Risk assessment in those with brain injury

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Overview of Risk Assessment and placement for those with

brain injury

Paul Fenton

Note

• This brief primer/overview was designed and delivered to social workers within a community social work setting in 2006, 2007 & 2008

• Effective Risk Assessment involves clinical, cultural and community knowledge experts who all contribute to a sound assessment of risk

• Effective risk assessment usually takes place within a multidisciplinary rehabilitation setting

• Assessment of risk following brain injury is complex; this primer should not replace professional advice and/or direction

• This overview should be considered within the evolving body of academic, clinical, cultural and community understandings of risk following brain injury.

• The following slides have been designed to use as notes for viewers/readers. 2

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Overview

① What is Risk?

② Risk Assessment Assumptions

③ Traumatic Brain Injury (TBI)a. Overview

b. Consequences

c. Assessment

d. Functional Neuroanatomy

e. Facts

④ Risk Assessment (RA)a. Basics

b. RA and Mental Illness

c. Structure

d. Special Cases

⑤ Placement Issues.

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1. What is Risk?

There are several definitions of the risk, Adams (1995) defines risk as:

“the probability of an adverse future event multiplied by its magnitude” (p.69)

Risk by this definition involves two dimensions of assessment: Probability (how likely the event is to occur), and Magnitude (the significance of the event)

In short, how likely is this event, and how bad will it be?

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1. What is Risk?

• Risk does not only relate to self harm and/or harm to others

• Risk also includes:– Risk of progression to illness (e.g. in cases of drug & alcohol abuse)

– Unintentional harm to self

– Exploitation

– Risk of abuse by others

– Intentional or unintentional violence or fear-inducing behaviour toward others

– Risk of property destruction.

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Risk to self Risk to others• Safety• Health• Quality of life• Vulnerability• Self-neglect• Cultural/Spiritual

• Violence• Intimidation, threats• Stalking• Harassment• Property damage• Public nuisance• Reckless behaviour

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1. What is Risk?

2. RA Assumptions

The BEST predictor of future risk is PAST behaviour

Risk can be measured in some way

Risk can be predicted

Risk prediction is not 100% certain, but is based on probability/liklihood of future risk

Risk is not stable, but is variable

Risk triggers can be both static and dynamic.

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3a. TBI: Overview

Traumatic Brain Injury (TBI) types: Closed, Open, and Crush injuries

Mild, moderate, severe

Common injuries/events during TBI Diffuse axonal injury (DAI) due to acceleration forces

Loss of consciousness

Coup and contré-coup injuries

Brain shaking

Bleeding and swelling (oedema), which places brain under physical pressure due to the confined space of the skull

Other non-brain related injuries (this can mean that head injury may not be the main focus of treatment).

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3b. TBI: Consequences

Isolation from family Likely in majority of cases that the patient will be unsupported by

whānau (family) or friends after TBI

Neuropsychiatric & Neurobehavioural sequelae i.e. Emotional effects, physical effects, etc. (see slide 11)

TBI symptoms dependent on things such as: The site of injury; severity; education level, and age at injury

Malingering may be an issue

Legitimacy of the impact/effects may be questioned Specifically, in Mild TBI, long-term symptoms may be viewed with

scepticism by health professionals and family/friends.

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3c. TBI: Assessment

• Cognitive Function– Overall current functioning (verbal & non-verbal)

– Verbal abilities

– Visuospatial abilities

– Processing speed

– Memory (visual/verbal)• Attention and Working memory

• Short-term

• Long-term

– Executive Functioning (potentially major consequences for Risk Assessment).

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3c. TBI: Assessment (con’t)

Quality of Life and Daily Living

Day-to-day and qualitative impact of the injury

Psychiatric Functioning

Anxiety

Depression, etc.

Neurobehavioural Functioning (cognitive, emotional, behavioural and physical effects) e.g.:

Memory

Somatic complaints

Affect/Mood

Aggression.

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3d. TBI: Functional Neuroanatomy

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The four lobes of the brain

3d. TBI: Functional Neuroanatomy

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The left hemisphere is associated with verbal abilities, verbal memory, reading, writing, logic, sequential analysis, mathematics: such as counting & measurement, and music (in expert musicians). In 95% of people, important language functions are ‘located’ here such as: speech production & comprehension, grammar/words, and patterns. Please Note: The left hemisphere is NOT the ‘dominant’ hemisphere; BOTH hemispheres MUST and DO work together for normal functioning.

