Brain Injury Professional, vol. 5 issue 1

BR A IN INJURY professional vol. 5 issue 1

The official publication of the North American Brain Injury Society

Violence and TBI Breaking the Silence: Violence as a Cause and a Consequence of Traumatic Brain Injury Diagnosing Abusive Head Trauma: A Primer for Health Care Providers Traumatic Brain Injury Among Prisoners Application of a Novel Theoretical Model to Suicide Risk Assessment after Traumatic Brain Injury

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contents

BRAIN INJURY professional vol. 5 issue 1, 2008

The official publication of the North American Brain Injury Society

north american brain injury society

departments 4 Executive Vice President’s Message 6 Guest Editor’s Message

chairman Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family liason Julian MacQueen executive vice president Ronald C. Savage, EdD executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Joyce Parker graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes

12 Book Review brain injury professional

publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD Editor, Legislative Issues Susan L. Vaughn founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Joyce Parker

14 bip expert Interview 30 Legislative Round-up 32 Non-profit News B R AIN INJURY professional vol. 5 issue 1

The official publication of the North American Brain Injury Society

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EDITORIAL ADVISORY BOARD Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD

4RAUMATICç"RAINç)NJURYç!MONGç0RISONERS !PPLICATIONçOFçAç.OVELç4HEORETICALç-ODELç TOç3UICIDEç2ISKç!SSESSMENTçAFTERç4RAUMATICç"RAINç)NJURYç

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features 8 Breaking the Silence: Violence as a Cause and a Consequence of

Traumatic Brain Injury

by Jean A. Langlois, ScD, MPH; Jeffrey Hall, PhD; Matt Breiding, PhD; Audrey A. Reichard, MPH, OTR; Anne McDonnell, MPA, OTR/L; Marlena Wald, MLS, MPH 18 Diagnosing Abusive Head Trauma: A Primer for Health Care Providers

By Rachel Berger, MD, MPH 22 Traumatic Brain Injury Among Prisoners

By Marlena M. Wald, MPH, MLS; Sharyl R. Helgeson, RN, BAN, PHN; Jean A. Langlois, ScD, MPH 28 Application of a Novel Theoretical Model to Suicide Risk Assessment

after Traumatic Brain Injury

by Lisa Brenner, PhD, ABPP

editorial inquiries Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org Email: contact@nabis.org

advertising inquiries Joyce Parker Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787

national office

North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2008 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mail@hdipub.com

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executive vice president’s message

In violence we forget who we are. ~ Mary McCarthy Assault. Abuse. Deadly weapons. Violence. Ugly words that are all too often linked with traumatic brain injury (TBI). While we often think of TBI in connection with motor vehicle crashes, falls and sports, violence and TBI has become embedded into our clinical work.

And with that comes a host of other clinical issues: how do we identify head trauma in women who have been assaulted and raped; how do we clinically treat infants who have been the victims of shaken baby syndrome; how do we deal with individuals who sustained TBI’s because of their own aggressive behaviors?

Ronald Savage, EdD

Our current data are frightening. Estimates range from 960,000 incidents of violence against a current or former spouse, boyfriend, or girlfriend per year (US Dept of Justice) to three million women who are physically abused by their husbands or boyfriends per year (The Commonwealth Fund). More than 750,000 young people ages 10 to 24 were treated in emergency departments for injuries sustained due to violence (CDC 2006). In a nationwide survey of high school students (CDC 2004): • 33% reported being in a physical fight one or more times in the 12 months preceding the survey.

• 17% reported carrying a weapon (e.g., gun, knife, or club) on one or more of the 30 days preceding the survey.

• An estimated 30% of 6th to 10th graders in the United States were involved in bullying as a bully, a target of bullying, or both (Nansel et al.

2001).

The American Academy of Pediatrics reports (2007) that more than 2.5 million cases of child abuse and neglect are reported each year. Of these, thirty-five of one hundred involve physical abuse and one in twenty children are physically abused

each year.

Dr. Jean Langlois and colleagues report in their article that The Centers for Disease Control and Prevention (CDC) estimates that 11% of TBI deaths, hospitalizations, and ED visits combined (a total of 156,000 each year) are related to assaults (Langlois et al, 2004). But this number likely is low because it excludes the many other TBIs, including concussions, caused by violence that go unidentified and unreported.

This issue of the Brain Injury Professional is not an easy one to read. The data are frightening and the related stories are about our neighbors and people we know. NABIS wants to thank Dr. Jean Langlois for tackling such a complex topic. Dr. Langlois was the recipient of the 2006 NABIS Advocacy and Public Policy Award. Her work at CDC and her dedication to improving our understanding of TBI is exemplary. We thank Dr. Langlois for serving as our Guest Editor of BIP and our other authors for providing us with an issue that is both useful and thought provoking.

Ronald Savage, EdD

BARRIERS AND RECOMMENDATIONS: ADDRESSING THE CHALLENGE OF AMERICANS WITH BRAIN INJURY Concerned by a lack of treatment and service options for brain injury survivors, more than one hundred of the most respected military and civilian leaders in brain injury treatment convened recently to address the crisis of brain injury in America. The resulting report, Barriers and Recommendations: Addressing the Challenge 4

BRAIN INJURY PROFESSIONAL

of Americans with Brain Injury, demands major reforms within the military and civilian sectors. The public release of this report takes a hard-hitting look at available medical care, exposing the grim realities facing Americans with brain injury. For more information, visit www.nabis.org.

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guest editor’s message

I recall my first encounter with traumatic brain injury and violence more than 20 years ago. A 17 year-old high school senior was transferred to us for post-acute rehabilitation.

“Geri” had been abducted while shopping for prom shoes. Her assailant, a 19 year-old drug user, led her at knifepoint to an empty lot behind the mall where he attacked her with a baseball bat and left her there. It was several hours before she was found unconscious and with a severe brain injury. She recovered but was left with serious physical problems, including difficulty speaking. She graduated that year and received her diploma from a wheelchair. Unfortunately she never did get to wear her new shoes to the prom.

Jean Langlois, ScD, MPH

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In this issue of the Brain Injury Professional, we explore this important yet complicated problem. It’s complicated because violence can be both a cause and a consequence of TBI. We begin with an overview article, followed by an interview with a rehabilitation professional working to identify and assist women who experience intimate partner (domestic) violence. These are followed by a clinical primer on diagnosing abusive head trauma in children, an introduction to TBI among prisoners, and the application of a novel theory to improve assessment of suicide risk after TBI. Since Geri’s injury, more is known about TBI and violence, but our work is not done. Professionals in medicine, psychology, rehabilitation, corrections, and law enforcement are just a few of the groups in need of information, tools and training.

The goal of this issue is to raise awareness about the problem of TBI and vio-

lence as well as the resources that are currently available. We do this by presenting up-to-date information in articles by innovative professionals and in sidebars that list specific websites and other relevant materials, including resources developed at the CDC. And we do it by presenting the stories of real people – people like Geri who need the help of all brain injury professionals to reduce the toll of violence. We hope these stories will inspire you to focus on this important issue in your own research or practice.

I would like to thank several people for their contributions to this special issue: Ron Savage and Chas Haynes for inviting me to work on it; all of the authors and co-authors for their excellent contributions; Cindi Johnson for providing case examples; Arlene Vincent-Mark for general assistance; and Lynn Zoll for her ongoing work on this important topic.

Jean Langlois, ScD, MPH

Real Life deserves Real Outcomes Learning Services programs are designed to provide specialized support for adults with brain injuries in a real life setting. All of our programs are equipped and staffed to maximize each resident’s quality of life as they take on the challenges of a brain injury. Our approach supports outcomes by offering individuals the tools necessary to live life on their terms.

As of April 2008, we are broadening our services to support adults with complex behavioral challenges by opening our second world-class neurobehavioral rehabilitation program. This new program is located in suburban Denver and features Board Certified Behavior Analysts and comprehensive rehabilitation therapies, all in a safe and progressive environment.

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Breaking the silence: Violence as a Cause and a Consequence of Traumatic Brain Injury

Jean A. Langlois, ScD, MPH; Jeffrey Hall, PhD; Matt Breiding, PhD; Audrey A. Reichard, MPH, OTR; Anne McDonnell, MPA, OTR/L; Marlena Wald, MLS, MPH

Acknowledgements The authors thank Dr. Tom Simon from the Division of Violence Prevention, National Center for Injury Prevention and Control, CDC for his critical review of the manuscript.

violence by summarizing the epidemiology and providing case examples for victimization and aggressive behavior. In addition, we focused on intimate partner violence and TBI because of the limited information published about this topic.

Disclaimer The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Violence as a Cause of Traumatic Brain Injury

Background The overlap between traumatic brain injury (TBI) and violence is an important yet little understood problem. The exact number of violence-related TBIs each year is not known. The Centers for Disease Control and Prevention (CDC) estimates that 11% of TBI deaths, hospitalizations, and ED visits combined (a total of 156,000 each year) are related to assaults (Langlois et al, 2004). But this number likely is low because it excludes the many other TBIs, including concussions, caused by violence that go unidentified and unreported. Although not a focus of this article, prisoners and young children are two of the groups at high risk of a violence-related TBI that may not be identified.

(See articles by Wald, et al, and Berger, this issue).

Furthermore, the problem of TBI and violence is complicated by the fact that violence is not only a cause, but a consequence of TBI. Specifically,TBI-related cognitive and behavioral problems can also result in aggressive behavior that leads to perpetration of violence, or a lack of insight and judgment, and resulting vulnerability, that can lead to victimization. Depression after TBI can lead to an increased risk of self-inflicted injury, including suicide (Oquendo et al., 2004). Although not a focus of this article, suicide is an important aspect of violence that is addressed elsewhere in this issue (See Brenner article).

The goal of this article is to increase awareness among TBI and health care professionals about the overlap between TBI and 8

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Intimate Partner Violence

The term intimate partner violence (IPV) is also known as domestic violence, spouse abuse, or woman abuse. An “intimate partner� is defined as a current or former partner, including a spouse, boyfriend, or girlfriend (Saltzman et al., 1999). After a relationship ends, many people continue to be at risk for violence from former partners. Intimate partners can be the opposite or the same sex as the victim (Burke et al., 1999; Moracco et al., 2007).

Each year in the United States, women experience about 4.8 million intimate partner-related physical assaults and rapes; men are the victims of about 2.9 million intimate partner violencerelated physical assaults (Tjaden et al., 2000). However, these numbers may underestimate the extent of the problem as certain populations who are more likely to report IPV (prisoners, those living in shelters, transient people, and the homeless) are less likely to be surveyed.

The number of cases of TBI associated with intimate partner violence is not known. However, as mentioned above, CDC estimates that at least 156,000 TBI-related deaths, hospitalizations, and emergency department visits in the U.S. each year are related to assaults (Langlois, et al., 2004). Strangulation or blows to the head may occur in 50 to 90 percent of IPV physical assaults against women (Wolfe et al, 1997; Greenfield et al., 1998). Thus, the true number of violence-related TBIs may be much higher than the CDC estimate. Multiple TBIs, including concussions are frequently reported by incarcerated women with a history of IPV (Pamela Diamond, PhD, University of TexasHouston, Personal Communication, October 2007).

In one study, 60 percent of the women with IPV-related TBI

continued to exhibit TBI-related symptoms 3 months after the injury (Monahan and O’Leary, 1999). Women with TBI frequently exhibit reduced capacity to make informed, consistent choices about whether to leave or return to the perpetrating partner, and their ability to plan and to respond appropriately to safety, health, child care, and parenting issues may be significantly compromised (Monahan and O’Leary, 1999). This increases the likelihood that they will remain in a violent relationship and the risk of sustaining additional injuries, including TBI. Many victims do not report IPV to police, friends, or family because they think others will not believe them and that the police cannot help (Tjaden et al., 2000).

This may be particularly true for persons with traumatic brain injury (Reichard et al., 2007) for several reasons. First, individuals with TBI are more likely to be dependent on a perpetrator for financial support and physical care. Second, communication problems associated with TBI may make it difficult for victims to report victimization. Third, the perpetrator may claim that the victim should not be taken seriously because of their TBI-related cognitive problems. Finally, victims may not be willing to admit that they have had a TBI because of the fear of negative consequences such as losing custody of their children.

Case example

Debra was born in in 1952. She spent 10 years in an abusive relationship with her female partner, and during that time sustained several possible concussions. In 2000, she was lying in bed asleep and was shot several times, including once in the head. She was rushed to the ER and remained in the hospital for 9 days for cranial hemorrhaging. (See sidebar “One Woman’s Story” for a more detailed account) (Published with permission from Ms. Gray, obtained by the Alabama Department of Rehabilitation Services)

Violence as a Consequence of TBI Victimization

A victim is defined as a target of emotional abuse or threatened or actual physical or sexual violence (Saltzman, et al., 2002).

Victimization can include physical violence, sexual violence, psychological or emotional abuse, stalking, and neglect.

