1. Wattle and Daub Consulting
Traumatic Brain Injury Update: Current Trends in Assessment and Intervention =
Susan M. Wolf, Ph.D.
Executive Director
Wattle and Daub Consulting
10225 East Iris Road
Suite One
Mesa, Arizona

2. Agenda Mr. Brain Neurodevelopment Epidemiology of injury
Understanding brain injury
Areas of impairment
Neuropsych assessment for disorders
Interventions in cognitive retraining

3. Objectives By the end of the training, the participant will:
Be able to describe the neurodevelopmental implications of childhood traumatic brain injury and school functioning
Be able to identify cognitive-communication disorders that can result from brain injury, dependent upon the localization of injury.
Be able to explain their role(s) in relationship to neuropsychological assessment and cognitive retraining for children who have sustained a brain injury.

4. Mr. Brain
Hemispheres
Lobes
Brain functions
Executive Functions

5. Mr. Brain Brain Function
The brain is –
Our personal, private universe.
What makes us distinctly human.
Our sensory processor.
Responsible for reasoning, language, complex social relationships, and morality.
Functioning as an interrelated whole; however injury may disrupt a portion of its activity that occurs in a specific part of the brain.

6. Mr. Brain Brain Function
The brain is –
Most active organ in the body – uses the most oxygen; uses 20% of body’s blood supply; brain constantly active requiring an uninterrupted flow of blood and oxygen; blood and oxygen supply to the brain takes precedence over all other organs of the body; when blood supply is interrupted – neurons and neural networks die
Brain is approximately 3 lbs in weight; 2% of total body weight (adult); one trillion neurons
Baby/child’s brain – 10% of body mass in a baby – 1/3 size of adult brain – during first twelve months, brain cells differentiate and begin developing neural connections.

7. Cognitive Skills/Functions Associated with Hemispheres of the Brain
Left Hemisphere – Logical
Words (spelling)
Verbal meaning
Vocabulary in language
Details – rules
Analysis
One-by-one selectivity
Step-by-step instructions
Sequential ordering
Cause and effect relationships
Learned facts
Letter-symbol associations
Abstract reasoning
Academically-learned information
Ideas
Serial/ordered structures
Self-verbalizations
Selective attention
Consciousness – reasoning
Scientific logic
Right Hemisphere – Aesthetic
Images, pictures, and colors – spatial
Music and feelings
Gestalt – whole/relational
Synthesis, comparisons
Simultaneous patterning
Whole process
Whole units
Analogies
Creativity – new combinations
Visual symbolism
Concrete
Practical – common sense knowledge
Patterns of things/theory
Random-without structure body language
Facial expression, tone of voice
Sustained attention
Meditation, spontaneous ideas, subconscious
Spiritual – mythical
Patterns of logical associations
Used with Permission: Maureen Priestley 2004

8. Mr. Brain Cerebral Cortex
Both hemispheres are able to analyze sensory data, perform memory functions, learn new information, form thoughts, and make decisions.
But each hemisphere acts upon sensory information in a unique manner.

9. Mr. Brain Left hemisphere –
Concern is with discrete and concrete pieces of information.
Memory is stored in a language format.
Helps an individual see details and keep information organized.
Helps the individual use language skills (read, write, and speak) although each of these skills is done in a different lobe of that hemisphere.

10. Mr. Brain Right hemisphere -
Memory is stored in auditory, visual, and spatial modalities.
Helps a person see “the whole” – the “big picture” and to put things together (e.g. recognize shapes).
Supports artistic and musical skills and abilities.

12. Mr. Brain Executive Function
Executive Functions are housed in the frontal lobes, one of the last areas of the brain to fully develop. Refinement (differentiation and integration) of the frontal lobes can continue into the early 20’s.
Executive Functions are highly dependent upon normal neuro-development and the ability to acquire higher level cognitive skills.

13. Mr. Brain Executive Function
Executive Functions represent an individual’s:
Capacity for self-control and direction, planning and organization, mental flexibility, problem solving skills, initiation and motivation.
Ability to regulate one’s thoughts, emotions, and behavior.
Ability to “know where one is heading” as opposed to having no idea of what the consequences will be for volitional behavior.

14. Mr. Brain Executive Functions
Impaired Executive Functions
may interfere with a person’s ability to:
Control emotions.
Benefit from experience.
Learn new information.
Understand “social cues”.
Be sensitive to the emotional needs of others.
To accomplish activities of daily living and to live independently.

