Issues in Developmental Disabilities Traumatic Brain Injury Lecture Presenter: Donald L. Mickey, Ph.D. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture.
Jan 07, 2016
Issues in Developmental Disabilities
Traumatic Brain Injury
Lecture Presenter:
Donald L. Mickey, Ph.D. QuickTime™ and a
Photo - JPEG decompressorare needed to see this picture.
Video of Don Mickey
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
Definition
Sudden insult to the brain which may or may not involve loss of consciousness (LOC)
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
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
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
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
Pathology of TBI
Micro pathology – Excitotoxic Injury, Shear injury
Coup/Contra Coup Injury Diffuse Injury Pharmacological Intervention – Timing
is Critical Mannitol
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
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
Acute Care Treatment & Course of Recovery
Acute Care Treatment & Course of Recovery
Ideal Course of Recovery Course of recovery
-Coma-PTA (Post Traumatic Amnesia)
Retrograde and Anterograde amnesia General ConfusionAgitation
Hospital Rehabilitation Post Acute Rehabilitation Gradual Return to Community, and work, (with
Supports) Often Dependent on Insurance
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
Neuropsychological & Radiological Assessment
Neuropsychological & Radiological Assessment
Neuropsychological Assessment Attention/concentration and orientation Memory Behavioral observation Language ability Visual spatial/visual constructive Motor performance Executive functioning Motivation Personality factors Summary Recommendations
Radiological Assessment
MRI fMRI PET scans CT’s
Picture of Whole Brain
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
Picture of Whole Brain
General Functions; Lobes
Parietal: Sensation, reading, listening, awareness of spatial relationships, and memory
Occipital: Visual perception
Picture of Whole Brain
Terminology, Injury and Manifestation
Terminology, Injury and Manifestation
Specific terms (all caused by the injury)
Denial Apathy Emotional Liability Impulsivity and Disinhibition
Specific terms (all caused by the injury)
Frustration and Intolerance Lack of insight Inflexibility Confusion Forgetting
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
Manifestation of injury Decreased alertness and arousal Inadequate attention and concentration
-Focused-Sustained-Selective-Alternating-Divided
Confusion and disorientation Impaired memory of new information
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
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
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)
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
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
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
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
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
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
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
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
Ongoing Needs
Neuropsychological examination results
Community supports - are they coordinated?
“Family” supports Specific information for care providers
so they know how to assist individual
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
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