Traumatic Brain Injury in Children

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Nov 17, 2013 (3 years and 6 months ago)

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Traumatic Brain Injury in Children
and Adolescents

Justin J. Boseck, PhD, CBIS

Trinity Health

Minot, North Dakota


Brain Injuries = Bad





Knowledge about brain


injuries = Good

Overview


Neuroanatomy


Neuroplasticity


Childhood TBI


Questions to be Addressed


Treatment


Neuropsychological Assessment


Neurorehabilitation


Assistive Technology

Neuroanatomy

Neuroanatomy


80 billion neurons in the CNS


100 billion glia (supporting cells)


200 billion STARS in the UNIVERSE!


Axons


send messages from neurons


Dendrites


receive messages from axons and send to
neurons


Synapses are the connections between neurons through
axons and dendrites


100,000,000,000,000 (100 TRILLION)
synapses in the human brain




Neuronal Organization


The brain is undergoing significant change
throughout childhood and adolescence.


The brain may compensate for these rapid
changes by distributing information in a
manner that is different from adults
1
.

Neuroplasticity


Until the 1970s it was commonly thought that
the nervous system was essentially fixed.


1998


Fred Gage (Salk Institute, CA) & Peter
Erikkson

(Sahlgrenska
University
Hospital,

Sweden)

*THE HUMAN BRAIN PRODUCES NEW CELLS!!!!*

Neuroplasticity


Plasticity


the brain’s ability to rewire and alter brain tissue for the
purpose of adapting to changes externally or internally
2


Structural plasticity


the change of physical structures by the brain
due to environmental stimuli or injury


Functional plasticity


the brain’s ability to alter function from one
area to another due to damage


Activity
-
dependent plasticity


changes in the brain’s ability to
adapt to the environment based on activities that are performed
that result in changed gene expression secondary to organized
cellular mechanisms
3



Experience
-
dependent plasticity


plasticity in areas of the brain
that are highly used on a daily basis such as a typist having
especially large differences in dendritic cells in the trunk and finger
neurons of the brain
4

Pediatric Acquired Brain Injury

Pediatric Acquired Brain Injury


Leading cause of death and disability for
Americans under the age of 35
21


About 900,000 new cases per year


Federal research budget for PABI < $10 MILLION per
year in research


Autism = about 24,000 new cases per year


Federal Government spends nearly $1 BILLION per
year in research


HIV/AIDS = about 56,000 new cases a year


Federal Government spends over $4 BILLION per year
in research

Annual Prevalence


1.4 million TBI cases per year (child & adult)


50,000 Deaths


235,000 Hospitalizations


1,100,000 Emergency Department Visits

Epidemiology


After one TBI the risk for a second injury is
three times greater


After the second injury the risk for a third
injury is eight times greater

Annual Incidence by Age

0
200
400
600
800
1000
1200
0.0 - 4.0
5.0 - 9.0
10.0 -
14.0
15.0 -
19.0
20.0 -
24.0
25.0 -
34.0
35.0 -
44.0
45.0 -
54.0
55.0 -
64.0
65.0 -
74.0
>75
Incidence in American per 100,000

per 100,000
Neural Development

There are 5 distinct brain maturation milestones
that have been identified through
neuropsychological testing, MRI, and EEG
11
.






Thus, injury to a child’s brain before the age of 3 is
devastating to brain development


0
2
4
6
8
2 to 3
7 to 8
12
19
% Maturation

% Maturation
Causes


Children 0
-
4 (1035/100,000)


Most common cause is a fall with few long
-
term
consequences


Severe head trauma is generally due to child
abuse or car accidents


Children 4
-
11


Pedestrian and bike
accidents


Teenagers


Automobile accidents


Shaken Baby Syndrome


Abusive Head Trauma


Shaken Impact Syndrome


Approximately 64% of all head injuries in infants is
due to child abuse
22


Approximately 1300 infants die per year from inflicted
head trauma


30/100,000 of children under 1 suffer inflicted brain
injury


National Center on Shaken Baby Syndrome

www.dontshake.org

Kennard Principle


Early
brain injury is associated with better
functional recovery compared to similar
injuries sustained during adulthood.




“The
time to have one’s cortical lesion, if one
can arrange it, should be early because early
lesions seemed less disabling than those
acquired later in
life”
13




Early v Late


Preschoolers with injuries to their frontal
lobes often look fine within a few weeks or
months after an injury.

