin to respond to sounds, sights, touch or movement; respond slowly, inconsistently, or after a delay; responds in the same way to what he hears, sees or feels. Responses may include chewing, sweating, breathing faster, moaning, moving and/or increasing blood pressure. III. Localized ResponseA person at this level will:be awake on and off during the day; make more movements than before; react more specifically to what he sees, hears or feels. For example, he may turn towards a sound, withdraw from pain, and attempt to watch a person move around the room; react slowly and inconsistently; begin to recognize family and friends; follow some simple directions suck as &quot;Look at me&quot; or &quot;squeeze my hand&quot;; begin to respond inconsistently to simple questions with &quot;yes&quot; or &quot;no&quot; head nods. IV. Confused-AgitatedA person at this level will:be very confused and frightened; not understand what he feels, or what is happening around him; overreact to what he sees, hears or feels by hitting, screaming, using abusive language, or thrashing about. This is because of the confusion; be restrained so he doesn&apos;t hurt himself; be highly focused on his basic needs; ie., eating, relieving pain, going back to bed, going to the bathroom, or going home; may not understand that people are trying to help him; not pay attention or be able to concentrate for a few seconds; have difficulty following directions; recognize family/friends some of the time; with help, be able to do simple routine activities such as feeding himself, dressing or talking. V. Confused-Inappropriate, Non-AgitatedA person at this level will:be able to pay attention for only a few minutes; be confused and have difficulty making sense of things outside himself; not know the date, where he is or why he is in the hospital; not be able to start or complete everyday activities, such as brushing his teeth, even when physically able. He may need step-by-step instructions; become overloaded and restless when tired or when there are too many people around; have a very poor memory, he will remember past events from before the accident better than his daily routine or information he has been told since the injury; try to fill in gaps in memory by making things up; (confabulation) may get stuck on an idea or activity (perseveration) and need help switching to the next part of the activity; focus on basic needs such as eating, relieving pain, going back to bed, going to the bathroom, or going home. VI. Confused-AppropriateA person at this level will:be somewhat confused because of memory and thinking problems, he will remember the main points from a conversation, but forget and confuse the details. For example, he may remember he had visitors in the morning, but forget what they talked about; follow a schedule with some assistance, but becomes confused by changes in the routine; know the month and year, unless there is a serious memory problem; pay attention for about 30 minutes, but has trouble concentrating when it is noisy or when the activity involves many steps. For example, at an intersection, he may be unable to step off the curb, watch for cars, watch the traffic light, walk, and talk at the same time; brush his teeth, get dressed, feed himself etc., with help; know when he needs to use the bathroom; do or say things too fast, without thinking first; know that he is hospitalized because of an injury, but will not understand all the problems he is having; be more aware of physical problems than thinking problems; associate his problems with being in the hospital and think he will be fine as soon as he goes home. VII. Automatic-AppropriateA person at this level will:follow a set schedule be able to do routine self care without help, if physically able. For example, he can dress or feed himself independently; have problems in new situations and may become frustrated or act without thinking first; have problems planning, starting, and following through with activities; have trouble paying attention in distracting or stressful situations. For example, family gatherings, work, school, church, or sports events; not realize how his thinking and memory problems may affect future plans and goals. Therefore, he may expect to return to his previous lifestyle or work; continue to need supervision because of decreased safety awareness and judgement. He still does not fully understand the impact of his physical or thinking problems; think slower in stressful situations; be inflexible or rigid, and he may be stubborn. However, his behaviors are realted to his brain injury; be able to talk about doing something, but will have problems actually doing it. VIII. Purposeful-AppropriateA person at this level will:realize that he has a problem in his thinking and memory; begin to compensate for his problems; be more flexible and less rigid in his thinking. For example, he may be able to come up with several solutions to a problem; be ready for driving or job training evaluation; be able to learn new things at a slower rate; still become overloaded with difficult, stressful or emergency situations; show poor judgement in new situations and may require assistance; need some guidance making decisions; have thinking problems that may not be noticeable to people who did not know the person before the injury. © Los Amigos Research and Educational Institute (LAREI), 1990
