1. Issues in Developmental Disabilities Traumatic Brain Injury Lecture Presenter: Donald L. Mickey, Ph.D.

2. Video of Don Mickey

3. 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

4. Definition  Sudden insult to the brain which may or may not involve loss of consciousness (LOC)

5. 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

6. 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

7. Prevalence  TBI results in 1.5 more deaths a year than AIDS  Each year 230,000 individuals are hospitalized with TBI and survive  4 th 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

8. Prevalence-Scope  400,000 Americans with spinal cord injury  500,000 with Cerebral Palsy  4 million with Alzheimer’s disease  5 million with persistent mental illness  5.3 million with TBI disability

9. Pathology of TBI  Micro pathology – Excitotoxic Injury, Shear injury  Coup/Contra Coup Injury  Diffuse Injury  Pharmacological Intervention – Timing is Critical Mannitol

10. 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

11. 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

12. Acute Care Treatment & Course of Recovery

13. 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

14. 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

15. Neuropsychological & Radiological Assessment

16. Neuropsychological Assessment  Attention/concentration and orientation  Memory  Behavioral observation  Language ability  Visual spatial/visual constructive  Motor performance  Executive functioning  Motivation  Personality factors  Summary  Recommendations

17. Radiological Assessment  MRI  fMRI  PET scans  CT’s

18. Picture of Whole Brain

19. 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

20. Picture of Whole Brain

21. General Functions; Lobes  Parietal: Sensation, reading, listening, awareness of spatial relationships, and memory  Occipital: Visual perception

22. Picture of Whole Brain

23. Terminology, Injury and Manifestation

24. Specific terms (all caused by the injury)  Denial  Apathy  Emotional Liability  Impulsivity and Disinhibition

25. Specific terms (all caused by the injury)  Frustration and Intolerance  Lack of insight  Inflexibility  Confusion  Forgetting

26. 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

27. Manifestation of injury  Decreased alertness and arousal  Inadequate attention and concentration -Focused -Sustained -Selective -Alternating -Divided  Confusion and disorientation  Impaired memory of new information

28. 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

29. 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

30. 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)

31. Inconsistencies for the Individual  The effect of fatigue compounds the effects of the injury  “Can’t walk and chew gum”!  Frontal lobe problems - too many choices and decisions  Simple definition - no auto pilot now, must always be alert

32. 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

33. 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

34. 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

35. Community Issues  Unawareness of how to treat the brain injured individual, i.e. can I set limits, what should I say when happens, we don’t want him to get upset, etc.  One size does not fit all

36. 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

37. 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

38. Problems and Changes  How can we expect individuals to change if they don’t 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

39. Ongoing Needs  Neuropsychological examination results  Community supports - are they coordinated?  “Family” supports  Specific information for care providers so they know how to assist individual

40. 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

41. 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