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3d. TBI: Functional Neuroanatomy

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The right hemisphere is associated with visuospatial abilities, visual memory, pattern recognition, parallel processing, face recognition, and synthesis of information. Important language functions are: intonation & prosody (making sense of tone of voice and meaning), and contextual cues. The right hemisphere, once viewed as “word deaf and word blind” makes a VITAL contribution to language and social interaction, without which, we would not, for example, understand if someone is speaking literally of figuratively, or even when someone is making a joke.

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3d. TBI: Functional Neuroanatomy

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The frontal lobe is associated with planning, sequencing, abstract thought, personality, impulse control, intentional behaviour, problem-solving, monitoring and regulating behaviour. The frontal lobe is viewed by some as the lobe that, if affected in some way, can have the most devastating consequences on human functioning. As such, a person with frontal lobe damage may present greater challenges for risk management than say a person with temporal lobe impairments such as memory.

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3d. TBI: Functional Neuroanatomy

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The temporal lobe is associated with memory and learning (the hippocampus is located there), auditory processing, and language functions involved in speech comprehension (Wernicke’s area), visual pathways in the temporal lobe include the ventromedial pathway involved in face recognition and shape/form and categorical/orientation in visual recognition.

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3d. TBI: Functional Neuroanatomy

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The parietal lobe is associated with somatosensory system, and the dorsolateral visual pathway involved in visual perceptual processes such as 3-d representation of objects, and what is thought to be an disorder associated with attention called “hemi-neglect” (ignoring (usually) the left side of space).

Please also note that the boundaries between the lobes is not as distinct as shown.

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3d. TBI: Functional Neuroanatomy

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The occipital lobe is where the primary visual cortex lies. Neural signals from the eyes travel along the optic nerve via the thalamus and then radiate to the visual cortex. Damage to this area affects vision possibly causing blind spots, tunnel vision and affecting vision quality. The distinctions between the occipital and temporal and occipital and parietal lobes are not clear cut and the occipital lobes play a role in object recognition, motion-detection, and shape discrimination.

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3e. TBI: Facts

TBI may cause decades-lasting vulnerability to psychiatric illness in some individuals

It may cause new illness in those with no prior history

It may exacerbate existing illness

TBI seems to make people susceptible to depressive episodes, delusional disorder, and personality disturbances

Mild Head Injury may cause long-lasting neurobehavioural impairment (see previous slide)

Alcohol abuse and illegal drugs are forbidden for those with head injury

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3e. TBI: Facts (con’t)

In comparison to the general population, higher proportions of those with TBI develop psychiatric illness Usually depression, anxiety and panic disorder History of prior psychiatric illness associated

with: Lower Glasgow Outcome Scale scores, lower

Mini-Mental State Exam scores, and fewer years of formal education.

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3e. TBI: Facts (con’t)

• In relation to RA, focal prefrontal lobe damage is associated with an impulsive subtype of aggressive behaviour

• But, general frontal lobe dysfunction is linked to aggressive dyscontrol, but the increased risk of violence is less than widely presumed

– i.e. we don’t know what brain areas are predictive of violence.

• Also, temporal lobe structures are implicated in psychopathy – antisocial/sociopathic characteristics1

1. This term refers to people of average or superior intelligence, free from psychosis, who are cold and callous, domination-seeking, emotionally-detached, abnormally aggressive and irresponsible, and are unable to make enduring relationships or learn from experience.

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4a. RA Basics

Usually, the best predictor of future behaviour is usually past behaviour

But, this might pose a problems with TBI as they have no history to go on, barring review of prior function and multi-deminsional assessment

Assessment is a combination of:

Clinical expertise & judgement

Knowledge of Actuarial Methods (Statistics e.g. car stats for youth…)

Knowledge of Literature

Knowledge of Culture & Environment

Collaboration with professionals and whānau (family)

Assessment should be multi-dimensional.

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4a. RA Basics (con’t)

Must include Strengths, Coping and Protective Factors This ensures comprehensive understanding of the individual

and capabilities, rather than weaknesses only (avoid deficit thinking)

Assess multiple domains (“ABCDEF”) Affect (emotions/feelings)

Behaviour

Cognition

Drugs

Education

Family.

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4b. RA and Mental Illness

Mental illness does not necessarily predispose people to greater risk

Greater majority of those with mental illness pose no greater risk to general population

Best predictors of risk are offending and previous history of risk

Risk posed by severely ill is only increased when in actively psychotic phase

Risk of violence increased in those who have active symptoms and misuse drugs/alcohol

Challenge mental health misperceptions.

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4c. RA Structure

1. Characteristics of riska. Risk fluctuates (regularly assess)

b. Degree of risk occurs at all ages

c. Prediction of risk is <100% accurate; at best, it’s a short-term predictor

d. Good clinical judgment is the best way to minimise risk

e. Don’t rely on actuarial factors alone (e.g. age & gender, etc.).

