2. Children & Brain Injury Anastasia Edmonston MS CRC TBI Projects Director Maryland Mental Hygiene Administration

3. What We Will Talk About The big picture What about concussion and kids? Strategies Prevention tips State, regional and national brain injury resources

4. Definitions Traumatic Brain Injury is an insult to the brain caused by an external physical force Diffuse Axonal Injury the tearing and shearing of microscopic brain cells Acquired Brain Injury is an insult to the brain that has occurred after birth, for example; TBI, stroke, near suffocation, infections in the brain, anoxia

5. IDEA Definition of TBI Federal Public Law 101-476, 1990 ……..an acquired injury to the brain caused by an external physical force resulting in total or partial functional disability or psychosocial impairment or both that adversely affects a child’s educational performance……..

6. The Big Picture

7. The Brain Injury Quiz How many pounds is the adult brain? a) 7 lbs b) 3 lbs c) 1.5 lbs At what age is your brain fully mature? a) 16 b) 21 c) 25 What is the last part of the brain to mature? a) temporal lobe b) brain stem c) frontal lobe Who has not had a traumatic brain injury? a) George Clooney b) Mike Wallace c) Jason Priestly d) Anne Hathaway

8. About 3.17 Million American civilians (more than 1.1% of population, live with the consequences of traumatic brain injury CDC in Journal of Head Trauma Rehabilitation 2008 (Vol. 23, No. 6, pp 394-400)

9. Limitations of Study Does not include discharge records from military and veteran affairs hospitals Does not include children under 15 years of age (from SC data) Does not include persons treated and released from emergency department or other healthcare setting, and those not treated in any healthcare setting following a blow to the head

10. NATIONWIDE 1.4 million Americans sustain a brain injury each year 50,000 do not survive their injuries 235,000 are hospitalized 1.1 million are treated and released from our nations emergency department’s following a brain injury Annual Incidence of TBI with disability AN ESTIMATED 124,000 American civilians

11. NATIONWIDE-children ages 0-14 2,685 deaths 37,000 hospitalizations 435,000 emergency department visits (accounting for over 90% of emergency department visits in children 0-14 years old)

12. “Reframed, the numbers nauseate. In America alone, so many people become permanently disabled from a brain injury that each decade they could fill a city the size of Detroit……...

13. …. Seven of these cities are filled already. A third of their citizens are under fourteen years of age.” …. Seven of these cities are filled already. A third of their citizens are under fourteen years of age.” From Head Cases, Stories of Brain Injury and its Aftermath Michael Paul Mason 2008 published by Farrar, Straus and Giroux

14. In Maryland…….. In 2000 there were 5,229 traumatic brain injuries 5% of all hospitalizations were TBI related 25% of all injury related deaths for ages 15-24 were TBI related 11% of all injuries to children 14 and under were TBI related CDC 2006

15. Why are the Numbers so Big? 30 years ago, 50% of individuals with TBI died, the number today is 22% due to: Improved medical technology and techniques Safety features such as car seatbelts, child safety seats and airbags

16. Simplified Brain Behavior Relationships Frontal Lobe Initiation Problem solving Judgment Inhibition of behavior Planning/anticipation Self-monitoring Motor planning Personality/emotions Awareness of abilities/limitations Organization Attention/concentration Mental flexibility Speaking (expressive language) Parietal Lobe Sense of touch Differentiation: size, shape, color Spatial perception Visual perception Occipital Lobe Vision Cerebellum Balance Coordination Skilled motor activity Temporal Lobe Memory Hearing Understanding language (receptive language) Organization and sequencing Brain Stem Breathing Heart rate Arousal/consciousness Sleep/wake functions Attention/concentration

17. What happens in a TBI? Mechanism – Acceleration/Deceleration –Differential movement of partially tethered brain within the skull Results in: –Bruising of the brain surface against rough areas of the skull –Stretching and twisting of nerve axons

18. Skull Anatomy Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury Bony ridges The skull is a rounded layer of bone designed to protect the brain from penetrating injuries. The base of the skull is rough, with many bony protuberances. These ridges can result in injury to the temporal and frontal lobes of the brain during rapid acceleration.injury to the temporal and frontal lobes

19. Brain & Skull Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury Injury to frontal lobe from contact with the skull

20. Diffuse Axon Injury Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury Can directly impact the major pathways of the brain.

