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Traumatic Brain Injury 101:Traumatic Brain Injury 101:Causes, Consequences & Causes, Consequences &

Coping StrategiesCoping Strategies

March 20, 2008March 20, 2008Brain Injury Association of Ohio Staff Members: Brain Injury Association of Ohio Staff Members:

Suzanne Minnich, Ex. Director Suzanne Minnich, Ex. Director Rich Haddix, CSN Coordinator Area 11Rich Haddix, CSN Coordinator Area 11Jennie Horner, CSN Coordinator Area 5Jennie Horner, CSN Coordinator Area 5

Special thanks to our panelistsSpecial thanks to our panelists

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ObjectivesObjectives Increase knowledge of demographics & scope Increase knowledge of demographics & scope

of brain injuryof brain injury Gain understanding of common Gain understanding of common

consequences and challenges following brain consequences and challenges following brain injury injury

Better understand the impact on the Better understand the impact on the individual and his or her familyindividual and his or her family

Learn about BIAOH & other sources of Learn about BIAOH & other sources of information & assistance in a information & assistance in a state where TBI state where TBI lacks a “home” agency within government.lacks a “home” agency within government.

Identify skills and strategies to assist Identify skills and strategies to assist individuals with brain injury individuals with brain injury

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Brain Injury Association of Brain Injury Association of Ohio: Key Program StaffOhio: Key Program Staff

State Office-ColumbusState Office-Columbus + + CSN 1, Toledo: Christine VeronieCSN 1, Toledo: Christine Veronie CSN 3, Cleveland: Lori SurtmanCSN 3, Cleveland: Lori Surtman CSN 5, Lima: Jennie HornerCSN 5, Lima: Jennie Horner CSN 8, New Philadelphia: Chris CSN 8, New Philadelphia: Chris

CurtissCurtiss CSN 11, Columbus: Rich HaddixCSN 11, Columbus: Rich Haddix CSN 12, Caldwell: Jenny RuckerCSN 12, Caldwell: Jenny Rucker CSN 13, Cincinnati: Peggy O’NeillCSN 13, Cincinnati: Peggy O’Neill CSN 15, Marietta: Cindy AukerCSN 15, Marietta: Cindy Auker

BIAOH’s goal is to create a comprehensive, statewide, resource facilitation system providing information, service linkage, education, and advocacy benefiting children & adults with brain injury and their families; the system’s blueprint is known as “The Ohio Plan”.

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What is the Brain Injury What is the Brain Injury Association of Ohio?Association of Ohio?

• Statewide education & advocacy organization for people with brain injury & their families

• Affiliated with BIAA (Brain Injury Association) - 1 of 44 State Affiliates

• Grassroots/Consumer Directed Organization, started by families, medical & rehabilitation professionals

• Non-Profit, Tax Exempt Organization incorporated in 1983

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Who Are the People Who Are the People Behind Behind BIAOHBIAOH

• Board of Trustees - Who govern the organization, setting direction and providing oversight

• Staff - Who implement its programs (13 or 10 FTEs)

• Volunteers (in addition to Board Members) serving in many capacities, including as support group leaders

• Members & Constituents

• Collaborating Organizations & Partners

• Funders & Supporters

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What is BIAOH’s Purpose?What is BIAOH’s Purpose?

VisionVision: A world where all preventable : A world where all preventable brain injuries are prevented, all brain injuries are prevented, all unpreventable brain injuries are minimized unpreventable brain injuries are minimized and all individuals who have experienced and all individuals who have experienced brain injury maximize their quality of lifebrain injury maximize their quality of life

Mission:Mission: To create a better future through To create a better future through brain injury prevention, research, brain injury prevention, research, education and advocacyeducation and advocacy

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What Are BIAOH’s What Are BIAOH’s Services & SupportsServices & Supports

Information & Resource Coordination:Information & Resource Coordination: HelplineHelpline Community Support Network (CSN) Community Support Network (CSN)

field offices located throughout the field offices located throughout the statestate

Education & TrainingEducation & Training Peer SupportPeer Support Outreach & PreventionOutreach & Prevention AdvocacyAdvocacy

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What is BIAOH’s Central goal & why is it so important?

Unlike disability populations of comparable size, there is no state agency responsible for addressing the needs of those with BI.

