Behavioral Health Guide: 

Considerations for Best Practices 

for Children, Youth, and Adults 

with TBI 

June 22, 2022

TBI TARC is supported by contract number 

HHSP233201500119I from the U.S. Administration for 

Community Living, Department of Health and Human 

Services, Washington, D.C. 20201
Welcome

Terry

Camacho-Gonsalves, 

PhD

Director 

Traumatic Brain Injury 

Technical Assistance and 

Resource Center (TBI 

TARC)

Thank you for joining us to learn about the Behavioral 

Health Guide: Considerations for Best Practices for 

Children, Youth, and Adults with TBI.

This webinar is sponsored by the TBI TARC which is 

funded by the Administration for Community Living. 

The TBI TARC provides technical assistance and support 

to the Traumatic Brain Injury State Partnership Grant 

Program grantees and to other TBI stakeholders including 

other states, policymakers, providers, people with lived 

experience with TBI and their family members. 

The TBI TARC is administered by the Human Services 

Research Institute (HSRI) with the assistance of the 

National Association of State Head Injury Administrators 

(NASHIA). 

TBI TARC webinars are free and open to the public. 

2
Behavioral Health Guide: Considerations for Best 

Practices for Children, Youth, and Adults with TBI

The guide is available for download 

from the Administration for 

Community Living (ACL) website: 

https://acl.gov/sites/default/files/prog

rams/2022-

05/TBITARC_BH_Guide_Final_May

2022_Accessible.pdf

3
Webinar Logistics

• Participants will be in listen-only mode during the webinar. 

Please use the chat feature in Zoom to post questions and 

communicate with the hosts. 

• Towards the end of each section our speakers will have an 

opportunity to respond to questions that have been entered 

into chat.

• The webinar will be live captioned in English and Spanish. To 

access the Spanish captions, please use this link: 

https://www.streamtext.net/player?event=HSRI

• El seminario de web estará subtitulado en vivo en inglés y 

Español. Para tener acceso a los subtítulos en español, 

utilice este enlace: 

https://www.streamtext.net/player?event=HSRI

• This live webinar includes polls and evaluation questions. 

Please be prepared to interact during polling times. 

4
Feedback and Follow-Up

• After the webinar, you can send follow-up questions 

and feedback to tbitarc@hsri.org

(Please note: This email address will not be monitored 

during the webinar.)

• A recording, including a pdf version of the slides, will 

be available on the ACL website (acl.gov)

5
Who’s Here?

“In what role(s) do you self-identify? Select all that apply.”

1. Person with a traumatic brain injury 

(TBI) or other disability

2. Family member or friend of

a person with a TBI or other 

disability 

3. Self-advocate / advocate

4. Peer-specialist / peer-mentor

5. Social worker, counselor, or care 

manager

6. Researcher / analyst

7. Service provider organization 

employee

8. Government employee 

(federal, state, tribal, or municipal)

6
SECTION 1: 

PURPOSE OF 

THE GUIDE AND 

OVERVIEW OF 

BEHAVIORAL 

HEALTH AND TBI
Section 1 Speaker

Judy Dettmer, 

BSW 

Director for Strategic 

Partnerships

TBI TARC and NASHIA

Judy Dettmer has been working in the field of 

brain injury for 30 years. Ms. Dettmer is 

currently the Director for Strategic Partnerships 

and a Technical Assistance Lead for the 

Traumatic Brain Injury Technical Assistance and 

Resource Center (TBI TARC) at the National 

Association of State Head Injury Administrators 

(NASHIA). Ms. Dettmer has worked extensively 

with adults, children and family members of 

individuals with brain injury. She has provided 

direct and systems consultation to improve the 

lives of individuals with brain injury. Judy has 

also assisted with research efforts related to 

brain injury and has conducted countless 

presentations, classes and seminars on brain 

injury both in the state of Colorado and 

nationally. 

8
Purpose of the Guide

• Given the significant prevalence of brain injury and co-occurring behavioral 

health conditions, there is a need for guidance to states about how to 

effectively support these individuals.

• State government-led brain injury programs are in a unique position to 

affect policy, increase training and implement practice changes within the 

state behavioral health system to ensure improved outcomes for this 

population. 

