By Carolyn Rocchio

Brain injury rehabilitation overlooks sexual impact of trauma

One of the common consequences of traumatic brain injury (TBI) is sexual dysfunction. Unfortunately addressing sexual issues as a component of rehabilitation is often overlooked for a variety of reasons.

“Sexuality is an integral part of the human experience” (Sander). We are all sexual beings and sexuality is part of our life experience. Social mores and cultural differences make sexuality a taboo issue in some societies. Many therapists and other direct care providers in hospital and rehabilitation settings are untrained about sexuality and persons with disabilities. Their personal values often interfere with their ability or comfort level discussing the topic. When sexuality is overlooked as part of rehabilitation, sexual dysfunction can become an issue that is very difficult for families to understand.  Social isolation, common for persons after TBI, limits opportunities for developing meaningful relationships. 

Decreased dollars for rehabilitation services add to the problem.  With shorter number of days for care in rehabilitation programs to address the life altering effects of brain injury, such as mobility and cognitive impairments, there may be little time to discuss sexuality. Reimbursement for extended psychological and counseling has been all but eliminated from many insurance policies.

Hyposexuality and hypersexuality after brain injury

Sexual dysfunction after a brain injury may take the form of hyposexuality, as in loss of libido and lack of satisfaction. Hypersexuality can be equally problematic, but far more troubling to manage in rehabilitation and community settings. Hypersexuality manifests as inappropriate behaviors, such as verbal remarks, touching one self or others, exposing genitals, and sexual demands that are considered aberrant. These issues appear equally between men and women.

Cognitive, physical and emotional changes affect sexual functioning   

Injury to structures of the brain can result in varying degrees of dysfunction. Systemically a complex set of changes can occur affecting emotions, cognition, behavior, and mobility. Physical changes may alter the ability to enjoy satisfaction, particularly when there are residual physical changes such as:

• spasticity
• hemiparesis
• ataxia
• movement disorders 
• decreased balance    

Body positioning, balance, and arousal may require greater patience and guidance from partners. In addition, damage to the frontal or temporal lobes of the brain can affect the endocrine system and neurochemistry, resulting in such emotional responses as apathy, disinhibited behaviors, impulsivity, as well as physical changes in hormone levels.

Even more disabling are the cognitive changes. The frontal and temporal lobes of the brain regulate sexual functioning and are more frequently injured in car crashes and falls causing the brain to bounce around in the skull striking the bony protuberances on the inside of the skull. This often results in the following difficulties in maintaining or initiating satisfying sexual experiences: 

• decreased empathy for others
• inability to understand nonverbal cues (feedback)
• impaired social interaction with partners (inappropriate verbal/physical responses)
• difficulty self monitoring (can become aggressive)

Emotional issues, such as depression, can have a negative effect on sexuality. Some persons with brain injury may exhibit a child-like dependency on their partner.  Self centeredness in the person after TBI may result in exclusion of the views of others.  Any of these can sabotage  relationships. Medications commonly prescribed to control seizures and other residual medical and psychological complications of TBI can create additional problems with sexual functioning.

Rehabilitation professionals do not routinely treat or even discuss sexuality with patients for some of the following reasons: 

• family members’ discomfort discussing the subject
• therapists’ lack of training about sexuality
• lack of reimbursement for services
• level of cognitive recovery at time of individual’s discharge

How, when and what information on sex and sexuality should be addressed?

There is probably no perfect time that applies to all individuals due to the uniqueness of TBI, the person’s age and life situation, and the individual’s interest in resuming or initiating sexual activity. It is important that rehabilitation programs have printed materials for discussions with the patient, if appropriate during the inpatient stay.  They should also be included as part of a discharge plan to help guide discussion once the person is in the community and indicates interest and readiness for sexual activity.

These materials should include:

• general discussion of the many ways brain injury or TBI can affect sexual functioning, i.e., emotionally, physically, cognitively, and psychologically
• safe sex practices, HIV/AIDS, birth control, and sexually transmitted diseases
• methods and devices for self stimulation in the absence of a partner
• community resources should further treatment be required

With proper guidance, family and community support, most survivors of TBI will find ways to express themselves sexually in a responsible manner as part of the experience of their humanness.

References

Sander, AM. Integrating Sexuality into Traumatic Brain Injury Rehabilitation. Brain Injury/Professional. 7(1) 8-12, 2010

Recommended reading

This Fact Sheet is based on an article: Integrating Sexuality into Traumatic Brain Injury Rehabilitation. Brain Injury/Professional. 7(1) 8-12, 2010. Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to order the entire issue or join.

For more information, see:  

Sexuality after a Person has a Brain Injury

By David Strauss, Ph.D.

Corrects myths about sexuality among adults with disabilities and brain injuries. Gives strategies for families and caregivers on how to respond to sexual behaviors, disinhibition and changes in judgment and social skills.

Brain Injury It is a Journey

By Flora Hammond, M.D. and Tami Guerrier, B.S., Editors

This brain injury book for families explains consequences of traumatic brain injury and gives strategies for coping with changes in the survivor’s physical abilities, memory, attention, thinking and emotions. 

Brain Injury Magazine

These Fact Sheets are based on special issues published by Brain Injury Professional.

Back issues are available by calling the publisher HDI at (800) 321-7037. 

Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to become a member.

By Carolyn Rocchio

Treatment for cognitive functioning after brain injury

Cognitive rehabilitation is a “systemically applied set of medical and therapeutic services designed to improve cognitive functioning and participating in activities that may be affected by one or more cognitive domains” (Katz, Ashley, et al, 2006).

