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Traumatic Brain InjuryPRESENTED BY: SAMHSA SOAR TECHNICAL ASSISTANCE CENTERPOLICY RESEARCH ASSOCIATES, INC.

UNDER CONTRACT TO: SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATIONU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Welcome!KRISTIN LUPFER, PROJECT DIRECTOR SOAR TECHNICAL ASSISTANCE CENTER POLICY RESEARCH ASSOCIATES, INC.DELMAR, NEW YORK

Webinar InstructionsMutingRecording availabilityDownloading documentsEvaluationhttp://soarworks.prainc.com/article/soar-webinar-tbi

Learning ObjectivesUnderstand the prevalence and causes of TBI among Veterans and others who experience homelessness or at risk of homelessnessUnderstand the challenges interviewing SOAR applicants with TBI, by sharing practice tips and an assessment tool to overcome themLearn the major methods of evaluating a TBI and the evidence required to evaluate a claim involving TBI

AgendaTraumatic Brain Injury Prevalence and Practice Tips for Engaging & Interviewing SOAR Applicants Anastasia Edmonston, MS, CRC, Trainer, Maryland Behavioral Health Administration,

Catonsville, Maryland Evaluating Traumatic Brain Injury for Disability Determination E. Caroline Mason, Medical Relations Director, Maryland Disability Determination

Services, Timonium, Maryland Dr. Carla Sarno, M.D., Chief Psychiatric Consultant, Maryland Disability Determination

Services, Timonium, Maryland

Questions & Answers

Poll Question #1How familiar are you with a Traumatic Brain Injury (TBI) impairment?a. Not familiar with TBI diagnosis, signs, symptoms and functional limitations.

b. Basic understanding of TBI diagnosis, signs, symptoms and functional limitations, but unsure how DDS evaluates

c. Basic understanding of TBI diagnosis, signs, symptoms, functional limitations and how DDS evaluates

d. Good understanding of TBI and success with representing applicants with TBI diagnosis for SSI/SSDI benefits

Traumatic Brain Injury: An Often Hidden DisabilityANASTASIA EDMONSTON, TRAINER,

MARYLAND BEHAVIORAL HEALTH ADMINISTRATION,

CATONSVILLE, MARYLAND

We Will Discuss TodayWhat are TBI and ABI?Who and how many are affected?How a history of brain injury can create barriers to behavioral health and success in the community, workplace and in making and maintaining relationshipsSupporting the functional impact of brain injury via documentation and prescriptive assessment

Definitions Traumatic Brain Injury (TBI) is an insult to the brain caused by an external physical force, for example; fall, MVA, assault, sports related, IED explosion.

Both mechanisms of injury can result in chronic disability that may get worse with age*

Acquired Brain Injury (ABI) is an insult to the brain that has occurred after birth for example; stroke, near suffocation, infections in the brain, anoxia

Incidence of TBI

In the United States, at least1.7 million sustain a TBI each year…

275,000 are hospitalized

CDC 2010, 2002-2006 dates

TBI By CauseFalls-35.2% (young children & elderly)Unknown/Others-21%Motor Vehicle-Traffic-17.3%Struck by/against-16.5% (unintentionally by object or another person)Assault-10%

CDC 2010

Who may have a TBI?People who are incarceratedPeople experiencing homelessnessVictims and Perpetrators of Domestic ViolenceIndividuals with behavioral health disordersReturning military service members

The TBI & Homelessness Connection 2008 CMJ- 904 individuals surveyed53% lifetime prevalence of TBI Hwang et.al

2014 CMJ- 111 men screened45% screened positive for history of TBI73% had 1st TBI before adulthoodFor 87% the injury predated homelessness.

Mechanism of injury: assault, sports/recreation, MVA, fall Positive screen (+) associated with history of arrest or mental

illness and parental history of substance abuse . Topolovec-Vranic et. al

The TBI & Homelessness Connection 2015 Journal of Health Care for Poor & UnderservedOf 229 veterans seeking homeless services, nearly all (83%) had sustained at least 1 TBI prior to first episode of homelessness. 43% sustained at least 1 TBI following first episode of homelessness. Median lifetime # of TBI’s incurred was three.

