Lecture 5 - TBI Paeds

Question 1

Are the vast majority of Paediatric TBIs mild, moderate or severe?

Answer 1

Mild - 90%

Question 2

What is the prevalence of TBI is Paeds?

Answer 2

Approx 745 per 100,000 children in any year. (Mitra et al 2007, Australian study)

Question 3

How does the TBI vary based on age and Gender?

Answer 3

Age affects type:

Infants (inflicted injuries)
Toddlers (falls)
Primary school (pedestrian, bicycle, sport)
Secondary school (MVA related, sport, falls)

Overall, Males more likely to have severe TBI. But interaction between age and gender….
Preschool occurring 1.5:1 male-female - by school age the ratio is 2:1 male-female.

Question 4

What are some of the pre-injury characteristics associated with increased risk of TBI?

Answer 4

Up to 23% of children met criteria for ADHD pre-injury

Social disadvantage also associated with TBI.

Question 5

What indices of severity are commonly used?

Answer 5

Level of consciousness - Glascows coma scale and Children’s Coma scale (for young children [age less than 5] with limited verbal abilities)

+

Post-traumatic amnesia - westmead PTA scale

+ MRI/CT information, undertaken acutely for medical management

Question 6

Describe the Glasgow coma scale and the typical categories used to classify TBI severity.

Answer 6

Made up of 3 parts, scores range from 3-15. eye-opening(4), verbal response (5), Motor response (6).

13-15 = mild
9-12 = moderate
lessthan 8 = severe

Question 7

Why might you use the ‘children coma scale’ for young children?

Answer 7

Because the children may have limited verbal abilities to begin with and this measures has a changing verbal scale based on age.

Question 8

Describe the verbal scale of children’s coma scale.

Answer 8

0-23 months: smiles, coos, orientated to sound/ cries but not consolable/ persistent writers / grunts / no verbal response

2-5 years: app words/inapprop words/cries/grunts/no verbal response

> 5 years: orientated/confused/inapprop words/incomprehensible sounds / no verbal response

Question 9

Can the westmead PTA scale be used reliably in children? are there alternative PTA scales?

Answer 9

Can be used reliably in children over 8 years of age, some modified Questions for 6-7 year olds (though not well normed).

Starship PTA scale for 4-6 year olds is an alternative, but is not routinely used in Aus.

Question 10

Describe the levels of severity using the westmead PTA scale

Answer 10

Most use: 
less than 5mins = very mild
5-60mins = mild
1-24hours = moderate
1-7days = severe
more than 4 weeks = extemely severe

Used at Westmead:
less than 5mins = very mild
1-6days= Moderate
1-4 weeks = severe
4+ weeks = extremely severe (Westmead group, Khan and Baguley, 2003)

Question 11

What is a primary TBI injury, give examples (2 types of injuries):

Answer 11

caused by contact forces

e.g.,:
Linear: skull fractures, contusions, lacerations, and contre-coup

Rotational: aceleration-deceleration resulting in DAI

Question 12

What is a secondary injury, give examples:

Answer 12

Initiated at the time of injury and develops over time.

Vascular: extradural, subdural, or intracerebral haemorrhage, raised ICP, hydrocephalus, cerebral oedema, hypoxia, infection and/or metabolic and respiratory changes.

Diffuse axonal injury also occurs from changes in metabolism (presence of free radicals and excitatory amino acids, changes in glucose metabolism)

Question 13

What are late effects (of TBI, pathophysiology), give examples:

Answer 13

Any effects occurring outside primary and secondary effects. E.g., white matter degeneration and cortical thinning, cerebral atrophy and ventricular enlargement.

Question 14

What brain areas are particularly vulnerable to the primary contact force injury of TBI?

Answer 14

Prefrontal cortex and fronto-temporal cortex particularly.

Question 15

Are skull fractures more common in older or younger children?

Answer 15

Younger ages (infant and toddler) - thinner skulls.

Question 16

Are mass lesions (incl. haematoma, contusions) more frequent in younger or older children?

Answer 16

Less frequent in younger children (infant and toddlers), than adolescents and adults.

Question 17

Are secondary injuries such as brain swelling, hypoxia, and diffuse axonal injury more common in children or adults?

Answer 17

More common in children.

Question 18

Describe the general pattern of physical and then neuropsychological outcomes to mod-severe TBI (not specific domains, just the general pattern)

Answer 18

• Physical issues often resolve in the short term
• Cognitive and behavioural difficulties common and likely to significantly impact on participation and progress
• Considerable variation beween cognitive and behavioural outcomes within mod-sec tbi - this reflects the contribution of multiple factors.

