Pediatric Traumatic Brain Injury

1. Pediatric Traumatic Brain Injury Epidemiology Sequelae Educational Management

3. Definitions • Traumatic Brain Injury: damage occurring to the brain as a result of an external force • Anoxic/Hypoxic Brain Injury: damage occurring to the brain as a result of decreased oxygen supply • Acquired Brain Injury: damage occurring to the brain from any etiology (includes trauma, anoxia, infection, stroke, etc)

4. TRAUMATIC BRAIN INJURY • Closed or Open Head Injury • Evidence of Brain Involvement • Level of Consciousness • Focal Signs

5. EPIDEMIOLOGY Trauma: Major cause of Morbidity and Mortality in Children Head Trauma: Major determinant of severity of injury

6. Estimated Average Annual Number of Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths, United States, 2002-2006

7. EPIDEMIOLOGY • Each year in the US approximately 511,000 TBIs occur among children ages 0 to 14 years; ED visits account for more than 90% of the TBIs in this age group • Cumulative risk of TBI by age 16 • Boys 4.0 % • Girls 2.5 %

8. Estimated Average Annual Rates of Traumatic Brain Injury-Combined Emergency Department Visits, Hospitalizations, and Deaths, by Sex, United States, 2002-2006

9. Rates of traumatic brain injury by age group (per 100,000 population), in United States, 2003 Rutland-Brown, Langlois, Thomas, and Xi, 2006

10. ETIOLOGY by AGE • Infants: Inflicted Trauma and falls • Preadolescents: MVC Pedestrians/Cyclists • Adolescents: MVC Occupants

11. Estimated Average Annual Rates of Traumatic Brain Injury-Combined Emergency Department Visits, Hospitalizations, and Deaths, by External Cause, United States, 2002-2006

12. MVC Falls Sport Falls MVC 0-4 years old 5-9 years old MVC Sport MVC 10-14 years old 15-19 years old

13. ETIOLOGY by SEVERITY

14. Sex Age Race Socio-Economic Status (SES) Inner City Behavior (ADHD, LD) Substance Abuse Prior TBI RISK FACTORS

15. PRIMARY INJURIES • Results when person sustains a blow to head through acceleration-deceleration movement with co-occurring rotational trauma • tearing and bruising of blood vessels results in contusions in frontal and anterior temporal lobes • DAI in gray/white junctions around basal ganglia, periventricular regions, and fiber tracts in brain stem

16. Contusions • larger areas of bleeding and “bruising” • due to impact of brain against skull Dorsolateral frontal Orbitofrontal Medial Temporal Lateral Temporal Anterior Temporal Dorsolateral frontal Orbitofrontal Lateral Temporal Anterior Temporal

17. Corpus Callosum Gray-White Junction Central White Matter Midbrain Midbrain Diffuse Axonal Injury • microscopic injuries to cellular structures • due to shearing, occurs throughout brain

18. Coup-Contrecoup Injury

19. Secondary Injury • Results from decreased cerebral blood flow, increased cerebral blood volume, and increased intracranial pressure (causing ischemic injury, herniation, and death) • Specific brain regions more vulnerable to neurochemical changes (parts of cortex, hippocampus, thalamus, striatum, and subcortical nuclei)

21. CLASSIFICATION OF SEVERITY

22. IMPAIRMENTS AFTER TBI

23. RECOVERY • GENERAL RULES: • MOST RECOVERY IN FIRST TWO YEARS • SMALL BUT SIGNIFICANT RECOV ERY, YEARS 2-5 • MOTOR RECOVERY UP FRONT • RECOVERY SUPERIMPOSED ON DEVELOPMENT

24. Impairments Following TBI • Physical and Motoric • Watch for increased: • fatigue • headaches • chance of seizure • Look for Impairments in: • mobility • coordination • strength • balance • (spasticity, ataxia, hemiplegia, quadriplegia)

25. AMBULATION AND ADLs AFTER SEVERE TBI Average length of coma 5-6 weeks • Independent 73% • Partially Dependent 10% • Dependent 9% • Comatose 8%

26. Neuropsychological Sequelae • Intellectual Functioning - PIQ < VIQ • Attention - Disturbances common following TBI, sustained attention and ADHD-like symptoms • Memory - Deficits in both verbal and visual memory. Difficulty with initial encoding and organization of task. • Language - Aphasia not common • Pragmatics: set of rules governing conversation the social use of language • Discourse: connected communication of thought sequences

27. Neuropsychological Sequelae • Visuoperceptual/spatial/constructional Skill • Few studies examining nonmotor aspects • Often deficits related to motor skill, attention, and response time. • Constructional impairments related to organizational difficulties as well as motor skill and speed • Executive Functions • Goal-directed behavior such as development and implementation of strategies for problem solving. • Deficits often evident.

