Traumatic brain injury: effects on employment and social life

Psychology & Nbsp;(general)

Taumatic brain injury indiviiuals regarding employment and their social life

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Individuals with traumatic brain injury (TBI) often struggle with basic tasks and social skills, primarily due to the impact the injury may have on particular neurological functions. Depending on the severity of the injury and the parts of the brain that are impacted, individuals with TBI may experience issues that impact their new identity, self-esteem, their ability to maintain focus in the workplace, and appropriate resources in regards to the knowledge of the professionals who deal with TBI individuals. The main question that will be focused on in this capstone project is: What factors impact the growth of traumatic brain injury individuals to be successful at work which leads to a social life? In addition, this capstone project will be describing and analyzing the factors that impact the success of TBI individuals by their new identity, self-esteem, returning back to work, appropriate resources needed; all are intertwined together by these factors.

APA ONLY USE PEER REVIEW JOURNALS

FOR CAPSTONE REQUIRE to HAVE

PROBLEM STATEMENT

LITERATURE REVIEW (INTERGRATE SYNTHESIS of 4 PEER REVIEW JOURNALS)

A CRITICAL ANALYSIS NARRATIVE

PROPOSED RESOLUTION (the USE of JOB COACHES and MENTORING)- IS it REALISTIC? WHAT ARE the CONSEQUENCES of the RESOLUTION and WHO WILL BE IMPACTED? WHAT WOULD BE the CHALLENGES and BARRIERS to IMPLEMENT THIS?

CONCLUSION -- a NARRATIVE on FINAL THOUGHTS ABOUT the PROBLEM and GENERATED SOLUTION

Introduction and Problem Statement

Most people have in the past few years become more aware of the sometimes terrible consequences of traumatic brain injury because so many members of the American armed forces in Afghanistan and Iraq have received such injuries. Like others with traumatic brain injury (TBI), these soldiers often struggle with basic tasks and social skills, primarily due to the impact the injury may have on particular neurological functions. Injuries to the brain can disrupt not only basic physiological functions but also a person's most basic sense of self.

Depending on the severity of the injury and the parts of the brain that are impacted, individuals with TBI may experience issues that impact their new identity, self-esteem, and their ability to maintain focus in the workplace. And despite the fact that there is an increasing amount of information is being discovered about TBI, a number of individuals with such injuries still find it difficult to gain access to the resources that they need to heal most fully:

They may well find themselves working with medical and mental health professionals who are not sufficiently knowledgeable about this condition. This paper examines the ways in which individuals living with TBI can best meet their needs and what factors are most important to them in terms of acquiring the skills they need for both work and their social lives.

The National Institute of Health defines traumatic brain injury in the following way:

TBI, a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. The damage can be focal - confined to one area of the brain - or diffuse - involving more than one area of the brain. TBI can result from a closed head injury or a penetrating-head injury. A closed injury occurs when the head suddenly and violently hits an object but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and enters brain tissue.

Mild Traumatic Brain Injury

Because the human brain itself is so complex, injuries to this organ can have highly complex consequences that affect emotional and cognitive functioning as well as physical functioning. There is a wide range of severity of traumatic brain injuries, with a corresponding range of severity of injuries. Mild traumatic brain injury -- which is also often called mild head or brain injury or concussion -- is present if a person suffers a loss of consciousness or confusion that lasts for less than thirty minutes.

Such a level of traumatic brain injury is often overlooked even when an individual seeks medical attention since a minor traumatic brain injury may not be detectable through either MRI or CAT scan imaging. However, there can be long-term consequences that seem anything but mild to the individual concerned and his or her family.

While I will develop this point in much greater degree further on, it is important to note here that traumatic brain injury can have profound consequences for the family and friends of the injured individual. Because TBI can have significant consequences for an individual's personality and emotions -- so much so that the person may seem to be someone else entirely -- the family of the injured person may be at a loss how to react to this seeming stranger.

Both mild and severe traumatic brain injury can arise from a number of different causes, including self-harm:

Half of all TBIs are due to transportation accidents involving automobiles, motorcycles, bicycles, and pedestrians. These accidents are the major cause of TBI in people under age 75. For those 75 and older, falls cause the majority of TBIs. Approximately 20% of TBIs are due to violence, such as firearm assaults and child abuse, and about 3% are due to sports injuries. Fully half of TBI incidents involve alcohol use.

