Prolonged Issues with Cognitive Function Julie Miller, Psy.D., ABPP-CN Neuropsychologist Wallace-Kettering Neuroscience Institute
Presentation Outline Basics of human brain development Vulnerability of the child & teen brain Comorbid diagnoses & complicated recovery Role of Neuropsychological evaluation Case presentation
Brain Development
Synaptic Density
Myelination Fatty substance that coats the axon and speeds electrical impulses Coating of myelin is not complete until about age 20
Cerebellum Best known for coordination of voluntary motor movement, balance, equilibrium, muscle tone Also coordinates cognitive processes via cortical connections (i.e., long term memory, executive functions)
Temporal Lobes Responsible for hearing, memory, emotional Contains the limbic-reward system (amygdala, hippocampus, nucleus acumbens) Matures around ages 18-19 Amygdala Within temporal lobe, memory for emotional experiences Instinctive emotional reactions Matures before the frontal lobe So, adolescents respond with gut reactions before reasoned ones
Frontal Lobe Functions Judgment Reasoning Controlling Impulses Goal and priority setting Planning and organization of multiple tasks Self-control & Emotional control Moral judgment/reasoning
Vulnerability of Child/Adol Brain Increased neural activity may render brain more vulnerable to effects of TBI Higher risk of cerebral swelling & structural injury than adults May be a different cerebral autoregulatory response to trauma (McRory, 2001)
Vulnerability of Child/Adol Brain Malignant brain edema syndrome- rapid neurologic deterioration from alert/conscious state to coma/death Second Impact Syndrome Need for more increased diagnostic vigilance, conservative injury management & importance of early recognition when any signs of neurologic deterioration are evident
Protective Factors? Neuroplasticity- ability of the brain to adapt to deficits and injury overabundance of hard-wired neural networks (not yet fully pruned) When injury destroys an important neural network in children, another less useful neural network that would have eventually been pruned takes over the responsibilities of the damaged network Silent effects that manifest later in development
MTBI Characteristics & Symptoms
Spectrum of TBI Diagnoses: Severity Parameters Index Mild Moderate Severe GCS 13-15 9-12 3-8 LOC <30 Min 30 Min-24 hr >24 hr PTA <24 Hrs 1-7 Days >7 Days
Traumatic Brain Injury There is a continuum of brain injury severity 1. Mild 2. Moderate 3. Severe 4. Catastrophic Very Mild/ Uncomplicated Complicated Moderate Severe Catastrophic Transient Mild Mild
Somatic Concussion Symptoms Headache- 86% in athletes (Guskiewicz et al., 2000) >7 days assoc. w/ more postconcussion sx, slowed RT & memory problems on NP tests, higher on-field anterograde amnesia (Collins et al., 2000) Dizziness & balance problems
Concussion Symptoms Cognitive Attention/concentration; in a fog Memory complaints Slowed mentation Cognitive fatigue and limited cognitive stamina Role of headaches, cyclic
Concussion Symptoms Sleep Disturbance Hypersomnolence or insomnia Changes in sleep patterns of adolescents
Concussion Symptoms Emotional Irritability, reduced frustration tolerance, mood changes, anxiety, sadness, withdrawal Identity issues in adolescents Social functioning, retirement from sports Overwhelmed with school responsibilities
Recovery About 80% of HS athletes recover within 3 weeks (Collins et al., 2006) 90% of university athletes recover within 2 weeks Majority fully recover within 1 month May take longer in younger children
Age Premorbid Considerations In more severe TBIs, earlier age has been assoc w/ poorer outcome, concussion unclear b/c ltd research While young children are at increased risk for more severe and persisting functional deficits than older children and adolescents, beneath a certain severity threshold, negative ramifications based on age appear to diminish (Anderson et al. 2009; Catroppa et al. 2007) Field et al (2003) : HS football/soccer athletes (vs. controls) had significant memory impairment at least 7 days after injury. College athletes only 24 hours
Gender Premorbid Considerations Research in MTBI cases limited, tentative and inconclusive Males age 7-18 more at risk for social skill difficulties & emotional lability following moderate to severe TBI; greater risk for anxiety & depression in females post TBI (Poggi et al. 2003) HS & college females showed greater severity of cognitive impairment following sports-concussion (Broshek et al. 2005) Males age 6-16 more deficits in memory & processing speed following mild/mod-severe injuries (Donders & Hoffman, 2002) Greater overall risk for PCS among females Female brains have higher cortical metabolic demands, so decreased cerebral blood flow & increased glycemic demands following MTBI result in stronger & more prolonged sx
Premorbid Considerations Cognitive Functioning Relative to children without preexisting learning problems who sustain TBI, children with preinjury dx AD/HD, Reading disorders, Mathematics disorder, and Learning Disability-NOS exhibit greater impairment in: Memory functioning Attention Executive functioning Adaptive behavior Behavioral functioning (Farmer et al. 2002; Ponsford et al. 1999; Sesma et al. 2008; Woodward et al. 1999)
Premorbid Considerations Brain Reserve Capacity (BRC) Theoretical construct (Saltz 1993) that refers to brain s capacity to cope with cerebral damage to minimize functional manifestations Once BR is depleted beyond a critical threshold, specific clinical or functional deficits emerge or steeper decline in functioning commences
