Transcript Brain Injury - Wales Counseling

Brain Injury
Calista Nabors, LMSW
Sedrick Jackson, LCSW
What is Brain Injury
 Injury
to brain tissue that temporary or
permanently impairs brain function
“Brain injury is not an event or an outcome.
It is the start of a misdiagnosed,
misunderstood, under-funded neurological
disease.”
-Brain Injury Association of America
Disability Prevalence
Millions
 Why
is this
important?



Depression
Stroke
Epilepsy
 The
“Silent
Epidemic”
20
15
10
5
0
Incidence
 Annual
Rates
 1.7 Million per year (CDC)



50,000 Deaths
235,000 Hospitalizations
1,100,000 ED visits
Comparison

Incidence of Select Health Problems in the U.S
TBI
Per every
100,000 people
All Cancers
combined
Breast Cancer
Colon Cancer
HIV/Aids
0
200
400
600
Traumatic Brain Injury Act of 1996
 Passed

July 29th, 1996
Acknowledged the incidence and
prevalence of brain injury nationally
 “to
expand efforts to identify methods of
preventing traumatic brain injury; expand
biomedical research efforts or minimize the
severity of dysfunctions a result of such an
injury; and to improve the delivery and qualify
of services through State Demonstration
Projects”
Funding





Private Insurance
Department of
Defense/Veterans
Administration
Some Federal grants
for TBI-No feveral
money for ABI
Private Pau
Non-Profit supportScholarships given from
community fundraising
 Medicaid

After
hospitalization
 Only
5% of
individuals with
severe brain injuries
have adequate
funding for long
term treatment
Cost

Staggering


Life-long costs
Year 2000


$60 Billion
Lifetime cost


$406 Billion
Neurological Rehab
starts at approx
$30,000 per month
 No
two brain injuries are exactly the
same
 The
effects of a brain injury are
complex and vary greatly from
person to person
 The
effects of a brain injury depend
on such factors as cause, location,
and severity
Types of Brain Injury
 TraumaticBrain
Injury (TBI)

Penetrating:
foreign objects
enters the brain
 Example:

bullet
Closed Head: blow
to the head
 Example:
accident
car
 Acquired
Brain
Injury (ABI)

occurred after birth,
but is not related to
congenital defect or
degenerative
disease
Causes
TBI





Falls
Motor VehicleTraffic Accidents
Struck by/against
Assaults
Blasts- Leading
cause of TBI for
active military in
war zones.
ABI
 Hypoxia
 Illness
 Infection
 Stroke
 Substance abuse
 Toxic exposure
 Tumor
Severity
 Mild





Brain Injury
Loss of consciousness for less than 30
minutes (or no loss)
Glasgow Coma Scale of 13-15
Post-Traumatic amnesia less than 24 hours
Temporary or permanently altered mental
state
Post-concussion symptoms
Severity
 Moderate





Coma more than 20-30 minutes but less
than 24 hours
Glasgow Coma Scale of 9-12
Skull fractures may be present
Signs on EEG, CT or MRI
Long term problems in one or more areas of
life
Severity
 Severe
 Coma
longer than 24 hours
 Glasgow Coma Scale of 3-8
 Bruising, bleeding in brain
 Signs on EEG, CT or MRI
 Long term impairments in one or more
areas of life.
Brain and Behavior
Relationships
Brain Stem
 Breathing
 Heart
Rate
 Arousal/Consciousness
 Sleep/Wake funtions
 Attention/Concentration
Cerebellum
 Balance
 Coordination
 Skilled
motor
activity
Occipital Lobe
 Vision
Temporal Lope
 Memory
 Hearing
 Understanding
language
 Organization & sequencing
Frontal Lobe
 Initiation
 Personality/Emotions
 Problem-solving
 Awareness
 Judgment
 Inhibition
of behavior
 Planning/Anticipation
 Self-monitoring
 Motor planning
of
abilities/Limits
 Organization
 Attention/Concentration
 Mental Flexibility
 Speaking
Common Disabilities

Problems with cognition


Sensory processing


expression and understanding
Behavior or mental health


sight, hearing, touch, taste, and smell
Communication


thinking, memory, and reasoning
depression, anxiety, personality changes,
aggression, acting out, and social
inappropriateness
More serious injuries my result in
unresponsiveness with periods of alertness; a
persistent vegetative state
Substance Abuse
 58%
of individuals with acquired brain
injury had a history of alcohol abuse or
dependence prior to injury (Kreutzer,
Dougherty, &Harris, et al., 1990
 Post Injury

As many as 50% of individuals with an
acquired brain injury will return to using
drugs and alcohol post-injury. (Sparadeo,
Strauss &Barth, 1990)
Treatment

Initial


Mild injury


Little can be done to reverse the initial brain damage,
medical personnel try to stabilize an individual and focus
on preventing further injury
Mild traumatic brain injuries usually require no treatment
other than rest and over-the-counter pain relievers to
treat a headache.
Moderate to severe cases

Rehabilitation that involves individually tailored
treatment programs in the areas of physical therapy,
occupational therapy, speech/language therapy,
physiatry (physical medicine), psychology/psychiatry,
and social support.
Medication Therapy
 Depakote
and Tegretol –work well for
aggression
 Desyrel (sedating property)
 Anti- Depressants

No MAOI’s- due to dietary constraints
 Inderal
and Clonidine (antihypertensive
medications)
 Antipsychotics- impair recovery, memory,
learning, and lower seizure threshold.
Social Workers Role

Social workers play a very meaningful role.