28. * * * * * * = statistically significant difference from Fracture, p < .05 Executive Function

29. Neuropsychological Sequelae • Academic Achievement • Declines in performance and increased risk for special education. • Declines often not evident on standardized testing and poor performance may reflect behavioral or neuropsychological deficits rather than specific decrements in academics skills as measured by standardized testing.

30. Behavioral Sequelae • Emotional/Personality • Behavioral disturbance and personality change is often present following TBI • Problems include aggressiveness, hyperactivity, disinhibition, poor social judgement, apathy, increased dependency, and increased fears and phobias. • 50% if children develop novel psychiatric disorder (PC, ADHD, Depression, ODD, PTSD) • Emotional/Behavior problems less likely to recover over time

31. OUTCOME: BEHAVIOR • PSYCHIATRIC DIAGNOSES: > 50% • SECONDARY-ADHD (S-ADHD) • DISINHIBITION

32. Variables Related to Outcome • Individual Factors • Age • Pre-injury characteristics • Family Factors • SES • Chaotic/Stressful Family

33. Variables Related to Outcome • Injury Variables • Glasgow Coma Scale • Trajectory of Recovery • Length of Coma • Length of PTA • Extent of neurological injury (number of lesions, location and depth of lesions) • Secondary injury?

34. Environmental Factors • Psychosocial adversity, a measure of global family stress, has been predictive of psychiatric morbidity after TBI • SES and family demographics also related to outcome • Preinjury family functioning related to outcome at one year • Family dysfunction significant impacts TBI patients more than orthopedic controls

35. Environmental Factors: Family Burden • Family burden associated with functional impairments • Parental perception of unmet healthcare needs related to family burden • Identification and provision of services is a potentially modifiable factor that may decrease family burden Aitken et al., 2009

36. Other Environmental Factors: Analysis of Need • Almost 1/3 of children had unmet (approximately 20%) or unrecognized (approximately 10%) healthcare needs. • Cognitive services were the most frequent type of service associated with unmet or unrecognized need. Slomine et al., 2006

37. Recovery Mechanisms • Spontaneous recovery – due to resolution/absorption of hematomas, decreased swelling, normalization of blood flow, return of electrolyte/neurochemical balance • Plasticity – neural and/or behavioral resilience (ability to reorganize) • Axonal growth – regeneration of neural elements following injury with activity practice/rehabilitation • Behavioral compensation – new or different behavioral strategy via rehabilitation

38. Educational Management • Considerations

39. Educational Management • Considerations • time since injury

40. Educational Management • Considerations • time since injury • severity of injury

41. Educational Management • Considerations • time since injury • severity of injury • age at injury

42. Educational Management • Considerations • time since injury • severity of injury • age at injury • pre-injury functioning

43. Educational Management • Considerations • time since injury • severity of injury • age at injury • pre-injury functioning • profile of impairments

44. Educational Management • Considerations • time since injury • severity of injury • age at injury • pre-injury functioning • profile of impairments • available resources

45. Features of Appropriate School Programming • Willingness for contact between educational and medical providers • Team approach with designated case manager • Willingness to plan creatively • Evaluation of plan done regularly • Highly structured environment • Focus on process to learn content • Integrated therapies • Behavioral support available • Psycho-social support available • Support for physical needs and nonacademic activities

46. Specialized Transition Program • Both rehabilitation and education program • Therapies model school activities • Intense, coordinated, short term • Goal for smooth school transition • Guide family through Special Education process • Provides training to family and school staff • Provide peer training

47. TBQ • From the neuropsychological sequelae discussed in this presentation, which of them do you think provides the greatest challenge in the classroom? Remember that these may be in either cognitive, academic or behavioral areas of function.