Ann Tarpy, M.Ed. Education, Prevention & Training Officer

1. Understanding Traumatic Brain InjuryFriday April, 25, 2008Workshops Session l9:30 a.m. – 10:30 a.m.Southwestern Arizona Conference on Disability RightsYuma Civic and Convention CenterYuma, Arizona Ann Tarpy, M.Ed. Education, Prevention & Training Officer Arizona Governor's Council on Spinal & Head Injuries 10640 N. 28th Drive Ste. B-102 Phoenix, AZ 85029 602.863.0484 atarpy@azdes.gov

2. Objectives • By the end of this Session, the participant will: • Comprehend the nature and consequences of brain injury. • Identify resources for persons with brain injury and families.

3. Agenda • Opening activities • Part 1 - Understanding the brain • Part 2 – Understanding brain injury • Part 3 – What happens after brain injury • Closing activities and evaluation

4. Understanding Brain Injury • Traumatic brain injury is not: • An acute illness with symptoms that will resolve over time. • A single, unified disorder with a clear, consistent set of symptoms

5. Understanding Brain Injury • Traumatic brain injury is: • A condition with potential life-long implications that may require ongoing services and supports • A multidimensional syndrome affecting a wide variety of areas of function including: • Cognitive • Sensory • Motor • Social • Emotional • Physical

6. Part 1 Understanding the brain –

7. Understanding the Brain • A basic understanding of brain structure may help understand what happens to the brain in brain injury

8. Understanding the Brain • The brain is a very complex and delicate structure with pathways that determine memories, emotions, and basic motor functions. In sum – who we are.

9. Understanding the Brain • It is through our brains that we experience ourselves, the environment and understand our relationships to others.

10. Understanding the Brain • We do not come into this world with a fully developed brain. • The brain begins development in-utero and continues into early adulthood.

11. Understanding the Brain • The brain is made up of billions of nerve cells (neurons) through which messages are transmitted. • As the brain matures the nerve cells develop into different “systems” that develop at specific times.

12. The Developmental Pyramid 16 - 19:… Judgment 12 - 16: Integration/ Problem Solving 6 - 12: New Learning/Attention 3 - 6: Thinking/Emotion/Behavior 0 - 3 Cause/Effect Relationships

13. Understanding the Brain • These systems are designed to serve specific and important functions and are designed to work together.

14. Left Hemisphere – Logical Words (spelling) Verbal meaning Vocabulary in language Details – rules Analysis One-by-one selectivity Step-by-step instructions Sequential ordering Cause and effect relationships Learned facts Letter-symbol associations Abstract reasoning Academically-learned information Ideas Serial/ordered structures Self-verbalizations Selective attention Consciousness – reasoning Scientific logic Right Hemisphere – Aesthetic Images, pictures, and colors – spatial Music and feelings Gestalt – whole/relational Synthesis, comparisons Simultaneous patterning Whole process Whole units Analogies Creativity – new combinations Visual symbolism Concrete Practical – common sense knowledge Patterns of things/theory Random-without structure body language Facial expression, tone of voice Sustained attention Meditation, spontaneous ideas, subconscious Spiritual – mythical Patterns of logical associations Cognitive Skills/Functions Associated with Hemispheres of the Brain

16. Brain-Behavior Model OUTPUTS (motor, oral, written) Concept formation, reasoning, logical analysis Language skills Visual-spatial skills Manipulations in Active Working Memory Attention, concentration, memory Inputs Visual Inputs Auditory Inputs Kinesthetic

17. Part 2 Understanding Brain Injury

18. Understanding Brain Injury

19. Understanding Brain Injury • Examples of non-traumatic brain injury from medical conditions include: • Infectious disease (e.g., meningitis, encephalitis) • Brain tumor and their treatments (chemotherapy and radiation can cause diffuse brain damage) • Neurological disease (e.g. multiple sclerosis) • Cerebrovascular disorders (e.g. stroke) • Toxic chemical or drug reactions (e.g., lead poisoning, carbon monoxide poisoning) • Hydrocephalus • Substance abuse

20. Understanding Brain Injury • Hypoxia/Anoxia may be traumatic or non-traumatic and results in generalized, diffuse damage to the brain: • Suffocation • Suicide attempts • Near drowning • Other injuries (cardio or pulmonary) can reduce blood flow to the brain

21. Understanding Brain Injury A traumatic brain injury (TBI) is a result of: • Blunt or penetrating trauma to the head such as a gunshot wound.

22. Understanding Brain Injury • Coup – contrecoup injury from acceleration - deceleration forces such as motor vehicle crashes or shaken baby syndrome.

23. Understanding Brain Injury • Mild, moderate, and severe brain injury are the clinical terms used to describe the “type” of brain injury the person sustained. • However, these same descriptors often fail to tell us about the “functional outcome” of the injury.

24. Part 3 What happens after brain injury

25. What happens after brain injury • After brain injury, traumatic or non-traumatic, a person may present with a complex interplay of: • physical, • psychological, • cognitive symptoms or signs…

26. What happens after brain injury • … that may lead to behavioral changes and social impairments that can continue in varying degrees after physical recovery.

27. What happens after brain injury • It is the complex neurobehavioral problems that may cause the greatest disruption in the survivor’s and family’s life.