There is no longer any doubt about the effectiveness of cognitive and behavioral rehabilitation   following brain injury. However, insurance companies too frequently move patients with brain injury out of the medical model more rapidly for cost savings.  Children and youth comprise a very low percentage of those who receive any meaningful extended rehabilitation of functional impairments.  Most children and youth are discharged home to the care of parents and school systems.

Children are not “little” adults…their brains are still developing

During the developmental years, the child’s brain is not yet fully formed.  Nor is it as sophisticated as the brain of an adult.  In these developmental years which extend through the late teens and early twenties, children are expected to reach a number of milestones as they grow and mature.  A brain injury interrupts the normal developmental process.  This can subsequently have an impact on the child’s academic achievement and ability to socially interact with family and peers.  In most cases, the burden and responsibility of follow up care and remediation of the child’s deficits fall to parents and educators.

Parents are usually neither educated nor prepared to recognize and assess how the injury has affected their child’s learning capabilities and interactions within the family.  Yet parents ultimately become the case managers for their child’s follow-up services at school and in the community.  Educational systems vary significantly nationwide; however, all must comply with the Individuals with Disabilities Education Act which is the foundation for special education in all states. 

The student with a brain injury will have changing educational needs as the latent effects of the trauma to the brain emerge over time.   So it is important for educational programs for these students to include check points and flexibility to address the student’s emerging and developing special needs after an acquired brain injury.  Parents and educators can be most effective when they work as partners on behalf of the child and student. 

Cognitive rehabilitation for children requires special considerations

The following key factors must be considered when designing and providing cognitive rehabilitation for children and youth:

• Effects of the injury may be delayed; the younger the child when injured, the more likely that expected developmental milestones may be delayed or unattained.
• Youngsters with brain injuries need different approaches to learning to compensate for cognitive deficits in school.
• Increased guidance and cognitive models of rehabilitation can provide necessary checkpoints and flexibility to support optimal maturation when brain injury negatively impacts the child’s interactions with family and peers.
• Dual roles of parenting and case management increase stress for parents.  They require educational resources, information and support to successfully assist with the child’s transition from the medical and rehabilitation arena to the school system and community.

Transition from hospital to school after brain injury is critical

Ideally, day cognitive rehabilitation programs resembling school-like environments can provide children with individually designed approaches to academic achievement with feedback from therapists experienced in brain injury rehabilitation.  These programs facilitate the child’s transition from medical to school systems and the community.  This transition is critical as schools focus on learning and achievement, not on remediation of cognitive deficits.  A few hospital to school transition programs for children with acquired brain injuries exist within some large urban pediatric medical centers; however, overall their availability ranges from scarce to non-existent in local communities.  

Cognitive rehabilitation for children requires partnerships with parents and monitoring the brain injury’s effects on the child’s development and academic achievements.  The future holds the promise of greater interventions to enhance the progress of children with brain injuries. Research that is more focused on longitudinal studies can provide the information that will ultimately lead to the development of more comprehensive models of care for children with acquired brain injuries.

References

Katz, DI, Ashley, MJ, O’Shanick, GJ & Connors, S. Cognitive Rehabilitation: The evidence for funding and case for advocacy in brain injury. Retrieved January 16, 2009 from Brain Injury Association of America website at www.biausa.org/policyissues.htm.

Haarbauer-Krupa, J (2009).  Cognitive Rehabilitation for Children and Youth: Moving toward collaborative partnerships. Brain Injury/Professional 6(2) 20-22.

Recommended reading

This Fact Sheet is based on a special issue of Cognitive Rehabilitation: Efficacy and Best Practice of the Brain Injury/professional (vol. 6, issue 2) 2009.

Brain Injury/professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Brain Injury/professional is published jointly by NABIS and HDI Publishers.  Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to join.

Handling Behavior after Brain Injury

By Carolyn Rocchio

There are many misconceptions concerning the word “behavior.”  The American Heritage Dictionary defines behavior as “the actions or reactions of a person (or animal) in response to external or internal stimuli.”  The reality is that no two people react similarly to the same stimuli.  Occasions considered to be happy by most may be too over stimulating or interpreted differently by a person with an acquired brain injury (ABI) leading to their acting out inappropriately.  Both parties are reacting to the same external stimuli (the event) but internalizing it differently. Everything we do constitutes behavior.

Brain injury can create major challenges to the way an individual thinks and acts in many of the following functions:

• attention
• concentration
• awareness
• memory
• initiation
• organization
• abstraction
• sequencing
• stamina
• vision
• smell
• touch
• other factors unique to the individual.

These cognitive impairments coupled with physical residual, i.e., mobility issues, pain and premorbid conditions can contribute to unexpected or unreasonable responses to a situation.

Behavioral challenges change over time

Behavior is always changing and it is important for the observer to be aware of what occurred before the behavior changed. Identifying the antecedent is an important step toward determining how to redirect or manage the resulting behavior.  As a result of ABI, the individual may undergo many changes in daily routines, diminished skills, altered relationships, loss of income, lowered self awareness and many other factors over which they have may have little control.  The result is that the person is not necessarily acting badly but acting differently in relation to a diversity of internal and external factors.

Premorbid issues can have a profound effect on behavior.  Science and medicine can do very little to “fix” neurologic impairments.  It may be some time after the conclusion of medical and rehabilitative treatment before the behavioral challenges are addressed.  Ideally, a proactive approach might offset a crisis by identifying the challenges, defining the factors that promote these behaviors and developing strategies that promote functional competency.  This approach could potentially prevent the behavior from escalating to a crisis stage.