  • Rancho Los Amigos Scale I. No ResponseA person at this level will:not respond to sounds, sights, touch or movement. II. Generalized ResponseA person at this level will:begin to respond to sounds, sights, touch or movement; respond slowly, inconsistently, or after a delay; responds in the same way to what he hears, sees or feels. Responses may include chewing, sweating, breathing faster, moaning, moving and/or increasing blood pressure. III. Localized ResponseA person at this level will:be awake on and off during the day; make more movements than before; react more specifically to what he sees, hears or feels. For example, he may turn towards a sound, withdraw from pain, and attempt to watch a person move around the room; react slowly and inconsistently; begin to recognize family and friends; follow some simple directions suck as &quot;Look at me&quot; or &quot;squeeze my hand&quot;; begin to respond inconsistently to simple questions with &quot;yes&quot; or &quot;no&quot; head nods. IV. Confused-AgitatedA person at this level will:be very confused and frightened; not understand what he feels, or what is happening around him; overreact to what he sees, hears or feels by hitting, screaming, using abusive language, or thrashing about. This is because of the confusion; be restrained so he doesn&apos;t hurt himself; be highly focused on his basic needs; ie., eating, relieving pain, going back to bed, going to the bathroom, or going home; may not understand that people are trying to help him; not pay attention or be able to concentrate for a few seconds; have difficulty following directions; recognize family/friends some of the time; with help, be able to do simple routine activities such as feeding himself, dressing or talking. V. Confused-Inappropriate, Non-AgitatedA person at this level will:be able to pay attention for only a few minutes; be confused and have difficulty making sense of things outside himself; not know the date, where he is or why he is in the hospital; not be able to start or complete everyday activities, such as brushing his teeth, even when physically able. He may need step-by-step instructions; become overloaded and restless when tired or when there are too many people around; have a very poor memory, he will remember past events from before the accident better than his daily routine or information he has been told since the injury; try to fill in gaps in memory by making things up; (confabulation) may get stuck on an idea or activity (perseveration) and need help switching to the next part of the activity; focus on basic needs such as eating, relieving pain, going back to bed, going to the bathroom, or going home. VI. Confused-AppropriateA person at this level will:be somewhat confused because of memory and thinking problems, he will remember the main points from a conversation, but forget and confuse the details. For example, he may remember he had visitors in the morning, but forget what they talked about; follow a schedule with some assistance, but becomes confused by changes in the routine; know the month and year, unless there is a serious memory problem; pay attention for about 30 minutes, but has trouble concentrating when it is noisy or when the activity involves many steps. For example, at an intersection, he may be unable to step off the curb, watch for cars, watch the traffic light, walk, and talk at the same time; brush his teeth, get dressed, feed himself etc., with help; know when he needs to use the bathroom; do or say things too fast, without thinking first; know that he is hospitalized because of an injury, but will not understand all the problems he is having; be more aware of physical problems than thinking problems; associate his problems with being in the hospital and think he will be fine as soon as he goes home. VII. Automatic-AppropriateA person at this level will:follow a set schedule be able to do routine self care without help, if physically able. For example, he can dress or feed himself independently; have problems in new situations and may become frustrated or act without thinking first; have problems planning, starting, and following through with activities; have trouble paying attention in distracting or stressful situations. For example, family gatherings, work, school, church, or sports events; not realize how his thinking and memory problems may affect future plans and goals. Therefore, he may expect to return to his previous lifestyle or work; continue to need supervision because of decreased safety awareness and judgement. He still does not fully understand the impact of his physical or thinking problems; think slower in stressful situations; be inflexible or rigid, and he may be stubborn. However, his behaviors are realted to his brain injury; be able to talk about doing something, but will have problems actually doing it. VIII. Purposeful-AppropriateA person at this level will:realize that he has a problem in his thinking and memory; begin to compensate for his problems; be more flexible and less rigid in his thinking. For example, he may be able to come up with several solutions to a problem; be ready for driving or job training evaluation; be able to learn new things at a slower rate; still become overloaded with difficult, stressful or emergency situations; show poor judgement in new situations and may require assistance; need some guidance making decisions; have thinking problems that may not be noticeable to people who did not know the person before the injury. © Los Amigos Research and Educational Institute (LAREI), 1990
  • Paint a portrait
  • Eye contactMotor behaviors pain posture slowing restlessness
  • Accurate?Oriented to purpose?GuardedDefensiveseductive
  • Fluency of speechThe initiation and flow of languageComprehension/Receptive languageNaming Close head injuries or dementia may cause an inability to name objects. ProsodyVariations in the rate, rhythm and stress in speech.Quality of speechLoudness, pitch, spontaneity, articulation.
  • d/o’s of perception:Ah/vhDepersonalization, derealization
  • Must use physical findingsNeurologic deteriorationUnilaterally dilated pupilHemiparesisPosturing
  • Def. of terms; spontaneous recovery; generalization
  • Def. of terms; spontaneous recovery; generalization
  • 197”
  • Make task shorter, build in breaks, use salient r+ for afterwards, make steps more explicit, make task more appealing (beat the clock, write steps down on slips of paper, in jar)
  • 242”
  • TBI ct: independence and power
  • We use our senses to interface with world around us, retreating from “too much” or “too tight” or “too loud” and seeking lights and sound and movement when we’re understimulated
  • We use our senses to interface with world around us, retreating from “too much” or “too tight” or “too loud” and seeking lights and sound and movement when we’re understimulated
  • Dx approach
  • Texts which are visually cluttered or demanding.