• The Behavioral Health Guide: Considerations for Best Practices for 

Children, Youth, and Adults with TBI provides states with tools for initiating 

or improving their partnerships within state mental health systems.

9
This Guide Provides

• An overview of the prevalence and systematic issues that add to 

the complexity for support.

• A review of partners and strategies for partnering.

• Insight into training approaches that states might implement.

• An overview of screening protocol that can be implemented in 

behavioral health settings.

• Strategies for modifying clinical interventions.

• Guidance for modifying pharmacological interventions.

10
Overview 

of 

Behavioral 

Health and 

TBI

• 1/3 of individuals with brain injury will 

experience mental health concerns 6 

months to 1 year post injury.

• People with brain injury of any severity 

have two to four times the risk of 

attempting or having a death by 

suicide.

• Between 23% and 51% of adolescents 

and adults sustaining a TBI were 

intoxicated when the injury occurred.

• 1/4 of people hospitalized for TBI have 

a history of substance use disorders.

11
Systemic 

Issues

•Identifying brain injury

• Medical paradigm

• Lack of training for the 

behavioral health workforce

12
Addressing Systemic Issues

Two steps are needed by state brain injury programs to 

effect change in the behavioral health system: 

• Step 1 is to review the system’s policies to ensure the 

language is not exclusive of supporting individuals with 

brain injury. 

• Step 2 is to develop and implement training protocols for 

the behavioral health workforce in each state, which 

addresses the third systemic issue identified.

13
QUESTIONS: PURPOSE OF GUIDE AND OVERVIEW 

OF BEHAVIORAL HEALTH AND TBI
SECTION 2: 

PARTNERS AND 

STRATEGIES
Section 2 Speaker

Thomasine 

Heitkamp, LCSW

Chester Fritz Distinguished 

Professor Emeritus

University of North 

Dakota 

Thomasine Heitkamp is a Chester Fritz Distinguished Professor 

Emeritus at the University of North Dakota and is a Licensed 

Clinical Social Worker. She has 35 years of professional 

experience providing education, training, and technical assistance 

on organizational leadership. Professor Heitkamp has personally 

experienced the opportunities and challenges of establishing and 

maintaining partnerships and is committed to the application of 

best practices in addressing behavioral health needs in an 

expansion of integrated care models. She is the author of 30 Steps 

for Cross-System Collaboration Specific to Technology Transfer in 

April 2020 and helped facilitate a July 2020 report, Substance Use 

Disorder Collaborations that Work: Findings from Providers in 

Region 8. Professor Heitkamp partnered with National Association 

of State Head Injury Administrators and the Mountain Plains 

Addiction Technology Transfer Center to provide training and 

technical assistance. She also served as a co-editor of the 

Traumatic Brain Injury and Substance Use Disorder: Making the 

Connect toolkit published in November 2021 in collaboration with 

the Substance Abuse and Mental Health Services Administration’s 

funded Addiction Technology Transfer Centers. 16
Advantages to Partnerships

“A collaborative 

relationship between 

entities to work toward 

shared objectives 

through a mutually 

agreed-upon division 

of labor.”

--World Bank, 2003

• Enhancing the capacity to better serve clients and 

the community 

• Sharing best practices 

• Collaborating on cross-referrals

• Increasing knowledge-based resources that 

improve the effectiveness

• Improve organizational capacity 

• Engage new audiences 

• Build organizational networks

17
Ingredients to Effective 

Partnerships

Strategies Provided (slide 1 of 2)

• Shared Vision

• Shared Purpose

• Mutual Trust and Respect

• Transparent Communications

• Flexibility 

18
Ingredients to Effective 

Partnerships

Strategies Provided (slide 2 of 2)

• Anticipate Challenges

• Adherence to a Code of Conduct

• Use of collaborative technology

• Culturally responsive practice (DEI)

19
Lessons Learned

• Partnerships require time and due diligence in maintaining and 

supporting relationships.

• Avoid grandstanding with partners. 

• Do your share of the work, be honest, and communicate 

professionally.

• Praise accomplishments publicly and address concerns 

privately.

• Maintain a focus on the objectives and the needs of the 

population you serve. 

