1 traumatic brain injury update: current trends in assessment and intervention = susan m. wolf,...

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Traumatic Brain Injury Update: Current Trends in

Assessment and Intervention

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Susan M. Wolf, Ph.D.

Executive Director

Wattle and Daub Consulting

10225 East Iris Road

Suite One

Mesa, Arizona 85207-3627

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Agenda

• Mr. Brain• Neurodevelopment• Epidemiology of injury• Understanding brain injury• Areas of impairment• Neuropsych assessment for disorders• Interventions in cognitive retraining

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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.

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Mr. Brain

• Hemispheres

• Lobes

• Brain functions

• Executive Functions

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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.

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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.

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Cognitive Skills/Functions Associated with Hemispheres of the Brain

Left Hemisphere – LogicalWords (spelling)Verbal meaningVocabulary in languageDetails – rulesAnalysisOne-by-one selectivityStep-by-step instructionsSequential orderingCause and effect relationshipsLearned factsLetter-symbol associationsAbstract reasoningAcademically-learned informationIdeasSerial/ordered structuresSelf-verbalizationsSelective attentionConsciousness – reasoningScientific logic

Right Hemisphere – AestheticImages, pictures, and colors – spatial

Music and feelingsGestalt – whole/relational

Synthesis, comparisonsSimultaneous patterning

Whole processWhole units

AnalogiesCreativity – new combinations

Visual symbolismConcrete

Practical – common sense knowledgePatterns of things/theory

Random-without structure body languageFacial expression, tone of voice

Sustained attentionMeditation, spontaneous ideas, subconscious

Spiritual – mythicalPatterns of logical associations

Used with Permission: Maureen Priestley 2004

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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.

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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.

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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.

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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.

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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.

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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.

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Clinical Model of Executive Functions

• 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

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Brain-behavior Relationships

•Neurodevelopment

•Brain-Behavior Relations

•Model

•New Learning

•Personality

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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.

Draft for discussion only 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

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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.

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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.

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InputsAuditory

Language skills Visual-spatial skills

OUTPUTS(motor, oral, written)

Brain-Behavior Model

Manipulations in Manipulations in Active Active

Working MemoryWorking Memory

InputsVisual

InputsKinesthetic

Attention, concentration, memory

Concept formation, reasoning,logical analysis

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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:

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Brain Behavior Relationships

What is Personality?

What does it mean when you say

someone is “reliable”?

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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.

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Understanding Brain Injury

•Epidemiology of Injury

•Types of Injury

•Concussion

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Incidence and Prevalence of TBI

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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.

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Incidence & Prevalence of TBI

• Someone in America will sustain a brain injury every fifteen seconds.

720 peopleduring this

3 hour training

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TBI Incidence & Prevalence

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 disability6.5 million Americans living with some effect

CDC figures as of 4/02

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The Real Statistics

Since 1992, on average more than 5,000 Arizonans each year sustain a TBI severe enough to cause death (20%*) or hospitalization.

* estimate

‘92

‘93

‘94

‘95

‘96

‘97

‘98

‘99

‘00

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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.

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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.

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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.

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• 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.

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These hidden injuries may result in:

Depression DelinquencyAnxiety PTSDAggression ImpulsivenessHyperactivity Mood regulationImpulse control Suicidal ideationCommunication difficulties Substance abusePlanning and problem solving difficulties

Brain Injury Source, Winter 1998, Volume 2, Issue 1, pages 12 – 13

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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):

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Understanding Brain InjuryBrain Injury Types

Congenital Brain Injury

Acquired Brain Injury

Traumatic Brain Injury Non-traumatic

Brain Injury

Closed Head Injury

Open Head Injury Savage, 1991

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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.

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• 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.

Understanding Brain InjuryHypoxia/Anoxia

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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:

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• 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

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Understanding Brain InjuryCOUP - CONTRECOUP Injury

LifeArt: Williams & WilkinsLifeArt: Williams & Wilkinshttp://www.lifeart.comhttp://www.lifeart.com

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Shaken Baby SyndromeViolent shaking or sudden impact may cause excessive brain movement

and damage bridging cerebral veins.

Shaking ExertsShaking Exerts10x 10x gg Force Force

Impact ExertsImpact Exerts300x 300x gg Force Force

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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.

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Understanding Brain InjuryConcussion: Common Symptoms

• 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

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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.

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Understanding Brain InjuryConcussion: Common Symptoms

• 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

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• 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.

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Areas of Impairment(s)after Injury

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What Does TBI Look Like?

• Functional Impacts

• Personality and Emotional Impacts

• Psychological and Behavioral Impacts

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Functional Impacts of TBI

• Impaired Mobility

• Impaired Body Functions

• Impaired Sensory Experiences

• Impaired Cognitive Functioning

• Impaired Communication

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• Impaired mobility

– Paralysis (partial or full)

– Hemiparesis

– Spasticity, contractures

– Balance and equilibrium

– Gait challenges

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• Impaired body functions

– Swallowing difficulties

– Temperature control

– Changes in other voluntary controls (motor)

– Changes in involuntary controls

– Seizures

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• Impaired sensory experiences

– Vision

– Hearing

– Smell

– Taste

– Touch

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• Impaired cognitive functions

– Decision making and executive functioning

– Attention/Concentration/Distractibility

– Memory (active, short-, long-term)

– Organization

– Judgment and reasoning

– Mental fatigue, lowered pain threshold

– Self-awareness and metacognition

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• Impaired communication

– Understanding language (e.g., aphasia, auditory speed of processing concerns, limited verbal memory or attention)

– Speaking and producing language (e.g., anomia, confabulation, tangential, fragmentation, devoid of content)

– Speech patterns (e.g., perseveration, hyperverbal speech, cocktail language)

– Poor pragmatics (e.g., poor turn taking, poor topic maintenance, reduced sensitivity to partner)

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• Impaired pragmatics is CRITICAL !

