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Traumatic Brain Injury in Children and Adolescents Katherine C. Nordal, Ph.D. The Nordal Clinic Vicksburg, MS 39183

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Presentation on theme: "Traumatic Brain Injury in Children and Adolescents Katherine C. Nordal, Ph.D. The Nordal Clinic Vicksburg, MS 39183"— Presentation transcript:

1 Traumatic Brain Injury in Children and Adolescents Katherine C. Nordal, Ph.D. The Nordal Clinic Vicksburg, MS

2 Traumatic Brain Injury n Injury to brain n External force n Total or partial disability or psychosocial impairment n 1 or more areas n Cognition, language, memory, attention, reasoning, abstract thinking, judgment, problem solving, sensor, perceptual, or motor abilities, psychosocial behavior, physical functions, information processing, speech

3 TBI does NOT include n strokes, vascular accidents n anoxic injuries, infections n tumors, metabolic disorders n exposure to toxic substances

4 Types of Brain Injuries n Open brain injuries n Closed brain injuries 1. Diffuse1. Diffuse 2. Focal2. Focal

5 Severity of Brain Injury n Mild: brief or no LOC, nausea, signs of concussion, GCS , PTA < 1 hr, 50%- 75% n Moderate: coma < 6 hrs, skull fracture or bleeding, GCS 9-12, PTA 1-24 hrs n Severe: coma > 6 hrs, PTA > 1 day, GCS 3-8

6 Glasgow Coma Scale (GCS) n Eye Opening Spontaneous4Spontaneous4 To speech3To speech3 To pain2To pain2 None1None1 n Best Motor Response Obeys command6Obeys command6 Localizes pain5Localizes pain5 Withdraws from pain4Withdraws from pain4 Abnormal flexion to pain3Abnormal flexion to pain3 Extension to pain2Extension to pain2 None1None1 n Verbal Response Oriented conversation5Oriented conversation5 Confused conversation4Confused conversation4 Inappropriate words3Inappropriate words3 Incomprehensible sounds2Incomprehensible sounds2 None1None1

7 GCS Facts n 8 is the critical score n 90% with scores less than or equal to 8 are in a coma n 50% with scores less than or equal to 8 at 6 hours will die

8 Post Traumatic Amnesia (PTA) n Time after coma when person is still unable to form new memories n Measured by COAT or GOAT

9 Rancho Los Amigos Scale n Level I No Response n Level IIGeneralized Response n Level IIILocalized Response n Level IVConfused/Agitated n Level VConfused/Inappropriate Nonagitated n Level VIConfused Appropriate n Level VII Automatic, Appropriate n Level VIII Purposeful, Appropriate

10 Epidemiology n Who gets injured? TBI not randomly distributed TBI not randomly distributed Predominately male Predominately male Lower SES Lower SES High family or life stress High family or life stress Behavioral propensity toward risk taking and high action levels Behavioral propensity toward risk taking and high action levels

11 Epidemiology n Who gets injured? 3-8 year olds 3-8 year olds year olds year olds n Kids at greatest risk: HA/ emotionally disturbed/delinquent HA/ emotionally disturbed/delinquent Under 5, w/ prior adjustment problems, of low SES, parents w/ problems Under 5, w/ prior adjustment problems, of low SES, parents w/ problems

12 Risk Factors for TBI n Prior behavioral problems n Family stress n Family instability n Crowded living conditions n Prior TBI

13 Major Causes of Brain Injuries n Infants: accidental dropping, physical abuse, shaken baby syndrome n Toddlers and Preschoolers: falls, car accidents, physical abuse n Elementary school children: car and bike accidents, playground and recreational accidents n Adolescents: car accidents, sports injuries, assault

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15 TBI: Some Statistics n 7,000 deaths of children n >500,000 hospitalizations n Hospital care costing over $1 billion n 30,000 children becoming permanently disabled

16 TBI: Some Statistics n The NHIF estimates that < 10% of all who survive TBI receive adequate rehab to return them to self- sufficiency n TBI survivors requires between $4 and $9 M for a lifetime of care n TBI accounts for about 16% of all pediatric hospital admissions for children between the ages of birth and 14 n 50% of battered children who survive a TBI suffer permanent neurological, intellectual, and psychological impairment

