ORTH 3137 - Examen Final - Module 7 Flashcards
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Module 7
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Pediatric Traumatic Brain Injury
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Pediatric Traumatic Brain Injury
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- TBI (traumatic brain injury) is a leading cause of death and disability among children ages 1 to 19
- Each year, approximately 40% of TBIs in the United States occur in the pediatric population (ages 0 to 19)
- Higher rates of TBI in MALES
- Leading cuases of BTI in the pediatric population = FALLS and MOTOR VEHICLE-RELATED EVENTS
- Other common cause is being struck by/against a person or object (ex: at a sporting event)
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PTBI - Commonly Examined Postconcussive Symptoms
Physical
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- Headache
- Fatigue
- Balance problems/dizziness
- Nausea or vomiting
- Light of noise sensitivity
- Sleep disturbance
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PTBI - Commonly Examined Postconcussive Symptoms
Cognitive
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- Poor concentration
- Forgetfulness
- Mental slowing
- Fogginess
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PTBI - Commonly Examined Postconcussive Symptoms
Emotional/Behavioural
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- Sadness
- Nervousness
- Irritability
- Lack of initation
- Personality change
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PTBI - Causes
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Infants
- Mishandling by caregivers (accidental dropping, rolling from changing tables, physical abuse)
Toddlers:
- Falls, MVA, Physical abuse
Preschoolers:
- Falls, MVA, Physical abuse
Elementary school children:
- MVA, bicycle accidents, falls, injuries during play
Adolescents:
- MVA (including alcohol or drug misuse), sports injuries, assault, risk-taking behaviours
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PTBI - Introduction
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- Evidence base for effective treatment, at both acute and more chronic stages or recovery post-TBI, is largely lacking, across medical, pharmacological, and behavioural domains
- An additional complication is that children who suffer TBI are not representative of healthy population, and are more likely to have pre-existing behavioural and learning problems as well as social disadvantage
- These factors may impact negatively on recovery, and confound our ability to determine which post-injury predated the injury
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PTBI - Acquired Brain Inury (ABI)
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More general term that includes all types of injury to the brain.
- Including both non-traumatic (anoxic, toxic) and traumatic injuries
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PTBI - Head Injury
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This injury involves damage to any part of the head. It is a broad term that encompasses injury from internal accidents such as stroke or external forces such as a blow to the head. Head injury can imply injuries to the face, scalp, skull or brain.
- May be open- or closed- head injuries
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PTBI - Open Head Injury
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Brain tissue is penetrated from the outside, as with an obvious wound to the head such as a gunshot wound or a crushing of the skull, the skin and bone of the skull are actually penetrated and the brain may be exposed; The injury tends to result in localized (focal) damage and somewhat predictable impairments.
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PTBI - Closed Head Injury
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There is no open wound to the head, with damage caused by a blunt blow to the head or an aceleration/deceleration of the brain within the skull; there is no actual lesion to the skin or skull, but there is still damage to the brain within the skull; the injury results in more diffuse brain damage with resultant variable and unpredictable consequences.
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PTBI - Traumatic Brain Injury (Definition)
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- Type of acquired brain injury (ABI)
- Is the results of an external blow to the head
- TBI generally results in diffuse axonal injury secondary to acceleration forces
- This means there can be widespread damage within the cortex that can impair any variety of brain functions in unusual pattersn
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PTBI - Primary Injury Mechanisms
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Damage at the time of the injury
- Coup vs Contrecoup vs. Coup-contrecoup
- Damage can be localised (or focal) to the point of impact (coup)
- A second focal injury (contrecoup) can occur as teh brain bounces from the point of impact to the opposite side of the skull - Focal Contusions
- Portions of the prefrontal lobes and anterior and posterior temporal lobes are in close proximity to the bony prominences of the skulls
- When the brain is accelerated rapidly enough, it can be pushed into these bony protuberances; bruising and an increase of blood or fluid can be seen
- Diffuse axonal shearing damage also can be widespread (diffuse)
Tables 1-1 and 1-2
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PTBI - Secondary Mechanisms
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Complications after initial injury
- Oedema: swelling occurs at the time of injury and can continue for some time afterward. In closed-head injuries, there is no room for swelling tissue to expand beyond the cranium, resulting in an increase in intracranial pressure that can contribuet to a decline in consciousness. Treatment usually includes medication to reduce swelling and occasionally surgery to remove a portion of the skull or brain to alleviate the pressure of the swelling brain against the skull.
- Hypoxia: Abnormally low amounts of oxygen are supplied to the brain. This is particularly of concern to areas of the brain such as the hippocampus (memory), basil gnaglia (movement), and end arterial supply areas of the cerebral cortex and cerebellum (feeding the cortex).
