A description and criteria for Traumatic Brain Injury using DSM-IV-TR
According to the Center for Disease Control, a traumatic brain injury (TBI) occurs when an individual sustains a jolt to his head or a piercing head damage that interrupts the functions of human brain. The degree of TBI varies from mild to traumatic. Mild TBI occurs when a person loses consciousness for a short period.
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Traumatic TBI on the other hand occurs when an individual experiences long-term period of unconsciousness that normally lead to amnesia. TBI can lead to a number of temporary and lasting emotional and behavioral regulation problems (Niehuser, 2009, p.1).
According to the DSM-IV-TR criteria, symptoms of TBI include dizziness, headache, blurred vision, lightheadedness, fatigue, alteration in sleeping patterns, ringing in the ears and mood swings (Niehuser, 2009, p.18).
TBI is catalogued according to the severity and mechanism of the damage.
There are three types of TBI:
Some indicators of mild TBI are:
- short-term loss of consciousnesses;
- memory loss;
- eyes open;
- brief spells of confusion.
Symptoms of moderate TBI include: incidences of brain inflammation or bleeding causing drowsiness; eyes open to stimulation; sluggishness; and spells of unconsciousness that last between 30 minutes to six hours.
During severe TBI, the victim losses consciousness for more than six hours and cannot open eyes, even when provoked.
The present Diagnostic and Statistical Manual (DSM-IV-TR) has a partial classification structure with regard to the description of mild, moderate or traumatic TBI. Glasgow Coma Scale (GCS) is one of the frequently used severity classification systems to determine the degree of TBI.
The GCS scale is normally used for the preliminary assessment of TBI severity. It is an experimental prognostic pointer and helps in early assessment of the severity of brain damage. In Mary’s case, the GCS scale could have been used to determine whether she received any initial resuscitative measures by the poolside.
The GCS can be used to ascertain if Mary had any prior history of head injury. The GCS scale consists of simple form with yes/no/unknown content responses that the nurse could use to determine the severity of TBI experienced by Mary (Ara &Bhat, 2010, p.19).
The medical severity of intracranial damages is shown by the level of consciousness, determined by the GCS scale. In many cases, there is a close affinity between a low GCS score and poorer outcome.
In patient with severe TBI, the motor element of the GCS has the most prognostic value since the eye and verbal response in these patients is usually missing.
However, in Mary’s case, the predictive value of the eye and verbal elements of the GCS scale was significant because she was able to respond to verbal and tactile stimuli. She was also able to look at the nurses and moved her finger upon request.
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Thus, the predictive value of the eye and verbal components of GCS is relevant in Mary’s case because she was able to obey instructions from the nurse (Lingsma & Roozenbeek, 2010, p.546).
Several methods are used to evaluate levels of intellectual functioning. To determine level of intellectual capability, most neuropsychologists utilize the WAIS-IV assessment tools that allow patients (like Mary) to carry on with subtest despite giving successive incorrect answers.
The WAIS-IV can thus be used to give adequate information concerning Mary’s cognitive abilities. TBI is usually characterized by memory loss. The WAIS-IV scale can be used to assess memory loss in Mary’s case.
The WAIS-IV scale was modified from WAIS-III since clinicians usually assess memory loss and intellectual capability simultaneously.
The WAIS-IV subset scores are merged into eight primary indexes that can be used in Mary’s case to test a series of memory functioning such as immediate memory, visual immediate, auditory immediate, auditory delayed, auditory recognition delayed, visual delayed and general memory and working memory.
Four complementary auditory processes composite can as well be computed to be employed in evaluating memory processes when stimuli are presented via auditory (Clinical Psychology, 2010, p. 35).
Visual–spatial abilities are vital for a wide variety of activities such as parallel parking a car, interpretation of a map and tossing a baseball from the outfield to a base. Majority of neuropsychologists that try to evaluate visual-spatial abilities assess performance on some WAIS-IV subtests, for example the Block Design subtest.
A number of exceptional tests of these abilities are also presented. For instance, the evaluation of Line Orientation Test obliges examinees (such as Mary) to point out the pair of lines on a response card that correspond to the two line on the stimulus card (Clinical Psychology, 2010, p. 36).
Several forms of TBI can also have an effect on knowledge of language. For example, Mary complained that when the class was given a writing assignment in English, all the other students finished on time but she had not even finished the introductory paragraph.
It is quite clear that the TBI she suffered affected her language skills. The WAIS-IV test however cannot be used to assess her language skills. The test would require that Mary repeat phrases, words and sentences to evaluate her articulation problems and word substitution.
Her language skills can be evaluated by the Receptive Speech Scale of the Luria- Nebraska. Mary would be required to react to verbal instructions.
On the other hand, the neuropsychologist may decide to refer Mary’s case to speech and language pathologists if the screening assessment shows that Mary has difficulties in language comprehension (Clinical Psychology, 2010, p. 36).
The use of Stroop Color and Word Task to assess cognitive functioning
The Stroop Color and Word Task can be used to evaluate cognitive speed and working memory in Mary’s case. Inhibition of automatic reading abilities is usually ascertained using the Stoop test. The test is made up of three cards, each having 10 rows of objects.
The initial card demands the examinee to read words that refer to some colors, for example, blue, red and yellow. The second card consists of squares printed in diverse colors (for example, a yellow square) and the examinee is required to identify the colors.
The last card contains words that denote to names of various colors but these words are presented in a different color from what the word stands for. The examinee is usually required to identify the color of the word in the third card (Hurks, 2003, p.128).
