10/24/12

1

Charlotte Johnson, PhD, LP

 TBI = outside force impacts the head hard enough to cause the brain to move within the skull OR if the force cases the skull to break and directly hurts the brain.

 Direct blow to the head—MVA, guns, falls, sports, physical violence.

 Rapid acceleration & deceleration that forces the head to move back & forth in the skull. Stress from rapid movements pulls apart nerve fibers & damages tissue. Examples are MVA, fights, and Shaken Baby Syndrome.

¨  The CDC estimates that at least 5.3 million children and adults in the US have experienced a TBI significant enough to create long-term or lifelong need for help in performing daily activities.

¨  Of the 1.4 million who sustain a TBI each year in the US, 50,000 die; 235,000 are hospitalized with TBI and survive; and 1.1 million people are treated and released from hospital emergency departments.

10/24/12

2

¨  Census information for the state of MN estimated the population in 2010 as 5,303,925

¨  85.3% White, 5.2% Black, 1.1% American Indian/Alaska Native, 4% Asian

¨  Minnesota Department of Health’s (MDH) Registry noted 10,202 TBI-related hospital visits in 2011

¨  There were 7,312 TBI-related non-fatal ER/ED

visits (142 per 100,000) ¨  199 persons died with or due to a TBI ¨  Estimated between 90,000 and 100,000

Minnesotans with a TBI-related disability

10/24/12

3

¨  MN Department of Corrections (MN DOC) reports that as of January 10, 2010 the state inmate population was 9,619 adults and 129 juveniles

¨  Average age was about 36 ¨  Approximately 54% White, 35% Black, 8%

American Indian, 7.3% Hispanic, & 2% Asian ¨  Most require basic education for literacy,

training for vocational skills, and have chemical dependency and mental health issues

¨  3-year federal grant secured through the Department of Human Services

¨  The study was supported in part by project

H25MC00264 from the Maternal and Child Health Bureau (Title V. Social Security Act), Health Resources and Services Administration, Dept of Health and Human Services.

¨  Grant Initiatives: Prevalence rates, provide

training and education, and discharge planning/community resources

10/24/12

4

¨  1,029 adult male consecutive admissions ¨  The TBI screening was done from September

2006 to January 2007 at admission as part of the routine battery of psychological, medical, chemical dependency and educational assessments

¨  Assessments occurred in the first month of each offender’s admission.

¨  998 of the 1,029 adult male consecutive admissions were successfully interviewed

¨  MCF-SHK (100 interviewees) and MCF-Red Wing (52 interviewed)

¨  Severe = > 1 hour of LOC and/or >24 hours of PTA

¨  Moderate = < 1 hour LOC and/or 1 day PTA

¨  Mild = No or minimal LOC or PTA

10/24/12

5

Severe: >24 hours LOC and/or >24 hours PTA

Moderate: 60 minutes-24hrs LOC and/or 1-24 hours PTA

Mild: 0-59 minutes LOC and/or PTA < 1hr PTA

¨  Severe: 13.9% ¨  Moderate: 12.4% ¨  Mild: 73.7% ¨  NO TBI: 172 offenders ¨  Severe and Moderate were nearly double using

the other criteria

¨  Admission Process: All new offenders are interviewed by a nurse within hours of admission and by a psychologist within days.

¨  During both of these interviews, the offenders

are asked whether they have ever had a head injury.

¨  Out of the 998 offenders participating in this

study,1 reported a head injury during the nurse assessment and 9 reported head injuries during the psychological interview.

10/24/12

6

¨  Diamond and colleagues (2007) reported that a one-item, self-administered screener used during admission to prison detected

only 19% of the TBIs identified via structured interview. ¨  Previous studies indicate the prevalance rate of TBI amongst the

offender population may be as high as 85%. In contrast, it is estimated that 8.5% of non-incarcerated adults report a history of TBI.

¨  Question posed was how can the rates be almost 10 times higher than the general population?

¨  Likely answer: They asked one question: Have you ever had a severe head injury that was associated with loss of consciousness or confusion?

