Acquired Brain Injury in Children

1. Acquired Brain Injury in Children Dr Megan Eve, BSc (Hons) DClinPsy, PGDip, QiCN Paediatric Clinical Neuropsychologist

2. Questions: • How does the brain develop? • What is an Acquired Brain Injury (ABI)? • What are the social, emotional and cognitive consequences for young people with ABI? • How can children with an ABI be supported?

3. The Brain

4. True or False..? “We only use 10% of our brains”

5. FALSE! We essentially use all of our brains all of the time (although not all neurons are firing at the same time).

6. True or False..? “There are more synapses (connections) in an average human brain than there are stars in our Milky Way galaxy”

7. TRUE! • There are estimated to be around 100 trillion connections (synapses) between neurons in a human brain. (and there are estimated to be between 100-400 billion stars in the milky way)

8. True or False..? “People are either left brained or right brained?”

9. FALSE! Both hemispheres of the brain are connected and work together. People don’t show a dominance for one side or another. Lateralization of brain function means that there are certain mental processes that are mainly specialized to one of the brain's left or right hemispheres.

10. True or False..? “Exercise can improve integration of hemispheric brain function”

11. FALSE! There is no good evidence for specific programmes promoting co-ordination activities. However, there is strong evidence that aerobic exercise in general is beneficial for cognition in children.

12. How does the brain develop? • At birth we have potential for learning but very few skills. • Different areas develop at different times and at different rates. • Our genes and our environment influence how our brains develop.

13. How does the brain develop? • The brain continues to develop into our early to mid 20s.

14. How does the brain develop? • We are born with all the neurons we need and over time the connections between neurons become more efficient.

15. Brain Stem • Vital autonomic functions. • Breathing. • Heart Beat. • Blood pressure. • Swallowing. • Alertness.

16. Cerebellum Also know as the “little brain” • Movement. • Coordination and balance. • Executive functioning. • Knowing where you are in space & sequence of learning.

17. Temporal Lobe • Processing auditory information (sounds). • Recognising faces and objects. • Recognising and processing sound. • Sorting new information. • Memory & learning. • Language and speechcomprehension.

18. Frontal Lobe • Personality, emotional and behaviour control. • Planning & organising. • Problem solving. • Decision making. • Controlling impulses and behaviour. • Expressive Language (speech production). • Theory of mind (understanding others perspectives). • Social cognition (recognising and empathising with emotions).

19. Parietal lobe • Integrates information from different senses. • Processes visual pathways and tells us what and where things are. • Spatial awareness • Spelling, reading and number processing.

20. Occipital Lobe • Receives and processes visual information. • Visual perception. • Colour, Orientation, Motion.

21. What is an ABI? • Traumatic Brain Injury (TBI): the result of an impact to the head. • Non-traumatic brain injury: events going on inside the body, e.g. meningitis, encephalitis, brain tumour, stroke or lack of oxygen.

22. How common is ABI? • Head injury is the commonest cause of death and disability in people aged 1–40 years in the UK. • There are around 300,000 attendances to A&E with head injuries in children and young people under 16 years of age in the UK each year. • Up to 1 in every 30 children will sustain a TBI before the age of 16! • Often undetected or mistaken for other things e.g. autism, ADHD etc.

23. Common Causes in Children • Trips, slips and falls (bikes and scooters!) • Accidents –sports, horses. • Road traffic accidents (passenger or pedestrian). • Illness – encephalitis, meningitis, measles, epilepsy. • Brain tumours. • Stroke. • Drowning. • Non-accidental - ‘shaken baby’, drugs overdose, asphyxiation.

24. The ‘Hidden Disability’ • No two injuries are the same. • Most children recover some function particularly in the first few years post-injury. • New learning may be impaired but old memory and learning is often intact. • Having one ABI puts young people at greater risk of having another. • After the acute recovery period the brain doesn’t ‘fix itself’ but rather adapts and makes things work, often finding new ways to do the same job.

25. “Growing into” an ABI • The full consequences of a brain injury may not be immediately apparent in young children. • Difficulties may not appear until a particular cognitive skills would typically ‘come online’ during development. • …A child who had meningitis as an infant may manage at primary school but start to struggle at secondary.

27. Cognitive: Attention and Concentration • Difficulty focusing in a busy environment (i.e. a classroom!) and ignoring irrelevant stimuli. • Difficulty maintaining single train of thought, going off on tangents. • Becoming easily overwhelmed by large amounts of information. • Difficulty following through with instructions. • Difficulty completing tasks. • Interrupting others or changing the subject.

28. Attention and Concentration strategies • Break tasks down into smaller chunks. • Use short prompts and cues. • Schedule activities with clear start and end points (now: next board) • Timers. • Regular ‘brain’ breaks. • Given written instructions and/or visual prompts. • Environment- reduce distraction. • Quiet work areas. • Eye contact and check they are attending.

29. Cognitive: Short Term (Working) Memory • Only able to follow one or two instructions at a time (and may still need prompting!) • Difficulty following conversations. • Difficulty with mental arithmetic.