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Contacting BIAOH is easy . . .Contacting BIAOH is easy . . .

1-866-644-6242 (1-866-OHIO-BIA)1-866-644-6242 (1-866-OHIO-BIA)

Toll-free Helpline within OhioToll-free Helpline within Ohio

help@biaoh.orghelp@biaoh.org

www.biaoh.orgwww.biaoh.org

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What is a Brain Injury?What is a Brain Injury?

Acquired Brain Injury (ABI)Acquired Brain Injury (ABI) Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)

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Acquired Brain InjuryAcquired Brain Injury Any injury to the brain that occurs Any injury to the brain that occurs

after birth as a result of:after birth as a result of:• Physical force (due to an accident)Physical force (due to an accident)• TumorsTumors• StrokesStrokes• Violent Acts (e.g., gun shot wound)Violent Acts (e.g., gun shot wound)• Infectious Diseases (e.g., Infectious Diseases (e.g.,

encephalitis)encephalitis) ABI is the broadest category and ABI is the broadest category and

includes all brain injuries that occur includes all brain injuries that occur after birth.after birth.

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Traumatic Brain InjuryTraumatic Brain Injury

A brain injury from an external A brain injury from an external forceforce• Vehicle accidentsVehicle accidents• Violent Acts (e.g., gun shot wound)Violent Acts (e.g., gun shot wound)• FallsFalls• Physical AbusePhysical Abuse• Sports InjuriesSports Injuries

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Severity ContinuumSeverity Continuum

Things to ConsiderThings to ConsiderSymptomology Symptomology Pre-injury functioningPre-injury functioningSymptoms varySymptoms vary

Mild SevereModerate

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15% of all TBIs are 15% of all TBIs are considered moderate considered moderate to severeto severe

85% of all TBIs are 85% of all TBIs are considered mildconsidered mild

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Severe Brain InjurySevere Brain Injury

Severe Brain Injury Severe Brain Injury Almost always Almost always results in prolonged unconsciousness results in prolonged unconsciousness or coma, brain contusions, or coma, brain contusions, hematomas, damage to nerve fibers hematomas, damage to nerve fibers and axons, and/or anoxiaand axons, and/or anoxia• Often results in permanent physical, Often results in permanent physical,

behavioral, and/or cognitive behavioral, and/or cognitive impairmentsimpairments

• Significant improvements are generally Significant improvements are generally made during the first 1-2 years and made during the first 1-2 years and continue thereafter at a slower ratecontinue thereafter at a slower rate

• (Glascow Coma Scale score 3-8)(Glascow Coma Scale score 3-8)

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EpidemiologyEpidemiology An estimated An estimated 5.3 5.3 million Americans have a long-million Americans have a long-

term or life long need for help with activities of term or life long need for help with activities of daily living as a result of TBI (daily living as a result of TBI (est. 227,000 est. 227,000 OhioansOhioans))

An estimated An estimated 1.41.4 million people will sustain a TBI million people will sustain a TBI each year in the United States.each year in the United States.

Of these:Of these: 50,000 die;50,000 die; 235,000 are hospitalized235,000 are hospitalized 1.1 million are treated and released from an ER1.1 million are treated and released from an ER

*The number of people with TBI who are not seen in *The number of people with TBI who are not seen in an ER or who receive no treatment is unknown.an ER or who receive no treatment is unknown.

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Disability Prevalence Rates

500,000 with Cerebral Palsy

2 million Americans with Epilepsy

3 million with Stroke disabilities

4 million with Alzheimer’s Disease

5 million with persistent mental illness

7.3 million Americans with mental retardationNational organizations’ web sites, 4/00; Slide source: Brain Injury Association of America

227,000 Ohioans - Estimate of adults living w/disability due to TBI - source CDC

400,000 with Spinal Cord Injuries

5.3 MILLION WITH TBI DISABILITY

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Leading Causes of TBILeading Causes of TBI11stst Falls (among elderly and very young)Falls (among elderly and very young)

22ndnd Vehicle accidents, bicycle, or pedestrian-Vehicle accidents, bicycle, or pedestrian-vehicle incidents (account for most vehicle incidents (account for most hospitalizations)hospitalizations)

33rdrd Violent actsViolent acts

44thth Sports accidents – An estimated 90% are mildSports accidents – An estimated 90% are mild

and go unreportedand go unreported

(Source: BIA of America Fact Sheet) (Source: BIA of America Fact Sheet)

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If you have a brain injury, you If you have a brain injury, you are 3 times more likely to get are 3 times more likely to get

another. After the second another. After the second injury, the risk for the third injury, the risk for the third injury is 8 times greater.injury is 8 times greater.

