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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 85207-3627. Agenda. Mr. Brain Neurodevelopment Epidemiology of injury

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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 85207-3627


  • Mr. Brain

  • Neurodevelopment

  • Epidemiology of injury

  • Understanding brain injury

  • Areas of impairment

  • Neuropsych assessment for disorders

  • Interventions in cognitive retraining


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.

Mr. Brain

  • Hemispheres

  • Lobes

  • Brain functions

  • Executive Functions

Mr. BrainBrain 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.

Mr. BrainBrain 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.

Cognitive Skills/Functions Associated with Hemispheres of the Brain

Left Hemisphere – Logical

Words (spelling)

Verbal meaning

Vocabulary in language

Details – rules


One-by-one selectivity

Step-by-step instructions

Sequential ordering

Cause and effect relationships

Learned facts

Letter-symbol associations

Abstract reasoning

Academically-learned information


Serial/ordered structures


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


Creativity – new combinations

Visual symbolism


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

Mr. BrainCerebral 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.

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.

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.

Mr. BrainExecutive 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.

Mr. BrainExecutive 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.

Mr. BrainExecutive 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.

Initiation and drive

Response inhibition

Task persistence


Generative thinking


Starting behavior

Stopping behavior

Maintaining behavior

Sequencing and timing behavior

Creativity, fluency, problem-solving skills

Self-evaluation and insight

Clinical Model of Executive Functions

Brain-behavior Relationships

  • Neurodevelopment

  • Brain-Behavior Relations

  • Model

  • New Learning

  • Personality


  • 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.

The Developmental Pyramid

16 - 19:


12 - 16:


Problem Solving

6 - 12:

New Learning/Attention

3 - 6:


0 - 3

Cause/Effect Relationships

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.

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.

Brain-Behavior Model


(motor, oral, written)

Concept formation, reasoning,

logical analysis

Language skills

Visual-spatial skills

Manipulations in Active

Working Memory

Attention, concentration, memory







Brain-Behavior RelationshipsNew Learning

  • 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.

  • New learning is one’s ability to:

Brain Behavior RelationshipsWhat is Personality?

What does it mean when you say

someone is “reliable”?

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.

Understanding Brain Injury

  • Epidemiology of Injury

  • Types of Injury

  • Concussion

Incidence and Prevalence of TBI

TBI: Data and Research

Centers for Disease Control and Prevention. “Traumatic Brain Injury in the United States: A Report to Congress.” (January 16, 2001).

Traumatic brain injury is now classified as a public health epidemic in America.

Incidence & Prevalence of TBI

  • Someone in America will sustain a brain injury every fifteen seconds.

    720 people

    during this

    3 hour training

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

TBI Incidence & Prevalence

CDC figures as of 4/02

The Real Statistics



Since 1992, on average more than 5,000 Arizonans each year sustain a TBI severe enough to cause death (20%*) or hospitalization.








* estimate

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.

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.

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.

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.

Incidence & Prevalence of TBI TBI Research

These hidden injuries may result in:




HyperactivityMood regulation

Impulse controlSuicidal ideation

Communication difficulties Substance abuse

Planning and problem solving difficulties

Brain Injury Source, Winter 1998, Volume 2, Issue 1, pages 12 – 13

Understanding Brain Injury

Understanding Brain InjuryBrain Anatomy

  • 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.

Quick overview (from the outside in):

Understanding Brain InjuryBrain Injury Types

Congenital Brain Injury

AcquiredBrain Injury

Traumatic Brain Injury

Non-traumatic Brain Injury

Closed Head Injury

Open Head Injury

Savage, 1991

Understanding Brain InjuryNon-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.

Understanding Brain InjuryHypoxia/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 3 - 4 minutes causes generalized damage.

  • Suicide attempts.

Understanding Brain InjuryTraumatic

  • 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.

A traumatic brain injury (TBI) is a result of:

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

Understanding Brain InjuryCOUP - CONTRECOUPInjury

LifeArt: Williams & Wilkins

Shaken Baby SyndromeViolent shaking or sudden impact may cause excessive brain movement and damage bridging cerebral veins.

Shaking Exerts

10x g Force

Impact Exerts

300x g Force

Understanding Brain InjuryConcussion

  • 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.





Nausea with or without vomiting

Disorientation to time and place

Slow to respond or follow instructions

Being uncoordinated


Persistent headache

Poor attention and concentration

Memory dysfunction

Vision disturbance

Ringing in the ears

Anxiety and depressed mood


Intolerance to loud noise

Understanding Brain InjuryConcussion: Common Symptoms

Understanding Brain InjuryConcussion 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.

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

Understanding Brain InjuryConcussion: Common Symptoms

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.

Areas of Impairment(s)after Injury

What Does TBI Look Like?

  • Functional Impacts

  • Personality and Emotional Impacts

  • Psychological and Behavioral Impacts

Functional Impacts of TBI

  • Impaired Mobility

  • Impaired Body Functions

  • Impaired Sensory Experiences

  • Impaired Cognitive Functioning

  • Impaired Communication

Functional Impacts of TBI

  • Impaired mobility

    • Paralysis (partial or full)

    • Hemiparesis

    • Spasticity, contractures

    • Balance and equilibrium

    • Gait challenges

Functional Impacts of TBI

  • Impaired body functions

    • Swallowing difficulties

    • Temperature control

    • Changes in other voluntary controls (motor)

    • Changes in involuntary controls

    • Seizures

Functional Impacts of TBI

  • Impaired sensory experiences

    • Vision

    • Hearing

    • Smell

    • Taste

    • Touch

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

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)

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.

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




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


“Flat” affect


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

Impact: Organic-based Personality / Emotional Changes









Irritability and aggressiveness

Deep sense of anger over what has happened



Hopelessness and despair


Reduced self-esteem

Withdrawal from social contact

Increased sense of dependency on others

Psychologically-based denial or minimization of problems


Pre-occupation with the past

Unrealistic expectations of family, friends, co-workers

Impact: Psychological / Behavior

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."



  • Psychoeducational Evaluation

  • Neuropsychological Evaluation

  • Formal and Informal Assessment Discussion

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

Psychoeducational Assessment (cont.)

  • Discussion of Results

  • Summary

  • Recommendations: Educational/Learning Implications

  • Referral (i.e., neuropsychologist, clinical psychologist, etc.)

  • Psychometric Summary (Explanation of Scores)

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

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

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

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)

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

Neuropsychological Evaluation

  • Recommendations

    • School programming / Vocational programming

    • Therapy needs

    • Compensation strategies, adaptations, accommodations

    • Psychosocial intervention(s)

    • Re-evaluation (need for and timing of)

What critical role can SLPs play in neuropsychological evaluation?

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) 81-101.

Identify formal (standardized) and informal assessments that you have used or can use to ascertain impairments in the following areas:

Sustained attention

Divided attention

Short-term memory

Long-term (sematic) memory

Episodic memory

Prospective memory


Awareness of behavior


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

Intervention Approaches after BITime-based shifts in responsibility

Primarily EXTERNAL

Primarily INTERNAL

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

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)

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

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

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