Traumatic Brain Injury:

Challenging Behavior

Anastasia Edmonston MS CRC

TBI Projects Director
Maryland Traumatic Brain Injury Project
MD Mental Hygiene Administration
 What We will Cover Today

• Brain Anatomy-form and

function
• Brain Injury-how many & who is
affected
• Types of Brain Injury
 What We will Cover Today

• The Physical, Cognitive and

Emotional/Behavioral Aftermath
of Brain Injury
• TBI Screening Tool
• Brain Injury and Co-occurring
disorders
 What We will Cover Today

• Strategies for Supporting

Individuals with Brain Injuries
• Resources Available Statewide,
Regionally and Nationally
 Skull Anatomy
The skull is a rounded layer
of bone designed to protect
the brain from penetrating
injuries.
The base of the skull is rough, with
many bony protuberances.
These ridges can result in injury to
the temporal and frontal lobes of the
brain during rapid acceleration.

Bony ridges
 Skull Anatomy

Injury to frontal lobe from contact with the skull

 Lobes of the Cerebrum

Frontal
lobe
Parietal
lobe Limbic
Lobe

Occipital
lobe
Temporal
Lobe
 The Frontal Lobe
The frontal lobe is the area of
the brain responsible for our
“executive skills” - higher
cognitive functions.
These include:
• Problem solving
• Spontaneity
• Memory
• Language
• Motivation
• Judgment
• Impulse control
• Social and sexual
behavior.
 Frontal Lobe Injury
The frontal lobe of the brain can
be injured from direct impact on
the front of the head.
During impact, the brain tissue is
accelerated forward into the bony
skull. This can cause bruising of
the brain tissue and tearing of
blood vessels.
Frontal lobe injuries can cause
changes in personality, as well as
many different kinds of
disturbances in cognition and
memory.
 Prefrontal Cortex
The prefrontal cortex
is involved with
intellect, complex
learning, and
personality.
Injuries to the frontal
lobe can cause
mental and
personality changes.
 The Developing Brain
• Children’s brains do not reach their
adult weight of 3 pounds until they are
12 years old
• The brain, and most importantly, the
brain’s frontal lobe region does not
reach it’s full cognitive maturity till
individuals reach their mid twenties
 The Developing Brain
• The Frontal Lobe houses our executive
skills, these include; judgement,
problem solving, mental flexibility, etc.
• The Frontal Lobe is very vulnerable to
injury
• Damage to the Frontal Lobe any where
along the developmental continuum can
impact executive skill functioning
 Temporal Lobe
The temporal lobe
plays a role in
emotions, and is also
responsible for
smelling, tasting,
perception, memory,
understanding music,
aggressiveness, and
sexual behavior.
The temporal lobe
also contains the
language area of the
brain.
 Temporal Lobe Injury
The temporal lobe of the brain is vulnerable to injury
from impacts of the front of the head.
The temporal lobe lies upon the bony ridges of the
inside of the skull, and rapid acceleration can cause the
brain tissue to smash into the bone, causing tissue
damage or bleeding.
 Parietal Lobe
The parietal lobe plays a
role in our sensations of
touch, smell, and taste. It
also processes sensory
and spatial awareness, and
is a key component in eye-
hand co-ordination and
arm movement.
The parietal lobe also
contains a specialized area
called Wernicke’s area that
is responsible for matching
written words with the
sound of spoken speech.
 Side Impact Injuries
May Impact the Parietal Lobe

Injuries to the right or left

side of the brain can
occur from injuries to the
side of the head.
Injuries to this part of the
brain can result in
language or speech
difficulties, and sensory
or motor problems.
 Occipital Lobe

The occipital lobe

is at the rear of the
brain and controls
vision and
recognition.
 Occipital Lobe Damage
Occipital lobe injuries
occur from blows to the
back of the head.
This can cause bruising
of the brain tissue and
tearing of blood
vessels.
These injuries can
result in vision
problems or even
blindness.
 The Limbic System
The limbic system is the
area of the brain that
regulates emotion and
memory. It directly connects
the lower and higher brain
functions.
 Coup-Contra Coup Injury
A French phrase that
describes bruises that
occur at two sites in the
brain.
When the head is struck,
the impact causes the
brain to bump the
opposite side of the
skull. Damage occurs at
the area of impact and
on the opposite side of
the brain.
 Diffuse Axonal Injury

Brain injury does not require a

direct head impact. During rapid
acceleration of the head, some
parts of the brain can move
separately from other parts. This
type of motion creates shear forces
that can destroy axons necessary
for brain functioning.
These shear forces can stretch the
nerve bundles of the brain.
 Diffuse Axon Injury
is a very serious injury, as it directly impacts
the major pathways of the brain.
The Neuron

Dendrites:
Collects
information from
other neurons

Cell Body

Axon:
Transmits information to
other neurons.
 Definitions
• Traumatic Brain Injury is an insult to the
brain caused by an external physical
force
• Diffuse Axonal Injury the tearing and
shearing of microscopic brain cells
• Acquired Brain Injury is an insult to the
brain that has occurred after birth, for
example; TBI, stroke, near suffocation,
infections in the brain, anoxia
Incidence of TBI CDC 2004

In the United States, at

least
1.4 million sustain
a TBI each year
(That we know about)
What are the Costs of
TBI? CDC 2006

Direct medical costs and indirect

costs such as lost productivity of
TBI totaled an estimated 60 billion in
the United States in 2000. (That is
equal to the cost of building the
international space center or 60
times the net worth of Oprah
Winfrey )Jean Langlois of the CDC
About 3.17 Million American
civilians (more than 1.1% of
population, live with the
consequences of traumatic
brain injury
CDC in Journal of Head Trauma
Rehabilitation 2008 (Vol. 23, No. 6, pp
394-400)
What Might it Feel Like

Handwriting
&
Processing Exercise
 Incidence of TBI Of CDC 2004

those 1.4 million..

• 51,000 die;
• 290,000 are hospitalized; and
• 1,224,000 million are treated
an released from an
emergency department
 “Reframed, the numbers
nauseate. In America alone,
so many people become
permanently disabled from a
brain injury that each decade
they could fill a city the size of
Detroit……...
….Seven of these cities are
filled already. A third of their
citizens are under fourteen
years of age.”

