Integrated Behavioral Health: Connecting Community and School Services
Phoenix Area Integrated Behavioral Health Conference ... · traumatic brain injury: Phoenix Area...
Transcript of Phoenix Area Integrated Behavioral Health Conference ... · traumatic brain injury: Phoenix Area...
traumatic brain injury:
Phoenix Area Integrated Behavioral Health Conference
August 17, 2016
tips for human service providers
Robin Hoskins, M.A., MAPC, BC-HSP, LAC
Faculty Associate, ASU, School of Social Work
Vicki Staples, MEd, CPRP
Associate Director for Clinical Initiatives
ASU Center for Applied Behavioral Health Policy
Acknowledgements & Disclaimer
These slides and associated materials were developed by:
Vicki Staples, MEd, CPRP
Associate Director of Clinical Initiatives
Center for Applied Behavioral Health Policy (CABHP)
College of Public Service and Community Solutions
Arizona State University
Robin Hoskins, M.A., MAPC, BC-HSP, LAC
Faculty Associate, ASU, School of Social Work
The presentation and associated materials may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior permission from CABHP.
defining tbi
causes
brain and behaviors
signs and symptoms
tips/interventions-challenging behaviors;
managing emotions; fatigue;
social skills; loss, mourning,
grief; coping with survival ; and
self care
motivational
interviewing
adolescents
screening
best practices
overview of this workshop
defining TBI
TBI comparison
Centers for Disease Control and Prevention. “Traumatic Brain Injury in the United States: A Report to Congress.” (January 16, 2001).
Traumatic brain injury is
now classified as a
“public health epidemic”
in America.
1,288
Deaths
6,943
Hospitalizations
43,369
Emergency Department Visits
???
Receiving Other Medical Care of No Care
Arizona Department of Health Services
Annual number of TBI’s in AZ
underestimation of the problem
number reported with TBI underestimates the
magnitude of the problem because the following
are not included in those estimates:
those treated by private physicians
those treated in private clinics, and urgent
care centers
individuals who did not seek medical care
what is TBI?
• A traumatic brain injury (TBI) is
caused by a blow or jolt 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,” i.e., a brief
change in mental status or
consciousness to “severe,” i.e.,
an extended period of
unconsciousness or amnesia
after the injury.
types of brain injury
Congenital Brain Injury Acquired Brain Injury
Traumatic Brain Injury
Non-traumatic
Brain Injury
Closed
Head Injury
Open
Head Injury
Savage, 1991
Brain Injury Association
of America estimates
approximately
2.5 million Americans experience
a TBI every year
concussions – minor
and most common TBI
skull fracture – skull
cracks or breaks
depressed
penetrating
contusion – bruising or
bleeding of brain
hematoma – collection
of blood inside body
more about TBI
causes of TBI
Traumatic brain injuries accidents
20% due to violence
3% due to sports
injuries
50% associated alcohol
use associated
Non-traumatic brain injuries – not associated with trauma and typically involves entire brain loss of oxygen
drowning
toxic exposure to carbon monoxide
heart attack
stroke
causes
accidents - top causes
• falls 40%– 55% among children
are ages 0 – 14
– 81% among adults are 65 +
• unintentional blunt trauma– 15% - all age groups
– 24% among children ages 0 - 15
• vehicle crashes– 14% - all age groups
– Accounts for 26% of all TBI related deaths
• assaults– 10% - all age groups
– 75% assaults associated with TBI occur in ages
15 - 44
let’s break it down
men 3x as likely to die than women
rates are higher for ages 65 +
leading cause of TBI related
deaths by age: falls for ages 65 +
vehicle crashes for ages 55 – 24
assaults for ages 0 - 4
continued…
other and
unknownleading causes
19%
and there is the unknown
approximately 18% of all TBI-related emergency department visits involved children aged 0 to 4 years.
approximately 22% of all TBI-related hospitalizations involved adults aged 75 years and older.
males are more often diagnosed with a TBI (59%).
blasts are a leading cause of TBI for active duty military personnel in war zone
other vulnerable populations:
veterans
persons who are homeless
persons in jail or prison
DV survivors
who is at the highest risk?