• Recognize the problem.
• Assess the factors that contribute to it.
• Understand the goals and abilities of the individual.
• Develop the supports needed to promote increased function.

“The concept of ‘behavior’ is not just relegated to ‘bad things’ people do, but represents the sum of everything that we do” (Jacobs, 2008).

Specialized behavioral modification programming

Behavioral modification, specific to ABI, was slow to develop as most disruptive or difficult patients were channeled into the mental health systems.  The origin of behavioral modification has its roots in Northampton, England over thirty years ago.  One of the pioneers, neuropsychiatrist Dr. Peter Eames, was experienced in managing behavioral programs for disturbed adolescents and believed the same principles could be applied in the treatment of persons with brain injury.  Their first program was a classic token economy with the emphasis on positive reinforcement for acceptable behavior.  In order that the tokens distributed were meaningful, the staff was required to make all interactions with the clients positive and enjoyable.

To work effectively, token economies have to have consequences when performance does not measure up to the expected level.  When that occurred, clients were unceremoniously removed to a quiet room for short periods of “time out” until the unwanted behavior ceased. Realizing that the clients had injured and under functioning brains, in addition to the positive reinforcement some clients were placed on medications to replace lost functioning.  Those medications that control abnormal behaviors that interfere with daily functioning were found to be efficacious.  Clients with Episodic Dyscontrol (sudden outburst of short duration, with sudden onset and offset, followed by remorse) usually benefited from certain seizure medications.  Anti-depressives were used for those with depressive illness and antipsychotics for those with clearly defined psychiatric disorders.

The programs developed by Dr. Eames, et. al, later abandoned the token system for an internally recorded point system relying purely on the power of social reinforcement combined with use of time out interventions for positive reinforcement.  With this change, staff became more engaged in the program goals.  They even quit locking the time out room which seemed to make no difference to staff or clients or the effectiveness of the intervention.

Although behavioral modification programs are universally used with both inpatients and outpatients, Dr. Eames believes the results are less stable and lasting when limited to short term time frames.  He further states, “There have really been no new initiatives or methods of behavioral modification in recent years.  That may be simply because the basic nature of this form of treatment has long been well established” (Eames, 2008).

Crisis hospitalization

Quality programs exist to manage all phases of recovery following brain injury; however, when it comes to crisis hospitalizations there is scarcity of care available in most communities.  Mental health professionals are often poorly equipped to manage patients with ABI.  When behavioral decompensation occurs, traditional treatments and protocols are frequently ineffective.

“Other then brief screenings of limited value, mental health units do not routinely conduct neuropsychological evaluations on all individuals with ABI.  The lack of such data can undermine treatment since behavioral dyscontrol leading to hospitalization often has its roots in cognitive dysfunction” (Karol, Sevenich, 2008).

The key variables that ABI presents for effective treatment in mental health systems include:

• Consideration of cognitive deficits and strengths.
• Unique adjustments following brain injury.
• The response of the patient to psychotropic medications.
• The need for supradisciplinary teams.
• Specialized discharge planning.

Traditional mental health counseling and psychotherapy, in order to be effective, must be adapted to compensate for the cognitive and communication challenges of this population. Mental health professionals can be unlikely to address the way ABI behavior can be so different from other mental health issues in ways, such as:

• Catastrophic condition or the failure to perform as expected.
• Manifestation of grief which is different from depression.
• Psychological denial (anosognosia) or unawareness of the truth.

Medications are an important component to managing behavior. But medications in mental health programs may produce a very different response with ABI. Community supports must be carefully managed and in place before discharge to prevent relapse. Crisis hospitalization for ABI should be managed in dedicated brain injury neurobehavioral units with experts in brain injury and behavioral management working in a supradisciniplinary team.

References

Eames, P. (2008). Neurobehavioral Beginnings: the kelmsley unit. Brain Injury/Professional 5:4(12-14).

Jacobs, H. (2008). Ain’t Misbehaving! Brain Injury/Professional 5:2(8-10).

Karol, R & Sevenich, R. Neurobehavioral Crisis Hospitalization: on the need to provide specialized hospital brain injury crisis programming. Brain Injury/Professional 5:4(16-21).

Recommended reading

This Fact Sheet is based on a special issue on Behavior of the Brain Injury/Professional (vol. 5, issue 4, 2008). Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS).  Brain Injury Professional is published jointly by NABIS and HDI Publishers. Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to order the entire issue or become a member.

For more information, see:

Myths & Facts about Behavior after Brain Injury

By Harvey E. Jacobs, Ph.D.

Brain injury behavior problems are reinforced by myths with inaccurate information about changes in behavior after head trauma. Helps families and caregivers understand causes and reasons for behaviors and learn how to respond positively.

Behavior at Home

By Carolyn Rocchio and Harvey E. Jacobs, Ph.D.

Information and tips for families and caregivers on managing behaviors after brain injury at home. Identifies behavior problems and shows families how to develop successful strategies for change and positive support.

Behavior Programs and Behavior Problems

By Harvey E. Jacobs, Ph.D.

Information on changes in behavior after traumatic brain injury and challenges for behavior programs are described. Helps caregivers, staff and families identify effective treatment strategies and develop positive behavior supports.

Recognizing Mild Traumatic Brain Injury Concussion

By Marilyn Lash, M.S.W.

Lash and Associates Publishing/Training, Inc.

