Brain Injury Joke of the Day
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1 KIDS, Inc. (schoolneuropsych.com) School-Neuropsychology Post-Graduate Certification Program Neuropsychology of Traumatic Brain Injury Presented by Dr. Robb Matthews March 11, 2017 Brain Injury Joke of the Day 1
2 Outline Defining Brain Injuries Biological/Biochemical Factors Brain Lesions Brain Injury Causes/Frequency IDEA and TBI Closed Head Injuries Neurocognitive Evaluation Issues Programming Question What are brain injuries? Blow to the head? Penetration of the skull? Congenital defect? Degenerative conditions? Birth trauma injury? Medical procedure? Medical condition? 2
3 Conceptualizing Brain Injury Short answer: Yes Brain Injuries occur from a variety of known and unknown causes The injury may disrupt functioning in a distinct area (focal damage) or broad areas (diffuse damage) Resulting effects can vary along a continuum from short-term to life-long Recovery is not necessarily an all or none process Conceptualizing Brain Injury Impact can be mediated by child s point in the developmental progression 3
4 Conceptualizing Brain Injury Conceptualizing Brain Injury 4
5 Conceptualizing Brain Injury mouse embryonic stem cells differentiated into brain cells. neurons green nuclei of the cells - blue radial glia - red 5
6 Conceptualizing Brain Injury Conceptualizing Brain Injury Brain Injury Congenital and Perinatal (brief or no period of normal development) Acquired Perinatal (e.g., stroke, hypoxia) Congenital (e.g., hydrocephalus) Non-traumatic (internal - e.g., tumor, status, Anoxia, drugs) Traumatic (external physical force) Open (e.g., gunshot) Closed (e.g., fall, drowning) 6
7 Brain Lesions Research regarding lesion type and outcomes suggest: Focal lesions generally have better outcomes Large unilateral lesions may have similar outcomes, depending on factors such as plasticity and cognitive reserve Brain Lesions Research regarding lesion type and outcomes suggests: Moderate or bilateral lesions tend to benefit less from plasticity and consequently have fewer positive outcomes Global (generalized) damage almost always results in enduring poor outcomes 7
8 Conceptualizing Brain Injury Brain Injury Congenital and Perinatal (brief or no period of normal development) Acquired Perinatal (e.g., stroke, hypoxia) Congenital (e.g., hydrocephalus) Non-traumatic (internal - e.g., tumor, status, anoxia, drugs) Traumatic (external physical force) Open (e.g., gunshot) Closed (e.g., fall, drowning) Conceptualizing Brain Injury 8
9 Conceptualizing Brain Injury Brain Injury Congenital and Perinatal (brief or no period of normal development) Acquired Perinatal (e.g., stroke, hypoxia) Congenital (e.g., hydrocephalus) Non-traumatic (internal - e.g., tumor, status, Anoxia, drugs) Traumatic (external physical force) Open (e.g., gunshot) Closed (e.g., fall, drowning) Acquired Brain Injury - Causes 9
10 Acquired Brain Injury - Frequency 18% of all TBI-related ER visits involved children 0- to 14-years (CDC, 2010) about 500,000 in total TBI rates are generally higher in males Males in the 0 to 4 age range have the highest rates of TBI-related ER visits, hospitalizations, and death (approximately 1,451 per 100,000) Approximately 275,000 of all TBIs require hospitalization Approximately 52,000 of all TBIs are not compatible with life (about 4%) Acquired Brain Injury Risk Factors Behavior management problems Difficult temperament Dysfunction in family Depressed mother ADHD diagnosis Premorbid impulsivity and/or hyperactivity Previous TBI 10
11 Traumatic Brain Injury - IDEA 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 Traumatic Brain Injury - IDEA The term applies to open or closed head injuries resulting in impairments in one or more areas, such as: Cognition Language Memory Attention Reasoning Abstract thinking Judgment Problem solving Psychosocial behavior Sensory, perceptual, & motor abilities Physical functions Information processing Speech 11
12 Traumatic Brain Injury - IDEA The term does not apply to brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma Closed Head Brain Injuries Acceleration/Deceleration Injuries Falls Vehicular accidents Shaken baby syndrome Sports injuries 12
