Screening for Mild Traumatic Brain Injury: A Guide for Rehabilitation Counselors.

In the United States alone, the occurrence of approximately 1,000,000 head injuries is reported each year which is the equivalent of one injury every 15 seconds (Picard, Scarisbrick, & Paluck, 1991). Additionally, close to 500,000 hospitalizations per year occur as a result of head injury with 75% of these injuries being classified as mild in degree (Novak, Roth, and Boll, 1988). Most individuals who sustain mild trauma to the brain are expected to experience full recovery within several weeks (Dikman, Temkin, & Armsden, 1989). Some individuals, however, develop symptoms even in the absence of a detectable injury to the brain (Berrol, 1992). It has been estimated that approximately 25% of individuals who sustain a mild traumatic brain injury (mild TBI) experience delayed symptoms to the degree that daily functioning is significantly impaired (Harrington, Malec, Cicerone, and Katz, 1993).

Persons who sustain a mild TBI and seek medical treatment are usually either not admitted to the hospital or hospitalized for only a brief period of time for observation and then discharged with minimal, if any, follow-up assuming no apparent medical problems are identified. Initial treatment may actually be direct, ed at other injuries rather than screening or attending to trauma to the brain. Some individuals may never seek medical treatment at all, particularly if there appear to be no accompanying injuries and/or immediate functional difficulties. Consequently, functional difficulties, that become apparent only after daily activities are resumed, may never be connected to injury to the brain.

Even those individuals who seek treatment and whose symptoms are immediately assessed, may not receive appropriate diagnosis and treatment. Traditional assessment tools often fail to identify significant pathology directly (e.g., physical evidence of damage to the brain). Cognitive difficulties following mild TBI have not been supported by structural neuroimaging techniques such as computerized tomography (CT) scans and magnetic resonance imaging (MRI). As a consequence of the discrepancy between objective findings and subjective complaints, the difficulties experienced by some individuals with mild TBI have been discounted or ignored. In spite of the limitations of many established non-functional neuroimaging techniques (e,g., CT, MRI) in documenting mild TBI, there is considerable interest within medicine and neuropsychology in utilizing the latest state-of-the-art functional imaging techniques to document mild TBI (Ruff, Levin, & Marshall, 1986). Research has been initiated using new functional imaging techniques such as positron emission tomography (PET) which may be more sensitive to detecting the subtle changes caused by mild TBI (Ruff et al., 1994). Clearly, technology and new advances make information on mild TBI ever-changing. Irrespective of advances in more specific diagnostic techniques to "document" mild TBI physiologically, rehabilitation counselors may still find themselves in the unique position of identifying reported symptoms as potentially related to a mild TBI event and from that recognition, trying to develop a rehabilitation plan which assists the individual to function effectively in daily life.

Because of the startling frequency of mild TBI and the nature of the potential long-standing implications for functioning in daily life, vocational rehabilitation counselors are advised to develop the knowledge and skills to identify whether a client might have experienced trauma to the brain. Counselors may encounter clients who are unaware of any brain injury but are requesting services due to unexplainable difficulties they are experiencing in daily activities and in employment. Other clients may present with seemingly unrelated disabilities (e.g. orthopedic impairments, learning disabilities, psychiatric disorders, or alcohol and substance abuse), and the functional limitations caused by mild TBI may not become apparent until after the rehabilitation plan has already been initiated. Counselors may not immediately note subtle limitations if the client has good verbal skills which mask cognitive deficits. Deteriorating coping skills and work performance, combined with the failure to find appropriate diagnosis and treatment, can further aggravate functional difficulties. Rehabilitation counselors are, therefore, in an optimal position to observe, correctly identify, and assist with accommodations for the potential functional difficulties individuals with mild TBI face in daily activities (e.g., work, school).

This article is intended to serve as a guide to use in screening for possible mild TBI so that a rehabilitation plan can be developed which appropriately addresses the functional problems identified. It must be emphasized that the counselor's role is not to diagnose, but to recognize when the client may have a problem requiring further investigation.