Question 19

Multiple factors affect cognitive outcome after paediatric TBI, what are four main categories of factors?

Answer 19

1. Biological insult: nature, severity, dose-response effect
2. Development of a child: age at injury, age at ax
3. Time since onset: Acute phase v chronic, post-injury
4. Reserve/resilience: pre-injury factors (child and family), mental health, family stress and functioning, school & social supports.

Question 20

What is the concept of a ‘double hazard’?

Answer 20

That multiple factors compound the effects of any one factor – to affect cognitive outcome after paediatric TBI

Question 21

Briefly describe how early TBI can affect later development?

Answer 21

Slowed developmental progress. Raw scores increase but not at an age appropriate rate, therefore abilities fall further behind peers over time.

Question 22

What cognitive problems may affect later development?

Answer 22

Children who suffer a significant neurological event have a range of cognitive problems. e.g., attention, memory, executive deficits that compromise their ability to maintain their normal intellectual/developmental trajectory.

Question 23

How does TBI affect intellectual development?

Answer 23

A unique TBI IQ profile not identified!
- age at injury and severity relate to overall IQ ability level. e.g., Younger age at time of injury results in reduced IQ relative to injuries sustained in late childhood or adolescence. AND
Greater injury severity >IQ impairment

HOWEVER….very general clinical findings:

• verbal IQ resillient to changes in early stages, but can find a widening gap emerging in these areas over time
• performance based IQ and processing speed, vulnerable acutely, but more likely to show recovery.

Question 24

Is IQ a good indicator of general functioning following TBI? why not?

Answer 24

No. as IQ can remain in low avg to avg range following moderate to severe TBI, but that does not mean the child is functioning well. May have many other cognitive issues or fatigue etc.

Question 25

Why do you need to consider fatigue in TBI?

Answer 25

Cognitive fatigue or tiredness is associated with length periods of mental effort/concentration and is very common following TBI

• this impacts upon cognition and behaviour
• fatigue is cumulative
• fatigue is very debilitating, from academic and social perspectives
• numerous strategies can be implemented which depend on age and year level

Question 26

What cognitive domains are typically affected in TBI?

Answer 26

• IQ (performance immediately but improves, verbal ok but worsens over time)
• Processing speed (associated with DAI, recovery over first 12 months, but can persist in severe TBI)
• Attention (may develop ADHD like symptoms, selective attention more vulnerable at early ages, shifting/divided and complex behaviours more likely to be affected at older ages.
• Executive Functioning (WM, idea generation, problem solving, planning, organisational skills, self-monitoring, initiation etc - reflect vulnerability of prefrontal cortex)
• New learning and memory ( reflect susceptibility of temporal and frontal regions, issues with encoding and learning, poor generalisations of new learning, widens over time, children more vulnerable to adults as less preexisting info to rely on)
• Language and communication
• Academic functioning
• Behaviour
• Social compentency
• Psychological and psychiatric outcomes
• The family system

Question 27

Processing speed in paediatric TBI, describe. (Pathophysiology, recovery, how it effects the child)

Answer 27

• Processing speed is sensitive to TBI, it is associated with the effects of diffuse axonal injury/shearing of white matter.
• Recovery occurs in the first 12 months, but processing speed difficulties can persist as a deficit in severe to very severe TBI
• It impacts the efficiency with which a child can take in and respond to information. Children can be overwhelmed by the rate at which material is presented, therefore miss out on new learning opportunities.

Question 28

Attention in paediatric TBI, describe. (Pathophysiology, age difference, how it effects the child)

Answer 28

• attention difficulties are common following paediatric TBI (independent of PS reductions). these deficits are related to the age-related development of attention (and disruption)
• *selective attention develops at younger ages, therefore is more vulnerable if injury is sustained early in development
• • Shifting, divided attention and more complex behaviours develop later (skills ‘on line’).
• Children with attention difficulties can only take on limited information at the one time. As a result children miss out on learning in the classroom; find it hard to complete tasks independently. + Socially unable to keep track of all cues to make sense of social situations.

-

Question 29

Executive functioning in paediatric TBI, describe. (Pathophysiology, aspects of exec func affected, how it effects the child)

Answer 29

• Disruption of the development of executive skills notable in paediatric TBI. Reflects vulnerability of prefrontal cortex. Also reflects impaired acquisition rather than skill loss (deficits may not be expressed until the child reaches the age when the skills mature in typically developing children)
• Involves: working memory capacity; idea generation and problem solving; planning and organisational skills; self-monitoring; initiation (confused with laziness at times); behaviourally: self-regulation, flexibility and shifting.
• Secondary impact upon general cognitive development, required for adaption and new learning + Associated with poorer social outcomes and social problem solving.

