Children & Brain Injury

1. Children& Brain Injury Anastasia Edmonston MS CRC TBI Projects Director Maryland Mental Hygiene Administration

2. What We Will Talk About • The big picture • What about concussion and kids? • Strategies • Prevention tips • State, regional and national brain injury resources

3. Definitions • Traumatic Brain Injury is an insult to the brain caused by an external physical force • Diffuse Axonal Injury the tearing and shearing of microscopic brain cells • Acquired Brain Injury is an insult to the brain that has occurred after birth, for example; TBI, stroke, near suffocation, infections in the brain, anoxia

4. IDEA Definition of TBIFederal Public Law 101-476, 1990 ……..an acquired injury to the brain caused by an external physical force resulting in total or partial functional disability or psychosocial impairment or both that adversely affects a child’s educational performance……..

5. The Big Picture

6. The Brain Injury Quiz • How many pounds is the adult brain? a) 7 lbs b) 3 lbs c) 1.5 lbs • At what age is your brain fully mature? a) 16 b) 21 c) 25 • What is the last part of the brain to mature? a) temporal lobe b) brain stem c) frontal lobe • Who has not had a traumatic brain injury? a) George Clooney b) Mike Wallace c) Jason Priestly d) Anne Hathaway

7. About 3.17 Million American civilians (more than 1.1% of population, live with the consequences of traumatic brain injuryCDC in Journal of Head Trauma Rehabilitation 2008(Vol. 23, No. 6, pp 394-400)

8. Limitations of Study • Does not include discharge records from military and veteran affairs hospitals • Does not include children under 15 years of age (from SC data) • Does not include persons treated and released from emergency department or other healthcare setting, and those not treated in any healthcare setting following a blow to the head

9. NATIONWIDE • 1.4 million Americans sustain a brain injury each year • 50,000 do not survive their injuries • 235,000 are hospitalized • 1.1 million are treated and released from our nations emergency department’s following a brain injury • Annual Incidence of TBI with disabilityAN ESTIMATED 124,000 American civilians

10. NATIONWIDE-children ages 0-14 • 2,685 deaths • 37,000 hospitalizations • 435,000 emergency department visits (accounting for over 90% of emergency department visits in children 0-14 years old)

11. “Reframed, the numbers nauseate. In America alone, so many people become permanently disabled from a brain injury that each decade they could fill a city the size of Detroit……...

12. ….Seven of these cities are filled already. A third of their citizens are under fourteen years of age.”From Head Cases, Stories of Brain Injury and its AftermathMichael Paul Mason2008 published by Farrar, Straus and Giroux

13. In Maryland…….. • In 2000 there were 5,229 traumatic brain injuries • 5% of all hospitalizations were TBI related • 25% of all injury related deaths for ages 15-24 were TBI related • 11% of all injuries to children 14 and under were TBI related CDC 2006

14. Why are the Numbers so Big? • 30 years ago, 50% of individuals with TBI died, the number today is 22% • due to: • Improved medical technology and techniques • Safety features such as car seatbelts, child safety seats and airbags

15. Simplified Brain Behavior Relationships Frontal Lobe• Initiation• Problem solving• Judgment• Inhibition of behavior• Planning/anticipation• Self-monitoring• Motor planning• Personality/emotions• Awareness of abilities/limitations• Organization• Attention/concentration• Mental flexibility• Speaking (expressive language) Parietal Lobe• Sense of touch• Differentiation: size, shape, color• Spatial perception• Visual perception Occipital Lobe• Vision Cerebellum•Balance• Coordination• Skilled motor activity Temporal Lobe• Memory• Hearing• Understanding language (receptive language)• Organization and sequencing Brain Stem• Breathing• Heart rate• Arousal/consciousness• Sleep/wake functions• Attention/concentration

16. What happens in a TBI? • Mechanism – Acceleration/Deceleration • Differential movement of partially tethered brain within the skull • Results in: • Bruising of the brain surface against rough areas of the skull • Stretching and twisting of nerve axons

17. Skull AnatomyDr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury The base of the skull is rough, with many bony protuberances. These ridges can result in injury to the temporal and frontal lobes of the brain during rapid acceleration. The skull is a rounded layer of bone designed to protect the brain from penetrating injuries. Bony ridges

18. Brain & SkullDr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury Injury to frontal lobe from contact with the skull

19. Diffuse Axon InjuryDr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and InjuryCan directly impact the major pathways of the brain.

