Issues in Developmental Disabilities Traumatic Brain Injury

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Issues in Developmental DisabilitiesTraumatic
Brain Injury

• Lecture Presenter
• Donald L. Mickey, Ph.D. 

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Video of Don Mickey
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ORGANIC VERSUS PATHOLOGICAL? (Keep In Mind)

• What is the causal agent for the behavior and
  problems that we see exhibited?
• We must be aware that each individual is
  different and each person had a life, which they
  may be able to remember, prior to the brain injury

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Definition

• Sudden insult to the brain which may or may not
  involve loss of consciousness (LOC)

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Causes

• Major Assaults, falls, car accidents, gun shots
• May also include stroke, anoxia, carbon monoxide
  poisoning, infections, toxic exposure
• Add-Blasts as additional cause due to the war

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Prevalence-Risk Groups

• Males 1.5 times as likely as females to sustain a
  TBI
• Two age groups most likely 0-4 year olds, 15-19
  year olds, and over 75
• Now-Military

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Prevalence

• TBI results in 1.5 more deaths a year than AIDS
• Each year 230,000 individuals are hospitalized
  with TBI and survive
• 4th leading cause of death overall
• Each day 5,500 individuals sustain a TBI
• Approximately 1 in every 10 individuals are
  touched by TBI
• 80,000-90,000 people experience onset of long
  term consequences of TBI

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Prevalence-Scope

• 400,000 Americans with spinal cord injury
• 500,000 with Cerebral Palsy
• 4 million with Alzheimers disease
• 5 million with persistent mental illness
• 5.3 million with TBI disability

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Pathology of TBI

• Micro pathology Excitotoxic Injury, Shear
  injury
• Coup/Contra Coup Injury
• Diffuse Injury
• Pharmacological Intervention Timing is Critical
• Mannitol

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Outcomes of TBI-Basic Elements

• Extent and Location of Gross Damage
• Extent of Microscopic Damage
• Pre Morbid Brain Factors
• Response to Post injury Therapies
• GCS within 24 hours post injury

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Neuropathology and Neurotransmission Vulnerable
Areas

• White Matter- Shear Injury Affects Corpus
  Callosum and Basal Ganglia
• Coup/Contra Coup Injury- Affects Frontal,
  Temporal, and Occasionally Occipital Structures
• Chronic Injuries May Alter the Homeostasis of
  Neural Transmission

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Acute Care Treatment Course of Recovery

• Acute Care Treatment Course of Recovery

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Ideal Course of Recovery

• Course of recovery
• -Coma
• -PTA (Post Traumatic Amnesia)
• Retrograde and Anterograde amnesia
• General Confusion
• Agitation
• Hospital Rehabilitation
• Post Acute Rehabilitation
• Gradual Return to Community, and work, (with
  Supports)
• Often Dependent on Insurance

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The Other Course of Recovery

• Hospital Management at Acute Level
• Return to Community with Limited Outpatient
  Therapy
• Patient and/or Family is Left to Figure Out What
  is Next

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Neuropsychological Radiological Assessment

• Neuropsychological Radiological Assessment

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Neuropsychological Assessment

• Attention/concentration and orientation
• Memory
• Behavioral observation
• Language ability
• Visual spatial/visual constructive
• Motor performance
• Executive functioning
• Motivation
• Personality factors
• Summary
• Recommendations

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Radiological Assessment

• MRI
• fMRI
• PET scans
• CTs

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Picture of Whole Brain
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General Functions Lobes

• Frontal, left vs right Emotional control center
  and highest intellective area of the brain
  includes language, creative thought, problem
  solving, initiation of movement, judgment, and
  impulse control
• Temporal Memory, language, sequencing, musical
  ability

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Picture of Whole Brain
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General Functions Lobes

• Parietal Sensation, reading, listening,
  awareness of spatial relationships, and memory
• Occipital Visual perception