The cause of the TBI plays a role in determining the patient's outcome. For example, approximately 91% of firearm TBIs (two-thirds of which may be suicidal in intent) result in death, while only 11% of TBIs from falls result in death. (Natural Institute of Health)

Assessments of Traumatic Brain Injury

The symptoms of even mild TBI can include such emotional and psychological consequences, include problems in cognition (such as difficulty in thinking clearly and problems in both short-term and long-term memory and difficulty in focusing on tasks) as well as significant mood swings and anger over the loss of function. The individual may also be angry at the treatment that he is getting from both his family and friends and the professionals that he is relying on to become better.

Other symptoms that can arise from even "mild" TBI include -- not surprisingly, but sometimes with severe physical and emotional consequences -- headaches along with visual problems, fatigue, depression, nausea, seizures, loss of smell, balance problems, photosensitivity and over-sensitivity to noises. This range of symptoms from even mild traumatic brain injury can cause problems in all aspects of an individual's life, from personal relationships to the ability to care for other family members (such as young children) to the ability to function at work.

Individuals who suffer severe traumatic brain injury can have devastating symptoms in all aspects of their functioning, including emotional, cognitive, psychological, and physical. Individuals with severe TBI may be left in a permanently non-responsive state. (of course, severe traumatic brain injury can result in death.) the severity of a traumatic brain injury -- from mild to severe -- is assessed by using the Glasgow coma scale, which is detailed below. This scale should be used by medical professionals. (This table is taken from the National Institute of Health's National Institute of Neurological Disorders and Stroke.)

The eye opening part of the Glasgow Coma Scale has four scores:

4 indicates that the patient can open his eyes spontaneously.

3 is given if the patient can open his eyes on verbal command.

2 indicates that the patient opens his eyes only in response to painful stimuli.

1 is given if the patient does not open his eyes in response to any stimulus.

The best verbal response part of the test has five scores:

5 is given if the patient is oriented and can speak coherently.

4 indicates that the patient is disoriented but can speak coherently.

3 means the patient uses inappropriate words or incoherent language.

2 is given if the patient makes incomprehensible sounds.

1 indicates that the patient gives no verbal response at all.

The best motor response test has six scores:

6 means the patient can move his arms and legs in response to verbal commands.

A score between 5 and 2 is given if the patient shows movement in response to a variety of stimuli, including pain.

1 indicates that the patient shows no movement in response to stimuli.

One important note to make here is that even an individual who has no apparent (or few) symptoms after a head injury should consider seeking professional medical help given that the initial absence of serious symptoms does not mean that there is not a significant risk to the individual who has been injured.

A recent very public example of the potential for even seemingly mild head injuries to have severe consequences occurred in March 2009 when actress Natasha Richardson died after a ski accident:

British actress Natasha Richardson has died from head injuries suffered during a skiing accident at the Mont Tremblant ski resort in Quebec. Her death was confirmed Wednesday evening in a written statement by Alan Nierob, the Los Angeles-based publicist for her husband Liam Neeson. The accident occurred while the actress was taking a skiing lesson. She initial experienced no symptoms from her fall, but later complained of a headache and was taken to a local hospital. Reports indicate that her fall was not very spectacular and occurred at a low speed on a beginner run. She was not wearing a helmet at the time of the accident. (Quinn, 2009)

However, while it is true that sometimes there are no immediately obvious signs of a severe brain injury, at other times there are.

Severe Traumatic Brain Injury

The symptoms of a severe traumatic brain injury (which can result in permanent neurological damage) include a number of cognitive problems including inability to concentrate, problems with memory, problems in focusing and paying attention, ability to process new information at a normal rate, a high level of confusion, and perseveration, which is the action of doing something over and over again because an individual has forgotten that he or she has already done it. Other symptoms of severe traumatic brain injury can include problems with vision and hearing as well as a reduction in the ability to smell, paralysis, loss of control of bladder and bowels, sleep disorders, menstrual irregularity, inability to regulate body temperature, and a range of level of pain.

Individuals who have suffered a severe traumatic brain injury may also have a number of problems with language along with "executive functioning." Executive functioning is key to a range of important activities: This level of cognitive functioning allows for most of the goal-oriented behavior that individuals pursue:

Executive functions are necessary for goal-directed behavior. They include the ability to initiate and stop actions, to monitor and change behavior as needed, and to plan future behavior when faced with novel tasks and situations. Executive functions allow us to anticipate outcomes and adapt to changing situations. The ability to form concepts and think abstractly are often considered components of executive function. (Barry, n.d.)