15. Clinical Model of Executive Functions
Initiation and drive
Response inhibition
Task persistence
Organization
Generative thinking
Awareness
Starting behavior
Stopping behavior
Maintaining behavior
Sequencing and timing behavior
Creativity, fluency, problem-solving skills
Self-evaluation and insight

16. Brain-behavior Relationships
Neurodevelopment
Brain-Behavior Relations
Model
New Learning
Personality

17. Neurodevelopment
Vast difference between the adult brain and the child’s developing one (size, structure, networks).
From birth to adolescence, the brain undergoes dynamic change resulting in increasing differentiation and integration.
Brain development causes maturation in thinking ability, behavior, emotional regulation, and social capabilities.

18. The Developmental Pyramid:
Judgment :
Integration/
Problem Solving
6 - 12:
New Learning/Attention
3 - 6:
Thinking/Emotion/Behavior
0 - 3
Cause/Effect Relationships
The Developmental Pyramid

19. Key Points in Neurodevelopment
Injury in childhood can result in an underdevelopment of the brain functions of the impacted areas.
Abilities that are just developing or have not yet emerged are the most sensitive and more likely to be disrupted as a result of brain injury.
These abilities and their associated areas of function are likely to be the “Achilles Heel” for a child with a brain injury, even after growing up.

20. Brain Behavior Relationships
It is through our brains that we experience ourselves, the environment and understand our relationships to and with others.
Our experience of ourselves and our environment is dependent on our brain’s ability to receive, process, store, retrieve, and transmit sensory information.

21. Brain-Behavior Model Inputs Inputs Inputs OUTPUTS
(motor, oral, written)
Concept formation, reasoning,
logical analysis
Language skills
Visual-spatial skills
Manipulations in Active
Working Memory
Attention, concentration, memory
Inputs
Visual
Inputs
Auditory
Inputs
Kinesthetic

22. Brain-Behavior Relationships New Learning
New learning is one’s ability to:
Attend and concentrate on visual, auditory, and/or kinesthetic input(s).
Process information in active, working memory by linking new information to visual, auditory, and/or kinesthetic memory.
Encode the new information:
Hold it in memory for a short period of time.
Integrate it into long-term memory.
Retrieve the information when necessary:
Timely.
Accurately.

23. Brain Behavior Relationships What is Personality?
What does it mean when you say
someone is “reliable”?

24. Brain-Behavior Relationships
Brain injury can impact a person’s ability to store, process, accumulate, and retrieve information.
The extent to which the brain is impaired is what assessment and intervention are all about.

25. Understanding Brain Injury
Epidemiology of Injury
Types of Injury
Concussion

26. Incidence and Prevalence of TBI

27. TBI: Data and Research
Traumatic brain injury is now classified as a public health epidemic in America.
Centers for Disease Control and Prevention. “Traumatic Brain Injury in the United States: A Report to Congress.” (January 16, 2001).

28. Incidence & Prevalence of TBI
Someone in America will sustain a brain injury every fifteen seconds.
720 people
during this
3 hour training

29. TBI Incidence & Prevalence
2 million/year injured
1 million/year seek emergency care
270,000/year are hospitalized
50,000/year die from a TBI
75,000/year result in long-term disability
5.3 million Americans with significant disability
6.5 million Americans living with some effect
CDC figures as of 4/02

30. The Real Statistics
‘00
‘99
‘98
Since 1992, on average more than 5,000 Arizonans each year sustain a TBI severe enough to cause death (20%*) or hospitalization.
‘97
‘96
‘95
‘94
‘93
‘92
* estimate

31. Incidence & Prevalence of TBI
Who is at risk?
Close to 1/3 of those surviving brain injury are children and teens.
Males are 2 times more likely to sustain a TBI compared to females.
Risk of traumatic brain injury is highest in adolescents and young adults.
Second highest risk group is adults older than 75 yrs.

32. Incidence & Prevalence of TBI
How are they injured?
Motor vehicle crashes account for 50% of all traumatic brain injuries.
Falls are the second leading cause and the most prevalent cause among the elderly.
Violence, particularly from firearms, ranks third.

33. Incidence & Prevalence of TBI TBI Research
While the behavioral effects of child abuse have been understood for many years, it is only recently that we have begun to recognize the impact of trauma on the physiological development of a child’s brain.

34. Incidence & Prevalence of TBI TBI Research
As a result of growing up with violence in their homes, many children have neurological deficits caused by repeated blows to the head and face (most common area hit), and by the chemical reaction to prolonged stress.
Brain alterations caused by shock and trauma of witnessing violence, for both women and children, is a negative outcome of violence in the home.