•30% of individuals sustained injuries with severity levels that would be expected to be associated with ongoing TBI-related deficits Barnes et. al.

2000 Epidemiological Study of Mild TBI 5,000 interviewed

7.2% recalled a blow to the head w/unconsciousness or period of confusionFollow up testing found; 2x rate of depression, drug and alcohol abuseElevated rates of panic and obsessive-compulsive disorderBy J. Silver of NYU, cited in WSJ by Thomas Burton 1.29.08

http://online.wsj.com/article/SB120156672297223803.html?mod=googlenews_

Christchurch, New ZealandBirth Cohort Study (2014)

Compared with non-injured individuals, inpatients (at least 1 night in hospital) , those injured between 0-5 &16-21 were more likely to have symptoms consistent with drug dependenceAll inpatient groups had increased risk of arrest, with the age group 0-5 & 6-15 more likely to be involved in violent offenses

McKinlay et. al, Journal of Head Trauma 2014

Often, individuals are unaware of how a prior history of brain injury or brain injuries is contributing to difficulty at home, work, school and problems with relationships with othersAS WELL as difficulty accessing/participating in and benefiting from mental health and/or substance abuse services

Why is it so important to screen for a history of TBI?

“Unidentified traumatic brain injury is an unrecognized major source of social and

vocational failure.”

Wayne Gordon, Ph.D. of the Brain Injury Research Center at Mount Sinai School of Medicine

Quoted in the Wall Street Journal 1.29.08

Possible Physical ChangesInjury related problem How it may affect a person

functionally

Coordination Unsteady gait, poor eye-hand coordination, slow or slurred speech, tremors, paralysis

Visual Deficits Staring or poor eye contact, blurred or double vision, inability to follow an object with their eyes

Additional Physical Challenges: Seizures, deaf or hard of hearing , fatigue

Possible Changes in Thinking aka Cognitive Skills

Injury related problem How it may affect a person functionally

Memory Trouble following directions, providing requested information, making appointments

Processing (receptive) Understanding what being said, reading

Processing (expressive) Trouble putting thoughts into words, tip of the tongue syndrome

Problem solving (related to frontal lobe & temporal tipInjury)

Impulsive, easily frustrated, sexually disinhibited, verbally/physically combative, interpersonally inflexible, poorly organized

Attention Decreased ability to focus and sustain attention, difficulty splitting and dividing attention, can compromise memory for new information

Possible Changes in Personality & Behavior *

Injury related problem How it may affect a person functionally

Depression Flat affect, lack of initiation, sadness,irritability

Unawareness Unable to take social cues from others

Confabulation “making up stories”

Perservation Gets “stuck” on a topic of conversation or physical action

Anxiety Can exacerbate other cognitive/behavioral problems

Functional Clues to a Possible History of TBI

Does the individual need reminders to perform basic ADLs?Does the individual need reminders to perform higher level ADLs such as cooking & community activities and/or are they a safety risk if they use a stove etc.Does the individual need assistance to remember appointments , do they lose their way in the community?Does the individual have a history of losing jobs?Do you note any attempt by the individual to use strategies to support memory, attention, processing etc.?Are they orientated X3?

Other ConsiderationsDid the individual experience abuse as a child, did the individual’s mother drink during pregnancy?Does the individual report they received special education services in school?Does the individual have a history of losing jobs?Do the professionals working with the individual report that they often feel like they are starting from square one in each session/appointment (e.g. little or no follow through on between session assignments such as collecting/completing paperwork)

Obtaining Supporting Data for a History of Brain Injury

Obtain a snap shot of “before” TBI

Was there a dramatic loss of functioning at home, work and community post the TBI? Did the individual…

Have a stable employment history?Have no or an insignificant legal history?Graduate from high school, attend college or trade/vocational training?Manage any or all of the above despite other health or behavioral health issues? *Have social ties, including; family, volunteering, church, hobbies etc.