**HOWEVER**


A
s they get older and their brains mature, that
part of the brain previously damaged may not
work as well as it should.

Early v Late


Children who sustain a brain injury early in life
may look fine at that moment in time, but more
serious cognitive and behavioral problems may
emerge as the child grows and
demands grow in
complexi
ty
.


“An injury that occurs at an early age is generally
associated with more significant deficits than one
that occurs later on” as patterns of recovery and
future learning is more highly impacted due to
incomplete development (of the cortex)
21

Questions to be Addressed

Cognitive Adjustment


How do we:


Help the
child pay
attention and concentrate?


Get started in activities and work?


Become organized and plan ahead?


Reason and problem
-
solve?


Learn new information?


Recall previously learned information?


Communicate clearly and effectively in speech and
writing?


Make good and safe decisions
?

Behavioral/Adaptive Adjustment


How do we:


Help the
child with
their self
-
esteem and self
-
control?


Increase awareness of how feelings affect others?


Increase knowledge of expectations in social
situations?


Increase
ability to control
comments
, gestures,
and actions?


Improve ability to handle frustration and control
anger?


Physical Sensory Adjustment


How do we:


Compensate for changes in vision and hearing?


Detect changes in sound, height, distance, and
touch?


Adjust to changes in body coordination?


Slow down or speed up movements?


Improve balance and steadiness?


Recognize and handle fatigue?


Improve
hand/eye
coordination?


TREATMENT

Recovery


Most adults regain skills from TBI within 6
-
9
months


For children, recovery from severe TBI can
span 5
-
6 years post
-
injury with most
improvement seen within 2
-
3 years after
injury
23


Team Approach to Treatment


Primary Care


Neuropsychology


Neuropsychiatry


Rehabilitation Specialists


Physical Therapy


Occupational Therapy


Speech Therapy


Behavioral Medicine (Psychology)


School


Family

Neuropsychological Evaluation


Assess


Attention


Memory


Executive Functioning


Language


Visual
-
spatial


Adaptive
skills


Suggest treatment planning based on neuropsychological
pattern of strengths and
weaknesses

Neurorehabilitation

Achieve

functional improvements by reinforcing,
strengthening, or
re
-
establishing
previously learned
patterns of behavior

E
nable

functional
improvement by
“establishing
new patterns of cognitive activity or
compensatory
mechanisms
for impaired neurological
systems”
14


Alter

the external environment, rather than the
individual
themselves
15

Goals of
Neuro
r
ehabilitation


Return children to their communities and daily
activities


Help children adapt to the expectations of the
community


H
elp the community accept and respect the
differences that people with challenges may
have


Role of Brain Injury Specialists in
Treatment


Implementing treatment plans


Interacting with professionals outside the
facility such as physicians, neuropsychologists,
neuropsychiatrists
, clinical coordinators, case
managers, OT, PT, cognitive therapists


Meeting with family members


Evaluating therapeutic
effects


General Components of Effective
Treatment


A
reas of emphasis for most injured individuals


Memory


Executive Functioning


Language


Impulsivity/Aggression


Activities of Daily Living

External Aides for Cognition


Agenda books


Binders


Color Coding


File Folders


Calendars


Post
-
it Notes

Assistive Technology


Calendar


Cell Phone


Watch Minder


Memo Me


Online Calendars


Dictation software


Audio Books


Word Processors

Assistive Technology


Communication


Pictello


Pictello Website


Look2Learn


Look2Learn Website



Assistive Technology


Communication


My Choice
Board


Description


One Voice


Description


Proloquo2Go


Website


TapSpeak


Website



Assistive Technology


Audio Books


Learning Ally


Reading/Writing


Text
-
to
-
Speech Software


Natural Readers


Voice Recognition


Dragon Dictation Software



Assistive Technology


Memory/Planning/Organization


Google Calendar


www.futureme.org


www.wheresmycellphone.com


Assistive Technology


Memory/Planning/Organization


Qcard

(app)


Website


Supernote

(app)


Description


Med
Minder (
app)


Description


Other Treatment Recommendations


Formal imaging (CT, MRI, etc.)


Vestibular Disorder?


Serial Neuropsychological testing to document
symptoms


Physical Therapy


Occupational Therapy


Cognitive Therapy


Speech Therapy


Psychotherapy/Family Therapy



Sarah Jane Brain Project


http://www.thebrainproject.org/


Brain Injuries = Bad





Knowledge = Good


Questions/Comments

References

1.
Wahlstrom, D., & Luciana, M. (2011). Functional
neuroanatomy

of the cerebral cortex. In A. Davis (Ed.).
Handbook of Pediatric Neuropsychology
, New York, NY: Springer Publishing.