35. Incidence & Prevalence of TBI TBI Research
These hidden injuries may result in:
Depression Delinquency
Anxiety PTSD
Aggression Impulsiveness
Hyperactivity Mood regulation
Impulse control Suicidal ideation
Communication difficulties Substance abuse
Planning and problem solving difficulties
Brain Injury Source, Winter 1998, Volume 2, Issue 1, pages 12 – 13

36. Understanding Brain Injury

37. Understanding Brain Injury Brain Anatomy
Quick overview (from the outside in):
Outside - Bony skull
Inside
Brain tissue – gelatinous substance – firm jello consistency.
Brain wrapped in thick covering (dura) that protects and segments the brain.
Within the covering, the brain “floats” in cerebrospinal fluid. It surrounds the brain, and under normal circumstances, cushions the brain from contact with its hard, spiny shell.

38. Understanding Brain Injury Brain Injury Types
Congenital Brain Injury
Acquired Brain Injury
Traumatic Brain Injury
Non-traumatic Brain Injury
Closed Head Injury
Open Head Injury
Savage, 1991

39. Understanding Brain Injury Non-Traumatic
Examples of non-traumatic brain injury from medical conditions include:
infectious disease (e.g., meningitis, encephalitis)
brain tumor
cerebral-vascular dysfunction (e.g., stroke, cardiac disorders)
intercranial surgery
toxic chemical or drug reactions (e.g., lead poisoning, carbon monoxide poisoning).
anoxic/hypoxic episodes.

40. Understanding Brain Injury Hypoxia/Anoxia
Near drowning.
Suffocation.
Other injuries (cardio or pulmonary) can reduce blood flow and oxygen to the brain.
Lack of oxygen/blood flow for more than minutes causes generalized damage.
Suicide attempts.

41. Understanding Brain Injury Traumatic
A traumatic brain injury (TBI) is a result of:
Blunt or penetrating trauma to the head such as a fall or gunshot wound.
Coup – Contrecoup injury from acceleration - deceleration forces such as motor vehicle crashes or shaken baby syndrome.

42. Understanding Brain Injury
Primary injury (immediate impact)
Skull fracture (O)
Hematomas (C)
Anoxia/hypoxia (C)
Contusions (C)
Axonal shearing (C)
Secondary injury (reaction to impact)
Secondary tissue damage/necrosis
Increased intracranial pressure
Increased internal temperatures
Swelling/inflammatory response
Intracranial infection

43. Understanding Brain Injury COUP - CONTRECOUP Injury
LifeArt: Williams & Wilkins

44. Shaken Baby Syndrome Violent shaking or sudden impact may cause excessive brain movement and damage bridging cerebral veins.
Shaking Exerts
10x g Force
Impact Exerts
300x g Force

45. Understanding Brain Injury Concussion
May or may not result in a loss of consciousness.
Clear structural damage may or may not be present on radiographic/imaging studies.
Can result in dysfunction in the absence of structural damage.
Dysfunction may not be evident until the tasks or demands of the environment present the individual with challenges for which s/he may not be able to compensate.

46. Understanding Brain Injury Concussion: Common Symptoms
EARLY SYMPTOMS
Headache
Confusion
Dizziness
Nausea with or without vomiting
Disorientation to time and place
Slow to respond or follow instructions
Being uncoordinated
LATE SYMPTOMS
Persistent headache
Poor attention and concentration
Memory dysfunction
Vision disturbance
Ringing in the ears
Anxiety and depressed mood
Irritability
Intolerance to loud noise

47. Understanding Brain Injury Concussion Related Issues
For children and adolescents, whose brain development is ongoing, the effects of a concussive brain injury may be distinct from those seen in adults.
Repeated concussions, such as sports injuries or repeated incidents of abuse can have cumulative effects.
Symptoms related to post-concussive syndrome can have significant life-long impairments and debilitating effects on those who survive them.

48. Understanding Brain Injury Concussion: Common Symptoms
Second Impact Syndrome (SIS)
2nd concussion while still symptomatic
Can occur within hours, days or weeks
May lead to lifelong impairments
Post-Concussion Syndrome
Effect of repeated concussions
Cumulative neurologic and cognitive deficits
More concussions, more risk

49. Understanding Brain Injury
Mild (70-80%), moderate (10-15%), and severe (5-7%) brain injury are the clinical terms used to describe the “type” of brain injury the person sustained. (e.g. Glasgow Coma Scale, Rachos Los Amigos Scales)
However, these same descriptors often fail to tell us about the “functional outcome” (long-term prognosis) of the injury.