17 What Happens After the Injury? PhysicalCognitivePsychosocialBehavioral/Emotional

18 Physical Effects n Reduced stamina and endurance n Regulation of physical functions n Motor deficits, ataxia n Seizures and/or headaches n Skeletal deformities n Hormonal and body temperature changes n Dysarthria

19 Cognitive Effects n Short and long term memory problems n Intellectual functions hindered n Attention and concentration diminished n Language difficulties n Academic functioning reduced

20 Psychosocial Effects n Depression and anxiety n Social withdrawal n Feelings of worthlessness n Guilt n Loss of interest in school and family activities

21 Behavioral Effects n Acting socially inappropriate..loss of friends n Being unaware of ones impact on others...may seek younger peers n Irritable n Impulsive and/or aggressive n More emotional n Unmotivated

22 Emotional Effects n Poorer tolerance, more rigid n Greater dependence, insensitivity n Flat affect, oppositional, blaming n More demanding n More labile, immature coping

23 Factors Influencing Outcome n Type of injury n Medical complications n Severity of injury: carries most weight re: prognosis for recovery n Premorbid functioning Gender and SES do not affect outcome Gender and SES do not affect outcome Pre-injury psychiatric d/o predictive of later problems w/ severe TBI Pre-injury psychiatric d/o predictive of later problems w/ severe TBI

24 Factors Influencing Outcome n General principles: Not just the injury the brain sustains, but the brain that sustains the injury Not just the injury the brain sustains, but the brain that sustains the injury Understand the individual who has the accident, the context in which he/she lives, and will continue to live Understand the individual who has the accident, the context in which he/she lives, and will continue to live Multifactorial influences on outcome at time make dose and response seem hopelessly out of proportion Multifactorial influences on outcome at time make dose and response seem hopelessly out of proportion

25 Factors Influencing Outcome n > 5 y.o., age unrelated to severity of neurocognitive deficits or rate of > 5 y.o., age unrelated to severity of neurocognitive deficits or rate of < 5 y.o., more severe long-term neurocognitive < 5 y.o., more severe long-term neurocognitive deficits May be difficult to determine severity of injury w/ absence of baseline data-- comparison w/ siblings, parents May be difficult to determine severity of injury w/ absence of baseline data-- comparison w/ siblings, parents

26 Factors Influencing Outcome n Pre-existing disorders Injury may interact w/ prior learning disability, low intellectual capacity, psychiatric d/o etc. Injury may interact w/ prior learning disability, low intellectual capacity, psychiatric d/o etc. Addition of even a minor insult to premorbidly compromised individual may produce an apparent disproportionate increment in disability Addition of even a minor insult to premorbidly compromised individual may produce an apparent disproportionate increment in disability

27 Factors Influencing Outcome n Neurological damage more severe than initially realized Overlooked due to other systemic injuries requiring emergency attention, surgery, long convalescence, etc. which put few cognitive demands on patient Overlooked due to other systemic injuries requiring emergency attention, surgery, long convalescence, etc. which put few cognitive demands on patient But, multiple injuries can also produce PCS symptoms with no neurologic substrate But, multiple injuries can also produce PCS symptoms with no neurologic substrate

28 Factors Influencing Outcome n Co-existing habit patterns Alcohol and substance Abuse Alcohol and substance Abuse Previous head injuries Previous head injuries Produce difficulties in life functioning and, in some cases, make individual more susceptible to negative outcome Produce difficulties in life functioning and, in some cases, make individual more susceptible to negative outcome

29 Factors Influencing Outcome n Family competence Well-functioning vs. barely tolerable situation which is poorly managed Well-functioning vs. barely tolerable situation which is poorly managed Injured child may increase strain in already marginally coping family--produce more negative consequences than neurological event itself Injured child may increase strain in already marginally coping family--produce more negative consequences than neurological event itself

30 Factors Influencing Outcome n Recovery Rates Dependent upon severity--milder injuries have faster recovery Dependent upon severity--milder injuries have faster recovery More rapidly a function returns, better the prognosis for that function More rapidly a function returns, better the prognosis for that function Major portion of recovery within first year Major portion of recovery within first year n Note: there are different fields of thought about TBI recovery rates