Question 30

New learning & Memory in paediatric TBI, describe. (Pathophysiology, what type of issues/how it effects the child)

Answer 30

One of the most common deficits reported by children and families following TBI. Reflects susceptibility of temporal and frontal regions.

• Issues particularly with encoding and learning, poor generalisation of new learning. ALSO, some suggestion of reduced retention of long-term memory over longer periods e.g., 7 days (accelerated long-term forgetting, like in children with temporal lobe epilepsy); this may impact upon future thinking, behaviour, and social problem solving.

– The gap between children & their peers widens over time. Children more susceptible than adults as they have less knowledge and skills to rely on.

Question 31

Language and Communication in paediatric TBI, describe.

Answer 31

Aphasic disorders are RARE. but specific language difficulties have been found:

• slowed speech
• word-finding difficulties
• poor organisation of language output (oral and written)
• difficulties with comprehension (auditory and written)

Question 32

Social Pragmatics in paediatric TBI, describe. (describe how other cognitive issues affect pragmatic of communication)

Answer 32

Pragmatic language problems can occur in relation to cognitive difficulties (poor attention, memory, executive skills).

• poor self-monitoring: off-topic in conversation, inappropriate comments
• poor memory: trouble learning new vocabulary
• poor flexibility: resulting in concrete interpretation, unable to understand sarcasm, double meanings, teasing/humour.

Question 33

Academic Functioning in paediatric TBI, describe. (what factors lead to better/worse academic func + limits of academic testing.)

Answer 33

Pead TBI associated with reduced academic functioning. high %tage of children with TBI are reported to either repeat a grade or received special education assistance. However, outcome affected by age, severity, SES, and cognition.

• Academic outcomes poorer for younger age at injury and more severe injury. Type of academic deficits differ according to the age of injury (Developmental stage) Low SES also associated with poor outcomes.

– Better outcomes associated with better verbal learning, better SES, less severe, older.

• Basic academic tests not necessarily predictive

Question 34

Behaviour following paediatric TBI, describe. (what type of issues/how it effects the child)

Answer 34

Initially: fatigue, irritability. –> THEN High incidence of persistent behavioural difficulties, but no typical profile.

Disorder of self-regulation/control (Common):

• behavioural inhibition (inappropriate behaviours)
• impulsitivity (difference between knowing and doing)

Disorders of drive:
- poor initiation, flat affect, apathy

Multiple factors contribute to the presentation.

Question 35

Social competency following paediatric TBI, describe. (what cognitive issues impact upon it? When do problems become most apparent?)

Answer 35

Executive dysfunction can impact on social functioning
- socially inappropriate, concrete interpretation of information, poor decision making, and poor self-regulation results in difficulty making and maintaining friendships

Problems become apparent particularly during adolescent years
- children report low self-esteem, loneliness

Question 36

Psychological and Psychiatrict outcomes following paediatric TBI, describe. (what cognitive issues impact upon it? When do problems become most apparent?)

Answer 36

High incidence of new psychiatric disturbance following TBI, related to injury severity.

• secondary ADHD mot common (35%-44%)
• Mood and anxiety disorders
• Post-traumatic stress disorders
• Personality change due to medical condition

NOT COMMON:

• oppositional defiant disorder (may be pre-existing traits)
• conduct disorder (may be pre-existing traits)

Question 37

Why is the family system important to consider in paediatric TBI?

Answer 37

Increased family burden and distress associated with lower levels of child’s adaptive behaviour and ?npsych functioning (the ties that bind:)

• increased input required from parent sin terms of practical support (self-care, day to day living, community access); rehab support (Access, attend and participate in therapy; additional “homework”; advocacy (School support, funding avenues, with family and friends)
• less time for parental involvement in work and to maintain social/family relationships
• can impact on finances, reduce social network/social isolation

Pre-existing vulnerabilities within the family system can be exacerbated by severe TBI

Reciprocal/bi-directional influence between child recovery and family adaptation (Yeates, Taylor, Wade etc)

Question 38

Outline the family responses (in order) to child’s TBI noted by Ponsford 1995.