21. RECAP: The Developing Brain Children’s brains do not reach their adult weight of 3 pounds until they are 12 years old The brain, and most importantly, the brain’s frontal lobe region does not reach it’s full cognitive maturity till individuals reach their mid twenties

22. The Developing Brain The Frontal Lobe houses our executive skills, these include; judgement, problem solving, mental flexibility, etc. The Frontal Lobe is very vulnerable to injury Damage to the Frontal Lobe any where along the developmental continuum can impact executive skill functioning

23. According to the USDE, in Maryland……. Only 324 students out of 98,811with identified disabilities were receiving services under a TBI diagnosis in 2006. U.S. Department of Education, Office of Special Education Programs 7/17/06 httpt://www.ideadata.org/tables29th/ar_1-3.xls

24. Why the Gaps in numbers? Not all children experience lasting effects The etiology of a student’s disability may be unidentified or misunderstood Student may be served under a 504 plan Effects of a early brain injury may not be expressed until the student is older When the effects do surface, they may diagnosed as having a learning disability, emotional disorder, or other disability Adapted from TBI and Educator’s Guide by the MD TBI Implementation Project and the BIAM 2003

25. Mild Traumatic Brain Injury (AKA concussion) Most common, 75%-85% of all brain injuries are mild Individuals experience a brief (<15 minutes)or NO loss of consciousness Post Traumatic Amnesia < 1hour Normal neurological exam 90% of individuals recover within 6-8 weeks, often within hours or days

26. The American Academy of Neurology: “Concussion is a trauma-induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia are hallmarks of concussion” http://search.aan.com/vivisimo/cgi-bin/query-meta?input- form=simple&v%3Asources=AANNew&v%3Aproject=aan&query=concussion

27. Importance of Post Traumatic Amnesia PTA is the period of time after injury when a person is unable to lay down new memories For Example...

28. “That first morning, wow, I didn’t want to move, I was thankful that nothing’s broken, but my brain was all scrambled” Ryan Church, NYT 3/10/08 “All he remembers from the collision with Anderson is the aftermath, being helped off the field by two people, although he said he did not know who they were until he saw a photograph later” Ben Shpigel NYT reporter

29. Concussion and Kids-Sports In sports alone, 300,000 + concussions are “estimated” to occur annually For every 1 concussion in the NFL, there are 5,650 youth injuries Sports associated with concussion: soccer, football, lacrosse, hockey, horseback riding, cheerleading…….. Gerard Gioia, Ph.D., Children’s National Medical Center in remarks at the Brain Injury Association of MD conference 2005

30. Concussion and Kids- Sports Football has the highest rate of concussions in high school sports, girls soccer 2nd highest rate (New York Times 10.2.07) 29,167 concussions suffered by US high school girl soccer players, 20,929 concussions suffered by high school boy soccer players 2005-2006 (Time Magazine 2008) Female concussion rates in high school basketball were almost 3xs higher than among boys. In girls, symptoms take longer to resolve (NYT 10.2.07)

31. Quoted in Time Dr. Joseph Maroon U of Pittsburgh Medical Center “More-developed necks allow boys to better absorb a blow to the head”

32. Implications for Children Children who incur a brain injury are twice as likely as other children to have a second brain injury within 6 months. According to the researchers, factors included a “complex interaction between children and their social environments” ( Pediatrics 2007 & Eric Nagourney of the NY Times 4/3/07)