31 Factors Influencing Outcome n Summary Neurocognitive and psychiatric residuals for kids with mild or even moderate injuries seem less clear and when injuries at this severity level do produce deficits, recovery seems to occur over a short (several months) period of time Neurocognitive and psychiatric residuals for kids with mild or even moderate injuries seem less clear and when injuries at this severity level do produce deficits, recovery seems to occur over a short (several months) period of time Pediatric TBI research is in its infancy-- good longitudinal studies are needed Pediatric TBI research is in its infancy-- good longitudinal studies are needed

32 Factors Influencing Outcome n Management of case Appropriate management of mild to moderate injuries usually results in successful re-integration to school Appropriate management of mild to moderate injuries usually results in successful re-integration to school Inappropriate attribution of pattern of neurocognitive variability to brain injury may generate self-fulfilling negative expectations, misattributions, anxiety Inappropriate attribution of pattern of neurocognitive variability to brain injury may generate self-fulfilling negative expectations, misattributions, anxiety

33 Neuropsychological Assessment: Conceptual Approach n Presenting problem Significant others as informantsSignificant others as informants Childs presentation colored by limitations in conceptual capacity and self-awarenessChilds presentation colored by limitations in conceptual capacity and self-awareness Consistency and contradictions in reportsConsistency and contradictions in reports Pervasiveness/duration of symptoms identity etiologic factorsPervasiveness/duration of symptoms identity etiologic factors

34 n Collection of background information Records of injury/hospitalization Records of injury/hospitalization Neurodiagnostics Neurodiagnostics Length of coma Length of coma Approximate length of PTA Approximate length of PTA Current Medications Current Medications Anticonvulsants can adversely affect test results if blood levels are high Anticonvulsants can adversely affect test results if blood levels are high Neuropsychological Assessment: Conceptual Approach

35 n Collection of background information Premorbid history Premorbid history Medical Medical – prior TBI – History of seizures – Birth records Psychiatric history Psychiatric history Comprehensive developmental history Comprehensive developmental history Family history--trends re: ADD, LD Family history--trends re: ADD, LD School history--attendance, testing, sped, etc. School history--attendance, testing, sped, etc.

36 Neuropsychological Assessment: Conceptual Approach n Appraisal of presenting problems and collection of background information provides an estimate of premorbid functioning, determination of current factors which might influence the assessment process, and hypothesis development about pattern/severity of expected neuropsychological deficits

37 Neuropsychological Assessment: Conceptual Approach n Neuropsychological Examination Selection of assessment procedures determined by nature of referral question, childs age, childs physical and mental capacities, and psychologists own preferencesSelection of assessment procedures determined by nature of referral question, childs age, childs physical and mental capacities, and psychologists own preferences Measures a full range of abilities necessary for success in youths environmentsMeasures a full range of abilities necessary for success in youths environments

38 Neuropsychological Assessment: Conceptual Approach n Assessment Domains General IntelligenceGeneral Intelligence Academic AchievementAcademic Achievement Motor SkillsMotor Skills Sensory, Perceptual, ConstructionalSensory, Perceptual, Constructional Language/SpeechLanguage/Speech Auditory Attention/Information ProcessingAuditory Attention/Information Processing Visual Attention/Information ProcessingVisual Attention/Information Processing

39 Neuropsychological Assessment: Conceptual Approach n Assessment Domains Executive Functions/Problem SolvingExecutive Functions/Problem Solving MemoryMemory Personality/Behavioral/Adaptive SkillsPersonality/Behavioral/Adaptive Skills

40 Assessment Instruments n Neuropsychological Test Batteries Halstead-Reitan Neuropsychological Test Battery for Older Children, 9-14 yrs. Halstead-Reitan Neuropsychological Test Battery for Older Children, 9-14 yrs. Reitan-Indiana Neuropsychological Test Battery for Children, 5-8 yrs Reitan-Indiana Neuropsychological Test Battery for Children, 5-8 yrs Luria-Nebraska Neuropsychological Test Battery for Children, 8-12 yrs Luria-Nebraska Neuropsychological Test Battery for Children, 8-12 yrs NEPSY NEPSY