Mild traumatic brain injury is often described as a “hidden” condition because too often it is not diagnosed by medical professionals. Consequently, many individuals are unaware that their brain has been injured and do not seek help. Changes in their executive functions and social skills are often confusing to these individuals and their families with no clear cause or explanation for altered abilities and behaviors. Fortunately, the effects are brief for most people and they soon “get back to normal.” For others, however a so called “mild” brain injury has life long consequences that directly contribute to educational, vocational and economic difficulties.

How many people have mild brain injuries?

It’s difficult to come up with an exact number because many people do not seek medical treatment and are not hospitalized. One of the few estimates comes from a National Institutes of Health Consensus Statement on TBI in 1998 that calculated up to 6.5 million people who have been hospitalized with a traumatic brain injury live with significant changes in their lives. It is estimated that 75-85% of them have mild brain injuries. This results in an estimate of 5.5 million people having a mild traumatic brain injury (Gordon & Brown, 2008).

But this large number still misses people who are not treated in the hospital and those who do not seek treatment. For every person with a mild traumatic brain injury who is hospitalized, 3 to 5 other people are not hospitalized (Gordon & Brown, 2008). This increases the number significantly.

Does a mild brain injury have lasting effects?

Only 15% of people with mild brain injuries will have long-term difficulties (Gordon & Brown, 2008). Yet this group may have serious issues that affect their lives. An important study by Silber and colleagues in New Haven, CT compared people with traumatic brain injuries to people with no disability and to people with a physical disability. The findings were striking. Among people with traumatic brain injuries (mostly mild and unidentified):

• 1/3 more reported poor physical health
• 2/3 more reported poor emotional health
• 2/3 more received welfare or disability payments
• 4 times as many had attempted suicide (Gordon & Brown, 2008).

How do mild brain injuries affect children?

Even though the Individuals with Disabilities Education Act includes a specific category for traumatic brain injury, the numbers of these children who are receiving special education services in school remains very low across all states. Many educators are not adequately trained to distinguish between the symptoms of traumatic brain injury, learning disabilities and emotional disability. One study of students found that 1/3 of students in a special tutoring program for children with a learning disability were in fact children with traumatic brain injuries (Gordon & Brown, 2008).

What about people who abuse substances?

Another study of 850 enrolled in substance abuse programs in New York were screened for traumatic brain injury with significant results. More than 50% reported one or more brain injuries. Of that group, 40% reported symptoms consistent with a mild brain injury (Gordon & Brown, 2008).

This same study found that people with a history of a traumatic brain injury were more likely to have:

• more than 2 previous episodes of substance abuse treatment
• a current or past mental illness
• history of hospitalization for mental illness
• a parent with alcoholism
• used cocaine (Gordon & Brown, 2008).

Conclusion

By helping medical professionals, educators, and community staff become more aware of the large incidence of mild traumatic brain injury, early identification and treatment can be improved. This in turn can lead to providing individuals with appropriate treatment, education and social supports to address the immediate and potential long-term effects.

References

Gordon, W & Brown, M. (2008). Mild Traumatic Brain Injury: Identification, the key to preventing social failure. Brain Injury/ Professional 5:2(8-11).

Recommended reading

This Fact Sheet is based on a special issue on Pediatrics and TBI of the Brain Injury/Professional (vol. 3, issue 1, 2006). Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to order the entire issue or become a member.

Books on mild brain injury and concussion discussing symptoms, treatment and recovery from mild TBI are available from Lash and Associates Publishing/Training, Inc.

By Marilyn Lash, M.S.W.

Lash and Associates Publishing/Training Inc.

Traumatic brain injury and blasts in the military

Soldiers in Afghanistan and Iraq have been exposed to frequent blasts with the use of improvised explosive devices (IED). Both civilians and military personnel can be targeted or caught in an explosion. It is estimated that as many as 47% of all blast injuries affect the soldier’s head (Suh, Sarkar, Kolster, Drexel, & Ghajar 2007). Despite this high number, some brain injuries are not diagnosed because there may be no external sign of injury.

As recently as 2006, the Office of the Surgeon General of the Army noted that 64% of wounded in action injuries were caused by IEDs, rocket propelled grenades, land mines and mortar/artillery shells. Even with improvements in helmet design and body armor, blast related closed head injuries have become known as the signature injury of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) which includes Afghanistan (Trudel, Davanzo, Mattingly, Nidiffer, & Barth, 2007).

What is a blast injury?

Just as the severity of a brain injury can range widely from very minor to extremely severe in the civilian population, this also applies to blast injuries among the military. But service members are exposed to additional risks of damage from the blast’s impact, being thrown or propelled by the blast, possible burns and inhalation of toxic substances (Suh et al., 2007).

There are different types of blast injuries.

• Primary blast injuries Organs are damaged by the wave of changes in atmospheric pressure that follows the blast.
• Secondary blast injuries The service member is hit by objects put into motion by the blast.
• Tertiary blast injuries Service members are injured by being thrown or put into motion from the blast.
• Quaternary blast injuries Service members are burned or inhale gases from the blast (Ziejewski, Karami & Akhatov, 2007).

The brain is especially vulnerable to secondary and tertiary blast injuries. An explosive material, such as TNT, is used to create a blast. The damage that can be caused depends largely on the weight of the explosive charge and the distance between the source of the blast and the target. Once a mass of TNT is detonated, the pressures of the shock wave can build as it meets objects or structures in its path. This is known as a reflection factor and it can become even stronger than the original force (Ziejewski et al., 2007).