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Who experiences brain Who experiences brain injuries?injuries?

Extremely DiverseExtremely Diverse Highest risk Highest risk 0-40-4 years, 15-24, and 75 years, 15-24, and 75

years and olderyears and older Males are 1.5 times more likely than Males are 1.5 times more likely than

females to experience TBIfemales to experience TBI 70% of people who incur TBI recover 70% of people who incur TBI recover

“completely”“completely” 15% remain symptomatic for the 15% remain symptomatic for the

remainder of their livesremainder of their lives Alcohol is reported to be associated with Alcohol is reported to be associated with

50% of all TBI50% of all TBI

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TBI is the TBI is the leading cause of death leading cause of death and disability for children, and disability for children,

adolescents, and young adults adolescents, and young adults in the United Statesin the United States. 90,000 of . 90,000 of

those injured will sustain those injured will sustain permanent injuries.permanent injuries.

(www.biausa.org)(www.biausa.org)

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Neuroanatomy and Physiology Neuroanatomy and Physiology of the Brainof the Brain

Deficits vary depending upon location Deficits vary depending upon location and severity of brain injuryand severity of brain injury

Major Brain AreasMajor Brain Areas• Frontal LobeFrontal Lobe• Parietal LobeParietal Lobe• Temporal LobesTemporal Lobes• Occipital LobeOccipital Lobe• CerebellumCerebellum• Brain StemBrain Stem

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Simplified Brain Behavior Relationships

Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

Brain Stem

Parietal Lobe• Sense of touch• Differentiation: size, shape, color• Spatial perception• Visual perception

Occipital Lobe• Vision

Cerebellum• Balance• Coordination• Skilled motor activity

Brain Stem• Breathing• Heart rate• Arousal/consciousness• Sleep/wake functions• Attention/concentration

Temporal Lobe• Memory• Hearing• Understanding language (receptive language)• Organization and sequencing

Frontal Lobe• Initiation• Problem solving• Judgment• Inhibition of behavior• Planning/anticipation• Self-monitoring• Motor planning• Personality/emotions• Awareness of abilities/limitations• Organization• Attention/concentration• Mental flexibility• Speaking (expressive language)

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Frontal LobeFrontal Lobe(Almost always sustains injury due to coup-contra-coup & boney undersurface (Almost always sustains injury due to coup-contra-coup & boney undersurface of skull; domaine of “executive functions”; damage to this portion of the brain of skull; domaine of “executive functions”; damage to this portion of the brain

– and resulting deficits – considered to be the “thumbprint of brain injury”)– and resulting deficits – considered to be the “thumbprint of brain injury”)

Problem SolvingProblem Solving PlanningPlanning JudgmentJudgment Abstract thoughtAbstract thought MemoryMemory Self-monitoringSelf-monitoring Attention/ConcentrationAttention/Concentration OrganizationOrganization Inhibition of BehaviorInhibition of Behavior InitiationInitiation

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Parietal LobeParietal Lobe

Sense of touchSense of touch Sensory integrationSensory integration Spatial perceptionSpatial perception Visual perceptionVisual perception Identification of size, Identification of size,

shape, colorshape, color Language Language

comprehensioncomprehension

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Temporal LobeTemporal Lobe

Interpretation of speech/Receptive Interpretation of speech/Receptive languagelanguage

Memory of new informationMemory of new information

Organization & Sequencing Organization & Sequencing

HearingHearing

Ability to identify smells and soundsAbility to identify smells and sounds

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Occipital LobeOccipital Lobe

VisionVision

Ability to process Ability to process visual info.visual info.

