1. Mental Health, Medical, and Behavioral Management of offenders with an
Acquired traumatic Head Injury
MANAGING OFFENDERS WITH TBI

2. Traumatic Brain Injury
Developing an understanding of the socio-
cultural impact and implications for
management of TBI survivors within the
correctional setting.

3. Stephen W Ford PhD NCC Sue Carol-Lehman MeD LSW
SAP ► Thirteen years as a Social
►Four years in child welfare Work Supervisor in
► Three Years in Crisis Care corrections (Active)
► Two years in foster care ►Three years as a multi-
► Seven years in community systemic therapist with the
mental health Lawrence County Courts
► Seven years as a mental ► Seven years as a
health consultant community support mental
health/crisis care social
► Five years in Corrections worker
(Active)
►Served on Domestic
► Twelve years as a Pastor Violence task force
(Active)
► Served with the Ohio Arts
► Four years in private Council
practice (Active)
► Adjunct Professor for
Liberty University Online
(Active)

4. Why this Subject is of Interest to Us!
► We both have professional and personal reasons for interest
in this subject.
Ms. Lehman and my professional interest in this topic is related
to the fact that we have several inmates that we currently work
with that have traumatic brain injury that have caused us some
stress.
I have also worked with several individuals in my private practice
that have acquired a traumatic brain injury and are struggling to
adjust.
&
Our personal interest relates to our friend and co-worker
that suffered a traumatic brain injury three years ago.

5. Introduction
► Tell us who you are.
► The name of your institution.
► Your job title.
► Years of experience.
► Why you may be interested in this
topic.
► One thing you like to do for fun that
isn’t work related.

6. Where we got all our cool stuff!
• All treatment and workbook materials are
copyrighted by and purchased from Lash and
Associates. We were given verbal permission
from the company to demonstrate and promote
these materials
• All videos were public service videos and used
with permission for this training.
• All case study handouts were created from real
life events or from stories gathered through our
research.
• All Visual aids were purchased by your instructors
are distributed to you as part of this training.

8. What Should I Get From this Training?
You should gain a basic understanding of the
following:
1) Brain Anatomy and Function
2) Epidemiology of Traumatic Brain Injury
3) Neuropathology
4) Neuropsychological Disorders
5) Neuropsychiatric Symptoms
6) Social Issues
7) Treatment/Management

9. What Will the Impact of What I’ve
Learned Be on How I perform My Job?
By understanding: the structure of the brain, the
sum of the factors controlling the presence of a TBI,
the structural and functional deviations from the
normal that constitute TBI, the psychological
disorders, the psychiatric symptoms, and the social
Issues that are a result of TBI you should be able to
develop or provide more comprehensive and
effective treatment and correctional management
strategies for this specialized population of inmates.

11. What is Traumatic Brain Injury (TBI)?
Studies regarding brain injury do not appear to
present a concise definition of traumatic Brain Injury
(TBI).
► Definitions reviewed throughout the literature within
the last twenty years make understanding TBI
difficult because some studies only include
neurological trauma whereas some studies include
non-neurological head injuries such as fractures of
the skull, fractures of bones in the face, and
damage to the soft tissues of the head and face.

12. What is Traumatic Brain Injury (TBI)?
For the purpose of understanding how to manage
incarcerated inmates and the problems they
present, we are only concerned with inmates that
have neurological damage as the result of a (TBI).

13. What is Traumatic Brain Injury (TBI)?
► Traumatic Brain Injuries (TBI) are insults to the
brain by an external physical force, which cause
either temporary or permanent impairments,
partial or total functional disability, or
psychosocial maladjustment.
TBI can be divided into primary injuries, which
occur immediately at the time of trauma, and
secondary injuries, which begin immediately after
the trauma and continue for an indefinite period of
time.
The clinical manifestations of TBI can range from
a concussion to profound coma and even death.