From Head Cases, Stories of Brain

Injury and its Aftermath
Michael Paul Mason
2008 published by Farrar, Straus and Giroux
 Brain Injury and
Children
• According to the BIAA, Brain Injury is
the leading cause of death and disability
among children
• Approximately 470,000 TBI’s occur
among children 0-14 years old a year
• Brain injuries account for over 90% of
emergency department visits in children
0-14 years old CDC Report “Traumatic Brain injury in the United States January
2006
 Brain Injury and Concussion
in Children
• In sports alone, 300,000 + concussions are
“estimated” to occur annually
• For every 1 concussion in the NFL, there are
5,650 youth injuries
• Sports associated with concussion: soccer,
football, lacrosse, hockey, horseback riding,
cheerleading…….. Gerard Gioia, Ph.D.,
Children’s National Medical Center in remarks at the
BIAMD conference 2005
Other potential Neurotoxins
that may impact the brain
• Exposure to lead paint
• Regarding exposure to alcohol in utero,
according to Dr. Jacobson of Wayne
State University “We found more
serious cognitive impairment in
relation to alcohol than cocaine or other
drugs, including marijuana and
smoking” From “Fetal Brains Suffer Badly From
Effects of Alcohol” NYT 11.4.03
 To Underscore
The Developing Brain
• Children’s brains do not reach their
adult weight of 3 pounds until they are
12 years old
• The brain, and most importantly, the
brain’s frontal lobe region does not
reach it’s full cognitive maturity till
individuals reach their mid twenties
This is important to keep in
mind because…..

The Adult Consumer you

are serving in your
program may have
suffered a brain injury as
a child
 Causes of TBI CDC 2006

Suicide, 1% Unknown,
9%
Other Transport, Other, 7%
2%
Falls, 28%
Pedal Cycle
(non MV), 3%

Assault, 11%

Motor Vehicle-
Traffic, 20%
Struck
By/Against, 19%
 Who is at the Highest Risk
of TBI? 2005
• Males 1.5 times as likely as females to
sustain a TBI
• Two age groups most at risk are 0-4
year olds and 15-19 year olds
• The elderly, 75 and older from falls
• African Americans have the highest
death rate from TBI
 What about those with
unidentified TBI?
Adapted from MCHB webcast, Wayne Gordan, Ph.D 5.21.08

• 425,000 people treated by MDs in office

visits Langlois 2004
• 90,000 treated in other types of
outpatient settings Langlois, 2004
• Uncounted injuries on the playground,
on the playing fields, from falls in the
home, assaults, domestic violence,
returning veterans, etc. etc. etc…...
 The Scope of the Problem
• Distribution of Severity:

– Mild injuries = 80%

(LOC < 30 min, PTA ,1 hour)

– Moderate = 10 - 13%
(LOC 30 min-24 hours, PTA 1-24 hours)

– Severe = 7 - 10%
(LOC >24 hours, PTA >24 hours)
The Importance of Post
Traumatic Amnesia

PTA is the period of time

after injury when a
person is unable to lay
down new
memories…for example
“That first morning, wow, I didn’t want
to move, I was thankful that nothing’s
broken, but my brain was all
scrambled” Ryan Church, NYT 3/10/08
“All he remembers from the
collision with Anderson is the
aftermath, being helped off the
field by two people, although he
said he did not know who they
were until he saw a photograph
later” Ben Shpigel NYT reporter
The Faces of Brain
Injury
A short video by the Brain Injury Association of
Florida
 Possible Changes-Physical
• Motor skills/Balance
• Hearing
• Vision
• Spasticity/Tremors
• Speech
• Fatigue/Weakness
• Seizures
• Taste/Smell
 Possible Changes-Thinking
• Memory • Executive skills
• Attention • Problem solving
• Concentration • Organization
• Processing • Self-Perception
• Aphasia/receptive • Perception
and expressive • Inflexibility
language • Persistence
 Possible Changes-Personality
and Behavioral
• Depression
• Social skills problems
• Mood swings
• Problems with emotional control
• Inappropriate behavior
• Inability to inhibit remarks
• Inability to recognize social cues
 Personality and Behavioral
cont..
• Problems with initiation
• Reduced self-esteem
• Difficulty relating to others
• Difficulty maintaining relationships
• Difficulty forming new relationships
• Stress/anxiety/frustration and reduced
frustration tolerance
 A memory deficit might look like
trouble remembering or it might
look like……
(Capuco & Freeman-Woolpert)

• She frequently misses appointments-

avoidance, irresponsibility (for example...)
• He says he’ll do something but doesn’t get
around to it (for example...)
• She talks about the same thing or asks the
same question over and over-annoying
perservation
• He invents plausible sounding answers so you
won’t know he doesn’t remember (for example…)
 An attention deficit might look
like trouble paying attention or
it might look like …
(Capuco & Freeman-Woolpert)

• He keeps changing the subject

• She doesn’t complete tasks
• He has a million things going on and
none of them ever gets completed (for
example…)

• When she tries to do two things at once

she gets confused and upset
A deficit in executive skills might
look like the inability to plan and
organize or it might look like...
(Capuco & Freeman-Woolpert)

• Uncooperativeness,
stubbornness
• Lack of follow through
• Laziness
• Irresponsibility
Unawareness might look like…
(Capuco & Freeman-Woolpert)

• Insensitivity, rudeness
• Overconfidence
• Seems unconcerned about the extent of her
problems
• Doesn’t think she needs supports
• Covering up problems (“everything’s fine…”)
• Big difference in what he thinks and what everyone
else thinks about his behavior
• Blaming others for problems, making excuses
Lack of Awareness
A common and difficult to remediate
hallmark of a brain injury
 Levels of Awareness
Crossen et.al (1989) J Head Trauma Rehabilitation

• Intellectual Awareness-individual is able to understand at some

level, that a particular function or functions is impaired. A greater
level of intellectual awareness is required to recognize some
common thread in the activities in which they have difficulty
• Emergent Awareness-individual is able to recognize a problem
when it is actually happening. To do so, they must recognize a
problem exists (intellectual awareness), and realize when it
occurs
• Anticipatory Awareness-individual is able to anticipate a problem
will occur and plan for the use of a particular strategy or
compensation that will reduce the chances that a problem will
occur, e.g. keep and refer to a calendar to support memory for
daily schedule
 The Relationship
Between Brain Injury and
Mental Health
 Depression
• Depression is the most common Axis I
psychiatric disorder after TBI followed by alcohol
abuse, panic disorder, specific phobia and
psychotic disorders (Gordon et. al 2004)
• A 50 yr.. Follow-up of 1,198 WWII vets found that
520 had incurred a TBI. 18.5% of vets with brain
injuries had a life time prevalence of major
depression verses 13.4% rate of depression
among on brain injured vets (Holsinger et.al 2002)
 The Post -Concussive
Syndrome and PTSD Dr. Paul McClelland

• Increased startle response;

especially to loud sounds
• Irritability
• Avoidance of many social events
• Intolerance of new situations
 Organic Personality Disorder &
Anti-Social or Hysterical
Personality Traits Dr. Paul McClelland