Answer 38

• Shock: confusion, anguish, frustration, helplessness
• Expectancy: exaggerated optimism about recovery, denial, hope
• Reality: depression, anger, guilt, withdrawal and social isolation, disruption of family relationships and existing roles
• Mourning: awareness of the permanence of the situation, acceptance of changes in the injury family member, grieving what might have been.
• Adjustment: Readjusting expectations, redefining relationships and roles, restructuring family environment.

Question 39

Note some of the issues facing children and family after moderate to severe TBI (Anderson 2001)

Answer 39

Acute Survival - Hospitalisation

• Child: survival, early rehab, separation from parents, coin with medical procedures
• family: hope/fear concerning child’s survival, helplessness, guilt/blame over injury, family separation, practical pressures: child care for other siblings, financial and employment concerns

Subacute: recovery/adjustment - Discharge and rehab

• child: intensive rehab; adjustment of acute disability; fatigue and irritability; social isolation
• family: adjusting to changss in child; denial of child’s disability; balancing needs of injured child and family; practical issues (financial and employment); stress following through on rehab procedure.

Chronic acceptance: reintegration into the community

• child: adjustment to residual physical and cognitive disability; social rejection and isolation; feelings of loss and frustration; depression
• family: practical issues: organising education resources; managing family changes; accepting residual disabilities of the child and adjusting expectations; managing behavioural and physical problems.

Question 40

What are some of the outcomes of childhood TBI in adulthood?

Answer 40

• twice as likely to have a mental health problem
• Severe TBU assoc with lower level of education and employment difficulties
• Severe TBI 5 x more likely than mild-mod gp to report reduced QOL
• Poor QOL assoc with low levels of perceived independence, severe TBU, young age at injury, failure to complete high school, psychological problems
• Parents report 1-x more psych problems than participants
• Lower incidence of establishment and maintenance of intimate relationships.

Question 41

What is the role of the paediatric neuropsychologist in Paediatric TBIs?

Answer 41

• performing assessments to establish cognitive profile
• working with the multi-disciplinary team to gain a holistic understanding of the child’s functioning and impact of cognitive impairment on functioning
• providing education to child, families, school and any others involved in child’s care
• Preparing a report with indvidualised recommendations, advising on appropriate interventions
• re-assessing the child at critical periods (e.g., transition points)
• Advocating for various supports (E.g., teacher aide, special provisions)

Question 42

What are alternative terms for a ‘mild TBI’?

Answer 42

Concussion
minor/mild head injury
minor/mild head trauma
minor/mild brain injury
mild traumatic brain injury
complicated mild traumatic brain injury

Question 43

What are some of the criteria for mild TBI?

Answer 43

Head injury –> transient alteration of mental states (confusion or disorientation) loss of memory for events immediately before or after the injury OR a brief loss of consciousness.

Question 44

What is a complicated mild TBI?

Answer 44

Given the broad definition of ‘mild TBI’ there has been some stratification to include complicated mild TBI.

• Inclusion of complicated mild TBI (cmTBI) category
  abnormality detected on neuroimaging (e.g., haemorrhage present on the day-of-injury brain CT scale, fractured skull)
  …hospitals will also consider the extent of this injury when judging the severity of the TBI.

Question 45

What is post-concussive syndrome?

Answer 45

Post-concussive syndrome is a collection of symptoms seen prominently acutely/early and that typically resolve within 2-3 months.

These include:

• Physical: headache, fatigue
• Cognitive: inattention, forgetfulness, slowed processing
• Affective: irritability, reduced emotional regulation

Small sub-group experience persistent symptoms (15-25%, Ponsford, 2000)

• not always more severe mTBU or evidence of neurological abnormality (multifactorial, ponsford, 2002)
• Yeates, 2012: higher functioning families and more environmental resources more likely to demonstrate somatic symptoms
• Impacts on psychological and emotional well-being, social functioning and participation.

Question 46

Describe cognitive outcomes following mTBI

Answer 46

• methodological issues with many studies of mTBI in both paediatric and adult populations
• large meta-analysis studies = no evidence of persistent cognitive deficits following childhood mTBI
• BUT, infants, toddlers, and preschoolers not studied to same extent
  …? more severe end of mTBI spectrum or complicated mild TBU may be more vulnerable
  …? younger age in conjunction with pre-existing learning and/or behaviour disturbance may increase risk of subsequent cognitive difficulty.

Question 47

How should m TBI be managed?

Answer 47

Education is very important in early stages:

• what to expect, prognosis
• reassurance
• information and advice given to school

Time to recover
- graded increase in participation occurring in first couple of months

If difficulties persist
- Examine potential contributing factors, provide psychological support