14. What is Traumatic Brain Injury (TBI)?
What we will be primarily concerned with today are
the cognitive, behavioral, physical and social
problems that are a direct result of traumatic brain
Injury and that directly impact our ability to manage
inmates in our institutions.

15. Anatomy and Function

17. The sum of the factors controlling
the presence of a TBI.

18. Handout page one

19. Handout Page Two

27. Neuropsychological Assessment
Six essential areas of cognition must be assessed in
patients who have sustained moderate to severe TBI.
Attention- Deficits are associated with diffuse
brain injuries that are particularly known to occur
in patients with frontal lobe pathology.
Deficits in attention will significantly effect
cognitive performance in areas of memory and
language comprehension

28. Open To Suggestions
• I have not been able to find something that suits
my needs here.

29. Neuropsychological Assessment
Memory - Is the cornerstone of successful
neuropsychological rehabilitation.
Declarative Memory – Facts that are directly
accessible to conscious recollection (Phone and
Social Security Numbers).
Procedural Memory – Includes learned skills and
habits and modifiable cognitive operations (Ability to
drive and performance of activities of daily
living.).

30. Test of Memory and Learning 2nd
Edition
• A standard battery of eight core subtests, six
supplementary subtests, and two delayed
recall tasks
• TOMAL-2 subtests include Memory for Stories,
Facial Memory, Word Selective Reminding,
Visual Selective Reminding, Object Recall,
Abstract Visual Memory, Digits Forward, Visual
Sequential Memory, Paired Recall, Memory for
Location, Manual Imitation, Letters Forward,
Digits Backward, and Letters Backward, plus two
verbal delayed recall tasks and cued recall
procedures.
• TOMAL-2 core indexes consist of the Verbal
Memory Index, Nonverbal Memory Index, and
Composite Memory Index.
• TOMAL-2 supplementary indexes are composed
of the new Verbal Delayed Recall Index,
Learning Index, Attention and Concentration
Index, Sequential Memory Index, Free Recall
Index, and the Associative Recall Index.
• Reliability estimates are uniformly high—all
composite and some subtest reliability values
are in the .90s, with the balance exceeding .85.
Test-retest reliability coefficients are all greater
than .70 for the
• subtests, with most greater than .80. For the
composite indexes, all but one value exceeds .
80.

31. Neuropsychological Assessment
Language – Deals with changes in language
comprehension, expression, and repetition.
This involves the ability to follow verbal and written
commands.
Naming common items as well as written and verbal
expression.
Repetition of common words mixed with less common
words that occur with less frequency in everyday
use.

32. Wide Range Achievement Test 4th
Edition
• This is best assessed if you have a baseline of
functioning before the traumatic head injury, but
this assessment instrument will assist you in
knowing where their current level of functioning is
in reading comprehension, spelling and
arithmetic

33. Neuropsychological Assessment
Visual-Spatial Abilities – Is the ability to manually
arrange objects in patterns or copy drawings after
seeing them.
Executive Functioning – A person’s ability to
organize, plan, and execute purposeful behaviors.

34. Multiple Assessment Instruments are
Useful
For Executive Functioning
• Wisconsin Card Sort Test
• Delis-Kaplan Executive Functioning Assessment
System
For Assesment of Visual-Spatial Abilities
• Bender Gestalt
• Hooper Visual Organizational Test

35. Brain Injury Effects
TBI effects can be mild moderate or severe. We are
focusing on the chronic effects seen in Moderate to
Severe Cases of TBI.