Keep in mind for some individuals, who grow up in chaotic environments, there may be no clear cut “before” in terms of their functional status.

Conduct the OSU TBI-IDHTTP://OHIOVALLEY.ORG/TBI-ID-METHOD/

THIS SHORT TUTORIAL VIA TEXT AND VIDEO WALKS THE VIEWER THROUGH THE ADMINISTRATION OF THE SCREENING TOOL

A Product of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation

John Corrigan PhDDirector, Ohio Valley Center for Brain Injury Prevention and Rehabilitation, The Ohio

State University; Columbus, Ohio.

http://ohiovalley.org/informationeducation/whatif/index.cfm

“What if There is a Traumatic Brain Injury?”

Tips Regarding Supporting DocumentationBe mindful that a standard psychological assessment may not provide information regarding the ability to learn new information and/or ability to apply information in novel situations (executive functioning)Obtaining a full neuropsychological evaluation may not be feasible, however there are alternative ways to gather information regarding executive functioning skills that can support your observations and the individual’s self-report in addition to the OSU TBI-ID

Language from a Support Letter for VA benefits: TBI & PTSD *

“A few years following the shooting at Fort X ( ) chose not to reenlist and left the Army. He felt returning to civilian life would open up a variety of educational and career opportunities not available to him in the service. However, the army provided something that was critical to his successful functioning day to day following his injuries, and that is structure. While in the military the expectations were laid out for him, literally day to day he knew exactly what to do. In the civilian world, we are expected to impose structure on our lives, make decisions that are in our best interest and follow through with our responsibilities. The ability to multitask and make thoughtful, measured decisions are high level cognitive skills that most of us take for granted. For individuals who receive a blow or blows to the temporal/frontal regions of their brain, this skill can be compromised. Although it is related to organic brain damage, the behavioral manifestations of the damage often looks to the casual observer as if the person is unmotivated, lazy, self-centered, disorganized and impulsive.”

Alternative TestsWisconsin Card Sorting Test- Trail Making A & BWechsler Adult Intelligence Scale IVWechsler Memory Scale IV

Language from a Support Letter for

SSDI benefits *Cognitively, ( ) brain injury has resulted in some right side weakness and some cognitive deficits. She has moderate deficits in attention and immediate memory but her speech is within normal limits. She has continued to make progress in these areas. She has residual impairments in verbal fluency, visual motor tracking, verbal memory and construction. Secondary to ( ) brain injury, her cognitive impairments limit her attention, insight, judgment, and ability to make informed decisions. ( ) demonstrates significant problems with mood regulation and impulsivity. ( ) presents as social and alert. When asked direct questions, she is able to verbalize her responses on topic. ( ) is oriented to time, place and person. She can follow When given a simple three step command, she can successfully complete three steps, however, she breaks down if there are more than 4 or 5 steps, especially if the information is novel. “

ResourcesBrain Injury Association of America 703-236-6000, www.biausa.orgBrain Injury Association of Maryland 410-448-2924, www.biamd.orgOhio Valley Center For Brain Injury Prevention and Rehabilitation, 614-293-3802, www.ohiovalley.org. Excellent SA TX resource & informationwww.brainline.org , wealth of information and supports available for individuals with brain injury, their families and professionals.

Resources Rehabilitation Research and Training Center on Traumatic Brain Injury Interventions & New York Traumatic Brain Injury Model System at Mount Sinai School of Medicine and the Mount Sinai Rehabilitation Research and Training Center

www.mssm.edu/tbinet

Contact Information Anastasia Edmonston MS CRCanastasia.edmonston@maryland.gov

410-402-8478

ACKNOWLEDGEMENT

Dawn Roher of the Maryland Brain Injury Association roher@biamd.org

410-448-2924

Poll Question #2True or False? The behavioral manifestations of the TBI often looks to the casual observer as if the person is unmotivated, lazy, self-centered, disorganized and impulsive.

