Traumatic Brain Injury (TBI) Essentials: workshop at Worcester State University

1. Traumatic Brain Injury (TBI)
Essentials

2. Today’s Schedule
• 8-8:30 Registration
• What is Traumatic Brain Injury & Screening
for TBI-related deficits
• 10-10:15 Break
• How TBI Impacts Executive Functioning &
Populations at Greater Risk for Brain Injury
• 12-1 Lunch
• Locating Community Supports and Services
for Head Injured Clients
• 2:15-2:30 Break
• Counseling Brain Injury Survivors and Their
Families
• 3:45-4:00 Question and Answer

3. Overview
• Epidemiology
• Mechanisms of Injury
• Deficits Associated with TBI
• Identification
• Treatment
• Special cases

4. #tbiwsu

5. EPIDEMIOLOGY

6. National prevalence rates of various
disabilities
400,000 with Spinal Cord Injuries
500,000 with Cerebral Palsy
2.3 million with Epilepsy
3.0 million with Stroke-related Disabilities
4.0 million with Alzheimer’s Disease
5.3 million with Traumatic Brain Injury
5.4 million with persistent Mental Illness
7.2 million with Mental Retardation

7. Incidence
In the United States, at least
1 million sustain a TBI each year

8. Causes of TBI

9. Who is at Highest Risk for TBI?
• Males 1.5 times as likely as females to sustain
a TBI
• Two age groups most at risk are 0-4 year olds
and 15-19 year olds, and
• The elderly, frequently from falls
• African Americans have the highest death rate
from TBI

10. Incidence of TBI x Age and Gender

11. MECHANISMS OF INJURY

12. Types of Brain Injuries
Acquired Brain Injuries
Traumatic Brain Injuries Other Brain Injuries:
•Strokes
•Hydrocephalus
•Tumors
•Demyelinating disorders
•Infections
Penetrating Closed Head Injury •Toxic encephalopathy
•Anoxic/hypoxic injury

14. Causes of TBI

15. Mechanisms of Injury
• Primary mechanisms of injury
– Contusions
– Small vessel disruption
– Diffuse axonal injury

16. Coup-Contra Coup

20. Hematoma

23. Mechanisms of Injury
• Secondary mechanisms of injury
– Edema
– Evolving hematoma
– Hydrocephalus

25. Normal ventricles

26. Managing intracranial pressure

27. Introduction to Neuroanatomy

28. Introduction to Neuroanatomy
What’s different about the brain?

29. Neuron

30. Synapse

31. Peripheral and Central Nervous System

32. Introduction to Neuroanatomy
• Front – back x
• Top – bottom
• Left - right

33. what IS…
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34. …what COULD BE
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35. Introduction to Neuroanatomy
• Front – back
• Top – bottom
• Left – right x

37. ?

38. Frontal Lobe

39. Temporal Lobe

40. Parietal Lobe

41. Occipital Lobe

42. Limbic System

43. Cerebellum

44. The Ventricles

45. Normal ventricles

46. DEFICITS ASSOCIATED WITH TBI

47. Medical
• Physical stamina
• Pain
• Headaches
• Seizures (within 2 years of injury)
• Bowel/bladder continence

48. Motor Functioning
• Paresis or spasticity
• Gross motor strength
• Fine-motor speed and dexterity
• Motor coordination and planning
• Spatial-based movement
• Oculomotor
• Balance

49. Sensory-Perceptual Abilities
• Tactile, visual, and auditory modalities
• Sometimes, olfaction

50. Attention
• Alertness and arousal.
• Selective or focused attention.
– Modality specific
• Sustained attention (vigilance).
• Span of attention.
• Hemi-neglect (ignoring one side of the body).