Premorbid Considerations Common indices of BRC: Intellectual ability, learning & academic achievement, adaptive functioning May have significant implications on postconcussion recovery in pediatric concussion Higher preinjury adaptive functioning predicts better recovery of intellectual abilities, language functions, and memory after mild to severe TBI (Anderson et al. 2004) School age children with stronger preinjury adaptive fx are less likely to demonstrate postinjury deficits in attention, hyperactivity, and impulsivity (Max et al. 2005)
Other Premorbid Considerations Preinjury Psychopathology Adult literature clear about increased risk for anxiety, depression, psychological & social adjustment issues following TBI of even mild severity Effects of preinjury psychopathology less clear Preliminary evidence that prior psych illness increases risk for subsequent psych disorders after MTBI in children Massagli et al. 2004: new-onset psych illness in 3 yr follow-up was estimated to occur in 26% of MTBI subjects with no psych hx versus 55% of MTBI with psych hx (most significant was increased incidence of AD/HD dx)
Other Premorbid Considerations Family Factors/SES Lower SES assoc w/ worse functional outcome SES, years of maternal education, family income assoc w/ outcome from moderate and severe TBI (Taylor et al. 2002) Race/Ethnicity Evidence inconsistent despite controlling for SES
Postconcussion Syndrome (PCS) Small percentage of cases DSM-IV: history of TBI & presence of least 3/8 sx: fatigue, sleep disturbance, headache, vertigo/dizziness, irritability, anxiety or depression, personality change, and apathy Persist > 3 months -Sx begin or worsen after injury Must interfere with social or occupational fx ICD-10 change: no longer indication of how long sx must be present to consider diagnosis
PCS Risk Factors No way to predict, but risk factors may contribute to PCS or protracted recovery: Athletes with history of prior concussions Amnesia
PCS Management No specific tx exists Focus on management of PCS symptoms Headache most persistent sx Academic accommodations Education regarding the recovery process Time <1 month
PCS Management Management in the child & adolescent patient requires understanding and sensitivity to developmental factors Identity vs. Role Confusion (Erikson) Concept of time/future orientation Social ramifications Emotional changes Cognitive/brain changes Natural shifts in circadian rhythms affecting sleep
Neuropsychological Assessment
Role of the Neuropsychologist Psychologists who specialize in study of brain-behavior relationships Specialize in measuring human behavior (i.e., cognition, language, motor and sensory functioning, emotional functioning, personality) following brain injury or disease
Objective Testing Concerns about subjectivity and lack of reliability of self-report measures Data-driven method for making return-toplay decisions Pre-season baseline assessment is ideal Computerized programs Neuropsychological evaluation Neurocognitive performance must return to personal baseline
When to Involve a Neuropsychologist Complex cases involving slow or atypical recovery In cases with pre-existing conditions that may complicate recovery (i.e., history of AD/HD, learning disabilities, mental health issues such as depression) Shortly after injury (i.e., of a school-aged athlete), if athlete is highly symptomatic; may work with the athlete, family, & school
NP Assessment Approaches Computerized- baseline & serial follow-up Paper and pencil- when more comprehensive testing required (i.e., protracted recovery; pre-morbid conditions)
Concussion Evaluation A comprehensive, developmentally sensitive model of concussion evaluation requires 4 key components 1. Understanding of typical development 2. Developmentally appropriate measures of the injury s clinical manifestations 3. Involvement of additional key persons familiar with the child 4. Expectation that recovery may be longer in the younger child
Evaluation Across Injury Timeline Recovery from concussion is dynamic process, described in 3 stages: 1. Acute (first 3 days): recognize injury, stabilize child, provide basic postinjury guidance 2. Postacute (3 days-3 months): more in-depth assessment of sx and neurocognitive issues to inform service planning. Focused NP eval 3. Long-term (3 months +): persisting sx beyond this time indicate need for comprehensive NP eval, neurologic, and social-emotional functions to identify factors assoc. with poor recovery
Components of NP Evaluation Neurocognitive testing in cases of concussion involves a focus on domains that are sensitive to effects of concussion Intellectual ability Processing Speed* Working memory Learning/Memory Attention/concentration Executive functioning Effort testing also included in all evaluations
Case Presentation 16 year old, right handed, 10 th grade Ice hockey 60 days prior; no LOC; PTA 2 hours CT/MRI WNL PT eval: core weakness, balance & gait deficit, increased distractibility NP deficits: auditory & visual working memory mental processing speed attention to detail cognitive flexibility & novel problem solving Self-report: severe depression overwhelmed with academic demands
Conclusions 1. Literature on MTBI in child/adol in infancy stages 2. Consider development in the context of injury 3. Vast majority recover w/n 1-3 months 4. Subjective experience vs. objective testing 5. NP testing most useful in postacute & long-term phases of recovery; cases of very young children and/or in context of pre-existing problems (i.e., learning disabilities, AD/HD, medical dx)