Persons with disabilities are particularly vulnerable to violence, and their position of vulnerability often makes it more difficult to leave a violent situation. The number of persons with TBI in the U.S. who are victimized each year is not known and existing information regarding the victimization of persons with disabilities has been gleaned from a small number of studies (Marge, 2003). Such studies have shown that persons with disabilities are 4 to 10 times more likely to become a victim of violence, abuse, or neglect than persons without disabilities (Petersilia, 2001). One recent study found that men and women with activity limitations were more likely to experience physical, emotional, and financial abuse, and that women with activity limitations were more likely to experience sexual abuse (Cohen, et al., 2006). Another study found that women with disabilities were 40% more likely to experience intimate partner violence than women without disabilities (Brownridge, 2006).

Research suggests that certain conditions increase the likelihood of violence, abuse or neglect. One study found that violence was more likely among women with a physical disability when they also had more than one disability, a hearing impairment, or were divorced/separated (Milberger, et al., 2003). An-

Traumatic Brain Injury and Domestic Violence: One Woman’s Story Background Debra Gray was born in 1952 in Dallas, Texas, the second of six children. In 1972, she gave birth to a son. In the late ‘70’s, she tried going to school but didn’t have the finances, so she started up a residential and commercial cleaning business which she later sold.

The Injury Debra spent 10 years in an abusive relationship with her female partner, and sustained several possible concussions. In 2000, she was lying in bed asleep and was shot four times, once in the head behind the right ear, once in the right thigh, and twice in the right hip. One bullet remains in her pelvis, thigh, and in her back between the 11th and 12 vertebrae.

After being shot, she got out of bed and dragged herself to the phone; reportedly this took her several hours. Debra called 911, was rushed to the ER and remained in the hospital for 9 days for cranial hemorrhaging. She then moved in with her son who at the time was 27 years old.

Her partner had three sons of her own who also had been abused, and who were home at the time of the assault. The partner blamed her own 14 year-old son for the shooting. However, all 3 of the children testified against their mother. The partner was found guilty of attempted murder and received a 25-year sentence; she is up for parole in 2016.

The Aftermath After the assault, Debra wanted to move on with her life, and was interested in finally returning to school. She was told by many people that, due to her brain injury, she would not be able to attend, or retain the information learned. However, with the help from an Alabama Head Injury Foundation Resource Coordinator and a Vocational Rehabilitation counselor with the Alabama Department Rehabilitation Services, Debra went back to school despite a number of deficits. These include hearing loss in her right ear, and a hearing aid in her left ear, vision loss in both eyes, short term memory problems, word finding difficulties, visual processing deficits, headaches, fatigue, post-traumatic stress disorder, and problems with numbers-math.

To accommodate her deficits, she uses a note-taker, large print materials, a magnifier, and is allowed an extended time and a distraction-free environment for taking tests. The use of a CCTV (which magnifies the material from a base unit to a screen at eye level) is used in taking tests.

Today Debra is attending school part-time; full time was too demanding. She is scheduled to graduate in the spring of 2008 with a Bachelor’s degree in Social Work. She regularly attends TBI support group meetings and Domestic Violence support group meetings, and volunteers for Safeplace, (a shelter for victims of domestic violence), VOCAL (Victims of Crime and Leniency), The Healing Place (grief support for loss from homicide or suicide), and the Alabama Head Injury Foundation (AHIF).

She was nominated for Shoals Woman of the year-2007. Two of her partner’s children (ages 21 and 20) have come back to live with or near her, and Debra is seeking joint custody of the third child (age 17). All things considered, she has an enormously positive outlook on life.

Published with permission from Ms. Gray, obtained by the Alabama Department of Rehabilitation Services BRAIN INJURY PROFESSIONAL

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other study found that men and women with activity limitations were more likely to report intimate partner violence if they were single, younger, had lower income, and/or had poor health (Cohen, et al., 2006). (For more detailed information about victimization, see the sidebar).

Little is known about the experience of victimization among persons with TBI, however. A recent qualitative research report

by Reichard et al. (2007) has begun to shed some light on the problem and provides a number of examples. Selected narratives collected as part of this study are presented below.

Case examples Victimization of persons with TBI Physical abuse

I guess because I had on a shirt he didn’t like. I remember it was something about clothes and he threatened to cut the shirt off my body, and I told him he wasn’t cutting the shirt off my body, that I’d go take it off, and then he was going to cut the shirt to shreds, and I told him no, he wasn’t. That I’d take the shirt off but he wasn’t cutting the shirt up, and something about the shirt. He didn’t like the shirt or something, and he had the scissors and he got mad, and I took the scissors away from him, and that’s the only way I’d take off the shirt if he gave me the scissors, and that’s when he pounded me in the head.

Physical and financial abuse

Saturday evening, this fellow [name], who I was going to marry, he tore...he gave me a black eye, he tore up my apartment and demanded a $300 check. [This was not the first time this happened]. He’d hit me and stuff like that. I’ve gone to work with a black eye.

Seeking protection

I went to the police to see what I could do. They told me the temporary restraining order wasn’t worth the paper it was written on. They told me basically it was all a joke. I could get it, but he could show up with a gun and blow me away.

That if I was going to do anything, I needed to do it and disappear. I needed to go out of state. I needed to file the papers, go out of state, and then not show up until the day of the court date. That I needed to go ahead and get what I needed done, do it fast, and then leave the state of [state name]. I told them I didn’t have no money. I didn’t have...if I left the state of [state name], how was I going to live? Where was I going to live? How was I going to get there? Due to seizures, I couldn’t drive. I didn’t have no way of driving. What was the deal? And they said they couldn’t help me.

Sexual abuse

I was at a car dealership … getting the car serviced and everything. This elderly man walked in, big smile on, plopped down right next to me, started talking to me very friendly. I started feeling very comfortable with him. Felt like he was like a father figure, you know because my father died when I was...about 5 or 6 years old. Then he started. He put his arm out back behind me. It was a loveseat type thing, which I was feeling very comfortable with him because I was identifying with a father. He started asking questions and so I was talking with him about [the problems he said he was having with his wife and what he could do about them]. And with that he kept getting closer to me… and he moved his hand 10 BRAIN INJURY PROFESSIONAL

from the back of the sofa down to the seat and all of a sudden I became aware he was shoving his hand at my butt, up under it and had his thumb stroking my thigh on the outside... my hip area…he was still engaging me in the conversation so that was distracting me…The next thing I know he’s got his hand up my short leg, over into my pubic area, probing, massaging, and I’m looking at him. What are you doing?

He said…oh, you’ve just given me the thrill of my life today.

And I said remove your hand... I came home rattled…The first thing I did was pick up the phone and I called [name of state] and talked to my friend there and I told him what happened, and I was in hysterics. I mean I was sobbing. I was frantic. I was shaking as I was holding the phone. It’s like I don’t understand why do these things keep happening, you know, and we talked about it and that’s when I first got the insight. He talked to me. He was friendly. You know, he was gentle. He started off appropriate. He kept me distracted, and he was the perfect predator...I’ve been in a situation of no control, … and … distracted, not really able to anticipate where stuff is going. I’m just trying to deal with each moment, so I mean that’s a problem because that means I’m wide open for rape and anything else, and I’ve been fortunate so far no one’s raped me. They’ve molested me, but they have not raped me.

Sexual abuse by a medical professional

It was the second [gynecological exam] in my whole life…

[The doctor] dismissed the nurse and he told me to change into a paper gown and he didn’t leave the room....Yeah. And he made me put the thing so it opened in the front…, and then he came over and he pulled the paper open at my breast and everything and he was just looking and his looks were bedroom looks…., and then he took his hands and he started fondling my breasts. After [talking to me about sex and masturbation and touching my private area in a sexual way] … he put [the speculum] in hot and he said I can sterilize you if you ever tell anybody and besides you’ve got a brain injury.

They’re not going to believe you.

Violence as a consequence of TBI Aggressive behavior

According to Silver et al (2005), aggressive behavior after TBI includes explosive behavior that can be set off by minimal provocation and occur without warning. Episodes range in severity from irritability to outbursts that result in damage to property or assaults on others.

Reports of the incidence of aggression vary widely. Studies of patients with TBI conducted in medical outpatient settings typically report low rates of aggressive behavior (Kreutzer et al, 1999). In contrast, persons in a TBI neurobehavioral program displayed an average of about 280 aggressive acts per day during a 14-day period (Alderman et al, 2002). Sexual aggression was reported in 6.5% of a sample of male patients receiving either inpatient or outpatient TBI rehabilitation; the most common offenses were “touching” offenses followed by exhibitionism and overt sexual aggression (Simpson et al., 1999) Increasing evidence suggests that TBI-related aggressive behavior is strongly associated with depression (Kreutzer et al,1996; Tateno et al, 2003; Baguley et al, 2006).

Case examples

Paul was a new 16 year-old driver when he ran his car off the

road and both he and his girlfriend sustained TBIs. After a 2 month coma and years of recovery, his social skills have not caught up with his age of 24. He was taken by police to the emergency room when a group of guys beat him severely and took his wallet. Surprised and humiliated, he responded, ”I don’t understand. I just asked them ‘do you want some of this.’ I guess they thought I wanted to fight because they just started beating me up.” Now four years later, despite his best intentions, he loses new friends when he throws things and screams obscenities at them. “They are looking at me and talking too loud” he says. “I said I’m sorry, I go too far before I know it.”

(Source: Cindi Johnson, Side-by-Side Clubhouse,

Atlanta, GA, January, 2007).

After sustaining a brain injury in Iraq, Steve was diagnosed with post-traumatic stress disorder and depression.

One of the effects of his brain injury is that he has a harder time keeping his emotions under control. He blurts out what he’s thinking or flashes his anger. Late one night driving his pickup truck, he and his wife, came to an intersection where he usually turned left. Now there was a ‘No left turn’ sign. Confused, he stopped and tried to figure out what to do. A policeman walked up. According to his wife “The cop, he shines the flashlight right in at Steve, and he’s screaming, ‘Can you not read, stupid?’ and he got irate.

Steve said to his wife, ‘This guy just called me stupid.’ He let out the clutch on the truck and yelled at the cop. ‘I’ll show you stupid, because I’m not stupid. It just takes me longer to comprehend.’ ” He wanted to get out of the car then, but his wife told him “No, it’s not worth it.” She calmed him down and the couple drove on. In rehab, Steve is learning strategies to jog his memory and control his anger. He says “I bite my tongue so many times. I--they’ve taught me to really walk off, and it’s a hard thing for me to do, but I’m learning that.”

Adapted from National Public Radio report from November 29, 2005: http://www.npr.org/templates/story/story. php?storyId=5030571. Accessed 12/28/07 Reducing the toll of violence after TBI Victimization

Screening for possible TBI among persons who have experienced intimate partner violence is critical to ensuring that those with TBI-related problems are diagnosed and receive needed services and/or accommodations. Professionals working in IPV prevention can benefit from information and training aimed at helping them identify and manage persons with TBI. Potentially useful methods for screening, identifying and assisting such cases have been proposed by both the Alabama Department of Rehabilitation Services and the Brain Injury Association of Virginia (See Interview with Maria Crowley, this issue, and sidebar of Intimate Partner [Domestic] Violence Resources). Additional research is needed to ensure that the screening methods for identifying TBI are both valid and reliable. The November-December 2007 issue of the Journal of Head Trauma Rehabilitation, which was devoted to articles about screening and identification of TBI, includes information about promising new screening methods.

Similarly, screening for victimization among persons with TBI is also important. Physicians are especially well-placed to conduct such screening. However, recent studies of the screen-

Victimization and TBI Fact Sheets For more information about victimization of people with TBI, see these fact sheets from the Centers for Disease Control and Prevention (CDC): Victimization of Persons with Traumatic Brain Injury or Other Disabilities: A Fact Sheet for Friends and Families

This fact sheet provides a general overview of victimization and risks to people with TBI or other disabilities. www.cdc.gov/ncipc/tbi/FactSheets/VictimizationTBI_FactSheet4FriendFam.htm

Victimization of Persons with Traumatic Brain Injury or Other Disabilities: A Fact Sheet for Professionals

This fact sheet was developed for professionals and provides an overview of the topic of victimization of persons with TBI or other disabilities. www.cdc.gov/ncipc/tbi/FactSheets/VictimizationTBI_FactSheet4Professionals.htm

ing practices of physicians, including obstetrician–gynecologists, indicate that most conduct screening for violence only when warning signs are observed (Horan et al., 1998; Rodriguez et al., 1999).

Unfortunately, violence can exist in the absence of warning signs in the patient’s behavior or medical history. Women who are victims of violence may not present with symptoms, especially those who experience psychological or emotional abuse.

They may conceal what they are experiencing at home. Because of the increased vulnerability of women with disabilities, including those with TBI, it is important to study the utility of screening these patients for IPV. One of the most widely used screening tools is the Abuse Assessment Screen (McFarlane et al, 1992). This tool is short and has been tested in clinical settings. This and other tools for assessing IPV can be found in the Centers for Disease Control’s publication Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings. [See Intimate Partner (Domestic) Violence Resources sidebar, page 16.]