behavioral health and TBI
73% of women in state prison have been
diagnosed with a mental health problem
research is showing that there is
a high prevalence of individuals
reporting TBI with co-occurring
substance disorder and severe
mental illness, one study reports
up to 72%
symptoms like paranoia,
obsessional disorder, depression
PTSD
suicide and TBI
people with TBI are 4 times as likely to
commit suicide
one study screened 172 participants with
TBI using the Beck Scale for Suicide
Ideation
35% had significant levels of
hopelessness
23% had suicide ideation
18% had made a suicide attempt
“TBI, mental illness, substance abuse, PTSD –they all go together like peanut butter and jelly.”
-- George
nationally…
1.7 million injured
50,000 die from a TBI
235,000 are hospitalized
1.1 million treated and released from ED
80,000 – 90,000 result in long-term disability
6.5 million Americans living with some effect
5.3 million with long-term, lifelong disability
3 main areas of impact
behavioral
physical
cognitive
6.5 million living
with some effect:
Native Americans/Alaska Natives
hospitalization rates highest
among all minority groups
age group
highest 15 – 24 years of
age
25 - 34 years of age
35 – 44 years of age
0 -14 years of age
compared to other
populations - TBI death
rates are greatest among
Native Americans/Alaska
Natives at any age
Native American summit on TBI
sponsored by the Health Resources and Services
Administration
Harold – “Living takes a lot of energy. We must find
the story that was given us and must not terrorize
ourselves with our thoughts.”
prayer, ceremonies, the earth, and elements must all
be incorporated into the care of an Indigenous
person with brain injury.
identify unique challenges
available services and gaps
provide information to agencies
completing tasks
gaining acceptance
game playing (child
to parent)
being institutionalized
coping with a lack of
understanding from
hospital workers and
police officials
“putting up with me”
overprotective family
letting go
no family support
top struggles for post-injury for
indigenous people
• unemployment rate as high as 75% in some areas
• alcohol and drug use is common
• 60% of people in general population experience depression after injury - within the Indigenous community, 60% is the depression rate pre-TBI
• violence, suicide attempts, accidents at the root of injury for Indigenous people
• telephone, transportation, education, comprehensive deficits cause Indigenous people to fall through the cracks
other considerations
brain and behavior. . .how it works
brain behavior relationships
different levels of TBI - mild
headaches
confusion
lightheadedness
dizziness
blurred vision
tired eyes
ringing in the ears
bad taste in mouth,
loss of smell, taste
attention
concentration
trouble with
memory
mood changes
change in sleep
patterns
trouble with
thinking
fatigue
trouble with speech
different levels of TBI – moderate/ssevere
may be similar to
those of mild TBI
headaches gets worse
and does not go away
repeated vomiting or
nausea
convulsions or
seizures
inability to awaken
from sleep
dilation of one or both
pupils
slurred speech
weakness or
numbness
loss of coordination
increased confusion
restlessness
agitation
signs and symptoms
remember this:
attention is the gateway to all
other functions
understanding and addressing
challenging behaviors
what you can do
organizing the living environment and planning your
approach as a helping professional can increase
opportunities for learning and decrease the chances of a
behavioral episode
behavioral challenges
no way to predict or know how long it will last
can interfere with all aspects of life
rate of recovery
safety issues
ability to socialize
types of challenges
typical problems include:
not being able to control temper
not being aware of proper social behavior
not obeying directions
restlessness
agitation
easily frustrated
things you can do
approaching and interacting
use a social greeting
introduce self each time
speak slowly and clearly
give time for person to
process if cognitive
processing slowed by TBI
be direct and brief
avoid repeatedly
disagreeing
not effective to
logically reason with
person who has
tendency to agitation
always explain your
intentions
redirect the attention of
person with TBI
formally end contact
managing the environment
hard to remain calm in
an active environment
stimulation can
increase restlessness
loud TV
loud conversations
crowds
create calm
environment
stay in control of your
behavior
use gentle physical
contact with permission
discuss use of physical
restraints with their
doctor if needed
medications
medications can help