51. Receptive Language
• Word and phrase comprehension
• Conflictual and comparative statements
• Vocal tone and prosody
• Speed of processing
• Pragmatics (social meaning in language)

52. Expressive Language
• Fluency
• Naming
• Word and phrase repetition
• Organization of output (e.g., spontaneous versus
confrontational speech)
• Vocal tone and prosody
• Pragmatics (social use of language)

53. Memory and Learning

54. The Executive Functions
X

57. Places
• San Jose
• Aberdeen
• Paris
• Hattiesburg

58. Places
• San Jose
• Aberdeen
• Paris
• Hattiesburg

59. Boys’ Names
• Dante
• Pete
• Jordan
• Elvis

60. Boys’ Names
• Dante
• Pete
• Jordan
• Elvis

64. “a healthy well-adjusted 26 year old”

66. The Executive Functions
• Inhibition
• Shift
• Regulation
• Initiation
• Working memory
• Planning / organizing
• Self-monitoring

67. The Executive Functions
• Bridging the now with the past
• Bridging the now with the future

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69. Preschool
1. 1-step errands
2. Chores with cues
3. Basic inhibition
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70. Kindergarten -
2nd Grade
1. 2-3 step directions
2. Bring papers home
3. 20-30 minute assignments
4. Simple spending decisions
5. Follow rules/inhibit/no grabbing
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71. 3rd-5th Grade
1. Simple shopping list
2. Keep track of personal items
3. Longer homework assignments
4. Simple project planning
5. Keep track of variable daily schedule
6. Save money
7. Inhibit and regulate even without teacher present
8. Manners
9. Simple delayed gratification (phone)
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72. 6th – 8th Grade
1. Complex chores
2. Babysitting
3. Organizing system
4. Complex schedule
5. Longer term projects
6. Time management
7. Self soothe
8. Manage conflict
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73. Teenage-mid 20’s
1. Independent with assignments
2. Make adjustments based on feedback
3. Longer term goal setting
4. Manage leisure time
5. Inhibit reckless behavior
6. Easily walk away from provocation
7. Say “no” to fun activity if other plans already made
8. Take others’ perspective
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74. School and Vocational Outcomes
• Problems initiating and completing work.
• Slowed work pace.
• Increased impulsivity.
• Trouble navigating physical surroundings.
• Decreased productivity.

75. School and Vocational Outcomes
• Confusion and increased stress.
• Resistance to change.
• Trouble with generalization of new learning.
• Distractible.
• May resent special assistance.

76. Social-Behavioral Outcomes
• Loss of friends and social circles.
• Decreased affective regulation.
• Increased impulsivity.
• Increased agitation.

77. Social-Behavioral Outcomes
• Poor perspective taking.
• Comparison to preinjury level of functioning.
• Poor understanding of TBI and recovery.
• Premature return to school/work.
• Unrealistic predictions.

78. Emotional
• Dependent behaviors / amotivation
• Irritability / emotional lability / anger
• Depression
• Disinhibition
• Denial/lack of insight
• At risk for substance abuse

79. Who Gets Better? Predictors of
Positive Outcome
x

80. Preinjury Predictors of Positive
Outcome
• History of good academic achievement
• Good social relationships
• No history of learning, attention, or behavioral
difficulties
• No history of substance abuse
• No significant family problems

81. Preinjury Predictors of Positive
Outcome
• Strong-willed and determined
• Under 21 years of age
• No previous neurological history (e.g., a prior
TBI)
• Good self regulation skills

82. Preinjury Predictors of Positive
Outcome
• No criminal history
• Good relationships with family members
• Warm and supportive family
• No psychopathology

83. Behavioral Predictors of Positive
Outcome
• Motivated and persistent
• Optimistic
• Has the capacity to recognize errors and self-
correct
• Aware of behavioral deficits
• Ambulatory

84. Behavioral Predictors of Positive
Outcome
• Relatively independent with activities of daily
living
• Initiates tasks with no/minimal assistance
• Preserved perspective-taking capacity
• Relatively preserved neurocognitive abilities

85. Environmental Predictors of Positive
Outcome
• Individual treatment plans
• Continuity and coordination of treatment
throughout the recovery process
• Structure, consistency, and repetition in daily
activities
• Good, stable resources
(e.g., financial, family, friends, community, etc.
)

86. Environmental Predictors of Positive
Outcome
• Presence of “key” person in the family
• Family involved in the treatment plan
• Family realistic about individual’s status
• Presence of “key” person on team

87. Neurological Predictors of Positive
Outcome
• Coma < 6 hours
• PTA < 24 hours
• GCS > 7
• Normal EEG and MRI
• Normal intracranial pressure
• Normal ventricle size
• No intracranial hematoma