PTSD in the military

Every person responds differently when exposed to the physical and emotional trauma of wartime combat. Reactions are influenced by age, gender, previous exposure, personality, and the nature of the trauma. Continuous exposure to violence and dangerous situations can result in stress related disorders with physical symptoms and cognitive and behavioral changes (Nidiffer, Errico, Trudel & Barth, 2007).

Post Traumatic Stress Disorder (PTSD) has long been known to occur in the military as a consequence of combat exposure. A recent study among military personnel deployed to Iraq found that the incidence of PTSD increased by the number of firefights soldiers encountered. The study also found that 15-17% of military personnel met the criteria for major depression, generalized anxiety or PTSD after duty in Iraq. The same finding occurred in 11% after duty in Afghanistan (Nidiffer et al., 2007).

The importance of the military screening for psychological conditions is clear. This same study found that 9% of the military personnel involved had one of these diagnoses prior to deployment. Rates of PTSD increased more than any other condition when pre and post deployment data were examined (Nidiffer et al., 2007).

Traumatic brain injury and PTSD

The combination of these two diagnoses can be devastating for service members and their families and must be treated together. Common brain injury symptoms such as fatigue, agitation, distractibility, lower attention and mood swings can interact with PTSD symptoms to create an intolerable situation for service members and their families (Nidiffer et al., 2007). Much more research is needed to develop effective treatment strategies for military members, particularly as they make the transition from active duty to civilian life.

References

Nidiffer, F, Errico, A, Trudel, T, and Barth, J. (2007). Current Trends in Post Traumatic Stress Disorder and Traumatic Brain Injury among Military Personnel. Brain Injury/ Professional 4:1(26-29).

Suh, M., Sarkar, R, Kolster, R, Drexel,P & Ghajar, J. (2007). New Ways to Diagnose and Assess Attentional and Cognitive Deficits following Blast Injury. Brain Injury/ Professional 4:1(18-19).

Trudel, T, Davanzo, J, Mattingly, E, Nidiffer, D, & Barth, J. (2007).Reintegrating Military Personnel after Traumatic Brain Injury (TBI): A community integrated rehabilitation model in practice. Brain Injury/ Professional 4:1(22-25).

Ziejewski, M, Karami, G, & Akhatov, I. (2007). Selected Biomechanical Issues of Brain Injury Caused by Blasts. Brain Injury/ Professional 4:1(10-14).

Recommended reading

This Fact Sheet is based on the special issue of Blast Injury and TBI of the Brain Injury/Professional (vol. 4, issue 1), 2007.

Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Members of NABIS receive a subscription as a benefit , go to  www.nabis.org

Understanding the Effects of Concussion, Blast and Brain Injuries

Blast injury, PTSD and brain injury guide for families and caregivers on the consequences of concussion in veterans. Used by many VA Hospitals, Military Hospitals and Vet Centers. 

The PTSD Workbook 

By Mary Beth Williams, Ph.D., LCSW, CTS and Soili Poijula, Ph.D. 

Workbook on symptoms and consequences of PTSD after blast injury, concussion and brain injury with exercises for coping and reducing stress amd symptoms.

Down Range to Iraq and Back   

By Bridget Cantrell, Ph.D. and Chuck Dean

Book for returning veterans and families describes effects of post traumatic stress disorder (PTSD), concussion and stress among service members coming home from wars in Iraq and Afghanistan. 

Students and Brain Injury Recovery

By Marilyn Lash, M.S.W.

Lash and Associates Publishing/Training Inc.

The child’s brain is injured

An injury to a child can be an emotionally devastating event for families. Whether it is caused by a car crash, fall, sports injury or biking collision, many parents feel that have failed to protect their child from harm.

“Traumatic brain injury in childhood is the most prevalent cause of death and long term disability in children and affects all socioeconomic levels” (Bond Chapman, 2006).

How do children recover?

The recovery process for children with a brain injury is complex because the child’s brain is still developing. A new view of brain injury recovery in children describes two phases.

Immediate recovery phase

This is the time from the injury up to about one year. During this phase, the child may receive emergency medical treatment as well as intensive hospital care and rehabilitation with dramatic improvements in cognitive, motor and social skills. Because of this rapid change, families often bring their child home with the expectation of a full or almost complete recovery (Bond Chapman, 2006).

Latent recovery phase

This the period from one year after the injury to years later, even up to young adulthood. The full impact of an injury to a developing brain becomes apparent during this later phase (Bond Chapman, 2006).

Definition of neurocognitive stall

Dr. Chapman proposes that children with severe brain injuries are at risk for displaying a neurocognitive stall during the latent phase of recovery. She defines is as “…a halting or slowing in later stages of cognitive, social and motor development beyond a year after brain injury. Despite remarkable recovery during the first year after severe brain injury, children may appear to ‘hit a wall’ or ‘fail to thrive’ in terms of their continued cognitive growth. It is not so much that they lose already acquired skills as it is a failure or lag in development of later emerging cognitive milestones.” (Bond Chapman, 2006).

Children with severe brain injury are at greatest risk for a neurocognitive stall. With the lapse of time, they appear to grow into rather than out of their deficits. This often becomes evident during adolescence when the frontal lobes have rapid rates of growth and development from age 13 up to age 25 (Bond Chapman, 2006).

School work becomes more complex and so do social pressures with adolescence. These youth may have new difficulties keeping up with classmates and peers as they struggle to reach more complex cognitive levels in the classroom and with homework. The latent effects of earlier damage to the child’s brain emerge with time. Unfortunately, the link between an earlier injury to the child’s brain and emerging cognitive problems in school is often missed. When families and educators do not recognize the latent effect of a childhood brain injury, their behaviors are misidentified as symptoms of learning disability, ADHD or emotional disorders (Glang & Lash, 2004).