33. Implications for Children Concussion and repeated concussions can occur from falls and sports injuries Most soccer concussions are due to hard falls or player collisions Secondary impact syndrome, a rare but potentially fatal result of two concussions within a short period of time

34. “The Faces of Brain Injury” A short video by the Brain Injury Association of Florida

35. Brain Injury’s Impact on Physical Functioning…. Adapted from BIA Utah & BIA NJ Tired all the time/ Tires more quickly Continuing headache (maybe accompanied by nausea), may also be bothered by noise or light Less active Dizziness Ringing in the ears Slurred speech Changes in balance, difficulty grasping objects Bothered by light and noise Sleep changes (can’t sleep, nightmares etc.)

36. Brain Injury’s Impact on Thinking.. Adapted from BIA Utah Memory, especially short-term memory Difficulty learning new information Trouble paying attention & staying on task Misses instructions Multi-tasking or splitting and dividing ones’ attention (aka “executive skills”) can be very challenging

37. Emotional and Behavioral Consequences… Adapted from BIA Utah and NIA NJ Impulsive worried and moody flat affect or little change in emotion Spends more time alone Easily upset (teary, agitated, aggressive) Self-centered of finding it hard to take another’s point of view Difficulty exercising good social judgement Difficulty following daily routine at school and/or home

38. Possible Changes-Personality and Behavioral... MD TBI Project Depression Social skills problems Mood swings Problems with emotional control Inappropriate behavior Inability to inhibit remarks Inability to recognize social cues

39. Possible Changes-Personality and Behavioral Problems with initiation Reduced self-esteem Difficulty relating to others Difficulty maintaining relationships Difficulty forming new relationships Stress/anxiety/frustration and reduced frustration tolerance

40. Children “Grow into Their Brain Injuries” (Gioia) as children grow, more is expected, children with a history of brain injury may not be able to meet the demands……. Impact of an injury may not become apparent till years post injury and…not be attributed to an earlier blow to the head

41. Recommended Supports and Services-The Ideal Pathway Following Concussion or Mild Brain Injury-Childhood Injury Family and child is educated about the possible symptoms of concussion If symptoms emerge or persist following a concussion, appropriate referrals are made to a neurologist, pediatric neuropsychologist. Appropriate interventions and supports including outpatient speech, occupational and physical therapy are provided and coordinated with school personnel Exposure to situations where a second impact is a possibility is minimized

42. If Symptoms Persist and are Left Untreated….in children Teachers and family may notice irritability Schoolwork suffers Behaviors attributed to factors other than the brain injury (family/peer problems, adolescence) Child continues to experience problems, becomes depressed/may begin to act out Is at risk for academic/social difficulties Is at risk for a subsequent brain injury, exacerbating the above

43. If Symptoms Persist and are Left Untreated….in adults Job loss Mental Health Problems Relationships and supports erode At risk for Substance Abuse At risk for entry into the criminal justice system

44. Why Screen? What other TBI Screening efforts have found

45. 2000 Epidemiological Study of Mild TBI J. Silver of NYU, cited in WSJ by Thomas Burton 1.29.08 http://online.wsj.com/article/SB120156672297223803.html?mod=googlenews_ wsj 5,000 interviewed 7.2% recalled a blow to the head w/unconsciousness or period of confusion Follow up testing found; 2x rate of depression, drug and alcohol abuse Elevated rates of panic and and obsessive-compulsive disorder

46. Findings from the Literature…Criminal Justice System Researchers at Indiana State University found that 83% of felons studied reported a head injury that predated their first encounter with the law (1998) Adults who had frontal lobe damage prior to age 8 exhibited recurrent impulsive and aggressive behavior 14% of the subjects in the Vietnam Head Injury Project with frontal lobe lesions engaged in fights or damaged property compared to 4% of controls without TBI