13 Closed Head Brain Injuries Types of Injuries Mild Traumatic Brain Injury (mtbi) aka concussion cerebral contusions diffuse axonal injury shearing effects Mild Traumatic Brain Injury (mtbi) Major Features of mtbi May result from a direct blow to face, head, neck, or elsewhere on body with impulsive force to head Rapid onset (in some cases symptoms and signs may evolve over a number of minutes to hours) of short-lived neurologic weaknesses that resolve spontaneously Symptoms usually due to functional disturbance rather than structural injury Results in graded set of clinical syndromes that may or may not include loss of consciousness (LOC) Typically associated with grossly normal neuroimaging 13
14 Mild Traumatic Brain Injury (mtbi) Common Signs and Symptoms LOC ( 10%) <1 Hour Headache Dizziness Confusion Amnesia <1 Hour Seizures Nausea/vomiting Unaware of time, place, date Vacant stare/glassy eyed Slurred speech Unaware of time, score, etc Feeling slow or foggy Visual changes Sensitivity to light/sound Unusual/inappropriate emotions (cry, laugh) Inappropriate game behavior (running in wrong direction) Mild Traumatic Brain Injury (mtbi) Extended Signs and Symptoms -Post- Concussive Syndrome (PCS) decreased attention/concentration decreased processing speed decreased abstract reasoning/problem solving learning and/or memory deficits irritability depression anxiety noise/light sensitivity dizziness or vertigo sleep disturbance/fatigue 14
15 Traumatic Brain Injury Moderate Injuries LOC 1-24 hours PTA <24 hours 2/3 do not return to work/school within 3 months 33-50% have residual problems Severe Injuries LOC >24 hours PTA >1 day Significant ongoing neurocognitive symptoms Social isolation Likely psychiatric issues Closed Head Brain Injuries Injury to brain tissue at the site of coup and contrecoup Localized/focal injuries Shearing and tearing of neurons throughout the brain Diffuse axonal injuries (DAI) or Traumatic axonal injury (TAI) 15
16 Closed Head Brain Injuries Closed Head Brain Injuries 16
17 Closed Head Brain Injuries Closed Head Brain Injuries Biochemical Impact Increase in extracellular potassium and sodium, and intracellular calcium Initial hypermetabolism and hyperglycolysis to restore homeostasis Subsequent hypometabolism while the surrounding tissue asks for more 17
18 Closed Head Brain Injuries Secondary Impact Bleeding (increased intracranial pressure) Swelling (increased intracranial pressure) Loss of oxygen (focal and widespread cell loss) Closed Head Brain Injuries Biochemical Impact 18
19 Closed Head Brain Injuries Biochemical Impact - Neuroinflammation A key feature in CNS pathologies including pain, MS, stroke, spinal cord injuries, and brain injuries Underlies neuropsychiatric disorders including anxiety and depression May increase the brain s sensitivity to stress Closed Head Brain Injury 19
20 Closed Head Brain Injury Closed Head Brain Injuries Types of brain herniation 1. Uncal 2. Central - The brainstem herniates caudally. 3. Cingulate herniation - The brain squeezes under the falx cerebri. 4. Transcalvarial herniation - through a skull fracture 5. Upward herniation of the cerebellum 6. Tonsillar herniation the cerebellar tonsils herniate through the foramen magnum. 20
21 Repeated Closed Head Brain Injuries CHRONIC TRAUMATIC ENCEPHALOPATHY Tau Protein: Amygdala (McKee et al. 2009) Healthy Brain Football Player Boxer Closed Head Brain Injuries Outcome Predictors Duration of coma Degree of Post-traumatic amnesia (PTA) Age (point in the developmental progression) Pre-injury functioning Location of injury Available support systems 21
22 Closed Head Brain Injuries Problems Beyond Neurocognitive Deficits Overstimulation Decreased frustration tolerance Difficulty conceptualizing or recognizing new deficits Emotional lability Impulsivity Aggression Grade level retention Closed Head Brain Injuries 22
23 Closed Head Brain Injuries Conceptualizing Head Injuries How we conceptualize a brain injury or history of brain injury can have a significant impact on the child now and in the future Delayed effects (e.g., white matter degeneration, seizures, vascular changes) Secondary brain injury (e.g., hypoxia, ischemia) Should we use terms others understand (e.g., ADHD)? 23
24 Conceptualizing Head Injuries Information Gathering Details of injury/condition, review of records Developmental History Presenting problems - home and school Analysis of behavior patterns - home and school Assessment of family adjustment Conceptualizing Head Injuries Factors Mediating Cognitive Outcomes of TBI to consider during history gathering Type of Injury and Lesion location Pathological nature of lesion Severity of the initial injury Time elapsed since the injury Age and developmental stage at time of injury and time of testing Level of functioning prior to injury Psychosocial and emotional factors 24
