1 Arizona Governor’s Council on Spinal and Head Injury “Understanding Traumatic Brain Injury” Southern Arizona Disability Rights and Resources Conference

1Arizona Governor’s Council on Spinal and Head Injury

“Understanding Traumatic Brain Injury” Southern Arizona Disability Rights and

Resources Conference Saturday April 4, 2009

Session l Workshops 9:15 a.m. – 10:45 a.m.Windemere Hotel and Convention Center

Sierra Vista, Arizona

Ann Tarpy, M.Ed.Ann Tarpy, M.Ed.Acting Executive DirectorActing Executive Director

Arizona Governor's Council on Spinal and Head InjuriesArizona Governor's Council on Spinal and Head Injuries10640 N. 2810640 N. 28thth Drive Ste. B-102 Drive Ste. B-102

Phoenix, AZ 85029Phoenix, AZ 85029602.863.0484602.863.0484

[email protected]@azdes.gov


ObjectivesObjectives

By the end of this Session, the By the end of this Session, the participant will:participant will: Comprehend the brain behavior Comprehend the brain behavior

relationships and the impact of relationships and the impact of brain injury.brain injury.

Describe the impact of brain Describe the impact of brain injury on the family system.injury on the family system.


AgendaAgenda Opening activitiesOpening activities Part 1 - Understanding brain injury Part 1 - Understanding brain injury Part 2 – Understanding brain behavior Part 2 – Understanding brain behavior

relationships and what happens when these relationships and what happens when these relationships are interrupted from brain relationships are interrupted from brain injury injury

Part 3 - Impacts on the Family SystemPart 3 - Impacts on the Family System Part 4 – Brain Injury Association of Arizona Part 4 – Brain Injury Association of Arizona

(BIAAZ)(BIAAZ) Closing activities and evaluationClosing activities and evaluation


Traumatic brain injury is:Traumatic brain injury is: A condition with potential life-long A condition with potential life-long

implications that may require ongoing implications that may require ongoing services and supportsservices and supports

A multidimensional syndrome affecting A multidimensional syndrome affecting a wide variety of areas of function a wide variety of areas of function including:including:

CognitiveCognitive SensorySensory Motor Motor SocialSocial Emotional Emotional PhysicalPhysical

Understanding Brain InjuryUnderstanding Brain Injury


Part 1Part 1

UnderstandinUnderstanding Brain g Brain InjuryInjury


Understanding Brain InjuryUnderstanding Brain Injury Individuals can sustain brain injuries from Individuals can sustain brain injuries from

medical conditions such as:medical conditions such as: Infectious disease (e.g., meningitis, Infectious disease (e.g., meningitis,

encephalitis)encephalitis) Brain tumor and their treatments Brain tumor and their treatments

(chemotherapy and radiation can cause (chemotherapy and radiation can cause diffuse brain damage)diffuse brain damage)

Neurological disease (e.g. multiple Neurological disease (e.g. multiple sclerosis)sclerosis)

Cerebrovascular disorders (e.g. stroke)Cerebrovascular disorders (e.g. stroke) Toxic chemical or drug reactions (e.g., lead Toxic chemical or drug reactions (e.g., lead

poisoning, carbon monoxide poisoning)poisoning, carbon monoxide poisoning) HydrocephalusHydrocephalus Substance abuseSubstance abuse


Hypoxia/Anoxia are other forms Hypoxia/Anoxia are other forms of brain injury. Examples are:of brain injury. Examples are: SuffocationSuffocation Suicide attemptsSuicide attempts Near drowningNear drowning Other injuries (cardio or Other injuries (cardio or

pulmonary) can reduce blood pulmonary) can reduce blood flow to the brainflow to the brain




Blunt or penetrating Blunt or penetrating trauma to the head such trauma to the head such as a gunshot wound.as a gunshot wound.

Coup – contrecoup Coup – contrecoup injury from acceleration injury from acceleration - deceleration forces - deceleration forces such as motor vehicle such as motor vehicle crashes.crashes.

A traumatic brain injury (TBI) is a result of:



Mild, moderate, and severe brain Mild, moderate, and severe brain injury are the injury are the clinical termsclinical terms used used to describe the “type” of brain to describe the “type” of brain injury the person sustained.injury the person sustained.

However, these same descriptors However, these same descriptors often fail to tell us about the often fail to tell us about the ““functional outcomefunctional outcome” of the ” of the injury.injury.