Ability recognize Ability recognize shapes, colors, shapes, colors, letters and wordsletters and words

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CerebellumCerebellum

BalanceBalance CoordinationCoordination Skilled motor activitySkilled motor activity PosturePosture

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Brain StemBrain Stem

BreathingBreathing Arousal and Arousal and

consciousnessconsciousness Sleep/wake cyclesSleep/wake cycles Attention and Attention and

concentrationconcentration Heart rateHeart rate Basic life functionsBasic life functions

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TRAUMATIC TRAUMATIC BRAIN INJURYBRAIN INJURY

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Living with a Brain Injury: Living with a Brain Injury:

The Impact on the The Impact on the IndividualIndividual•Physical

•Cognitive

•Social

•Behavioral & Emotional

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Physical DisabilitiesPhysical Disabilities HeadachesHeadaches DizzinessDizziness Chronic painChronic pain SeizuresSeizures Decreased coordination, balance Decreased coordination, balance

problemsproblems Loss of limbs or use of limbsLoss of limbs or use of limbs Nerve Damage (i.e., optic nerve, facial Nerve Damage (i.e., optic nerve, facial

palsy)palsy) Sensory limitations (visual disturbances, Sensory limitations (visual disturbances,

hearing loss, decreased taste and smell, hearing loss, decreased taste and smell, increased sensitivity to noise and light)increased sensitivity to noise and light)

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CognitionCognition Broad range of symptoms that occur Broad range of symptoms that occur

independently or in combinationindependently or in combination• Memory impairmentMemory impairment• Impaired attentionImpaired attention• Inability to remain on taskInability to remain on task• Difficulty focusing on thoughts, words, Difficulty focusing on thoughts, words,

eventsevents• Deficits in language useDeficits in language use• Deficits in visual perceptionDeficits in visual perception

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Cognition-DeficitsCognition-Deficits in in Executive Skills – the Executive Skills – the

“thumbprint” of brain injury“thumbprint” of brain injury Inability to self-monitor and inhibit Inability to self-monitor and inhibit

responsesresponses Poor initiationPoor initiation Difficulty sequencing steps and Difficulty sequencing steps and

completing activitiescompleting activities Poor judgmentPoor judgment

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SocialSocial Difficulty attending to social cuesDifficulty attending to social cues Relearning appropriate social skillsRelearning appropriate social skills Loss of friendsLoss of friends Loss of familiar activitiesLoss of familiar activities Loss of selfLoss of self Personality changesPersonality changes Problems with emotional controlProblems with emotional control Susceptible to mood and anxiety disordersSusceptible to mood and anxiety disorders Increased risk of suicide Increased risk of suicide EgocentricEgocentric

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Behavioral and EmotionalBehavioral and Emotional

FrustrationFrustration IrritabilityIrritability RestlessnessRestlessness AnxietyAnxiety Low self esteemLow self esteem DepressionDepression Emotional Lability Emotional Lability

(Mood Swings)(Mood Swings) Behavioral Behavioral

OutburstsOutbursts DisinhibitionDisinhibition

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MedicationsMedicationsProperly prescribed & closely monitored Properly prescribed & closely monitored medications can help individuals w/BI deal medications can help individuals w/BI deal with physical, emotional, and/or behavioral with physical, emotional, and/or behavioral

impairments due to TBI.impairments due to TBI.

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Medications Medications Often on multiple medicationsOften on multiple medications

• SSRIsSSRIs (e.g., Prozac) often prescribed for anxiety (e.g., Prozac) often prescribed for anxiety and depressionand depression

• AnticonvulsantsAnticonvulsants (e.g., Tegretol) often (e.g., Tegretol) often prescribed to prevent seizure activity or to treat prescribed to prevent seizure activity or to treat behavioral problems behavioral problems

• Sleep medicationsSleep medications (e.g., Melatonin) often (e.g., Melatonin) often prescribed for sleep disturbancesprescribed for sleep disturbances

• NeurolepticsNeuroleptics (e.g., Risperdal) prescribed for (e.g., Risperdal) prescribed for psychosis and/or aggressionpsychosis and/or aggression

Need for continued re-assessmentNeed for continued re-assessment Physical Medicine & Rehabilitation (PMR) Physical Medicine & Rehabilitation (PMR)

doctors, experienced in working with those doctors, experienced in working with those with BI, are especially helpful. (AKA – with BI, are especially helpful. (AKA – physiatrists)physiatrists)

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Substance AbuseSubstance Abuse

Higher rates of substance abuseHigher rates of substance abuse• Effects 28%-32% of individuals with TBIEffects 28%-32% of individuals with TBI

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Practical Practical Adaptations/AccommodatioAdaptations/Accommodatio

nsns

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Reasoning/Problem SolvingReasoning/Problem Solving Signs . . .Signs . . .