  • Victim and perp more likely to be male
  • !Nerves in brain may be destroyed or damaged!Seizures may occur!Brain may swell following the injury, resulting in permanent brain damage or death!Retinal hemorrhages!Fractures of the endplates of the long bones!Fractured ribs
  • MYSTERY BOXHAVE ST / VP PUT NAMES OF ATTENDEES IN HATAPPENDIX A p. a2: TO DO
  • Transcript of "Tbi essentials wsu"

    1. 1. Traumatic Brain Injury (TBI)Essentials
    2. 2. Today’s Schedule• 8-8:30 Registration• What is Traumatic Brain Injury & Screening for TBI-related deficits• 10-10:15 Break• How TBI Impacts Executive Functioning & Populations at Greater Risk for Brain Injury• 12-1 Lunch• Locating Community Supports and Services for Head Injured Clients• 2:15-2:30 Break• Counseling Brain Injury Survivors and Their Families• 3:45-4:00 Question and Answer
    3. 3. Overview• Epidemiology• Mechanisms of Injury• Deficits Associated with TBI• Identification• Treatment• Special cases
    4. 4. #tbiwsu
    5. 5. EPIDEMIOLOGY
    6. 6. National prevalence rates of various disabilities400,000 with Spinal Cord Injuries500,000 with Cerebral Palsy2.3 million with Epilepsy3.0 million with Stroke-related Disabilities4.0 million with Alzheimer’s Disease5.3 million with Traumatic Brain Injury5.4 million with persistent Mental Illness7.2 million with Mental Retardation
    7. 7. Incidence In the United States, at least1 million sustain a TBI each year
    8. 8. Causes of TBI
    9. 9. Who is at Highest Risk for TBI?• Males 1.5 times as likely as females to sustain a TBI• Two age groups most at risk are 0-4 year olds and 15-19 year olds, and• The elderly, frequently from falls• African Americans have the highest death rate from TBI
    10. 10. Incidence of TBI x Age and Gender
    11. 11. MECHANISMS OF INJURY
    12. 12. Types of Brain Injuries Acquired Brain Injuries Traumatic Brain Injuries Other Brain Injuries: •Strokes •Hydrocephalus •Tumors •Demyelinating disorders •InfectionsPenetrating Closed Head Injury •Toxic encephalopathy •Anoxic/hypoxic injury
    13. 13. Causes of TBI
    14. 14. Mechanisms of Injury• Primary mechanisms of injury – Contusions – Small vessel disruption – Diffuse axonal injury
    15. 15. Coup-Contra Coup
    16. 16. Hematoma
    17. 17. Mechanisms of Injury• Secondary mechanisms of injury – Edema – Evolving hematoma – Hydrocephalus
    18. 18. Normal ventricles
    19. 19. Managing intracranial pressure
    20. 20. Introduction to Neuroanatomy
    21. 21. Introduction to NeuroanatomyWhat’s different about the brain?
    22. 22. Neuron
    23. 23. Synapse
    24. 24. Peripheral and Central Nervous System
    25. 25. Introduction to Neuroanatomy• Front – back x• Top – bottom• Left - right
    26. 26. what IS… © 2011 David D. Nowell, Ph.D. All rights4/27/2012 33 reserved.
    27. 27. …what COULD BE © 2011 David D. Nowell, Ph.D. All rights4/27/2012 34 reserved.
    28. 28. Introduction to Neuroanatomy• Front – back• Top – bottom• Left – right x
    29. 29. ?
    30. 30. Frontal Lobe
    31. 31. Temporal Lobe
    32. 32. Parietal Lobe
    33. 33. Occipital Lobe
    34. 34. Limbic System
    35. 35. Cerebellum
    36. 36. The Ventricles
    37. 37. Normal ventricles
    38. 38. DEFICITS ASSOCIATED WITH TBI
    39. 39. Medical• Physical stamina• Pain• Headaches• Seizures (within 2 years of injury)• Bowel/bladder continence
    40. 40. Motor Functioning• Paresis or spasticity• Gross motor strength• Fine-motor speed and dexterity• Motor coordination and planning• Spatial-based movement• Oculomotor• Balance
    41. 41. Sensory-Perceptual Abilities• Tactile, visual, and auditory modalities• Sometimes, olfaction
    42. 42. Attention• Alertness and arousal.• Selective or focused attention. – Modality specific• Sustained attention (vigilance).• Span of attention.• Hemi-neglect (ignoring one side of the body).
    43. 43. Receptive Language• Word and phrase comprehension• Conflictual and comparative statements• Vocal tone and prosody• Speed of processing• Pragmatics (social meaning in language)
    44. 44. Expressive Language• Fluency• Naming• Word and phrase repetition• Organization of output (e.g., spontaneous versus confrontational speech)• Vocal tone and prosody• Pragmatics (social use of language)
    45. 45. Memory and Learning
    46. 46. The Executive FunctionsX
    47. 47. Places• San Jose• Aberdeen• Paris• Hattiesburg
    48. 48. Places• San Jose• Aberdeen• Paris• Hattiesburg
    49. 49. Boys’ Names• Dante• Pete• Jordan• Elvis
    50. 50. Boys’ Names• Dante• Pete• Jordan• Elvis
    51. 51. “a healthy well-adjusted 26 year old”
    52. 52. The Executive Functions• Inhibition• Shift• Regulation• Initiation• Working memory• Planning / organizing• Self-monitoring
    53. 53. The Executive Functions• Bridging the now with the past• Bridging the now with the future
    54. 54. © 2011 David D. Nowell, Ph.D. All rights4/27/2012 68 reserved.
    55. 55. Preschool 1. 1-step errands 2. Chores with cues 3. Basic inhibition © 2011 David D. Nowell, Ph.D. All rights4/27/2012 69 reserved.
    56. 56. Kindergarten -2nd Grade 1. 2-3 step directions 2. Bring papers home 3. 20-30 minute assignments 4. Simple spending decisions 5. Follow rules/inhibit/no grabbing © 2011 David D. Nowell, Ph.D. All rights4/27/2012 70 reserved.