20. RECAP:The Developing Brain • Children’s brains do not reach their adult weight of 3 pounds until they are 12 years old • The brain, and most importantly, the brain’s frontal lobe region does not reach it’s full cognitive maturity till individuals reach their mid twenties

21. The Developing Brain • The Frontal Lobe houses our executive skills, these include; judgement, problem solving, mental flexibility, etc. • The Frontal Lobe is very vulnerable to injury • Damage to the Frontal Lobe any where along the developmental continuum can impact executive skill functioning

22. According to the USDE, in Maryland……. Only 324 students out of 98,811with identified disabilities were receiving services under a TBI diagnosis in 2006. U.S. Department of Education, Office of Special Education Programs 7/17/06 httpt://www.ideadata.org/tables29th/ar_1-3.xls

23. Why the Gaps in numbers? • Not all children experience lasting effects • The etiology of a student’s disability may be unidentified or misunderstood • Student may be served under a 504 plan • Effects of a early brain injury may not be expressed until the student is older • When the effects do surface, they may diagnosed as having a learning disability, emotional disorder, or other disability • Adapted from TBI and Educator’s Guide by the MD TBI Implementation Project and the BIAM 2003

24. Mild Traumatic Brain Injury (AKA concussion) • Most common, 75%-85% of all brain injuries are mild • Individuals experience a brief (<15 minutes)or NO loss of consciousness • Post Traumatic Amnesia < 1hour • Normal neurological exam • 90% of individuals recover within 6-8 weeks, often within hours or days

25. The American Academy of Neurology: “Concussion is a trauma-induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia are hallmarks of concussion”http://search.aan.com/vivisimo/cgi-bin/query-meta?input-form=simple&v%3Asources=AANNew&v%3Aproject=aan&query=concussion

26. Importance of Post Traumatic Amnesia PTA is the period of time after injury when a person is unable to lay down new memories For Example...

27. “That first morning, wow, I didn’t want to move, I was thankful that nothing’s broken, but my brain was all scrambled”Ryan Church, NYT 3/10/08 “All he remembers from the collision with Anderson is the aftermath, being helped off the field by two people, although he said he did not know who they were until he saw a photograph later” Ben Shpigel NYT reporter

28. Concussion and Kids-Sports • In sports alone, 300,000 + concussions are “estimated” to occur annually • For every 1 concussion in the NFL, there are 5,650 youth injuries • Sports associated with concussion: soccer, football, lacrosse, hockey, horseback riding, cheerleading……..Gerard Gioia, Ph.D., Children’s National Medical Center in remarks at the Brain Injury Association of MD conference 2005

29. Concussion and Kids-Sports • Football has the highest rate of concussions in high school sports, girls soccer 2nd highest rate(New York Times 10.2.07) • 29,167 concussions suffered by US high school girl soccer players, 20,929 concussions suffered by high school boy soccer players 2005-2006(Time Magazine 2008) • Female concussion rates in high school basketball were almost 3xs higher than among boys. • In girls, symptoms take longer to resolve (NYT 10.2.07)

30. Quoted in TimeDr. Joseph MaroonU of Pittsburgh Medical Center “More-developed necks allow boys to better absorb a blow to the head”

31. Implications for Children • Children who incur a brain injury are twice as likely as other children to have a second brain injury within 6 months. • According to the researchers, factors included a “complex interaction between children and their social environments” (Pediatrics 2007 & Eric Nagourney of the NY Times 4/3/07)

32. Implications for Children • Concussion and repeated concussions can occur from falls and sports injuries • Most soccer concussions are due to hard falls or player collisions • Secondary impact syndrome, a rare but potentially fatal result of two concussions within a short period of time

33. “The Faces of Brain Injury”A short video by the Brain Injury Association of Florida

34. Brain Injury’s Impact on Physical Functioning…. Adapted from BIA Utah & BIA NJ • Tired all the time/ Tires more quickly • Continuing headache (maybe accompanied by nausea), may also be bothered by noise or light • Less active • Dizziness • Ringing in the ears • Slurred speech • Changes in balance, difficulty grasping objects • Bothered by light and noise • Sleep changes (can’t sleep, nightmares etc.)