It should be immediately clear how harmful the effects in terms of an individual's overall functioning any diminishment in a person's executive functioning skills would be. Barry notes that "Executive functions are important for successful adaptation and performance in real-life situations. They allow people to initiate and complete tasks and to persevere in the face of challenges."

Ironically -- or most tragically -- a high level of executive functioning is needed to adapt to changing and novel circumstances, the very type of environment that is present when an individual is adapting to the consequences of a serious injury.

Because the environment can be unpredictable, executive functions are vital to human ability to recognize the significance of unexpected situations and to make alternative plans quickly when unusual events arise and interfere with normal routines. In this way, executive function contributes to success in work and school and allows people to manage the stresses of daily life. Executive functions also enable people to inhibit inappropriate behaviors. People with poor executive functions often have problems interacting with other people since they may say or do things that are bizarre or offensive to others.... When executive functions are impaired, however, these urges may not be suppressed. Executive functions are thus an important component of the ability to fit in socially. (Barry, n.d.)

Neuroplasticity

Much of the ability of an individual with traumatic brain injury to heal from their injuries arises from the quality of the human brain to be neuroplastic. This idea is a relatively new one at least to the extent that it is now used. Only a few decades ago, scientists believed that only the very young human brain (and possibly even only the prenatal human brain) could repait itself. Now, however, scientists believe that the ability of the brain to repair itself andmake new connections extends throughout the human life.

More technically, neuroplasticity refers to the ability of the brain to compensate for injury by forming new neural connections throughout an individual's lifetime. These new neural connections can adjust their activities to respond to new demands made on the individual, thus restoring the ability of an individual with traumatic brain injury to respond to the complexity of the real world. Neuroplasticity works through the process of axonal sprouting, in which axons extend their reach into new spaces.

Neuroplasticity can occur within a single hemisphere if the brain is not too badly damaged to heal itself on a single side. It can also occur in a cross-hemispherical fashion, in which new neurons are formed on one side to compensate for injury on the other side. Levin (2003) summarized the importance of this type of regrowth:

The evidence to date indicates that the traditional view of enhanced reorganization of function after early focal brain lesions might apply to early focal brain lesions, but does not conform with studies of early severe diffuse brain injury. In contrast to early focal vascular lesions, young age confers no advantage in the outcome of severe diffuse brain injury. Disruption of myelination could potentially alter connectivity, a suggestion which could be confirmed through diffusion tensor imaging (DTI). Initial reports of DTI in TBI patients support the possibility that this technique can demonstrate alterations in white matter connections which are not seen on conventional magnetic resonance imaging (MRI) and might change over time or with interventions. Preliminary functional MRI studies of TBI patients indicate alterations in the pattern of brain activation, suggesting recruitment of more extensive cortical regions to perform tasks which stress computational resources. Functional MRI, coupled with DTI and possibly other imaging modalities holds the promise of elucidating mechanisms of neuroplasticity and repair following TBI p. 665).

In other words, the brain regenerates nerve cells differently in an adult than in an infant. Though the reason for this differential is not yet well-known, determining the reason holds potential for increasing the ability of researchers to use natural neuroplasticity to help individuals heal from brain disease or damage.

Treatment for Traumatic Brain Injury

The above summary of the potential consequences of traumatic brain injury should make it clear that both the short-term and long-term consequences of such an injury can be devastating. To limit the effects of traumatic brain injury, the injured person should receive a range of treatments. These include a number of purely medical interventions that occur immediately after the injury (such as stabilizing an individual's head and neck and transporting him or her to a hospital) to repairing skull fractures. Less immediate but still essential follow-up care may include physical therapy and speech therapy. These can both be extremely helpful. Neurological interventions may also be helpful.

Although all of the above forms of treatment and therapy can be extremely helpful. However, many individuals who have suffered a traumatic brain injury also need additional forms of therapy and support to help them regain the social (and related workplace) skills that they lost as a result of the accident. Unfortunately, this type of support is often neglected or simply not available to individuals with traumatic brain injury.