Aggressive behavior

The need to improve the effectiveness of strategies to manage the anger, aggression, and disinhibition following TBI has been well established (Corrigan and Bach, 2005). The link between TBIrelated behavioral problems and violent victimization described in this article provides an additional reason why work in this area is vitally important. Improvements in behavioral management techniques might yield benefits beyond achieving reductions in problematic behaviors. This could include reduced risks for the forms of victimization that may accompany diminished coping abilities, impulse control problems, and increased irritability.

Conclusion Violence as both a cause and a consequence of TBI is a serious problem. TBI professionals can play an important role in educating domestic violence workers, health care providers, and other professionals, including those in law enforcement, about ways to better identify and assist persons who experience violence. Additional research is needed to better quantify the extent of the problem and to ensure that screening methods for identifying a history of TBI are valid and reliable.

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About the Authors

Jean A. Langlois, ScD, MPH is a senior epidemiologist with the Centers for Disease Control and Prevention. She holds master’s and doctoral degrees in injury epidemiology and health policy from the Johns Hopkins University School of Hygiene and Public Health. Dr. Langlois worked in pediatric traumatic brain injury rehabilitation at the Kennedy Krieger Institute at Johns Hopkins Hospital, and was a Senior Staff Fellow in epidemiology at the National Institute on Aging of the National Institutes of Health before joining the CDC. She has published numerous articles and reports on traumatic brain injury, and is considered a national expert on the epidemiology of TBI. In 2006, she was the recipient of the Brain Injury Association of Ohio’s Awareness Award, and the North American Brain Injury Society’s Public Policy Award Jeffrey E. Hall, Ph.D., M.S.P.H. is a behavioral scientist with CDC’s Division of Violence Prevention. He is a medical sociologist whose research has focused on etiologic aspects of youth violence, elder maltreatment, and violence against women.

Matt Breiding, Ph.D. is a behavioral scientist with CDC’s Division of Violence Prevention.

He is a psychologist whose research has focused on the topics of intimate partner violence and sexual violence.

Audrey A. Reichard MPH, OTR is an epidemiologist who currently conducts research on occupational injuries at the CDC, National Institute for Occupational Safety and Health, Division of Safety Research. She previously worked in the CDC, National Center for Injury Prevention and Control, Division of Injury Response. Prior to beginning a full-time research position, she practiced as an occupational therapist.

Ms. McDonnell is the Executive Director of the Brain Injury Association of Virginia. She has a Bachelor of Science in Occupational Therapy from the Medical College of Virginia, a postgraduate Certificate in Health Care Management and Administration from Old Dominion University, and a Masters of Public Administration degree from Virginia Commonwealth University (VCU). Anne has over 20 years of experience in brain injury rehabilitation across a continuum of hospital and community based settings, and has worked as a consultant for state agencies and private service providers. She serves on the advisory boards for the VCU and Ohio Valley Center Traumatic Brain Injury Model Systems grants, and holds a clinical faculty position in the School of Occupational Therapy at VCU. Marlena Wald, MLS, MPH is an epidemiologist at the National Center for Injury Prevention and Control, CDC. She has a strong interest in research on victimization of persons with TBI and is the developer CDC’s fact sheets on this topic and on TBI among prisoners.

References

Alderman, N., Knight, C., Henman, C. Aggressive behaviour observed within a neurobehavioural rehabilitation service: utility of the OAS-MNR in clinical audit and applied research. Brain Injury. 2002; 16(6):469-489.

Baguley, I.J., Cooper, J., Felmingban, K. Aggressive behavior following traumatic brain injury: how common is common?

Journal of Head Trauma Rehabilitation. 2006; 21(1):45-56.

12 BRAIN INJURY PROFESSIONAL

Brownridge, DA. Partner violence against women with disabilities: prevalence, risk, and explanations. Violence Against Women.

2006; 12(9):805-22.

Burke, L K. Follingstad, D R. Violence in lesbian and gay relationships: theory, prevalence, and correlational factors. Clinical Psychology Review. 1999;19(5):487-512.

Cohen MM, Forte T, Du Mont J, Hyman I, Romans S. Adding insult to injury: intimate partner violence among women and men reporting activity limitations. Annals of Epidemiology 2006;16(8):644-51.

Corrigan PW, Bach PA. Behavioral treatment. In Silver JM, McAllister TW, Yudofsky SC (eds): Textbook of Traumatic Brain Injury. Washington, DC: American Psychiatric Publishing, 2005.

Greenfield, L.A., and Rand, M. R. (1998). Violence by Intimates, NCJ-167237, US Department of Justice Bureau of Justice Statistics.

Horan DL, Chapin J, Klein L, Schmidt LA, Schulkin J. Domestic violence screening practices of obstetrician-gynecologists.

Obstet Gynecol. 1998;92:785-789 Kreutzer, J.S., Marwitz, J.H., Seel, R., Serio, C.D. Validation of the neurobehavioral functioning inventory for adults with traumatic brain injury. Arch Phys Med Rehabil. 1996; 77:116-124.

Kreutzer JS, Seel RT, Marwitz JH. The Neurobehavioral Functioning Inventory (NFI) Manual. San Antonio, TX: The Psychological Corporation; 1999.

Langlois, J.A., Rutland-Brown, W., and Thomas, K.E. (2004) Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Marge K. Introduction to violence and disability. In: Marge K, editor. A call to action: Ending crimes of violence against children and adults with disabilities, a report to the nation. Syracuse: State University of New York, Upstate Medical University; 2003. p. 1-16.

McFarlane J, Christoffel K, Bateman L, Miller V, Bullock L. Assessing for abuse: self-report versus nurse interview. Public Health Nurs. 1991;8:245-250.

Milberger S, Israel N, LeRoy B, Martin A, Potter L, PatchakSchuster P. Violence against women with physical disabilities.

Violence and Victims. 2003;18(5):581-91.

Monahan K, O’Leary KD. Head in jury and battered women: an initial inquiry. Health and Social Work. 1999;24(4):269-278.

Moracco KE, Runyan CW, Bowling JM, Earp JA. Women’s experiences with violence: a national study. Women’s Health Issues.

2007;17:3-12.

Oquendo MA. Harkavy Friedman J. Grunebaum MF, et al., Suicidal behavior and mild traumatic brain injury in major depression. Journal of Nervous and Mental Disease. 2004; 192(6): 430-434.

Petersilia JR. Crime victims with developmental disabilities: a review essay. Criminal Justice & Behavior. 2001; 28(6):655–94.

Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA. 1999; 282:468-474.

Reichard AA, Langlois JA, Sample PL, et al. Violence, abuse, and neglect among people with traumatic brain injuries. J Head Trauma Rehabil. 2007;12(6):390-402.

Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. Intimate partner violence surveillance: uniform definitions and recommended data elements, Version 1.0. Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2002.

Silver JM, Yudofsky SC, Anderson KE. Aggressive disorders.

In Silver JM, McAllister TW, Yudofsky SC (eds): Textbook of Traumatic Brain Injury. Washington, DC: American Psychiatric Publishing, 2005.

Simpson, G., Blaszczynski, A., Hodgkinson, A. Sex offending as a psychosocial sequela of traumatic brain injury. Journal of Head Trauma Rehabilitation. 1999; 14:567-580.

Tateno, A., Jorge, R.E., Robinson, R.G. Clinical correlates of aggressive behavior after traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2003; 15(2):155-160.

Tjaden P, Thoennes N. Extent, nature and consequences of intimate partner violence: findings from the National Violence Against Women Survey. Washington (DC): Department of Justice (US) ; 2000. Publication No. NCJ 181867. Available from URL:www.ojp.usdoj.gov/nij/pubs-sum/181867.htm.

Wolfe, D. (1997). Interrupting the cycle of violence - Empowering youth to promote healthy relationships. In Wolfe, D., McMahon, R., and Peters, R.D. (Eds.), Child Abuse; New Directions in Prevention and Treatment Across the Lifespan; Sage Publications, Thousand Oaks California.

book review Head Cases: Stories of Brain Injury and Its Aftermath Michael Paul Mason.

Farrar, Straus and Giroux, New York. 2008.

(ISBN-13: 978-0-374-13452-5) Mike Mason is an experienced case manager who has worked with hundreds of individuals with brain injuries and their families. In his book, Head Cases: Stories of Brain Injury and Its Aftermath, he has traveled throughout the United States and even into Iraq to write about the “real people” who sustained brain injuries from various kinds of external physical forces and internal occurrences. Mason writes not just about the injury per se, but about the unraveling of people and the courage each person had to pull the broken pieces of their lives together in some way, shape or form. As importantly, Mason also focuses on the uniqueness of each brain injury and the vivid glimpses each injury provides us about the inner workings of the human brain in an Oliver Sack’s kind of way.

There are twelve stories in all, including “The Hermit of Hollywood Boulevard” about a struggling actor with violent seizures, “The Hospital in the Desert” and the hidden costs of brain injury in this war, “A Prisoner of the Present” about a mother who has no memory of the daughter she lost in the accident or the husband she cares for every day, “Rob Rabe Cannot Cry” about a man who lost his ability to cry after suffering a TBI in an alcohol related car crash, and “Ultraviolent Bryan” a heart wrenching story about a child who, after a tumor was removed from his brain, lost his ability to control his behaviors and had to have other areas of his brain removed. Each story, like each person, is unique and examines the different kinds of brain injuries, the mysteries of mindbrain connections, the therapies that worked and the ones that didn’t, and the remarkable courage that people and family members often exhibit in the aftermath.

This is an intriguing book written by an experienced clinician who has also been featured on PBS’s “Newshour with Jim Lehrer” and wrote the much heralded article “Dead Man Walking” in the February 2007 issue Discover magazine.

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bip expert interview TBI and Domestic Violence:* Alabama’s Efforts to Bridge the Gap An Interview with Maria Crowley How did you get interested in working with women who sustained TBI as a result of violence?

I work for the Alabama Department of Rehabilitation Services (ADRS). We had focused on the State’s education and mental health systems with previous HRSA TBI program* grant funding, and wanted to focus on a new issue for our 2003-04 application. ADRS has had the most success building on existing partnerships, and since this was a one-year grant, we knew it would be particularly critical this time.

We already had relationships established with a few staff inside the domestic violence (DV) community and after looking at the studies related to TBI and Domestic Violence, we chose this issue for several reasons: • Lack of TBI awareness in the DV community • Lack of knowledge about DV among TBI service providers • Lack of identification/referral of TBI within the DV system • Existing collaboration with the Alabama Coalitions Against DV (ACADV) staff through community rehabilitation programs.

Considering the number of women served by the Alabama Head Injury Foundation (AHIF) who sustained their brain injury as a result of DV, and the number served through the DV network, we saw a critical need to work together to help ensure successful rehabilitation of women with a TBI resulting from DV. How common is DV in the setting(s) in which you are working?

More common than anyone realizes. Reports from the Alabama Head Injury Task Force (AHITF), the state’s TBI Advisory Board, analyzing trends to identify emerging needs, showed an alarming increase in the number of women sustaining a brain injury as a result of domestic violence. Case data from the AHIF’s network of family service coordinators indicated that 14 BRAIN INJURY PROFESSIONAL

1 in 10 women served reported DV as the cause of their brain injury. We found research showing that more than 90% of injuries secondary to DV occur to the head, neck, or face, but TBI is not identified in the majority of cases. Other studies show that women with a history of DV are at greater risk of TBI than those without such a history. Repeat TBI is also a major problem, especially in ongoing abusive relationships. A study of a sample of women in a DV shelter showed that on average they reported 5 brain injuries, and nearly one third of them reported 10 or more, in the previous year. Some of the women we’ve identified in Alabama have reported similar histories.

What are the biggest problems you see for women with TBI and DV? Recognizing the brain injury, and having professionals recognize it, are big problems. Many women don’t recognize the consequences of brain injury and don’t seek specialized services. According to information we read, typical descriptions of women who have experienced DV and fare the worst in DV programs include: “unmotivated,” “unfocused,” “poorly organized,” “unable to plan ahead,” “unable to follow a train of thought,” and “forgetful.” These terms are similar to those used to describe the cognitive challenges of individuals with brain injury. So, the characteristics of women with DV may actually be the consequences of a brain injury. Combined, DV and brain injury increase a woman’s risk of continued harm, repeat brain injuries, and an increased likelihood that interventions will be unsuccessful. Abused women with TBI have difficulty initiating an intervention plan, gaining/maintaining employment, managing finances, daily living skills, and shelter/community living – they just don’t do well in group settings.

Health care providers are also unaware of the high risk of brain injury in abused women. As a result, they may fail to link the psychodynamic issues presented by women with the challenges emerging from an undiagnosed brain injury. Without linking DV and BI, they fail to recognize the brain injury

and so do not refer for appropriate brain injury-related rehabilitation services. Also, law enforcement is not aware of the difficulty - and inconsistency - in reporting by victims because of their TBI. • How did you find domestic violence programs interested in working with you?