Understanding Understanding brain behavior brain behavior relationships and relationships and what happens what happens when these when these relationships are relationships are interrupted from interrupted from brain injury brain injury

Part 2Part 2


Part 2Part 2Understanding Brain Behavior Understanding Brain Behavior

RelationshipsRelationships

InputsAuditory

InputsAuditory

Language skills

Language Language skillsskills

Visual-spatial skills

VisualVisual--spatial spatial skillsskills

Behavioral Outputs(Verbal, non-verbal, motor)


Manipulations in Active

Working Memory

Manipulations in Manipulations in Active Active

Working MemoryWorking Memory

InputsVisual

InputsVisual

InputsKinesthetic

InputsKinesthetic

Attention, concentration, memory*Attention, concentration, memory*Attention, concentration, memory*

Concept formation - higher-order thinking(reasoning, logical analysis)


Information Processing ModelInformation Processing Model

Brain Function


The brain is a very The brain is a very complex and complex and delicate structure delicate structure with pathways that with pathways that determine such determine such things as things as memories, memories, emotions, and emotions, and basic motor basic motor functions. In sum – functions. In sum – who we are. who we are.

Understanding Brain Behavior Understanding Brain Behavior RelationshipsRelationships


It is through ourIt is through ourbrains that we:brains that we: Experience Experience

ourselves and the ourselves and the environmentenvironment

Understand our Understand our relationships to relationships to others.others.

Form our Form our perceptionsperceptions of our of our world. We don’t world. We don’t react to the world react to the world out there, but out there, but rather to our rather to our perception of it. perception of it.



The Role of The Role of the Neuronthe Neuron The The

MessengerMessenger


The brain is made up of The brain is made up of billions of nerve cells billions of nerve cells (neurons) through which (neurons) through which messages are transmitted.messages are transmitted.

Neurons of the brain Neurons of the brain connectconnect and organize into and organize into functionalfunctional units/networksunits/networks with specific roles to sense, with specific roles to sense, perceive, process and act on perceive, process and act on information from both information from both outside of us and within us.outside of us and within us.

The units serve specific and The units serve specific and important functions important functions andand are are designed to work together.designed to work together.



Interruption of Brain Behavior Interruption of Brain Behavior RelationshipsRelationships

During brain injury, During brain injury, these neurons/axons these neurons/axons and networks can be and networks can be damaged causing an damaged causing an interruption in the interruption in the way that information way that information flows through the flows through the networks within and networks within and between the between the functional units.functional units.


Brain FunctionsBrain Functions


Cognitive Skills/Functions Associated with Hemispheres of the Brain

Left Hemisphere – LogicalWords (spelling)Verbal meaningVocabulary in languageDetails – rulesAnalysisOne-by-one selectivityStep-by-step instructionsSequential orderingCause and effect relationshipsLearned factsLetter-symbol associationsAbstract reasoningAcademically-learned informationIdeasSerial/ordered structuresSelf-verbalizationsSelective attentionConsciousness – reasoningScientific logic

Right Hemisphere – AestheticImages, pictures, and colors – spatial

Music and feelingsGestalt – whole/relational

Synthesis, comparisonsSimultaneous patterning

Whole processWhole units

AnalogiesCreativity – new combinations

Visual symbolismConcrete

Practical – common sense knowledgePatterns of things/theory

Random-without structure body languageFacial expression, tone of voice

Sustained attentionMeditation, spontaneous ideas, subconscious

Spiritual – mythicalPatterns of logical associations




Areas of ImpactAreas of Impact Functional / PhysicalFunctional / Physical CognitiveCognitive Personality / EmotionalPersonality / Emotional Psychological / Psychological /

BehavioralBehavioral


What Happens What Happens during during CognitiveCognitiveDevelopment?Development?



Cognitive Cognitive development:development: Is a dynamic and Is a dynamic and

interactive process of interactive process of the development of the development of skills gross motor, skills gross motor, fine motor, language, fine motor, language, cognitive, and social.cognitive, and social.

Causes Causes maturationmaturation in in thinking ability, thinking ability, behavior, emotional behavior, emotional regulation, and social regulation, and social capabilities.capabilities.



Injury during cognitive Injury during cognitive development…development… Results in an Results in an

underdevelopment of the underdevelopment of the brain functions of the areas brain functions of the areas impacted by the injury, impacted by the injury,

Impacts further cognitive Impacts further cognitive development,development,

Impacts how those working Impacts how those working with the individual set with the individual set realistic expectations realistic expectations regarding behavior and regarding behavior and accomplishments.accomplishments.