25 Evaluation After Head Injuries Establishing a Baseline Hereditary factors Grades, teacher reports, achievement testing Pre-injury diagnoses or referrals Pre-injury psychosocial and behavioral functioning Environmental influences Evaluation After Head Injuries Intellectual Functioning Often no detectable change following mild injuries Nonverbal tends to be more affected than verbal immediately following TBI Effects on intellectual testing largely resolve over time Intellectual test measures may not detect subtle persistent neurocognitive changes, particularly in individuals with a history of mild or moderate injury 25
26 Evaluation After Head Injuries Wechsler Full Scale Scores Evaluation After Head Injuries Attention Problems with arousal and attention occur almost universally immediately after TBI Attentional problems are a persistent symptom Areas of attentional difficulties may include: focused attention, sustained attention, alternating attention, divided attention 26
27 Evaluation After Head Injuries Injuries Impacting Attention Injury to the Brainstem, (responsible for arousal) may result in coma, affecting most basic functions Injury to sensory input from temporal, parietal, and occipital lobes may result in omissions and errors in processing and integrating incoming signals varies from failure to attend to functions signs in a math problem to unawareness of one side of the body Evaluation After Head Injuries Injuries Impacting Attention Injury to frontal output system may interfere with the ability to manage, allocate, and direct attention in a purposeful or productive manner 27
28 Evaluation After Head Injuries Learning and Memory Memory problems are also very common and persistent consequences of TBI particularly the process of establishing memories for new information Memory is a complex process that involves multiple areas of the brain Initial processing, encoding/acquisition, storage, retrieval Recognition of new verbal and nonverbal information Retrieval/recall of remote memories Evaluation After Head Injuries Learning and Memory Recall of old or previously learned information is often well-preserved, even after severe brain injury procedural memory is often well-preserved, such as knowing how to ride a bike and learning new motor skills Declarative memory is more likely to be disrupted facts or episodes of personal experience such as the time, place, or sequence of events 28
29 Evaluation After Head Injuries Visual-Motor and Perceptual Deficits in this domain are present in approximately 1/3 of children following TBI (Levin & Eisenberg, 79) Response speed during visual processing and visual-motor tasks Facial Recognition Constructional Praxis Skills Visual motor Integration/Copying Skills Disruptions be less than other cognitive domains Evaluation After Head Injuries Executive Functioning Deficits Poor problem solving, planning, organizational skills Cognitive flexibility Perseveration Impulse Control Mood lability Insight about problems Hyperactivity Shifting personality/interpersonal problems 29
30 Evaluation After Head Injuries Psychosocial Adjustment Interaction of trauma variables and environment Pre-morbid functioning of child and family Medical recovery complete recovery TBI Summary 30
31 Programming After Head Injuries Communication is critical Understand the injury/condition Planning should begin before child enters Gather, coordinate information, assessments, records Attend to informal information and observations Anticipate needs that will be difficult to quantify Programming After Head Injuries Needs Identification Take a broad approach to identifying the complex interaction of factors affecting learning Plan on serial assessments Understand that formal assessments have limitations to validity Emphasize process of learning versus the academic product Adopt a task analysis approach to input/output Family support and education 31
32 Programming After Head Injuries Guiding Principles Too much service early on is better than not enough Maintain awareness of interaction between TBI affected domains Avoid a discrepancy model to identify or plan for needs Plan for frequent updates of educational plans and supports Case Review Most of the concussion patients I have seen: were preforming relatively well in school before their injury present with significant emotional/behavioral symptoms True for males and females 32
