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