• Decreased impulse control

• Labile and superficial affect
• Impaired insight and self awareness
• Decreased empathy and social
awareness
• Impaired initiative (Depression?)
 Partial Seizures & Panic
Attacks or Dissociative States
Dr. Paul McClelland

• Most common type of post-traumatic epilepsy

• Temporal lobe damage and complex partial
seizures
• “Spells” starting suddenly & lasting a few
minutes
• Olfactory (smell) or gustatory (taste)
hallucinations
• Déjà vu or jamais vu
• Micropsia, macropsia and other symptoms
Obsessive-Compulsive Traits after TBI: Pre-
Existing Conditions or Adaptation to
Cognitive Deficits & Other Changes? Dr. Paul
McClelland

• Compulsive behaviors as adaptations

for memory loss
• Temper tantrums and other adaptations
• Non-pharmacological management of
brain-injured patients
 Other Mental Health
Disorders Related to TBI
• PTSD is noted in some individuals
following TBI even if there is no memory
of the incidence (Klein, Caspi 2003)
• Rapid cycling bipolar is rare but noted in
the literature for individuals with temporal
lobe damage (Murai, Fujimoto 2003)
• Psychotic syndromes occur more
frequently in individuals who have had a
TBI then in the general population
(McAllister, Ferrell 2002)
 TBI & Suicide
• “The risk of attempted or completed suicide in
neurological illness is strongly related to
depression, feelings of hopelessness or
helplessness, and social isolation” (Arciniegas &
Anderson, 2002)
• Simpson and Tate (2002) screened 172
individuals for suicidal ideation and
hopelessness. Findings using the Beck Suicide
Ideation and Hopelessness Scales found 35%felt
hopeless and 23%expressed suicide ideation.
18% had attempted suicide post injury
 Individuals with or without a
history of brain injury often share
identical risk factors for suicide
Teasdale & Engberg 2001

• Young Adults
• Males
• Substance Abuse
• Other psychosocial
disadvantages
Teasdale & Engberg’s population
study of 145,440 Danes post TBI:
• Followed individuals with concussion, skull fractures
and cerebral contusions or traumatic intracranial
hemorrhages (lesions) for 15 years
• Incidence of suicide among all three groups higher
compared to general population
• Presence of a co-occurring substance abuse
diagnosis increased suicide rates among all three
groups
• Significantly greater risk for suicide found among
those with lesions than those with concussion or
fracture
• Rate of suicide was 1% over a 15 year period
 Subsequent Studies…..
Simpson & Tate

• A 2003 study found of 172 individuals post

TBI, 17%attempted suicide over a period of 5
years
• A 2005 study of 172 individuals with a hx of
brain injury found that those with comorbid
post injury history of psychiatric/emotional
disturbance and substance abuse were 21
times more likely to attempt suicide post
injury
 Why Screen?

What other TBI Screening

efforts have found
2000 Epidemiological Study
of Mild TBI J. Silver of NYU, cited in WSJ by Thomas
Burton 1.29.08
http://online.wsj.com/article/SB120156672297223803.html?mod=googlenews_

• 5,000 interviewed
• 7.2% recalled a blow to the head
w/unconsciousness or period of
confusion
• Follow up testing found; 2x rate of
depression, drug and alcohol abuse
• Elevated rates of panic and and
obsessive-compulsive DO
Brain Injury in the Correctional
Setting-Nationally CDC website 2008
• According to jail and prison studies,25-
87% of inmates report having
experienced a TBI-this compared with
8.5% of the general population
• Prisoners with a history of TBI may also
experience mental health disorders
(including; severe depression, anxiety,
substance abuse)
Brain Injury in the Correctional
Setting-Nationally
CDC website 2008

• Woman inmates who are convicted of a

violent crime are more likely to have
sustained a pre-crime TBI or some
other form of physical abuse
• Women with substance abuse disorders
have an increased risk for TBI
compared with women in the general
population
In Maryland- Screening Results
from the MD TBI Post Demo II
Project-2005
– Summary of TBI Incidence Among all Screened at 7
public mental health agencies in Frederick and Anne
Arundel counties
– N=190
– 39% no reported history of TBI (78)
– 58.94% of individuals with a history of TBI (112)
– 35.78% of individuals with a history of a single incidence of
TBI (68)
– 23% of individuals with a history of 2 or more TBIs (44)
Details-County Detention
Center 2005
– N=41
– Single TBI= 16
– 2 or more incidents of TBI= 14
– No history of TBI= 11
– 73% screened reported a history of TBI
County Detention Center
2008
– N=25 (16 male, 9 female)
– 22 reported possible TBI(s)
– Single TBI=10
– 2 or more incidents of TBI= 12
– No History of TBI =3
– 88% screened reported a history of TBI
 TBI in a County Jail
Population
Slaughter et. al Brain Injury 2003
• 69 randomly selected inmates
• 60 (87%) reported TBI over their lifetime
• 25 (36%) reported TBI in the prior year
• Later group had worse anger and
aggression scores, trend towards
poorer cognitive test results and higher
prevalence of psychiatric DO then those
w/out TBI in prior year
Brain Injury in the Correctional
Setting-Nationally
CDC website 2008

• According to jail and prison studies,25-

87% of inmates report having
experienced a TBI-this compared with
8.5% of the general population
• Prisoners with a history of TBI may also
experience mental health disorders
(including; severe depression, anxiety,
substance abuse)
Brain Injury in the Correctional
Setting-Nationally
CDC website 2008

• Woman inmates who are convicted of a

violent crime are more likely to have
sustained a pre-crime TBI or some
other form of physical abuse
• Women with substance abuse disorders
have an increased risk for TBI
compared with women in the general
population
 Brain Injury & Violence
Domestic Violence

• Greater than 90% of all injuries secondary to

domestic violence occur to the head, neck or face
region (Monahan & O’Leary 1999) Adapted from The
Alabama Department of Rehabilitation Services DV Training

• Corrigan et.al., (2003) found that of 167 individuals

treated for domestic violence related health issues,
30% experienced a loss of consciousness on at least
one occasion, 67% reported residual problems that
were potentially TBI related
• Valera and Berenbaum, (2003) assessed 99 battered
women. Of these, 57 had brain injured related
symptomatology
 Homelessness & Brain Injury
A little studied population,
however…..
• A University of Miami study found that 80% of 60
homeless individuals had high incidence of
neuropsychological impairment
• Researchers in Milwaukee found possible cognitive
impairment in 80% of 90 homeless men evaluated.
• Dr. LaVecchia of the MA Statewide Head Injury
Program reported in 2006 that of 140 homeless
individuals evaluated, 83.6% of males and 16.4% of
females had an acquired brain injury
• Other studies in the UK and Australia show similar
rates of brain injury among homeless individuals
 Correlation between TBI &
Homelessness
Hwang et.al 10.7.08 Canadian Medical
Journal
• 904 homeless individuals surveyed
• Lifetime Prevalence of TBI-53%, more
common among men than women
surveyed
• Rates 5 or more times greater than the
8.5% lifetime prevalence in general
population and consistent w/ prison
studies
 TBI & Homelessness
“For Veterans, A Weekend
Pass From Homelessness”
from the New York Times 7.26.09, Erick Eckholm