- Hemorrhage or hematoma: As a result of the contusion or bruising process, bleeding or developement of blood clots continue to be a concern. Any disruption of the cerebral blood flow or its regulation can contribute to additional brain damage.
- Seizures: Seizure activity after injury is a possible complication. Often, children/adolescents are placed on medication as a preventative measure.
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PTBI - Glasgow Coma Scale
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- Scale employed in acute care facilities to determine level of consciousness and is a tool for localizing neurologic findings.
- Allows medical professionals to observe a patient throughout the first 48 hours in which the injury has occurred and assign levels of responsiveness in three areas:
1/ Eye opening
2/ Motor response
3/ Verbal response - The patient’s GCS score helps determine the severity of the TBI:
- Severe TBI = 3-8
- Moderate TBI = 9-12
- Mild TBI = 13-15
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PTBI - Acquired Brain Injury - Types
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- Mild TBI (GCS Score 13-15): Synonymous with post-concussive syndrome, a very brief or no loss of consciousness. Signs of a concussion include dizziness, headache, nausea, vomiting, lethargy, irritability, difficulty concentrating, and possible inability ot recall the injury.
- Moderate TBI (GCS Score 9-12): Loss of consciousness up to 24 hours. Neurological signs of trauma to the brain may include skull fracture, contusions, hemorrhage, or focal damage identified by computerized tomography (CT) or magnetic resonance imaging (MRI). Implications for children/adolescents with moderate TBI include physical, weakness, cognitive-communicative impairments, difficulty learning new information and psychosocial problems. Learning and job maintenance can be a problem for a lifetime in 33 to 50% of this population.
- Severe TBI (GCS Score 3-8): Coma duration is longer than 24 hours. Multiple cognitive, cognitive-communicative, physical, social, emotional, and behavioural problems can exist for a lifetime for up to 80% of this population. Special considerations in home, school, community and the workplace are often required.
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PTBI - Very Long-Term Neuropsychological and Behavioural Consequences of Mild and Complicated TBI
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- Approximately 80% of all TBI are classified as mild
- Most pediatric caes (81-85%) are MTBI, about 8% are moderate are severe, and 5% are fatal.
- Even after MTBI, it is common to suffer acute cognitive problems, but most persons recover fully within three months.
- However, there is a group of patients who continue to experience cognitive, behavioural and neurological symptoms long after sustaining their injury.
- This group of symptoms is often referred to as postconcussive syndrome and characteristic symptoms are headache, fatigue, dizziness, depression, anxiety, irritability and problems with concentration and memory. Occurrence from 7-8% to about 15%.
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PTBI - What is it like?
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- In pediatric TBI, a variety of physical, social, behavioural, cognitive, communicative and emotional problems are apparent.
- Abilites that are just developing within the brain of a child are very vulnerable, therefore these are most likely to be disrupted by a TBI.
- Additionally, brain injury sustained early in life can disrupt the appearance of skills at a later period of life.
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PTBI - What is it like? Characteristics of TBI
Attention and concentration
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- Following injury, the brain is generally not as alert and is less able to sustain focus or filter sensory informaiton; The ability to maintain awareness long enough to respond to a stimulus is affected; Poor vigilance.
Changes that may be observed:
- Easily distracted
- Can apepar spacey, forgetful, and disorganized
- Inconsistent performance
- Difficulties with following instructions, shifting attention and staying still.
- Dividing attention in the presence of two or more stimuli is a frequent problem
- Slower mental processing speed
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PTBI - What is it like? Characteristics of TBI
Memory, Long-Term
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- The ability to mentally record and store past events, feelings, actions and reactions, and then recall them as needed; This memory is less affected by brain injuries; often, memory of past information and events is retained after a TBI; However, certain long-term memory skills may be affected
- Semantic (memory for facts) and episodic (memory for temporal events) memory skills may be lacking after TBI
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PTBI - What is it like? Characteristics of TBI
Memory, Short-Term
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- Information is not stored, but is used to process stimuli, allowing the ability to follow directions or hold information in memory long enough to act on it; Short-term memory is frequently affected by brain injury; Brain will have trouble remembering new learning and experiences; This is often the type of memory problem that is the most difficult for persons with TBI.
Changes that may be observed:
- Forgetfulness
- Difficulty recalling new information
- Repeatedly asks the same questions
- Requires multiple repetition of instructions
- Tends to wander to lose their way in school, at home or in the community
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PTBI - What is it like? Characteristics of TBI
Executive Functioning
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- The ability to self-analyze, monitor and set goals as well as determine success; executive functioning develops throughout childhood; Brain injury early in life can disrupt this development; TBI can interfere with the development of self-awareness and insight, planning, mental-flexibility, reasoning, organization and problem solving.
Changes that may be observed:
- Difficulties with time management
- Rigidity of thinking (cannot think of more than one way of completing a task or solving a problem; no “outside the box” thinking) and difficulties with abstract thinking.