    57. 57. 3rd-5th Grade 1. Simple shopping list 2. Keep track of personal items 3. Longer homework assignments 4. Simple project planning 5. Keep track of variable daily schedule 6. Save money 7. Inhibit and regulate even without teacher present 8. Manners 9. Simple delayed gratification (phone) © 2011 David D. Nowell, Ph.D. All rights4/27/2012 71 reserved.
    58. 58. 6th – 8th Grade 1. Complex chores 2. Babysitting 3. Organizing system 4. Complex schedule 5. Longer term projects 6. Time management 7. Self soothe 8. Manage conflict © 2011 David D. Nowell, Ph.D. All rights4/27/2012 72 reserved.
    59. 59. Teenage-mid 20’s 1. Independent with assignments 2. Make adjustments based on feedback 3. Longer term goal setting 4. Manage leisure time 5. Inhibit reckless behavior 6. Easily walk away from provocation 7. Say “no” to fun activity if other plans already made 8. Take others’ perspective © 2011 David D. Nowell, Ph.D. All rights4/27/2012 73 reserved.
    60. 60. School and Vocational Outcomes• Problems initiating and completing work.• Slowed work pace.• Increased impulsivity.• Trouble navigating physical surroundings.• Decreased productivity.
    61. 61. School and Vocational Outcomes• Confusion and increased stress.• Resistance to change.• Trouble with generalization of new learning.• Distractible.• May resent special assistance.
    62. 62. Social-Behavioral Outcomes• Loss of friends and social circles.• Decreased affective regulation.• Increased impulsivity.• Increased agitation.
    63. 63. Social-Behavioral Outcomes• Poor perspective taking.• Comparison to preinjury level of functioning.• Poor understanding of TBI and recovery.• Premature return to school/work.• Unrealistic predictions.
    64. 64. Emotional• Dependent behaviors / amotivation• Irritability / emotional lability / anger• Depression• Disinhibition• Denial/lack of insight• At risk for substance abuse
    65. 65. Who Gets Better? Predictors of Positive Outcomex
    66. 66. Preinjury Predictors of Positive Outcome• History of good academic achievement• Good social relationships• No history of learning, attention, or behavioral difficulties• No history of substance abuse• No significant family problems
    67. 67. Preinjury Predictors of Positive Outcome• Strong-willed and determined• Under 21 years of age• No previous neurological history (e.g., a prior TBI)• Good self regulation skills
    68. 68. Preinjury Predictors of Positive Outcome• No criminal history• Good relationships with family members• Warm and supportive family• No psychopathology
    69. 69. Behavioral Predictors of Positive Outcome• Motivated and persistent• Optimistic• Has the capacity to recognize errors and self- correct• Aware of behavioral deficits• Ambulatory
    70. 70. Behavioral Predictors of Positive Outcome• Relatively independent with activities of daily living• Initiates tasks with no/minimal assistance• Preserved perspective-taking capacity• Relatively preserved neurocognitive abilities
    71. 71. Environmental Predictors of Positive Outcome• Individual treatment plans• Continuity and coordination of treatment throughout the recovery process• Structure, consistency, and repetition in daily activities• Good, stable resources (e.g., financial, family, friends, community, etc. )
    72. 72. Environmental Predictors of Positive Outcome• Presence of “key” person in the family• Family involved in the treatment plan• Family realistic about individual’s status• Presence of “key” person on team
    73. 73. Neurological Predictors of Positive Outcome• Coma < 6 hours• PTA < 24 hours• GCS > 7• Normal EEG and MRI• Normal intracranial pressure• Normal ventricle size• No intracranial hematoma
    74. 74. Indices of Severity of TBI• Intracranial Pressure• Retrograde Amnesia• Anterograde Amnesia/Post-traumatic Amnesia• Duration of Loss of Consciousness (LOC)• Glasgow Coma Scale score• Rancho Los Amigos Scale (1 to 10)
    75. 75. Indices of Severity of TBI
    76. 76. Mild injury0-30 minute loss of consciousnessModerate injury30 minutes to 24 hours LOCSevere injury> 24 hours LOC
    77. 77. IDENTIFICATION OF TBI
    78. 78. Identification of TBI• Obtain the medical records if possible• Interview family/friends for collaboration• Arrange for a neuropsychological evaluation• Refer to a neurologist or psychiatrist for medication and behavioral consultation• Consider referral to a brain injury rehabilitation program
    79. 79. Inquiry Regarding TBI• Any history of concussion or head injury?• Ever been knocked out?• Note: this question may lead to discussion of – Alcohol abuse – Domestic violence• Postconcussive symptoms?• Return to work/school?
    80. 80. “Getting at” PTA in the clinical interview• When did you wake up from the head injury? Do you remember being transported to the hospital? Do you remember being in the trauma unit? Being transferred to the rehab unit?• PTA: period of time after the CHI for which the patient has no memory
    81. 81. Comprehensive Mental Status Examination• Behavior• Emotion• Cognition
    82. 82. ABC STAMPLICKER
    83. 83. ABC STAMPLICKER• appearance
    84. 84. ABC STAMPLICKER• behavior
    85. 85. ABC STAMPLICKER• cooperation
    86. 86. ABC STAMPLICKER• speech
    87. 87. ABC STAMPLICKER• thought –Form –Content
    88. 88. ABC STAMPLICKER• affect
    89. 89. ABC STAMPLICKER• mood
    90. 90. ABC STAMPLICKER• perception
    91. 91. TO ORIENT To understand one’srelationship to the environment
    92. 92. ABC STAMPLICKER• level of arousal
    93. 93. ABC STAMPLICKER• insight
    94. 94. Judgment• The ability to weigh and compare the relative values of different aspects of an issue.