a. True

b. False

Disability Determination Services: Evaluating Traumatic Brain Injury (TBI)E. CAROLINE MASON, MEDICAL RELATIONS DIRECTOR, MARYLAND DISABILITY DETERMINATION SERVICES, TIMONIUM, MD

DR. CARLA SARNO, M.D., CHIEF PSYCHIATRIC CONSULTANT, MARYLAND DISABILITY DETERMINATION SERVICES, TIMONIUM, MD

Social Security Definition of Disability

The inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months.Substantial Gainful Activity (SGA)Medically Determinable Impairment (MDI)Duration

Sequential Evaluation Process

Is the individual engaging in SGA?Does the individual have a severe impairment?Does the individual have an impairment which meets or equals the listing?Does the impairment preclude the ability to perform past relevant work?Does the impairment preclude the ability to perform other work?

Evaluation of Traumatic Brain Injury

Neurological and mental impairments, wide variety of posttraumatic symptoms and signsRecovery highly variable – long term outcomes difficult to predict first few months post injuryMedical hold 3-6 months Determine stabilization with improvement or worsening

Medical Listings - Physical

Disability Evaluation Under Social Security Listing of Impairments 11.00 Neurological – Adult11.18 Cerebral trauma11.02 Epilepsy – convulsive epilepsy11.03 Epilepsy – nonconvulsive epilepsy11.04 Central nervous system vascular accident

Medical Listings - Mental 12.00 Mental Disorders – Adult12.02 Organic mental disorders: Psychological or

behavioral abnormalities associated with a dysfunction of the brain. History and physical examination or laboratory tests demonstrate the presence of a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities.

The required level of severity for these disorders is met when the requirements in both A and B are satisfied, or when the requirements in C are satisfied.

Medical Listings – A Criteria

A. Demonstration of a loss of specific cognitive abilities or affective changes and the medically documented persistence of at least one of the following:Disorientation to time and place; orMemory impairment, either short-term, intermediate, or long-term; orPerceptual or thinking disturbances; or Change in personality; orDisturbance in mood;Emotional lability and impairment in impulse control; or Loss of measured intellectual ability of at least 15 IQ points from premorbid

levels or overall impairment index clearly within the severely impaired range on neuropsychological testing

Medical Listings – B Criteria

B. Resulting in at least two of the following:1. Marked restriction of activities of daily living; or2. Marked restriction in maintaining social functioning; or3. Marked difficulties in maintaining concentration,

persistence, or pace; or4. Repeated episodes of decompensation, each of an

extended duration; or

Medical Listings – C Criteria

C. Medically documented history of a chronic organic mental disorder of at least 2 years duration that has caused more than a minimal limitation of ability to do basic work activities, with symptoms or signs currently attenuated by medication or psychosocial support, and one of the following:Repeated episodes of decompensation, each of extended duration; orA residual disease process that has resulted in such marginal adjustment

that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate; or

Current history of 1 or more years inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement.

Mild TBI SymptomsPhysical symptomsLoss of consciousness – few seconds to few minutesState of being dazed, confused, or disoriented (no LOC)HeadacheNausea or vomitingFatigue or drowsinessDifficulty sleepingSleeping more than usualDizziness or loss of balance

Mild TBI SymptomsSensory symptomsBlurred visionRinging in earsBad taste in mouthChanges in ability to smell Sensitivity to light or sound

Cognitive or mental symptomsMemory or concentration problemsMood changes or swings Feeling depressed or anxious

Moderate to Severe TBI Symptoms

Moderate to severe TBI can include any of the signs and symptoms of mild injury, as well as, the following symptoms that may appear within the first hours to days after a head injury:

Physical symptoms Loss of consciousness from several minutes to hours Persistent headache or headache that worsens Repeated vomiting or nausea Convulsions or seizures Dilation of one or both pupils of the eyes Clear fluids draining from the nose or ears Inability to awaken from sleep Weakness or numbness in fingers and toes Loss of coordination

Moderate to Severe TBI Symptoms cont.