Inappropriate and Inappropriate and potentially harmful potentially harmful decisionsdecisions

Unable to make inferencesUnable to make inferences

Disorganized thinkingDisorganized thinking

Difficulty drawing Difficulty drawing conclusionsconclusions

Rigidity in changing plansRigidity in changing plans

Accommodations . . .Accommodations . . .

Instruct and post note for Instruct and post note for “Stop and Think”“Stop and Think”

Help identify the problem Help identify the problem and possible solutionsand possible solutions

Help predict consequencesHelp predict consequences

Break the task down into Break the task down into several easier stepsseveral easier steps

Write steps in Write steps in notebook/plannernotebook/planner

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Attention/ConcentrationAttention/Concentration Signs . . .Signs . . .

ConfusionConfusion Rambling Rambling

ConversationsConversations StaringStaring Unable to finish a taskUnable to finish a task Difficulty attending to Difficulty attending to

more than one thing more than one thing at a timeat a time

Accommodations . . .Accommodations . . .

Get individual’s Get individual’s attention before attention before beginning a discussion beginning a discussion

Reduce unnecessary Reduce unnecessary noise or unneeded noise or unneeded materials on deskmaterials on desk

Limit the amount of Limit the amount of information presentedinformation presented

Pace the work with Pace the work with short work periods short work periods followed by brief followed by brief breaksbreaks

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Memory LossMemory Loss

Signs . . .Signs . . .

Confusion regarding Confusion regarding appointments or daily appointments or daily scheduleschedule

Unable to remember tasks Unable to remember tasks from day to dayfrom day to day

Unable to remember new Unable to remember new informationinformation

Confabulates (makes up Confabulates (makes up stories to fill memory gaps; stories to fill memory gaps; this is not lying)this is not lying)

Accommodations . . Accommodations . . ..

Establish consistent scheduleEstablish consistent schedule Structure tasksStructure tasks Provide written cues Provide written cues

(memory book, chart, etc.)(memory book, chart, etc.) Provide verbal cues (initial Provide verbal cues (initial

sounds, choices)sounds, choices) Use compensatory tools Use compensatory tools

(alarm, watches, calculators)(alarm, watches, calculators) Link new information with old Link new information with old

informationinformation

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Loss of Loss of Impulsivity/Poor Self ControlImpulsivity/Poor Self Control

Signs . . .Signs . . .

Acts or speaks without Acts or speaks without considering the considering the consequencesconsequences

Inappropriate comments to Inappropriate comments to or about othersor about others

Lower tolerance for Lower tolerance for frustrating situationsfrustrating situations

Inappropriate laughing or Inappropriate laughing or cryingcrying

Gets stuck on one idea or Gets stuck on one idea or thoughtthought

Accommodations . . .Accommodations . . . Encourage the person to Encourage the person to

slow down and work through slow down and work through tasktask

Provide verbal and/or Provide verbal and/or nonverbal feedback in a nonverbal feedback in a supportive waysupportive way

Respond to inappropriate Respond to inappropriate ideas, but maintain focus on ideas, but maintain focus on original discussionoriginal discussion

Expect the unexpectedExpect the unexpected Provide alternatives for Provide alternatives for

inappropriate or inappropriate or perseverative behaviorperseverative behavior

Give frequent and consistent Give frequent and consistent positive reinforcementpositive reinforcement

Remove the individual from Remove the individual from a frustrating task or a frustrating task or environmentenvironment

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Impaired Self-awareness, Impaired Self-awareness, Difficulty with Social SituationsDifficulty with Social Situations

Signs . . .Signs . . .

Lack of awareness of Lack of awareness of deficits and limitationsdeficits and limitations

Inaccurate self-Inaccurate self-image/self perceptionimage/self perception

Accommodations . . .Accommodations . . .