    95. 95. ABC STAMPLICKER• cognition
    96. 96. ABC STAMPLICKER• knowledge
    97. 97. ABC STAMPLICKER• endings
    98. 98. Risk Assessment Protocol• Identify predisposing factors• Examine potentiating factors• Conduct a specific suicide inquiry Ideation? Plan? Intent?• Determine level of intervention• Documentation
    99. 99. ABC STAMPLICKER• reliability
    100. 100. Diagnostic Issues• Cognitive Disorder NOS• Dementia Due to Head Trauma
    101. 101. Diagnostic Issues• Distinguishing psychiatric from TBI-related impairment – Insight/denial/anosagnosia – Explosive behavior disorders – Pseudodementia – “Acquired ADHD”?
    102. 102. TBI TREATMENT
    103. 103. Considerations in TBI Recovery• What constitutes “recovery”• Will he/she be 100%?• It takes a year?• “Plateaus”• The normal neurological evaluation• Independence and modified independence• No magic bullets – Meds – Rehab technologies
    104. 104. Medical Management: Acute TBI• Airway• Close monitoring for edema• Seizure control• Close monitoring for increased intracranial pressure
    105. 105. Normal ventricles
    106. 106. Increased intracranial pressure
    107. 107. ICP monitor
    108. 108. Pharmacological Treatments• Amantadine x• Anti-seizure agents• Antipsychotics• Antidepressants• Stimulants
    109. 109. Pharmacological Treatments• Amantadine x• Anti-seizure agents• Antipsychotics• Antidepressants• Stimulants
    110. 110. Early Rehabilitation Efforts:• Formal family meetings• Use of an interdisciplinary team approach in overall treatment• Discharge planning by team members, family, and community services
    111. 111. Referrals
    112. 112. ReferralsBrain Injury and Statewide SpecializedCommunity Services
    113. 113. Referrals• Assistive technologies• Independent living skills training• Speech therapy• Occupational therapy• Physical therapy• Neurology• Psychiatry• Physiatry• Substance abuse treatment
    114. 114. Referrals• Case management• Home modifications• Transportation• Cognitive rehabilitation• Counseling• Financial management• Respite care• Neuropsychological evaluation
    115. 115. Goals of Neuropsychological Assessment• Determine spared versus impaired abilities.• Understanding impact of injury and/or a neurodevelopmental problem (e.g., LD).• Assist in localization of function and dysfunction.
    116. 116. Goals of Neuropsychological Assessment• Assist in determining whether to remediate or to compensate.• Generate suggestions for remediation and compensation.• Suggestions for monitoring and tracking of progress in school setting.
    117. 117. When to Consider a Referral to Neuropsychology• Documented brain injury/insult• Suspected brain injury or insult• Neurodevelopmental disorder• Unusual psychological profile• Positive neurological findings• Severe behavior problems• Treatment needs
    118. 118. Cognitive Rehabilitation• 4 ways our patients “get better” – Brain healing – Brain re-organization / plasticity – Compensatory skills – Restructuring the environment
    119. 119. Cognitive Rehabilitation: Specific Approaches• Psychometric approach (healing/plasticity)• Stimulus-based approach (restructuring the environment)• Developmental approach (plasticity and compensatory)• Behavioral engineering approach (compensatory skills)
    120. 120. Cognitive Rehabilitation• Research challenges• Cognitive orthotics and prosthetics
    121. 121. Yoga / readPhone callsStaff meetingPlanningsession billing
    122. 122. Vh: jeff w/ puritan oilVc: kate re: brimfieldTC umass dermatology.Spoke w/ cindy 508 8564000
    123. 123. Learn FrenchBe a better spouseStop smoking
    124. 124. Vh: jeff w/ puritan oilVc: kate re: brimfieldTC umass dermatology.Spoke w/ cindy 508 8564000
    125. 125. Learn FrenchBe a better spouseStop smokingCall umass dermatolody- cindy 508 8564000
    126. 126. Yoga / readPhone callsStaff meetingPlanningsession billing
    127. 127. The “Good-Fit” Personal Organizer forthe Client with Executive Dysfunction• 2 pages per day• 7 am to 9 pm• Contains a master to-do list• With the client at all times• Use for work and home• Have only one system
    128. 128. Use of the personal organizer or PDA• Move it from your head to your calendar• Break long term goals into action items• The organizer is your budget – how you “spend” your time• Use your organizer for every part of your life
    129. 129. Use of the personal organizer or PDA• Use your organizer for every part of your life – Your to-do list should contain things you have to do, but also things you want to do, or to be, or to have. – You make appointments with your doctor or insurance agent, because they’re important. You can make appointments with yourself as well. – “Hi Cindy, this is David…..” (win friends and influence people with your amazing phone log)
    130. 130. easy hard © 2011 David D. Nowell, Ph.D. All rights 4/27/2012 162 reserved.