30. Working Memory Strategies • Keep instructions short and only give as many as the child can manage. • Expect to have to repeat yourself. • Give visual/written instructions/prompts. • Help the child to practice techniques e.g. silent rehearsal and chunking of information. • There is no good evidence base for working memory ‘training’ programs.

31. Cognitive: Long Term (Episodic) Memory • Difficulty remembering information from one lesson to the next. • Difficulty remembering what they’ve done or where they’ve been. • Unable to follow a book, film or story. • Difficulty learning their way around school. • Confabulation.

32. Memory Strategies • Opportunities for over-learning (repetition with variation). • Hand-outs/written records. • Teach efficient note taking techniques. • Limit information. • Use cue cards / graded prompts. • Errorless learning.

33. Cognitive: Executive Skills • Forward Planning – Starting tasks without planning. • Using judgement – difficulty prioritising tasks or making choices. • Organisation e.g. of notes. • Initiating tasks – difficulty getting started despite knowing what to do. • Problem solving when things go wrong. • Time management. • Keeping track of belongings (e.g. packing the right things for school, loosing PE kit.) • Difficulty inhibiting immediate responses- blurting things out.

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36. Executive Skills Strategies • Sitting down to plan or problem solve before an event, step by step. • Setting up organisational systems e.g. folders etc. • Checklists (e.g. of what to remember at the end of the day). • Encourage use of diary/planner/watch/alarms on ipad/phone. • Opportunities to practice time management techniques. • Explicitly teaching exam techniques (and allowing access arrangements such as a prompter if needed).

37. Executive Skills Strategies • Problem solving ‘in the heat of the moment’. • Weighing up the pros and cons of a particular action at the time/ using judgement. • Help to update a plan if the situation changes. • Spending time reflecting on choices made in the heat of the moment or role playing theoretical scenarios and thinking about different possible outcomes/ choices. • Highlighting and praising good decision making (and explaining why it was good).

38. Speed of Processing • Only taking in the start of instructions given. • Struggling to keep up with conversations, particularly with multiple people. • Not producing very much work despite understanding it.

39. Speed of Processing: Strategies • Quality not quantity. • Ensure extra time is available in tests and exams. • DON’T keep the child in at break to finish their work. • Set homework by time not by quantity of work.

40. Language • Difficulty processing language efficiently. • Not being able to follow conversations. • Difficulty with sentence structure/grammar/word meanings. • Going off on tangents mid sentence. • Word retrieval difficulties. • Reduced fluency of speech.

41. Word Retrieval Difficulties… • Turn to the person next to you and spend one minute telling them what you did last night. • Now do the same thing but without using the letter E

42. Communication Strategies • Allow time for children to process and respond. • Supply key words if needed. • Provide written/visual information to support verbal communications. • Reduce distractions (e.g. no TV/ music in the background). • Keep language simple and give one instruction at a time. • Use verbal/non-verbal clues.

43. Social Skills • Lack of insight into behaviour of other or own difficulties. • Being left behind/left out by peers. • Difficulty to alter behaviour to different situations (e.g. home vs school). • Difficulty taking turns in play. • Reduced eye-contact and understanding of humour / sarcasm. • Disinhibition with language (speaking before thinking!)

44. Social Skills Strategies • Buddy system. • Use Social Stories. • Discuss rules and expected behaviour. • Identify the triggers and intervene. • Avoid getting into arguments/debates. • Try verbal / non-verbal cues to discourage behaviour. • Look out for isolation / bullying.

45. Fatigue • Variable levels of energy. • Reduced motivation, engagement & concentration. Cognitive difficulties increase. • Cognitive, not just physical fatigue. • Sometimes children find it difficult to recognise when they’re fatigued.

46. Fatigue Strategies • Phased return to school • Try to identify which times of the day the child is more or less alert and capitalise on this. • Include short breaks within or outside the classroom. • Pupils need lots of help and structure to help them to catch up.

47. Behaviour that Challenges • Non-compliance. • Disrupting class/others. • Inappropriate behaviour. • Disinhibited behaviour (impulsiveness). • Sexually disinhibited behaviour. • Verbally/physically challenging. • Exacerbation of previous behaviours. • Withdrawn and quiet. • Reduced insight.

48. Behaviour that Challenges - Strategies • Observe the behaviours • What are the triggers/behaviours/consequences? ABC chart. • Try to understand what is underpinning the difficulty e.g. is is that the child can’t keep up with instructions? Is the child very fatigued? Is the child over stimulated? • Praise desired behaviours. • Behaviour contracts, rewards. • Consistency between settings (home and school). • The problem is the problem, not the young person!

49. In Summary • ABI in children is common. • A range of cognitive, social, communication, physical and behavioural difficulties are common following ABI. • No two brain injuries are the same. • Difficulties may not become apparent until the age that a cognitive skill usually develops. • There are lots of things you can do to help improve outcomes for children with ABI.