This is in large part a function of the ways in which the American medical system works as a whole: While our system of healthcare is generally quite good at supplying people with the care that they need in an urgent situation (for example, if a person with traumatic brain injury were to have bone fragments embedded in his or her skull, there are numerous skilled surgeons who could remove these fragments just after the injury occurred. But our healthcare system -- or rather, our health-delivery system as it is currently constructed -- does a less competent job in delivering long-term sub-acute care. Unfortunately for those people with traumatic brain injuries, this is often precisely the kind of care that they need to regain their ability to functionally in interpersonal relationships and at work.

The problems that individuals with traumatic brain injury face in receiving adjunctive services is made worse for many if they cannot return to work. Since the majority of Americans receive health insurance through their jobs, they may well be left with a very minimum of healthcare options. The bare-bones plans that they may be able to afford will often offer care only for acute situations. While this is a far-from-ideal situation for the recovering individual, there are ways in which friends and family members can help the patient to recover even in the absence of professional support. Again, this is not ideal, but it is sometimes the only option.

I should emphasize that I am not dismissing the importance of family and friends in helping individuals with traumatic brain injury recover. There are several important reasons, in fact, why people who are emotionally close to an injured person can be especially effective in helping that person heal. The first of these is that family members (and other intimates) have a level of emotional connection to the individual and thus loyalty to him or her and desire to see him or her healed that cannot be matched by even the most well-meaning professionals.

The second reason that people close to the injured person may be especially helpful in the healing process is that people with traumatic brain injury are often very suggestible: Family members can use this fact to make continual suggestions throughout the day and over the often long course of healing that will be most helpful in restoring social and employment skills.

Moreover -- and this is absolutely central to the ways in which family and friends can help individuals recover from traumatic brain injury -- is that it is only people who knew the individual before the injury can help him or her recover a sense of self because only these people know what that sense of self is. The following woman, who helped her brother recover from traumatic brain injury after he returned from a deployment in Iraq, demonstrates this.

When he got back -- I didn't even recognize him. That was at first because of the bandages -- and all the bruises. His lips were about four times the size that they should have been. But even after he had all of the stitches out and he was done with his physio, he still wasn't himself. He would just stand there in the middle of the room like he'd forgotten who he was.

And I think that really was what had happened to him. He really had forgotten who he was. It wasn't a question of him having a hard time getting back to who he was. He didn't even know how to start to find himself. It was like he was trying to find this stranger.

Sometimes he would seem like himself for a few minutes and one of us would say to him -- "Hey there, welcome back." But that would just make him angry, like we were making fun of him.

And at first that would make me angry. But that I realized how it must feel for him. That it really did seem as if we were making fun of him. So after that I was very careful to make it clear to him that I was just trying to help him find himself. I made it clear that it wasn't a joke and that I knew how hard it was for him and that my only role -- my only goal -- was to be there for him and to find him find himself.

We used to joke that we were like Hansel and Gretel trying to find our way back. The witch was the war -- or I guess the other way around. And I wasn't really lost -- just Hansel -- my brother -- was. But it was my job to leave the breadcrumbs for him to follow.

After he started to feel better, he wrapped up one of those round containers of breadcrumbs and gave it to me as a present.

No one else could have helped him find his way "back" to himself except someone who knew him as well -- and loved him as much -- as his sister.

Drug Therapies

There are a number of different basic types of therapies that can be used in the treatment of traumatic brain injury. One of these is the use of medication to treat some of the symptoms of traumatic brain injury and to help restore full function to an individual. One very important thing that is true of drug treatment for traumatic brain injury is that it is generally far more effective when used in conjunction with other types of therapies. This depends, of course, on the exact nature of the injury, the age of the patient, and other idiosyncratic or idiopathic features. However, it is generally true that especially in the later, sub-acute period of treatment for traumatic brain injury, a combination of therapies is best.

So how might pharmaceutical treatment be an important part of care for the individual with traumatic brain injury? In a number of different ways, according to Writer & Schillerstrom (2009). In reviewing dozens of articles on the use of various pharmacological approaches to the treatment of TBI with a view to overall high functioning (including in the social arena), they found that a range of possible medications could prove helpful, but those that target the neurotransmitter dopamine tend to be the most successful.