    131. 131. “error-free learning”
    132. 132. © 2011 David D. Nowell, Ph.D. All rights4/27/2012 165 reserved.
    133. 133. Psychotherapy with the brain-injured client• Mild TBI interventions• Severe TBI interventions
    134. 134. Psychotherapeutic Interventions Individual Therapy• Permitting appropriate expression of emotional reaction to TBI and loss• Patient education• Social skills training• Family/spouse involvement• Impact of memory problems and decreased insight
    135. 135. Psychotherapeutic Interventions Individual Therapy• Critical for the therapist to be TBI-savvy• Consider the environment in which the person functions• “Lieben und arbeiten”
    136. 136. Psychotherapy with the brain-injured client• Develop routines• Energy conservation
    137. 137. Psychotherapy with the brain-injured client• Values and motivators
    138. 138. © 2011 David D. Nowell, Ph.D. All rights4/27/2012 172 reserved.
    139. 139. Psychotherapy with the brain-injured client• Self-esteem
    140. 140. Self - esteem
    141. 141. Activity Scheduling
    142. 142. Psychotherapy with the brain-injured client• Substance abuse and dependence
    143. 143. Psychotherapeutic Interventions Group Therapy• Modeling• Problem solving• Peer feedback• Social skills practice
    144. 144. Behavioral Therapies• Very few people with TBI have fully lost the ability to learn new behaviors• Structure, consistency, and repetition• Role of cognition in self regulation• External feedback
    145. 145. Behavioral Strategies: Defining the Problem• This requires a measurable and precise definition of the target behavior – Always get specific examples – Cross check across settings – “Pick your battles”?• Inquire about the antecedents and consequences
    146. 146. Behavioral Strategies: Identifying the Function• Everybody’s doing the best he/she can• Every behavior serves a function• Every behavior problem is either – A skills deficit, or – A contingency problrm
    147. 147. Behavioral Strategies: Identifying Resources• Personal resources: Memory? Flexibility? Persistence? Motivation?• Social / family / peer resources• Organizational resources
    148. 148. Behavioral Strategies: Guidelines• Skills• Safety• Least restrictive• Managing the antecedent: Set me up for success!
    149. 149. Examples of Behavioral Strategies • Antecedents • Interventions • Provide clear, concrete• Does not understand instructions; notes • Give prompts; reinforce• Does not begin task initiative • Simplify task; provide skill-• Unable to do task based training • Increase interest or• Is not motivated relevance; reward for task completion
    150. 150. Examples of Behavioral Strategies Consequences  Interventions• Avoids failure by not  Alternate difficulty complying tasks with easy ones• Gets out of work  Premack principle• Receives attention for  Time out or ignoring; not doing task reinforce for attention• Gets to assert  Offer choices when independence/control appropriate
    151. 151. Behavior Management Strategies:X
    152. 152. Behavior Management Strategies: Agitation and Irritability
    153. 153. Behavior Management Strategies: Agitation and Irritability• Redirection• Offer an alternative activity• Relaxation strategies• Recognize antecedent conditions• Speak calmly• Use key familiar phrases
    154. 154. Behavior Management Strategies: Apathy
    155. 155. Behavior Management Strategies: Apathy• Give choices between doing one thing or another; not between doing and not doing• Activity scheduling, in advance
    156. 156. Behavior Management Strategies: Denial/Lack of Insight
    157. 157. Behavior Management Strategies: Denial/Lack of Insight• Have ongoing discussions of “strengths and needs”• Create discrepancy• This may be the most difficult problem to address
    158. 158. Behavior Management Strategies: Impulsivity/Disinhibition
    159. 159. Behavior Management Strategies: Impulsivity/Disinhibition• Structured and organized daily routine• Rewarding/praising impulse control and inquiring “how exactly did you do that?”• “Talking stick”
    160. 160. Behavior Management Strategies: Depression/Withdrawal
    161. 161. Behavior Management Strategies: Depression/Withdrawal• Help students identify preserved abilities and strengths - rather than focusing on their deficits• Keep TBI survivor involved in the present rather than dwelling on the past• Use active listening techniques, but focus on positive feelings
    162. 162. A B C ANTECEDENTS BEHAVIOR CONSEQUENCES © 2011 David D. Nowell, Ph.D. All rights4/27/2012 199 reserved.
    163. 163. A B C ANTECEDENT BEHAVIOR CONSEQUENCES © 2011 David D. Nowell, Ph.D. All rights4/27/2012 200 reserved.
    164. 164. A B C ANTECEDENT BEHAVIOR CONSEQUENCES © 2011 David D. Nowell, Ph.D. All rights4/27/2012 201 reserved.
    165. 165. A B C ANTECEDENTS BEHAVIOR CONSEQUENCES © 2011 David D. Nowell, Ph.D. All rights4/27/2012 202 reserved.
    166. 166. © 2011 David D. Nowell, Ph.D. All rights4/27/2012 203 reserved.
    167. 167. A B C ANTECEDENT BEHAVIOR CONSEQUENCES metacognition © 2011 David D. Nowell, Ph.D. All rights4/27/2012 204 reserved.