Cognitive or mental symptomsProfound confusionAgitation, combativeness or other unusual behaviorSlurred speechComa and other disorders of consciousness

Causes of TBITBI is caused by a blow or other traumatic injury to the head or body. The degree of damage can depend on several factors, including the nature of the event and the force of impact.injury may include one or more of the following:Damage to brain cells may be limited to the area directly below the point of impact on the skull.A severe blow or jolt can cause multiple points of damage because the brain may move back and forth in the skull.

Causes of TBI cont.A severe rotational or spinning jolt can cause the tearing of cellular structures.A blast, as from an explosive device, can cause widespread damage.An object penetrating the skull can cause severe, irreparable damage to brain cells, blood vessels and protective tissues around the brain.Bleeding in or around the brain, swelling, and blood clots can disrupt the oxygen supply to the brain and cause wider damage.

Intellectual Problems  Many people who have had a significant brain injury will experience changes in their thinking (cognitive) skills. Traumatic brain injury can result in problems with many skills, including:Cognitive problems MemoryLearningReasoningSpeed of mental processingJudgmentAttention or concentration

Intellectual Problems cont.

Executive functioning problemsProblem-solvingMultitaskingOrganizationDecision-makingBeginning or completing tasks

Communication Problems Language and communication problems are common following traumatic brain injuries. These problems can cause frustration, conflict and misunderstanding for people with a traumatic brain injury, as well as family members, friends and care providers.

Communication problems may include: Cognitive Difficulty understanding speech or writingDifficulty speaking or writingInability to organize thoughts and ideasTrouble following conversations

Communication Problems cont.

SocialTrouble with turn taking or topic selectionProblems with changes in tone, pitch or emphasis to express

emotions, attitudes or subtle differences in meaningDifficulty deciphering nonverbal signalsTrouble reading cues from listenersTrouble starting or stopping conversationsInability to use the muscles needed to form words (dysarthria)

Behavioral ChangesBehavioral changes can often be mistaken for other psychiatric conditions.People who have experienced brain injury often experience changes in behaviors, to include:

Difficulty with self-control Lack of awareness of abilitiesRisky behavior Inaccurate self-imageDifficulty in social situations Verbal or physical outbursts

Emotional ChangesEmotional changes may include:DepressionAnxietyMood swingsLack of empathy for othersAngerInsomniaChanges in self-esteem

Sensory ProblemsProblems involving senses may include:Persistent ringing in the earsDifficulty recognizing objectsImpaired hand-eye coordinationBlind spots or double visionA bitter taste, a bad smell or difficulty smellingSkin tingling, pain or itchingTrouble with balance or dizziness

Degenerative Brain Disease

A traumatic brain injury may increase the risk of diseases that result in the gradual degeneration of brain cells and gradual loss of brain functions, though this risk cannot yet be determined with any certainty for an individual. These include:Alzheimer’s Disease – primarily causes the progressive loss of memory and thinking skillsParkinson’s Disease – a progressive condition that causes movement problems, such as tremors, rigidity and slow movementsDementia Pugilistica – most often associated with repetitive blows to the head in career boxing, which causes symptoms of dementia and movement problems

Tests and DiagnosisGlasgow Coma ScaleMild TBI GCS 13-15Moderate TBI GCS 9-12Severe TBI GCS 3-8

Information about injury and symptomsImaging TestsIntracranial pressure monitorNeuropsychological testing

Online ResourcesDisability Determination Services Website http://dors.maryland.gov/resources/Pages/DDS.aspxDisability Evaluation Under Social Security https://www.ssa.gov/disability/professionals/bluebook/index.htmSocial Security Websitehttp://www.socialsecurity.gov/ Social Security Publications http://www.ssa.gov/pubs/

Poll Question #3Which of the following Listings is a TBI evaluated under?

a. Listing 11.18- Cerebral Trauma

b. Listing 11.02- Epilepsy

c. Listing 11.04- Central Nervous System

d. All of the above

Contact Information E. Caroline Mason,Medical Relations Director Maryland Disability Determination Services

Timonium, Maryland Phone: (410) 308-4336

Email:elizabeth.c.mason@ssa.gov

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