36. Brain Injury Effects

37. Brain Injury Effects

38. Functional Changes
► Short term memory loss
► Long Term memory loss
► Slowed ability to process information
► Trouble concentrating
► Trouble paying attention
► Difficulty keeping up with conversation
► Word finding problems
► problems understanding language
► loss of a second (acquired language)
► spatial disorientation
► driving difficulties
► Impulsivity
►Inflexibility

39. Functional Changes
►Time Disorientation
► Organizational Problems
► Impaired Judgment
►Problems Multi-tasking
► Seizures
► Muscle Spasticity
► Double Vision
► Impaired Visual Fields
► Loss of Smell or Taste
► Slow or Slurred Speech
► Headaches or Migraines
► Fatigue
► Lack of Initiating Activities

40. Functional Changes
► Difficulty Completing Tasks without Reminders
► Increased Depression, Anxiety, and Mood Swings
► Denial of Deficits
► Impulsive Behavior
► Lack of Insight
► Agitation
► Egocentricity
► Explosive or Erratic Behavior
► Sensory Losses
► Inability to Deal with Novel or New material
► Impairment in reading Writing and Arithmetic

41. Assessing areas of Cognition Affected and Observable
Effects of Injury

42. Group Activity Directions
1) Identify area (s) of cognition that are effected by
traumatic brain injury.
2) Identify psychosocial changes that presented
after a traumatic brain injury.
3) Identify what area (s) of the brain have been
Injured to create the example depicted.

44. Disorders that Share Symptomatology
with (TBI)
Amnesia – often occurs in patients who have
sustained head trauma, cerebral anoxia,
brain tumors, cerebrovascular accidents
(strokes), history of cariopulmonary arrest,
electroconvulsive therapy, insulin overdose,
surgical removal of the temporal lobes, and
excessive drinking that results in Wenicke-
Korsakoff’s syndrome will typically exhibit
severe Amnesia.

45. Disorders that Share Symptomatology
with (TBI)
Dissociative Disorders – Disturbance in an
individual’s sense of identity, memory, and
consciousness.
Delirium – A global disturbance in cognitive
functioning with associated clouding of
consciousness, impaired attention, disorientation,
increased sympathetic nervous system activity,
altered sleep-wake cycle, and psychomotor activity.

46. Disorders that Share Symptomatology
with (TBI)
Dementia - is characterized by the development of multiple
cognitive deficits that are due to the direct physiological
effects of a general medical condition, the persistent use of a
substance, or to multiple etiologies.
The essential feature of this disorder is the
development of memory impairment and at least
one other cognitive disturbance such as Aphasia,
Apraxia, or Agnosia.
Two main types of Dementia are Alzheimer’s type
and Vascular Dementia

47. Disorders that Share Symptomatology
with (TBI)
Attention Deficit Disorder - The essential feature
is a persistent pattern of inattention and
hyperactivity/impulsivity that is more frequently
displayed and more severe than is typically
observed in individuals at a comparable level of
development.
Three subtypes:
1.) ADHD Combined Type
2.) ADHD predominately inattentive type
3.) ADHD predominately hyperactive type

48. Disorders that Share Symptomatology
with (TBI)
Mental Retardation – is a significantly sub-average
general intellectual functioning that is
accompanied by significant limitations in adaptive
functioning in at least two of the following areas.
Communication, self-care, home-living, social
interpersonal skills, use of community resources,
self-direction, functional academic skills, work
leisure, health or safety.

49. Disorders that Share Symptomatology
with (TBI)
Complex PTSD - The DSM IV presents criteria to
diagnose PTSD based on contact with a single or
discreet stressor rather than frequent or numerous
exposures to stressors.
Complex PTSD is a syndrome with varied and
divergent symptoms such as alteration in attention
and consciousness, amnesia, dissociative episodes,
and depersonalization

52. What is involved in Treatment?
Traditional Treatment Alternative Treatments
Cognitive therapy • Craniosacral therapy
• Speech/language therapy • Hyperbaric oxygen
• Physical therapy treatment
• Occupational therapy • Biofield therapies
• Neurobehavioral therapy • Meditation/mindfulness
• Vocational rehabilitation
• Neuropsychological
testing
• Family Support
• Highlighted in Yellow
Counseling Showing what we are able
to functionally do in
corrections