    168. 168. Beginning Middle End © 2011 David D. Nowell, Ph.D. All rights4/27/2012 205 reserved.
    169. 169. A B C ANTECEDENT BEHAVIOR CONSEQUENCES © 2011 David D. Nowell, Ph.D. All rights4/27/2012 206 reserved.
    170. 170. Treating Sensory Defensiveness
    171. 171. Addressing Visuomotor Problems with Reading
    172. 172. What’s the kid’s deal?• Greene, Ross. The Explosive Child.
    173. 173. Family Issues and Needs• Family stress related to severity of TBI• The family’s resilience may be key to a brain injured child’s successful rehabilitation• Divorce rates range from 15% to 54%
    174. 174. Sources of Family Stress• Uncertainty about recovery• Cognitive and personality changes• Financial strain• Transitions to “new” settings• Lack of respite care
    175. 175. Family Definition of the Event
    176. 176. Family Issues and Needs• Family’s adaptation may take years• Any change may trigger emotional response• Watch for signs of grieving
    177. 177. Return to School• Accommodations and Modifications• IDEA and Section 504
    178. 178. IDEA Definition of TBI:An acquired injury to the brain caused by an external physical force resulting in functional disability or psychosocial impairment that adversely affects a child’s educational performance.
    179. 179. School Re-Entry Issues• Educational consultation should begin before return to school• Continuity of care between school and rehabilitation services• Prepare for multiple transitions• Re-entry should include interdisciplinary support
    180. 180. Percentage Referred for Services Home Tutor 3.6 Special Ed. 1.8 Psych. services 2Family counseling 2.8 Speech therapy 10.1 Ocupational 13.2 therapyPhysical therapy 23.7
    181. 181. Basic Criteria for School Re-Entry• Attends to a task for 10 to 15 minutes – Adjust for age• Can tolerate 20 to 30 minutes of classroom stimulation• Can function adequately in a group of 2 or more students• Engages in meaningful communication• Follows simple directions accurately• Gives some evidence of learning potential
    182. 182. School Re-Entry Procedures• Assess needs –Adaptive domain –Cognitive domain –Communication domain –Sensorimotor domain –Social-emotional-behavioral domain –Transportation needs –Family needs
    183. 183. School Re-Entry Procedures• Identify the best setting for intervention – Outpatient counseling? – Home-based family interventions? – School-based SLP / OT? – Buddy system at school? – In-service for school staff? – Modified school day? – In-school breaks? – “Study halls” with resource teacher? – Pre-vocational training?• Regular re-evaluation for change over time
    184. 184. Developing IEP Goals• Focus on 2 or 3 priority issues• Identify metacognitive & organizational strategies• Write measurable goals that incorporate the strategies• Include specific information about how the strategy should be taught and implemented across settings• Write short-term goals that are truly short-term
    185. 185. TBI Impact at School• Problems initiating and completing work.• Slowed work pace.• Increased impulsivity.• Topographical disorientation• Distractible• Difficulty generalizing new learning
    186. 186. Classroom Management• Two key factors : – Structure – Motivation• Explicitly teach rules & expectations• Establish prompts or cues, such as gestures and reminder cards
    187. 187. Classroom Management• Can students answer the following questions: – What do I have to do? – How much do I have to do? – When am I finished? – What do I do next?
    188. 188. Classroom Management• Use repetition & feedback• Avoid multi-step instructions• Supplement verbal instructions with nonverbal / modeling• Provide additional time for information processing• Assist with organization of materials and schedule
    189. 189. Classroom Management• To be motivating, a task must be interesting• Intersperse difficult or novel tasks with easy or previously learned ones• Distinguish cognitive factors from other issues (impact of headache, or depression)
    190. 190. Specific Classroom Strategies: Attentional Processes• Reward on-task behavior;• Use novel, unusual, relevant or stimulating activities• Redirect• Remove unneccessary distractors• Explore a variety of cueing systems – Verbal cues – Physical prompts – Gestural cues
    191. 191. Specific Classroom Strategies: Attentional Processes• Reduce the number of individual tasks on a printed page• Reduce the amount of copying from the board• Provide a ruler or EZ-Reader to focus visual attention• Avoid asking a student to multi-task• Chunking / Pomodoro
    192. 192. Specific Classroom Strategies: Memory and Learning• Enhance the saliency of material• Regularly summarize information as it is being taught• Dry-erase board• Use overlapping techniques, such as repetition and rehearsal
    193. 193. Specific Classroom Strategies: Memory and Learning• Couple new information with previously learned information• Identify in advance the key information to be learned• Make use of over-learning
    194. 194. Specific Classroom Strategies: Language• Limit length and complexity of communication• Do not use figurative speech• Recognize the student may not understand humor or sarcasm
    195. 195. Specific Classroom Strategies: Language• Reminders to start, end, or repair a conversation• Use question prompts to help the student share more information, especially in groups• Allow for slowed information processing
    196. 196. Specific Classroom Strategies: Language• Speak slowly• Reduce background noise
    197. 197. Specific Classroom Strategies: Visual Processing• Provide longer viewing times or repeat viewings when using visual instructional materials• Facilitate a systematic approach to reading and math by covering parts of the page• Provide support for orientation to building and grounds• Limit visual distractions (web page, handouts, text, desk)
    198. 198. Specific Classroom Strategies: Executive Functions • Problem Solving Processes• Develop a problem-solving guide to help student through the stages of problem solving – Identifying the problem – Acquire relevant information – Generate several possible solutions – List pros and cons for each solution – Identify best solution – Create a plan of action – Evaluate the effectiveness of the plan – Encourage generalization
    199. 199. Specific Classroom Strategies: Executive Functions• Raise questions about alternatives and consequences• Provide ongoing, non-judgmental feedback• Provide part of a sequence and have the student finish it• Frequent cues re: main topic vs. supporting ideas
    200. 200. Specific Classroom Strategies: Executive Functions• Note impact of fatigue on cognition• Note impact of some medications• Consider reduced workload• Consider note-taker• “How exactly did you do that?”