41 Assessment Domains n General Intellectual Measures Purposes Purposes Overall IQ will be a benchmark for other comparisons Overall IQ will be a benchmark for other comparisons Identify cognitive strengths/weaknesses Identify cognitive strengths/weaknesses Formulate diagnostic decisions Formulate diagnostic decisions Plan intervention strategies Plan intervention strategies

42 Assessment Domains n General Intellectual Measures IQ and brain injury IQ and brain injury Full Scale IQ is the most reliable and valid score from a psychometric viewpoint Full Scale IQ is the most reliable and valid score from a psychometric viewpoint Verbal abilities recover more rapidly Verbal abilities recover more rapidly With severe TBI, PIQs are lowered and deficits are persistent at 5 years post-injury (slowed reaction time, deficits in problem solving and novel tasks) With severe TBI, PIQs are lowered and deficits are persistent at 5 years post-injury (slowed reaction time, deficits in problem solving and novel tasks) Coding, PC, BD distinguish the severely injured; no differences with PA and OA Coding, PC, BD distinguish the severely injured; no differences with PA and OA VIQ-PIQ patterns map recovery of function VIQ-PIQ patterns map recovery of function

43 Assessment Instruments n General Intelligence Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-III), ages 3-7Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-III), ages 3-7 Wechsler Intelligence Scale for Children, Third Ed. (WISC-IV), ages 6-16 yrs Wechsler Intelligence Scale for Children, Third Ed. (WISC-IV), ages 6-16 yrs Wechsler Adult Intelligence Scale, Third Ed. (WAIS-III), ages 16+ yrs Wechsler Adult Intelligence Scale, Third Ed. (WAIS-III), ages 16+ yrs

44 Assessment Instruments n General Intelligence Kaufman Assessment Battery for Children (K-ABC), ages yrs Kaufman Assessment Battery for Children (K-ABC), ages yrs Leiter International Performance Scale Leiter International Performance Scale McCarthy Scales of Childrens Abilities, ages yrs McCarthy Scales of Childrens Abilities, ages yrs Stanford-Binet Intelligence Scale, 4th Ed., ages 2-23 yrs Stanford-Binet Intelligence Scale, 4th Ed., ages 2-23 yrs

45 Assessment Instruments n General Intelligence Woodcock-Johnson Psycho-Educational Battery-Revised: Tests of Cognitive Abilities, ages 3-80 yrs Woodcock-Johnson Psycho-Educational Battery-Revised: Tests of Cognitive Abilities, ages 3-80 yrs Test of Non-Verbal Intelligence, 2nd Ed, yrs Test of Non-Verbal Intelligence, 2nd Ed, yrs Columbia Mental Maturity Scale (CMMS), yrs Columbia Mental Maturity Scale (CMMS), yrs

46 Assessment Domains n Academic Assessment Profile strengths/weaknesses Profile strengths/weaknesses Measures must be comprehensive Measures must be comprehensive Skill based deficits (lack of knowledge) vs. performance based (execution of skills and abilities that may be present) deficits Skill based deficits (lack of knowledge) vs. performance based (execution of skills and abilities that may be present) deficits

47 Assessment Domains n Academic Assessment Academic Performance and Brain Injury Academic Performance and Brain Injury Difficulty with new/novel material Difficulty with new/novel material Slowed information processing Slowed information processing Poor independent work efforts Poor independent work efforts Problems with higher order cognition: generalization, abstraction, organization, planning, strategy generation Problems with higher order cognition: generalization, abstraction, organization, planning, strategy generation Written language particularly susceptible--as an emerging skill that is not well consolidated Written language particularly susceptible--as an emerging skill that is not well consolidated

48 Assessment Domains Academic Performance and TBI Academic Performance and TBI With moderate to severe injuries, reading, writing and math affected and increased need for sped With moderate to severe injuries, reading, writing and math affected and increased need for sped Even with milder injuries, academic performance can be affected Even with milder injuries, academic performance can be affected REMEMBER: Skills demonstrated on individual assessment may not be commensurately demonstrated in the classroom (performance based deficit)--where rapid attention, organization, and retrieval are required REMEMBER: Skills demonstrated on individual assessment may not be commensurately demonstrated in the classroom (performance based deficit)--where rapid attention, organization, and retrieval are required