47. Domestic Violence TBI Findings Batterers fared worse on three neuropsychological indicators of cognitive functioning then a nonbatterer control group (Cohen et. Al 1999) Corrigan et.al., (2003) found that of 167 individuals treated for domestic violence related health issues, 30% experienced a loss of consciousness on at least one occasion, 67% reported residual problems that were potentially TBI related Valera and Berenbaum, (2003) assessed 99 battered women. Of these, 57 had brain injured related symptomatology

48. TBI Among Individuals with Persistent Mental Illness Kathleen Torsney (2004) found in one mental health treatment setting 13% of individuals served had a history of TBI These same individuals had been treated in various mental health settings but not received specific brain injury treatment

49. In Maryland- Screening Results from the MD TBI Post Demo II Project-2005 –Summary of TBI Incidence Among all Screened at 7 public mental health agencies in Frederick and Anne Arundel counties –N=190 –39% no reported history of TBI (78) –58.94% of individuals with a history of TBI (112) –35.78% of individuals with a history of a single incidence of TBI (68) –23% of individuals with a history of 2 or more TBIs (44)

50. TBI Screening The HELPS Brain Injury Screening Tool (see handout) The original HELPS tool developed by M. Picard, D. Scarisbrick, R. Paluck, 9.1991 Updated by the Michigan Department of Community Health

51. H ELPS Have you ever Hit your Head or been Hit on the Head? Prompt individual to think about; TBI at any age, MVAs. Assaults, Sports injuries, Service related injuries, Shaken baby and/or adult

52. H E LPS Were you ever seen in the Emergency room, hospital, or by a doctor because of an injury to your head? Explore the possibility of “unidentified traumatic brain injury” many do not present in medical settings

53. HE L PS Did you ever Lose consciousness or experience a period of being dazed and confused because of an injury to your head? Remember, a LOC isn’t required for someone to develop symptoms subsequent to a blow to the head. “alteration of consciousness” AKA post traumatic amnesia (PTA). At this point, the interviewer may consider asking the individual if they have had multiple mild TBI

54. HEL P S Do you experience any of these Problems in your daily life since you hit your head? You want to know when any problems began (or began to be noticed) Remember, lack of awareness is a hallmark of brain injury, you might ask if anyone close to the individual has made any observations regarding changes in function.

55. HEL P S Headaches Dizziness Anxiety Depression Difficulty concentrating Difficulty remembering Difficulty reading, writing, calculating Poor problem solving Difficulty performing your job/school work poor judgement (being fired from job, arrests, fights, relationships affected)

56. HELP S Any significant Sickness? Acquired Brain Injury (ABI) can result in many of the same functional impairments as traumatic brain injury (TBI). For example, brain tumor, meningitis, West Nile virus, stroke, seizures, toxic shock syndrome, aneurysm, AV malformation, any history of anoxic injury, e.g. heart attack, near drowning, carbon monoxide poisoning can all result in multiple deficits

57. Scoring the HELPS Positive for a possible Brain Injury when the following three are identified: An event the could have caused a brain injury (YES to H, E, or S), and A period of loss of consciousness or altered consciousness after the injury or another indication that the injury was severe (YES to L or E), and the presence of 2 or more chronic problems listed under P that were not present before the injury.

58. Scoring the HELPS A positive screening is not sufficient to diagnose TBI as the reason for current symptoms and difficulties-other possible possible reasons need to be ruled out Some individuals could present exceptions to the screening results, such as people who do have TBI- related problems but answered “no” to some questions Consider positive responses within the context of the person’s self-report and documentation of altered behavioral and/or cognitive functioning

59. Additional comments and observations of the interviewer Any visible scars? Walks with a limp? Uses a cane or walker? Has a foot brace? Limited use of one hand? Appears to have difficulty focusing vision? Difficulty answering questions? Answers are unorganized and/or rambling Becomes easily distracted, agitated or is emotionally labile