88. Indices of Severity of TBI
• Intracranial Pressure
• Retrograde Amnesia
• Anterograde Amnesia/Post-traumatic Amnesia
• Duration of Loss of Consciousness (LOC)
• Glasgow Coma Scale score
• Rancho Los Amigos Scale (1 to 10)

89. Indices of Severity of TBI

90. Mild injury
0-30 minute loss of consciousness
Moderate injury
30 minutes to 24 hours LOC
Severe injury
> 24 hours LOC

91. IDENTIFICATION OF TBI

92. Identification of TBI
• Obtain the medical records if possible
• Interview family/friends for collaboration
• Arrange for a neuropsychological evaluation
• Refer to a neurologist or psychiatrist for medication
and behavioral consultation
• Consider referral to a brain injury rehabilitation
program

93. Inquiry Regarding TBI
• Any history of concussion or head injury?
• Ever been knocked out?
• Note: this question may lead to discussion of
– Alcohol abuse
– Domestic violence
• Postconcussive symptoms?
• Return to work/school?

94. “Getting at” PTA in the clinical
interview
• When did you wake up from the head injury? Do you
remember being transported to the hospital? Do you
remember being in the trauma unit? Being
transferred to the rehab unit?
• PTA: period of time after the CHI for which the
patient has no memory

95. Comprehensive Mental Status
Examination
• Behavior
• Emotion
• Cognition

96. ABC STAMPLICKER

97. ABC STAMPLICKER
• appearance

98. ABC STAMPLICKER
• behavior

99. ABC STAMPLICKER
• cooperation

100. ABC STAMPLICKER
• speech

101. ABC STAMPLICKER
• thought
–Form
–Content

102. ABC STAMPLICKER
• affect

103. ABC STAMPLICKER
• mood

104. ABC STAMPLICKER
• perception

105. TO ORIENT
To understand
one’s
relationship to the
environment

106. ABC STAMPLICKER
• level of arousal

107. ABC STAMPLICKER
• insight

108. Judgment
• The ability to weigh and compare the relative
values of different aspects of an issue.

109. ABC STAMPLICKER
• cognition

110. ABC STAMPLICKER
• knowledge

111. ABC STAMPLICKER
• endings

112. Risk Assessment Protocol
• Identify predisposing factors
• Examine potentiating factors
• Conduct a specific suicide inquiry
Ideation?
Plan?
Intent?
• Determine level of intervention
• Documentation

113. ABC STAMPLICKER
• reliability

114. Diagnostic Issues
• Cognitive Disorder NOS
• Dementia Due to Head Trauma

115. Diagnostic Issues
• Distinguishing psychiatric from TBI-related
impairment
– Insight/denial/anosagnosia
– Explosive behavior disorders
– Pseudodementia
– “Acquired ADHD”?

116. TBI TREATMENT

117. Considerations in TBI Recovery
• What constitutes “recovery”
• Will he/she be 100%?
• It takes a year?
• “Plateaus”
• The normal neurological evaluation
• Independence and modified independence
• No magic bullets
– Meds
– Rehab technologies

118. Medical Management: Acute TBI
• Airway
• Close monitoring for edema
• Seizure control
• Close monitoring for increased intracranial
pressure

119. Normal ventricles

120. Increased intracranial pressure

121. ICP monitor

122. Pharmacological Treatments
• Amantadine x
• Anti-seizure agents
• Antipsychotics
• Antidepressants
• Stimulants

124. Pharmacological Treatments
• Amantadine x
• Anti-seizure agents
• Antipsychotics
• Antidepressants
• Stimulants

125. Early Rehabilitation Efforts:
• Formal family meetings
• Use of an interdisciplinary team approach in
overall treatment
• Discharge planning by team
members, family, and community services

126. Referrals

127. Referrals
Brain Injury and Statewide Specialized
Community Services

128. Referrals
• Assistive technologies
• Independent living skills training
• Speech therapy
• Occupational therapy
• Physical therapy
• Neurology
• Psychiatry
• Physiatry
• Substance abuse treatment

129. Referrals
• Case management
• Home modifications
• Transportation
• Cognitive rehabilitation
• Counseling
• Financial management
• Respite care
• Neuropsychological evaluation

130. Goals of Neuropsychological Assessment
• Determine spared versus impaired abilities.
• Understanding impact of injury and/or a
neurodevelopmental problem (e.g., LD).
• Assist in localization of function and
dysfunction.