What does this mean for schools?

While there have been many advances and promising research in the acute care and rehabilitation of children with brain injuries, there has not been comparable progress in psychosocial and educational research on children. This population is underidentified and underserved in local schools.

“The challenge of addressing the latent developmental effects of childhood brain injuries is compounded by the fact that families often must assume the primary care giving role and schools often become the sole providers of rehabilitation services. Neither families nor educators have been systematically prepared or trained for this role, despite the inclusion of traumatic brain injury as a category under the Individuals with Disabilities Education Act in 1991″ (Glang & Lash, 2004).

So what can be done?

By taking a holistic approach, families and educators can be better prepared and develop the required skills to support and educate children with brain injury

Develop innovative approaches to family training

Families need information to build a knowledge base about their child’s brain injury. They also need home based training on strategies for managing their child’s cognitive, behavioral and physical challenges. Training must also include advocacy skills for negotiating services at school. It also requires preparing parents to manage services over the course of their child’s development and education. It is important to recognize the emotional trauma of parents and to help them develop coping skills, find support for grieving, and reduce caregiver stress (Glang & Lash, 2004).

Look at instructional strategies used with other student populations

Little research has been done on the effectiveness of educational strategies for students with traumatic brain injury. Yet there is a large body of research on effective instructional and behavioral strategies for students with other disabilities but similar functional challenges such as problems with attention, memory, impulse control, etc. This knowledge must be examined to determine how it can be applied and modified, if necessary, for students with brain injury. This approach builds on the strengths and skills of educators (Glang & Lash, 2004).

Build capacity of educational systems

Ongoing training and brain injury consulting teams are effective models for increasing the identification of students with brain injury and for providing educators with new strategies and skills (Glang & Lash, 2004).

Support parents as educational advocates

A child’s return to school after a brain injury introduces parents to an unfamiliar and confusing educational system involving special education and 504 plans. Training programs for parents of children with special needs have demonstrated that families can become effective advocates support, training and guidance. Parents of children with brain injury need comparable programs as well as mentors through other families (Glang & Lash, 2004).

References

Bond Chapman, S. (2006). Neurocognitive Stall: A paradox in long term recovery from pediatric brain injury. Brain Injury/professional 3(4), 10-13.

Glang, A & Lash, M. (2006). A Holistic Approach for Improving Educational Outcomes of Students with TBI: Promising practices and new directions for research. Brain Injury/professional 3(4), 16-18.

Recommended reading

This Fact Sheet is based on a special issue of Pediatrics and TBI of the Brain Injury/Professional (vol. 3, issue 4) 2006.

Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Brain Injury Professional is published jointly by NABIS and HDI Publishers.  Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to become a member.

Lash and Associates Publishing/Training, Inc. has a full line of manuals on educating students with brain injury in school. 

No insurance…now what?

By Tonya Hellard

Lash & Associates Publishing/Training, Inc.

People of all walks of life go about their days, months and years believing that they are living the “normal” life. Budgets are put into place to reflect their lifestyle. Homes are purchased. Vehicles are bought. Recreational activities are planned and vacations are taken. Life is life. It is full of emotions and experiences. But most of all, we strive to make life better.

What about the very unexpected? What about a situation where life does not go back to “normal”? Life is changed. Finances are different. Bills are a reality!

Life changes in an instant

When someone experiences a traumatic brain injury (TBI) the first thoughts are focused on the person and their survival. Statistics are built on these pieces of information. The focus is on helping the person recover as much as possible and for as long as possible. But with treatment comes costs.

Just off the top, are loss of wages for the working injured and loss of wages for their loved one who may stay with them at the hospital? All the while home expenses remain the same as life goes on.

“Difficulties can occur immediately as families struggle to pay medical bills, in the medium-term as lost income impairs the ability to service debt, and into the long-term if cognitive problems from the injury affect financial management.”[1]

Medical expenses are climbing while wages are drastically altered. The patient and family quickly can find themselves in a financial struggle.

“The cost of treatment and rehabilitation for patients with traumatic brain injury (TBI) are staggering. In the year 2000, the costs and productivity losses attributable to TBI in the US totaled $60 billion”[2]

As these costs rapidly mount, the patient may remain in the hospital in a very critical condition. Unknowingly, to them or the family, the costs are incurring at a rate they cannot control or may not even know until much later. The hope is insurance will cover the bills. But too often, insurance has deductibles, co-pays, restrictions and cap on the covered services. This leaves the non covered fees to the individual or the family to pay.

“…financial problems after TBI often play a key role in a negative spiral of events. Injury depletes income and wealth, which represents additional obstacles to accessing needed health care, further reducing health and wealth.”[3]

In some cases, the individual with a brain injury or the family will find themselves making the devastating decision to file bankruptcy.

“Bankruptcy represents just the tip of the iceberg of financial problems following injury. Many injured patients struggle to repay medical debts or maintain income without filing bankruptcy.”[4]

 In the current economy with jobs being scarce, layoffs occurring every week and businesses closing, it is not uncommon for the average person to already be in financial difficulty prior to an injury. When the home budget is under financial strain, it is not surprising that the costs of treatment for a brain injury can easily tip a family into bankruptcy.

