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1
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
2
Agenda
• Mr. Brain• Neurodevelopment• Epidemiology of injury• Understanding brain injury• Areas of impairment• Neuropsych assessment for disorders• Interventions in cognitive retraining
3
Objectives
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.
4
Mr. Brain
• Hemispheres
• Lobes
• Brain functions
• Executive Functions
5
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.
6
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.
7
Cognitive Skills/Functions Associated with Hemispheres of the Brain
Left Hemisphere – LogicalWords (spelling)Verbal meaningVocabulary in languageDetails – rulesAnalysisOne-by-one selectivityStep-by-step instructionsSequential orderingCause and effect relationshipsLearned factsLetter-symbol associationsAbstract reasoningAcademically-learned informationIdeasSerial/ordered structuresSelf-verbalizationsSelective attentionConsciousness – reasoningScientific logic
Right Hemisphere – AestheticImages, pictures, and colors – spatial
Music and feelingsGestalt – whole/relational
Synthesis, comparisonsSimultaneous patterning
Whole processWhole units
AnalogiesCreativity – new combinations
Visual symbolismConcrete
Practical – common sense knowledgePatterns of things/theory
Random-without structure body languageFacial expression, tone of voice
Sustained attentionMeditation, spontaneous ideas, subconscious
Spiritual – mythicalPatterns of logical associations
Used with Permission: Maureen Priestley 2004
8
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.
9
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.
10
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.
11
12
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.
13
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.
14
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.
15
Clinical Model of Executive Functions
• Initiation and drive• Response inhibition• Task persistence• Organization
• Generative thinking
• Awareness
• Starting behavior• Stopping behavior• Maintaining behavior• Sequencing and
timing behavior• Creativity, fluency,
problem-solving skills• Self-evaluation and
insight
16
Brain-behavior Relationships
•Neurodevelopment
•Brain-Behavior Relations
•Model
•New Learning
•Personality
17
Neurodevelopment
• 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.
Draft for discussion only 18
The Developmental
Pyramid
16 - 19:
Judgment
12 - 16:
Integration/
Problem Solving
6 - 12:
New Learning/Attention
3 - 6:
Thinking/Emotion/Behavior
0 - 3
Cause/Effect Relationships
19
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.
20
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.
21
InputsAuditory
Language skills Visual-spatial skills
OUTPUTS(motor, oral, written)
Brain-Behavior Model
Manipulations in Manipulations in Active Active
Working MemoryWorking Memory
InputsVisual
InputsKinesthetic
Attention, concentration, memory
Concept formation, reasoning,logical analysis
22
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:
23
Brain Behavior Relationships
What is Personality?
What does it mean when you say
someone is “reliable”?
24
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.
25
Understanding Brain Injury
•Epidemiology of Injury
•Types of Injury
•Concussion
26
Incidence and Prevalence of TBI
27
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.
28
Incidence & Prevalence of TBI
• Someone in America will sustain a brain injury every fifteen seconds.
720 peopleduring this
3 hour training
29
TBI Incidence & Prevalence
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 disability6.5 million Americans living with some effect
CDC figures as of 4/02
30
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
‘92
‘93
‘94
‘95
‘96
‘97
‘98
‘99
‘00
31
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.
32
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.
33
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.
34
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.
35
Incidence & Prevalence of TBI TBI Research
These hidden injuries may result in:
Depression DelinquencyAnxiety PTSDAggression ImpulsivenessHyperactivity Mood regulationImpulse control Suicidal ideationCommunication difficulties Substance abusePlanning and problem solving difficulties
Brain Injury Source, Winter 1998, Volume 2, Issue 1, pages 12 – 13
36
Understanding Brain Injury
37
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):
38
Understanding Brain InjuryBrain Injury Types
Congenital Brain Injury
Acquired Brain Injury
Traumatic Brain Injury Non-traumatic
Brain Injury
Closed Head Injury
Open Head Injury Savage, 1991
39
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.