Self-Report TBI Hx

0102030405060708090

100

No TBI

Mild

Mode

rate

Sever

e

Self-report TBI Hx

Per

cen

t All Offenders (N=998)

Registry Only (n=52)

¨  In MN 2010: 128 fatal injuries & 6,374 non-fatal injuries

¨  DOC: September 2006 to January 2007:

37%

25%

10%

11%

11%

6% Assault

Auto

Bicycle

Falls

Sports

Other

10/24/12

7

¨  96 out of 100 female offenders met criteria for having sustained a head injury

¨  33.7% Severe (male=13.9%) ¨  44.2% Moderate (male=12.4%) ¨  22.1% Mild (male=73.7%)

¨  Provided system wide trainings to educate staff regarding TBI ¡  This included correctional staff, behavioral mental

health staff, and education staff ¡  Community outreach training for ancillary

correctional systems (e.g., probation) ¡  Began a process of helping identified offenders with

TBI obtain community resources

¨  Need a more refined process in place to identify offenders with TBI & TBI-related functional impairment

¨  Needed a plan to assist them in prison and with their discharge back to the community

¨  Realized need for ongoing training and staff dedicated to TBI put in place in critical programs

¨  Realized that our attention could be directed toward working with populations that continue to be underserved

10/24/12

8

¨  What about the 9000 other offenders who may not be housed at one of our designated areas or who can’t complete a comprehensive neuropsychological evaluation?

¨  Screening and assessment of offenders for TBI-related impairments

¨  Offenders with TBI and co-occurring disorders of chemical dependency or mental health problems.

¨  The limited literature to date suggests that cognitive problems associated with a past history of traumatic brain injury (TBI) may affect inmates’ potential to succeed in rehabilitation (Valliant, et al, 2003; Corrigan, 1995, as cited in Wald, Helgeson, & Langlois, 2008, para. 8), including SA treatment (SAMHSA, 1998a, as cited in Wald, Helgeson, & Langlois, 2008).

¨  Investigate benefit from learning self-management skills, TBI specific programming and release planning

¨  Enhanced family education to support a more successful return to community

¨  Development and implementation of protocol system to identify and track offenders with TBI who require supportive services

¨  Follow identified offenders as they complete chemical dependency treatment

10/24/12

9

¨  Release planning to coordinate appropriate TBI services in the community after leaving prison

¨  Comprehensive psychological/cognitive assessment process to identify offenders with special needs

¨  Ultimate goal is systemic change within the DOC to offer an improved response for offenders with TBI

¨  Coordination of services to better transition to the community

¨  Need to address cultural competence in project planning and design.

¨  Addressed through project methodology, input from individuals and families, and through expert consultation.

¨  Minnesota has the 13th largest American Indian population in the U.S. with 11 reservations.

¨  Release planning and transition to the community will address how American Indians can access mental health and substance abuse services through state, county, tribal government and American Indian Health Boards, and other cultural considerations.

10/24/12

10

¨  A U.S. epidemiologic study indicated that TBI-related hospital discharge rates were highest amongst American Indians/Alaskan Natives (75.3 per 100,000 and African-Americans (Langlois, Kegler, & Butler, 2003, as cited in McCrea, 2008)

¨  Other risk factors for TBI include SES and substance abuse

¨  Native Americans were identified as a group of interest for the current grant

 Language problems  Poor judgment of space  Confusing right/left  Problems reading or writing or adding  Problems following conversations  Getting stuck on topics  Not following instructions

 Tremors  Weakness/fatigue  Sensation deficits  Vision problems   Ignoring one side of body   Irritability, anger, mood swings  Change in appetite/hygiene/social skills

10/24/12

11

¨  Behavioral: Dealing with people ¨  Physical: Dizziness ¨  Cognitive: Reading, writing, or math

¡  Learning new information ¡  Easily Distracted ¡  Losing train of thought ¡  Forgetting things that have been completed

¨  35% to 96% show agitated behavior during acute recovery (Silver, Yudofsky, & Anderson, 2011)

