Traumatic Brain Injury Update: Current Trends in Assessment and Intervention =

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 – Logical Words (spelling) Verbal meaning Vocabulary in language Details – rules Analysis One-by-one selectivity Step-by-step instructions Sequential ordering Cause and effect relationships Learned facts Letter-symbol associations Abstract reasoning Academically-learned information Ideas Serial/ordered structures Self-verbalizations Selective attention Consciousness – reasoning Scientific logic Right Hemisphere – Aesthetic Images, pictures, and colors – spatial Music and feelings Gestalt – whole/relational Synthesis, comparisons Simultaneous patterning Whole process Whole units Analogies Creativity – new combinations Visual symbolism Concrete Practical – common sense knowledge Patterns of things/theory Random-without structure body language Facial expression, tone of voice Sustained attention Meditation, spontaneous ideas, subconscious Spiritual – mythical Patterns 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.

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. 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 Clinical Model of Executive Functions

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.

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. Brain-Behavior Model OUTPUTS (motor, oral, written) Concept formation, reasoning, logical analysis Language skills Visual-spatial skills Manipulations in Active Working Memory Attention, concentration, memory Inputs Visual Inputs Auditory Inputs Kinesthetic

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 RelationshipsWhat 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 people during this 3 hour training

29. 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 disability 6.5 million Americans living with some effect TBI Incidence & Prevalence CDC figures as of 4/02

30. The Real Statistics ‘00 ‘99 Since 1992, on average more than 5,000 Arizonans each year sustain a TBI severe enough to cause death (20%*) or hospitalization. ‘98 ‘97 ‘96 ‘95 ‘94 ‘93 ‘92 * estimate

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 Delinquency Anxiety PTSD Aggression Impulsiveness Hyperactivity Mood regulation Impulse control Suicidal ideation Communication difficulties Substance abuse Planning 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 AcquiredBrain 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. Understanding Brain InjuryHypoxia/Anoxia • 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.

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 - CONTRECOUPInjury LifeArt: Williams & Wilkins http://www.lifeart.com

44. Shaken Baby SyndromeViolent shaking or sudden impact may cause excessive brain movement and damage bridging cerebral veins. Shaking Exerts 10x g Force Impact Exerts 300x g 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. 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 Understanding Brain InjuryConcussion: Common Symptoms

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. 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 Understanding Brain InjuryConcussion: Common Symptoms

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