131. Goals of Neuropsychological Assessment
• Assist in determining whether to remediate or
to compensate.
• Generate suggestions for remediation and
compensation.
• Suggestions for monitoring and tracking of
progress in school setting.

132. When to Consider a Referral to
Neuropsychology
• Documented brain injury/insult
• Suspected brain injury or insult
• Neurodevelopmental disorder
• Unusual psychological profile
• Positive neurological findings
• Severe behavior problems
• Treatment needs

133. Cognitive Rehabilitation
• 4 ways our patients “get better”
– Brain healing
– Brain re-organization / plasticity
– Compensatory skills
– Restructuring the environment

135. Cognitive Rehabilitation:
Specific Approaches
• Psychometric approach (healing/plasticity)
• Stimulus-based approach (restructuring the
environment)
• Developmental approach (plasticity and
compensatory)
• Behavioral engineering approach
(compensatory skills)

145. Cognitive Rehabilitation
• Research challenges
• Cognitive orthotics and prosthetics

148. Yoga / read
Phone calls
Staff meeting
Planning
session
billing

149. Vh: jeff w/ puritan oil
Vc: kate re: brimfield
TC umass dermatology.
Spoke w/ cindy 508 8564000

154. Learn French
Be a better spouse
Stop smoking

155. Vh: jeff w/ puritan oil
Vc: kate re: brimfield
TC umass dermatology.
Spoke w/ cindy 508 8564000

156. Learn French
Be a better spouse
Stop smoking
Call umass dermatolody
- cindy 508 8564000

157. Yoga / read
Phone calls
Staff meeting
Planning
session
billing

158. The “Good-Fit” Personal Organizer for
the Client with Executive Dysfunction
• 2 pages per day
• 7 am to 9 pm
• Contains a master to-do list
• With the client at all times
• Use for work and home
• Have only one system

159. Use of the personal organizer or PDA
• Move it from your head to your calendar
• Break long term goals into action items
• The organizer is your budget – how you
“spend” your time
• Use your organizer for every part of your life

160. Use of the personal organizer or PDA
• Use your organizer for every part of your life
– Your to-do list should contain things you have to do, but
also things you want to do, or to be, or to have.
– You make appointments with your doctor or insurance
agent, because they’re important. You can make
appointments with yourself as well.
– “Hi Cindy, this is David…..” (win friends and influence
people with your amazing phone log)

162. easy hard
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164. “error-free learning”

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166. Psychotherapy with the brain-injured
client
• Mild TBI interventions
• Severe TBI interventions

167. Psychotherapeutic Interventions
Individual Therapy
• Permitting appropriate expression of
emotional reaction to TBI and loss
• Patient education
• Social skills training
• Family/spouse involvement
• Impact of memory problems and decreased
insight

168. Psychotherapeutic Interventions
Individual Therapy
• Critical for the therapist to be TBI-savvy
• Consider the environment in which the person
functions
• “Lieben und arbeiten”

169. Psychotherapy with the brain-injured
client
• Develop routines
• Energy conservation

171. Psychotherapy with the brain-injured
client
• Values and motivators

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174. Psychotherapy with the brain-injured
client
• Self-esteem

175. Self - esteem

176. Activity Scheduling

179. Psychotherapy with the brain-injured
client
• Substance abuse and dependence

180. Psychotherapeutic Interventions
Group Therapy
• Modeling
• Problem solving
• Peer feedback
• Social skills practice

181. Behavioral Therapies
• Very few people with TBI have fully lost the
ability to learn new behaviors
• Structure, consistency, and repetition
• Role of cognition in self regulation
• External feedback

182. Behavioral Strategies:
Defining the Problem
• This requires a measurable and precise
definition of the target behavior
– Always get specific examples
– Cross check across settings
– “Pick your battles”?
• Inquire about the antecedents and
consequences

183. Behavioral Strategies:
Identifying the Function
• Everybody’s doing the best he/she can
• Every behavior serves a function
• Every behavior problem is either
– A skills deficit, or
– A contingency problrm

184. Behavioral Strategies:
Identifying Resources
• Personal resources: Memory? Flexibility?
Persistence? Motivation?
• Social / family / peer resources
• Organizational resources

185. Behavioral Strategies:
Guidelines
• Skills
• Safety
• Least restrictive
• Managing the antecedent: Set me up for
success!