50. Areas of Impairment(s) after Injury

51. What Does TBI Look Like? Functional Impacts
Personality and Emotional Impacts
Psychological and Behavioral Impacts

52. Functional Impacts of TBI
Impaired Mobility
Impaired Body Functions
Impaired Sensory Experiences
Impaired Cognitive Functioning
Impaired Communication

53. Functional Impacts of TBI
Impaired mobility
Paralysis (partial or full)
Hemiparesis
Spasticity, contractures
Balance and equilibrium
Gait challenges

54. Functional Impacts of TBI
Impaired body functions
Swallowing difficulties
Temperature control
Changes in other voluntary controls (motor)
Changes in involuntary controls
Seizures

55. Functional Impacts of TBI
Impaired sensory experiences
Vision
Hearing
Smell
Taste
Touch

56. Functional Impacts of TBI
Impaired cognitive functions
Decision making and executive functioning
Attention/Concentration/Distractibility
Memory (active, short-, long-term)
Organization
Judgment and reasoning
Mental fatigue, lowered pain threshold
Self-awareness and metacognition

57. Functional Impacts of TBI
Impaired communication
Understanding language (e.g., aphasia, auditory speed of processing concerns, limited verbal memory or attention)
Speaking and producing language (e.g., anomia, confabulation, tangential, fragmentation, devoid of content)
Speech patterns (e.g., perseveration, hyperverbal speech, cocktail language)
Poor pragmatics (e.g., poor turn taking, poor topic maintenance, reduced sensitivity to partner)

58. Functional Impacts of TBI
Impaired pragmatics is CRITICAL !
Pragmatics transcend isolated word and grammatical structures (discourse in social context)
Pragmatics is an interplay of cognitive and affective factors and decreased self-awareness also plays a role
People with TBI often exhibit normal linguistic skills but have difficulty adapting communication to specific contexts
Poor pragmatics do not spontaneously improve over time (Snow, Douglas, Ponsford (1998))
Poor pragmatics leads to social isolation and because it is critical to community reintegration, clinicians have begun to prioritize assessment and treatment of deficits.

59. Uniqueness of Injury: Predictability Challenging
Very specific areas of impairment may exist side-by-side with high-functioning areas
Example: high intelligence but slow visual or auditory processing of information
Example: language skills age-appropriate but significant working memory impairment
Location of injury can help determine (to some extent) the type(s) and severity of impairment

60. Impact: Organic-based Personality / Emotional Changes
Disinhibition
Suspiciousness
Impulsivity
Lack of awareness of deficit and unrealistic appraisal
Reductions in or lack of the capacity for empathy; inability to experience emotions
Childlike emotional reactions or behavior
Uncontrolled laughing or crying; mood swings (emotional lability)
Preoccupation with one’s own concerns (egocentrism)
Poor social judgment
Rage reactions
Euphoria
“Flat” affect
Agitation
Reduced or altered sense of humor
Low frustration tolerance
Misperception of other people’s facial expressions /intentions; inability to perceive emotions
Hyper-sexuality or hypo-sexuality
Catastrophic emotional reactions

61. Impact: Psychological / Behavior
Depression
Anxiety
Panic
Shame
Humiliation
Grief
Loss
Sadness
Irritability and aggressiveness
Deep sense of anger over what has happened
Resentment
Blame
Hopelessness and despair
Helplessness
Reduced self-esteem
Withdrawal from social contact
Increased sense of dependency on others
Psychologically-based denial or minimization of problems
Defensiveness
Pre-occupation with the past
Unrealistic expectations of family, friends, co-workers

62. Functional Impacts of TBI
"Left to fend for themselves, the survivors of traumatic brain injury, already confused by their inability to be the people they were prior to the injury, now face the daunting task of demonstrating that an injury they do not understand and cannot comprehend is producing the confusion they cannot communicate."

63. Questions

64. Assessment Psychoeducational Evaluation Neuropsychological Evaluation
Formal and Informal Assessment Discussion

65. Psychoeducational Assessment
Referral Question
Family History
Medical/Developmental History
Educational History
Primary Language
Educational/Cultural Limitations
Classroom or Other Observation
Assessment Battery (Tests Used)
Testing Observation and Student Interview

66. Psychoeducational Assessment (cont.)
Discussion of Results
Summary
Recommendations: Educational/Learning Implications
Referral (i.e., neuropsychologist, clinical psychologist, etc.)
Psychometric Summary (Explanation of Scores)