“Home equity loans and house price decreases mean that some individuals are unable to sell their homes to repay the whole debt. For patients with TBI, it is not uncommon for the value of the secured asset to be destroyed in the incident that caused the TBI. Many patients also have

How much?

pre-existing unsecured debts and obligations such as student loans, credit card debt, store charge cards, alimony, child support payments and unpaid income tax. Some of these unsecured debts are taken on in the expectation that future income will be sufficient to repay them, a hope that may have to be revised after TBI.”[5]

It has been said that our percentage of disposable income has decreased statistically since the 80’s. Meaning our debts are increasing faster than our actual income. With less money in our pockets for saving or purchase as you go theory, this statistic will only continue to increase.

“Therefore, TBI often affects those least prepared to deal with the economical consequences.”[6]

No insurance…now what?

What about the uninsured patient? What happens to them financially when there is an injury?

“It is estimated that approximately 46.5 million Americans aged less than 65 do not have medical care insurance. At 31%, the probability of having no insurance is highest among young adults.”[7]

We are finding more and more people have little to no insurance. Someone has to take on the burden. The state’s Medicaid program and the federal Medicare and Social Security Disability programs are discovering that they compensate for these individuals.

“…some of the burden is shared by the tax payer (through programs such as Medicare and Social Security Disability Insurance ), employers…a substantial proportions falls upon the patient and their family.”[8]

The costs are many and can continue over a lifetime

As the average family saves less and spends more, there is little money available for them when an emergency arises.

“…79% of parents of children with severe TBI reported financial problems 1 month after the injury.”[9]

“…from the 1980’s, interviewing spouses of individuals with head injury, found that 48% had to borrow money, 26% lost possessions or sold a house and 9% declared bankruptcy”[10]

With so many variables and little research, it is difficult to determine a cost in traumatic brain injury. Except to say that TBI is costly and very much affects the patient and family financially causing some to fall into poverty. Work may or may not be an option post-injury further damaging the financial outcome. Medical expenses may be required for the duration of the person’s life post injury creating a further spiral in finances.

Be prepared. Know your insurance policy by reviewing it annually. If you hear the words “It’s not covered”, don’t panic. Verify that with an attorney and an insurance expert to receive all the benefits due. Be aggressive! Do all you can do to help and protect yourself financially. The unexpected can happen at any time.

Recommended reading

This Fact Sheet is based on a special issue on Hidden Issues in Brain Injury of the Brain Injury/Professional (vol. 5, issue 2, 2008). It is published: North American Brain Injury Society, PO Box 1804, Alexandria, VA 22313. Tel 703-960-6500. You can order the entire issue at www.nabis.org

For more information, see books on brain injury in adults, veterans, teens and children at Lash and Associates Publishing/Training, Inc., 708 Young Forest Drive, Wake Forest, NC 27587 Tel 919-556-0300. Request a free catalog or order at www.lapublishing.com

Brain Injury and Aging 

By Marilyn Lash, M.S.W.

Lash & Associates Publishing/Training Inc.

Aging after a brain injury

The number of elderly persons has increased dramatically along with the number of people with disabilities who are aging. The overall death rate from traumatic brain injury decreased with advances in long-term medical care, rehabilitation and social support. However, successful aging is more than simply living longer. It involves maintaining physical, cognitive and social functions (Aravich & McDonnell, 2005).

Little is still understood about the long-term impact of a traumatic brain injury. Yet researchers estimate that overall life expectancy in survivors may be reduced by 7 years. Predictors of premature death among survivors of traumatic brain injury are older age, unemployment when injured, and presence of disability when discharged from rehabilitation. Circulatory and respiratory diseases, seizures and choking have been linked to increased death rates among long-term survivors. Traumatic brain injury increases the risk of Alzheimer’s disease (Aravich & McDonnell, 2005).

While many people fear old age, aging is not a disease. Most of us are familiar with changes among elderly persons in what is called “fluid intelligence” – examples are decreases in processing speed and memory span. On the positive side, aging usually is accompanied by an increase in “crystallized intelligence” as demonstrated by an older person’s fund of general information and vocabulary (Aravich & McDonnell, 2005). Because the more disabling effects of a traumatic brain injury are cognitive changes, many families and survivors fear the double whammy of aging with an injured brain. What can be done?

Ten rules to promote successful aging in survivors of TBI

Aravich and McDonnell suggest the following…

• Take care of the survivor’s heart
• Exercise the survivor’s body
• Exercise the survivor’s brain
• Feed the survivor’s brain
• Promote mental health in the survivor
• Avoid tobacco, alcohol and other drugs of abuse
• Avoid social isolation
• Protect the survivor’s brain
• Form more partnerships for individuals with TBI
• Look for greatness in each person (Aravich & McDonnell, 2005)

Aging of survivors

Facts about mental health after brain injury…

• Suicide accounts for two-thirds of all traumatic brain injury firearm deaths.
• Traumatic brain injury increases the lifetime risk of depression by 54%.
• A mild traumatic brain injury increases the risk of a mental illness within 6 months.
• Depression affects successful aging by reducing quality of life and increasing the risk of cardiovascular disease and Alzheimer’s.
• Estimates are 57% of persons with traumatic brain injury were heavy drinkers before their injury (Aravich & McDonnell, 2005).

A review of the literature by Gaultieri and Cox identified five delayed sequelae of traumatic brain injury: delayed amnesia, affective disorders, post-traumatic epilepsy, post traumatic psychosis and dementia. Among the affective disorders, depression is a common condition that can complicate recovery from a brain injury both during the acute and long-term stages. It can be complicated to treat because it is a combination of neuroanatomical, neurochemical and psychosocial factors. Other contributing factors are social isolation, unemployment, and less leisure activity as survivors struggle to build a new life in the community (Trudel, Felicetti & Mozzoni, 2005).