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4c. RA Structure (con’t)

2. Assessment of riska. Assess constantly, especially after:

i. First contact with service

ii. Changes in care

iii. Changes in life events

iv. Significant Changes in mental state

v. Discharged to less-restrictive environments

vi. Diagnosed with chronic illness.

b. Assess regularly and note any changes

c. Based on Collateral Information (see point “d” overleaf).

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4c. RA Structure (con’t)

2. Assessment of risk (con’t)d. Assessment is based on:

i. Patient history

ii. Self-report when interviewed

iii. Discrepancy in verbal accounts

iv. Psychological and Physiological tests

v. Relevant statistics

vi. Actuarial indicators.

All of the above taken together = Clinical judgment

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4c. RA Structure (con’t)

3. A. Risk Assessment Information sources:i. Factual information

ii. Informed opinion

iii. Actuarial information

iv. Weight given to those who know the individual well.

B. Risk Assessment Information Considerations:

i. Don’t rely on distorted summary reports

ii. Look for Objective, Verifiable data sources

iii. Use first-hand sources if possible

iv. You might use family to corroborate/validate information – within reason (use judgment)

v. Lack of insight and denial may be present in those with TBI (both are neurological conditions, not necessarily psychological conditions).

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4c. RA Structure (con’t)

4. Formulation of risk – the whya. Summarises risk data, sets out

management planb. Checks adequate assessment

donec. Ensures we THINK about the

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4c. RA Structure (con’t)

4. Formulation of risk (con’t) – the howa. Background:

Relevant demographics; culture; history of violence/self-harm/other; psychiatric history; and behaviour

b. Current situation:

Current mental state; sources of stress; precipitating events; and stressors & circumstances

c. Risk Factors:

ID relevant risk factors (e.g. “SAD PERSONAS, SLAP” - see slide 35); and prioritisation of risk factors

d. Risk Statement:

Nature and magnitude of likely event; probability; Precipitating factors/circumstances; how long assessment valid for; and when next assessment due.

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4c. RA Structure (con’t)

5. Managing risk

a. Aim to ID actions and implement them

b. Evaluate outcomes of risk management plan

i. Immediate risks

ii. Ongoing management

iii. Preventive actions

iv. Contingency plans.

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4c. RA Structure (con’t)

6. Balancing risksa. Sometimes necessary to take risks for therapeutic benefit

b. Total risk avoidance can be restrictive.

7. Harm to othersa. Remember mental illness poses no greater risk

b. But, watch those in active psychotic stages (command hallucinations, etc.)

c. Also, watch those who abuse alcohol and drugs or go off medication

d. Also, watch those with history of conduct disorder/antisocial disorder and substance abuse

e. Also, watch those with untreated symptoms.

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4d. RA Special Cases

Violence Risk Assessment Also assess aggression/threats Predictors:

Previous history Gender – male 18-30 Psychiatric patients – BUT only when:

In coercive situations In active phase of psychosis Alcohol/Drug use Psychopathy (see slide 21).

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4d. RA Special Cases (con’t)

Violence Risk Assessment Clinical history History of risk-taking behaviours Escalation of risk Victim ID and Profile Early warning Interventions.

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4d. RA Special Cases (con’t)

Suicide Risk Assessment Risk factors: Sex, Age, Depression,

Previous Attempts, Excess Alcohol, Rational thought gone, Support, Organised, No spouse, Abuse, Sickness (“SAD PERSONAS”)

Severity, Lethality, Availability, Proximity to Help (“SLAP”).

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5. Placement Issues

Placement is based on outcome of the RA, rather than desire to place a person in secure care regardless of outcome

However, prevailing mental health belief and prejudice might suggest otherwise

In this case, we must minimise risk as best as possible (see overleaf and slide 31 – Managing Risk).

Balance between what is best for patient and what is best for family/community.

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5. Placement Issues (con’t)

Where to place? (this can minimise risk) Secure facility option

Semi-secure facility option

Open facility/Home/Hostel option

How to minimise risk? (see slide 31 also) Monitor risk

Ensure ongoing support – use family support/monitoring too, if possible

Ongoing management

Take Preventive actions

Have contingency plans.

Documentation and tracking is important.

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5. Placement Issues (con’t)

Will we get it wrong at times? Yes, sadly This may be more a matter of “if”, but

“when”, for mental health and allied professionals

Assessment is not 100% accurate Supervision and support is important

here.

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FINISH

The key to Risk Assessment is to support and confer with one another

Work in a community of best practice professionals and community experts

Look for examples of best practice

If in doubt, seek expert advice.

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