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BrainSTARS: Weaving a safety net for children and adolescents who have Acquired Brain Injuries. Jeanne E. Dise-Lewis, Ph.D. Professor University of Colorado School of Medicine Director, Psychology Programs in Rehabilitation Medicine Children’s Hospital Colorado
Jeanne E. Dise-Lewis, Ph.D.
University of Colorado School of Medicine
Director, Psychology Programs in Rehabilitation Medicine
Children’s Hospital Colorado
Vilans Medical Education
June 7, 2012
Team-based neuropsychological evaluations of children seen in Physical Medicine & Rehabilitation outpatient clinic
10 years of work together as multidisciplinary team; several hundred neuropsychological assessments
85% requests for evaluation were for children who had had previous moderate-severe ABI– common themes and repetitive information
About 100 requests/year for consultation from parents and school personnel about pediatric ABI sequelae
Critical incidents in lives of children who had had pediatric ABI many years earlier
suicide attempt, incarceration, school failure
needed to offer more than one point in time evaluation
Empirically developed and field-tested based on 50 team-based neuropsychological assessments.
Intended audience: the normal adults in a child’s world.
Teaches them to understand how a child’s brain injury causes cognitive changes which in turn affect many areas of development.
Teaches them to identify behavior and learning problems clearly.
Connects these problems (symptoms) to underlying cognitive difficulties.
Guides effective accommodations and interventions.
A self-paced, stand-alone education about moderate-severe ABI for “regular people” to use in normal environments.
11th grade reading level, tabs, spiral binding, lots of white space, professional editing, multiple stopping points within short chapters.
Use like a cookbook– Neurodevelopmental clusters and Index.
Our hope: People would be able to understand their child and modify their expectations/features of the environment so that child could be successful in everyday settings in which all children grow, learn and develop.
Continued requests from parents and/or school personnel for consultation despite having had one education session and manual.
Manual still in shrink-wrap/ in Special Education office or library.
Most people were in need of basic orientation to using manual, walking through the education provided, and guidance to individualize the material for a specific child.
“The Manual is a heavy piece of work”
Two different medical syndromes/ two different populations.
Require very different types of education, approaches, and expectations.
BrainSTARS is for Moderate-Severe TBI or ABI.
Brain should recover to full pre-concussion capacity in 3 months.
There is an initial impact on neurocognitive abilities, which recover to baseline levels in 4-6 weeks for most children.
There also is an impact on general physical and behavioral symptoms.
It is important to prevent a second concussion before recovery from the first concussion– especially in <age 20.
“Cognitive rest” may play a part in rate and completeness of recovery.
Multiple concussions over a lifetime appear to have significant cumulative detrimental effects
child vs adult concussion not studied
Provide family and child with good educational materials.
education about expected symptoms and usual course of recovery
Stay home from school/work/social activities for 2 days.
Keep your head out of traffic for awhile (at least 8 days).
Develop a school-based plan of accommodations providing a safety net for the student.
Collaboration among school, family, medical personnel
Initiation of school-based accommodations for cognitive rest
Kirkwood et al., 2007; Dise-Lewis 2011
Attention Processing Speed
Specific Learning Disabilities
Reading New Learning
Note-taking Expressive Language
Social Skills Test-taking
Problem Solving Long-Range Projects
Has Temper Tantrums Poor Frustration Tolerance
Messy Handwriting Doesn’t Follow Directions Looks “Blank”
Fights With Others Fails Tests Can’t Keep Up With Peers
These areas are likely to be the Achilles heel for a child with an acquired brain injury, even after he grows up.
A Brain-based skill or competency that
Has an developmental sequence of skill acquisition
Piaget, Erikson, Kohlberg
16-19: written language
12-16: reading comprehension
6 - 12: reading decoding
3 -6: expressive language
0 - 3: receptive language
16-19: reasoning, judgment
12-16: organization, working memory, self and task monitoring
6 - 12: attention, initiation, planning
3 -6: mental flexibility, emotion regulation
0 - 3: cause/effect relationships, self-regulation
Keep child functioning in everyday settings in which his/her peers are learning, growing, and developing.
Identify primary or underlying neurodevelopmental deficits that are tanking the child’s performance.
Especially MPS, executive functions, reading
Remediate/ accommodate these deficits.
Focus academic program on strengths.
Identify and teach age appropriate play/ peer skills.
Nurture hobbies and interests through which friendships can develop.Effective TBI Intervention
hold the key to developing appropriate behavior for the student with BI
specify clearly/ link with underlying neurodevelopmental deficits
consequences-based approaches are ineffective with children who have TBI
Modeling of Skills and Positive Behavior
Instructions and Directions
Schedules and Mini-Schedules
Child’s Physical and Emotional state
Assure optimal physical and emotional state
address student’s anxiety
good nutrition and energy
Provide a “warm-up” before tests, class-work, introduction of new material.
Carefully task analyze activity and provide explicit instruction for each component.
Don’t quiz or question; teach using the “I do/ We do/ You do” model.
Provide prepared materials
Make the task concrete
Stick to a routine during the day and problem-solve snags in the environment where they occur.
Organize work, play, relaxation, and regrouping spaces to support the activity.
Prepare your child in advance if there is something you need him to do
Focus on the positive: tell your child what to do; avoid telling the child what s/he should stop doing.
Rehearse with your child what he/she will be doing during unstructured times or in new settings.
Hold a small and clearly defined set of expectations for your child.
Use visual reminders and teach their use.
Break down complex or multi-step activities and sequence them, using pictures or written phrases to serve as a concrete representation and reminder.
Construct, and teach the use of, a daily planner.
Role-play specific activities and desired behaviors.
Teach play-yard or free time skills.
Practice desired responses to stressful events.