    201. 201. SPECIAL CASES
    202. 202. • Domestic violence• Shaken baby syndrome• Combat trauma• Alcohol abuse/dependence• Mild TBISPECIAL CASES
    203. 203. • Domestic violence SPECIAL CASES
    204. 204. In women reporting to ERs for injuries associated with DV:• 30% of battered women reported a loss of consciousness at least once.• 67% reported residual problems that were potentially head-injury related. (Corrigan 2003)
    205. 205. Domestic Violence…Greater than 90% of all injuries secondaryto domestic violence occur to thehead, neck or face region. (Monahan & O’Leary 1999)
    206. 206. • Shaken baby syndromeSPECIAL CASES
    207. 207. American Academy of Pediatrics-Committee on Child Abuse and Neglect Pediatrics 2001 “ …95% of serious intercranial injuries and 64% ofall head injuries in infants younger than 1 year were attributable to child abuse” Pediatrics, 2001
    208. 208. Shaken Baby Syndrome
    209. 209. Shaken Baby Syndrome• Rotational, acceleration, deceleration forces• There may or may not be impact trauma• Brain rotates inside the skull• Bridging veins in the brain may be stretched or torn• Subdural hematoma may develop
    210. 210. Shaken Baby SyndromeKirschner & Wilson’s “dirty dozen”• 1. Child fell from a low height• 2. Child fell and struck head on floor or furniture, or hard object fell on child• 3. Child unexpectedly found dead (age and/or circumstances not appropriate for SIDS)• 4. Child choked while eating and was therefore shaken or struck on back
    211. 211. Shaken Baby SyndromeKirschner & Wilson’s “dirty dozen”• 5. Child suddenly turned blue or stopped breathing, and was then shaken• 6.Sudden seizure activity• 7. Aggressive or inexperienced resuscitation• 8. Alleged traumatic event one day or morebefore death
    212. 212. Shaken Baby SyndromeKirschner & Wilson’s “dirty dozen”• 9. Caretaker tripped or slipped while carrying child• 10. Injury inflicted by sibling• 11. Child left in dangerous situation (e.g. bathtub) for just a few moments• 12. Child fell down stairs
    213. 213. Shaken Baby SyndromeSymptoms• Apnea• Listlessness• Lethargy• Poor feeding• Irritability• Vomiting• Seizures
    214. 214. • Combat traumaSPECIAL CASES
    215. 215. Combat Trauma• TBI as “signature wound” of Iraqi conflict • USA Today 9/07
    216. 216. Combat Trauma• Iraq characterized by different kind of weaponry: explosive munitions.• 15% of soldiers returning from Iraq may have sustained at least mild TBI (Hoge et al 2008)• 36% may have been exposed to blasts (Maguen et al 2012)
    217. 217. Combat Trauma• Comorbid PTSD• Headache• Sensory impairment• Alcohol use
    218. 218. • Alcohol abuse/dependency SPECIAL CASES
    219. 219. Alcohol Abuse• May increase morbidity of MVA-related TBI (Cunningham et al 2002)• Although low amounts may be protective• Chronic alcohol abuse associated with falls, assaults, multiple head injuries• Overlay of alcohol-related impairment
    220. 220. • Mild TBI SPECIAL CASES
    221. 221. TBI Severity: Mild TBI (mTBI)• Concussion signs and symptoms include ANY changes in behavior such as: – Cognitive impairments – Physical symptoms (e.g., headaches, blurry vision, diplopia, dizziness) – Emotional symptoms (e.g., irritability, volatility) – Sleep difficulties – Not “feeling like themselves.”
    222. 222. TBI Severity: Mild TBI (mTBI)• Persistent symptoms following the concussion is often referred to as Post-Concussive Syndrome.• Cumulative effect
    223. 223. TBI Severity: Mild TBI (mTBI)• Chronic traumatic encephalopathy
    224. 224. Psychotherapy with the persistent post-concussive client• Perfectionistic tendencies• Somatic focus• Poignancy• Secondary gain• “old me / new me”• Check to see whether you are working at cross-purposes
    225. 225. The “Big 5” (plus 1)• The “Big 5” – Daily planner – Daily organization time – Movement – Nutrition – Connection – Sleep
    226. 226. Let’s stay in touch! Join my e-newsletter list:  Fill out a card today and drop it in the box.  Text to join: text DNSEMINARS to 22828  Sign up on my web site or Facebook page Visit us on the web: www.DrNowell.com davidnowell David Nowell Seminars
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