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https://learn.extension.org/events/3010
This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military
Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
Gray Matters: Understanding Traumatic Brain
Injury’s Impact on Families

Connecting military family service providers
and Cooperative Extension professionals to research
and to each other through engaging online learning opportunities
militaryfamilies.extension.org
MFLN Intro
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Heidi Knock, Psy.D
• Staff Psychologist- Polytrauma Unit at
Richard L. Roudebush VA Medical Clinic
• Provides individual, marital, and group
psychotherapy to veterans and their families
• Conducts presentations on PTSD and
Traumatic Brain Injury to organizations to help
facilitate veteran focused care and integration
Today’s Presenter
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We want to know about YOU!
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https://pixabay.com/en/group-team-feedback-confirming-1825510/

Facts about Mild Traumatic Brain Injury
(MTBI)
✓ Approximately 80% of all brain injuries
are mild
✓ Males outnumber females 2:1
✓ 5.3 million people are estimated to
have ongoing problems related to
MTBI
✓ Direct care costs are estimated at
$5.3 billion
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https://pixabay.com/en/thought-idea-innovation-imagination-2123971/

Traumatic Brain Injury (TBI)
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• Occurs when an external
force causes injury to the
brain. Can be closed or
penetrating (open) head injury.
o Motor vehicle crash- Closed
Head Injury
o Gun shot wound- Penetrating
Head Injury
https://pixabay.com/en/abstract-brain-stylistic-top-1293337/

Traumatic Brain Injury (TBI)
Diffuse Axonal Injury (DAI)
• Occurs when the axon of the neuron is stretched, twisted, or torn
(sheared)
• Can result from acceleration/deceleration injuries or other similar
mechanisms
• Can lead to microscopic injury all over the brain
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https://pixabay.com/en/neuron-nerve-cell-dendrites-axon-29147/

TBI from Blast Injury
• Leading cause of TBI in veterans
• Not well understood
• Causes organs and different densities to shift at different rates leading to
shearing and tearing of brain tissue 8
Primary
• Direct injury to brain via rapid shifts in air
pressure
Secondary
• Impact from fragments or objects propelled by
explosion
Tertiary
• Structure collapse or being thrown from blast
wind
Quaternary
• Burns; crush injuries; other illnesses or
diseases not caused by the other mechanisms

Average Annual Percentages
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Average annual percentages, 1995-2001; ED visits, hospitalizations, and deaths combined (CDC, 2004)

Frequency of Diagnoses among
OEF/OIF/OND Veterans
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1Includes both provisional and confirmed diagnoses.
aThese are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of September 30, 2011; Veterans can have multiple
diagnoses with each health care encounter. A Veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers and percentages add up to greater than 741,954.
bPercentages reported are approximate due to rounding. Data obtained from Office of the Assistant Deputy Under Secretary for Health for Policy and Planning, http://vaww4.va.gov/vhaopp/vast2.asp

Frequency of Mental Disorders among
OEF/OIF/OND Veterans since 2002
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Cumulative from 1st Quarter FY 2002 through 4th Quarter FY 2011
1 Includes both provisional and confirmed diagnoses.
2 These are cumulative data since FY 2002. ICD-9 diagnoses used in these analyses are obtained from computerized administrative data. Although diagnoses are made by trained health care providers, up to one-third of initial diagnostic codes may not be
confirmed because the diagnosis is provisional, pending further evaluation.
aThe total will be higher than the 385,711 unique patients who received a diagnosis of a possible mental health disorder. A Veteran may have more than one mental health disorder diagnosis and each diagnosis is entered separately in this table.
bThis row of data does not include a) information on PTSD from VA’s Vet Centers , b) data from Veterans not enrolled for VA health care, or c) Veterans with a diagnoses of adjustment reaction (ICD-9 309) but not PTSD (ICD-9 309.81).
cThis category currently excludes Veterans who have a diagnosis of a) tobacco use disorder only, ICD-9 305.1 (n=103,905); b) alcohol abuse only, ICD-9 305.0, (n=26,293); or both tobacco use disorder and alcohol abuse, ICD-9 305.0 and 305.1 ,(n=20,947).