Role of the Role of the Information Information Processing Processing ModelModel

InputsAuditory

InputsAuditory

Language skills







Working Memory



InputsVisual

InputsVisual

InputsKinesthetic

InputsKinesthetic







InputsAuditory

InputsAuditory

Language skills







Working Memory



InputsVisual

InputsVisual

InputsKinesthetic

InputsKinesthetic




Information Processing ModelInformation Processing ModelWhen the brain is When the brain is functioning normally- functioning normally-

It receives It receives messages/information messages/information through our senses and through our senses and interprets them; filters interprets them; filters out irrelevant out irrelevant information.information.

It puts together the It puts together the messages in a way that messages in a way that has meaning for us, has meaning for us,

Stores that information Stores that information in our memory; in our memory;

Uses that memory and Uses that memory and retrieves the information retrieves the information timely and accurately.timely and accurately.



If an individual is If an individual is unable unable to receiveto receive (input) (input) information or information or

If they receive If they receive inaccurate or unreliable inaccurate or unreliable sensory input, and/or sensory input, and/or

If their ability to process If their ability to process information or filter out information or filter out irrelevant information is irrelevant information is disrupted disrupted from injury… from injury… Inputs

Auditory

InputsAuditory

Language skills







Working Memory



InputsVisual

InputsVisual

InputsKinesthetic

InputsKinesthetic







A person’s A person’s behavior, ability behavior, ability to function, and to function, and ability to ability to communicate communicate change.change.

InputsAuditory

InputsAuditory

Language skills







Working Memory



InputsVisual

InputsVisual

InputsKinesthetic

InputsKinesthetic







Sensory information may Sensory information may not be able to get into not be able to get into the brain or may not be the brain or may not be able to get in accurately;able to get in accurately;

Different parts of the Different parts of the brain may no longer be brain may no longer be able to communicate able to communicate with one another;with one another;

Processing speed Processing speed (receptive and (receptive and expressive) may be expressive) may be slowed.slowed.



Changes in the way Changes in the way they are able to process they are able to process information may information may interfere with the interfere with the individual’s ability to individual’s ability to control emotions, control emotions, benefit from experience, benefit from experience, and be sensitive to the and be sensitive to the emotional needs of emotional needs of others.others.



It is the complex It is the complex neurobehavioral problems neurobehavioral problems that may cause the greatest that may cause the greatest disruption in the survivor’s disruption in the survivor’s and family’s life.and family’s life.



Changes based on the parts of the brain that Changes based on the parts of the brain that were injured (e.g. in personality, cognition and were injured (e.g. in personality, cognition and behavior)behavior)

Complications caused by emotional reactions Complications caused by emotional reactions to difficulties and changes from the injuryto difficulties and changes from the injury

Pre-morbid characteristicsPre-morbid characteristics Family system/family functioning (pre/post Family system/family functioning (pre/post

injury)injury) EnvironmentEnvironment Reaction to medicationReaction to medication History of substance abuseHistory of substance abuse Level of awareness and understanding of brain Level of awareness and understanding of brain

injury.injury.

Behavior following brain injury is likely to be influenced by or an interaction between the following factors:



Environment is the one variable Environment is the one variable over which family members, over which family members, caregivers, and service providers caregivers, and service providers have the most control.have the most control.

Changing the expectations of the Changing the expectations of the individual in the environment can individual in the environment can change/improve the behavior.change/improve the behavior.





Comments about MedicationsComments about Medications

Side-effects of medications can be Side-effects of medications can be enhanced after brain injury making enhanced after brain injury making compliance problematic.compliance problematic.

Typical medication regimens may not Typical medication regimens may not produce the desired result and may have produce the desired result and may have the opposite reaction.the opposite reaction.

Individuals with brain injuries are likely Individuals with brain injuries are likely to need assistance managing their to need assistance managing their medications.medications.

Due to the fragmented nature of care Due to the fragmented nature of care following brain injury, the survivor may following brain injury, the survivor may end up with multiple medications that end up with multiple medications that they may or may not need. They may not they may or may not need. They may not have a physician monitoring all of the have a physician monitoring all of the medication and may be over-medicated.medication and may be over-medicated.