Human service professionals will be

seeing increasing numbers of returning
service members in need of services over
the next few years
 “….The ranks include young men like Kenneth
Kunce, 26, who suffered a traumatic brain injury
when his Humvee was hit by a roadside bomb
in Iraq. The injury left him disorientated, jumpy
and temperamental. When he came home he
started using Ecstasy and alcohol, he said he
lost his wife and more than one job. He said he
was grateful to the Veterans Affairs hospital for
providing speech and physical therapy, but
added that he still had trouble coping with
noises and anger.
Mr. Kunce, who sometimes lost his train of
thought as he spoke to this reporter, is living out
of his car.”
The HELPS Brain Injury
Screening Tool
(see handout)

The original HELPS tool developed by M. Picard, D.

Scarisbrick, R. Paluck, 9.1991
Updated by the Michigan Department of Community
Health
 HELPS
• Have you ever Hit your Head or
been Hit on the Head?
• Prompt individual to think about;
TBI at any age, MVAs. Assaults,
Sports injuries, Service related
injuries, Shaken baby and/or adult
 HELPS
• Were you ever seen in the
Emergency room, hospital, or by a
doctor because of an injury to your
head?
• Explore the possibility of
“unidentified traumatic brain injury”
many do not present in medical
settings
 HELPS
• Did you ever Lose consciousness or
experience a period of being dazed and
confused because of an injury to your head?
• Remember, a LOC isn’t required for someone
to develop symptoms subsequent to a blow to
the head. “alteration of consciousness” AKA
post traumatic amnesia (PTA). At this point,
the interviewer may consider asking the
individual if they have had multiple mild TBI
 HELPS
• Do you experience any of these Problems in
your daily life since you hit your head?
• You want to know when any problems began
(or began to be noticed) Remember, lack of
awareness is a hallmark of brain injury, you
might ask if anyone close to the individual
has made any observations regarding
changes in function.
 HELPS
• Headaches • Difficulty reading,
writing, calculating
• Dizziness
• Poor problem solving
• Anxiety
• Difficulty performing
• Depression
your job/school work
• Difficulty
• poor judgement (being
concentrating
fired from job, arrests,
• Difficulty fights, relationships
remembering affected)
 HELPS
• Any significant Sickness?
• Acquired Brain Injury (ABI) can result in many
of the same functional impairments as
traumatic brain injury (TBI). For example,
brain tumor, meningitis, West Nile virus,
stroke, seizures, toxic shock syndrome,
aneurysm, AV malformation, any history of
anoxic injury, e.g. heart attack, near
drowning, carbon monoxide poisoning can all
result in multiple deficits
 Scoring the HELPS
Positive for a possible Brain Injury when the
following three are identified:
• An event the could have caused a brain
injury (YES to H, E, or S), and
• A period of loss of consciousness or
altered consciousness after the injury or
another indication that the injury was
severe (YES to L or E), and
• the presence of 2 or more chronic
problems listed under P that were not
present before the injury.
 Scoring the HELPS
• A positive screening is not sufficient to diagnose
TBI as the reason for current symptoms and
difficulties-other possible possible reasons need to be
ruled out
• Some individuals could present exceptions to the
screening results, such as people who do have TBI-
related problems but answered “no” to some
questions
• Consider positive responses within the context of the
person’s self-report and documentation of altered
behavioral and/or cognitive functioning
 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…..And Why
• Any reported or suspected functional
difficulties that are interfering with
home, work or community activities
• With the identification a history of
brain injury, professionals can better
support the individuals served and
make informed referrals to brain
injury specialists when appropriate
 Remember, for most, Brain
Injury is:

• -A loss of Self
• -A loss of future
• -loss of possibilities
 “I had a job, I had a girl, I
had something going mister
in this world…………”

A 10 year survivor of a TBI

quoting a Bruce Springsteen
song when describing what he
had lost because of his injury
A compromised brain can lead
to compromised behavior,
further adding to social
isolation and social failure
The following slides 3 are adapted from
Webcast:
sponsored by the Health Resources and
Services Administration’s
Federal TBI Program Web cast
July 27, 2006
 Speakers:
• Harvey E. Jacobs, Ph.D., Licensed
Clinical Psychologist/Behavioral Anaylist
• Marty McMorrow, Director of National
Business Dev., The MENTOR Network
• Jane Hudson, JD., senior Staff Attorney,
National Disability Rights Network
 Behavioral Statistics
• Approximately 90% of all people who
experience severe disability following
brain injury experience some emotional
or psychiatric distress
• 40% continue to demonstrate
behavioral difficulty five years post
injury
 Behavioral Statistics
• 25% experience behavior dysfunction
that interferes with other activities of
daily life
• 3%-10% experience severe behavioral
dysfunction that may require intensive
professional and residential intervention
(~3,000-9,000 new people per year)
Research findings regarding
Behavior Problems after TBI
• “Aggressive behavior is associated
with presence of major depression,
frontal lobe lesions, poor premorbid
social functioning and a history of
alcohol and substance abuse” Tateno
et.al J of Neuropsychiatry Clin. Neuroscience 2003
Research findings regarding
Behavior Problems after TBI
• Research conducted by Wood and Liossi in
2006 reports “it is tentatively suggested that
significant impairment in verbal memory and
visuospatial abilities against a background of
diminished executive-attention functioning is
associated with the development of aggression
after brain injury,especially when other risk
factor such as low premorbid IQ, low
socioeconomic status, and male gender are
present” J of Neuropsychiatry Clin. Neuroscience
Research findings regarding
Behavior Problems after TBI
• “Impairments in recognizing the
emotional state of others may underlie
some of the problems in social
relationships that these patients
experience……TBI patients were found
to be impaired on emotional recognition
compared to the control patients both
early after injury and one year later”
Ietswaart et. al. Neuropsychologia, 2007
 According to McMorrow,
Jacobs and Hudson; HRSA
Webcast July 27, 2006
“Almost all people who experience
disability following brain injury are not
inherently aggressive or assaultive.
However, for some people, when
challenges are not properly
addressed this can result in…”
-Lack of responsiveness to
requests
-Property destruction
-Verbal or physical aggression
-Violation of personal or
sexual boundaries
-Wandering or flight
-Self harm/self abuse/suicide
“Neurobehavioral Challenges”
According to McMorrow, Jacobs and Hudson
are caused by:
• Pre-injury history
• Post-Injury learning and experiences
• Inability to negotiate “difficult” situations
• Others’ not recognizing the basic
challenges to an individual with TBI, and
• Not providing proper treatment
With the Proper Supports:

• -A renewed sense of self

• -A future can be imagined
• -New possibilities can be
created
Strategies
 Attention is the ability to
stay focused on a specific
topic or task. It is critical to
successful participation in
purposeful activity.

