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Traumatic Brain Injury in Children and Adolescents. Katherine C. Nordal, Ph.D. The Nordal Clinic Vicksburg, MS 39183 Knordal@vicksburg.com. 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

Knordal@vicksburg.com

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
epidemiology
Epidemiology
  • 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
epidemiology11
Epidemiology
  • 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

Cognitive

Psychosocial

Behavioral/Emotional

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
AssessmentInstruments
  • 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