186. Examples of Behavioral Strategies
• Antecedents • Interventions
• Provide clear, concrete
• Does not understand instructions; notes
• Give prompts; reinforce
• Does not begin task initiative
• Simplify task; provide skill-
• Unable to do task based training
• Increase interest or
• Is not motivated relevance; reward for task
completion

187. Examples of Behavioral Strategies
 Consequences  Interventions
• Avoids failure by not  Alternate difficulty
complying tasks with easy ones
• Gets out of work  Premack principle
• Receives attention for  Time out or ignoring;
not doing task reinforce for attention
• Gets to assert  Offer choices when
independence/control appropriate

188. Behavior Management Strategies:
X

189. Behavior Management Strategies:
Agitation and Irritability

190. Behavior Management Strategies:
Agitation and Irritability
• Redirection
• Offer an alternative activity
• Relaxation strategies
• Recognize antecedent conditions
• Speak calmly
• Use key familiar phrases

191. Behavior Management Strategies:
Apathy

192. Behavior Management Strategies:
Apathy
• Give choices between doing one thing or
another; not between doing and not doing
• Activity scheduling, in advance

193. Behavior Management Strategies:
Denial/Lack of Insight

194. Behavior Management Strategies:
Denial/Lack of Insight
• Have ongoing discussions of “strengths and
needs”
• Create discrepancy
• This may be the most difficult problem to
address

195. Behavior Management Strategies:
Impulsivity/Disinhibition

196. Behavior Management Strategies:
Impulsivity/Disinhibition
• Structured and organized daily routine
• Rewarding/praising impulse control and
inquiring “how exactly did you do that?”
• “Talking stick”

197. Behavior Management Strategies:
Depression/Withdrawal

198. Behavior Management Strategies:
Depression/Withdrawal
• Help students identify preserved abilities
and strengths - rather than focusing on
their deficits
• Keep TBI survivor involved in the present
rather than dwelling on the past
• Use active listening techniques, but focus
on positive feelings

199. A B C
ANTECEDENTS BEHAVIOR CONSEQUENCES
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200. A B C
ANTECEDENT BEHAVIOR CONSEQUENCES
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201. A B C
ANTECEDENT BEHAVIOR CONSEQUENCES
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202. A B C
ANTECEDENTS BEHAVIOR CONSEQUENCES
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204. A B C
ANTECEDENT BEHAVIOR CONSEQUENCES
metacognition
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205. Beginning Middle End
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206. A B C
ANTECEDENT BEHAVIOR CONSEQUENCES
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207. Treating Sensory Defensiveness

208. Addressing Visuomotor Problems with
Reading

209. What’s the kid’s deal?
• Greene, Ross. The Explosive Child.

210. Family Issues and Needs
• Family stress related to severity of TBI
• The family’s resilience may be key to a brain
injured child’s successful rehabilitation
• Divorce rates range from 15% to 54%

211. Sources of Family Stress
• Uncertainty about recovery
• Cognitive and personality changes
• Financial strain
• Transitions to “new” settings
• Lack of respite care

212. Family Definition of the Event

213. Family Issues and Needs
• Family’s adaptation may take years
• Any change may trigger emotional
response
• Watch for signs of grieving

214. Return to School
• Accommodations and Modifications
• IDEA and Section 504

215. IDEA Definition of TBI:
An acquired injury to the brain caused by
an external physical force resulting in
functional disability or psychosocial
impairment that adversely affects a
child’s educational performance.

216. School Re-Entry Issues
• Educational consultation should begin
before return to school
• Continuity of care between school and
rehabilitation services
• Prepare for multiple transitions
• Re-entry should include interdisciplinary
support

217. Percentage Referred for Services
Home Tutor 3.6
Special Ed. 1.8
Psych. services 2
Family counseling 2.8
Speech therapy 10.1
Ocupational
13.2
therapy
Physical therapy 23.7

218. Basic Criteria for School Re-Entry
• Attends to a task for 10 to 15 minutes
– Adjust for age
• Can tolerate 20 to 30 minutes of classroom
stimulation
• Can function adequately in a group of 2 or
more students
• Engages in meaningful communication
• Follows simple directions accurately
• Gives some evidence of learning potential