20
Partners for Consideration

• National Association of State Mental Health Program Directors 

(NASMHPD)

• National Association of State Alcohol and Drug Abuse 

Directories (NASADAD)

• Substance Abuse and Mental Health Services Administration 

(SAMHSA)

• National Alliance on Mental Illness (NAMI)

• Mental Health America (MHA)

• National Institute on Drug Abuse (NIDA)

21
QUESTIONS: PARTNERS AND STRATEGIES
SECTION 3: 

TRAINING 

APPROACHES 
Section 3 Speaker

Maria Crowley, 

MA, CRC

Director, Professional 

Development

TBI TARC and the National 

Association of State Head 

Injury Administrators 

(NASHIA)

Maria Crowley, MA, CRC is NASHIA’s 

Professional Development Director and a 

Technical Assistance Lead for the 

Traumatic Brain Injury Technical Assistance 

and Resource Center. She has worked in 

the disabilities field with state government 

for 30 years, and specifically in brain injury 

since 2000, helping individuals to 

successfully transition to home, community, 

and employment. Maria was the State TBI 

Program Director for the Alabama 

Department of Rehabilitation Services for 

14 years. She has led numerous state 

initiatives, conducted training and provided 

technical assistance related to brain injury, employment and disability, concussion 

management, intimate partner violence, 

service coordination and trauma registries. 

24
Why Is Training Important?

• Increases awareness of brain injury

• Reduces risk

• Increases successful intervention

Does everyone need to be a brain injury expert?

25
Training Tiers

The Basics Intermediate 

Steps Advanced

26
Trainers and 

Resources

• Use what’s out there:

• TBI TARC staff and website

• NASHIA staff and website

• State BI Programs

• State Affiliates through 

USBIA and BIAA

• TBI Model Systems and 

KTC Resources

27
QUESTIONS: TRAINING APPROACHES
SECTION 4: 

SCREENING 

FOR LIFETIME 

HISTORY OF 

TBI
Section 4 Speaker

John D. Corrigan, 

PhD, ABPP

Professor

Department of Physical 

Medicine and Rehabilitation; 

and director, Ohio Valley Center 

for Brain Injury Prevention and 

Rehabilitation, the Ohio State 

University 

Dr. John D. Corrigan is the 

Director of the Ohio Valley Center 

for Brain Injury Prevention and 

Rehabilitation and the Ohio Brain 

Injury Program. Dr. Corrigan is 

Editor-in-Chief of the Journal of 

Head Trauma Rehabilitation. He is 

co-creator with Jennifer Bogner, 

the Ohio State University TBI 

Identification Method.

30
Why screen 

for TBI?

• A brain injury that is affecting current cognitive 

function, emotional expression or behavior control will 

affect multiple BH treatment issues, for example:

• Clients’ awareness of their own behavior

• Ability to understand the rationale or methods of 

treatment

• Cognitive endurance to meet the daily demands

• Social skills for participating with other clients

• Need to know nature and extent of lifetime history

• Severity, cumulative effects, age at injury, recency

31
Why use 

retrospective 

self-report?

• Lifetime history very different than diagnosis of TBI 

that just occurred:

• Imaging, neuropsychological assessment are not 

sensitive to lifetime history, biomarkers are not 

specific

• Medical records only if treated, and commonly 

miss mild TBI

• Retrospective self-report is the gold standard, despite 

limits

• Injuries before age 5; injuries in one’s remote past, 

stigma about impaired brain function

• Depends how self-report is elicited–stimulate 

recall of less severe injuries, avoid self-diagnosis, 

use signs but not symptoms

32
Screening Tools

• Boston Assessment of Traumatic Brain Injury 

Lifetime (BAT-L)

• Brain Injury Screening Questionnaire (BISQ)

• Defense and Veterans Brain Injury Center’s 

Brief TBI Screen (BTBIS)

• Ohio State University TBI Identification 

Method (OSU TBI-ID)

• TBI Questionnaire (TBIQ)

• Brain Check Survey (for children and youth)

The screening tools appear on page 37 of the Behavioral Health 

Guide: Considerations for Best Practices for Children, Youth, and 

Adults with TBI. It can be downloaded here: 

https://acl.gov/sites/default/files/programs/2022-

05/TBITARC_BH_Guide_Final_May2022_Accessible.pdf 33

Table 1: Valid and Reliable Screening Tools 

Instrument Instrument Information 

Boston Assessment of 

Traumatic Brain Injury 

Lifetime (BAT-L)20 

. 15-37 items depending on history of 1, 2 or 

3 TBls. . Length of administration depends on 

number of TBls and version. 

