Deployment-Related Traumatic Brain Injury and Co-Occurring Conditions
A Course for Civilian Health Care Providers from BrainLineMilitary.org
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VIDEO: Course II: Deployment-Related TBI and Co-Occurring Conditions Intro
Begin this course by watching this video.
"You just really have to sit down, get to know your patient and then treat them symptom by symptom "
About This Course
This course is for civilian health care workers who will be seeing military service members veterans or members of the National Guard or Reserve who had a mild traumatic brain injury (mTBI or concussion) and now have ongoing related symptoms. More than 200,000 American men and women have incurred a concussion during their service in Iraq or Afghanistan, and a significant number of these men and women will experience other medical concerns in addition to their mTBI. For people who have ongoing symptoms, experts are now treating traumatic brain injury as a chronic health condition. A small but significant percentage of people will have problems that persist beyond the immediate time frame of the injury.
Watch this video segment from Capt. J.L. Hancock, who sustained a concussion/mTBI in Afghanistan:
VIDEO: Capt. J.L. Hancock Shares His Story and His Questions
Capt. J.L. Hancock Shares His Story and His Questions
Capt. J.L. Hancock discusses his persistent symptoms after sustaining a deployment-related traumatic brain injury.
During this course, if you have any questions, please email firstname.lastname@example.org and a TBI expert will respond promptly.
This course will help you identify and treat the co-occurring conditions that are common in deployment-related concussion.
Family nurse practitioner Helen Coronel describes the important role of primary health care providers in treating both the acute symptoms of concussion and the co-occurring conditions that may continue to cause problems after the resolution of the concussion injury itself.
VIDEO: Treating Concussion at the Primary Care Level
Treating Concussion at the Primary Care Level
Oftentimes, though in a civilian population, what you're dealing with isn't an acute concussion. You're dealing with these co-occurring conditions which have been brewing for a long time
What You'll Learn
Here you'll find information about:
- The most common co-occurring conditions associated with concussion
- Recommended treatments for these conditions
- Prognosis when conditions are identified and treated
- Related resources for service members and their families
This course includes an introduction and six sections:
At the end is a post-test that provides a score and feedback on incorrect answers.
How the Course Works
You can follow the course from start to finish by using the "next" button at the bottom of each page. Arrows on the right and left of each page allow you to move back and forth between pages. You can jump to any section by clicking on the section titles across the top of the course. You can keep track of your progress by checking the progress bar at the top of each page. Links to additional resources are listed on the last page of each section.
Need a refresher on concussion/mTBI?
If you would like to take a step back and review the basics of concussion/mTBI, please take the first course in our series, Identifying and Treating Concussion/mTBI in Service Members and Veterans.
What Is Traumatic Brain Injury?
In order to understand the persistent symptoms that can accompany a concussion or mild TBI, it is important to first understand the general characteristics of the broader condition of traumatic brain injury or TBI.
A traumatic brain injury (TBI) is a blow or jolt to the head that disrupts the normal function of the brain. The severity of the TBI is determined at the time of the injury and may be classified as: mild, moderate or severe.
A concussion, or mild traumatic brain injury is the most common type of TBI. CDC
To learn more about concussion in a military context, please view our web course: Identifying and Treating Military Traumatic Brain Injury.
Five Guiding Principles
Before diving into the details of treating the symptoms or co-occurring conditions that may accompany concussion, here are a few principles to guide you.
First Guiding Principle: Take a Thorough Clinical History
This is probably the single most important thing you can do. Here is a checklist that asks about previous brain injuries with some questions you can ask.
- What was the service member's health like before this concussion? For example, was this her first ever (military or civilian) concussion?
- Did he have headaches before the trauma?
- Did the service member have a history of substance abuse or psychological issues including stress before the injury?
- Does the service member have a history of learning disabilities or attention deficit disorder?
If the service member had headaches or psychological issues prior to this concussion, he or she has a greater likelihood of having persistent problems after the injury. While it's helpful to understand which symptoms are likely related to one or more recent concussions, it's even more important to treat the presenting symptoms because if untreated, these symptoms can become significant problems.