The next 10 slides are from the

Rhode Island BIA presentation “Brain
Injury: A Practical Training for
Caregivers”
 Attention
 Gain and encourage eye contact when
appropriate.
 Use an opening statement such as “Are you
ready to get started” to gain the consumer’s
attention before explaining an activity or giving
directions.
 Be specific and clear. Avoid lengthy or vague
explanations.
 Slow down when you speak. It is very difficult
to listen carefully to someone who is talking at
a fast pace.
 Limit interruptions when possible.
 Attention
 Minimize environmental distractions
(competitive background noise, cluttered
work areas and cluttered walls).
 Present information in an organized fashion.
 Pause to allow the consumer to process or to
finish taking notes before moving to the next
direction or to a new piece of information.
 Attention
 Encourage a steady work pace. Rushing can
result in an increase in mistakes or in
skipping an important step in an activity.
 Breakdown assignments into smaller more
manageable portions.
 Provide a task breakdown or assist the
consumer in developing a task breakdown for
specific activities
 Attention
 Avoid overwhelming the consumer. Don’t plan
on covering large amounts of information in a
single session.
 When assigning tasks that the consumer will
be expected to complete independently, begin
with simple activities. Progress to more
difficult or complicated tasks if the consumer
is successful with the simple activities.
 Attention
 If you notice that the consumer is beginning to lose
focus, give a cue to redirect to task, or ask if they
need a short break.
 Provide positive feedback when the individual is
performing well or requesting to use appropriate
modifications or strategies during a session.
 When finishing an instructional session, help the
consumer to review the material that was covered.
Place emphasis on any follow up activities the
consumer is supposed to complete independently.
 Attention
To pay attention, we must be awake and alert,
this is referred to as arousal level. Under
normal circumstances our central nervous
system automatically keeps the arousal level
regulated. As a result of brain injury clients
may experience lethargy or sluggishness
referred to as a state of under arousal. Or
they may appear to be ‘hyper’ or over
stimulated known as a state of over arousal.
In some cases the use of sensory stimulation,
relaxation or focusing techniques can be
helpful. Responses to sensory input can vary
from person to person.
 Attention
 Use an appropriate volume and tone of voice for the
individual consumer. A softer voice may be more
tolerable to someone who is over stimulated. A louder
voice with extra emphasis on key words may be
helpful to someone who is under aroused.
 Determine if the use of white noise or environmental
sound machines is helpful.
 Use high intensity white light or bright natural light for
individuals who are under aroused, dimmed lighting
for those who are over aroused.
 Attention
 Play background music that the individual
finds helpful when paying attention to a
particular activity, or for relaxation (soft
soothing music, upbeat or rhythmic music).
 Include breaks into the daily schedule to
listen to short guided meditation or relaxation
tapes.
 Pause between activities or during lengthy
activities to take a few deep breaths.
 Attention
 Movement such as gentle use of a rocking
chair, or brisk movement can help to regulate
arousal.
 Joint and muscle stimulation experienced
during weight bearing or resistive exercises
can also assist with regulation of arousal.
 Encourage participation in a regular exercise
program or activity such as Yoga or Tai Chi
when appropriate.
 The Benefits of Exercise
Post Injury
TBI Consumer Report # 2 TBI Central MT. Sinai Model Program
• Those who exercise had fewer physical, emotional and cognitive
complaints. E.g. sleep problems, irritability, forgetting and being
disorganized
• Non-exercisers complained of more cognitive problems or
symptoms than those who exercise
• Exercisers with TBI were less depressed
• Exercisers viewed themselves as healthier
• Exercisers were often engaged in school, work, and “got
around” the community more freely
• Exercisers had more severe brain injuries than the non-
exercisers, suggesting that a severe injury does not prevent
engaging in exercise
Memory functions are complicated
and sensitive. Memory is frequently
the first function to be notably
impaired and one of the last
functions to be regained in the
recovery process.
The next 32 slides are
adapted from the Rhode
Island BIA presentation
“Brain Injury: A Practical
Training for Caregivers”
 Memory
Memory Systems can significantly
improve client follow through and
independence when used on a regular
basis. When a new system is
introduced a ‘repetitive training’ and
cueing period is recommended to
reinforce consistent use. Systems can
be updated to accommodate for
improvements in memory, or for
changing needs.
 Memory
• When designing a memory system:
 Define the goals or exact needs the system will be
meeting.
 Designate separate sections based on specific
needs.
 Use a format and style that the individual prefers.
 Encourage use of one system that is taken
everywhere. (technology!) See Tony Gentry, Ph.D.
OTR/L’s website:
www.vcu.edu/partnership/pda/Jobcoach
 Memory
 Timers, wrist watch alarms or talking watches
can provide prompts.
 Use check off sheets (this allows the
individual to self-monitor and reference back).
 Post simple reminder signs for prompts to
turn off appliances, lights, etc.
 Label drawers and cupboard fronts indicating
their contents.
 Memory
 Post step by step directions for appliances
such as the coffee maker, microwave etc.
 Post-it notes for extra reminders, for example
place a post it note on the memory book as a
reminder to check the ‘to do’ list if there is a
critical item on the schedule the next day.
 Provide written or picture based instructions
in addition to verbal instructions.
 Memory
 Color code folders, storage containers, or
calendar entries to help with recall and
identification.
 Use tape recorders to record meetings or
appointments.
 Provide repetitive training or instruction when
reintroducing functional activities into the
daily schedule, and with all activities that
require new learning.
 Encourage note taking at meetings,
appointments, etc.
 Memory
 Pocket “Voice it” recorders can be used to
record reminders throughout the day.
 Use the home answering machine to leave
“reminders to self”.
 Have a back up plan. For instance, in addition
to strategies for remembering keys, have a
contingency plan with extra keys available at
accessible locations (neighbors, friends, etc.)
 Problem Solving
Problem solving is used for completion of a
wide range of activities throughout the day.
Many activities are sequenced; performed by
using a step by step approach. Cues can
support consumer participation in activities
Written or picture task breakdowns can be
used during early training or as a prop for
independent task completion as the consumer
progresses.
Strategies and approaches can also be
developed to help consumers with higher level
or abstract problem solving skills.
 Problem Solving/Sequencing
example
• Squat Pivot Transfer
• 1)Park- at an angle along the mat, left front of the
wheelchair touching the mat.
• 2)Lock both wheels
• 3)Check your locks
• 4)Flip up left arm rest
• 4)Scoot your bottom forward
• 5)Feet flat on the floor 8 -10 inches apart, left foot
forward
• 6)Hands- Left hand on the mat, Right hand on the
chair arm
• 7)Push on arms, lift up bottom, pivot onto the mat
 Problem Solving
State Problem:_________________________
List 3 solutions: 1)_____________________
2)_____________________
3)_____________________