Depression

Depression is not the only major disorder found among survivors. Gaultieri and Cox also found that psychosis following brain injury was found among 2-5% of persons with mild or moderate injuries and among 10% or more among those with severe injuries (Trudel, Felicetti & Mozzoni, 2005).

Post traumatic epilepsy

This was found to be a contributing factor to the probability of developing a psychosis. The risk of developing post traumatic epilepsy is related to the nature and extent of the brain injury. A mild to moderate brain injury increases the risk by 2-5 times; a severe brain injury by 10 times; and a penetrating brain injury by 50 times (Trudel, Felicetti & Mozzoni, 2005).

Alzheimer’s disease

Three factors have been identified as risks for Alzheimer’s: age, family history of Alzheimer’s or Down’s syndrome, and traumatic brain injury. Because a brain injury can result in the death of neurons and weakening of the blood-brain barrier, one theory is that the brain is more vulnerable to neurotoxins. The deposit of beta-amyloid in the brain has been found in young and old persons with brain injury upon autopsy. This protein has been linked to the formation of senile plaques found in Alzheimer’s disease (Trudel, Felicetti Mozzoni, 2005).

Conclusion

Brain injury is not a short term condition, rather it is a chronic condition requiring many services and supports over the life time of an individual.

Aravich, P. & McDonnell, A. (2005). Successful Aging of Individuals with Brain Injury. Brain Injury/Professional 2(2).

Trudel, T, Felicetti, T, Mozzoni, M. (2005). The Graying of Brain Injury: An overview. Brain Injury/Professional 2(2).

Recommended reading

This Fact Sheet is based on the special issue of Aging and TBI of the Brain Injury/Professional (vol. 2, issue 2), 2005. Back issues are available by calling the publisher at (800) 321-7037 or ordering at www.nabis.org

Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Members of NABIS receive a subscription as a benefit of NABIS.

For more information, see:

Aging with a Brain Injury

By Mary Hibbard, Ph.D.

Tips on aging for adults with acquired brain injury discusses common misunderstandings and fears about dementia, Alzheimer’s disease, repeated head injuries, memory and dependence.

By Marilyn Lash, M.S.W.

 Lash and Associates Publishing/Training Inc.

Risks of injury, PTSD and concussion among troops and veterans

 The wars in Iraq and Afghanistan have involved the greatest numbers of American armed forces fighting in foreign lands since the end of the Vietnam War. But the men and women who have been deployed for Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan) differ markedly from the troops fighting in any other war in US history. The Department of Defense reported close to half – about 45% – of them are Reservists and members of the National Guard. More than 40% of National Guard members have been sent there more than once. And it’s not just the male Reservists who have been called up. Over 14% are women, many who have young children at home (Driscoll, 2008).

Time to move!

These men and women have been in active service for periods often as long as 2 years or more. This has resulted in enormous disruptions for their families and communities. For many, it means leaving their job, putting educational plans on hold, and taking a drop in income. But the biggest changes are those faced by their families as siblings, parents, sons and daughters leave for combat.

The changes and stresses are enormous for the family members who are left behind – whether it is aging parents worried about their son or daughter’s safety or spouses now raising children and managing a household as single parents. All worry about the safety of their loved one. There is always the fear of injury or death– with daily reminders in the newspaper and news programs of just how dangerous it is over there. Not until they return home can their loved ones finally experience the relief of knowing they are safe.

Coming home can boomerang 

Because our Reservists have such extended tours of duty, many are exposed to multiple explosive blasts. Each blast carries the risk of having a concussion or mild brain injury. Under the intense pressures of combat, symptoms may not be recognized. However, cognitive changes may be more evident months later when they interfere with returning to work, resuming studies, and living with family. Mild traumatic brain injury has been found to be strongly associated with PTSD and physical health problems three to four months after service members returned home (Driscoll, 2008).

Local providers need new expertise

The Veterans Administration has implemented a national system for TBI screening and referral. However, as National Guard members and Reservists return home and come back to their local communities, they are likely to be seeking care in many different settings, some within the VA and others in the civilian sector. This means that community providers, including primary care physicians, counselors, clergy, and emergency departments are now on the front lines for identifying the effects of PTSD and mild brain injuries. It becomes imperative for the private health sector to become educated and familiar with these conditions in order to provide the necessary care, treatment and support (Driscoll, 2008).

Reference

Driscoll, J. 2008. Traumatic Brain Injury among “Citizen Soldiers”. Brain Injury/Professional 5(2): 18-21.

Recommended reading

This Fact Sheet is based on the special issue of Hidden Issues in Brain Injury of the Brain Injury/Professional (vol. 5, issue 2), 2008. Back issues are available by calling the publisher at  (800) 321-7037 .

Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Brain Injury/Professional is published jointly by NABIS and HDI Publishers. Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to become a member.

Additional resources on military are available from the Military/Veterans page at Lash and Associates Publishing/Training, Inc. including:

Understanding the Effects of Concussion, Blast and Brain Injuries

Blast injury, PTSD and brain injury guide for families and caregivers on the consequences of concussion in veterans. Used by many VA Hospitals and Army Medical Facilities.

Veterans Tool Kit 

Brain Injury Concussion Veterans Tool Kit for families and clinicians treating veterans. Includes books and manuals with practical information on treatment, rehabilitation and recovery after traumatic brain injury,concussion and PTSD.