A person with a A person with a brain injury may brain injury may engage in engage in behaviors behaviors (adaptive and (adaptive and maladaptive) as a maladaptive) as a means of means of communication…communication…



They may be trying to communicate –They may be trying to communicate –

That a basic need is not metThat a basic need is not met That others are not listeningThat others are not listening That they need more assistance to do the That they need more assistance to do the

task or activitytask or activity All other efforts have failedAll other efforts have failed Frustration due to other impairments Frustration due to other impairments

associated with the injury (e.g., delaying associated with the injury (e.g., delaying information processing speed, memory information processing speed, memory impairments, physical limitations, etc.)impairments, physical limitations, etc.)



By understanding that behavior By understanding that behavior may be a manifestation of the may be a manifestation of the brain injury or a means of brain injury or a means of communication - family members, communication - family members, caregivers, and service providers caregivers, and service providers can begin to interpret the can begin to interpret the behavior differently - behavior differently - not as volitional or not as volitional or a demonstration of a lack of interest.a demonstration of a lack of interest.




Important for the Important for the family member, family member, caregiver, and/or caregiver, and/or service provider service provider to be aware of to be aware of his/her perception his/her perception of what the of what the behavior means.behavior means.



Stress is a common reaction when living or Stress is a common reaction when living or working with individuals with a brain injury. working with individuals with a brain injury.

The stress reaction generally occurs in The stress reaction generally occurs in situations where the demands of the situations where the demands of the environment exceed an individual’s environment exceed an individual’s (perceived) resources to handle the situation.(perceived) resources to handle the situation.

The stress reaction can occur in the individual The stress reaction can occur in the individual with the brain injury, the caregiver, family with the brain injury, the caregiver, family member and/or service provider.member and/or service provider.


Part 3Part 3

Impacts on the Impacts on the Family SystemFamily System


Impacts on the Family SystemImpacts on the Family System

Understanding brain Understanding brain injury and the injury and the impact of the brain impact of the brain injury on the injury on the individual and the individual and the family is really about family is really about understanding understanding grief grief and lossand loss – at many – at many levels.levels.


Impacts on the Family SystemImpacts on the Family System For the individual – (depending on their level For the individual – (depending on their level

of awareness) s/he may mourn the loss of:of awareness) s/he may mourn the loss of:

Memories of experiences that connect Memories of experiences that connect them with family and friendsthem with family and friends

Sense of self – who they were before the Sense of self – who they were before the injuryinjury

His/her role and status in the family, at His/her role and status in the family, at work, with friendswork, with friends

Physical functioningPhysical functioning Changes in thinking and behaviorChanges in thinking and behavior Ability to do some of the things they did Ability to do some of the things they did

beforebefore The life they had before the injuryThe life they had before the injury



For the family, they are mourning the loss of:For the family, they are mourning the loss of:

Who the individual was before the injury - Who the individual was before the injury - connection to the individual through memories connection to the individual through memories of shared experiences. of shared experiences.

Hopes, dreams, and plans for the future they Hopes, dreams, and plans for the future they had for the individual.had for the individual.

Their way of life and now facing the reality Their way of life and now facing the reality that life may never be returning to the way it that life may never be returning to the way it was before.was before.

The role the individual played in the familyThe role the individual played in the family For a spouse, they may be mourning the loss For a spouse, they may be mourning the loss

of their companion, their support, their of their companion, their support, their partner.partner.



Families members, Families members, individually and as a unit, individually and as a unit, experience an ongoing experience an ongoing journey filled with challenges journey filled with challenges and changes through the and changes through the recovery period and then recovery period and then adjusting to life after brain adjusting to life after brain injury.injury.

In many cases, recovery In many cases, recovery becomes a lifelong process becomes a lifelong process of adjustments and of adjustments and accommodations for the accommodations for the individual and the family as individual and the family as they deal with acceptance they deal with acceptance and understanding of the and understanding of the injury and subsequent injury and subsequent limitations and consequence.limitations and consequence.



For the individual with For the individual with a brain injury, a brain injury, survivorship is about survivorship is about understanding the understanding the “new person”“new person” who is who is developing. developing.

For the family, it is For the family, it is understanding the understanding the new new familyfamily that is that is emerging.emerging.


ResourcesResources Brain Injury Brain Injury

Association of Association of Arizona will now Arizona will now provide you provide you with with information information about their about their services.services.


QuestionsQuestions


Closing Closing activities activities and and evaluationevaluation

Thank You for attending this

session today.

Documents

1 Arizona Governor’s Council on Spinal and Head Injury “Understanding Traumatic Brain Injury” Southern Arizona Disability Rights and Resources Conference