49 Assessment Instruments n Academic Achievement Kaufman Test of Educational Achievement, 6-18 yrs Kaufman Test of Educational Achievement, 6-18 yrs Wechsler Individual Achievement Test (WIAT-II), 5-adult Wechsler Individual Achievement Test (WIAT-II), 5-adult Woodcock Johnson Psycho-Educational Battery: Tests of Achievement, 2-90 yrs Woodcock Johnson Psycho-Educational Battery: Tests of Achievement, 2-90 yrs Wide Range Achievement Test (WRAT3), 5-Adult Wide Range Achievement Test (WRAT3), 5-Adult

50 Assessment Instruments n Academic Achievement Key Math Diagnostic Arithmetic Test, Grades 1-6Key Math Diagnostic Arithmetic Test, Grades 1-6 Gray Oral Reading Test, 7-18 yrsGray Oral Reading Test, 7-18 yrs Stanford Diagnostic Reading Test, Grades 1-12Stanford Diagnostic Reading Test, Grades 1-12 Peabody Individual Achievement Test (PIAT-R), Kg-H.S. Peabody Individual Achievement Test (PIAT-R), Kg-H.S.

51 Assessment Instruments n Academic Achievement Nelson Denny Reading Test, Grades 9+Nelson Denny Reading Test, Grades 9+ Test of Early Written Language, 3-10 yrsTest of Early Written Language, 3-10 yrs Test of Written Language, yearsTest of Written Language, years Test of Written Expression, yearsTest of Written Expression, years

52 Assessment Domains n Motor & Sensory Functions Difficulties usually resolve within 6 months; mildly injured match controls at 6 mos Difficulties usually resolve within 6 months; mildly injured match controls at 6 mos With severe TBI, simple and complex motor speed 1- & 2-yr. f/u With severe TBI, simple and complex motor speed 1- & 2-yr. f/u With younger kids see problems with: With younger kids see problems with: fine motor coordination/tremors fine motor coordination/tremors rapid alternating movements rapid alternating movements visual-motor integration visual-motor integration

53 Assessment Domains n Motor and Sensory Functions Extracurricular motor movements after 10 y.o. indicate dysfunction with motor inhibitory system Extracurricular motor movements after 10 y.o. indicate dysfunction with motor inhibitory system Sensory errors--for lateral comparisons Sensory errors--for lateral comparisons Rule out peripheral injuries, difficulty with focused attention Rule out peripheral injuries, difficulty with focused attention

54 Assessment Instruments n Sensory, Perceptual, Constructional Bender Visual Motor Gestalt Test, 4+ yrs Bender Visual Motor Gestalt Test, 4+ yrs Benton Visual Retention Test, 8+ yrs Benton Visual Retention Test, 8+ yrs Halstead Reitan subtests, 5+ yrs Halstead Reitan subtests, 5+ yrs – Sensory imperception – Tactile finger recognition – Fingertip number writing – Tactile form recognition

55 Assessment Instruments n Sensory, Perceptual, Constructional Tactual Performance Test (TPT), 5+ yrs Tactual Performance Test (TPT), 5+ yrs Perceptual-Motor Assessment for Children, 4-16 yrs Perceptual-Motor Assessment for Children, 4-16 yrs Developmental Test of Visual-Motor Integration (Beery VMI), 3-18 yrs Developmental Test of Visual-Motor Integration (Beery VMI), 3-18 yrs Judgment of Line Orientation, 7+ yrs Judgment of Line Orientation, 7+ yrs Test of Visual-Perceptual Skills, 4-12 yrs Test of Visual-Perceptual Skills, 4-12 yrs

56 Assessment Instruments n Motor Skills Bruininks-Osteresky Test of Motor Proficiency, , w/ disabilities Bruininks-Osteresky Test of Motor Proficiency, , w/ disabilities Developmental Test of Visual-Motor Integration (Beery VMI), 3-18 yrs Developmental Test of Visual-Motor Integration (Beery VMI), 3-18 yrs Grooved Pegboard and Purdue Pegboard Grooved Pegboard and Purdue Pegboard Wide Range Assessment of Visual-Motor Abilities yrs Wide Range Assessment of Visual-Motor Abilities yrs