helps the person stay in bed and go to sleep
better choice than restraints
be aware of side effects
affect person’s mental status
made worse if person already has memory loss
may make it difficult to participate in daily
activities – slowing the recovery process
treatment challenges
Arizona Department of Health Services
treatment challenges
determine what
activity is being
refused and why, if
possible
redirect the
attention
explain activities so
they know what to
expect
provide choices
bargaining
written goals
make the tasks
meaningful
provide feedback
temper outbursts
• gates fly open and emotions come out
• temper rises rapidly
• outbursts over relatively minor events
• unpredictable
• remain calm
• look for obvious reasons for the temper outburst
• do not try to reason or get into an argument
• nip it in the bud
• use a reinforcement program
• remember – it is a result of the injury and not personal
10 recommendations
1. increase rest time
2. keep environment
simple
3. keep instructions
simple
4. give feedback and
set goals
5. provide choices
6. decrease the
chance of failure
7. vary activities
8. over-plan
9. be calm
10.redirect the
person to task
managing emotions
Burnout is associated with stress and hassles involved in your work; it is very cumulative, is relatively predictable and frequently a vacation or change of job helps a great deal
emotions
anxiety feeling of fear or nervousness that is out of proportion
to the situation
can be harder to handle (being in crowds, being
rushed, or adjusting to sudden changes in plan)
cause of TBI replays over and over
too many demands (returning to work too soon, time
pressure)
overwhelmed (asked to make decisions)
situations that require a lot of attention (crowded
environments, heavy traffic, noisy children)
emotions
signs of depression are also
symptoms of TBI
more likely if they show up a
few months after the injury
rather than soon after the
injury
depression
feeling sad is a normal response after TBI
often appear in the later stages of recovery –
realization of long term impacts
if this becomes overwhelming or interfere with
recovery – depression may be the cause
tips for your clients on handling
emotions
stay in the moment
allow emotions to subside
or quiet
review and reflect
find someone you trust
consider the opposite
emotion
for families on handling
client’s emotions
remain clam and avoid reacting emotionally
yourself
take person to a quiet place
acknowledge feelings and give person a chance
to talk about it
provide gentle feedback once person gains
control
gently redirect attention to different topic or
activity
temper outbursts caused by several
factors
injury to parts of the brain controlling
emotional expression
frustration and dissatisfaction with changes
in life
feeling isolated, depressed, misunderstood
difficulty concentrating, remembering,
expressing oneself or following
conversations
tiring easily
pain
for families
• reducing stress and decreasing irritating situations
• self calming strategies, relaxation, better communication
methods
• try not to take it personally
• try not to argue with the person during the outburst
• do not try to calm them down be giving into their demands
• set rules for communication (not acceptable to threaten,
refuse to talk to the person when in a tantrum)
• afterward, talk about outburst and what might have led to it
• suggest outlets (leaving the room, taking a walk)
for families on forgiveness
consider how you would feel had you been the
cause of the injury. what does it mean to be truly
forgiven?
recognize the amount of effort you are putting into
resentment. what would it feel like if you could
use that energy for something else?
realize you are not able to move to acceptance of
the changes in the person if you continue to focus
on fault. how would it feel to be truly valued and
accepted?
tips on hope and gratitude• be realistic – the potential for recovery
is often underestimated
• recognize what is good already, notice
the person’s strength and resilience
• recognize the small successes
happening every day
• be thankful for what is rather than
what isn’t
this may help prepare the family for the
challenges ahead
66
what is fatigue?
feeling of exhaustion
tiredness
weariness
listlessness
feeling of not being
able to finish a task
overwhelms most
other feelings
can make it hard to
work physically and
mentally
sleep may not help
why is fatigue important?
you have less energy
makes it hard to care for yourself
impacts willingness to socialize
impacts ability to do things you enjoy
affects your mood
may keep people
with TBI from
going back to work
how common is fatigue?