¨  Of 60 offenders in jail those with TBI in last year showed worse anger/aggression (Slaughter, 2003)

¨  Risk factors: irritability, impulsivity, & past aggression

¨  The case of Phineas Gage ¨  Orbital-frontal cortex

¡  Paralimbic functions ¡  Tied to behavioral response to emotional stimuli ¡  Recognition of reinforcing factors ¡  Injury can lead to impairment in ability to associate

connections to appropriate reinforcment

10/24/12

12

¨  Obital-frontal damage ¡  Perseverate in responding ¡  Difficulty modulating behavior in face of changing

reinforcement contingencies ¡  Lower thresholds for emotional reactions (rage) ¡  Increased social withdrawal ¡  Heightened incidents of depression, irritabily,

anxiety, & anger

¨  Pseudobulbar affect—crying without recognition it is happening and not feeling depressed

¨  Lacking empathy & social restraints ¨  Excessive involvement in pleasure-seeking

behavior ¨  Reduction in sensitivity to negative risks ¨  Impulsive & antisocial ¨  Impaired recognition of facial expressions

¨  Likely to appear attentive, but miss information

¨  Appears to forget 5 seconds (or less) after being told information

¨  Fidgety and moving around ¨  Hard to sit still ¨  Appears defiant ¨  Irritable and easily angered

10/24/12

13

¨  Instructions must be divided into small concrete components of expectations.

¨  Modeling cues and gestures to comprehend expectations

¨  Written instructions alone are not sufficient

¨  When learning a new task, specific parts of the job must be broke down

¨  Instruction of the first part must be given along with an opportunity to practice this and receive feedback to correct problems

¨  After successful completion of the first part then teach the second part, and so on with further aspects of the task.

¨  There may have difficulty focusing on a topic if attention is stuck on an unrelated thought or if distracted by environmental stimuli

¨  Additional time is needed along with questions to follow important details of a conversation

10/24/12

14

¨  Pictorial presentation of information ¨  Use flashcards ¨  Laminated check lists ¨  Small notepads & calendars ¨  Electronic reminders ¨  Re-focus envelopes ¨  AA pamphlets ¨  Resource list

¨  Communication among providers is key ¨  Resources are there to help ¨  Develop a plan to prepare and avoid being

reactive ¨  A strong need to review plan regularly ¨  When in doubt, call

¨  Minnesota Brain Injury Alliance ¡  34 13th Avenue NE, Suite B001 Minneapolis, MN

55413 Phone: 612-378-2742 Toll Free: 1-800-669-6442 Fax: 612-378-2789 E-Mail:info@braininjurymn.org Hours: Monday-Friday, 8 a.m. to 4:30 p.m.

10/24/12

15

¨  Gordon, W.A., Haddad, L., Brown, M., Hibbardt, M.R., & Sliwinski, M. (2000). The Sensitivity and Specificity of Self-Reported Symptoms in Individuals with Traumatic Brain Injury. Brain Injury, 14, 21-23.

¨  McCrea, M. A., (2008). Mild traumatic brain injury and post concussion syndrome. American Academy of Clinical Neuropsychology.

¨  Minnesota Department of Health. (2011). Minnesota Injury Data Access System (MIDAS).

¨  Silver, J.M., Ydofsky, S.C., & Anderson, K.E. (2011). Aggressive Disorders. In Textbook of Traumatic Brain Injury. (2nd Edition). Arlington, VA: American Psychiatric Associaton.

¨  Slaughter, B. Fann, J.R., Ehde, D. (2003). Traumatic brain injury in a county jail population: prevalence, neuropsychological functioning and psychiatric disorders. Brain Injury, 17, 731—741.

¨  Wald, M., Helgeson, S.R., & Langlois, J. A., (2008). Traumatic brain Injury among prisoners. Retrieved September 17, 2010 from http://www.brainline.org/downloads/PDFs/Traumatic%20Brain%20Injury%20Among%20Prisoners.pdf