2.
Bhatnagar
, S.C. (2008).
Neuroscience for the study of communicative disorders (3rd ed.)
. Philadelphia,
PA: Lippincott Williams & Wilkins.

3.
Flavell
, S., & Greenberg, M. E. (2008). Signaling mechanisms linking neuronal activity to gene expression
and plasticity of the nervous system.
Annual Review of Neuroscience
, 31, 563
-
590.

4.
Lezak
, M. D.,
Howieson
, D. B., &
Loring
, D. W. (2004).
Neuropsychological
assessment
. New York, NY:
Oxford University Press.

5.
Brain
Injury Association of America. (2009). Facts about traumatic brain injury. Retrieved online at:
http://
www.biausa.org/aboutbi.htm
.

6.
National Head Injury Foundation, 1986

7.
Lash, M. (2009).
The Essential Brain Injury Guide: Edition 4.0
. Vienna, VA: Brain Injury Association of
America.

8.
Zitnay
, G.A. (2005). Lessons from national and international TBI societies and funds like NBI RTT.
Acta

Neurochivica

Supplementum

93:131

133

9.
Kraus, J. F. (1995) Epidemiological features of brain injury in children: occurrence, children at risk, causes
and manner of injury, severity and outcomes. In S. H. Broman & M. E. Michel (Eds.),
Traumatic Head
Injury in Children.
Oxford University
Press,

10.
Academy of Certified Brain Injury Specialist’s Essential Brain Injury Guide, 4
th

Edition.

11.
Boseck, J., McCormick, C., &
Noggle
, C. (In Press). Utilizing a developmental perspective: The influence
of age and maturation on approach. In C.
Noggle
, R. Dean, & M.
Barisa

(Eds.). Neuropsychological
Rehabilitation: Contemporary Neuropsychology. Guilford Press.


References

12.
Semrud
-
Clikeman, M., & Bledsoe, J. C. (2011). Traumatic brain injury in children and adolescents. In A.
Davis (Ed.), Handbook of Pediatric Neuropsychology, New York, NY: Springer Publishing.

13.
Teuber
, H. L. (1978). The brain and human behavior. In R. Held, W.
Leibowitz
, and H. L.
Teuber

(Eds.).
Handbook of Sensory Physiology, Volume 7, Perception. Berlin: Springer.

14.
Harley
, J.P., Allen, C.,
Braciszewski
, T.L., Cicerone, K.D., Dahlberg, C., Evans, S.,
Foto
, M.,

15.
Gordon,W.A
., Harrington, D.,
Levin,W
.,
Malec
, J.F., Millis, S., Morris, J., Muir, C.,
Richert
, J., Salazar, E.,
Schiavone
, D.A., &
Smigelski
, J.S. (1992) Guidelines for cognitive rehabilitation.
NeuroRehabilitation

2:62

67.

16.
Mateer
, C.A.,
Raskin
, S. (1999) Cognitive rehabilitation. In Rosenthal, M., Griffith, E.,

17.
Kreutzer
, J.S.,
Pentland
, B. (eds.):
Rehabilitation of the Adult and Child with
Traumatic

Brain
Injury
.
Philadelphia: FA Davis, pp. 254

270.

18.
Danes, S. M. (2011). Family Problem Solving. From
www.extension.umn.edu/distribution/familydevelopment/00072.htm

19.
Wade, S. (2011). The impact of TBI on family functioning: Models of family
-
centered intervention to
improve family and survivor adaptation. Presentation for BIAA.

20.
Mirotta
, M. (2012). APP Attack. Assistive Technology Presentation.

21.
Semrud
-
Clikeman
, M., & Bledsoe, J. (2012). Traumatic Brain Injury in Children and Adolescents. In A.
Davis (Ed.),
Handbook of Pediatric Neuropsychology
, Springer Publishing.

22.
Starling,
Sirotnak
,
Heisler
, & Barnes
-
Eley
. (2007). Inflicted skeletal trauma: The relationship of
perpetrators to their victims.
Child Abuse and Neglect
, 31, 993
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999.

23.
Draper,
Ponsford
, &
Schonberger
. (2007). Psychosocial and emotional outcomes 10 years following
traumatic brain injury.
Journal of Head Trauma Rehabilitation
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