VERY common
responsible to for approximately 7 million
visits to the doctor’s office
more than 1 billion spent annually trying to
evaluate or treat fatigue
people with TBI - as many as 70%
complain of mental fatigue no matter
how severe the TBI
other populations at risk
women
people who:
have other kinds of
neurological
problems
live alone
have chronic pain
have stressful, low
paying, or boring
jobs
have psychological or
psychiatric conditions
abuse alcohol or
drugs
take certain kinds of
medications
types of fatigue
physical - “I’m tired
and I need to rest. I’m
dragging today.”
psychological - “I
just can’t get motivated to
do anything. Being
depressed wears me out; I
just don’t feel like doing
anything.”
mental - “After awhile, I
just can’t concentrate
anymore. It’s hard to stay
focused.”
what type of fatigue
have you noticed in
your clients/service
recipients?
physical fatigue
muscle weakness
worker harder to do
things post TBI
dressing
working around the
house
walking
worse in evenings
after busy day
better in morning after
good sleep/rest
gets better as client
becomes more
active/stronger
psychological fatigue
depression
anxiety
gets worse with stress
sleep may not help
may be worse in the
morning
must find the cause of
the fatigue to help
client
medications may help
mental fatigue
make it hard to
concentrate
the more you have to
concentrate the more
fatigue
may cause irritability
forces client to
concentrate harder to
do tasks that were
used to be easier
the type of fatigue we
know the least about
social skills
social opportunities
problems with speech
self concept and emotions
self centeredness
awareness and social
perception
navigating social situations
(mobility, coordination and
endurance)
challenges for social skills
take the shame out of a problem situation
focus on practical and actual (not emotional)
emphasize positive over negative
build skills in less demanding situations first
role play or practice skills
help the person use his/her words and actions (not
yours)
practice sending and receiving skills
videotape for review
find a mentor to help cue them
tips
loss, mourning and grief
loss, mourning, grief
physical death
non-physical death
divorce
separation
illness
injury
transitions (loss of employment, empty-nest
syndrome, geographical moves)
grief and mourning
grieving = internal
response to loss
how one feels on the
inside
sad
angry
confused
afraid
alone
mourning =
external response
to the loss
how one
expresses
feelings about the
loss
funerals
ceremonies
rituals
talking
writing
primary and secondary loss
primary
impact on the
person’s life can be
staggering
day to day challenges
life altering changes
secondary
comes after the
primary loss
can be
physical
emotional
spiritual
financial
social
grief is a process
can be ongoing for
months, years
it is Unpredictable
not a step by step
process
the familiar is no longer
familiar
wide range of
responses
shock
numbness
disbelief
disorganization
disbelief
confusion
searching for
meaning
hello - goodbye - hello
goal is not to get over the pain and loss
the goal is to reconcile, heal, integrate loss into
one’s life
saying goodbye to the life they once had so they
can embrace the life they have now
tips for your clients
be gentle with yourself
your loss is real
take time to work through your feelings
recognize secondary losses
recognize your family is also experiencing grief
find appropriate ways to express your grief
take time to reflect (past, present, future)
ask for help
keep life in perspective
tips for families
recognize your personal loss
find someone to share your grief
have courage
allow yourself to seek respite or relief
ask for help
keep life in perspective
tips for the helper
S H A R E
Support
Hope
Acknowledge
Reflection
Engage in Life
self care for the helper and families
caused by the neurological disruption, not a personal issue
they are not purposefully misbehaving
eliminating the behavior is not realistic
knowing this can help you understand the behavior and lessen your concern, anxiety
manage your own behavior not that of the other person
work to minimize challenging and/or inappropriate behavior
key concepts for your own self care
as a helper
MI and TBI
adapted from Miller & Rollnick, 2002 and Rollnick, Miller, & Butler, 2008
adapted from Miller & Rollnick, 2002 and Rollnick, Miller, & Butler, 2008
children andadolescents
children and adolescents
about 4 out of every 100
boys and 2.5 of every 100
girls have a traumatic
brain injury by age 16
5 out of 8 adolescents
have sustained a head
injury (male and female)
brain development
develops from the
inside out
frontal lobe fully
develops in mid 20’s
(2+ years later in
males)
orbito- frontal cortex
last area to mature
and develop
highest level of
thinking and
reasoning occurs in
the OFC
OFC is most
vulnerable to impact
emotional regulation
and interpretation of
reward and
punishment , and
planning
brain development
injury in childhood can
result in key stages of
brain development being
altered
interrupted
halted
abilities that are just developing or have not yet
emerged are the most sensitive and more likely to be
disrupted
impacts of TBI may become more complex as the
child matures
screening
screening
adapted from the Ohio
Valley Center for Brain
Injury Prevention and
Rehabilitation
John Corrigan, Ph.D.