60. What you are looking for…..And Why Any visible scars? Walks with a limp? Uses a cane or walker? Has a foot brace? Limited use of one hand? Appears to have difficulty focusing vision? Difficulty answering questions? Answers are unorganized and/or rambling Becomes easily distracted, agitated or is emotionally labile

61. Strategies for supporting children with persistent symptoms

62. Strategies to enhance learning are included in a child’s IEP or in a 504 plan Some examples to support those with brain injury related challenges include with or with out an IEP or 504 plan... (For more information on IDEA & 504 plans go to resource section of this handout)

63. Strategies-Physical-for Children Visual aides (large print, screen adapters, scanning aides) Built in rest periods in daily schedule Structure and simplify the classroom environment (predictable schedule, reduced clutter, consistent cues, written classroom rules) Tailor assignments and homework (3 ten minute verses one half hour assignments) Adapted from TBI and Educator’s Guide by the MD TBI Implementation Project and the BIAM 2003 & BIA Utah

64. Strategies-Cognitive Calendar/keep schedule predictable Planner vs. loose paper Laptop/computer Tape recorder Timer/timer watches Untimed testing Alternative testing Use of a reader or note taker (buddy) Highlighter Books on tape/film adaptation Strategic scheduling Break tasks/assignments into steps

65. Strategies Continued Encourage active listening strategies e.g paraphrasing back to speaker the information, especially when it is novel Special seating Place visual cues in environment (calendars etc.) Use of an FM system (headphones that directly link child to the teacher to screen out distractions) Text reader programs Retention in long term memory is enhanced by the three R’s Repeat, Rehearse, and Review Checklists

66. Uses of Strategies at Home and When Navigating the Community Watch this clip from the movie “The Lookout” What are the strategies he uses to compensate for memory, organization, etc.

67. “The Only Cure for Brain Injury is Prevention”

68. Strategies for Prevention

69. Prevention Car safety Helmet use Sports Violence reduction

70. Car Safety Parents and caregivers-DRIVE THE POSTED SPEED LIMIT Drivers-insist all adult passengers wear their seatbelts. An unrestrained adult in the event of an accident can be transformed into an unguided missile that can injure or kill a child passenger (same goes for dogs, buckle them up too!) Don’t drink and drive, reaction time can deteriorate after only two drinks

71. Car Safety for Child Passengers Children up to 14 years of age or younger need to sit in the back seat and properly restrained for their age, weight and height. Children 40-80 pounds should sit in a booster seat. This enables the belt to sit properly, low and tight across the top of the thighs Kids in Safety Seats website

72. Car Safety for Child Passengers Although car manufacturers recommend not to place children 12 or under in the front seat with an air bag, research suggests that no child under 14 should sit in the front seat with an airbag. (Pediatrics 2005) At 14, the maturation of the bones and muscles is sufficient to tolerate the impact of a deployed airbag

73. The Good News! Because of increased use of seat belts, and placement of children in the backseat, it is estimated that from 1995- 2001, 1,700 lives were saved! Report by the Air Bag and Seat Belt Safety Campaign 2005

74. Helmets & Sports Brain injuries cause more deaths than any other sports injury Research shows that 85% of bicyclists head injuries can be prevented by a bicycle helmet Always wear a helmet when biking, playing, football, baseball (at bat), horseback riding, in-line skating, ice skating, roller skating, avoid “heading” the ball when playing soccer (Brain Injury of America website www.biausa.org)

75. Violence Prevention Keep guns unloaded and locked up Keep bullets locked up in a separate location Explain to children the difference between the violence they may see on TV and the real harm that guns can do (BIAA website, www.biausa.org.) Teach children to walk away from conflict

76. Resources Brain Injury Association of America 1-800-444-06443 www.biausa.org

77. Resources Brain Injury Association of Maryland 410-448-2924 www.biamd.org

78. Resources Centers for Disease Control Wonderful, free tool kits Heads Up: Concussion in high school sports- a tool kit for for coaches, parents and athletes http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm Head Up: Concussion in Youth Sports Tool Kit http://www.cdc.gov/ConcussionInYouthSports/default.htm