LMSW: facilitates access to service agencies, assists with
care decisions and planning, and facilitates
communication among various professionals, care
providers and family members
LCSW: continue support services to families and client.
Facilitate support groups and provide individual therapy
for the client and family members
Advocacy


Currently one of the hottest medical topics
Funding for treatment and placement is very limited

Medicaid does not pay for neurological rehabilitation
Common Therapy Models
 Cognitive

Mild/Moderate
 Cognitive

Behavioral Therapy (CBT)
Rehabilitation Therapy (CRT)
Mild/ Moderate
 Dialectical

Moderate/Severe
 Behavioral

behavior therapy (DBT)
Therapy
Mild/ Moderate/Severe
Cognitive Behavioral Therapy

CBT- Mild to Moderate


Cognitive-behavioral therapy focuses on altering
thoughts or perceptions that are causing
psychological distress
For those with moderate brain injury

Therapist train the client to continuously ask questions
about strong emotional response


Example: What is it that's really making me angry? Did it
always make me angry? Did it always make me this angry?
Computer-based cognitive therapy programs
have helped many individuals suffering from brain
injuries

Fun way to exercise each the brain with card
games, mystery games etc. that can improve
each area of the brain.
Cognitive Rehabilitation
Therapy
CRT





patient-specific and goal-oriented
increase their ability to process and interpret
information
Its goal is to help the client enhance his or her
ability to move through daily life by recovering or
compensating for damaged cognitive functions
CRT involves a variety of treatments and often
involves the participation of family or caregivers
CRT interventions are promising, however the
Department of Defense recommends an
investment in research to further define,
standardize, and assess the outcomes of CRT
interventions.
Dialectical Behavior Therapy
DBT

Multi-treatment approach
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Managing Crises
Multiple stages
Connection between borderline personality disorder and
brain injury


Individual Therapy
Coaching
Structure
Certain brain mechanisms underlying the impulsivity, mood
instability and negative emotions are responsible for
maladaptive behaviors
The amygdala, which normally regulates arousal and
emotions, may be involved in the disruption of normal
emotional responses due to injury
Behavioral Therapy
 Clients
with moderate to severe brain
injury's may not be able to cognitively
process actions

Severe brain injury may leave someone
intellectually inept
 Behavioral



Therapy
Reward and punishment systems
Operant conditioning
Positive reinforcement
Treatment Plan

Break it down!

Outcomes: the big idea
Goals: break the general outcome down
 Objectives: no ambiguity, clearly defined
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Person Centered
Supportive
Simple
Consistency
Positive
Daily Planner: Slowly adjusting daily plan.
Adjustment for All
6 stages of adjustment for the family
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1)Shock, Hope, Denial
2)Recognition and Helplessness
3) Annoyance, Expectations, Reality, Seeking
information
4)Realism, Exhausted, Pulling away, Bereavement
5) Sadness, grief, mourn
6) Understanding, acceptance, family unit
 PTSD
for entire family: acute or delayed anxiety
Change

Identifying events in environment: ABCs
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Antecedent
Behavior
Consequence
Positive reinforcement
Yes or No questions
Stay Calm
Maintain a Sense of Humor
Avoid Arguments
Don’t Take things personally
Redirection
Quiz

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
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



What part of the brain causes the most change in
personality when injured?
True or False: CBT is the best treatment for all
clients with Brain Injury
Are open ended questions appropriate for brain
injured clients?
True or false: all brain injuries are the same?
What are the two types of brain injury?
True or false: All brain injuries are the same.
True or False: Punishment for bad behavior is good
practice?
How many stages of adjustment are their?
True or False: Medicaid covers brain injured
individuals long term care
What is the 3rd most prevalent disability seen in the
United States?
References
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American Speech Language Hearing Association; Traumatic Brain
Injuryhttp://www.asha.org/public/speech/disorders/TBI.htm
Brain Injury Association of America; http://www.biausa.org/living-with-brain-injury.htm
Brain Injury Resource Center; http://www.headinjury.com/rehabcognitive.html
Centers for Disease Control and Prevention; http://www.cdc.gov/TraumaticBrainInjury/index.html
Institute of Medicine; http://www.iom.edu/Reports/2011/Cognitive-Rehabilitation-Therapy-forTraumatic-Brain-Injury-Evaluating-the-Evidence.aspx
The Gale Group Inc., Gale…. Gale Encyclopedia of Alternative Medicine
Mayo Clinic; http://www.mayoclinic.com/health/traumatic-brain-injury/DS00552/TAB=indepth
National Institute of Health; NINDS Traumatic Brain Injury
National Institute of Mental Health: Borderline Personality Disorder
PsycCentral;http://psychcentral.com/news/2011/10/13/cognitive-rehabilitation-therapy-fortraumatic-brain-injury-tbi-does-it-work/30325.html
Texas Health and Human Services Commission; office of Acquired Brain Injury;
http://www.hhsc.state.tx.us/hhsc_projects/abj/index.shtml
The Bridge of Central Massachusetts: DBT for Individuals with Intellectual Disabilities
Kreutzer, JS Dougherty DR, and Harris AZ. Et al (1990). Alcohol use among persons with traumatic brain
injury. Journal of Head Trauma Rehabilitation 5:9-20
Sparadeo, FR, Strauss D &Barth, JT(1990). The incidence, impact and treatment of substance abuse in
head trauma rehabilitation. Journal of Head Trauma Rehabilitation 5 (3), 1-8
The Essential Brain Injury Guide Academy of Certified Brain Injury Specialists, Brain Injury Association of
America.