The Stroop test is assumed to gauge numerous facets of information processing such as concentration, response intrusion and inhibition. The Stroop test can also be used to assess Mary’s cognitive flexibility. Mary complained of poor concentration and memory loss while in class.
Her current level of cognitive abilities can thus be assessed using the Concept Shifting task. The task comprises of five cards. During the first phase, Mary could be offered card A&B and requested to strike out successively numbered circles in card A and then strike out similar number of successively lettered circles in card B.
In the third card (card C), Mary would be asked to strike out a similar number of repeatedly numbered and letter circles on the card by interchanging between the two series (for example, 1-A, 2-B,).
Lastly, in card 1-O and 2-O, Mary will be required to strike out the identical number of empty circles as fast as she can to assess her speed.
Thus, the concept shifting tests can be used to assess several features of information processing such as cognitive flexibility, attention, motor skills, visual formation and visual-motor tracking (Hurks, 2003, p.128).
Recommendations for accommodations and rehabilitation
Persons who suffer from a traumatic brain injury are usually compelled to make a lot of changes in their lives due to the injury. Normally, when the injury sustained is severe, comprehensive periods of psychotherapy are required before a child can resume learning.
Granted, many people do not regain their complete abilities and functioning they had before the brain injury. Nonetheless, with suitable support and sufficient accommodation, majority of TBI victims, including young children like Mary are able to resume employment or school and be successful.
For individuals with TBI, the idea of resuming work or studies may at first appear daunting. However, there are several suggestions that can simplify this process. For example, the Department of Vocational Rehabilitation (VR) offers services to TBI victims who intend to resume their duties at workplace.
VR psychotherapists offer job training, assist a TBI victim get a suitable position and provide them with necessary support to enable them succeed in their duties. The VR efforts to help TBI victims have been boosted by the Ticket to Work program.
The recipients of the program are now able to select an Employment Network to present services to enable them (TBI victims) access and preserve employment (Bubar, n.d., p.1).
Children who suffer from TBI are also taken care of. For instance, children who experience brain damage while pursuing their education are entitled for transition services associated to employment via Section 504 of the Rehabilitation Act.
The Area agencies that form a segment of the Developmental Services System have a duty to offer employment related services for TBI victims aged below 21. Moreover, the American with Disabilities Act (ADA) grants protects individuals and children with TBI related disabilities from all forms of discrimination.
The ADA provides for equal opportunities and rights for TBI victims with respect to their education and employment pursuits (Bubar, n.d., p.2).
All employment and education institutions are required by law to provide suitable accommodations to enable TBI employees and students (like Mary) work and learn successfully. For example, the school must modify the learning environment to enable the student with TBI disabilities learn better (Bubar, n.d., p.2).
This adjustments are necessary for the student because the effects of TBI diverge significantly over time and may affect the victim’s concentration threshold, balance coordination, emotional control and short or long-term memory. Accommodations must be availed to the affected student at no charges.
Some of these accommodations include:
- shortened learning hours; tape recorder for memory aid;
- adjusted equipment such as desk chairs;
- rest breaks to avert exhaustion and stimulus overwork; modified learning programs;
- availability of leisure places where the student can have a quite time alone (Bubar, n.d., p.3).
Thus, rational accommodation must be made when a TBI student participates in educational and extra-curriculum activities. Assistance such as sign language interpreters must be provided if the affect student requires them.
Developing a Prognosis for TBI victims
There are several factors to be considered when developing a prognosis. A diagnostic perspective is usually done in TBI cases and entails an evaluation of the probability of structural brain injury, developing an intracranial hematoma and providing suggestions for CT scanning.
For instance, a recent study utilized a prediction rule to make out a subset of individuals who had minimal risk for intracranial injury that CT scans not necessary.
These kind of diagnostic results are chiefly relevant among patients whose intracranial pressure is examined in the intensive care units but such predictive rules have not been established. For victims with moderate and severe TBI, the prognosis of clinical result is critically important (Lingsma & Roozenbeek, 2010, p.543).
Age is one of the major forecasters of mortality and functional result in TBI. According to numerous studies, old age is closely associated poor result. The correlation between age and outcome becomes progressively poor when the victim is aged above 35 years (Lingsma & Roozenbeek, 2010, p.544).
Other demographic features such as ethnicity and sex are also related with the outcome after the occurrence of TBI. For example, men are highly likely to face TBI due to their high propensity for road traffic mishaps (Lingsma & Roozenbeek, 2010, p.545).
The correlation between outcome and ethnic background after TBI generated contentious debates until a Meta analysis was carried out over 5300 patients from diverse cultures. The results of the study showed that black patients had a lower outcome compared to their Asian and White counterparts.
Although the basis for this correlation is provisional, they may be due to disparities in genetic composition, resulting in diverse reaction to brain injury and variations in access to medical care (Lingsma & Roozenbeek, 2010, p.545).
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Clinical Psychology. (2010). Methods of Neurological Assessment. Web.
Hurks, PM. (2003). The influence of environment, behavior, and attention deficits on cognitive development in school-aged children. Maastricht: Neuropsych Publishers.
Lingsma, HF & Roozenbeek, B. (2010). Early prognosis in traumatic injury: from prophesies to predictions. Lancet Neurol Journal. 9, 543-554.
Niehuser, A. (2009). The Defense Rests: Attorney Recognition of Symptoms of Brain Injury. Web.