79. Resources/References "Brain Injury Partners: Navigating the School System”a collaboration of the National Institute of Child Health and Development and the Brain Injury Association of America. “Brain Injury: A Guide for Families About School” Published by the BIA of New Jersey, includes an excellent discussion on how the IEP and 504 plans can support students with brain injury http://www.bianj.org/publications-on-brain-injury Slides 17-19 adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury

80. Resources/References http://www.bianys.org/learnet/. A website full of information on strategies for children, teachers and clinicians on how to problem solve around various brain injury related issues. Created by the NIA of New York State Brain Injury Resource and Information Network of Tennessee www.tndisability.org/brain Brower MC, Price BH. Neuropsychiatry of frontal lobe dysfunction in violent and criminal behavior: a critical review. Journal of Neurological and Neurosurgery Psychiatry 2001;71:720-726.

81. Resources continued... National Safe Kids Campaign www.safekids.org 1301 Pennsylvania Ave., N. W. Washington D.C. 20004-1707 202-662-0600

82. Resources continued... Kids in Safety Seats Kiss@dhmh.state.md.us 1-800-370-SEAT, call for information as well as for a car seat safety check

83. Resources continued... The Safe Concussion Outcome Recovery & Education Program (SCORE) At the Children’s National Medical Center Washington DC 202-884-2429

84. National Center on Secondary Education and Transition www.ncset.org

85. Resources Specialized Health Needs Interagency Collaboration (SHNIC) Kennedy Krieger Institute 410-502-8419

86. Lash and Associates Publishing/Training www.lapublishing.com Information and Referral Brain Injury in Children and Adults Books, pamphlets and tip sheets on various aspects of brain injury can be purchased, the website also offers many articles that can be downloaded for free

87. National Dissemination Center for Children with Disabilities www.nichcy.org/pubs/factshe/fs18 txt.htm

88. Publications Available from Lash & Associates Pay Attention! Attention Training for Children Ages 4-10. 2nd edition, Jennifer Thomson and Kimberly Kerns. Resource for professionals and families working with children following TBI, brain tumors, and ADHD Getting A-Head of Concussion. Phil Hossler and Ron Savage. For school nurses, parents, pediatricians, and coaches. Discusses the signs of concussion and how to monitor at home and in the classroom

89. Recommended Reading I am the Central Park Jogger: A Story of Hope and Possibility by Trisha Meili, 2003 Every Good Boy Does Fine: A Novel by Tim Laskowski, 2003 Over My Head: A Doctor’s Own Story of Head Injury from the Inside Looking Out by Claudia Osborn, 2000

90. Recommended Viewing Film released by Miramax in 2007 The Lookout Starring Joseph Gordon-Levitt, Jeff Daniels, Matthew Goode and Isla Fisher Aside from being a great bank heist movie, this movie realistically depicts the struggles of a young man living with the aftermath of a traumatic brain injury he suffered as a high school senior Appropriate movie to share with teenagers, brings home the message of brain injury prevention without preaching

91. Brain Injury Training Available free of charge for human service professionals, agencies and advocacy groups in: Frederick Washington Montgomery Baltimore Howard Anne Arundel County All counties on Maryland’s Eastern Shore Contact Anastasia Edmonston 410-402-8478

92. Contact Information Anastasia Edmonston 410-402-8478 aedmonston@dhmh.state.md.us Thank you!

93. A Product of the Maryland TBI Partnership Implementation Project, a collaborative effort between the Maryland Mental Hygiene Administration, the Mental Health Management Agency of Frederick County and the Howard County Mental Health Authority 2006-2009 Support is provided in part by project H21MC06759 from the Maternal and Child Health Bureau (title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Service Please Copy and Distribute Widely