ADRS had an existing relationship with staff at the Alabama Coalition for Domestic Violence (ACADV) and at one of the DV shelters. Having worked with ADRS for several years at a community rehabilitation program, these DV staff members were familiar with disabilities as well as the ADRS/vocational rehabilitation process. This staff helped a lot by allaying initial concerns about allowing “outsiders” entry into a cautious, closed service provision community. Relationships and trust were built slowly with other staff and partners. They’re maintained by attending DV task force meetings, success with referrals, and continued training with new staff. ACADV has memoranda of understanding (MOUs) with all the DV shelters statewide, and grants with the Department of Public Health, so ADRS was able to take advantage of an existing network on both the TBI and DV sides of the fence. TBI players include the ADRS adult and pediatric TBI service coordinators, Alabama Head Injury Foundation resource coordinators, AHITF and its partners, and the University of Alabama at Birmingham’s TBI Model Systems Center and Injury Control Research Center.

•

•

process for intervention. TBI staff attend DV task force meetings statewide, and have actually gone out on law enforcement calls in some instances, to collaborate with DV staff.

Provide a training program series on issues of TBI and DV for shelter staff using a TBI Training Tool Kit – a trainthe-trainer toolkit was developed and distributed, training TBI staff using handouts, slides, and -pre and -post tests.

Develop and provide training, in collaboration with ACADV, for legal professionals and justice system staff – special training on DV and TBI was conducted for ACADV’s standing classes for legal system staff.

Contribute to systems change by influencing legislative initiatives and public policy – at the end of the grant year, funding was secured through the Alabama Department of Public Health and ACADV to create a DV and disabilities Task Force that meets to review legislation, program access, and common issues. ACADV is also a current member of the Alabama Head Injury Task Force.

Do you have any success stories that you would like to share?

We had a woman featured on our videos who was living with an abusive partner and her children, and was shot in the head and hip. She has a number of deficits but has gone back to school and is doing well there. Her story is in the sidebar on page 9.

What are some of the key features of your work specifically with women with TBI?

What would you like TBI professionals to know who are considering working in this area?

Based on what we had learned about DV and TBI, the goals of our HRSA grant project were to:

There are a number of challenges. DV community and shelter staff are extremely close/closed off – this group tends to be cautious, and with good reason. In working with them, we had to learn their language, ways, and legal concerns. Locating the women with TBI was difficult – because we chose to work with shelters, and because of the nature of the DV situations, once someone left a shelter, they disappeared, either back to home with the perpetrator or to anonymity, and we couldn’t do any follow up with them. We had to depend on self-identification.

Women were screened when time allowed, but it was largely determined by their ability and/or motivation to disclose a history of brain injury during screening. Also, in our project, children were not assessed for either TBI or PTSD, or other psychiatric issues – and they need to be. Victims of DV as a whole, tend to downplay their injuries, due to denial of their life situation, inability to self-assess and/or to pursue treatment. This may be related to concern that knowledge of their TBI could end up in the wrong hands – they’re afraid that they could lose custody of children due to being labeled brain-injured by the perpetrator.

We made a lot of progress with our project, but there is still a lot of work to be done. We had no process for identifying DV survivors in other systems – such as the Department of Human Resources (DHR), which includes child and adult protection services, Mental Health, Medicaid, and our own TBI registry service linkage system – and there needs to be. There are a number of other groups that need training: police academies, DHR staff, vocational rehabilitation staff to recognize DV, and

•

• •

•

•

Educate both DV service providers and TBI service providers – ADRS conducted cross training involving all players on both sides on brain injury, strategies, accommodations, DV and service systems.

Establish on-going collaborative relationships between TBI and DV service providers – service providers met in groups by county and individually, and began working together.

Develop protocol/process for acute intervention and long-term counseling for DV service providers, enhancing treatment outcomes of women with TBI due to DV – a process for identification and referral was established, involving a new brief screening tool devised specifically for DV shelter staff and a protocol for referral to AHIF for evaluation to confirm a history of TBI. Develop consumer-focused videos and literature explaining TBI issues and services to facilitate access to the TBI service system – materials including brochures, fact sheets, tip cards, posters, and accommodation strategies, and videos for victims and DV staff were developed for DV shelter staff to use/disseminate to women.

Build the capacity of the TBI system staff to recognize and effectively serve TBI consumers who are victims of domestic violence – DV training was conducted to recognize DV issues in existing/new TBI consumers, and a referral

BRAIN INJURY PROFESSIONAL

15

Intimate Partner (Domestic) Violence Victimization and TBI For more information about intimate partner violence, victimization, and TBI, visit the following: Alabama Department of Rehabilitation Services’ (ADRS) TBI and Domestic Violence (DV) Website This site has a wide range of materials for training domestic violence workers and victims of DV about TBI. www.rehab.state.al.us/tbi Brain Injury Association of Virginia Website This site has a Domestic Violence and Traumatic Brain Injury Tip Card that provides useful info for educating individuals about this topic. www.biav.net/docs/domesticviolence.pdf

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The Centers for Disease Control and Prevention (CDC) Website This site has a wide range of information and resources related to prevention of intimate partner violence. www.cdc.gov/ncipc/dvp/dvp.htm Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings This CDC report is a compilation of existing tools for assessing intimate partner violence and sexual violence victimization in clinical/healthcare settings. www.cdc.gov/NCIPC/pub-res/ipv_and_sv_screening.htm Additional Resources Go to: www.cdc.gov/ncipc/dvp/IPV/ipv-resources.htm

ongoing training for local DV task forces, legal/justice system training. And staff turnover always creates the need for continued training.

Maria Crowley is the State Head Injury Coordinator with the Alabama Department of Rehabilitation Services. She has a Master’s degree in Rehabilitation Counseling from the University of Alabama at Birmingham and has been working in rehabilitation and related fields since 1989. Maria was previously the Director of the State TBI registry.

* Note to readers: Alabama violence programs alternate between using the term “domestic violence” (DV) and the newer and broader term “intimate partner violence” (IPV). Because the programs are still referred to as domestic violence, for example, the Statewide Coalition against Domestic Violence, that term is used in this article. Also, the term “women” is used to refer to victims although we recognize that men also experience DV. ** Health Resources and Services Administration (HRSA) Federal Traumatic Brain Injury Program. For more information, go to: http://mchb.hrsa.gov/programs/tbi.htm.

16 BRAIN INJURY PROFESSIONAL

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17

Diagnosing Abusive Head Trauma: A Primer for Health Care Providers

Rachel Berger, MD, MPH

Abusive head trauma – sometimes referred to as shaken baby syndrome, shaken impact syndrome, or inflicted traumatic brain injury – is a leading cause of death from traumatic brain injury (TBI) in infants.1, 2 Population studies from Scotland,3 Wales4 and the United States1 all have demonstrated an incidence of abusive head trauma (AHT) of approximately 1 in 3,500. By comparison, a child in the United States has a 1 in 30,000 annual risk of being diagnosed with acute lymphocytic leukemia and a 1 in 4,000 risk of having muscular dystrophy; these are both diseases for which there is significantly more public awareness than there is for AHT. Timely and proper diagnosis of AHT is difficult because caretakers often do not provide a history of trauma,5, 6 children present with non-specific symptoms such as vomiting or fussiness7, 8 and the physical examination is often normal.9, 10 As a result, misdiagnosis is common and can have catastrophic medical consequences.8, 11 In a landmark study by Jenny and colleagues,8 31% of children diagnosed with AHT in a children’s hospital emergency department had been seen previously by a physician after the abuse, but were misdiagnosed with conditions such as gastroenteritis, apparent life-threatening event (ALTE) and upper respiratory infection. Over 40% of these children experienced medical complications related to the missed diagnosis; of the five deaths among the children with missed AHT, four might have been prevented by earlier recognition of abuse. In a separate study by Laskey,12 40% of patients diagnosed with AHT had previously been medically evaluated for seizures, fussiness, lethargy, limpness or vomiting, suggesting that many of these children had previous, unrecognized AHT. The importance of making the diagnosis of AHT as soon as possible cannot be overemphasized. Misdiagnosis of AHT allows children to be returned to potentially unsafe households where they can 18 BRAIN INJURY PROFESSIONAL

be abused again and delays treatment that may result in serious medical complications.

The goal of this article is therefore to improve awareness among health care providers and other brain injury professionals who may come into contact with infants and children at risk of AHT by presenting two scenarios, each with associated teaching points.

Scenario #1: Abusive head trauma presenting without a history of trauma: The importance of remembering to “think brain” when infants and young children present with non-specific symptoms.

A 3-month old healthy girl is brought to the ED by her mother for vomiting. Her mother reports that the babysitter had called her at work around 10 am because the baby had started vomiting. Throughout the day, she vomited 4-5 times and was more fussy than usual. She has no fever, diarrhea or cold symptoms. There are no sick contacts except that the babysitter’s own child was recently ill with vomiting and diarrhea. The baby has a history of gastro-esophageal reflux disease and receives thickened feeds, but is on no other medication for this. On exam, the baby is fussy, but consolable. Her mucous membranes are slightly dry, but she is otherwise well-appearing. Electrolytes are normal. She is observed for 3 hours, feeds 2 oz, does not vomit, and is discharged home with a diagnosis of gastroenteritis.

Four weeks later, the same baby is brought to the emergency department in the same hospital by EMS after a cardiac arrest.

Her head CT shows both acute and chronic subdural hemorrhages. A skeletal survey shows several healing posterior rib fractures. A dilated eye examination shows multiple retinal hemorrhages (RH) extending to the periphery. The treating physician makes a diagnosis of AHT.

Teaching points Virtually all health care professionals are taught to make diagnoses based on a combination of history and physical examination.

Infants and children with AHT present a unique situation in which a clinician must make a diagnosis of trauma in a patient without a history of trauma and with a physical examination that may not suggest trauma. Most children with AHT are brought to medical attention either by a perpetrator who does not provide accurate historical information or by a non-perpetrator who inadvertently provides inaccurate information. In a classic study

by O’Neill,5 the history of injury was either inaccurate or deliberately evasive in 95 of 100 cases of child abuse. In a study at Children’s Hospital of Pittsburgh, the caregivers of 50% of children diagnosed with AHT over a 5-year period did not report any history of trauma.6 The physical examination – including both the neurologic exam and the skin exam – can be normal in infants and young children with brain injury. In a study by Greenes and colleagues,13 27% of infants less than 6 months of age with intracranial injury of any etiology were asymptomatic. In a study by Rubin and colleagues,14 37% of infants with a suspicion of child abuse not involving the brain and a normal neurologic exam had evidence of AHT on head CT. Multiple studies have also demonstrated

that up to 50% of children with AHT – and even some who die from AHT – have no external signs of injury.9, 10, 15 Several studies have also suggested that when subtle indications of trauma such as a scalp or facial bruise are present, these injuries are overlooked, particularly if the lighting is poor or the examiner does not realize the significance of the finding.8, 13 The key is to ALWAYS think about the possibility of brain injury in infants and young children with symptoms which would suggest brain injury if there were a history of trauma. Symptoms that are particularly concerning are vomiting without diarrhea, a seizure, fussiness/irritability (which may be the way in which an infant with a headache presents) or an apparent life-threatening event (apneic or blue spell). In the scenario presented, the previous episode of isolated vomiting (without diarrhea) was likely the result of TBI and not gastroenteritis. While not all children with these high-risk symptoms warrant a head CT and while the diagnosis of AHT is clearly much less common than gastroenteritis or viral syndrome, considering trauma as a possible etiology of a patient’s symptoms is an important first step in decreasing the incidence of missed AHT.

Abusive Head Trauma in Children

An 8-month old boy is brought to the ED after reportedly falling from a bed onto a carpeted floor. He is brought in by his father who reports that he left the baby on a bed while he went to take a shower. When he came out of the shower, the baby was on the floor and crying. He reports that he went over and picked the baby up and that the baby went limp. He gave the baby CPR and then called EMS. In the ED the Glasgow Coma Scale score is 15 and the physical examination is normal. A head CT shows bilateral acute frontal subdural hemorrhages without a skull fracture. A skeletal survey shows no fractures. A dilated eye examination shows right-sided RH in multiple layers extending out to the periphery. A diagnosis of probable AHT is made by the treating physician.

Abusive head trauma (AHT), sometimes referred to as shaken baby syndrome, shaken impact syndrome, inflicted traumatic brain injury or inflicted childhood neurotrauma, is one type of child maltreatment.

For more information, see the following resources: Websites National Center for Injury Prevention and Control Child Maltreatment Fact Sheet.This fact sheet provides general information about child maltreatment, including shaken baby syndrome. http://www.cdc.gov/ncipc/factsheets/cmfacts.htm Additional resources http://www.cdc.gov/ncipc/dvp/CMP/CMP-resources.htm National Center for Shaken Baby Syndrome The site has been designed to be helpful to professionals and parents looking for information, ideas, and answers to questions about shaken baby syndrome. http://www.dontshake.com Articles Duhaime AC, Christian CW, Rorke LB, Zimmerman RA.Nonaccidental head injury in infants--the “shaken-baby syndrome”.

N Engl J Med 1998;338(25):1822-9 American Academy of Pediatrics: Committee on Child Abuse and Neglect.

Shaken baby syndrome: rotational cranial injuries-technical report. Pediatrics. 108(1):206-10,2001 Jul. Hotlines National Child Abuse Hotline 1-800-4-A-CHILD

Scenario #2: Abusive head trauma presenting with a history of minor trauma: Does the history explain the constellation of injuries?