Nurse practitioner Helen Coronel explains why it's so important to understand which symptoms are new versus pre-existing:
VIDEO: Getting a Thorough History Is the Necessary Starting Point for Patients with TBI
Getting a Thorough History Is the Necessary Starting Point for Patients with TBI
"Oftentimes, it's been months even years from the time that this person has suffered the injury to the time that you're going to see them in your practice "
Sometimes, problems don't seem obvious until the service member is back home. Changing routines and environments can highlight symptoms that might have been overlooked in the deployed setting.
Adam Anicich talks about going back to work and realizing that something was different:
VIDEO: When Problems Linger Past the Normal Readjustment Period
When Problems Linger Past the Normal Readjustment Period
"I was having troubles remembering the names of the customers or what I'd helped them with there was just a huge difference in my personality, a huge difference in my temperament."
Second Guiding Principle: Be Optimistic
Be optimistic about the likelihood of recovery. Most people who have persistent symptoms after a concussion do in fact recover well, and an upbeat outlook demonstrably aids recovery. Neuropsychologist Cynthia Boyd emphasizes the importance of positivity:
VIDEO: I Tell My Patients: "TBI Is a Temporary Condition"
I Tell My Patients: "TBI Is a Temporary Condition"
"You are young. You have the whole future ahead of you. We need to get you well right now, so you can prepare for it."
Third Guiding Principle: Have Patience
Realize that the longer the symptoms have been present, the more challenging and complex it may be to treat them. It may help service members to understand that it could take some time to see improvement but you will work with them to find an effective treatment.
VIDEO: Healing From TBI Is Often Not Something People Can Do on Their Own
Healing From TBI Is Often Not Something People Can Do on Their Own
"This wasn't something I was going to be able to fix on my own. It was really something that was going to require pretty advanced cognitive therapy "
Fourth Guiding Principle: Family Involvement
Remember family support can have a big impact on recovery. Physical therapist Katie Stout urges families to get involved. Additional resources for families can be found at the end of this section.
VIDEO: Involving the Family in Tailoring a Service Member's Long-Term Treatment Program
Involving the Family
"Involving the family with the service member's treatment plan is really imperative to helping them through long-term recovery "
The love and support of family and friends can also have an enormous impact on the recovery process. Helping families understand their crucial role can go a long way to achieving positive outcomes.
VIDEO: Educating Families and Children
Educating Families and Children
Capt. J.L. Hancock discusses the importance of education and family involvement as part of the treatment protocol for service members with mTBI.
Fifth Guiding Principle: Non-pharmacological Interventions
Try to use non-pharmacological interventions whenever they are indicated and appropriate. That's because medications that help one condition can worsen another. For example, prescriptions for pain can aggravate cognitive problems, anxiety medications (e.g., benzodiazepines) can increase balance problems, and SSRIs for depression can contribute to sexual dysfunction. Consider starting with a low dose and increase as necessary. Minimizing the number of pharmaceuticals an individual takes has the added benefit of reducing the risk of dangerous drug interactions.
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Sleep problems are among the most common symptoms that can accompany service-related concussion. Erratic work schedules may mask the problem initially. It's important to ask about sleep difficulties so problems can be identified and treated promptly. Better sleep can result in improved mood, reduced stress, and fewer headaches.
VIDEO: In the Quiet After Returning from Combat, Sleep Problems Become Louder
In the Quiet After Returning from Combat, Sleep Problems Become Louder
"I started to notice problems with my sleep after I was injured in Iraq "
Stress and hypervigilance can also contribute to difficulty with sleep. Physician John Rigg explains that many returning service members have left one war only to find themselves in another.
VIDEO: "War" with Sleep After Brain Injury
"War" with Sleep After Brain Injury
"Their amygdala has them pumped up, 'don't sleep, it's dangerous, people can get you.' So they'll wake up "
Treatment for sleep problems begins with common sense. Neuropsychologist Alison Cernich suggests asking service members about their "sleep hygiene."
VIDEO: Sleep Problems After a TBI May Not Be TBI-Related
Sleep Problems After a TBI May Not Be TBI-Related
"What you want to find out is what they're doing prior to going to sleep "
Finally, here are more practical tips for service members with concussion who are having trouble sleeping:
Getting a good night's sleep especially after a TBI is often harder than it seems.