Definitions of mild TBI will be presented along with a brief explanation of how it differs in etiology from more severe forms of TBI. Common functional difficulties will be described and listed in a table for use as a reference guide followed by a discussion of interview guidelines (e.g., behaviors to be aware of in the interview setting, a list of interview questions that can be used for screening purposes). Finally, the authors will recommend screening tools and additional resources that may be helpful to counselors.

Definition

Mild traumatic brain injury (mild TBI) is defined as a traumatically induced physiologic disruption of brain function, as manifested by at least one of the following: (a) brief loss of consciousness (less than 30 minutes); (b) loss of memory for events occurring immediately before or after the accident; (c) temporary change in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused); (d) temporary focal neurologic deficits; (e) post-traumatic amnesia not greater than 24 hours; and (f) an initial Glasgow Coma Scale score of 13-15 (Berrol, 1992, p.5). This definition includes all injuries in which the head is either struck by, or strikes an object, or in which the brain undergoes acceleration/deceleration movement (e.g., whiplash) without actually striking the head. It excludes trauma resulting from stroke, anoxia, tumor, encephalitis (Berrol, 1992).

Other terminology used to describe this type of trauma compares the injury with severe injury (Berrol, 1992). Such terminology includes "trivial head injury," "minimal head injury", and "mild head injury." "One cannot, however, assume that the scope, effect, or duration of symptoms will be trivial, minimal, or mild. Minor injuries -- that is, injuries with brief alterations of consciousness -- may have associated focal patterns of considerable significance, with life-long effects for the individual" (Berrol, 1992, p.2). Kay (1993) used the term "minor head injury" to refer to "an injury to the head, face, and neck area with symptoms caused by damage to the skull, scalp, soft tissues or peripheral nerves but not where there is necessarily injury to the brain" (p.75). Rutherford (1989) argued that the term "minor brain injury" is preferable to "minor head injury" because it is more descriptive of the problem, and "minor head injury" suggests injury to the head without direct insult to the brain. Berrol (1992) noted that using incorrect terminology can lead to denial of the existence of symptoms as well as failure to properly treat symptoms or to inform the patient of the cause of symptoms. Therefore, he recommends using the preferred term, "mild traumatic brain injury (mild TBI)" as designated by the Mild Traumatic Brain Injury Subcommittee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. The present authors will also use the term "mild TBI" to describe this type of injury.

Mild TBI differs from more severe forms of TBI in that it typically produces diffuse damage affecting various brain structures as opposed to localized damage restricted to specific brain structures (Gronwall, 1989). Although, localized lesions are easier to detect using neurologic, neuroradiologic and neuropsychological techniques (Gronwall, 1989), the diffuse damage caused by mild TBI can impair many complex cognitive tasks (e.g., divided attention, concentration, and rapid information processing) that require the transfer of neural signals from one brain structure to another (Novak, Roth, & Boll, 1988). Therefore, counselors must not be misled by the term "mild" since the resulting functional limitations can, in many cases, be quite severe. As Kay (1986) stated, "minor [TBI] does not always translate into minor disability" (p. 12).

Functional Difficulties

Blankenship (1988) reported that each individual with mild TBI will "present unique difficulties relative to the particular locations, type, and extent of injury. Hence, rehabilitation plans must be suited to each individual case based on the sequelae which continue to present after the initial recovery phase" (p.40). If these "sequelae" are never even identified by the rehabilitation counselor as functional limitations Which need to be circumvented, ameliorated or corrected, unsuitable rehabilitation planning is almost inevitable. Berrol (1992) noted that patients can exhibit persistent emotional, cognitive, behavioral, and/or physical symptoms that may produce a functional disability even when the initial signs of injury are no longer present. The possible functional deficits that may be experienced by individuals with mild TBI are listed in Table 1. As can be seen, the list is quite extensive, and some deficits can be present in other unrelated disorders (e.g., learning disability, psychiatric disorder, etc.). Therefore, it is easy to understand why mild TBI is frequently misdiagnosed.