35. Brain Injury’s Impact on Thinking.. Adapted from BIA Utah • Memory, especially short-term memory • Difficulty learning new information • Trouble paying attention & staying on task • Misses instructions • Multi-tasking or splitting and dividing ones’ attention (aka “executive skills”) can be very challenging

36. Emotional and BehavioralConsequences… Adapted from BIA Utah and NIA NJ • Impulsive • worried and moody • flat affect or little change in emotion • Spends more time alone • Easily upset (teary, agitated, aggressive) • Self-centered of finding it hard to take another’s point of view • Difficulty exercising good social judgement • Difficulty following daily routine at school and/or home

37. Possible Changes-Personality and Behavioral ...MD TBI Project • Depression • Social skills problems • Mood swings • Problems with emotional control • Inappropriate behavior • Inability to inhibit remarks • Inability to recognize social cues

38. Possible Changes-Personality and Behavioral • Problems with initiation • Reduced self-esteem • Difficulty relating to others • Difficulty maintaining relationships • Difficulty forming new relationships • Stress/anxiety/frustration and reduced frustration tolerance

39. Children “Grow into Their Brain Injuries”(Gioia)as children grow, more is expected, children with a history of brain injury may not be able to meet the demands…….Impact of an injury may not become apparent till years post injury and…not be attributed to an earlier blow to the head

40. Recommended Supports and Services-The Ideal Pathway Following Concussion or Mild Brain Injury-Childhood Injury • Family and child is educated about the possible symptoms of concussion • If symptoms emerge or persist following a concussion, appropriate referrals are made to a neurologist, pediatric neuropsychologist. Appropriate interventions and supports including outpatient speech, occupational and physical therapy are provided and coordinated with school personnel • Exposure to situations where a second impact is a possibility is minimized

41. If Symptoms Persist and are Left Untreated….in children • Teachers and family may notice irritability • Schoolwork suffers • Behaviors attributed to factors other than the brain injury (family/peer problems, adolescence) • Child continues to experience problems, becomes depressed/may begin to act out • Is at risk for academic/social difficulties • Is at risk for a subsequent brain injury, exacerbating the above

42. If Symptoms Persist and are Left Untreated….in adults • Job loss • Mental Health Problems • Relationships and supports erode • At risk for Substance Abuse • At risk for entry into the criminal justice system

43. Why Screen?What other TBI Screening efforts have found

44. 2000 Epidemiological Study of Mild TBIJ. Silver of NYU, cited in WSJ by Thomas Burton 1.29.08http://online.wsj.com/article/SB120156672297223803.html?mod=googlenews_wsj • 5,000 interviewed • 7.2% recalled a blow to the head w/unconsciousness or period of confusion • Follow up testing found; 2x rate of depression, drug and alcohol abuse • Elevated rates of panic and and obsessive-compulsive disorder

45. Findings from the Literature…Criminal Justice System • Researchers at Indiana State University found that 83% of felons studied reported a head injury that predated their first encounter with the law (1998) • Adults who had frontal lobe damage prior to age 8 exhibited recurrent impulsive and aggressive behavior • 14% of the subjects in the Vietnam Head Injury Project with frontal lobe lesions engaged in fights or damaged property compared to 4% of controls without TBI

46. Domestic Violence TBI Findings • Batterers fared worse on three neuropsychological indicators of cognitive functioning then a nonbatterer control group (Cohen et. Al 1999) • Corrigan et.al., (2003) found that of 167 individuals treated for domestic violence related health issues, 30% experienced a loss of consciousness on at least one occasion, 67% reported residual problems that were potentially TBI related • Valera and Berenbaum, (2003) assessed 99 battered women. Of these, 57 had brain injured related symptomatology

47. TBI Among Individuals with Persistent Mental Illness • Kathleen Torsney (2004) found in one mental health treatment setting 13% of individuals served had a history of TBI • These same individuals had been treated in various mental health settings but not received specific brain injury treatment

48. In Maryland- Screening Results from the MD TBI Post Demo II Project-2005 • Summary of TBI Incidence Among all Screened at 7 public mental health agencies in Frederick and Anne Arundel counties • N=190 • 39% no reported history of TBI (78) • 58.94% of individuals with a history of TBI (112) • 35.78% of individuals with a history of a single incidence of TBI (68) • 23% of individuals with a history of 2 or more TBIs (44)

49. TBI Screening The HELPS Brain Injury Screening Tool(see handout)The original HELPS tool developed by M. Picard, D. Scarisbrick, R. Paluck, 9.1991Updated by the Michigan Department of Community Health

50. HELPS • Have you ever Hit your Head or been Hit on the Head? • Prompt individual to think about; TBI at any age, MVAs. Assaults, Sports injuries, Service related injuries, Shaken baby and/or adult