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Coping with multiple problems after a concussion can make the frustrations of daily life seem overwhelming. Capt. J.L. Hancock likens this to overstretching a balloon.
VIDEO: Picture a "Mood Balloon"
Picture a "Mood Balloon"
"In normal, everyday life, that balloon's about half-full. So as you add problems of everyday life, you can contain it, it doesn't blow up "
Changes in Mood
Changes in mood and emotions often accompany concussion. Problems with memory and concentration can be frustrating. Sleep problems can add to irritability, as can headache and other kinds of pain. Alcohol can also alter mood. All of these combined factors can affect an individual's emotional state so assessing and treating mood should be a top priority.
VIDEO: Helping Patients with Mood Disorders
Helping Patients with Mood Disorders
"It's important for you to get that full history, like you would with any patient presenting with a mood disorder, and understand them "
One of the most common mood problems that can occur with concussion is depression. It's important to ask if the service member had any signs of depression prior to the mTBI. Prior psychological health issues should be carefully examined to determine if, and how, the intensity and severity of symptoms have changed since the concussion.
Dr. Joel Scholten says it's critical to ask people who seem sad or lethargic if they have had suicidal thoughts.
VIDEO: Thoughts of Suicide Are Not Uncommon After a Brain Injury
Thoughts of Suicide Are Not Uncommon After a Brain Injury
"When we think of depression we also need to think about risk of suicide "
Current suicidal thoughts need to be treated as an emergency. A report of occasional suicidal thoughts merits prompt referral and follow-up. Here are resources for service members:
Rehabilitation psychologist Karl Hursey discusses some of the causes of depression in returning service members.
VIDEO: The Physiological and Psychological Causes of Depression
The Physiological and Psychological Causes of Depression
"The person is often faced with multiple losses — loss of a career, perhaps loss of family, depending on how things unravel when they come back "
To be diagnosed with clinical depression, the individual must either have a depressed mood or have lost interest in pleasurable activities. View the complete definition of clinical depression.
In addition, your patient must have at least five of the following symptoms lasting more than two weeks:
- Sleep disturbance
- Anhedonia (loss of enjoyment in daily activities)
- Feelings of guilt, hopelessness, or worthlessness
- Trouble concentrating
- Reduced energy
- Alteration in weight or appetite
- Psychomotor agitation or retardation
- Suicidal ideation
- Somatic complaints
Even if someone does not meet the clinical criteria of depression, it's still important to recognize the signs and symptoms. Treatment should include evidence-based modalities if the depression is at the level of a disorder.
Here are treatment guidelines for depression, including an overview in the context of concussion:
Learn more about how depression and brain injury are connected.
Heightened anxiety is a common persistent symptom after a concussion. A service member might not be aware of this new level of worry until he or she returns to civilian life. Army Veteran Adam Anicich talks about how problems with remembering added to his anxiety.
VIDEO: Big, Crowded Events Are Difficult After a Brain Injury
Big, Crowded Events Are Difficult After a Brain Injury
"One thing that I just try and do is not be too hard on myself "
Anxiety is also one of the most common emotional changes in service members who have fought in Iraq and Afganistan, where many have experienced multiple tours of combat.
VIDEO: Concussions in Military Population Often Come with Anxiety
Concussions in Military Population Often Come with Anxiety
"Keep in mind that typically these concussions are the result of a terrorist activity, you have somebody who's also dealing with some anxiety issues "
Rehabilitation psychologist Karl Hursey discusses two of the reasons for heightened anxiety.
VIDEO: Brain Injuries Can Inhibit People's Coping Mechanisms
Brain Injuries Can Inhibit People's Coping Mechanisms
"An uncontrollable challenge, or even threat, is much worse than one that we're confident that we have a plan for and we're going to be able to manage."
Treatment for anxiety with counseling and/or medication is usually successful, so there's no reason not to get started immediately. Here are some treatment guidelines:
Following a life-changing event like a brain injury, it’s normal to feel intense stress. But sometimes stress can build up and lead to anxiety.
Another emotional change that commonly accompanies concussion and perhaps the one that needs most urgent intervention is irritability. Neuropsychologists Cynthia Boyd and Alison Cernich offer insight into some of the contributing factors.
