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Traumatic Brain Injury in Children and Adolescents. Katherine C. Nordal, Ph.D. The Nordal Clinic Vicksburg, MS 39183 Traumatic Brain Injury. Injury to brain External force Total or partial disability or psychosocial impairment 1 or more areas

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traumatic brain injury in children and adolescents

Traumatic Brain Injury in Children and Adolescents

Katherine C. Nordal, Ph.D.

The Nordal Clinic

Vicksburg, MS 39183

traumatic brain injury
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
tbi does not include
TBI does NOT include
  • strokes, vascular accidents
  • anoxic injuries, infections
  • tumors, metabolic disorders
  • exposure to toxic substances
types of brain injuries
Types of Brain Injuries
  • Open brain injuries
  • Closed brain injuries
    • 1. Diffuse
    • 2. Focal
severity of brain injury
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
glasgow coma scale gcs
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
    • None 1
  • Verbal Response
    • Oriented conversation 5
    • Confused conversation 4
    • Inappropriate words 3
    • Incomprehensible sounds 2
    • None 1
gcs facts
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
post traumatic amnesia pta
Post Traumatic Amnesia (PTA)
  • Time after coma when person is still unable to form new memories
  • Measured by COAT or GOAT
rancho los amigos scale
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
  • 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
  • Who gets injured?
    • 3-8 year olds
    • 15-29-year olds
  • Kid’s at greatest risk:
    • HA/ emotionally disturbed/delinquent
    • Under 5, w/ prior adjustment problems, of low SES, parents w/ problems
risk factors for tbi
Risk Factors for TBI
  • Prior behavioral problems
  • Family stress
  • Family instability
  • Crowded living conditions
  • Prior TBI
major causes of brain injuries
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
tbi some statistics
TBI: Some Statistics
  • 7,000 deaths of children
  • >500,000 hospitalizations
  • Hospital care costing over $1 billion
  • 30,000 children becoming permanently disabled
tbi some statistics16
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
what happens after the injury

What Happens After the Injury?





physical effects
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
cognitive effects
Cognitive Effects
  • Short and long term memory problems
  • Intellectual functions hindered
  • Attention and concentration diminished
  • Language difficulties
  • Academic functioning reduced
psychosocial effects
Psychosocial Effects
  • Depression and anxiety
  • Social withdrawal
  • Feelings of worthlessness
  • Guilt
  • Loss of interest in school and family activities
behavioral effects
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
emotional effects
Emotional Effects
  • Poorer tolerance, more rigid
  • Greater dependence, insensitivity
  • Flat affect, oppositional, blaming
  • More demanding
  • More labile, immature coping
factors influencing outcome
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
factors influencing outcome24
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
factors influencing outcome25
Factors Influencing Outcome
  • Age @ 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
factors influencing outcome26
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
factors influencing outcome27
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
factors influencing outcome28
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
factors influencing outcome29
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
factors influencing outcome30
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
factors influencing outcome31
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
factors influencing outcome32
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
neuropsychological assessment conceptual approach
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
neuropsychological assessment conceptual approach34
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
neuropsychological assessment conceptual approach35
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.
neuropsychological assessment conceptual approach36
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
neuropsychological assessment conceptual approach37
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
neuropsychological assessment conceptual approach38
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
neuropsychological assessment conceptual approach39
Neuropsychological Assessment: Conceptual Approach
  • Assessment Domains
    • Executive Functions/Problem Solving
    • Memory
    • Personality/Behavioral/Adaptive Skills
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
assessment domains
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
assessment domains42
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
assessment instruments43
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
assessment instruments44
Assessment Instruments
  • General Intelligence
    • Kaufman Assessment Battery for Children (K-ABC), ages 2.5-12.5 yrs
    • Leiter International Performance Scale
    • McCarthy Scales of Children’s Abilities, ages 2.5-8.5 yrs
    • Stanford-Binet Intelligence Scale, 4th Ed., ages 2-23 yrs
assessment instruments45
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), 3.5-9 yrs
assessment domains46
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
assessment domains47
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
assessment domains48
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
assessment instruments49
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
assessment instruments50
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.
assessment instruments51
Assessment Instruments
  • Academic Achievement
    • Nelson Denny Reading Test, Grades 9+
    • Test of Early Written Language, 3-10 yrs
    • Test of Written Language, 7.6-17 years
    • Test of Written Expression, 6.5-14 years
assessment domains52
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 deficits @ 1- & 2-yr. f/u
    • With younger kids see problems with:
        • fine motor coordination/tremors
        • rapid alternating movements
        • visual-motor integration
assessment domains53
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
assessment instruments54
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
assessment instruments55
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
assessment instruments56
Assessment Instruments
  • Motor Skills
    • Bruininks-Osteresky Test of Motor Proficiency, 4.5-14.5, 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. 3-17 yrs
assessment domains57
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
assessment domains58
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 performance @ 1yr for all severity levels (studies do not universally support this)
assessment instruments59
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

assessment instruments60
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
assessment domains61
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
assessment domains62
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
assessment instruments63
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
assessment instruments64
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
assessment domains65
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 deficits @ 12 mos
assessment domains66
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
assessment instruments67
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
assessment instruments68
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
assessment domains69
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
assessment domains70
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
assessment instruments71
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
assessment domains72
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 d/o @ 4mos. & f/u regardless of sex, age, or social class
assessment domains73
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
assessment domains74
Assessment Domains
  • Psychosocial Adjustment
    • Poor social adjustment with severe injuries: studies range from 25% @ 1 year to >50% at 3- and 5-yr follow-up
    • Significant declines in adaptive behavior seen @ 1 yr post-injury
    • Severely injured children carry w/ them substantial and continuing risk factors
assessment domains75
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
assessment instruments76
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+)
assessment instruments77
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)
assessment instruments78
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+
assessment instruments79
Assessment Instruments
  • Personality/Behavioral Measures
    • Children’s Personality Questionnaire (CPQ)
    • Behavior Rating Profile, 6.5-18.5 yrs
    • Personality Inventory for Children (PIC)
    • Trauma Symptom Checklist for Children (TSCC), 8-16 yrs
    • Adaptive Behavior Rating Scales, if needed
tbi evaluation schedule
TBI Evaluation Schedule
  • Do SERIAL evaluations
  • Initial evaluation within 6 months
  • Follow-up @ 1-yr intervals w/ mild to moderate TBI
  • Follow-up @ 6-month intervals w/ severe TBI