- Difficulties getting started on a task
- Difficulties with problem solving and coming up with new solutions
- Can appear to lack empathy, to be stubborn and argumentative, to have impulsive or aggressive behaviour
- Difficulties with transitions or with deviating from schedule
- Perseveration often present (getting stuck on one train of thought)
- Difficulties generalizing strategies to new situations
- Can act without thinking of the consequences (poor or unsafe choices)
- Deductive, inductive, and analytic reasoning is often affected
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PTBI - What is it like? Characteristics of TBI
Language
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- Brain injury cuasing damage to the left hemisphere where Wernicke’s area is located will hinder the ability to understand language and process incoming language-based information; Brain injury causing damage to the left hemisphere where Broca’s area is located will hinder expressive language and the ability to produce logical speech.
Changes that may be observed: Receptive Language:
- Inability to follow directions and process auditory information
- Central auditory processing or attentional difficulties can create receptive problems
- Can be confused by conversations or verbal instruction
- Delayed response during conversational speech (or offers no response at all)
- Does not understand dual meaning of words, inferential, figurative and more complicated abstract language (sarcasm, irony)
- Peripheral hearing loss may occur and always should be evaluated as a possible contributor to receptive problems
Changes that may be observed, Expressive Language:
- Difficulty formulating phonemes, words, or sentences
- Motor impairment may be present, dysarthria or cognitive processes may be impaired, and the ability to recall and retrive word or formulate sentences may be problematic.
- Poor use of grammar or use of immature speech
- Difficulties asking and answering questions
- Difficulties with word finding and use of non-specific vocabulary (ex: that thing, that lady)
- Certain difficulties with conversational speech (they are difficult to follow in conversations, they struggle with expressing certain topics, they have difficulties staying on topic and can become easily frustrated if they are not able to articulate what they want to say)
- Difficulty can extend to the printed word and affect both reading and writin
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PTBI - What is it like? Characteristics of TBI
Other difficulties
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- Anomia: Difficulty with word retrieval or naming tasks; this can be caused by poor memory, inappropriate processing, lack of vocabulary development over time, or weak categorization and assocation abilities.
- Hyperverbal speech: Inappropriate control of the conversation by maintaining long spoken sentences containing little relevant content.
- Tangential speech: Inability to remain on a specified topic or to return to a topic area
- Cofabulation: Untrue aspects of connected speech, story-telling filling in information
- Social pragmatics: Difficulty taking turns in conversations, struggles with reading and understanding facial cues and body language, inappropriate eye contact, tone of voice and proximity, difficulties with inferential reasoning.
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PTBI - What is it like? Milestone and Developmental Disruption
Infancy
Infancy (birth to 3 years of age):
Behavioural characteristics after brain injury:
- Quick shifts from one emotion or state to another
- Impulsivity
- Use of primitive behaviours (biting, hitting, etc)
- Lack of self-awareness
- Inability to self-regulate behaviours
- Lack of responsiveness to others
Developmental disruptions following brain injury:
- Disruption in the ability to regulate state or arousal and sleep
- Lack of understanding of cause-effect relationships
- High reliance on structure support supervision and modulation from others
- Sleep disturbance
- Lability: moods shift dramatically and quickly
- Emotional reactions unpredictable, often labeled "irrational"
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PTBI - What is it like? Milestone and Developmental Disruption
Preschool
Preschool (ages 3 to 6):
Behavioural characteristics after brain injury:
- Temper tantrums
- High emotionality
- Impulsivity
- Primitive behaviours (biting, hitting, etc.)
- Lack of concern for danger and safety
- Resistance to influence or direction from parents
Developmental disruptions following brain injury:
- Disruption in the connections among thinking-emotion-behaviour systems
- Emotional and behavioural extremism
- Executive function difficulties
- Poor organization of behaviour
- Immediate expression of feelings
- Temper tantrums and rigid behaviour
- Poor acquisition of preschool concepts (same/different, one/all, big/little, time concepts, shapes, etc.)