219. School Re-Entry Procedures
• Assess needs
–Adaptive domain
–Cognitive domain
–Communication domain
–Sensorimotor domain
–Social-emotional-behavioral domain
–Transportation needs
–Family needs

220. School Re-Entry Procedures
• Identify the best setting for intervention
– Outpatient counseling?
– Home-based family interventions?
– School-based SLP / OT?
– Buddy system at school?
– In-service for school staff?
– Modified school day?
– In-school breaks?
– “Study halls” with resource teacher?
– Pre-vocational training?
• Regular re-evaluation for change over time

221. Developing IEP Goals
• Focus on 2 or 3 priority issues
• Identify metacognitive & organizational strategies
• Write measurable goals that incorporate the
strategies
• Include specific information about how the
strategy should be taught and implemented across
settings
• Write short-term goals that are truly short-term

222. TBI Impact at School
• Problems initiating and completing work.
• Slowed work pace.
• Increased impulsivity.
• Topographical disorientation
• Distractible
• Difficulty generalizing new learning

223. Classroom Management
• Two key factors :
– Structure
– Motivation
• Explicitly teach rules & expectations
• Establish prompts or cues, such as gestures
and reminder cards

224. Classroom Management
• Can students answer the following
questions:
– What do I have to do?
– How much do I have to do?
– When am I finished?
– What do I do next?

225. Classroom Management
• Use repetition & feedback
• Avoid multi-step instructions
• Supplement verbal instructions with
nonverbal / modeling
• Provide additional time for information
processing
• Assist with organization of materials and
schedule

226. Classroom Management
• To be motivating, a task must be interesting
• Intersperse difficult or novel tasks with easy or
previously learned ones
• Distinguish cognitive factors from other issues
(impact of headache, or depression)

227. Specific Classroom Strategies:
Attentional Processes
• Reward on-task behavior;
• Use novel, unusual, relevant or stimulating
activities
• Redirect
• Remove unneccessary distractors
• Explore a variety of cueing systems
– Verbal cues
– Physical prompts
– Gestural cues

228. Specific Classroom Strategies:
Attentional Processes
• Reduce the number of individual tasks on a
printed page
• Reduce the amount of copying from the board
• Provide a ruler or EZ-Reader to focus visual
attention
• Avoid asking a student to multi-task
• Chunking / Pomodoro

229. Specific Classroom Strategies:
Memory and Learning
• Enhance the saliency of material
• Regularly summarize information as it is
being taught
• Dry-erase board
• Use overlapping techniques, such as
repetition and rehearsal

230. Specific Classroom Strategies:
Memory and Learning
• Couple new information with previously
learned information
• Identify in advance the key information to be
learned
• Make use of over-learning

231. Specific Classroom Strategies:
Language
• Limit length and complexity of communication
• Do not use figurative speech
• Recognize the student may not understand
humor or sarcasm

232. Specific Classroom Strategies:
Language
• Reminders to start, end, or repair a
conversation
• Use question prompts to help the student
share more information, especially in
groups
• Allow for slowed information processing

233. Specific Classroom Strategies:
Language
• Speak slowly
• Reduce background noise

234. Specific Classroom Strategies:
Visual Processing
• Provide longer viewing times or repeat
viewings when using visual instructional
materials
• Facilitate a systematic approach to reading
and math by covering parts of the page
• Provide support for orientation to building
and grounds
• Limit visual distractions (web
page, handouts, text, desk)

235. Specific Classroom Strategies:
Executive Functions
• Problem Solving Processes
• Develop a problem-solving guide to help student through the
stages of problem solving
– Identifying the problem
– Acquire relevant information
– Generate several possible solutions
– List pros and cons for each solution
– Identify best solution
– Create a plan of action
– Evaluate the effectiveness of the plan
– Encourage generalization

236. Specific Classroom Strategies:
Executive Functions
• Raise questions about alternatives and
consequences
• Provide ongoing, non-judgmental feedback
• Provide part of a sequence and have the
student finish it
• Frequent cues re: main topic vs. supporting
ideas

237. Specific Classroom Strategies:
Executive Functions
• Note impact of fatigue on cognition
• Note impact of some medications
• Consider reduced workload
• Consider note-taker
• “How exactly did you do that?”