57 Assessment Domains n Attention Levels of Attention: Arousal; Vigilance, attention span; Perseverance; Distractibility; Inhibitory processes Levels of Attention: Arousal; Vigilance, attention span; Perseverance; Distractibility; Inhibitory processes Attention is: Simple alertness & attention span; Sustained attention or vigilance; Divided attention Attention is: Simple alertness & attention span; Sustained attention or vigilance; Divided attention Direct measures & qualitative observation Direct measures & qualitative observation

58 Assessment Domains n Attention Common problem with TBI Common problem with TBI W/ severe injury, in young children: HA and poor attention span up to 5 yrs. post-injury W/ severe injury, in young children: HA and poor attention span up to 5 yrs. post-injury Deficits in concentration & speeded 1yr for all severity levels (studies do not universally support this) Deficits in concentration & speeded 1yr for all severity levels (studies do not universally support this)

59 Assessment Instruments n Auditory Attention/Information Processing Speed Auditory Continuous Performance Test (ACPT), yrs Auditory Continuous Performance Test (ACPT), yrs Conners CPT, 4+ yrs** Conners CPT, 4+ yrs** Goldman-Fristoe-Woodcock Selective Attention Test Goldman-Fristoe-Woodcock Selective Attention Test Gordon Diagnostic System, 4+ yrs** Gordon Diagnostic System, 4+ yrs** Test of Variable Attention (TOVA)** Test of Variable Attention (TOVA)** **denotes need for computer or special testing equipment

60 Assessment Instruments n Visual Attention/Information Processing Wechsler Scales: Digit-Symbol Coding; Symbol Search; Cancellation Test; Picture Completion; Picture ArrangementWechsler Scales: Digit-Symbol Coding; Symbol Search; Cancellation Test; Picture Completion; Picture Arrangement Trail Making Test, Part ATrail Making Test, Part A Ruff 2 & 7 Selective Attention TestRuff 2 & 7 Selective Attention Test Symbol Digit Modality Test, 8+yrsSymbol Digit Modality Test, 8+yrs Nelson Denny Reading Test, Reading RateNelson Denny Reading Test, Reading Rate

61 Assessment Domains n Language/Speech Deficits increase w/ TBI severity Deficits increase w/ TBI severity Expressive abilities more susceptible than receptive: Expressive abilities more susceptible than receptive: Description of object functions Description of object functions Repeating words, sentences Repeating words, sentences Word fluency Word fluency Writing to dictation Writing to dictation Copying sentences Copying sentences Object naming Object naming

62 Assessment Domains n Language/Speech Global deficits (mutisms, aphasias) with severe injuries, under 5 y.o., do improve with recovery Global deficits (mutisms, aphasias) with severe injuries, under 5 y.o., do improve with recovery Speculated that type of deficit is related to language skills in primary ascendancy at time of injury Speculated that type of deficit is related to language skills in primary ascendancy at time of injury Comprehensive Evaluation from Speech & Language Pathologist Comprehensive Evaluation from Speech & Language Pathologist

63 Assessment Instruments n Language Aphasia Screening Test of HRB, 5+ yrs Aphasia Screening Test of HRB, 5+ yrs Boston Naming Test, 6+ yrs Boston Naming Test, 6+ yrs Clinical Evaluation of Language Functions (CELF), Kg-H.S. Clinical Evaluation of Language Functions (CELF), Kg-H.S. Controlled Oral Word Association, 6+ yrs Controlled Oral Word Association, 6+ yrs Illinois Test of Psycholinguistic Abilities (ITPA), 2yrs,4mos-10yrs,3mos Illinois Test of Psycholinguistic Abilities (ITPA), 2yrs,4mos-10yrs,3mos