Teaching points Since abuse is a common cause of subdural hemorrhages in infants and young children and because of the potential adverse outcomes of missing a diagnosis of abuse, practitioners should consider evaluating all infants and young children with traumatic brain injury for possible AHT if the injury occurred without a witness other than the reporting source and/or if there is any concern that the injuries are not consistent with the history. An evaluation includes a complete skeletal survey (with a possible repeat skeletal survey in 14 days) to evaluate for fractures and a dilated eye examination to evaluate for retinal hemorrhages.

There is a significant literature about the injuries which occur from falls from various heights16-19 as well as falls down stairs.20, 21 These studies overwhelmingly demonstrate that significant injuries from short-distance falls are very uncommon. Any practitioner who is routinely making decisions about whether to call Child Protective Services should be aware of this literature and/or of who the experts are in their community.

The presence of RH per se is not diagnostic of AHT and can occur in children with non-inflicted TBI.22, 23 The RH found in these non-AHT situations, however, are virtually always localized to the posterior pole and pre-retinal. RH, which are in multiple BRAIN INJURY PROFESSIONAL

19

layers (e.g. preretinal and intraretinal) and/or extend to the periphery, are much more specific for AHT. Because of the difficulty of examining the retina of infants and young children,24 it is important for an ophthalmologist to be involved in cases of suspected AHT. Not all cases of AHT are severe, just as not all cases of non-inflicted TBI are severe. Be mindful of the circular reasoning that a child is not the victim of AHT because he/she is too well-appearing.

The key is for the practitioner to evaluate for the possibility of AHT in cases in which an infant or young child presents with a history of minor trauma and has an intracranial injury on head CT. An evaluation includes a skeletal survey and a dilated eye examination. It is imperative to evaluate whether the history of trauma is consistent with the constellation of findings and not to focus on a single finding (e.g. the subdural hemorrhage) which may or may not suggest abuse in isolation.

Almost every finding associated with child abuse is not diagnostic in isolation, but suggests abuse only in the context of the other diagnoses/findings.

In conclusion, AHT is an important – though under-recognized – public health problem. Misdiagnosis of AHT is common and results in significant morbidity and mortality. In order to protect the least protected members of society, it is incumbent upon all health care professionals to consider (1) the possibility of trauma in infants and young children who present with non-specific symptoms, such as vomiting, which could be due to brain injury and (2) the possibility of abuse in all infants and young children with TBI. As medical professionals, we evaluate and screen patients for many illnesses and conditions that are much less common than AHT. It is a rare parent who does not understand – and respect – why we are concerned about abuse in a sick infant or young child. In the few cases in which parents are offended or defensive, we need to remember that while our relationship with parents is important, the children are our patients and the death of a child at the hands of an adult is one of the greatest preventable societal tragedies.

About the Author

Rachel Berger is an assistant professor of Pediatrics at the University of Pittsburgh and a pediatrician at Child Advocacy Center at Children’s Hospital of Pittsburgh. In addition to her clini20 BRAIN INJURY PROFESSIONAL

cal duties as a child abuse physician, her research interests include improving both the detection of abusive head trauma and our understanding of the pathophysiology

References

1. Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH. A population-based study of inflicted traumatic brain injury in young children. JAMA. 2003;290(5):621-6.

2. Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants--the “shaken-baby syndrome.” N Engl J Med. 1998;338(25):1822-9.

3. Barlow KM, Minns RA. Annual incidence of shaken impact syndrome in young children. Lancet.

2000;356(9241):1571-2.

4. Sibert JR, Payne EH, Kemp AM, et al. The incidence of severe physical child abuse in Wales. Child Abuse Negl.

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5. O’Neill JA, Jr., Meacham WF, Griffin JP, Sawyers JL. Patterns of injury in the battered child syndrome. J Trauma.

1973;13(4):332-9.

6. Ettaro L, Berger RP, Songer T. Abusive head trauma in young children: characteristics and medical charges in a hospitalized population. Child Abuse Negl. 2004;28(10):1099111.

7. Duhaime AC, Partington MD. Overview and clinical presentation of inflicted head injury in infants. Neurosurg Clin N Am. 2002;13(2):149-54.

8. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. Jama.

1999;281(7):621-6.

9. Haviland J, Russell RI. Outcome after severe non-accidental head injury. Arch Dis Child. 1997;77(6):504-7.

10. Morris MW, Smith S, Cressman J, Ancheta J. Evaluation of infants with subdural hematoma who lack external evidence of abuse. Pediatrics. 2000;105(3 Pt 1):549-53.

11. Ewing-Cobbs L, Kramer L, Prasad M, et al. Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children.

Pediatrics. 1998;102(2 Pt 1):300-7.

12. Laskey A. Shaken baby syndrome: a missed diagnosis. In: 1998 National Shaken Baby Conference. 1998; Salt Lake City; 1998.

13. Greenes DS, Schutzman SA. Occult intracranial injury in infants. Ann Emerg Med. 1998;32(6):680-6.

14. Rubin DM, Christian CW, Bilaniuk LT, Zazyczny KA, Durbin DR. Occult head injury in high-risk abused children. Pediatrics. 2003;111(6 Pt 1):1382-6.

15. Gilliland MG, Folberg R. Shaken babies--some have no impact injuries. J Forensic Sci. 1996;41(1):114-6.

16. Barlow B, Niemirska M, Gandhi RP, Leblanc W. Ten years of experience with falls from a height in children. J Pediatr Surg. 1983;18(4):509-11.

17. Chadwick DL, Chin S, Salerno C, Landsverk J, Kitchen L. Deaths from falls in children: how far is fatal? J Trauma.

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18. Williams RA. Injuries in infants and small children resulting from witnessed and corroborated free falls. J Trauma.

1991;31(10):1350-2.

19. Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics. 1993;92(1):125-7.

20. Chiaviello CT, Christoph RA, Bond GR. Stairway-related injuries in children. Pediatrics. 1994;94(5):679-81.

21. Joffe M, Ludwig S. Stairway injuries in children. Pediatrics.

1988;82(3 Pt 2):457-1.

22. Schloff S, Mullaney PB, Armstrong DC, et al. Retinal findings in children with intracranial hemorrhage. Ophthalmology. 2002;109(8):1472-6.

23. Christian CW, Taylor AA, Hertle RW, Duhaime AC. Retinal hemorrhages caused by accidental household trauma. J Pediatr. 1999;135(1):125-7.

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2003;142(4):431-4.

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Traumatic Brain Injury Among Prisoners Marlena M. Wald, MPH, MLS Sharyl R. Helgeson, RN, BAN, PHN Jean A. Langlois, ScD, MPH Acknowledgments

The authors thank Heather Day and Jon Roesler from the Minnesota Department of Health for their assistance in analyzing the data, and Steven Allen and Ken Carlson of the Minnesota Department of Corrections, John Corrigan, and Pamela Diamond for their contributions to this work.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Background

Approximately 2.2 million people are currently in US prisons and jails (DOJ 2006). Although women account for about 8% of those incarcerated (DOJ 2006), from 1990 to 2000 the number of women in prisons and jails more than doubled (DOJ 2006).

Ensuring the successful community re-integration of prisoners is of concern since approximately 95% of people incarcerated in jail or prison will be released at some point (Commission Report, 2006).

Prevalence and causes of TBI among prisoners

The impact of traumatic brain injury (TBI) in the prison setting has not been well-recognized but is potentially quite great.

Previous studies suggest that a history of TBI is common among inmates, including women, occurring among an estimated 2522 BRAIN INJURY PROFESSIONAL

87% of the jail and prison population (Figure 1).

In contrast, it is estimated that 8.5% of non-incarcerated adults report a history of TBI (Silver et al, 2001). These data suggest that the prevalence of a TBI history may be as high as 10 times that of the general population.

Some more recent findings shed new light on the epidemiology of TBI among prisoners. In a recent survey conducted among male state prisoners in Minnesota, a history of having head injury was assessed using the Traumatic Brain Injury Questionnaire (TBIQ) (Diamond et al., 2007). Of the 998 inmates assessed, 82.8% reported having had one or more head injuries during their lifetime, which is consistent with a previous study (Slaughter et al., 2003). The majority were reportedly caused by assaults, followed by automobile crashes and sports (Figure 2). Of note, some of the specific causes of assault-related TBI among prisoners are unique. For example, in the Minnesota project, some of the reported head injuries among incarcerated gang members were the result of a gang initiation procedure called “pumpkinhead” in which new gang members are beaten until their heads swell “like pumpkins.” Also, anecdotal reports from corrections officials in South Carolina indicate that selfinflicted TBIs occur when inmates purposely knock their heads against the bars or the cell floor until they become unconscious.

This usually happens when inmates are moved to isolated cells (Anbesaw Selassie, DrPH, Medical University of South Carolina, Personal Communication, November 2007).

As an example of how common TBIs are among prisoners, in

a recent study of TBI among federal prison inmates, a high percentage of women reported a history of TBI, especially multiple concussions, often totaling 10 or more, and these were usually associated with interpersonal violence (Pamela Diamond, PhD, University of Texas-Houston, Personal Communication, October 2007). One subject in this study estimated that she had been hit in the head and often knocked unconscious by her boyfriend nearly every weekend during a three year period prior to entering prison. According to the study interviewers, many of the women seemed to describe the experience of multiple concussions in a matter-of-fact way, as though they were an expected part of life.

TBI-related secondary conditions

Although a history of TBI is quite common among the offender population, not all TBIs result in long-term disability. The prevalence of long-term problems resulting from these injuries has not been established. However, traumatic brain injury among prisoners is of particular concern because it often results in cognitive, social, emotional, and behavioral problems, including aggressive behavior (NIH Consensus Conference, 1998), and secondary conditions such as substance abuse that can greatly affect their ability to function both while they are in prison and after they return to the community. (Coid, 2005; Merbitz et al., 1995) Knowledge that these problems are related to TBI as opposed to other etiologies would help inform the implementation of TBIspecific interventions, resulting in more effective management and rehabilitation and ensuring greater potential for successful community reintegration.

Individuals with a history of TBI are significantly more likely to have problems with alcohol or other substance abuse (SA) compared with persons without TBI (Silver et al., 2001). However, the relationship between TBI and substance abuse problems among prisoners has not been well-studied. The limited literature to date suggests that cognitive problems associated with a past history of traumatic brain injury (TBI) may affect inmates’ potential to succeed in rehabilitation (Valliant, et al, 2003; Corrigan, 1995), including SA treatment (SAMHSA, 1998a).

TBI can result in irritability or aggressiveness, including explosive outbursts, which can be set off by minimal provocation or occur without warning (Silver et al, 2005). Among male prisoners, a history of TBI is strongly associated with perpetration of domestic violence (Cohen et al, 1999), and female prisoners who are convicted of a violent crime are more likely to have had a pre-crime TBI and/or some other form of physical abuse (Brewer-Smyth, 2004). In the prison setting, such aggression and other behavioral disturbances can lead to further injury for the prisoner or others (DOJ 2001; Maryland Police, 2001) and affect corrections center management (Schofield et al, 2006; Merbitz et al, 1995). Aggressive or violent behavior is also associated with recidivism (Coid, 2005). Thus, screening for TBI within the prison setting has been recommended to identify inmates with TBI-related behavior problems and help inform improved inmate safety and management (Schofield et al., 2006). Offenders exhibiting TBI-related aggression might also be taught behavioral and cognitive strategies to inhibit aggressive behaviors (Cohen et al., 1999), although to our knowledge this has not been demonstrated in a prison population.

Although few studies have investigated the topic, homelessness has been found to be associated with both imprisonment (Kushel et al., 2005) and with a history of head injury (Bremner

Rates of TBI in Prison Studies

Figure 1 100 80

60

40

78%

83%

83%

88%

87%

86%

20

0

TBI

60 50 40 30 20

58%

43%

43%

36%

10 0

TBI with Loss of Consciousness Ohio

NSW

Minn

TX

Tacoma

NZ

Causes of Traumatic Brain Injury Among Male Prisoners

Figure 2

6%

37%

11% 11%

25%

Assault Other Auto Bicycle Falls Sports

10% Ages > 18 Years, Minnesota, 2006-2007 N=998

et al., 2005), but the role of head injury (or TBI) as a risk factor has not been well described.

Identifying a history of TBI

Screening for traumatic brain injury in prisons has been recommended as a means of informing more effective substance abuse treatment (SAMHSA, 1998b) and inmate management (Schofield et al, 2006; Kaufman, 2005) within corrections facilities.

