Mild Traumatic Brain Injury: A Silent Epidemic in Our Practices

In recent years, mild traumatic brain injury (mTBI), also known as concussion, has emerged as a major public health concern. Of the 1.5 million Americans whose TBIs are documented by medical staff each year, estimates suggest that 85 percent are considered "mild" (Bazarian et al., 2005). Although these kinds of injuries were once considered a virtual "rite of passage"--particularly in sports--we now know that they have potentially lifelong cognitive, physical, emotional, and social consequences. Despite this slowly increasing awareness, countless mTBIs go undiagnosed every year as a result of a confluence of underawareness, underreporting, underdiagnosis, and misdiagnosis. The endemic prevalence of undiagnosed mTBI presents a significant and worrisome public health challenge, especially given the clear links between head injury and mental illness, substance abuse, and criminality (Helgeson, 2010). For social workers, this silent epidemic has practice implications that we cannot afford to ignore. There is mounting evidence that individuals in our practices may also be struggling with a history of TBI. One study found that approximately 70 percent of individuals with co-occurring substance abuse and mental health issues had a history--although not necessarily a diagnosis--of TBI (Corrigan & Deutschle, 2008). In another study, an astounding 87 percent of a county jail population reported a history of head injury (Slaughter, Fann, & Ehde, 2003). Combined with findings that suicide rates are higher among TBI survivors (Silver, Kramer, Greenwald, & Weissman, 2001), and potentially highest among the mild injury group (Teasdale & Engberg, 2001), this evidence suggests the need for new standards in competent practice. BACKGROUND A TBI is sustained when the brain experiences an external trauma resulting in neurological or neuropsychological impairment. Most commonly, TBI is understood as the result of direct traumatic contact with an object that sometimes results in structural damage, penetration, or both. This includes "hitting your head" or "being hit in the head," as we might expect in contact sports or domestic violence assaults. A less common understanding of TBI is the trauma that results from rapid acceleration/ deceleration in which the brain actually ricochets within the skull, as occurs in whiplash or shaken-baby syndrome. Even more misunderstood are the types of TBIs that occur as a result of blasts and explosions typical in combat situations. The sheer energy of the supersonic waves created from blasts can cause brain trauma, even without blunt force or acceleration/deceleration. A soldier who escapes a blast without any physical signs of trauma, such as wounds or broken bones, can sustain the same brain injury as someone whose head hits the windshield in a motor vehicle accident. TBI is categorized as severe, moderate, or mild. A diagnosis of severe or moderate TBI is relatively straightforward given the availability of diagnostic technology, including computer tomography scans and magnetic resonance imaging. Mild injuries, however, are far more difficult to diagnosis. The first issue is that survivors are often unaware of their injury, either because symptoms are subtle enough not to cause alarm or because the presence of other more acute injuries takes priority. Even when individuals suspect an injury, diagnosis is complicated because the current technology is not able to reliably detect the neural damage that occurs in mild injuries (Borg et al., 2004). Diagnoses of mTBI are often based on self-report. Individuals who experience mTBI experience a range of symptoms, including dizziness and vertigo, nausea, decreased coordination or balance, cognitive impairment, impaired vision, ear ringing, headaches and fatigue. Although symptoms often resolve within a few weeks or months, frequently without treatment, some survivors experience symptoms for long periods of time, even resulting in permanent disability. …