Solution 1 Solution 2
Solution 3
Pros Cons Pros Cons Pros
Cons

Describe the most logical and effective solution

based on the
above:________________________________
_____________________________________
 Impulsivity
Impulsivity is often a consequence of
injury to the frontal lobes.
Impulsivity can have a negative impact
on independent living, particularly
when life changing decisions are made
without carefully thinking things
through.
 Impulsivity
Change Plan
What change do I want to make?____________________
Why do I want to make the change?_________________

Change Not Changing

Pros Cons Pros Cons

List step for

change:1)________________2)______________
3)________________4)________________5)___________
___

Who could help

me?_________________________________
What might interfere with my
change?___________________
How would I evaluate success?
_______________________
 Initiation
Poor initiation, a decreased ability to
initiate or begin activities, can be a
consequence of brain injury. Initiation
deficits are often misinterpreted,
caregivers may assume the consumer
doesn’t care or that they aren’t
motivated. Damage to any one of
several different areas of the anterior
part of the brain can result in deficits in
this area.
 Initiation
 Many individuals respond well to structure and
consistent routines.
 When preparing daily and weekly schedules be
specific. Designate specific times for activities to be
performed. In addition to using a general concept
such as clean-up the kitchen, indicate specific tasks
for example: put dishes in the dishwasher, wipe off
the table, wash the counter.
 Begin with lighter demands that promote success.
The difficulty of demands can be increased when the
consumer demonstrates consistent follow through
with the easier activities.
 Initiation
 Encourage consumer participation when
developing schedules.
 Provide training and cues when introducing a
new or updated schedule.
 Accept close approximations of the desired
behavior when changes are initially instituted.
 Use positive reinforcement for all successful
follow through.
 Engage the consumer in a problem solving
approach when addressing areas of difficulty.
 Communication
Communication is very complex and
involves processing of both verbal and
nonverbal information. Individuals may
have receptive deficits, difficulty
understanding specific words or with
the way in which words are presented.
They may have expressive deficits,
difficulty remembering a word, or with
pronouncing words correctly when
speaking
 Communication
 Receptive Deficits:
• Slow your rate of speech
• Simplify sentence structure, be clear and
concise
• Pause between sentences or topics to allow
for processing
• Repeat key words or concepts
• Rephrase as needed
• Summarize information frequently
 Communication
 Expressive Deficits:
 Do not expect an immediate response to a question
or statement. Pause to allow the individual time to
prepare their response.
• Accept gestures and pantomime in addition to verbal
speech.
• Ask yes/no questions, avoid questions that require
lengthy or detailed answers.
• Provide extra time for consumers who are using
augmentative communication devices.
• Accept written answers or drawings.
 Hearing/Central Auditory
Processing
 When there is trauma to the temporal lobe area,
individuals may experience a change in the ability to
hear sound or in the ability to process auditory
(sound) input. Once sound is detected by the ear, the
brain processes what was heard on multiple levels.
Individuals with central auditory processing deficits
may have difficulty with:
 Filtering out competitive background noise
 Noticing the differences between similar sounds or
words
 Maintaining attention on a speaker who is giving a
presentation on complicated information or when
listening to a long presentation.
 Remembering information as it is processed.
 Hearing/Central Auditory
Processing
 Reduce or eliminate background noise.
 Instruct the client to directly face the speaker to
maximize on visual speech cues.
 Increase the volume of the speaker’s voice in relation
to the surrounding background noise at presentations
or meetings. Provide a speaker microphone or
assisted listening device.
 Speakers should avoid covering their mouth,
shouting or over-enunciating words.
 Consider referring for an audiological evaluation to
determine if hearing aides or specialized alerting
devices would be beneficial.
 Vision
Vision is an extremely important source of
sensory information. The eyes send many
messages to the brain, the brain must
interpret all of the incoming messages. There
can be problems with coordinated
movements of the eyes and/or with the brains
ability to process and interpret information
accurately. Deficits can range from mild to
severe. Even subtle deficits can affect the
individuals ability to work on visual tasks and
should be addressed.
 Vision
 Use enlarged print.
 Print on yellow instead of white paper or use
a yellow acetate overlay on documents to
increase contrast.
 A book mark or ruler can be used to help with
staying on the line when reading or scanning
for information.
 Change florescent lights to high intensity
white lights, or increase natural light.
 Simplify forms; determine if extra spacing,
grid lines, bold print or bold lines are helpful.
 Vision
 Use a cut out guide to isolate sentences or words.
 When consumers are working on near vision tasks
for long periods, have them take short breaks to shift
their gaze to distant objects to decrease eye fatigue.
 Refer to a vision care professional trained in working
with acquired brain injury for thorough assessment of
vision related complaints.
 Refer for adaptive technology assessment for
computer modification or low vision technology when
appropriate.
 Activity Tolerance
Fatigue is a common complaint after brain
injury. It is more difficult for individuals with
brain injury to compensate for their deficits
when they are over tired.
Consumers may need more sleep than they
did before they were injured. They may not
be able to tolerate a very busy schedule. It is
important to consider energy conservation
and work simplification when preparing daily
and weekly schedules.
In some cases they may have sleep
disturbances; the physician should be
consulted if a consumer is unable to get to
sleep or stay asleep during the appropriate
hours.
 Activity Tolerance
When developing a plan to manage fatigue:
Carefully review the current schedule with
the consumer.
Make a list of the most important activities,
those that must be done on a daily or weekly
basis, and plug them into the new schedule
(Some activities may need to be eliminated
when revising a schedule).
Schedule activities that are more difficult or
demanding throughout the week. Don’t
schedule all heavy or difficult activities on a
single day.
 Activity Tolerance
Alternate between light or low demand
activities and high demand more difficult
activities on the daily schedule.

Determine if there are certain times during

the day that the consumer is at his or her
‘best’ try to schedule important or priority
activities at those times.

Determine what times of the day the

consumer is usually more fatigued, schedule
only light activities or rest periods during
these times.
 Activity Tolerance
 Encourage consumers to increase their use of
accommodations and strategies or provide extra
supports during the times of day that they are usually
more fatigued.

 Avoid rushing, schedule enough time for each activity

to be performed at a steady and reasonable pace.