Anecdotal reports suggest that although some prison intake interviews ask about a history of head injury or TBI, valid and reliable measures for TBI screening have not routinely been used in the prison setting (John Corrigan, PhD, Ohio State University, Personal Communication, July 2006). Results from the recent Minnesota project (see above) suggest that a routine BRAIN INJURY PROFESSIONAL

23

intake question asking if the inmate ever had a head injury was inadequate in identifying head injury. Of the 998 inmates interviewed in that project, only 10 (1 percent) reported a history of head injury during the intake screening, as compared with 826 (83%) who reported having had at least one according to results from the TBIQ, a more detailed screening questionnaire. Similarly, Diamond and colleagues (2007) reported that a one-item, self-administered screener used during admission to prison detected only 19% of the TBIs identified via structured interview. Thus, detailed screening is needed to more accurately identify inmates with a history of TBI. Some important factors must be considered, however, before screening is begun. First, a good working relationship must be established with corrections officials who initially may have little understanding of the potential importance of TBI within their inmate populations. (Kaufman, 2005) However, their concern for the health and safety of both inmates and corrections officers may be a good starting point for initiating discussions about implementing screening for TBI. Dissemination of fact sheets produced by the CDC, including one specifically aimed at educating criminal justice professionals, could be helpful. (See Sidebar). Second, identification of inmates with TBI should lead to some beneficial action, and establishment of a plan to assist screened populations ideally should be established before screening begins. Some of the potential benefits of screening for TBI among prisoners are that it could lead to improved treatment or management that takes into account the cognitive problems that interfere with the potential of inmates with TBI to adhere to rehabilitation programs designed for persons without TBI. Programs that could benefit from knowledge of a history of TBI include substance abuse treatment, training for victims of violence in strategies to decrease risk, and for perpetrators to manage aggressive behavior, and work assignments, all of which should be tailored to account for TBI-related deficits. Strategies to help victims of violence decrease their risk of re-injury could be implemented. In the long-term, successful implementation of such strategies could lead to more successful reintegration of inmates into work or school, decreased risk of homelessness, and decreased risk of recidivism. Although much more research is needed to design and validate more effective rehabilitation programs for inmates with TBI, successful pilot projects could help inform the development of future, more effective interventions.

Once it’s decided that a screening program should be implemented, selection of the appropriate screening instrument is important. Selection of a validated screening tool will help ensure that identification is as accurate as possible and help to avoid mislabeling someone as having had a TBI (false positive), or missing a history of TBI (false negative). Two screening tools have been developed specifically for use with incarcerated populations and validation of these measures is currently in progress.

First, the Traumatic Brain Injury Questionnaire (TBIQ) (Diamond et al, 2007) is an interviewer-administered instrument with three sections: Section I consists of items asking whether the respondent has ever experienced a head injury from 12 situations associated with such injuries (e.g., vehicle crashes, falls, assaults). Section II probes for details of the head injuries reported in Section I. Questions include age at the time of the injury, whether there was any loss of consciousness or post-traumatic amnesia, and what care was received. Section III assesses the 24 BRAIN INJURY PROFESSIONAL

frequency and severity of 15 cognitive and physical symptoms commonly found with head injury (e.g., trouble concentrating or remembering, dizziness or headaches). Of note, inmates are asked about “head injuries” rather than “brain injuries” because the developers of the instrument found that inmates did not understand the term brain injury. The Ohio State University TBI Identification Method (OSU TBI-ID; Corrigan et al, 2007) consists of two steps: Step 1 asks participants to recall any injuries involving a blow to the head or neck or high velocity forces that could have shaken the head violently. Step 2 collects more detailed information about each injury, including whether consciousness was altered, medical attention was received, and if any TBI-related symptoms were experienced after the injury. For both measures, the length of time required to administer them depends on the number of injuries reported.

However, the TBIQ takes an average of 15 minutes and the OSU TBI-ID takes about 5 minutes to administer. The OSU Method is also available in a short-form version.

Though useful for identifying offenders with a history of TBI, screening measures are not designed to determine whether specific deficits in function are present. Thus, additional testing may also be needed to identify the smaller sub-sample of inmates with TBI-related deficits who are in greatest need of attention or intervention. For this reason, the Minnesota project is conducting additional testing of inmates who screened positive for a history of TBI using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The RBANS is a brief screen for assessment of cognitive deficits that has been shown to be useful in evaluating cognitive problems associated with TBI (McKay et al, 2007). With further validation, it is hoped that the OSU method will also provide information that can be used to identify particular characteristics of a history of TBI (severity, age at injury, etc.) that will help identify the inmates who are most in need of intervention. Administration of more detailed neuropsychological batteries may also be needed and helpful if resources are available.

Example of a successful TBI identification pilot project: The Minnesota experience

The Minnesota TBI Interagency Leadership Council (ILC), a public private partnership of agencies, identified behavioral health and criminal justice as areas for development of state capacity with respect to TBI. Various members, especially the Brain Injury Association of Minnesota (BIA-MN), had been contacted by corrections staff seeking service resource information to assist with planning for individuals with TBI. BIA-MN contacted the Minnesota Department of Corrections (DOC) to pursue DOC’s potential interest in TBI training and technical assistance. DOC was receptive and training was conducted for DOC staff and, importantly, the agency joined the TBI-ILC. The TBI-ILC then pursued grant funding for a TBI project in collaboration with the DOC. As a result of these efforts, in 2006 Minnesota was awarded a State TBI Implementation Partnership Grant which is being conducted as an interagency effort entirely through the Minnesota DOC. The three year project, titled “TBI in MN Correctional Facilities: Strategies for Successful Return to Community,” is administered by the federal Department of Health & Human Services, Maternal & Child Health Bureau, Health Resources & Services Administration (HRSA). The primary DOC goals

TBI among Prisoners For more information about traumatic brain injury in prisoners, see the National Center for Injury Prevention and Control (CDC) website: Traumatic Brain Injury: A Guide for Criminal Justice Professionals This guide provides an overview of TBI, information on the extent of TBI and related problems within the criminal justice system, and how these problem can be addressed http://www.cdc.gov/ncipc/tbi/FactSheets/Prisoner_Crim_Justice_Prof.pdf Traumatic Brain Injury in Prisons and Jails: An Unrecognized Problem This guide provides information for TBI professionals regarding what is known about individuals with TBI in prisons and jails, how TBI-related problems affect them and others while they are incarcerated, and what is needed to address these problems. http://www.cdc.gov/ncipc/tbi/FactSheets/Prisoner_TBI_Prof.pdf

for this grant include enhancing facility and community safety through identification and effective interventions for offenders with TBI. The project is currently in the second of three phases. A focus of the initial phase of the project was screening offenders for TBI utilizing the TBIQ. Approximately 1000 adult males, one hundred adult females and fifty juvenile males were screened. (Initial results of those screenings for males are reported in Figure 2). The current phase of the project involves identification of a range of “best practices” interventions that can be used with this population along the continuum of corrections systems and services (i.e., offender management, education, treatment). General information on TBI along with intervention strategies is being broadly disseminated within the DOC through education and training. Development of TBI release planning processes has also begun. In the final phase of the grant, implementation of the TBI identification and intervention strategies will continue along with efforts towards long-term project sustainability.

Conclusion:

TBI among incarcerated populations is an important public health problem. Increased collaboration between traumatic brain injury and criminal justice professionals has the potential to inform more effective management of offenders and increase their potential for successful reintegration into the community.

Further research is needed to refine screening methods and develop effective interventions.

About the Authors

Ms. Wald is an epidemiologist with graduate degrees from the Rollins School of Public Health at Emory University and the University of Maryland at College Park. Prior to moving to the Centers for Disease Control and Prevention, she was the Research Program Director for the Department of Emergency Medicine at Emory University School of Medicine where she managed prospective clinical trials and public health studies, including several TBI projects, in three emergency departments including Atlanta’s Level I Trauma Center, Grady Memorial Hospital.

Ms. Helgeson is the Project Director for the Minnesota State TBI Implementation Partnership Grant. Helgeson is a Mental Health Program Consultant for the Minnesota Department of Human Services (DHS), the

lead state agency for State TBI Grants. She has worked with disability services and policy for DHS for almost 30 years and with brain injury services for over 20 years.

Dr. Langlois is the Guest Editor for this issue of the Brain Injury Professional. She is a Senior Epidemiologist with the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention in Atlanta, GA.

References (Items with an asterisk ‘*” indicate data sources for Figure 1) *Barnfield TV, Leathem JM. Neuropsychological outcomes of traumatic brain injury and substance abuse in a New Zealand prison population. Brain Injury 1998;12(11):951-62.

Bremner AJ, Duke PJ, Nelson HE, Pantelis C, Barnes TRE. Cognitive function and duration of rooflessness in entrants to a hostel for homeless men. British Journal of Psychiatry 1996;169(4):434439.

Brewer Smyth K, Burgess AW, Shults J. Physical and sexual abuse, salivary cortical, and neurologic correlates of violent criminal behavior in female prison inmates. Biological Psychiatry. 2004;55:2131.

Cohen RA, Rosenbaum A, Kane RL, et al. Neuropsychological correlates of domestic violence.

Violence and Victims. 1999;14,397-411.

Coid J. Correctional populations: criminal careers and recidivism. Oldham JM, Skodol AE, Bender DS, Eds. Textbook of Personality Disorders. Washington, DC: American Psychiatric Publishing; 2005: 579-606.

Commission on Safety and Abuse in America’s Prisons. Gibbons JJ , Katzenbach NB, co-chairs.

Confronting confinement [online]. 2006 [cited 2006 June 8]. Available from: URL: http://www. prisoncommission.org Corrigan, JD. Substance abuse as a mediating factor in outcome from traumatic brain injury.

Archives of Physical Medicine and Rehabilitation 1995;76:302-309. *Corrigan JD. Unpublished data. 2007. *Diamond PM, Harzke AJ, Magaletta PR, Cummins AG, Frankowski R. Screening for traumatic brain injury in an offender sample: a first look at the reliability and validity of the Traumatic Brain Injury Questionnaire. Journal of Head Trauma Rehabilitation. 2007;22(6):330-38.

Kaufman CW. Handbook for Correction Officers and Other Institutional Staff to Identify and Manage Inmates With Traumatic Brain Injuries. Ann Arbor, MI: Dissertation Abstracts; 2005.

Kushel MB, Hahn JA, Evans JL, Bangsberg DR, Moss AR. Revolving doors: imprisonment among the homeless and marginally housed population. American Journal of Public Health 2005;95(10):1747-52.

Maryland Police and Correctional Training Commissions. Police interaction with individuals with brain injury: Student workbook [online]. 2001 [cited 2006 February 21]. Available from: URL: http://www.tbitac.nashia.org/tbics/download/mdpolice.pdf McKay C, Casey JE, Wertheimer J, Fichtenberg NL. Reliability and validity of the RBANS in a traumatic brain injured sample. Archives of Clinical Neuropsychology. 2007;22:91-98.

Merbitz C, Jain S, Good GL, Jain A. Reported head injury and disciplinary rule infractions in prison. Journal of Offender Rehabilitiation. 1995;22:11-19. *Schofield, PS, Butler TG, Hollis SJ, Smith NE, Lee SJ, Kelso WM. Traumatic brain injury among Australian prisoners: rates, recurrence, and sequelae. Brain Injury 2006; 20:499-506.

Silver J, Kramer R, Greenwald S, Weissman M. The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiologic Catchment Area Study.

Brain Injury. 2001;11:935-945.

Silver JM, Yudofsky SC, Anderson KE. Aggressive disorders. Silver JM, McAllister TW,Yudofsky SC, Editors. Textbook of Traumatic Brain Injury. 2nd ed. Washington, D.C.: American Psychiatric Publishing, Inc.; 2005:259-277. *Slaughter B, Fann JR, Ehde D. Traumatic brain injury in a county jail population: prevalence, neuropsychological functioning and psychiatric disorders. Brain Injury. 2003;17:731-41.

U.S. Department of Health and Human Services . National Institutes of Health. NIH consensus statement: rehabilitation of persons with traumatic brain injury (October 26-28, 1998). Ragnarsson KT, editor. Washington (DC): Government Printing Office; 1999.

U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration (SAMHSA). Substance Use Disorder Treatment For People With Physical and Cognitive Disabilities: Treatment Improvement Protocol (TIP) Series 29; DHHS Publication No. (SMA) 98-3249; Rockville, MD; U.S. Department of Health and Human Services, 1998a. [cited 2006 July 6]. Available from: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.52487 U.S. Dept. of Health and Human Services. Substance Abuse and Mental Health Services Administration. (SAMHSA). Put Prevention into Practice. Treatment Improvement Protocol (TIP) Series 44; DHHS Publication No. (SMA) 98-3249; Rockville, MD; U.S. Department of Health and Human Services, 1998b [cited 2006 August 3]. Available from: http://www.ncbi.nlm.nih.gov/ books/bv.fcgi?rid=hstat5.chapter.80044 U.S. Dept. of Justice. Office of Justice Programs. Bureau of Justice Statistics. Medical Problems of Inmates, 1997. Maruschak LM, Beck AJ (Eds.) Bureau of Justice Statistics Special Report. No (NCJ) 181644. Washington, D.C.; U.S. Department of Justice, 2001 [cited 2006 August 3]. Available from: http://www.ojp.usdoj.gov/bjs/pub/pdf/mpi97.pdf U.S. Dept. of Justice. Office of Justice Programs. Bureau of Justice Statistics. Prison and Jail Inmates at Midyear 2005. Harrison PM, Beck AJ (Eds.) Bureau of Justice Statistics Special Report.