Research
Neurological Rehabilitation Institute at Brookhaven
Hospital (August 2011)
(General population, not veteran specific)
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53% of individuals who
sustain a TBI will suffer a
major depressive episode
within the first year after injury
23% experienced suicidal
ideation after their injury
17% actually had a suicide
attempt after their injury

TBI and Rates of Suicide
Suicide rates for individuals who sustained a TBI was
3 times greater than the general population
13J Neuro/Neurosurg Psychiatry, 2001, 71: 436-440

TBI & Loss
Sense of significant loss of who they were and their
functioning related to the injury
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▪ Frustration over small tasks
being too big
▪ Simply can’t think the way
they used to
▪ Change of personality and
functioning
https://pixabay.com/en/despair-emotion-feeling-unhappy-2019938/
▪ Often cannot continue
employment
▪ May lose basic
independence skills
▪ Relationships suffer

Caregiving & TBI
The partner becomes more of a caregiver and less of a
spouse
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▪ Typically causes a great
deal of conflict
▪ Spouse experiences loss
and frustration too
▪ Spouse shoulders a great
deal of the responsibility
▪ Spouse often take
symptoms personally
https://pixabay.com/en/thoughtful-thinking-person-pensive-2031866/

Military Life & TBI
▪ Forced medical boarding/discharge
from the military due to TBI
▪ Pervasive sense of loss; sudden
isolation
▪ Sense of betrayal by the military
▪ Often wanted to be “lifers”
▪ Lack of marketable work skills
▪ Joined the military to have a real
family
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https://pixabay.com/en/african-american-sadness-man-sad-883376/

MTBI
• Focal neurological deficits that may or may not be
transient
• Loss of consciousness is not more than 30 minutes
• Post-traumatic amnesia does not exceed 24 hours
• Glasgow Coma Scale of 13-15 after 30 minutes
• Any alteration in mental state at the time of the accident
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Altered Mental State
• Headache
• Nausea
• Vomiting
• Dizziness
• Fatigue
• Trouble sleeping
• Drowsiness
• Sensitivity to light/noise
• Blurred vision
• Difficulty remembering
• Difficulty concentrating
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https://pixabay.com/en/trees-away-nature-eddy-turn-dizzy-358418/

TBI Severity
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Kay et al., 1993; Snyder & Nussbaum, 2000

Course of Recovery of MTBI
• In the majority of individuals,
symptoms resolve in 6 months
or less after the injury
• In some cases, symptoms can
persist longer (12-18 months)
and even life-long
• The majority of people with
moderate to severe TBI do not
return to their full pre-injury
status and will have ongoing
cognitive and behavioral issues
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https://pixabay.com/en/day-planner-calendar-organizer-828611/

Overview of Diffuse Symptoms of MTBI
• Cognitive
memory, attention, processing speed & intelligence
• Psychological
depression, anxiety, irritability, sleep & personality
change
• Physical
light/sound sensitivity, dizziness & fatigue
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Post-Concussive Symptoms
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If symptoms last:
>2 weeks: Post-Concussion Syndrome
>6 weeks: Persistent Post-Concussion Syndrome
http://dvbic.dcoe.mil/

What can be injured?
Anything the brain can do!
• Problem solving
• Personality
• Planning and organizing
• Emotional lability
• Understanding concepts
• Understanding verbal language
• Speech
• Visual recognition
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Co-Morbid Conditions
• Sleep deprivation
• Sleep apnea
• Depression and anxiety
• Substance use
• Trauma issues/ PTSD
• Medical issues/Chronic pain
• Multiple stressors
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https://pixabay.com/en/depressed-depression-sadness-sad-83006/

25Vanderploeg, 2007 25Vanderploeg, 2007
+ PTSD
Re-experiencing
Avoidance
Social withdrawal
Memory gaps
Apathy
? Mild
TBI
Residual
Difficulty with decisions
Mental slowness
Concentration
Headaches
Dizzy
Appetite changes
Fatigue
Sadness
Arousal
Sensitive to noise
Concentration
Insomnia
Irritability
+ Depression

Rehabilitation Team
• Neuropsychologist/Clinical
Psychologist
• Speech Language
Pathologist
• Cognitive Therapist
• Physiatrist
• Physical Therapist
• Occupational Therapist
• Recreational Therapist
• Neurologist
• Neuropsychiatrist
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https://pixabay.com/en/group-work-personal-group-458653/

Dealing with TBI as a Professional
• What signs to look for:
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✓ Distractibility
✓ Difficulties focusing
on what is being
said
✓ Answering slowly
or answering
questions that are
not asked
✓ Long pauses in
speech
✓ Talking very
loud/yelling
✓ Difficulty following
directions
✓ Easily agitated/irritable
and appear
disinhibited
✓ Significant
coordination issues
and involuntary
movements that are
neurologically based
✓ Visual field cuts
✓ Flat affect and
apathetic
✓ Poor initiation of
conversations

