T RAUMATIC BRAIN INJURY

November 2015

Understanding Capabilities and Workplace Success Strategies

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Atlanta Regional Mental Health Specialist

Dr. Suzanne Martin, PsyD, MPH

Diane Fairchild, B.A.

Disability ProgramConsultant

PRESENTERS

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OBJECTIVES

IDENTIFY POSSIBLE REASONABLE ACCOMMODATIONS FOR STUDENTS WITH TBI SPECIFIC TO THEIR FUNCTIONAL LIMITATION MANIFESTATIONS

UNDERSTAND THE CHALLENGES EXPERIENCED BY INDIVIDUALS WITH MILD TBI

DESCRIBE AT LEAST 3 STRATEGIES FOR BUILDING INDEPENDENCE WITH YOUNG ADULTS WITH TBI

DESCRIBE THE BASIC CAUSES AND SYMPTOMS OF MILD TBI IN A YOUNG ADULT POPULATION

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MILD TBI (mTBI) - CONCUSSION

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TBI Defined

“…..is caused by a blow to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the

head result in a TBI. The severity of a TBI may range from “mild” (a brief change in mental

status or consciousness) to “severe” (an extended period of unconsciousness or amnesia after

injury)”

- Centers for Disease Control & Prevention

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TBI Incidence

In the U.S., an estimated 1.7 million people sustain a traumatic brain injury (TBI) each year

Currently 5.3 million Americans are living with a disability as a result of TBI (about 2% of US population)

More than 50,000 people die each year from TBI (22% of people with TBI)

Firearm related TBIs are often a result of someone trying to attempt suicide

The risk of TBI in men is twice the risk in women Every 21 seconds, one person in the U.S. sustains a TBI

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What Happens in a mTBI?

Impact shakes the brain inside the skull A wave through brain tissue causes discharge of damaging

chemicals Nerve cells can cut off Microscopic damage can affect the anatomy and function of

brain cells – usually not visible even on an MRI

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LEVELS OF TBI

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Levels of TBI

Mild TBI

• Glasgow Coma Scale • Score of 13-15

• 85% of all TBIs are Mild

Moderate TBI

• Glasgow Coma Scale • Score of 9-12

Severe TBI

• Glasgow Coma Scale • Score of 8 or less

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SYMPTOMS OF TBI

Headache

SYMPTOMS OF TBI

Confusion

Nausea

Mood & Behavior Changes

Sensitivity toLight & Noise

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Headache

COMMON COMPLAINTS AFTER A TBI

Confusion

Nausea

Mood & Behavior Changes

Sensitivity toLight & Noise

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Common Myths

“If you didn’t lose consciousness you didn’t have a TBI.”

“You must have a positive MRI or CT scan to show that a TBI has occurred.”

“Mild TBI injury is immediate and easily recognizable.”

“If you have a TBI, then you have PTSD, too.”

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If there is mTBI, the likelihood of experiencing a repeated TBI is greater.

With athletes who have had at least two or three concussions, a decade, two, or even a lifetime of increased risk of concussion is possible.

RISKS

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GOOD NEWS:85% of people with mild TBI have no long-term symptoms

BAD NEWS:15% of people with mild TBI have lingering or long –term symptoms

PROGNOSIS

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Brain Damage

The part of the brain most frequently damaged in a TBI are the frontal lobes.

The frontal lobes govern personality and impulsivity.

Frontal Lobe Brain Functions

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CHALLENGES AFTER A TBI

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Challenges after a mTBI

Difficulty processing and understanding information Attention and concentration difficulty Language and communication problems Difficulty learning and remembering new information Planning and organization difficulty Difficulty reasoning, problem-solving and making

judgments Impulsive behavior

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Alcohol slows down or stops brain injury recovery.

Drinking alcohol puts survivors at an even higher risk of having a second brain injury. This may be because both brain injury and alcohol can affect coordination and balance.

ALCOHOL USE AFTER mTBI

Alcohol lowers the seizure threshold and may trigger

seizures.

Alcohol may affect brain injury survivors more than it did before

their injury.

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TREATMENT

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Treatment

The main treatments for a mild TBI are for symptom relief of:

• Pain • Impaired sleep • Mood disturbances• Cognitive challenges (e.g., memory)

SYMPTOM MANAGEMENT

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Go ahead and replace

Limit exertion with activities of daily living and limit

scholastic activity while symptomatic

“COGNITIVE” REST

PHARMACOLOGY

PHYSICAL REST

Management of specific symptoms

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Cognitive Rest

No computer activities No video games No recreational reading No board games No card games No text messaging No computer activities No practicing musical instruments

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What is OK on Cognitive Rest Can watch TV, movies, and listen to music (the

volume should be low). Attending classes and participating in center life

(e.g., dorm duties, etc.)• If attending classes and participating in required center

life activities increases symptoms, the student may need accommodations.

• The clinical team would evaluate and/or review and then refer to the RAC, as appropriate.

FUNCTIONAL CHALLENGES

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(learning, memory, and reasonsing(

(balance)

(communication, expression, and understanding)

(depression, anxiety, personality changes,

aggression, acting out, social inappropriateness)

COGNITION SENSATION

LANGUAGE EMOTION

Strategies that Promote Employability and Independence Capitalize on the student’s strengths Strengthen intact cognitive and communication

skills Teach compensatory strategies such as memory

aids Modify environment factors that serve as barriers

and enhance successful communication and participation, including development and use of appropriate accommodations

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FUNCTIONAL LIMITATIONS AND ACCOMMODATIONS

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Cognition

Accommodations to address learning, memory, and reasoning:

• Extended time• Use multiple ways to teach new concepts (UDL)• Allow students to demonstrate knowledge in multiple

ways (UDL)• Be as concrete as possible• Teach memory strategies• Direct instruction• Pre-teach key vocabulary and concepts

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Cognition Example

Functional Limitation Student is unable to

learn and remember the key components of the safety manual in Electrical.