2009
proposed questions
1. have you ever been injured following a blow
to the head? as a child?
playing sports?
from tbi – a fall, motor vehicle incident, interpersonal
violence?
2. have you ever been hospitalized or treated in
an emergency room following an injury? treated and released?
evaluated by a neurologist?
had a cat scan, mri or eeg done while in the er?
proposed questions
3. have you ever been unconscious following
an accident or injury? have no memory for the event?
felt dazed or confused?
experienced a violent shaking of the head and neck?
4. have you ever been injured in a fight? taken a direct blow to the head?
experienced a headache, fatigue, dizziness, or changes in
vision?
proposed questions
5. have you ever been injured by a spouse or
family member? pushed
punched
shaken
choked
6. have you ever had any major surgeries?
heart bypass
transplant
brain surgery to treat a tumor, aneurysm, stroke
proposed questions
7. illnesses? toxic shock syndrome
meningitis
encephalitis
hydrocephalous
seizure disorder
lead poisoning
exposure to chemotherapy (especially as a child)
proposed questions
8. additional comments and observations of
the interviewer any visible scars?
walks with a limp?
uses a cane or walker?
has a foot brace?
limited use of one hand?
appears to have difficulty focusing vision?
difficulty Answering questions?
answers are unorganized and/or rambling?
becomes easily distracted, agitated or is emotionally
labile?
what you are looking for……
any reported or suspected functional difficulties that are
interfering with home, work, or community activities.
red flags
red flags when screening
you intuition or professional sense are alarmed
obvious physical symptoms are present
individuals’ or family’s disclosure of injury
post-concussive complaints are offered
when typical interventions or strategies prove ineffective
individual’s behavior is not a logical expected response
to an auditory or visual request
when affective and emotional responses are not parallel
to stimuli or environmental influences
when medication regiments prove ineffective or the
person exhibits effects different from those expected
best practices
Best Practices
conduct comprehensive developmental screening upon
admission to school/district
collect in-depth social-developmental histories for all
clients experiencing referral
asking brain injury questions in multiple ways at multiple
times (Corrigan’s screening ?’s)
question/observe upon return to school/work/therapy
after extended absences
have heightened awareness of the signs of brain injury
inform others about TBI, its signs and impacts
screening requires action
documentation
referral
follow-up
offer interactions that are
respectful and take into
account the limitations
and impairments that
have resulted from the
brain injury
Ideal Brain Injury Rehabilitation
physical therapy
occupational therapy
speech therapy/cognitive
retraining
neuropsychology
neuro-psychiatry
social work
recreational therapy
physiatry
neurology
references• Brain Injury Association of Arizona, www.biaaz.org
• Centers for Disease Control and Prevention.
www.cdc.gov/traumaticbraininjury/
• Corrigan, J. (2009). Screening Questions. Ohio Valley Center for Brain
Injury Prevention and Rehabilitation
• Department of Health and Human Services. HHS.gov Health Resources
and Services Administration
• Hospital, C. (2008). Brainline. www.brainline.org
• Medley, A. and Powell (2010). Motivational interviewing to promote self-
awareness and engagement in rehabilitation for following acquired brain
injury: A conceptional review. Neuropsychological Rehabilitation 20(4), 481-
508.
• Moss, M.B. (2010). Understanding the Frontal Lobes: Emotional Regulation,
Social Intelligence and Motivation. Institute for Brain Potential
• Novack, T. (2002). TBI Inform – Managing Behavioral Problems after a TBI.
Traumatic Brain Injury Model System
• Wolf, S (2010). Brain Injury: Understanding TBI and Dysexecutive
Functioning. Wattle and Daub Research