28. What happens after brain injury • Injury in childhood results in an underdevelopment of the brain functions of the areas impacted by the injury.

29. What happens after brain injury • Abilities that are just developing or have not yet emerged are the most sensitive and more likely to be disrupted as a result of brain injury.

30. What happens after brain injury • These abilities and their associated areas of function are likely to be the Achilles Heel for a child with a brain injury, even after growing up. The impacts of the injury may become more complex as the child matures. • Often, depending on the age of injury, the effects of brain injury in childhood is not evidenced until later when the “developmental expectations” and/or demands of the “environment” (home, school, and/or community) increase – challenging the capacity of the individual to engage.

31. What happens after brain injury Brain injury impacts a person’s ability to: • Receive • Store • process • Accumulate, and/or • Retrieve information Resulting in changes in the person’s behavior (e.g. may be inappropriate, not as expected or anticipated, may no longer be able to function at their previous level of performance in school, at home, other environments.)

32. What happens after brain injury • If these behaviors or problems are ignored, misdiagnosed, or not understood as part of brain injury, they may lead to more lasting problems (e.g. depression, aggression, impulsivity, poor self-esteem) that will interfere with integration or reintegration into home, school, work, and the community.

33. What happens after brain injury Behavior following brain injury, is likely to be influenced by or an interaction between the following factors: • Acquired organically-based changes (e.g. in personality, cognition and behavior) • Complications caused by emotional reactions to difficulties and changes from the injury • Pre-morbid characteristics • Family system/family functioning (pre/post injury) • Environment • Reaction to medication • History of substance abuse • Level of awareness and understanding of brain injury.

34. What happens after brain injury • Environment is the one variable over which family members, caregivers, and service providers have the most control. • Changing the expectations of the individual in the environment can change/improve the behavior.

35. There are a number of ways that the effects of TBI impacts the individual’s ability to interact with the environment and his/her behavior: Impaired ability to interpret social cues Less able to inhibit impulses or select appropriate behavior Slowed information processing speed Poor or delayed recall Decreased ability to anticipate consequences What happens after brain injury

36. What happens after brain injury • A person with a brain injury may engage in deliberate behaviors (adaptive and maladaptive) as a means of communication…

37. What happens after brain injury • For the purpose of seeking control when control is threatened (stress reaction) • To have a basic need met • When others are not listening • When all else fails • Out of frustration due to other impairments associated with the injury (e.g., delaying information processing speed, memory impairments, physical limitations, etc.)

38. What happens after brain injury • The cognitive, physical, psychological, and emotional changes that occur after brain injury will affect the individual’s perception of his/her world and how s/he interacts with and responds to others.

39. By understanding that behavior may be a manifestation of the brain injury or a means of communication, family members, caregivers, and service providers can begin to interpret “compliance” or lack of compliance in light of the brain injury, not as volitional or lack of interest. What happens after brain injury

40. What happens after brain injury • Questions may remain about the volitional intent behind behaviors, especially if they are related to brain injury. • The answer to the question whether a particular behavior has an underlying organic cause or is manipulative, willful, or deliberate is complex. • Default approach is to consider the behavior is either directly or indirectly related to the injury.

41. What happens after brain injury • Important for the family member, caregiver, and/or service provider to be aware of his/her perception of what the behavior means.

42. What happens after brain injury • Understanding that changes in behavior after brain injury are a manifestation of the injury, helps family members, caregivers, and/or service providers change their reaction/response to the behavior(s) which may: • Increase their tolerance of the behavior(s). • Allow the family, caregivers, and/or service providers to blame the injury rather than the person and not take personal offense.

43. What happens after brain injury • Stress is a common reaction when working with individuals with a brain injury. • The stress reaction generally occurs in situations where the demands of the environment exceed an individual’s (perceived) resources to handle the situation. • The stress reaction can occur in the individual with the brain injury, the caregiver, family member and/or service provider.

45. What happens after brain injury Understanding brain injury and the impact of the brain injury on the individual and the family is really about understanding loss – at many levels.

46. What happens after brain injury • For the individual – (depending on the level of awareness) s/he may mourn the loss of: • Memories of experiences that connect them with family and friends • Sense of self – who they were before the injury • His/her role and status in the family, at work, with friends • Physical functioning • Changes in thinking and behavior • Ability to do some of the things they did before • The life they had before the injury

47. What happens after brain injury • For the family, they are mourning the loss of: • Who the individual was before the injury - connection to the individual through memories of shared experiences. • Hopes, dreams, and the future they had for the individual. • Their way of life and now facing the reality that life may never be returning to the way it was before. • The role the individual played in the family. • For a spouse, they may be mourning the loss of their companion, their support, their partner.

48. What happens after brain injury • Families members, individually and as a unit, experience an ongoing journey filled with challenges and changes through the recovery period and then adjusting to life after brain injury. • In many cases, recovery becomes a lifelong process of adjustments and accommodations for the individual and the family as they deal with acceptance and understanding of the injury and subsequent limitations and consequence.

49. What happens after brain injury • For the individual with a brain injury, survivorship is about understanding the “new person” who is developing. • For the family, it is understanding the new family that is emerging.

50. Resources • A separate handout of resources is included in your packet of materials.