 Remember that cognitive activities can be very tiring

for some consumers. You will need to observe how
each individual responds to different activities.
 Considerations for Plan
Development
 Each plan must be developed on a case by case
basis to meet the individuals needs.
 Always include the client in development of the plan
when possible.
 Each consumer may present with a wide variety of
strengths and challenges.
 Individuals may have deficits in multiple areas.
 Because a consumer does do well in some areas
does not mean they should automatically be
expected to do well in all areas.
 Considerations for Plan
Development
 Limitations in each deficit area may require specific
accommodations.
 Some deficits may not be obvious when your first
meet the consumer.
 Recovery can vary greatly from individual to
individual. Consumers may need extra support to
realize they can’t compare their recovery with that of
other brain injury survivors.
 Because recovery can continue for some time the
plan may need to be changed and updated on a
regular basis to meet the consumer’s changing
needs.
 Additional Considerations
 It is important that consumer is motivated to work on
the goals that have been developed.
 Always consider the consumer’s input when
developing goals.
 If the team has developed goals that are different from
the consumer’s, be sure to explain what the purpose
and potential value of working on those goals might be.
Discuss how the goals developed by the team may
compliment or support the consumer’s personal short
and long term goals.
 Keep the discussion focused on identifying goals and
activities that offer the opportunity for success.
Potential Disruptive Behaviors
Not all brain injury survivors will
experience difficulty with social
behavior. However, TBI survivors who
have had severe frontal lobe injury or
who have been more recently injured
may exhibit disruptive behaviors. You
may observe:
•Social judgment errors
•Threatening comments
•Inappropriate sexual comments or
advances
Potential Disruptive Behaviors
In most cases these behaviors are
not intentional but rather the result
of poor inhibition and judgment.
These behaviors, although
upsetting are not usually meant to
be harmful, and can be addressed
by using a consistent team
approach.
The next 10 slides are
adapted from the New
Hampshire Project
Response presentation
“Changes After Brain
Injury”
 Environmental Triggers for
Behavioral Problems
• Too much stimulation
• Rapid pacing
• Lack of predictability and clear structure
• Overwhelming physical and cognitive
demands
• Negative social input
Note: if you manage the
environment, you can
prevent many problems
 Guidelines For Behavior
Management
• Increase rest time. Fatigue is a
common problem.
• People have limited coping skills.
Reduce stress.
 Guidelines For Behavior
Management
• Keep the environment simple. People
with brain injuries are easily
overstimulated
• Decrease interruptions and distractions
• Be consistent
• Decrease surprises
 Guidelines For Behavior
Management

• Keep instructions simple, concrete.

• If the person has problems processing
language, try gesturing or cueing.
• Write things down.
 Guidelines For Behavior
Management
• Give feedback and set goals
• Feedback should be direct, caring,
nonjudgmental, but not subtle
• Avoid criticism
• Give supportive encouragement
• Have a positive attitude
• Use the “feedback” sandwich
 Guidelines For Behavior
Management

• Be calm, cool, and friendly during an incident

• This can reduce agitation
• Avoids reinforcing misbehavior
• Redirection works. When the person is upset,
agitated, aggressive, focus attention on some
other topic, task, person.
• Provide choices
 Guidelines For Behavior
Management
• Decrease chance of failure
• Keep success rate above 80%
• Watch for frustration
• Behavioral momentum
• Expect the unexpected. People with brain injuries can
have great variability from day to day. Mood swings
are common. People with TBI are sensitive to
changes, disruptions in routine, lack of sleep, alcohol,
minor illnesses, fatigue, other stressors.
 KEEP IN MIND…
Progress can be inconsistent and
unpredictable
• What works today may not work
tomorrow, but may work the following
day
– Reduced stamina and fatigue may persist
– Impairment of memory may hinder new
learning
– Transitions may be especially difficult
 Prevention, Prevention,
Prevention
• Communicate expectations
• Recognize internal and environmental
triggers, plan strategies
• Provide clear structure and predictable
routines
• Maintain realistic expectations
• Help peers learn to alter interactions to
avoid triggers
Additional Strategies

From the MD TBI Project

Most Strategies address
more than one cognitive
and or behavioral deficit
 Strategies

Spontaneous restoration of functioning

occurs most rapidly and dramatically in
the first year following a brain injury.
Generally speaking, the greater the
time from the injury the more
rehabilitation efforts will focus on
compensation
 Environmental
&
Internal Aides

Creative cognitive strategies will

employ both kinds of aids depending
on individual need
 Environmental,
AKA Prosthetic external
memory strategies and
devices
Changing or modifying the
environment to support and/or
compensate for a injury imposed
deficit
For Example: labeling kitchen
cabinets
 Internal
The strategy is “in your head”
For Example:
“I have to work the memory
muscle by counting everything,
like how many times I pedal when
I am on a bike”
Actor George Clooney discussing the use of internal memory strategies in The
London Sunday Times10. 23.05
 Oftentimes a strategy can
transition with practice from
the external to the internal
For Example:
Preparing remarks on paper with
“pauses” written in to slow down
impulsive speech can eventually
segue into a internal strategy, “At
the end of every 2-3 sentences, I
will take a breath and check in
with my listener”
 Strategies can help
individuals compensate for
the physical barriers
imposed by a brain injury

