Traumatic Brain Injury in Children and Adolescents

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

2. 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

3. TBI does NOT include • strokes, vascular accidents • anoxic injuries, infections • tumors, metabolic disorders • exposure to toxic substances

4. Types of Brain Injuries • Open brain injuries • Closed brain injuries • 1. Diffuse • 2. Focal

5. 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

6. 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

7. 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

8. Post Traumatic Amnesia (PTA) • Time after coma when person is still unable to form new memories • Measured by COAT or GOAT

9. 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

10. 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

11. 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

12. Risk Factors for TBI • Prior behavioral problems • Family stress • Family instability • Crowded living conditions • Prior TBI

13. 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

15. TBI: Some Statistics • 7,000 deaths of children • >500,000 hospitalizations • Hospital care costing over $1 billion • 30,000 children becoming permanently disabled

16. 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

17. What Happens After the Injury? Physical Cognitive Psychosocial Behavioral/Emotional

18. 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

19. Cognitive Effects • Short and long term memory problems • Intellectual functions hindered • Attention and concentration diminished • Language difficulties • Academic functioning reduced

20. Psychosocial Effects • Depression and anxiety • Social withdrawal • Feelings of worthlessness • Guilt • Loss of interest in school and family activities

21. 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

22. Emotional Effects • Poorer tolerance, more rigid • Greater dependence, insensitivity • Flat affect, oppositional, blaming • More demanding • More labile, immature coping

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. 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

37. 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

38. 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

39. Neuropsychological Assessment: Conceptual Approach • Assessment Domains • Executive Functions/Problem Solving • Memory • Personality/Behavioral/Adaptive Skills

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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.