• Administered by doctoral-level 

neuropsychologists or other comparably 

trained professionals. 

• Developed for military service members with 

adaptations for civilian and domesticviolence uses. . Lifetime history ofTBI. . Free . 

Brain Injury 

Screening Questionnaire 

(BISQ}21 

. 3 sections/173 items. . 10-15 minute administration. . Self-report or administrated with assistance . . Lifetime history ofTBI. 

• Pediatric & adult versions/scored, then minireport generated. 

• $10-$15 oer administration. 

Defense and Veterans Brain 

Injury Center's Brief TBI 

Screen (BTBIS)22 

• 3 questions with 6-8 sub-questions each . . 3-5 minute administration . . For military service members post-combat . 

• TBls incurred during deployment. . Free . 

Ohio State University TBI 

Identification Method 

(OSU TBI-ID}23,24,25,26 

. 3-step interview . . 3-5 minute administration . 

• Administered by anyone who completes 

online training. 

• Lifetime history ofTBI. 

• Free . 

TBI Questionnaire (TBIQ}27 . 

. 3 sections . 

15-minute administration . 

• Administered by clinician. 

• History of common TBls, symptom severity 

and physical and behavioral symptoms. 

• Free . 

Brain Check Survey28 

(for children and youth) 

. 

. 3 sections/173 items. 

10-15 minute administration . . Parent-/guardian-report measure . . History ofTBI, other sources of brain 

impairment and physical and behavioral 

symptoms. . Intended for children & youth . 

• Free . 
Reliability & Validity of Screening

• Reliability––if I ask again, will I get the same result?

• Test/retest most relevant for an interview-based screener

• Not all tools have tested reliability

• A tool cannot be anymore valid than it is reliable

• Validity––does the result reflect the condition of interest?

• Face, content, concurrent, predictive, and construct validity

• Correspondence with medically documented TBI

• Predicts current functioning that is a typical consequence of TBI

• Associated with structural or functional abnormalities

34
OSU TBI-ID

• Structured interview, self-administered developed more recently

• 3-5 minutes typically

• Multiple studies of test/re-test reliability

• Developed based on prediction of current effects from lifetime exposure

• Shown to correspond with contemporaneous medical records

• Associated with abnormalities observed via MRI, fMRI, DTI and proteomics

• Provides: worst lifetime, age at first, multiple TBIs, most recent

• Has been adapted for specialized uses

35
Other Acquired Brain Injuries (ABIs)

• Do not have validated instruments for self-report of other ABIs

• Anoxia/hypoxia 

• Residual executive function effects similar to TBI

• Need to cue multiple causes (e.g., strangulation, overdose, cardiac 

arrest, toxic exposures)

• Often may not receive medical attention

• Cardiovascular events typically focal vs. diffuse, receive medical attention

• Many other sources of ABI also receive medical attention

36
QUESTIONS: SCREENING FOR LIFETIME 

HISTORY OF TBI
SECTION 5: 

MODIFYING 

CLINICAL 

INTERVENTIONS FOR 

TBI
Section 5 Speakers

Maria Kajankova, 

PhD 

Assistant Professor

Department of 

Rehabilitation and Human 

Performance, Icahn School 

of Medicine at Mount Sinai

Theo Tsaousides, 

PhD, ABPP 

Clinical Assistant 

Professor

Department of 

Rehabilitation and Human 

Performance, Icahn School 

of Medicine at Mount Sinai

Dr. Maria Kajankova is a Clinical Instructor in the 

Department of Rehabilitation Medicine at the Icahn 

School of Medicine at Mount Sinai (ISMMS). She 

completed predoctoral and postdoctoral training at the 

Brain Injury Research Center of Mount Sinai (BIRC-MS), 

leading groups in the National Institute on Disability 

Independent Living and Rehabilitation Research 

(NIDILRR)-funded Short-Term Executive Plus (STEP) 

trial. She is the Director of Training of the BIRC-MS and 

Investigator on the current EmRegTM study, for which she 

trained and supervised study therapists in EmRegTM

protocol.