For Example:
Prism glasses may be prescribed
to address double vision after
injury just as bifocals are
prescribed for many after age 40
 Strategies
• Use of a template for routine tasks, on the
job, at home
• Use of a high lighter (RED)
• Use of ear plugs to increase attention, screen
out distractions (Parente & Herman 1996)
• Partitions/cubicles, at work, quiet space at
home
• Model tasks e.g. turning on a computer and
accessing email
 Strategies
• Use of pictures, for faces/names, basic
information, for step-by-step procedures, e.g.
making coffee
• Use of a timer, to track breaks at work, the
time minimum technique, allocated time to
puzzle over a problem or vent a frustration
• Books on tape, movies, keep the subtitles (for
processing content in the case of memory and
comprehension problems and increase
awareness of nonverbal cues/communication)
 Strategies
• Car Finder-low tech, install a longer radio
antenna with a day-glow flag, high tech,
Design Tech International by DAK Corp.
• Electronic pill boxes/blister packs with day of
the week labels
• Review schedule each day
• Post signs on the wall etc. (use
pictures/symbols for low literacy skills)
• Try to “routinize” the day as much as possible
 Teach a variety of strategies for
individuals to incorporate into their
daily routines
Michelle Rabinowitz OTR/L
• Safety checklist (e.g. for use of stove)reinforces
attention
• Checklists- “things to do before leaving the house”
(turn off all the appliances?, lock all the doors?, did I
take my morning medications? turn down the
heat/turn off the air conditioner?, do I have money or
keys?, where am I going?, how will I get there? What
time should I leave? Etc.) Very good for routine
tasks, reinforces memory
• Place visual cues in the environment (cupboard
labels, written directions, calendars, list of emergency
phone numbers) reinforces memory
 Memory Strategies
Adapted from:
Parente & Herman in Retraining Cognition 1996 Aspen Publishers
 SOLVE Mnemonic
• “S” (S)pecify the problem
• “O” (O)options-what are they?
• “L” (L)isten to advice from others
• “V” (V)ary the solution
• “E” (E)valuate the effect of the
solution, did it solve the problem?
Organizing the Environment
Consistency, accessibility, separation,
grouping, proximity
• Consistency-put things in the same place,
keys, wallet etc.
• Accessibility-things that are commonly
used, keep them physically close, in the
kitchen, in the office
• Separation-put things in logically distinct
locations. Clothes, mail
• Grouping-put things that are used together in
the same area, raincoat & umbrella
• Proximity-cooking utensils near the stove
 Setting GOALS
Executive Skills Training
• G” (G)o over your goals every day-helps
memory and awareness
• “O” (O)rder your goals-short and long term
• “A” (A)sk yourself two questions each day:
“what did I do today to achieve my goals?”
and “What could I have done differently to
achieve my goals”
• “L” (L)ook at your goals each day. Post goals
and progress on the wall, refrigerator etc.
 Listening Skills
• “L” (L)ook at the person-focus on
nonverbal aspects of communication
• “I” (I)nterest yourself in the
conversation- use “social fillers” e.g “I
see”, “Tell me more”
• “S”(S)peak less than half the time-
decrease the chance of getting off topic
 Listening Skills continued
• “T” (T)ry not to interrupt or change the
topic-stick to the topic at hand
• “E” (E)valuate what is being said.
Question the content, do not blindly
accept what is being said
• “N” (N)otice body language and facial
expression-train this skill via use of
pictures or scenes from movies, TV
 Try these techniques in
groups or as focus of
individual sessions.
During groups utilize a peer
feedback component
More Thoughts on Listening
Skills
• An area where reduced cognitive skills can
be misinterpreted as poor interpersonal skills
• No one likes a “noisy listener”
• Poor listening skills can be impacted by
anxiety (about memory, social skills etc.)
• Relaxation techniques can be helpful (breath
in slowly over 7 breaths, hold for 4-7 counts,
exhale over 7, repeat as necessary)
Strategies for Injury
Imposed Barriers
Watch this scene from the 2007
Movie The Lookout
What are the character’s
barriers?
What are the strategies he is
using to compensate?
 Brain Injury
the Long Term Consequences
Follow the injury and recovery of Iraq
veteran, “Toggle”, a character in the
Doonesbury comic strip. Gary
Trudeau accurately depicts blast
injury, living with motor, visual, and
speech and language deficits
(especially aphasia) and PTSD as
Toggle picks up his life post injury.

http://www.doonesbury.com/strip/dailydose/
 References
• Slides 3-21 adapted from Dr. Mary Pepping of the University of
Idaho’s presentation The Human Brain: Anatomy,Functions, and
Injury
• Corrigan JD. (1995). Substance Abuse as a Mediating Factor in
Outcome from Traumatic Brain Injury. Archives of Physical
Medicine and Rehabilitation Vol. 76, April: 302-309
• Bombardier, CH., Temkin, NR., Machamer, J., Dikmen
SS.(2003), The Natural History of Drinking and Alcohol-Related
Problems After Traumatic Brain Injury Archives of Physical
Medicine and Rehabilitation Feb;84(2):185-91.
• Bombardier C., Davis, C. (2001). Screening for Alcohol
Problems Among Persons with TBI. Brain Injury Source. Fall 16-
19.
• Corrigan J., et. al (1998) Utilities for Community Professionals.
Ohio Valley Center for Brain Injury Prevention and Rehabilitation
 Resource Coordination in
Maryland
• Charlotte Wisner, Resource Coordinator for Frederick
& Washington Counties, call 301-682-6017
• Lauren Dorsey, Resource Coordinator for Baltimore &
Howard Counties, call 301-529-1508
• Catherine Reinhart Mello, Resource Coordinator for
Montgomery County, call 301-586-0900
• Any questions regarding resource coordinator or free
training on brain injury related topics, call Anastasia
Edmonston, Project Director 410-402-8478
 RESOURCES
• Brain Injury Association of America 703-236-
6000, www.biausa.org
• Brain Injury Association of Maryland 410-448-
2924, www.biamd.org
• Ohio Valley Center For Brain Injury
Prevention and Rehabilitation, 614-293-3802,
www.ohiovalley.org. Excellent SA TX
resource & information
• www.headinjury.com. Good resource for
memory aides and tips
 The Michigan Department of
Community Health
Web-Based Brain Injury Training for
Professionals
www.mitbitraining.org
This free training consists of 4 module that
take an estimated 30 minutes each to
complete. The purpose of the training is
twofold, to “ensure service providers
understand the range of outcomes” following
brain injury and to “improve the ability of
service providers to identify and deliver
appropriate services for persons with TBI”
 Resources
The University of Alabama Traumatic Brain Injury
Model System has created the UAB Home Stimulation
Program. This program offers many activities for use
by individuals with brain injuries, their families and
the professionals who work with them. The activities
are designed to help support cognitive skills and can
be done in the home setting. The Home Stimulation
Program can be accessed from the Internet at
htt://main.uab.edu/show.asp?durki=49377. For
further information contact: Research Services, Dept.
of Physical Medicine and Rehabilitation, University of
Alabama at Birmingham, 619 19th St. S SRC 529,
Birmingham, AL 35249-7330/ 206-934-3283.
Tbi@uab.edu.
 Resources
Rehabilitation Research and Training
Center on Traumatic Brain Injury
Interventions & New York Traumatic
Brain Injury Model System at the
Mount Sinai School of Medicine and
the Mount Sinai Rehabilitation
Research and Training Center
www.mssm.edu/tbinet
 Recommended Reading
• I am the Central Park Jogger: A Story of
Hope and Possibility by Trisha Meili,
2003
• Every Good Boy Does Fine: A Novel by
Tim Laskowski, 2003
• Over My Head: A Doctor’s Own Story of
Head Injury from the Inside Looking Out
by Claudia Osborn, 2000
 A Product of the Maryland TBI Partnership
Implementation Project, a collaborative effort
between the Maryland Mental Hygiene
Administration, the Mental Health
Management
Agency of Frederick County and the Howard
County Mental Health Authority
2006-2009
Support is provided in part by project H21MC06759 from
the Maternal and Child Health Bureau (title V, Social
Security Act), Health Resources and Services
Administration, Department of Health and Human Service

This is in the public domain. Please use

and distribute widely.