Binder (1986) stated that poor concentration is the most commonly reported functional limitation. Poor concentration can be attributed to reduced information processing capacity or reduced capacity for the brain to carry on a number of different operations at the same time (Gronwall, 1989). Individuals with mild TBI may have difficulty analyzing several pieces of information simultaneously. They may present as distractible since they cannot monitor irrelevant stimuli at the same time they are attending to relevant stimuli. They may also present as forgetful and inattentive when the amount of information they are given exceeds their capacities (Gronwall, 1989). Fatigability is another common functional limitation which has been frequently observed in individuals with mild TBI. Mental and physical fatigue can result from the increased amount of effort that is required to attend and concentrate (Gronwall, 1989). As can be imagined, using up all available mental resources for tasks that previously required only a small portion of those resources would be quite exhausting, and explains why it may be very difficult to handle many aspects of employment (especially jobs requiting a fast pace, numerous changes in tasks throughout the day).

Rimmel et al. (1981) observed that a majority of the patients with mild TBI that they studied still suffered from persistent headaches and memory problems three months post-injury. One third of these individuals who were working prior to their injury had not resumed employment. Despite apparent complete physical recovery and lack of positive neurological findings, persistent headaches and memory problems may seriously impede the ability to function on the job.

Executive control functions can also be impaired if frontal lobe damage occurs. These functions include capacity for self-control and direction, planning and organization, mental flexibility and problem-solving skills, initiative, motivation, and regulation of behavior (Posthuma & Wild, 1988). These skills are not only crucial to maintaining employment, but are mandatory for conducting a job search as well. The successful job search requires self-motivation, initiative, and good organizational skills. It is imperative for counselors not to automatically attribute deficiencies in these skill areas to lack of motivation, poor attitude, or laziness before exploring the possibility of an organic cause.

Emotional changes are also common after mild TBI. Newly acquired deficits can lead to what Kay (1993) referred to as a "shaken sense of self," especially in the absence of external validation that the injury is even "real" and in the presence of normal appearance. Consequently, individuals can experience a disruption of their sense of stability which leads to a cycle of failure, fear, avoidance, anxiety, depression, loss of self-esteem, isolation, and alienation. "This psychological overlay, over time, can become more functionally disabling than the underlying primary deficits that fuel it" (Kay, 1993, p. 75). Some emotional changes (e.g., depression, anxiety, emotional lability, and increased anger) may be organic rather than a reaction to the traumatic event itself (Novak, Roth, and Boll, 1988). Any of these changes can be manifested in behavioral symptoms which are exhibited in the individual's interactions with others (e.g., family members, friends, supervisors, coworkers). Some of these symptoms are impatience, impulsivity and erratic behavior, difficulty getting along with others, and fearfulness. Like impaired executive control functions, behavioral symptoms can be very disruptive to the job search and employment processes. In many cases, behavioral symptoms are not even noted by the individual or others until after employment has already been resumed. Again, the potential for misdiagnosis due to the delayed reporting of symptoms is present.

Physical symptoms can be numerous as well. These may include impaired gait or motor coordination, weakness, and visual difficulties. (Referred to Table 1.) Counselors should avoid using the label "malingerer" even when physiological documentation for reported physical symptoms is lacking. Labeling could lead to wrongful closure of a case as "unsuccessful" or "uncooperative." It could also be potentially harmful to clients (and others) if reported physical symptoms are disregarded, and clients are placed in occupations incompatible with their limitations. Individuals with mild TBI will not display the same functional difficulties. Functional outcome is rather a product of extent of damage, persistence of symptoms, personality style, support systems, job and home requirements, age and medical factors, legal status, and adequacy of medical response to injury (Kay, 1993).

Table 1

Functional Deficits of Mild Traumatic Brain Injury (Kay, 1993; Larkin, 1992; Novak et al., 1988; Rutherford, 1989).

Emotional      Cognitive         Behavioral         Physical

Agitation      Tangentiality     Impatience         Headache
Irritability   Distractibility   Explosive temper   Dizziness
Low self       Confusion         Thoughtlessness    Vertigo/balance
 esteem
Depression     Amnesia           III-naturedness    Nausea/vomiting
                for event
Emotional      Impaired          Fearfulness        Blurred vision
 lability       judgment
Anxiety        Self-             Confrontational    Fatigue/poor
                monitoring                           stamina
Frustration    Problem           Difficulty with    Seizures
                solving/          relationships
                decision
                making
Increased      Slow              Impulsivity        Sensory Loss
 anger          information
                processing
                speed
Feeling        Difficulty        Lack of            Paralysis
 helpless       sequencing,       inhibition
                prioritizing,
                initiating
Guilt/         Reduced short     Sleep              Slow motor speed
 self-blame     term memory       disturbances-
                                  insomnia,
                                  nightmare
Fear of
 "going        Speech and       Apathy            Problems with
 crazy"         language
                problems                             coordination
Mood swings    Lack of                              Weakness of any
                awareness/                           extremity
                understanding
                of limitations
               Decreased                            Sensitivity
                reading,                             to light
                writing,                             and noise
                calculating
                ability
                                                    Tinnitus/Hearing
               Decreased                             problems
                ability to
                learn new
                or retrieve
                old information