Dr. Theo Tsaousides is a neuropsychologist, speaker, and 

author. For the last few years, he has been in 

independent practice in New York. He is an assistant 

professor in the Department of Rehabilitation Medicine at 

ISMMS, where he has served as a researcher and 

training director of the BIRC. He also co-created 

EmRegTM, a training program designed to improve 

emotion regulation, the ability to identify and influence 

one’s own emotions. His clinical and research work focus 

on goal achievement, mental fitness, and emotional 

intelligence. 39
Delivering 

Mental Health 

Interventions 

for People 

with TBI 

(slide 1 of 2)

• Diagnosis

• Know the prevalence

• Prevent misdiagnosis

• Modify the use of screening and 

assessment measures

• Select measures appropriate for people 

with TBI

40
Delivering 

Mental Health 

Interventions 

for People 

with TBI 

(slide 2 of 2)

• Treatment

• Be aware of the impact of reduced cognitive 

functioning and self-awareness

• Consider and adjust for cognitive challenges

• Memory

• Attention

• Processing speed

• Executive function

• Select interventions adapted for people with 

TBI

41
QUESTIONS: MODIFYING CLINICAL 

INTERVENTIONS FOR TBI
SECTION 6: MODIFYING 

PSYCHOPHARMACOLOGIC 

INTERVENTIONS FOR TBI
Section 6 Speakers

Lindsey Gurin, 

MD

Clinical Assistant Professor 

of Neurology, Psychiatry, 

and Rehabilitation Medicine

NYU Langone 

Health

NYU Langone 

Health

Michael Chiou, MD

Brain Injury Fellow

44
“It is not only 

the kind of 

injury that 

matters, but 

the kind of 

head.” 

-- Sir Charles 

Symonds, 

1937

• TBI-induced alterations in neural circuitry 

must be understood in the context of the 

whole person 

• Posttraumatic psychiatric symptoms are 

influenced by

• personality structure

• preexisting psychiatric vulnerabilities

• life experience and psychosocial factors

• The standard psychiatric assessment 

captures these essential elements and can 

be adapted to TBI with some modifications

45
Goals of psychiatric care in TBI

• Improve diagnostic clarity by identifying symptom clusters that

• Resemble primary psychiatric illness; or

• Are consistent with expected sequelae of TBI (e.g., cognitive impairments)

• Identify discrete target symptoms potentially amenable to intervention 

• Treat target symptoms by supplementing non-pharmacological interventions with 

rational pharmacotherapy

• Extrapolated from data for primary psychiatric illness;

• Informed by TBI-specific data, where available; or

• Driven by hypotheses about neurotransmitter disturbances caused by specific 

injury

46
Modifications 

to 

Psychiatric 

Assessment 

in TBI 

(slide 1 of 2)

 

• Timing: how recent was the TBI?

• Acute/post-acute period: be aware 

of posttraumatic amnesia; expect 

evolution of symptoms as individual 

recovers; consider contribution of 

medical complications of TBI

• Chronic: consider possibility of 

neurodegenerative cognitive 

impairment (TBI increases risk of 

dementia)

47

 
Modifications 

to 

Psychiatric 

Assessment 

in TBI 

(slide 2 of 2)

 

• Medical review of systems – attention to neurologic 

complications of TBI that may exacerbate psychiatric 

symptoms

• Headaches, chronic pain (and adverse effects of 

pain meds)

• Seizures (and adverse effects of antiseizure 

meds)

• Dysautonomia (e.g., paroxysmal sympathetic 

hyperactivity which can mimic/trigger agitation; 

positional orthostatic tachycardia syndrome 

[POTS] after mTBI which can trigger anxiety)

• Visual disturbances (common, increase cognitive 

fatigue and subjective stress, can improve with 

vision therapy)