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Picture of Whole Brain
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Terminology, Injury and Manifestation

• Terminology, Injury and Manifestation

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Specific terms (all caused by the injury)

• Denial
• Apathy
• Emotional Liability
• Impulsivity and Disinhibition

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Specific terms (all caused by the injury)

• Frustration and Intolerance
• Lack of insight
• Inflexibility
• Confusion
• Forgetting

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Specific terms (all caused by the injury)

• Verbosity
• Perseveration
• Confabulation
• Lack of Initiation and Follow-Through
• Slow and Inefficient Thinking
• Poor Judgment and Reasoning
• Social imperception
• Fatigue

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Manifestation of injury

• Decreased alertness and arousal
• Inadequate attention and concentration
• -Focused
• -Sustained
• -Selective
• -Alternating
• -Divided
• Confusion and disorientation
• Impaired memory of new information

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Manifestation of injury

• Impaired sequential memory of past information
• Expressive language problems
• Receptive language problems
• Agitation and irritability
• Catastrophic reaction and reactive depression
• Exacerbation or decrease of pre-injury mental
  health issues

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Manifestation of injury

• Impaired adaptive behavior Executive
  functioning
• -Difficulty in planning a course of action
• -Planning, organizing, and following through on
  any goal orientated task at home or work

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Inconsistencies for the Individual

• Everyone says you look good and are doing well
• Mirror says I look good
• No retrograde amnesia so I can remember all the
  things I have done and can do
• Impairments block understanding of self
  information (right hemisphere injury)

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Inconsistencies for the Individual

• The effect of fatigue compounds the effects of
  the injury
• Cant walk and chew gum!
• Frontal lobe problems - too many choices and
  decisions
• Simple definition - no auto pilot now, must
  always be alert

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Inconsistencies for the Individual

• Higher functioning individuals who use cognitive
  processes are more aware of even small short
  comings, which in turn magnifies the impairments
• Major memory impairment and adequate intellectual
  capacity often has impairment as focus of
  treatment versus use of preserved skills
• Minor memory impairments often are ignored as not
  important

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Community Issues

• Lack of understanding of the functional deficits,
  or too much understanding of the deficits
  blocks community success
• Normal verbal abilities and/or normal IQ
  often has support people down playing the
  impairments or ignoring the impairments as not
  important

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Community Issues

• What does brain injury mean to you? Individuals
  often select one or two cases as their idea of
  brain injury - this may not represent the current
  case
• Underlying or pre-existing mental health and/or
  life style issues are ignored or become focus

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Community Issues

• Unawareness of how to treat the brain injured
  individual, i.e. can I set limits, what should I
  say when happens, we dont want him to get upset,
  etc.
• One size does not fit all

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Needs

• Awareness of injury deficits in a functional
  sense - how does a right frontal lobe injury
  affect the person in the environment?
• This has to be an ongoing educational process
  with supports available following failures to
  process what happened
• Functional and verifiable knowledge of strengths
  and weaknesses

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Needs

• Energy Output
• -How much
• -How Long
• -Crashes/recovery
• Risk taking to develop new skills or verify
  existing skills
• Planned failure in the community setting to
  assist the learning process

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Problems and Changes

• How can we expect individuals to change if they
  dont know what is wrong?
• When you know, it is easier to take
  responsibility for your self versus listening to
  others tell you what and why you need to change
• Planned failure and community challenges

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Ongoing Needs

• Neuropsychological examination results
• Community supports - are they coordinated?
• Family supports
• Specific information for care providers so they
  know how to assist individual

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Questions and Ideas

• Importance of survival in the community
• -RISK TAKING-
• Psychological impact of accepting change
• Need to adapt everything to a real world
  environment - importance for care providers

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Caveat

• Always remember what you are dealing with a WHOLE
  system (person) that had a life prior to becoming
  a brain injured patient or client
• Always be aware that systems function together
  and may not always fit neatly into specialty areas