Behavioral Observations as a Screening Tool

Behavioral observation is a skill utilized by rehabilitation counselors on a daily basis which can be particularly powerful in screening for mild TBI. Behaviors manifested during the initial or subsequent appointments can sometimes provide evidence for the presence of mild TBI. However, counselors may fail to make this connection if they are not knowledgeable about possible functional difficulties and do not utilize effective observational skills.

Deficits in cognitive functioning may be suspected if clients exhibit certain behaviors that are not explained by the presence of other disabilities. Examples of behaviors that may lead a counselor to suspect cognitive deficits include slowness in responding to interview questions; difficulty concentrating and sustaining attention, with a tendency to become easily distracted by extraneous environmental stimuli (such as a ringing telephone or the voices of people talking in the hallway); and a tendency to go off on tangents or shift from topic to topic when responding to the interviewer. Impulsivity may also be observed by a tendency to act before thinking something through. For example, the client might begin to fill out a form before the counselor has finished giving instructions or rapidly complete an interest inventory without giving the items much thought. Difficulty may be observed in the client's ability to divide his or her attention between two separate tasks (e.g., conversing with the interviewer while filling out an application blank). Aphasia may be suspected if the client omits words when speaking, fails to complete sentences, or consistently violates grammatical rules (Holmes, 1993). The client may display tendencies to forget appointments, past events, dates, addresses, phone numbers, directions to the counselor's office, or where his or her car is parked. Again, counselors should avoid attributing problems with client follow-through to poor motivation until other explanations for such behaviors are ruled out. It is also important not to overreact to minor memory lapses since a certain degree of memory lapse is present in everyone and is usually acceptable unless it begins to interfere with daily activity or is not accommodated for (e.g., with a datebook).

Deficits in emotional functioning may also be inferred from observable behaviors. If the client becomes easily angered or upset during the interview, and this cannot be attributed to some other cause (e.g. dissatisfaction with services, situational stressors, or other disability), the counselor may want to explore the possibility of mild TBI. If the client continually makes derogatory statements about him or herself, and this occurs in combination with some of the other described behaviors, the counselor, again, may want to explore the possibility of mild TBI as a source of these difficulties. Statements such as "I can't do anything right anymore" or "Nobody understands me" may be evidence of the "shaken sense of self" that frequently accompanies mild TBI. Finally, physical symptoms such as the tendency to favor use of one side of the body over the other, difficulty ambulating, slowed or shuffling gait, abnormal movement or unusual jerking of the eyes, slurred or slowed speech, or inappropriate volume of voice may also be observed during the interview (Holmes, 1992).

Employers, family members, friends, and coworkers may be able to contribute useful information about the client's behavior since they have had the opportunity to observe the client in settings other than the counselor's office. This information may include descriptions of the client's ability to get along with others in social and work settings; the client's capacity to cope with stress; how well the client is able to perform functions of his or her job; whether or not there has been a noticeable change in abilities; and specific areas of emotional, interpersonal, and vocational functioning in which changes have been observed. Kay (1992) suggested that novel situations of reduced structure can be created to observe how the client handles these demands. If the client experiences stress or difficulties carrying out tasks without counselor-imposed structure, a mild TBI might be suspected, and rehabilitation planning may need to be modified to accommodate for this new information.