Anticipate lack of insightAnticipate lack of insight Prompt accurate self-Prompt accurate self-

statementsstatements Use feedback generously Use feedback generously

in a positive wayin a positive way Give realistic feedback as Give realistic feedback as

you observe behavioryou observe behavior

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Problems with Problems with ConversationsConversations

Signs . . .Signs . . .

Does not respond to Does not respond to another person’s another person’s conversation, questions or conversation, questions or commentscomments

Does not start, or is slow to Does not start, or is slow to start conversations, ask start conversations, ask questions, or make questions, or make commentscomments

Leaves long pausesLeaves long pauses Has difficulty explaining Has difficulty explaining

what he or she meanswhat he or she means

Accommodations . . .Accommodations . . .

Encourage the individual to Encourage the individual to participate, e.g., ask “What do participate, e.g., ask “What do you think about that?”you think about that?”

Ask open-ended questions; Ask open-ended questions; “Tell me about…”“Tell me about…”

Give time to organize Give time to organize thoughtsthoughts

Give the individual your full Give the individual your full attention and allow them to attention and allow them to complete the thoughtcomplete the thought

Re-phrase what the person Re-phrase what the person has said, “Do you mean…”has said, “Do you mean…”

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Problems w/Non-verbal Problems w/Non-verbal CommunicationCommunication

Signs . . .Signs . . .

Poor eye contactPoor eye contact Does not understand non-Does not understand non-

verbal cuesverbal cues Stands too closeStands too close Uncomfortable number/type Uncomfortable number/type

of physical contactsof physical contacts Body language/facial Body language/facial

expressions don’t seem to expressions don’t seem to “match” what is said (flat “match” what is said (flat affect)affect)

Accommodations . . .Accommodations . . .

Ask the person to maintain a Ask the person to maintain a comfortable distancecomfortable distance

Politely ask the individual to Politely ask the individual to modify their physical contacts; modify their physical contacts; explain that you are explain that you are uncomfortable with such uncomfortable with such contactcontact

Tell the person you are Tell the person you are confused by the difference in confused by the difference in body language and spoken body language and spoken messagemessage

Ask the person what he or she Ask the person what he or she is feelingis feeling

Politely ask the individual to Politely ask the individual to stop distracting movementsstop distracting movements

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General SuggestionsGeneral Suggestions

Structure the environmentStructure the environment Break tasks into component partsBreak tasks into component parts Pace the work (consider headaches, Pace the work (consider headaches,

fatigue, etc.)fatigue, etc.) Help develop organizational systems Help develop organizational systems BE CONSISTENTBE CONSISTENT

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Other considerations . . .Other considerations . . . Accommodate for both Accommodate for both cognitivecognitive and and

physicalphysical fatigue – they often impact multiple fatigue – they often impact multiple areas of functioningareas of functioning

When thinking through a person’s A-B-C When thinking through a person’s A-B-C patterns (antecedents, behavior, patterns (antecedents, behavior, consequences), recognizing & addressing consequences), recognizing & addressing antecedents to undesirable behavior often is antecedents to undesirable behavior often is more effective than an emphasis on more effective than an emphasis on consequences. Ditto to increase positive consequences. Ditto to increase positive behaviors.behaviors.

A person-centered, individualized approach A person-centered, individualized approach is paramountis paramount

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ResourcesResources to Rememberto Remember TBI Technical Assistance Center at TBI Technical Assistance Center at

NASHIA NASHIA (National Association of State (National Association of State Head Injury Administrators)Head Injury Administrators)‘‘

http://www.tbitac.nashia.org/tbics/http://www.tbitac.nashia.org/tbics/Brain Injury Association of America (Their Brain Injury Association of America (Their

mission is to create a better future through mission is to create a better future through brain injury prevention, research, education brain injury prevention, research, education and advocacy): and advocacy): www.biausa.orgwww.biausa.org

Brain Injury Association of Ohio (BIAOH)Brain Injury Association of Ohio (BIAOH)

1-866-644-6242 1-866-644-6242 www.biaoh.orgwww.biaoh.org

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March is Brain Injury March is Brain Injury Awareness MonthAwareness Month

Pick up a green “mind matters” wrist Pick up a green “mind matters” wrist bandband

Consider wearing it through the end Consider wearing it through the end of the month & share with others of the month & share with others information you’ve learned about BIinformation you’ve learned about BI

Thank you & safe travels!Thank you & safe travels!