64 Assessment Instruments n Language Peabody Picture Vocabulary Test (PPVT-R), 2.5+ yrs Peabody Picture Vocabulary Test (PPVT-R), 2.5+ yrs Test of Language Development (TOLD-2), 4-12 yrs Test of Language Development (TOLD-2), 4-12 yrs Utah Test of Language Development, 3-9 yrs Utah Test of Language Development, 3-9 yrs WIAT-II Oral Expression, Listening Comprehension subtests, Kg-Adult WIAT-II Oral Expression, Listening Comprehension subtests, Kg-Adult WISC-IV Verbal Comprehension Index,6+ yrs WISC-IV Verbal Comprehension Index,6+ yrs

65 Assessment Domains n Memory Assess: Immediate and delayed recall of story passages; visual recall; spatial memory; verbal retrieval of newly learned material; recognition memory Assess: Immediate and delayed recall of story passages; visual recall; spatial memory; verbal retrieval of newly learned material; recognition memory Mildly to moderately impaired TBIs usually recover in 6-12 months Mildly to moderately impaired TBIs usually recover in 6-12 months Severely impaired show 12 mos Severely impaired show 12 mos

66 Assessment Domains n Memory Adolescents show a stronger recovery of verbal memory deficits Adolescents show a stronger recovery of verbal memory deficits Young children are very unstable in their performance from one memory test to another--may be a result of their failure to employ useful learning strategies Young children are very unstable in their performance from one memory test to another--may be a result of their failure to employ useful learning strategies

67 Assessment Instruments n Memory Wide Range Assessment of Memory and Learning (WRAML), 5-17 yrs Wide Range Assessment of Memory and Learning (WRAML), 5-17 yrs Childrens Memory Scale (CMS), 5-16 yrs Childrens Memory Scale (CMS), 5-16 yrs Wechsler Memory Scale-III (WMS-III), 16+ Wechsler Memory Scale-III (WMS-III), 16+ Childrens Auditory Verbal Learning Test (CAVLT-2), 8+ URS Childrens Auditory Verbal Learning Test (CAVLT-2), 8+ URS Test of Memory and Learning, 5-19 YRS Test of Memory and Learning, 5-19 YRS

68 Assessment Instruments n Memory California Verbal Learning Test-Childrens Version (CVLT-C), 5-16 yrsCalifornia Verbal Learning Test-Childrens Version (CVLT-C), 5-16 yrs Memory/Localization Scores from TPTMemory/Localization Scores from TPT Benton Visual Retention Test, 8+ yrsBenton Visual Retention Test, 8+ yrs Rivermead Behavioral Memory Test, 5+yrsRivermead Behavioral Memory Test, 5+yrs

69 Assessment Domains n Executive Functions require: integration of motor, perceptual, attention, memory, and learning skills. integration of motor, perceptual, attention, memory, and learning skills. child to manage multiple simultaneous demands, often w/ speed & accuracy requirements, engaging multiple input & output modalities, and incorporating feedback child to manage multiple simultaneous demands, often w/ speed & accuracy requirements, engaging multiple input & output modalities, and incorporating feedback

70 Assessment Domains n Executive Functions (Self-management) Frontal lobes particularly susceptible to injury Frontal lobes particularly susceptible to injury Much of frontal areas do mature during childhood Much of frontal areas do mature during childhood Frontal Lobe Syndrome: alertness; appetite; sleep; irritability; distractibility; impulsivity; social problems; attention difficulties; academic production deficits;poor planning Frontal Lobe Syndrome: alertness; appetite; sleep; irritability; distractibility; impulsivity; social problems; attention difficulties; academic production deficits;poor planning

71 Assessment Instruments n Executive Functions/Problem Solving Childrens Category Test, 5-16 yrs Childrens Category Test, 5-16 yrs Porteus Mazes, 3-12 yrs Porteus Mazes, 3-12 yrs Ravens Progressive Matrices, 5-17 yrs Ravens Progressive Matrices, 5-17 yrs Wisconsin Card Sorting Test (WCST), 6.5+ Wisconsin Card Sorting Test (WCST), 6.5+ Delis-Kaplan Executive Function System (D-KEFS) subtests Delis-Kaplan Executive Function System (D-KEFS) subtests Trail Making Test, Part B Trail Making Test, Part B