It should be noted that the counselor may want to request additional medical and neuropsychological testing if there are concerns for medical or neuropsychological interventions (e.g., cognitive retraining, medication). Many of the described observable behaviors may be characteristic of other disabilities or the result of anxiety about the interview situation itself. Therefore, the counselor must be careful not to develop inaccurate explanations for any behaviors. One way to avoid doing this is to thoroughly question the client before developing any hypotheses and to obtain information from outside sources (e.g., medical records, neuropsychological reports). Resources that will assist the counselor in screening for mild TBI are presented in the following sections.

The Interview as a Screening Tool

The interview can be a particularly useful tool in screening for mild TBI. Interviewing clients with suspected mild TBI requires "skillful questioning and careful listening" and can be described as a "continuation of digging" (Misenti, 1992, p. 13). Interviewing may even be described as analogous to detective work which involves uncovering subtle clues to determine what is going on.

The following guidelines for using the interview as an assessment tool are offered by Misenti (1992): (a) obtain an in-depth personal history by making specific inquiries about the client's daily life, work history, personality, and family relations; ask if they ever had or were ever told they had sustained a brain injury; (b) question the client thoroughly about when symptoms first appeared (e.g., "Has anyone ever told you that you have started acting differently?" "When and how so?") while considering the individual's level of awareness of personal deficits; and (c) ask about premorbid functioning to make comparisons with the client's current level of functioning [e.g., What was life like before the symptoms first appeared? What is it like now? Are you capable of carrying on daily activities as well as was done before symptoms started? Do you have difficulty performing tasks that were easy to do prior to the injury (e.g., athletics, hobbies, household chores, job tasks, etc.)?] Look for inconsistencies to determine if deviations from former levels of functioning are actually present.

Misenti (1992) recommends questioning clients about the absence or presence of specific symptoms in addition to the questioning described above. Symptoms to inquire about include post-traumatic amnesia or loss of consciousness; prior brain injury; headaches, pain, dizziness, or loss of balance; changes in behavior; irritability or impulsivity; memory problems; motor or sensory problems; other stressors that may interfere with optimum functioning; difficulties in school or work performance; and changes in relationships with family or friends.

It may be helpful to interview family members for their perspectives on any changes they have noted in the client's behaviors. This strategy could prove to be particularly useful when working with clients who have limited awareness of their deficits and subsequent difficulty describing changes in their behaviors and cognitive abilities. Observations from employers, co-workers, and teachers can also be obtained, if appropriate, to document the existence of dysfunctional behaviors and the extent to which these behaviors are an obvious change from the client's usual behaviors.

When using the interview as a screening tool, counselors must always keep in mind that the goal is not to "prove" the existence of a mild TBI but to explore before/after contrasts in behavior to determine whether or not significant changes have occurred (Kay, 1992). Then the counselor can make an appropriate referral for additional assessment (e.g., medical, neuropsychological) and/or develop a more effective rehabilitation plan that addressees the functional limitations as cognitive/behavioral/physical implications of mild TBI rather than personality pathology.

Tools for Mild Traumatic Brain Injury Screening

While there certainly are highly sensitive, exhaustive (and expensive) methods for assessing cognitive impairment (i.e., complete neuropsychological batteries), brief and convenient screening instruments are of considerable interest as an initial step in rehabilitation planning. Increased emphasis has been placed on developing sensitive cognitive screening measures which detect not only global cognitive dysfunction but also areas of specific dysfunction (Mate-Kole, Major, Lenzer, & Connoly, 1994). Several screening instruments will be discussed within the context of potential rehabilitation applications. Rehabilitation counselors are cautioned that (a) these tools represent a non-exhaustive list of screening instruments of varying complexity, (b) screening test results may indicate cognitive difficulty without identifying the source or specific nature of the problem, (c) the limits of the instrument should be considered in drawing conclusions, (d) results should be incorporated into rehabilitation planning as only one component of assessment and observations, and (e) additional professional consultation should be considered (e.g., referral to a neuropsychologist, physician or other health professional).

HELPS

HELPS (Picard et al., 1991) is a brief screening device for determining if a person may have experienced a traumatic brain injury. This set of five standardized questions is especially useful because most initial physical and mental health assessments do not elicit information about possible TBIs (e.g., simply asking if a person had any significant blows to the head is often not enough to produce an accurate response). For various reasons (forgotten trauma, avoidance of stigma, preoccupation with current problems), individuals may not recognize a head injury until specific features, such as loss of consciousness and other symptoms are described to them.