VIDEO: Irritability After a TBI: Normal but Potentially Dangerous
Irritability After a TBI: Normal but Potentially Dangerous
"In the constellation of symptoms that I see in returning service members, one of the greatest behavioral symptoms is irritability "
Sleep problems and headaches can both cause irritability as well as worsen it.
Discuss ways to manage situations that are frustrating and strategize about avoiding circumstances that can trigger outbursts. Anger management skills including self-calming strategies, relaxation techniques, and communication methods — can be helpful as well. Consider referring the service member to a psychologist or other mental health worker who has experience with these techniques.
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Pain & Headache
Along with sleep problems, chronic pain is the most common presenting symptom of men and women with long-lasting effects of a service-related concussion.
VIDEO: Dealing with Concurrent Pain After a Brain Injury
Dealing with Concurrent Pain After a Brain Injury
"I used to be a lot more resilient and recover faster now it takes a week or two. That's definitely frustrating."
Chronic pain is pain that lasts longer than the normal healing time for a particular injury. More specifically, chronic pain is defined as pain that lasts longer than three to six months and is not associated with reversible conditions, for example, damage to the spine.
VIDEO: The Many Layers of Chronic Pain
The Many Layers of Chronic Pain
"Pain is good. Why is pain good? It tells you something's wrong, something's not working "
Capt. J.L. Hancock talks about the course of his recovery and the types of pain he continues to experience.
VIDEO: How Capt. J.L. Hancock Has Dealt with His Three Phases of Recovery from Brain Injury
Three Phases of Recovery
Capt. J.L. Hancock breaks down his recovery from his brain injury into three phases and talks about his persistent pain.
Headaches often follow a concussion and they can persist even when other symptoms have resolved.
VIDEO: Post-Concussive Headaches: "A Pulsating, Rumbling Fight Inside Your Head"
"The headaches are so severe that sometimes you're unable to concentrate. There's just a pulsating rumbling fight within your own head that makes it impossible to concentrate. "
Family nurse practitioner Helen Coronel emphasizes the importance of taking a good history before deciding on a treatment approach:
VIDEO: How Long Have These TBI-Related Headaches Been Going On?
How Long Have These TBI-Related Headaches Been Going On?
"You also want to get an idea of, did they have headaches prior to this injury, because that's going to be significant."
Nurse practitioner Helen Coronel explains why sleep problems should usually be addressed before treating the headaches.
VIDEO: Look at Sleep Issues Then Headaches
Look at Sleep Issues Then Headaches
"If you're dealing with a service member or a veteran who's had headaches, and you want to treat them, the first thing you want to look at is sleep "
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Stress is a normal reaction in combat situations. Keep in mind that for service members injured by an improvised explosive device (IED), not only was the blast a horrific and stressful event in and of itself, but it may have killed or injured close comrades.
John Rigg, an M.D. and rehabilitation specialist, discusses battlefield stress:
VIDEO: Stress, Not Craziness
Stress, Not Craziness
"One of the most important things that I tell the soldiers is they're not crazy. They're having a normal reaction to an abnormal situation "
PTS and TBI
Concussion frequently co-occurs with PTS (post-traumatic stress) in this population.
So when evaluating a patient for concussion, consider the possibility that your patient may have PTS, or PTS and concussion. If your patient has PTS (with or without concussion), making the diagnosis is valuable because evidence-based treatments are available.
Here is a brief overview of post-traumatic stress treatments from the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
The signs and symptoms of concussion and PTS overlap considerably, so use the graphic below to learn the symptoms that can help you discriminate between concussion and post-traumatic stress for patients who have only one or the other. A printable version of this graphic is available for download here.
Reference: Stein MB, McCallister TW (2009). Exploring the convergence of post-traumatic stress disorder and mild traumatic brain injury. Am J Psychiatry; 166:766-776.
Regardless of the cause of the symptoms, treating the symptoms themselves is the right approach.
Many returning service members will experience post-traumatic stress (PTS) without necessarily meeting the diagnostic criteria for post-traumatic stress disorder (PTSD), which is discussed below.
Read the following brief article which outlines ways to manage any kind of post-combat stress:
Stress weighing you down? Learn some easy ways to manage stress related to TBI.