Accommodations Peer mentor provides

opportunities for pre-teaching and reviewing key safety concepts by shadowing/modeling, repetition, use of pictures, videos, realia…

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Visually Supported List - Electrical

Step 1 Watch for warning signs.

Step 2 *Wear proper safety gear.

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Supporting “Cognitive” Rest Center physician and/or CMHC orders “light” duty for

a specified period of time. As a result, the RAC meets. What type of accommodations might be considered?

• Modified scheduleo All academics (although all academics might be taxing, too, so the

career technical component has to be evaluated)o More cognitive type tasks earlier in day to lighter tasks later in

the dayo Increased breaks

• Maybe a brief rest period in wellness once a day

• Mixing mediums of content deliveryo Pre-recorded audio, reading, manipulatives

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Supporting “Cognitive” Rest

Limit use of technology (computers, texting)

Reduced dorm duties or “lighter” dorm duties assigned

• Alternative might be to complete one light duty task, take a nap and complete another a little later

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Staying Organized

Make daily TO-DO lists and check items off as they are completed

• Keep lists brief so as not to overwhelm Remind student of important deadlines via memos

or e-mail or weekly supervision• Plan to transition this to a self-monitoring type support,

if possible Use a watch or phone/app with timer capability Use electronic organizers

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Staying Organized

Divide large assignments into smaller tasks and steps

Assign a mentor to assist in determining goals and provide daily guidance

• Transition to self-monitoring check-lists or electronic organizers, etc., over time to prepare for employment

Schedule weekly meetings with instructor, manager, or mentor to determine if goals are being met

• Transition to self-monitoring check-lists or electronic organizers, etc., over time to prepare for employment

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Supporting Memory

Allow the student to tape record (audio and/or video) key lectures/demonstrations or provide pre-recorded materials

Use notebooks, calendars, or sticky notes to record information for easy retrieval

Provide written as well as verbal instructions Allow additional training time Provide written checklists, use color-coding to help

identify items, or use cell apps Post instructions close to frequently used equipment

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Sensation

Accommodations to address balance:

• May need a mobility aido Caneo Walker with seato Wheelchair

• May need to address physical settings for accessibility

• Could be more than balance or mobility o Could include hypersensitivity to

sights, sounds, smells, etc.

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Language – Communication, Expression & Understanding Determine communication preference

• Allow to communicate in multiple ways (pictures, technology, writing, symbols)

Social skills training Evaluate and eliminate distractions

• Background noises• Traffic flow• Visual clutter

Model communication styles and options• Speak in clear short sentences avoiding words that are

technical or difficult to understand

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Emotion

Provide praise and positive reinforcement

Refer to social skills groups and/or counselor

Provide flexibility to take brain breaks

Provide sensitivity training to fellow students/co-workers

Allow the student to take a break as a part of a stress management plan

Remain calm, keep an even tone

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Let’s Practice!

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Scenario #1

Michael is a bright 19-year old student who was in a rollover motor vehicle accident 3 months ago. He lost consciousness for 30 minutes. He was evaluated at the ER and sent back a day later with instructions to rest for 3 days.

He presents to HWC with the following complaints 3 months later:

• Sleep disturbance• Chronic headaches• Irritability with peers and teachers

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Scenario #2

Minor student with mild TBI RAC met with parent and student

prior to arrival Requesting CNA or Office Functional Limitations include:

• Difficulty with expressive communication

• Confusion during transitions• Memory issues• Organizational issues

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Center-wide Accommodation Considerations Career Prep Academics (High School) Career Tech (Office or CNA Residential Transition/Independence

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RESOURCES

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Web Resources

CDC’s Injury Center• www.cdc.gov/TraumaticBrainInjury

Brain Line• www.brainline.org

Brain Injury Association of America (BIA)• www.biausa.org

Defense and Veterans Brain Injury Center (DVBIC)• www.dvbic.org

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Job Corps Disability Websitehttps://supportservices.jobcorps.gov/disability/Pages/default.aspx

Job Corps Health & Wellness Website

https://supportservices.jobcorps.gov/Health/Pages/default.aspx

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Job Accommodation Networkhttp://askjan.org

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Regional Mental Health Specialists Region 1 - David Kraft, MD,

MPH• dkraft@external.umass.edu

Region 1 (Puerto Rico) - Maria Acevedo, PhD • mmacevedo@onelinkpr.net

Region 2 - Valerie Cherry, PhD• vcherryphd@gmail.com

Region 3 - Suzanne Martin, PsyD, MPH• suzannempsyd@gmail.com

Region 4 - Lydia Santiago, PhD• lydia.v.santiago@att.net

Region 5 - Helena MacKenzie, PhD• helena.mackenzie530@g

mail.com Region 6 - Vicki Boyd,

PhD• vdelboyd@aol.com

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Regional Medical Specialists Regions 1 and 2 - John

Kulig, MD• jwkulig@gmail.com

Regions 3 and 5 - Gary Strokosch, MD• gstrokosch@aol.com

Region 4 - Drew Alexander, MD• cyvoc@yahoo.com

Region 6 - Sara Mackenzie, MD, MPH• saramack17@msn.com

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Regional Disability Coordinators Boston, Philadelphia, and Dallas Regions – Kristen

Philbrook• kristen.philbrook@humanitas.com

Atlanta and Chicago Regions – Sharon Hong• sharon.hong@humanitas.com

San Francisco Region – Kimberly Knodel• kimberly.knodel@humanitas.com

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Thank you for

attending!Questions?