They found the following:

Traumatic brain injury (TBI) is a growing national health issue that commonly results in clinically significant cognitive impairments. This article reviews and evaluates the many proposed psychopharmacological treatments for TBI-related cognitive impairment. A literature review was utilized to focus on stimulant and nonstimulant dopamine enhancing agents, acetylcholinesterase inhibitors, antidepressant agents, mood stabilizers, antipsychotics, and benzodiazepines. The most consistent evidence supports the use of dopamine enhancing medications. However, other medications such as acetylcholinesterase inhibitors and antidepressant agents may help select subgroups. A need remains for well designed, sufficiently powered studies that incorporate functionally relevant neuropsychological outcome measures. (p. 362)

This level of support for an individual recovering from traumatic brain injury is obviously not something that is available to many patients. However, it is an important tactic for researchers to be pursuing. This type of research has the potential to remedy the consequences of traumatic brain injury on the cellular level, which would obviously be ideal.

An analogue to such a form of treatment would be to clone new corneas for someone who had been blinded in an accident. Such a solution would restore sight, avoid the many problems of donor organ transplants, and allow the individual to regain the sense of self that existed before the injury. There are, of course, other ways of addressing the loss of sight in an accident, from donor corneas to teaching a person how to use Braille to providing support groups for the individual. All of these are valid and useful strategies for a person learning to live with blindness. However, essentially erasing the problem would be even more effective.

Being able to determine the exact molecular disturbances that result from traumatic brain injury, as Writer & Schillerstrom (2009) found, can be the most effective method of repairing the multifocal and diffuse nature of the injury. Understanding the ways in which different drugs affect the molecular processes of the injured brain may well lead to the ability of researchers to recreate normal brain chemistry and functioning.

McDowell etal (1998) had similar results. They were investigating the effects of different drugs on the dopamine levels in the brains of people both with and without injury in the prefontal cortex section of the brain. This is their hypothesis:

Thus, the goal of this study was to investigate further the link between dopamine and cognitive processes thought to depend on prefrontal function. Based on the cognitive models summarized above, we investigated the effects of a dopaminergic agonist, bromocriptine, on (i) working memory measures, (ii) clinical measures of executive function and (iii) measures not thought to tap prefrontal function.We chose patients with TBI, who we have previously demonstrated to have working memory and executive impairments (McDowell et al., 1997). These deficits are likely to be due to frontal lobe contusions (Adams et al., 1980) and diffuse axonal injury that disrupts dopaminergic inputs to the prefrontal cortex and neural connections between the prefrontal cortex and other areas of the brain (Adams et al., 1982). Based on the work in non-human primates, it was expected that performance on measures thought to depend on prefrontal function would improve on bromocriptine. (p. 1155)

They concluded that such a level of examination was essential both in terms of determining possible treatments and also because it can identify traumatic brain injuries that do not show up on other assessments. Since people with traumatic brain injuries can perform well on standard neuropsychological tests, other methods are necessary to determine the functional difficulties that these individuals may have.

Without the ability to make such assessments on a molecular level, appropriate treatments to cure (rather than to treat) traumatic brain injury will not be forthcoming. While acknowledging the long-term potential for such research, McDowell etal (1998) emphasized the real good that drugs can do in the short-term.

These practical difficulties, which seem to be caused by deficits in organization, planning and goal integration, are probably due to impairments in the processes that improved on bromocriptine in our study. Since incomplete recovery of prefrontal function prevents full reintegration into society, the development of more effective treatment approaches for these patients, such as pharmacological intervention, will be an extremely important component of their care. Thus, our findings provide a foundation for potential therapies that may not only improve executive function in patients with prefrontal damage, but also decrease the disability associated with these cognitive impairments. (p. 1163)

As noted above, it is the impairment of executive functioning that can be so problematic for individuals with traumatic brain injury. Thus drug therapies that address the molecular reasons for this loss of executive function -- especially if they lead to long-term remediation of loss of executive function -- are a key form of treatment to help those with traumatic brain injury to regain their social skills.

Again, it is imperative to stress the ways in which therapies that improve executive function and therefore social skills are vital to the injured person. While -- of course -- those with injuries wish to be out of pain and out of immediate danger of such problems as blood loss or infection, their ability to resume their lives completely and to return to work are extremely important too and therapies must be developed that address the psycho-social needs of the patient as much as her or his physiological needs.

Multimodal Therapies

Walker etal (2009) found that in children especially a single method approach to treatment of traumatic brain injury in terms of the administration of a single drug was often far less than successful. They also emphasized why finding a successful protocol for treating cihldren with traumatic brain injury is so important -- the sheer number of children involved -- 435,000 emergency department visits and 2,500 deaths in the United States each year.