Among men and women who served in Iraq and Afghanistan, Post-Traumatic Stress Disorder is common and can occur with or without a concussion. To merit a diagnosis of PTSD, a service member must have experienced not only a horrific, stressful, traumatic event, but also must re-experience that trauma persistently, avoid reminders of the event (certain places or objects, for example), and display increased arousal. With PTSD, these symptoms persist longer than a month and interfere materially with the service member's life. Neuropsychologist Cynthia Boyd describes a corpsman with multiple blast exposures who re-experiences a trauma in a manner consistent with PTSD:
VIDEO: Life After Five Deployments and TBI
Life After Five Deployments and TBI
"He thought they were under fire. He went in a full on flashback "
PTSD symptoms that emerge after a concussion can be treated with various types of therapy and/or medication. Therapies that have been found effective in the treatment of PTSD include exposure therapy, cognitive therapy, anxiety management and eye movement desensitization and processing (EMDR). Some service members find one type more effective than others, whereas, a combined approach may be more beneficial. Effective medications for PTSD may include tricyclic antidepressants (TCAs), Monoamine Oxidase Inhibitors (MAOIs), Selective serotonin reuptake inhibitors (SSRIs), mood stabilizers and/or anti-anxiety agents. Providers often individualize treatment based on the service member's needs, preferences, tolerance and reaction. A concussion may increase the challenge of managing multiple medications and possible side effects so, if possible, first consider non-pharmacological interventions.
For an overview of PTSD treatment methods, read this short article:
Learn about treatments for PTSD.
Remember that it's more important to treat symptoms of stress than to spend time and resources trying to decide whether someone meets the diagnostic criteria for PTSD.
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Attention & Memory
After a concussion people often complain about difficulty remembering appointments, trying to learn and retain new information, and generally feeling foggy and unfocused. Memories before the injury are usually intact.
VIDEO: Fast Conversations and Loud Groups: Challenging for Those with TBI-Related Short-Term Memory Issues
Fast Conversations and Loud Groups
"I noticed myself having troubles with short-term memory and attention when the subject is rapidly transitioning "
Attention, focus, and memory are closely related. Sometimes a service member may function well in some areas but may have surprising gaps in his abilities.
VIDEO: Cognitive Symptoms Can Change in the Short- and Long-Term Post-TBI
Cognitive Symptoms Can Change in the Short- and Long-Term Post-TBI
"Where truly I got into what I felt were cognitive difficulties was I began to have some problems with memory "
After a concussion, returning service members frequently report problems with memory, but often the real problem is attention, as physician John Rigg explains:
VIDEO: The Root Causes of Memory Problems Post-TBI and PTSD
The Root Causes of Memory Problems Post-TBI and PTSD
"In about 87 percent of our patients who complain of memory problems, neuropsychological testing has not found any cognitive deficits."
Regardless of the etiology of memory problems, a piece of everyday technology can help these service members, according to neuropsychologist Alison Cernich.
VIDEO: After a Brain Injury, a Phone Can Be Far More Than "Just a Phone"
A Phone Can Be Far More Than "Just a Phone"
"A phone can be almost like the best memory notebook we could have ever invented "
This tip sheet offers more practical tips for coping with cognitive problems after a concussion:
Tips patients with traumatic brain injury can use to improve their memory.
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Returning service members have a higher rate of alcohol and substance use than Americans of the same age who have not seen combat. One of the contributing factors may be self-medication for chronic pain or sleep problems, according to nurse practitioner Helen Coronel:
VIDEO: Drinking Alcohol Is Counter-Productive When Trying to Get Good Sleep After a Brain Injury
Drinking Alcohol Is Counter-Productive When Trying to Get Good Sleep After a Brain Injury
"Typically it's sleep that's going to get them to use alcohol as a self-medication "
Cognitive and mental issues arising from combat exposure can also contribute to drug abuse. With so many contributing factors, the rate of substance abuse is high in returning service members who have had a concussion.
VIDEO: Alcohol Abuse Is Unfortunately All Too Common for Young Service Members with TBI
Alcohol Abuse Is Unfortunately All Too Common for Young Service Members with TBI
"In my career prior to this, I've never seen a large population of young men drink to this extent in the numbers that I've seen."