67. Neuropsychological Evaluation
Background Information
Reason for referral
Diagnosis
Onset of injury, neurophysical insult(s)
Medical history, pre-injury status
Developmental, school history
Psychosocial status
Previous psychological, neuropsychological, or educational evaluation findings

68. Neuropsychological Evaluation
Behavioral Observations
Alertness and orientation and awareness of circumstances
Memory
Attention, concentration
Task persistence, fatigue
Speed of processing and performance
Speech-language
Judgment, reasoning
Affect, mood
Test behavior
Self-monitoring of performance, approach, effort

69. Neuropsychological Evaluation
Findings
Overall cognitive and intellectual functioning
Sensory/motor functioning
Attention and concentration
Basic, complex, independent
Memory
Immediate, over trials, delay, recognition, verbal/non-verbal
Language and Auditory Processing
Cognitive/verbal subtests (complexity input/output)
Word/speech fluency measures
Aphasia screening
Speech sounds / rhythm patterns

70. Neuropsychological Evaluation
Findings
Constructional abilities / Visual-perceptual Motor
Design copying tasks
Wechsler performance subtests
Figure drawing
Analysis and Synthesis of Complex Information / Shifting Set
Academic Assessment
Reading
Spelling
Math
Writing
Personality / Behavioral / Social Assessment
Adaptive Behavior Assessment (Functional)

71. Neuropsychological Evaluation
Impressions
Summary of deficits and impairments
Summary of intact areas of functioning and strengths
Comparison to reported level of pre-injury functioning
Contributing factors to performance
Impulse control
Attention / distractibility
Flexibility
Fatigue
Speed
Awareness of deficits
Impact on development, learning, social, emotional, vocational
Specific needs

72. Neuropsychological Evaluation
Recommendations
School programming / Vocational programming
Therapy needs
Compensation strategies, adaptations, accommodations
Psychosocial intervention(s)
Re-evaluation (need for and timing of)

73. What critical role can SLPs play in neuropsychological evaluation?

74. Comprehensive Assessment
Formal (standardized) evaluation tests
Informal measures such as modified test procedures and non-standardized tasks
Clinical observations
Simulated situations
Provides information on strengths and limitations as well addressing the unique treatment needs of the client
Frank & Barrineau (1996) Jrnl of Med Spch-Lng Path, 4(2)

75. GROUP DISCUSSION Sustained attention Divided attention
Short-term memory
Long-term (sematic) memory
Episodic memory
Prospective memory
Planning
Awareness of behavior
Identify formal (standardized) and informal assessments that you have used or can use to ascertain impairments in the following areas:

76. Intervention Approaches after BI Time-based shifts in responsibility
Environmental modifications
Behavioral strategies
Cues, prompts, and checklists
Teaching task-specific routines
Pharmacological interventions
Cognitive-behavioral interventions
Metacognitive/self-regulatory strategies
Training in use of compensation strategies
Practice at task management
Awareness training and psychotherapy
Primarily EXTERNAL
Primarily INTERNAL

77. Some Old Principles of Intervention (Revisited)
Observe, Observe, Observe
Gain insight into individual’s level of “readiness” (capacity) to participate
Honor the chasm between pre- and post-morbid self (many are very aware of the differences)
Identify strengths, assets, interests before focusing on deficits and impairments
Have heightened awareness that this population presents with more psychological and behavioral issues
Make tasks contextually relevant and meaningful
Look to modify the environment and task demands (your expectations) rather than focusing on “change” in the individual with brain injury

78. Sidebar: External Compensatory Aids
Careful needs assessment (with multiple sources of input) regarding the client’s needs and constraints
Organic factors (relevant physical/cognitive)
Personal factors (psychosocial/environmental)
Situational factors (contexts for aid use)
Options for external aids
Written planning systems
Electronic planners
Computerized systems
Auditory/visual symbol systems
Task-specific aids (post-it notes, bulletin boards, phone dialers, calculators, refrigerator magnets)

79. Sidebar: External Compensatory Aids
Adequate preparation for training a client to use
Patience with clients and caregivers (everyone needs reinforcement!)
Evaluating awareness issues (can procedures work?)
Breaking down the use of an aid into component parts
Anticipating the contexts in which the aid will be used
Training methods
Effective instructional techniques (academic, functional)
Errorless Instruction (Baddeley & Wilson, 1994; Evans, 2000)
Prompting (with rapid and gradual fading cues)
Monitoring client’s progress

80. Review of Intervention Handouts
Memory Theory Applied to Intervention
Functional and Prospective Memory
Working with Complex Attention
Managing Dysexecutive Symptoms
Working to Improve Unawareness
Research and Contemporary Publications and Resources