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Traumatic Brain Injury in Children and Adolescents

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Presentation on theme: "Traumatic Brain Injury in Children and Adolescents"— Presentation transcript:

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

2 Traumatic Brain Injury
Injury to brain External force Total or partial disability or psychosocial impairment 1 or more areas 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 strokes, vascular accidents
anoxic injuries, infections tumors, metabolic disorders exposure to toxic substances

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

5 Severity of Brain Injury
Mild: brief or no LOC, nausea, signs of concussion, GCS 13-15, PTA < 1 hr, 50%-75% Moderate: coma < 6 hrs, skull fracture or bleeding, GCS 9-12, PTA 1-24 hrs Severe: coma > 6 hrs, PTA > 1 day, GCS 3-8

6 Glasgow Coma Scale (GCS)
Eye Opening Spontaneous 4 To speech 3 To pain 2 None 1 Best Motor Response Obeys command 6 Localizes pain 5 Withdraws from pain 4 Abnormal flexion to pain 3 Extension to pain 2 Verbal Response Oriented conversation 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2

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

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

9 Rancho Los Amigos Scale
Level I No Response Level II Generalized Response Level III Localized Response Level IV Confused/Agitated Level V Confused/Inappropriate Nonagitated Level VI Confused Appropriate Level VII Automatic, Appropriate Level VIII Purposeful, Appropriate

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

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

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

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


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

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

17 What Happens After the Injury?
Physical Cognitive Psychosocial Behavioral/Emotional

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

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

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

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

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

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

24 Factors Influencing Outcome
General principles: 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 Multifactorial influences on outcome at time make “dose and response” seem hopelessly out of proportion

25 Factors Influencing Outcome
injury: @ > 5 y.o., age unrelated to severity of neurocognitive deficits or rate of recovery @ < 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

26 Factors Influencing Outcome
Pre-existing disorders 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

27 Factors Influencing Outcome
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 But, multiple injuries can also produce PCS symptoms with no neurologic substrate

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

29 Factors Influencing Outcome
Family competence 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

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

31 Factors Influencing Outcome
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 Pediatric TBI research is in its infancy--good longitudinal studies are needed

32 Factors Influencing Outcome
Management of case 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

33 Neuropsychological Assessment: Conceptual Approach
Presenting problem Significant others as informants Child’s presentation colored by limitations in conceptual capacity and self-awareness Consistency and contradictions in reports Pervasiveness/duration of symptoms identity etiologic factors

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

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

36 Neuropsychological Assessment: Conceptual Approach
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
Neuropsychological Examination Selection of assessment procedures determined by nature of referral question, child’s age, child’s physical and mental capacities, and psychologist’s own preferences Measures a full range of abilities necessary for success in youth’s environments

38 Neuropsychological Assessment: Conceptual Approach
Assessment Domains General Intelligence Academic Achievement Motor Skills Sensory, Perceptual, Constructional Language/Speech Auditory Attention/Information Processing Visual Attention/Information Processing

39 Neuropsychological Assessment: Conceptual Approach
Assessment Domains Executive Functions/Problem Solving Memory Personality/Behavioral/Adaptive Skills

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

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

42 Assessment Domains General Intellectual Measures IQ and brain injury
Full Scale IQ is the most reliable and valid score from a psychometric viewpoint Verbal abilities recover more rapidly With severe TBI, PIQ’s 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 VIQ-PIQ patterns map recovery of function

43 Assessment Instruments
General Intelligence Wechsler 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 Adult Intelligence Scale, Third Ed. (WAIS-III), ages 16+ yrs

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

45 Assessment Instruments
General Intelligence Woodcock-Johnson Psycho-Educational Battery-Revised: Tests of Cognitive Abilities, ages 3-80 yrs Test of Non-Verbal Intelligence, 2nd Ed, 5-85 yrs Columbia Mental Maturity Scale (CMMS), yrs

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

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

48 Assessment Domains Academic Performance and TBI
With moderate to severe injuries, reading, writing and math affected and increased need for sped 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

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

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

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

52 Assessment Domains Motor & Sensory Functions
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 younger kids see problems with: fine motor coordination/tremors rapid alternating movements visual-motor integration

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

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

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

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

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

58 Assessment Domains Attention Common problem with TBI
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)

59 Assessment Instruments
Auditory Attention/Information Processing Speed Auditory Continuous Performance Test (ACPT), 6-11 yrs Conner’s CPT, 4+ yrs** Goldman-Fristoe-Woodcock Selective Attention Test Gordon Diagnostic System, 4+ yrs** Test of Variable Attention (TOVA)** **denotes need for computer or special testing equipment

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

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

62 Assessment Domains Language/Speech
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 Comprehensive Evaluation from Speech & Language Pathologist

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

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

65 Assessment Domains 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 Severely impaired show 12 mos

66 Assessment Domains Memory
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

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

68 Assessment Instruments
Memory California Verbal Learning Test-Children’s Version (CVLT-C), 5-16 yrs Memory/Localization Scores from TPT Benton Visual Retention Test, 8+ yrs Rivermead Behavioral Memory Test, 5+yrs

69 Assessment Domains Executive Functions require:
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

70 Assessment Domains Executive Functions (Self-management)
Frontal lobes particularly susceptible to injury 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

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

72 Assessment Domains Psychosocial Functioning
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

73 Assessment Domains Psychosocial Functioning
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

74 Assessment Domains Psychosocial Adjustment
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 Severely injured children carry w/ them substantial and continuing risk factors

75 Assessment Domains Psychosocial adjustment
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

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

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

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

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

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

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