33 Case Review Chase is a 15-yo r-h male Born in 30 th wk of gestation at 7lb-5oz NICU 14 days - hypoplastic lungs Incubator for 10 days 4 days oxygen Phototherapy for jaundice Mostly normal developmental progression Nocturnal urinary incontinence until about age 13-years Case Review General education student Math tutoring for high-stakes testing Previously prescribed stimulant for attn problems (reportedly ineffective) Sustained concussion in fb practice No memory for event Dazed, dizzy, headache afterward for a few days Out of football for 7-10 days 2 weeks after rtp, began experiencing mood swings, sadness, and anger 33
34 Case Review Initially approached as consult Parents had lined up a psychiatrist and a counselor Additional information parent/patient reported during interview insomnia and hypersomnia decreases in sustained attention and appetite increased defiance toward his parents previously sent a text message to his mother stating he didn t think he could attend school because he might hurt himself or someone else Case Review Expresses support for the parents approach to addressing his mood issues and recommended they continue Mother came to my office wanting an evaluation that included consideration of a math LD Discussion point Where would you go from here and why? 34
35 Case Review Follow-up Interview information Long family history of addiction/substance abuse Family history incarceration related to drugs Family history of inpatient psychiatric/addiction treatment Chase enjoys science (aka making explosives) Mom fosters an enmeshed relationship with her sons Case Review During testing session: inconsistent eye contact generally passive sullen with flat affect very few spontaneous comments became overwhelmed and began to tear up during testing reported being fine Reportedly cried during lunch with his father, not wanting to complete the evaluation 35
36 Case Review Rating Scales Suggested : significant emotional distress across domains and circumstances Interview Suggested : daily mood changes resulting in suicidality, and in some instances homicidality, for the remainder of the day Discussion point How would these observations influence your interpretation of his results? Case Review Evaluation Conclusions While these results are believed to be accurate indication of Chase s level of functioning at the time of evaluation, it is difficult to draw conclusions about their reliability as his mood very likely affected his performance. Thus, the outcome of his performance should not viewed as an accurate reflection of his typical functioning or used as an indicator of his educational needs. 36
37 Feedback Case Review overall cognitive functioning average significant deficits in processing speed and several aspects of memory Presented the BASC-SR profile as an indicator of emotional difficulties Discussed the need for reevaluation Recommended inpatient psychiatric care Mother concerned about losing his trust Sent to ED for evaluation and transfer Case Review In the interim Referred for school eval receiving SPED for ED Prescribed guanfacine, bupropion XL, and fluoxetine Participated in outpatient counseling and weekly social coping group at school Significant improvement in overall mood symptoms 37
38 Case Review Reevaluation Observations consistent eye contact slow cognitive tempo during conversation and when recalling verbal information relatively disorganized in his approach benefitted from encouragement of additional effort discussion suggested a relatively unsophisticated view of social relationships reported ongoing intermittent difficulties with sleep and appetite Case Review Reevaluation Results Improvements in cognitive functioning and mood WM and PS continued to be a relative weaknesses Number of executive functioning difficulties Haphazard effort Significant feelings of inadequacy 38
39 Case Review Reevaluation Results Improvements in cognitive functioning and mood WM and PS continued to be a relative weaknesses Number of executive functioning difficulties Haphazard effort Significant feelings of inadequacy Case Review Reevaluation Conclusions While potentially less impactful than in his previous evaluation, Chase s depression seems to continue to affect his neurocognitive processing. It is important to consider that similar to many children and adolescents with emotional difficulties, the impact of his emotional struggles is likely to vary. In instances where his mood is better modulated he may perform better than during difficult times. 39
40 Questions, Comments, Concerns 40
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