72 Assessment Domains n Psychosocial Functioning W/ mild injuries: no increased risk for psychiatric disturbance although may have early change in temperament and other transient behavioral symptoms W/ mild injuries: no increased risk for psychiatric disturbance although may have early change in temperament and other transient behavioral symptoms W/ severe injuries (i.e., PTA> 7 days): >2X rate of psychiatric 4mos. & f/u regardless of sex, age, or social class W/ severe injuries (i.e., PTA> 7 days): >2X rate of psychiatric 4mos. & f/u regardless of sex, age, or social class

73 Assessment Domains n Psychosocial Functioning Types of behavioral disorders mimic general population except for grossly disinhibited social behavior w/ very severe injuries Types of behavioral disorders mimic general population except for grossly disinhibited social behavior w/ very severe injuries Pre-existing behavioral d/o and adverse psychosocial histories are additive rather than interactive Pre-existing behavioral d/o and adverse psychosocial histories are additive rather than interactive

74 Assessment Domains n Psychosocial Adjustment Poor social adjustment with severe injuries: studies range from 1 year to >50% at 3- and 5-yr follow-up Poor social adjustment with severe injuries: studies range from 1 year to >50% at 3- and 5-yr follow-up Significant declines in adaptive behavior 1 yr post-injury Significant declines in adaptive behavior 1 yr post-injury Severely injured children carry w/ them substantial and continuing risk factors Severely injured children carry w/ them substantial and continuing risk factors

75 Assessment Domains n Psychosocial adjustment Denial of personal awareness of deficits may result in more dangerous and risk- taking behaviors Denial of personal awareness of deficits may result in more dangerous and risk- taking behaviors Disinhibition, impulsivity,aggressiveness, and irritability may make maintaining old relationships and establishing new relationships difficult Disinhibition, impulsivity,aggressiveness, and irritability may make maintaining old relationships and establishing new relationships difficult

76 Assessment Instruments n Personality/Behavioral Measures Brown Attention Deficit Disorder Scales, 12+ yrs Brown Attention Deficit Disorder Scales, 12+ yrs Attention Deficit Disorders Evaluation Scales (ADDES) Attention Deficit Disorders Evaluation Scales (ADDES) Conners Rating Scale, 3-17 yrs Conners Rating Scale, 3-17 yrs Achenbach CBC/TRF, 2+ yrs Achenbach CBC/TRF, 2+ yrs Devereux Scales: Parent (DSMD, 5+) and School (DBRS, 5+) Devereux Scales: Parent (DSMD, 5+) and School (DBRS, 5+)

77 Assessment Instruments n Personality/Behavioral Measures Minnesota Personality Inventory- Adolescent Minnesota Personality Inventory- Adolescent Millon Adolescent Clinical Inventory (MACI) Millon Adolescent Clinical Inventory (MACI) Adolescent Psychopathology Scale (APS) Adolescent Psychopathology Scale (APS) High School Personality Questionnaire (HSPQ), Childrens Personality Questionnaire (CPQ), Early School Personality Questionnaire (ESPQ) High School Personality Questionnaire (HSPQ), Childrens Personality Questionnaire (CPQ), Early School Personality Questionnaire (ESPQ)

78 Assessment Instruments n Personality/Behavioral Measures Manifest Anxiety Scale for Children Manifest Anxiety Scale for Children Childrens Depression Inventory Childrens Depression Inventory Reynolds Childrens Depression Scale Reynolds Childrens Depression Scale Reynolds Adolescent Depression Scale Reynolds Adolescent Depression Scale Beck Depression Inventory, 13+ Beck Depression Inventory, 13+

79 Assessment Instruments n Personality/Behavioral Measures Childrens Personality Questionnaire (CPQ) Childrens Personality Questionnaire (CPQ) Behavior Rating Profile, yrs Behavior Rating Profile, yrs Personality Inventory for Children (PIC) Personality Inventory for Children (PIC) Trauma Symptom Checklist for Children (TSCC), 8-16 yrs Trauma Symptom Checklist for Children (TSCC), 8-16 yrs Adaptive Behavior Rating Scales, if needed Adaptive Behavior Rating Scales, if needed

80 TBI Evaluation Schedule n Do SERIAL evaluations n Initial evaluation within 6 months n 1-yr intervals w/ mild to moderate TBI n 6-month intervals w/ severe TBI


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