No. (NCJ) 213133. Washington, D.C.; U.S. Department of Justice, 2006 [cited 2006 August 3].

Available from: http://www.ojp.usdoj.gov/bjs/pub/pdf/pjim05.pdf Valliant PM, Freeston A, Pottier D, Kosmyna r. Personality and executive functioning as risk factors in recidivist. Psychological Reports. 2003;92:299-306.

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Application of a Novel Theoretical Model to Suicide Risk Assessment after Traumatic Brain Injury Lisa Brenner, PhD, ABPP

Dr. Brenner would like to thank Drs. Cornette, Gutierrez, Joiner and Saliman for their helpful feedback regarding this article.

Case Illustration

Mr. Keith Smith is a 25 year old veteran who served in Iraq. Prior to deployment, he married his girlfriend of 18 months. She had their first child while he was overseas. He was a machine gunner and maintained security for his convoy. Mr. Smith was a valued and respected member of his battalion. He sustained a traumatic brain injury (TBI) secondary to a roadside bomb. The blast blew him off the vehicle and shrapnel lodged in both frontal lobes. He received acute and rehabilitative care for the TBI and emerging post-traumatic symptoms. While in the hospital, he was medically discharged from the military. Despite problems with impulsivity, aggression, and limited insight, this veteran returned home with the goals of working, and caring for his son. A flaring temper, decreased sleep secondary to nightmares, and flashbacks impeded goal attainment. As Mr. Smith was unable to secure employment, the couple began having financial trouble. He often thought about the members of his convoy who were still in Iraq. Mr. Smith began feeling hopeless and suicidal. On several occasions, he loaded his gun and pondered killing himself.

Suicide is a leading cause of mortality in the United States, with 32,429 associated deaths recorded in 2004 (McIntosh, 2006). Many more individuals engage in non-lethal suicide-related behaviors, which include thinking about ending one’s own life (ideation) and/or attempting to do so (McIntosh, 2006). The above case illustration highlights challenges faced by military personnel who sustain TBIs. Because there is an increased risk of suicide post-TBI (Teasdale and Engberg, 2001), professionals working with these individuals need tools for comprehensive suicide assessment. In this article, research regarding self-harm behaviors in individuals with TBI and risk factors are presented.

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Additionally, assessment strategies, including those based upon the interpersonal-psychological theory of attempted and completed suicide (Joiner, 2005), are discussed.

TBI and Suicide

Depending on the type of injury sustained (i.e., concussion, cranial fracture, or cerebral contusion or traumatic intracranial hemorrhage), rates of suicide have been found to be 3.0, 2.7, and 4.1 times higher than for the population as a whole (Teasdale and Engberg, 2001). Individuals with a history of TBI also have a higher rate of suicide attempts than those without TBI (Silver et al., 2001). Finally, in a study of those receiving outpatient TBI services, 23% had significant suicidal ideation (Simpson and Tate, 2002). The etiology of increased suicidal behavior is not well understood; however, research suggests that the risk continues for years after the TBI (Teasdale and Engberg, 2001).

Suicide Risk Factors

Hendin et al. (2001) define suicide risk as the presence of any factor empirically correlated with self-harm behavior (e.g., age, sex, psychiatric history). Work conducted to identify such factors is presented in Maris et al., (2000). Unfortunately, variables that are statistically linked with self-harm do not necessarily predict individual behavior.

Limited research has been conducted to identify suicide risk factors for individuals with TBI. This process is complicated by the fact that TBI and suicide share antecedent risk factors (e.g., psychiatric symptoms, aggression, and substance abuse (SA); Fann et al., 2002; Maris et al., 2000; Miller and Adams, 2005; Oquendo et al., 2004; Teasdale and Engberg, 2001). Teasdale and Engberg (2001) found that for those with a history of TBI, SA was associated with increased risk of death by suicide. Research by Simpson and Tate (2005) suggested that subjects with a co-morbid post-injury history of psychiatric/emotional disturbance and SA were 21 times more likely to have attempted sui-

Suicide and TBI Websites National Center for Injury Prevention and Control (CDC) Suicide Prevention Website http://www.cdc.gov/ncipc/dvp/Suicide/ This site includes a wide range of general and scientific information about suicide and suicide prevention.

The National Suicide Prevention Lifeline Website http://www.suicidepreventionlifeline.org This site includes information about the hotline (see below) and other resources.

The American Foundation for Suicide Prevention (AFSP) http://www.afsp.org The American Foundation for Suicide Prevention (AFSP) is the only national not-for-profit organization exclusively dedicated to understanding and preventing suicide through research and education, and to reaching out to people with mood disorders and those affected by suicide.

American Association of Suicidology (AAS) http://www.suicidology.org AAS promotes research, public awareness programs, public education, and training for professionals and volunteers. In addition, AAS serves as a national clearinghouse for information on suicide.

The Melissa Institute for Violence Prevention and Treatment http://www.melissainstitute.org The Melissa Institute is a non-profit organization dedicated to the study and prevention of violence through education, community service, research support and consultation. Our mission is to prevent violence and promote safer communities through education and application of research-based knowledge.

Hotlines The National Suicide Prevention Lifeline This is a 24-hour, toll-free suicide prevention service available to anyone in suicidal crisis. If you need help, please dial 1-800-273-TALK (8255).

The Veterans Affairs Suicide Hotline To ensure veterans with emotional crises have round-the-clock access to trained professionals, the Department of Veterans affairs (VA) has begun operation of a national suicide prevention hotline. Veterans can call 1-800-273-TALK (8255) and press “1” to reach the VA hotline.

cide than those with TBI who did not report such histories. In light of known TBI sequelae, several general suicide risk factors may be of specific import. These include aggression, depression, impulsivity, and job and family problems (Hibbard et al., 1998; Kim 2002; Maris et al., 2000; Oquendo et al, 2004; Shames et al., 2005; Uysal et al., 1998). For example, Oquendo et al.

(2004) found that those with mild TBI had larger increases in adult aggression scores as compared with childhood aggression scores than those without a history of mild TBI. The authors suggest a history of TBI may contribute to aggression and subsequent increased risk of suicidal behavior.

A Theory of Suicide

Substantial numbers of individuals with a history of TBI possess risk factors, and yet do not engage in suicidal behavior. As a result, a model which incorporates known risk factors and provides clinicians with guidance regarding assessment of chronic and/or immediate risk of suicidal behavior is indicated. Joiner (2005) proposes a theory of suicide, the interpersonal-psychological theory of attempted and completed suicide, in which three com-

ponents, in conjunction with the desire to die, must exist for an individual to engage in suicidal behavior: 1) the acquired ability to engage in an act of lethal self-harm, 2) the sense that one is a burden to social supports, and 3) the feeling that one does not belong to a valued social group or relationship (Joiner, 2005).

Joiner (2005) suggests that individuals may acquire a decreased sense of fear regarding self-injury by engaging in or having exposure to painful or dangerous activities or events. As one becomes habituated to self-harm, violence, pain, and/or injury, suicide becomes increasingly possible (Joiner, 2005). In Why People Die

by Suicide (2005) Joiner discusses the 2003 suicide of the actor Spaulding Gray. Gray had attempted suicide multiple times after a 2001 motor vehicle accident in which he “sustained a severely broken hip as well as head injuries” (p. 58). Joiner (2005) hypothesized that the experience of having been injured, in conjunction with previous suicidal behavior, may have impacted Gray’s ability to engage in a lethal act of self-harm.

The experience of being injured and coping with sequelae (e.g., headaches) may facilitate habituation to painful experiences in those with TBI. Moreover, the psychosocial impact of TBI could contribute to suicidal risk by simultaneously increasing one’s sense of burdensomeness and failed belongingness. For members of the general population, burdensomeness and failed belongingness are conceptualized as arising from distorted cognitions regarding one’s significance to and integration with a social system (Stellrecht et al., 2006). Although individuals who have enduring neuropsychological impairment from a TBI may be at increased risk for such distortions, post-injury some also experience actual losses in relationship to self and others (Myles, 2004; Uysal et al, 1998).

The number of military personnel returning from current conflicts with symptoms related to brain injury (Warden, 2006) highlights the importance of developing a means of assessing suicide risk in those with TBI. Risk for these individuals may be further compounded by combat exposure and/or co-occurring PTSD (post traumatic stress disorder). There are existing literatures regarding relationships between military service and/or PTSD and suicide. These topics are outside the purview of this paper, and are discussed in the following publications: Veteran Military – Allen et al., 2005, and Zivin et al., 2007; and PTSD – Oquendo et al., 2005, and Sareen et al., 2007.

Assessment of Suicidal Behavior:

Currently, there are no evidence-based methods of suicide assessment for individuals with TBI (Simpson and Tate, 2007).

As a result, Simpson and Tate (2007) suggest 1) utilization of approaches based upon knowledge regarding suicide prevention, 2) adherence to current best practice for treating psychiatric TBI sequelae, and 3) conceptualization of cases with the inclusion of findings on suicidality after TBI. As such, clinicians assessing individuals with TBI should attend to whether endorsed psychiatric symptoms are sufficiently managed, and to the presence of suicide risk factors (e.g., SA, psychiatric distress, aggression).

However, this practice alone may not be sufficient.

According to Joiner’s theory (2005), evaluation of acquired capability for lethal self-harm, burdensomeness, and belongingness is also warranted. Such an assessment would include a history of self-inflicted (e.g. past/present suicidal behavior) and/or accidental or other-inflicted (e.g., accident or assault) pain. Also important is evaluation of increased comfort with planning and/ or carrying-out self-harm behaviors (e.g., availability of means to make an attempt, a specific attempt plan, history of preparaBRAIN INJURY PROFESSIONAL

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tions towards making an attempt) (Joiner 2005). Finally, Joiner (2005) suggests that suicide risk may be the highest if burdensomeness and failed belongingness are themes underlying one’s desire to die. Such themes may be especially poignant for persons with TBI. Ongoing assessment of losses associated with a TBI is indicated. Questions about finances, relationships, loss of status or purpose and/or one’s ability to direct self-care may highlight areas of concern.

Research suggests that suicide risk persists for years after TBI (Teasdale and Engberg, 2001). The need for an evidence-based assessment method to be developed is clear. The addition of questions regarding acquired ability, burdensomeness, and failed belongingness when evaluating risk in those with TBI may facilitate accurate assessment.

About the Author

Lisa A. Brenner, Ph.D., ABPP, is a Rehabilitation Psychologist at the Veterans Affairs VISN 19 Mental Illness, Research, Education, and Clinical Center. She is also affiliated with the Departments of Psychiatry and Physical Medicine and Rehabilitation at the University of Colorado Denver, School of Medicine, and is a member of the research team at Craig Hospital.

References

Allen JP. Cross G. Swanner J, Suicide in the Army: a review of current information. Military Medicine. 170(7): 580-584, 2005.

Fann JR. Leonetti A. Jaffe K, et al., Psychiatric illness and subsequent traumatic brain injury: A case control study. Journal of Neurology, Neurosurgery, & Psychiatry. 72: 615-620, 2002.

Hendin H. Maltsberger JT. Lipschitz A, et al. Recognizing and responding to a suicidal crisis.

Suicide and Life Threatening Behavior. 31: 115-128, 2001.

Hibbard MR. Uysal S. Kepler K, et al., Axis I psychopathology in individuals with traumatic brain injury. Journal of Head Trauma Rehabilitation. 13(4): 24-39, 1998.

Joiner T: Why People Die by Suicide. Massachusetts: Harvard University Press, 2005.

Kim E, Agitation, aggression, and disinhibition syndromes after traumatic brain injury. NeuroRehabilitation. 17(4): 297-310, 2002.

Maris RW. Berman AL. Silverman MM: Comprehensive Textbook of Suicidology. New York: The Guilford Press, 2000.

McIntosh, J. (2006). USA suicide: 2004 Official final data. Fact sheet developed by the American Association of Suicidology from National Center Health Statistics. www.suicidology.org Miller NS. Adams BS: Alcohol and drug disorders. In Textbook of Traumatic Brain Injury. JM Silver, TW McAllister, SC Yudofsky (Eds.) American Psychiatric Publishing, Inc., Washington, DC. Pages 509-532, 2005.

Myles SM. Understanding and treating loss of sense of self following brain injury: a behavior analytic approach. International Journal of Psychology and Psychological Theory. 4(3): 487-504, 2004.

Oquendo MA. Friedman JH, Grunebaum MF, et al., Suicidal behavior and mild traumatic brain injury in major depression. The Journal of Nervous and Mental Disease. 192(6): 430-434, 2004.

Oquendo M. Brent DA. Birmaher B, et al., Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior. American Journal of Psychiatry.

162(3): 560-566, 2005.

Sareen J. Cox BJ. Stein MB, et al., Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic Medicine. 69(3): 242-248, 2007.

Shames J. Treger I. Ring H, et al., Return to work following traumatic brain injury: trends and challenges. Disability and Rehabilitation. 29(17): 1387-1395, 2007.

Silver JM. Kramer R. Greenwald S, et al., The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiological Catchment Area Study. Brain Injury. 15(11): 935-945, 2001.