- Dependence on structure and organization provided by adults
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PTBI - What is it like? Milestone and Developmental Disruption
Elementary
Elementary (ages 6 to 12):
Developmental disruptions following brain injury:
- Disruption in reading, spelling and math skills
- Poor performance despite hard work
- School failure/avoidance
- Behaviour problems during unstructured times
- Depression, social isolation or withdrawal from peers
- Sleep disturbance
- Fatigue
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PTBI - What is it like? Milestone and Developmental Disruption
Early Adolescence
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Early adolescence (ages 12-16):
Developmental disruptions following brain injury:
- Unevenness in cognitive profile
- New learning deficits
- Slower rate of mental processing
- Difficulty organizing complex tasks over time
- Judgement and reasoning difficulties
- Increased "frustration" response
- Depression and fatigue
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PTBI - What is it like? Milestone and Developmental Disruption
Late Adolescence
Late adolescence (ages 16-19):
Developmental disruptions following brain injury:
- New learning deficits (ex: memory for numbers)
- Mental processing speed deficits
- Inability to organize complex tasks
- Conflict between specific challenges and career goals
- Interference in developmental drive toward independence/separation
- Social awkwardness, body image/social image issues
- Defensiveness regarding emotional/cognitive problems
- Depression
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PTBI - Cognitive-Communicative Performance
- Cognitive-communicative impairments will interfere with performance in many situations. The impairments can be:
> Rehabilitated in some instances,
> compensated for in others, and
> must be accepted as incapable of being modified in still others
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PTBI - A Frightening New World for Families
- Explain why the assessment is needed
- Who will conduct the assessment
- Where and when it iwll occur
- What kinds of instruments or procedures will be used
- And expected outcomes of the assessment
- Additionally, family members need to understand how the resutls will be used. This will increase the family's capability to make decisions about their child and decrease anxiety.
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PTBI - Formal Assessment
- One test that is specifically developed and normed for individuals 15 and over with TBI is the Scales and Cognitive Ability for Traumatic Brain Injury (SCATBI) by Admamovich and Henderson (1992)
- It is important to note that standardized tests, specifically designed for young children/adolescents with TBI are not available
- Because of the variability in functioning across different settings and tasks, it is unrealistic to assume that one instrument could reliably identify the scatter of strengths and weaknesses in communicative function commonly observed after brain injury.
- It my be useful to employ a selected battery of age-appropriate tests when determining the cognitive-communicative strengths and needs of a particular child.
- PLS, CELF-P, Reossetti, Token Test, ENNI, Informal Observaiton
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PTBI - Concerns About Use of Formalised Tests
- Reliance on battery of standardized tests that have some limitations cannot provide a full, accurate data for understanding the total communicative needs of this population.
- Kreutzer (1993) suggests that many persons with TBI may perform within the normal or slightly below range on standardized tests:
- Problem?
- Russell (1993) suggests that assessment should be guided by:
a) Questions about hte student's contextual and functional use of language
b) Questions about the impact of verbal and cognitive deficits on communicative functioning
- Combining standardized test scores with informal observations and assessment should provide the most complete picture of the child's functioning and potential to perform in a variety of settings.
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PTBI - Test Modifications
Modification of a test or subtest has become a subject for discussion in the past few years.
1. Allow untimed testing
2. Divide testing into several sessions to allow for fatigue or loss of attention
3. Reduce distractions to one-on-one in a quiet environment to determine maximum performance potentials
4. Enlarge printed materials or place fwer items on each page
Then ...
5. Introduce auditory or visual distractions such as testing in a classroom, cafeteria or busy physical therapy area
6. Lengthen the test time to determine if attention to talk decreases or if the child can persevere
7. Permit different types of response modes, such as gesturing or writing
8. Restate test directions by using simpler directions or by making directions more lengthy and complex
9. Repeat and cue to determine if multiple bits of information will stimulate recall
10. Select various subtests of different tests according to the needs of the individual
11. Observe pragmatic language skills during testing to sense appropriate use of problem solving, questioning, turn taking, self-monitoring
** Any change in the standardized testing protocol should be documented in the report of the test results
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PTBI - Specific Cognitive-Communicative Interventions
- Traditional treatment approaches to motor problems, anomia, vocabulary development, memory compensation, receptive and expressive language development, memory compensation
- However, the key to reasonable planning continues to be making therapy relevant to a person's unique environment and to outcome-based goals for that environment
- Interventions used should not be punitive as traditional consequence-based interventions may no always be successful with children who have had a brain injury.
- Individual-outcome-based goals for various environments should encompass skill development in a variety of communicative situations; treatment needs to be functionally based and focus on development of four major outcomes:
1/ Participation in the learning process
2/ Development of skills that make a person employable
3/ Understanding of social skills needed for communication at home, school, and work
4/ Development of independent living skills
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PTBI - Language Intervention
- Language problems in TBI can be mild to severe
- Interventions should take into consideration the receptive abilities, expressive competencies, and pragmatic performance of a child/adolescent in various situations
- Many of the traditional language stimulations and interventions will be useful with this population
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PTBI - Hints for Actively Involving Families
- Treat family as equal partners in the assessment, planning, and intervention processes
- Design services to foster the family's decision-making skills while protecting their rights and wishes
- Encourage family members to express their joys, fears, concerns, and ideas about their child's disabilities and ness. Listen attentively and respond meaningfully to what they say.
- Recognize the individuality and variability in families and modify services to meet unique needs , degrees of involvement, and styles of interaction.
- Provide complete information to families, using terminology that is easily understood.
- Assist families in accessing suport networks.
- Build sufficient time to work with families into treatment programs.