238. SPECIAL CASES

239. • Domestic violence
• Shaken baby syndrome
• Combat trauma
• Alcohol abuse/dependence
• Mild TBI
SPECIAL CASES

240. • Domestic violence
SPECIAL CASES

241. In women reporting to ERs for injuries
associated with DV:
• 30% of battered women reported a loss of
consciousness at least once.
• 67% reported residual problems that were
potentially head-injury related.
(Corrigan 2003)

242. Domestic Violence…
Greater than 90% of all injuries secondary
to domestic violence occur to the
head, neck or face region.
(Monahan & O’Leary 1999)

243. • Shaken baby syndrome
SPECIAL CASES

244. American Academy of Pediatrics-Committee on
Child Abuse and Neglect Pediatrics 2001
“ …95% of serious intercranial injuries and 64% of
all head injuries in infants younger than 1 year were
attributable to child abuse”
Pediatrics, 2001

245. Shaken Baby Syndrome

246. Shaken Baby Syndrome
• Rotational, acceleration, deceleration forces
• There may or may not be impact trauma
• Brain rotates inside the skull
• Bridging veins in the brain may be stretched or
torn
• Subdural hematoma may develop

247. Shaken Baby Syndrome
Kirschner & Wilson’s “dirty dozen”
• 1. Child fell from a low height
• 2. Child fell and struck head on floor or
furniture, or hard object fell on child
• 3. Child unexpectedly found dead (age and/or
circumstances not appropriate for SIDS)
• 4. Child choked while eating and was
therefore shaken or struck on back

248. Shaken Baby Syndrome
Kirschner & Wilson’s “dirty dozen”
• 5. Child suddenly turned blue or stopped
breathing, and was then shaken
• 6.Sudden seizure activity
• 7. Aggressive or inexperienced resuscitation
• 8. Alleged traumatic event one day or more
before death

249. Shaken Baby Syndrome
Kirschner & Wilson’s “dirty dozen”
• 9. Caretaker tripped or slipped while carrying
child
• 10. Injury inflicted by sibling
• 11. Child left in dangerous situation (e.g.
bathtub) for just a few moments
• 12. Child fell down stairs

250. Shaken Baby Syndrome
Symptoms
• Apnea
• Listlessness
• Lethargy
• Poor feeding
• Irritability
• Vomiting
• Seizures

251. • Combat trauma
SPECIAL CASES

252. Combat Trauma
• TBI as “signature wound” of Iraqi conflict
• USA Today 9/07

253. Combat Trauma
• Iraq characterized by different kind of
weaponry: explosive munitions.
• 15% of soldiers returning from Iraq may have
sustained at least mild TBI (Hoge et al 2008)
• 36% may have been exposed to blasts
(Maguen et al 2012)

254. Combat Trauma
• Comorbid PTSD
• Headache
• Sensory impairment
• Alcohol use

255. • Alcohol abuse/dependency
SPECIAL CASES

256. Alcohol Abuse
• May increase morbidity of MVA-related TBI
(Cunningham et al 2002)
• Although low amounts may be protective
• Chronic alcohol abuse associated with
falls, assaults, multiple head injuries
• Overlay of alcohol-related impairment

258. • Mild TBI
SPECIAL CASES

259. TBI Severity: Mild TBI (mTBI)
• Concussion signs and symptoms include ANY changes in
behavior such as:
– Cognitive impairments
– Physical symptoms (e.g., headaches, blurry
vision, diplopia, dizziness)
– Emotional symptoms (e.g., irritability, volatility)
– Sleep difficulties
– Not “feeling like themselves.”

260. TBI Severity: Mild TBI (mTBI)
• Persistent symptoms following the concussion is often
referred to as Post-Concussive Syndrome.
• Cumulative effect

261. TBI Severity: Mild TBI (mTBI)
• Chronic traumatic encephalopathy

262. Psychotherapy with the persistent
post-concussive client
• Perfectionistic tendencies
• Somatic focus
• Poignancy
• Secondary gain
• “old me / new me”
• Check to see whether you are working at
cross-purposes

263. The “Big 5” (plus 1)
• The “Big 5”
– Daily planner
– Daily organization time
– Movement
– Nutrition
– Connection
– Sleep

264. Let’s stay in touch!
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davidnowell David Nowell Seminars