Simpson G. Tate R, Suicidality after traumatic brain injury: demographic, injury, and clinical correlates. Psychological Medicine. 32: 687-697, 2002.

Simpson G. Tate R, Clinical features of suicide attempts after traumatic brain injury. Journal of Nervous & Mental Disease. 193(10): 680-685, 2005.

Simpson GK. Tate RL, Preventing suicide after traumatic brain injury: implications for general practice. The Medical Journal of Australia. 187(4): 229-232, 2007.

Strellrecht NE. Gordon KH. Van Orden K, et al., Clinical applications of the interpersonal-psychological theory of attempted and completed suicide. Journal of Clinical Psychology: In Session.

62(2): 211-222, 2006.

Teasdale TW. Engberg AW, Suicide after traumatic brain injury: a population study. Journal of Neurology, Neurosurgery & Psychiatry. 71(4): 436-440, 2001.

Uysal S. Hibbard MR. Robillard D, et al., The effect of parental traumatic brain injury on parenting and child behavior. Journal of Head Trauma Rehabilitation. 13(6): 57-71, 1998.

Warden D. Military TBI during the Iraq and Afghanistan wars. Journal of Head Trauma Rehabilitation. 21(5): 398-402, 2006.

Zivin K. Kim HM. McCarthy JF, et al., Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics. American Journal of Public Health. 97(12): 1-12, 2007. Advance online publication.

Retrieved October 30, 2007. doi:10.2105/AJPH.2007.115477.

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conferences 2008 APRIL 9-12 – The International Brain Injury Association’s 7th World Congress on Brain Injury, Pestana Palace Hotel, Lisbon, Portugal. Contact: chaynes@internationalbrain.org, www.internationalbrain.org.

JUNE 4-7 – European Congress on Physical Medicine & Rehabilitation, Brugge, Belgium. Contact: www.medicongress.com.

5-6 – Rehabilitation of the Adult and Child with Brain Injury: Practical Solutions to Real World Problems. Williamsburg Hospitality House Hotel and Conference Center, Williamsburg, VA. For Information on registration go to www. braininjurysvcs.org or contact Linda Nowsherwan at 703-451-8881.

6-8 – The 2008 National Brain Injury Caregiver’s Conference, Brain Injury Association of America, Westin Dallas Fort Worth Airport Hotel, Dallas, Texas.

Contact: Jenny Toth, jtoth@biausa.org or (703) 761-0750 x621 for more information.

7 - The National TBI Caregiver’s Conference, Virginia Commonwealth University Medical Center, Memorial Hermann/TIRR, TX, University of Alabama at Birmingham, Brain Injury Services and Brain Injury Association of Virginia.

Contact: www.braininjurysvcs.org or call Linda Nowsherwan at (703) 4518881.

10 – National Brain Injury Employment Conference, Denver, Colorado, tracks include professional, survivor and VA/military. Contact: www.ctat-training.com or nfreeman@denveroptions.org.

11-12 – Region VIII Employment Conference, Denver, CO Contact: www.ctat-training.com 17-20 – CMSA’s 17th Annual Conference and Expo, Orlando, FL. Contact: www.cmsa.org.

AUGUST 14-17 – the 116th APA Annual Convention, San Francisco, CA. Contact: www. apa.org.

SEPTEMBER 18-21 – 7th Mediterranean Congress of Physical Medicine & Rehabilitation Medicine, Potorose, Slovenia. Contact: marincek.crt@mail.ir-rs.si.

24-27 – 5th World Congress for NeuroRehabilitation, Rio de Janeiro, Brazil.

Contact: traceymole@wfnr.co.uk. Rio de Janeiro, Brazil. Contact: traceymole@wfnr.co.uk.

OCTOBER 2-4 – The North American Brain Injury Society’s Sixth Annual Brain Injury Conference, New Orleans Convention Center Marriott, New Orleans, Louisiana.

Contact: conference@nabis.org, or call (703) 960-6500.

2-4 – The 21st Annual Conference on Legal Issues in Brain Injury, New Orleans Convention Center Marriott, New Orleans, Louisiana. Contact: conference@nabis.org, or call (703) 960-6500.

22-25 - National Association of Neuropsychology Annual Meeting, New York, NY. Contact: www.nanonline.org.

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legislative round-up Susan L. Vaughn, Editor, Legislative Issues “You may never know what results come of your action, but if you do nothing there will be no result.” Mahatma Gandhi Brain Injury has certainly been in the national spotlight in recent months, largely due to the number of returning servicemembers with brain injury and related conditions. Congress has passed numerous bills to address the needs of returning troops with traumatic brain injury which has, in turn, spurred both the Department of Defense (DoD) and Department of Veterans Affairs (DVA) to engage in a number of activities to better screen, treat and coordinate resources.

In January 2008, President Bush signed the National Defense Authorization Act for Fiscal Year (FY) 2008 that along with other Defense Appropriations would provide some $600 million for a new Center of Excellence for Psychological Health and Traumatic Brain Injury. The current Defense and Veterans Brain Injury Center (DVBIC) is to be fully integrated into the new Center.

In addition, nearly 20 states have initiated activities to assist returning troops, including Governor appointed task forces, funding and legislation to screen returning National Guard and reservists for brain injury and referral to resources.

Although support has increased for the military, the civilian systems providing services to individuals with brain injury have not fared as well. On February 4, 2008, President Bush released his recommendations for federal spending for FY 2009 calling for the elimination of 151 health, education and human service related programs and cuts in entitlement programs. Many of these programs provide critical assistance to individuals with disabilities or who are elderly, including individuals with brain injury.

Included on the chopping block is the Federal TBI Program administered by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services -- the fourth consecutive year that the President has recommended the program be eliminated. Other programs proposed for elimination include Emergency Medical Services for Children (EMSC) and the Supported Employment State Grants program, which many states believe to be a successful employment model for individuals with brain injury.

Programs that were also proposed to be cut include Centers for Disease Control and Prevention (CDC), Section 8 Housing Voucher Program, Assistive Technology, Medicare and Medicaid, the primary funder of long-term care for individuals with disabilities. The President proposed to reduce Medicaid by $2 billion for FY 2009, and by $18.2 billion over five years from regulatory changes. These regulatory changes include rehabilitation optional 30 BRAIN INJURY PROFESSIONAL

services, case management and school-related health services for children with disabilities receiving special education services. Obviously, these proposed cuts would be passed on to states and local school districts to absorb.

On a brighter note, the TBI Act Reauthorization bill, S. 793, sponsored by Senators Orrin Hatch (R-UT) and Edward Kennedy (D-MA) passed the Senate in December, 2007, and has been tentatively scheduled for a hearing March 6 by the House Energy and Commerce’s Subcommittee on Health, chaired by Rep. Frank Pallone (D-NJ). The bill reauthorizes funding for the HRSA TBI Grant Program and CDC injury programs through 2011. S. 793 includes a new section relating to the incidence and prevalence of traumatic brain injury in the military. A similar bill, H.R. 1418, has been introduced by Reps. Bill Pascrell, Jr. (D-NJ) and Todd Platts (R-PA), who also co-chair the Congressional Brain Injury Task Force.

On March 12th, the Congressional Brain Injury Task Force hosted its “2008 Brain Injury Awareness Month Fair” on Capitol Hill. Events were held throughout the day, including educational exhibits in the foyer of the Rayburn House Office Building; a congressional briefing on community support needs, followed by a Congressional reception co-sponsored by the National Brain Injury Research Treatment and Training Foundation (NBIRTT), the Brain Injury Association of America (BIAA), the International Brain Injury Association (IBIA), the National Disability Rights Network (NDRN), North American Brain Injury Society (NABIS) and the National Association of State Head Injury Administrators (NASHIA).

This is a particularly challenging time for those of us interested in brain injury advocacy with regard to federal and state budgets. What can you do?

• Stay informed on state and national issues. A number of organizations and coalitions provide this information routinely.

• Take time to learn who your state and congressional delegation are and what committees they serve on. (This year is an election year for most state and national elected officials. Get to know them, even before they take office.)

• Take time to provide information on brain injury issues and how it affects your community to policy makers. As professionals, it is helpful to not only provide information on dire needs, but successful outcomes to reassure legislators that funding is well used.

• Participate in organized advocacy day(s), whether organized by your state Brain Injury Associate affiliate or other disability or health-related coalitions.

• Invite policymakers to visit your program or organize events with other organizations with similar interests to invite legislators to attend.

• Thank and recognize them for their help.

About the Editor

Susan L. Vaughn of S.L. Vaughn & Associates, consults with states on service delivery and serves as the Director of Public Policy for the National Association of State Head Injury Administrators. Ms. Vaughn retired from the State of Missouri after nearly 30 years, where she served as the first director of the Missouri Head Injury Advisory Council. She founded NASHIA in 1990, and served as its first president.

BRAIN INJURY PROFESSIONAL

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non-profit news Brain Injury Association of America In March, BIAA brought together 20 of the nation’s leading providers for a strategic planning meeting to improve access to comprehensive rehabilitation. On June 6-8, BIAA will host the National Brain Injury Caregivers Conference at the Westin Dallas Fort Worth Airport Hotel; Lee Woodruff is the keynote speaker. Plans are underway for the 4th Annual Brain Injury Business Practices College in Las Vegas in November. More information on these events is available from www.biausa.org.

Brain Trauma Foundation The Brain Trauma Foundation was recently awarded a grant from the Achelis Foundation to address the urgent and growing healthcare questions being asked by veterans returning from Afghanistan and Iraq suffering from traumatic brain injury. At the donor’s request, special emphasis is being placed on reaching those residing in New York BTF is beginning the project by vetting all existing websites providing information to service members and veterans regarding TBI, then creating a comprehensive directory of websites, other resources, answers to frequently asked questions and easy to understand summaries of the latest evidence-based research. We have brought together an advisory panel of experts to assist us in compiling and evaluating currently available resources and in forming collaborations with other organizations to disseminate the information. Please contact us if you wish to participate. Meanwhile, the authors of the second edition of Early Indicators of Prognosis in Severe TBI will complete their work in June and BTF is beginning the second edition of the pediatric TBI guidelines under the medical direction of Patrick M. Kochanek, MD.

International Brain Injury Association IBIA is putting the finishing touches on the Seventh World Congress on Brain Injury and we anticipate a tremendously successful event. Abstract submissions exceeded 400 and there was an excellent range of high-quality research submitted on topics ranging from animal research to post-acute rehabilitation and long-term living. All told, there will be over 200 speakers and 165 posters presented during the entire 5-day event. The first day of the Congress will run concurrently with the annual meeting of the Portuguese Society of PMR. With close to 700 registrants, the large majority of whom are coming specifically for the World Congress, this event will be one of the largest in IBIA’s history. Aside from the wonderful scientific program with world renowned experts in the field of brain injury, we are also introducing a number of new events including candlelight sessions with experts, and several new awards, including the Henry Stonnington Award for best review article in Brain Injury, IBIA’s officially endorsed organizational re-

32 BRAIN INJURY PROFESSIONAL

search journal, the Jennett & Plum award for clinical achievement in the field of brain injury medicine, and the IBIA Safe Car Award.

The IBIA leadership and executive staff are already working on the plans for the 2010 World Congress, as well as a number of significant new initiatives focusing on membership growth, electronic communications, and educational outreach to developing areas. Please visit our website often for updated information, www. internationalbrain.org.

National Association of State Head Injury Administrators The President’s proposed FY 09 budget once again has eliminated funding for the Health Resources and Services Administration (HRSA) Federal TBI Program. The National Association of State Head Injury Administrators (NASHIA) is asking for an increase in funding to $21 million for the HRSA Federal TBI Program to provide funding for States ($15 million) and Protection & Advocacy Systems ($6 million); and $9 million for the Centers for Disease Control and Prevention TBI Program. Your assistance is needed to convince Congress of the importance of these Programs. Be sure to check out the NASHIA website (www.nashia.org) to obtain the latest information on Congressional activities and state systems development to meet the needs of individuals with brain injury and their families.

North American Brain Injury Society NABIS is pleased to announce the details of two upcoming conferences to be held concurrently on October 2-4, 2008 at the New Orleans Marriott Convention Center, in New Orleans, Louisiana.

Building on the success of last year’s event that enjoyed attendance of 500 brain injury professionals, the Sixth Annual Conference Brain Injury will feature four distinct tracks of programming: Medical/ Clinical, Life-long Living, Research/Science and Legal Issues. Scientific abstracts are currently being accepted through our website with a submission deadline of June 1, 2008. The 21st Annual Conference on Legal Issues in Brain Injury will run concurrently with the medical conference and will offer over 20 CLE credits including one hour of ethics. More information on both events can be found on the NABIS website, www.nabis.org. Concerned by a lack of treatment and service options for brain injury survivors, more than one hundred of the most respected military and civilian leaders in brain injury treatment convened recently to address the crisis of brain injury in America. The resulting report, “Barriers and Recommendations: Addressing the Challenge of Americans with Brain Injury,” takes a hard-hitting look at available medical care while demanding major reforms within the military and civilian sectors and exposing the grim realities facing Americans with brain injury. To view the report, visit www.nabis.org.

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