• Get as much detail about the TBI as possible –

severity, extent, lesion location

48

 
Modifications 

to the Mental 

Status Exam

• Supplement standard psychiatric 

mental status exam with some form 

of cognitive assessment

• Evaluate for overt cognitive 

dysfunction during interview

• In-office screening tools as 

needed:

‒ Montreal Cognitive Assessment 

(MoCA)

‒Saint Louis University Mental Status 

(SLUMS) 

‒Mini-Mental Status Exam (MMSE)

49
Further Medical and Neurologic 

Assessment

• Review prior brain imaging or obtain new imaging 

(MRI preferred over CT)

• Consider EEG to evaluate paroxysmal or episodic 

symptoms

• Bloodwork: standard psychiatric labs (e.g., thyroid 

function, B12) + low threshold to obtain pituitary 

hormone screening labs (pituitary hypofunction is a 

known consequence of TBI)

50
Diagnostic Formulation

• TBI can interact with primary psychiatric illness, altering expression of both 

and producing confusing clinical presentations

• Apply “best fit” diagnoses to symptom clusters that resemble primary 

psychiatric illness (even if not all symptoms are explained)

• Identify target symptoms directly attributable to TBI

• Sleep/wake disorders

• Emotional dyscontrol: irritability, lability, pseudobulbar affect

• Behavioral dyscontrol: disinhibition, aggression

• Diminished motivation: apathy, abulia

• Cognitive impairment: especially inattention, memory impairment, executive dysfunction

• Agitation: usually driven by multiple underlying factors (i.e., not itself a specific target 

symptom)

51
Modifying 

Psychopharmacologic 

Treatment: General 

Principles 

(slide 1 of 2)

 

•“Without a map, you cannot get to your 

destination” – know your target symptoms

• When possible, add by subtraction first

• “Start low, go slow – but go”

• Reassess frequently and adjust as needed

• Avoid polypharmacy – most of the time

52

 
Modifying 

Psychopharmacologic 

Treatment: General 

Principles 

(slide 2 of 2)

 

• Treat recognizable psychiatric syndromes according to 

standard of care, keeping in mind that TBI increases 

sensitivity to medication adverse effects

• Treat TBI-specific symptoms according to available 

evidence base

• Supporting cognition is key - especially cholinergic 

and dopaminergic pathways essential for executive 

function and attention

• Avoid dopamine blockade if possible – atypical

antipsychotics preferred; quetiapine has best side 

effect profile and may improve cognition in TBI

• Avoid medications with significant anticholinergic 

activity

• Amantadine promotes neurobehavioral recovery in 

severe TBI and is used commonly in TBI of all 

severities for a wide range of symptoms

53

 
Overview of psychopharmacologic 

treatment of TBI-specific syndromes 

54

Sleep/wake 

disorders 

Emotional 

dyscontrol 

Diminished 

motivation 

Cognitive 

impairment 

Agitation 

First-line Melatonin 

Ramelteon 

Selective 

Serotonin Reuptake 

Inhibitors (SSRIs) 

Amantadine Amantadine Beta blockers 

(propranolol) 

Second-line Trazodone 

Mirtazapine 

Stimulants 

(promote daytime 

wakefulness) 

Anticonvulsants 

Amantadine 

Atypical 

antipsychotics 

Methylphenidate Donepezil 

Methylphenidate 

SSRIs 

Anticonvulsants 

Amantadine 

Atypical 

antipsychotics 

Stimulants 

(sometimes) 

Comments Treating can have 

broad benefits on 

mood, cognition, 

behavior 

SSRIs can work 

rapidly and at lower 

doses than needed 

for depression 

Treating can have 

secondary benefit 

for 

mood/behavioral 

symptoms 

Identify 

underlying 

contributors and 

treat those 

directly
QUESTIONS: MODIFYING 

PSYCHOPHARMACOLOGIC INTERVENTIONS FOR 

TBI
Wrap-up

56
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58
Thank You

The Traumatic Brain Injury Technical Assistance and Resources Center (TBI TARC) is 

an initiative from the Administration for Community Living that helps TBI State 

Partnership Program grantees promote access to integrated, coordinated services 

and supports for people who have sustained a TBI, their families, and their 

caregivers. The Center also provides a variety of resources to non-grantee states, 

people affected by brain injury, policymakers, and providers.