Interventions
• One thing at a time
• Repeat slowly and clearly
• Keep questions simple
• Maintain eye contact
• Include support person in session
• Ask them to reflect on what you have said
• Minimize distractions (noise, lights, movements, clutter)
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https://pixabay.com/en/talk-dialogue-discussion-together-2076968/

Interventions
• Write down any follow-up (and encourage the
use of Smart Phones for reminders)
• For those who are anxious or agitated,
encourage breathing and grounding skills
(stress ball, sensory loaded modality)
• Allow a time-out if necessary
• Structure/Routine
• Marker Board
• Take notes in session
• Involve Family
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https://pixabay.com/en/postit-memos-notes-colorful-1726554/
What works for YOU?

Treatment Considerations
• Possibility of missed appointments
• Follow-through on assigned tasks may be weak
• May be fearful of expressing that they do not understand
• May come across as agitated
(anxiety, overstimulation, impulsivity, distractibility)
• May self-medicate
(problems coping with loss associated with injury,
sleep issues, self-esteem issues)
• May make poor choices
(difficulties considering outcomes,
difficulties making decisions, irritability)
• May not remember what happened in previous session 30
https://pixabay.com/en/questions-demand-doubts-psychology-1922477/

Accommodations
• Write follow-up instructions in
bullet point style (assists in
breaking down tasks)
• Reduce stimulation in room to
minimize distractions
• Reduce rate of speech to adjust
for processing
• Allow for a time out if agitation is
present. Continuing to talk will
only escalate frustration
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Employment and Academic
Accommodations
Employment
• may need a job with repetition/job
coaching
• may need structure
• may need job coaching initially until
task is solidified
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Academic
• Extended time limit on tasks
• Testing in private room
• Open note tests when feasible
• Sunglasses or hates in classroom
• Class notes from instructor or peers
• Record classes
• Allow absences to be made up
• Allow to leave classroom as needed
https://pixabay.com/en/hands-writing-diary-journal-pen-1369316/

Family Involvement (Intervention)
Family or case manager will need to strongly advocate for
medical care…
What families can do with medical interventions:
✓Keep a symptom notebook
✓Have providers write down recommendations
✓Keep medication list
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WHY?

Interventions at Home
• Daily structure
• Marker boarding for cueing
• Basket of commonly misplaced items
• Common tasks broken down into 5 steps
• Assistance with finances/bills
• Find a brain injury support group
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https://pixabay.com/en/to-do-list-task-list-notes-written-734587/

Energy Management
• Set up a daily schedule, consider energy demands for the day
• Rest when tired- pushing can lead to a “melt down”
• Take breaks- stop for lunch/coffee, go for walks
• Cognitive breaks- find a non-stimulating place
• Take a nap- 30-60 minutes (longer will interfere with sleep at night)
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https://pixabay.com/en/break-rest-relaxation-recovery-1736072/

Resources
• Veterans Crisis Line:
Phone Number: 1-800-273-8255 (press 1)
Website: https://www.veteranscrisisline.net/
Text: 838255
• Military OneSource:
Phone Number: 1-800-342-9647
Website: http://www.militaryonesource.mil/
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Resources
• www.brainlinemilitary.org: Help for service members,
veterans, national guard, reserve, and families
• www.dvbic.org: Defense and Veterans Brain Injury
Center for service members and veterans, family and
caregivers, and medical providers
• www.braininjuryeducation.org: The Brain Injury Guide
and Resources
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Resources
• Dayton, OH VAMC and Lexington, KY VAMC: Offer inpatient TBI
programs and/or combined PTSD/TBI programs
• NeuroRestorative Care : Offers residential programs throughout
the country
• Wounded Warrior Project: offers an “Independent Living
Program”
• Project Victory (Texas): A grant-driven facility that offers residential
treatment for TBI
• Assisted Living (VA): TBI funding program to pay for care outside
of the VA for veterans with TBI/brain injuries
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MFLN Intro
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Evaluation and
Continuing Education Credits/Certificate
MFLN Family Development is offering 1.5 NASW
and GAMFT CEUs for today’s webinar.
Please complete the evaluation and post-test if
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MFLN Family Development
Upcoming Event
Unintended Consequences: What We
Now Know about Spanking and Child
Development
• Date: June 1, 2017
• Time: 11:00 am Eastern
• Location: https://learn.extension.org/events/3017
For more information on MFLN Family Development, go to:
https://militaryfamilies.extension.org/family-development
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militaryfamilies.extension.org/webinars
43This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family
Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.