53. Who is typically Involved in Treatment?
• Neuropsychologists
• Behavioral analysts
• Speech/language pathologists
• Cognitive therapists
• Physiatrists
• Physical therapists
• Recreational therapists
• Occupational therapists
• Neurologists
• Neuropsychiatrists

54. SOCF Newly Acquired
Resources

55. SR-Cognition Tool Kit: Cognitive
Rehabilitation Program
• Joanna Boyer, M.A., CCC-SLP and Terri Tarnoff Snyder, M.A. CCC-SLP
• SR-Cognition is a complete therapeutic multi-sensory tool kit targeting
cognitive rehabilitation in adults and adolescents with acquired brain injury,
neurological impairments, or developmental delays. The comprehensive kit
contains two workbooks (one with easel option and one with re-useable
reproducible pages) featuring hundreds of therapeutic activities; 85 photo
cards; 20 picture cards, and a dry erase marker all in a portable tote box.
Activities and exercises feature realistic every day scenarios, in real world
environments using current cues for memory and language building, daily
living and life skills development and reinforcement

56. APT Attention Process Training and
Cognitive Rehabilitation
• The APT-3 includes an extensive range of attention exercises appropriate for
people with mild to severe attention deficits due to acquired brain injuries.
Target populations include adolescents, adults and veterans. Unlike the APT-
1 and APT-2 programs, the APT-3 is a computer based program promoting
efficient data collection and analyses and treatment planning. The Kit includes
a USB drive with customized software that can be used on either a Mac or
PC. It includes 2 practice drives for clients. The program runs from the USB
drive and does not stay on the user's computer. The set of 2 manuals
contains a clinical overview, research evidence, discussion of therapy
principles, detailed instructions and guidelines for assessment and treatment,
as well as sample score sheets for all therapeutic activities and tasks.

57. Functional Rehabilitation Activity Kit
Kathryn Kilpatrick, M.A., CCC-SLP, Barbara Messenger,
M.Ed. and Niki Ziarnek, M.S., CCC, SLP/L
• There are five manuals in this Kit. They are Functional Rehabilitation Activities
on Behavior, Cognition, Cognitive Communication, Activities of Daily Living
and Leisure. Using a therapeutic style of interaction with a step-by-step
format, someone with little or no experience in working with persons with
disabilities can pick up these manuals and immediately be able to interact in a
therapeutic manner while facilitating independence.
• The functional activity manuals can be used by any caregiver including direct
care staff, nurses, therapists, family, teachers, and aides. They can be used
with children or adults with any type of neurological condition involving social,
cognitive, communicative and behavioral challenges. They are designed for
use in inpatient and outpatient rehabilitation programs, community programs,
residential settings, schools and at home.
• Each manual features worksheets and data forms for tracking performance
and outcomes, with full instructions for administration. Each activity has a
documentation form for easy inclusion in clinical records.

58. Additional Resources Available From
Lash and Associates
• Cognitive Rehabilitation Tool Kit after Brain Injury
• Concussion Tool Kit for Schools
• Instructional Tool Kit on Brain Injury for Educators
• PTSD Tool Kit for Veterans and Families
• Sports Concussion Tool Kit for Athletic Trainers
and Coaches
• Living with Blast Injuries, PTSD and TBI
• The Post Traumatic Insomnia Workbook; A Step-
by-Step Program for Overcoming Sleep Problems
after Trauma

59. Would you Like More Training on TBI
• Institute for Natural Resources
http://www.inrseminars.com/seminars.aspx
• Nebraska Brain Injury Conference April 4th and 5th
• “Brain Injury Throughout the Lifespan” April 5, 2013,
Delaware
• Brain Injury Alliance of Colorado 2013 Regional Brain
Injury Conferences: Pueblo – April 25th, Grand Junction –
May 4th, Durango – June 26th, Summit County – July 12th
• Williamsburg Brain Injury Rehabilitation
Conference May 2nd and 3rd , Williamsburg VA
• Biannual Conference on Brain Injury in Children
July 9-11, 2013 – Toronto, Canada