After a concussion, alcohol and other drug use can:
- lengthen the time of recovery.
- further damage a brain that’s already injured.
- lower the threshold for seizures.
- increase the likelihood of aggressive behavior.
- interfere with cognition that is already compromised by injury.
The age of the service members as well as the military culture they come from also contribute to this issue.
VIDEO: The Brain Is More Vulnerable to the Effects of Alcohol After a Concussion
The Brain Is More Vulnerable to the Effects of Alcohol After a Concussion
Dr. Boyd explains how to talk about alcohol use with this population.
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Resources for Health Care Providers
If you require one-on-one advice or information, please call the DCoE 24/7 Outreach Center: 1-866-966-1020.If you need help understanding military jargon or acronyms, please refer to the following document: War Psychiatry Acronyms and Abbreviations.
Look at this resource to see the Department of Veterans Affairs' advice for treating substance abuse: Substance Abuse.
Resources for Service Members and Their Families
Your patients and their families can get more information about concussion and what resources are available at any of the following sites:
- Defense and Veterans Brain Injury Center: Family & Friends Resources
- BrainLineMilitary.org Resource Directory: Finding Help Near You
- BrainLine.org: For Family and Friends
- Traumatic Brain Injury: The Journey Home
- Afterdeployment.org Getting Help
- Brain Injury Association of America
Each of the branches of the military Army, Navy, Marines, and Air Force has targeted resources for injured service members:
- Army Wounded Warrior Program: Dial 1-877-393-9058 or e-mail email@example.com.
- Air Force Wounded Warrior Program: Dial 1-800-581-9437 or e-mail firstname.lastname@example.org.
- Navy Safe Harbor: Dial 1-877-746-8563 or e-mail email@example.com.
- USSOCOM Care Coalition: Dial 1-877-672-3039.
- Veterans Crisis Line (suicide): Dial 1-800-273-8255 and press 1.
- Marine Wounded Warrior Regiment Call Center Phone: Dial 1-877-4USMCWW or 1-877-487-6299.
This article from DVBIC can help family members sort through those resources: Support for Wounded Service Members and Their Families.
Defense and Veterans Brain Injury Center
Lead Content Producer: Sherray Holland, P.A.-C., Neuroscience Clinical Advisor
Executive-in-Charge: Michael Wilmore, M.P.A.S., P.A.-C., Director of Clinical Affairs
Executive Producer: Sherry Chiasson, M.B.A./H.A., B.S.W., Manager, Multimedia Education Materials and Distribution
Co-Executive Producer: Leslie Shupenko, M.S., C.C.R.P., Former Manager, Office of Clinical Initiatives
Copy Editor: Susan Schept, Medical Writer
TBI Subject Matter Experts
Adam Anicich, Deputy Director of the Congressional Liaison Service, Department of Veterans Affairs
Cynthia Boyd, Ph.D., Co-Senior Scientific Director and Clinical Neuropsychologist, DVBIC Naval Medical Center San Diego
Alison Cernich, Ph.D., VA Senior Liaison for TBI, DCoE
Helen C. Coronel, M.S.N., B.C., Neuroscience Clinician, DVBIC
Capt. J. L. Hancock, M.D., U.S. Navy
Karl G. Hursey, Ph.D., Rehabilitation Psychologist, DVBIC
John L. Rigg, M.D., Program Director, TBI, Dwight D. Eisenhower Army Medical Center
Joel Scholten, M.D., Associate Chief of Staff, Rehabilitation Services, Washington D.C., VA Medical Center
Katie Ambrose Stout, P.T., D.P.T, M.S., C.B.I.S., Tele-Rehab Chief for the Army's Northern Region Department of Telemedicine
Producer: John Rubin, Ph.D., John Rubin Productions, Inc.
Co-Producer: James Donald, John Rubin Productions, Inc.
Medical Consultant: John Whyte, M.D., Ph.D., Moss Rehabilitation Research Institute
Web Producer: Kelly Deckert
Web Developer: Ian Collins
Associate Project Manager: Krystal Klingenberg
Editor: Victoria Tilney McDonough
Project Coordinator: Justin Rhodes
Executive Producer: Victoria Youcha, Ed.D.