40
• 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 InjuryHypoxia/Anoxia
41
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:
42
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
43
Understanding Brain InjuryCOUP - CONTRECOUP Injury
LifeArt: Williams & WilkinsLifeArt: Williams & Wilkinshttp://www.lifeart.comhttp://www.lifeart.com
44
Shaken Baby SyndromeViolent shaking or sudden impact may cause excessive brain movement
and damage bridging cerebral veins.
Shaking ExertsShaking Exerts10x 10x gg Force Force
Impact ExertsImpact Exerts300x 300x gg Force Force
45
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.
46
Understanding Brain InjuryConcussion: Common Symptoms
• EARLY SYMPTOMS– Headache– Confusion– Dizziness– Nausea with or without
vomiting– Disorientation to time
and place– Slow to respond or
follow instructions– Being uncoordinated
• LATE SYMPTOMS– Persistent headache– Poor attention and
concentration– Memory dysfunction– Vision disturbance– Ringing in the ears– Anxiety and depressed mood– Irritability– Intolerance to loud noise
47
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.
48
Understanding Brain InjuryConcussion: Common Symptoms
• 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
49
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.
50
Areas of Impairment(s)after Injury
51
What Does TBI Look Like?
• Functional Impacts
• Personality and Emotional Impacts
• Psychological and Behavioral Impacts
52
Functional Impacts of TBI
• Impaired Mobility
• Impaired Body Functions
• Impaired Sensory Experiences
• Impaired Cognitive Functioning
• Impaired Communication
53
Functional Impacts of TBI
• Impaired mobility
– Paralysis (partial or full)
– Hemiparesis
– Spasticity, contractures
– Balance and equilibrium
– Gait challenges
54
Functional Impacts of TBI
• Impaired body functions
– Swallowing difficulties
– Temperature control
– Changes in other voluntary controls (motor)
– Changes in involuntary controls
– Seizures
55
Functional Impacts of TBI
• Impaired sensory experiences
– Vision
– Hearing
– Smell
– Taste
– Touch
56
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
57
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)
58
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.
59
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
60
Impact: Organic-based Personality / Emotional Changes
• Disinhibition• Suspiciousness• Impulsivity• 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• Euphoria• “Flat” affect• Agitation• 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
61
Impact: Psychological / Behavior
• Depression• Anxiety• Panic• Shame• Humiliation• Grief • Loss• Sadness• Irritability and aggressiveness• Deep sense of anger over
what has happened
• Resentment• Blame• Hopelessness and despair• Helplessness• Reduced self-esteem• Withdrawal from social contact• Increased sense of dependency
on others• Psychologically-based denial or
minimization of problems• Defensiveness• Pre-occupation with the past• Unrealistic expectations of family,
friends, co-workers
62
Functional Impacts of TBI
"Left to fend for themselves, the "Left to fend for themselves, the survivorssurvivors of traumatic brain of traumatic brain injury, already confused by their injury, already confused by their inability to be the people they were inability to be the people they were prior to the injury, now face the prior to the injury, now face the daunting task of demonstrating daunting task of demonstrating that an injury they do not that an injury they do not understand and cannot understand and cannot comprehend is producing the comprehend is producing the confusion they cannot confusion they cannot communicate."communicate."
63
Questions
64
Assessment
• Psychoeducational Evaluation
• Neuropsychological Evaluation
• Formal and Informal Assessment Discussion
65
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
66
Psychoeducational Assessment (cont.)
• Discussion of Results• Summary• Recommendations: Educational/Learning
Implications• Referral (i.e., neuropsychologist, clinical
psychologist, etc.)• Psychometric Summary (Explanation of Scores)
67
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
68
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
69
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
70
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)
71
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
72
Neuropsychological Evaluation
• Recommendations– School programming /
Vocational programming– Therapy needs– Compensation strategies,
adaptations, accommodations– Psychosocial intervention(s)– Re-evaluation (need for and
timing of)
73
What critical role can SLPs play in neuropsychological
evaluation?
74
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.
75
GROUP DISCUSSION
• 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• Planning• Awareness of behavior
76
Intervention Approaches after BITime-based shifts in responsibility
• 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
Primarily EXTERNAL Primarily INTERNAL
77
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
78
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)
79
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
80
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