HELPS is administered by reading the following questions to the client:

(H) Did you ever hit your head? Were you ever hit on the head?

(E) Were you ever seen in an emergency room? (by a doctor or hospitalized?)

(L) Did you lose consciousness? For how long?

(P) Did you have any problems after you hit your head? (includes list of possible symptoms)

(S) Any other significant sickness? (e.g., hospitalizations for brain cancer, meningitis, stroke, heart attack; domestic violence or repeated shaking as a child)

One point is scored for every question answered "yes." If the client scores two or more points, and particularly if the client's functioning has been affected (P), then there exists a sign of possible injury and the need for a more extensive interview and medical work-up (Picard et al., 1991). HELPS was designed to be used by professionals whose primary field of practice is other than TBI (chemical dependency counselors, law enforcement officials, state vocational rehabilitation counselors, physicians, and teachers). A self-assessment version of HELPS is also available. SELF-HELP enables individuals to respond without the presence of an interviewer as well as allowing for administration to larger populations that might not access rehabilitation services (Picard et al., 1991). Studies on the validity of HELPS and SELF-HELP are in their preliminary stages.

Philadelphia Head Injury Questionnaire (PHIQ)

The PHIQ (Curry, Ivins, & Thomas, 1991) is a structured information-and history-gathering instrument which can be used to identify the presence of both objective and subjective symptomatology resulting from all degrees of head trauma. It is designed for use as an aid in documenting areas for further investigation and/or for making appropriate referrals. It is not intended for use as a diagnostic tool. The PHIQ can be administered by a variety of professionals (e.g., psychologists, neurologists, attorneys, rehabilitation counselors) providing services to individuals who have sustained head trauma. However, it is recommended that users of the PHIQ have some knowledge of head injury assessment or seek expert assistance in interpreting results.

The PHIQ is divided into seven sections. These include: identifying information; accident information; persistent symptoms; cognitive aspects of head injury; personality changes; pertinent personal/medical history; and comments and/or additional information. The questionnaire items reflect the constellation of symptoms consistently presented by individuals who have sustained head trauma. Simple language and a yes-no format is used whenever possible so that the time needed for administration is relatively brief, and the questionnaire can be completed in a variety of settings (e.g., inpatient, outpatient, rehabilitation, medical, legal). The PHIQ can be self-administered, but administration by a skilled interviewer will generally increase reliability. Reliability can also be increased by asking a family member to complete the PHIQ as well.

Quick Cognitive Screening Test (QCST)

The QCST is a brief (15-30 minute) screening instrument which was designed to detect global cognitive dysfunction as well as specific areas of cognitive dysfunction (Mate-Kole, et. al., 1994). This tool assesses orientation, attention and concentration, memory, language, construction, perception, spatial ability, and abstract reasoning. The QCST scoring is multidimensional with a score for each subtest as well as summary and global scores. This design allows for the likelihood of detecting impairment in a specific cognitive area (e.g., memory) when a global score alone my not indicate impairment. A preliminary validation study (Mate-Cole, et al., 1994) demonstrated the test's validity and reliability as a screening instrument for the detection of cognitive dysfunction.

The QCST is intended to serve as a preliminary or initial step in assessment (e.g., to identify the need for a more comprehensive neuropsychological examination) which can determine the presence of cognitive impairment and the cognitive area(s) affected (i.e., functional implications). It is not intended to diagnose organicity or identify the source of impairment (e.g., psychiatric illness, use of psychotropic medication, brain injury). The instrument is portable and is amenable to administration by health professionals other than neuropsychologists. In addition to potential use as a screening tool, the QCST has been proposed as a measure of a patient's level of cognitive functioning change as a result of rehabilitation intervention.

Behavior Change Inventory (Inventory of Pre- versus Post-Behaviors with Brain Injury)

The Behavior Change Inventory (BCI) (Hartlage, 1989) is a 68-item self-report behavior change inventory intended to identify specific behaviors that have changed subsequent to a brain injury or other specific event causing central nervous system damage. In addition to completion by individuals who have sustained a brain injury, the instrument can also be completed by parents, spouses, or others (e.g., teacher, co-worker, neighbor).

The BCI form has two separate columns for responses to differentiate between behaviors that describe the way the individual functioned before the injury and behaviors that describe how the individual currently functions. The respondent checks those behaviors which apply to each time period. Examples of behavioral items include: short-tempered, meek, forgetful, carefree, polite, easily upset. The author suggests that if the inventory is intended to compare status of behavior over time (e.g., improvement, deterioration) due to a programmatic regimen, then intervals of 1 month or greater between administrations are recommended. He also indicates that although the BCI is not intended for use as a diagnostic instrument or test, it can provide the examiner with a systematic approach to determining whether behaviors or feelings have changed after a given date or point of reference.

Cognitive Behavior Rating Scales (CARS)

The CBRS (Williams, 1987) was designed to assess the presence and severity of cognitive deficits, behavioral problems, and observable neurological signs. It requires a reliable observer (usually a family member) to rate the everyday behaviors of the person in question. It can be particularly helpful with clients who are unable to reliably rate their own cognitive deficits. It may also be a useful way to estimate what the client's functioning level was prior to the traumatic brain injury.

The CBRS, which can be administered in 15-20 minutes, contains the following nine scales: language deficit; apraxia; disorientation; agitation; need for routine; depression; higher cognitive deficits; memory disorder; and dementia. The 116 items are rated along a 5-point scale with 1 meaning "not at all like this person" and 5 meaning "very much like this person" (Williams, 1987). The items describe various symptoms of TBI (e.g., "has difficulty following directions;" "cannot tolerate frustration;" "becomes anxious when leaving familiar surroundings"; "forgets where he or she is").

Scores are interpreted in terms of percentiles, with low scores (1st-5th percentile) suggesting impairment. The manual suggests comparing high and low scores and eliciting more specific information about the rated deficits. However, caution should be used when interpreting scores for persons with suspected mild TBI since normative data for the CBRS is based on a standardization sample of individuals who were primarily elderly and/or disabled by Alzheimer's disease and other related disorders. Further research is needed to determine its appropriateness in screening for suspected mild TBI.

Summary

Mild TBI can result in serious physical, cognitive, emotional, social; and economic problems, particularly for those individuals who do not receive appropriate diagnosis and intervention. Failure to recognize and acknowledge the potential functional severity of this disability may lead to denial of much needed rehabilitation services. When mild TBI is suspected, screening is obviously only the first step in the process. The next step is often referral for additional testing (e.g., medical, neuropsychological) to obtain an accurate diagnosis. A critical factor in making an appropriate referral is the expertise the referral consultant (e.g., physician, neuropsychologist) possesses in the area of mild TBI. Additionally, the referral consultant should be competent at identifying functional strengths and limitations and at making specific recommendations for circumventing, correcting, or ameliorating limitations.

Clearly, more research and training is needed in this area. Rehabilitation counselors can gain a greater understanding of mild TBI by reading, attending workshops, classes, or seminars, and by becoming actively involved with individuals who have sustained a mild TBI. The National Head Injury Foundation (NHIF) can be a useful resource for acquiring more information. Their national hotline number is 800/444-6443. Additionally, handbooks such as Recognizing Brain Dysfunction: A Guide for Mental Health Professionals (Holmes, 1992) and Screening for Brain Impairment (Berg, Franzen, & Wedding, 1994) provide detailed screening information. Educational videos and handbooks (e.g., Wish & McLeish, 1994) are available as resources for continuing education and staff inservices. The more rehabilitation counselors educate themselves about mild TBI and its consequences, the better they will become at screening for possible organicity.

Acknowledgement

Special thanks to following rehabilitation professionals in Arizona who provided input to the senior author regarding their experiences working with persons with mild traumatic brain injury: Judith Bergman, Stephen Bergman, Kathleen McAlpine, Lynda Weaver, Rae Oldemeyer, Carole Nay, Michael Simpkins, and Ruth Van Vloat.

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Received: November 1994

Acceptance: February 1995

Ruth Torkelson Lynch, Ph.D., Assistant Professor, Department of Rehabilitation Psychology and Special Education, University of Wisconsin-Madison, 432 North Murray Street, Room 431, Madison, Wisconsin 53706. Electronic mail address: [e-mail].