– Pragmatics transcend isolated word and grammatical structures (discourse in social context)

– Pragmatics is an interplay of cognitive and affective factors and decreased self-awareness also plays a role

– People with TBI often exhibit normal linguistic skills but have difficulty adapting communication to specific contexts

– Poor pragmatics do not spontaneously improve over time (Snow, Douglas, Ponsford (1998))

– Poor pragmatics leads to social isolation and because it is critical to community reintegration, clinicians have begun to prioritize assessment and treatment of deficits.

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Uniqueness of Injury: Predictability Challenging

• Very specific areas of impairment may exist side-by-side with high-functioning areas

– Example: high intelligence but slow visual or auditory processing of information

– Example: language skills age-appropriate but significant working memory impairment

• Location of injury can help determine (to some extent) the type(s) and severity of impairment

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Impact: Organic-based Personality / Emotional Changes

• Disinhibition• Suspiciousness• Impulsivity• Lack of awareness of deficit

and unrealistic appraisal• Reductions in or lack of the

capacity for empathy; inability to experience emotions

• Childlike emotional reactions or behavior

• Uncontrolled laughing or crying; mood swings (emotional lability)

• Preoccupation with one’s own concerns (egocentrism)

• Poor social judgment

• Rage reactions• Euphoria• “Flat” affect• Agitation• Reduced or altered sense of

humor• Low frustration tolerance• Misperception of other

people’s facial expressions /intentions; inability to perceive emotions

• Hyper-sexuality or hypo-sexuality

• Catastrophic emotional reactions

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Impact: Psychological / Behavior

• Depression• Anxiety• Panic• Shame• Humiliation• Grief • Loss• Sadness• Irritability and aggressiveness• Deep sense of anger over

what has happened

• Resentment• Blame• Hopelessness and despair• Helplessness• Reduced self-esteem• Withdrawal from social contact• Increased sense of dependency

on others• Psychologically-based denial or

minimization of problems• Defensiveness• Pre-occupation with the past• Unrealistic expectations of family,

friends, co-workers

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"Left to fend for themselves, the "Left to fend for themselves, the survivorssurvivors of traumatic brain of traumatic brain injury, already confused by their injury, already confused by their inability to be the people they were inability to be the people they were prior to the injury, now face the prior to the injury, now face the daunting task of demonstrating daunting task of demonstrating that an injury they do not that an injury they do not understand and cannot understand and cannot comprehend is producing the comprehend is producing the confusion they cannot confusion they cannot communicate."communicate."

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Questions

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Assessment

• Psychoeducational Evaluation

• Neuropsychological Evaluation

• Formal and Informal Assessment Discussion

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Psychoeducational Assessment

• Referral Question• Family History• Medical/Developmental History• Educational History• Primary Language• Educational/Cultural Limitations• Classroom or Other Observation• Assessment Battery (Tests Used)• Testing Observation and Student Interview

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Psychoeducational Assessment (cont.)

• Discussion of Results• Summary• Recommendations: Educational/Learning

Implications• Referral (i.e., neuropsychologist, clinical

psychologist, etc.)• Psychometric Summary (Explanation of Scores)

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Neuropsychological Evaluation

• Background Information• Reason for referral• Diagnosis• Onset of injury, neurophysical insult(s)• Medical history, pre-injury status• Developmental, school history• Psychosocial status• Previous psychological, neuropsychological, or

educational evaluation findings

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• Behavioral Observations• Alertness and orientation and awareness of

circumstances• Memory• Attention, concentration• Task persistence, fatigue• Speed of processing and performance• Speech-language• Judgment, reasoning• Affect, mood• Test behavior• Self-monitoring of performance, approach, effort

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• Findings– Overall cognitive and intellectual functioning– Sensory/motor functioning– Attention and concentration

• Basic, complex, independent

– Memory• Immediate, over trials, delay, recognition, verbal/non-verbal

– Language and Auditory Processing• Cognitive/verbal subtests (complexity input/output)• Word/speech fluency measures• Aphasia screening• Speech sounds / rhythm patterns

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• Findings– Constructional abilities / Visual-perceptual Motor

• Design copying tasks• Wechsler performance subtests• Figure drawing

– Analysis and Synthesis of Complex Information / Shifting Set– Academic Assessment

• Reading• Spelling• Math• Writing

– Personality / Behavioral / Social Assessment– Adaptive Behavior Assessment (Functional)

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• Impressions– Summary of deficits and impairments– Summary of intact areas of functioning and strengths– Comparison to reported level of pre-injury functioning– Contributing factors to performance

• Impulse control• Attention / distractibility• Flexibility• Fatigue• Speed• Awareness of deficits

– Impact on development, learning, social, emotional, vocational

– Specific needs

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• Recommendations– School programming /

Vocational programming– Therapy needs– Compensation strategies,

adaptations, accommodations– Psychosocial intervention(s)– Re-evaluation (need for and

timing of)

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What critical role can SLPs play in neuropsychological

evaluation?

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Comprehensive Assessment

• Formal (standardized) evaluation tests• Informal measures such as modified test

procedures and non-standardized tasks• Clinical observations• Simulated situations

– Provides information on strengths and limitations as well addressing the unique treatment needs of the client

Frank & Barrineau (1996) Jrnl of Med Spch-Lng Path, 4(2) 81-101.

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GROUP DISCUSSION

• Identify formal (standardized) and informal assessments that you have used or can use to ascertain impairments in the following areas:

• Sustained attention• Divided attention• Short-term memory• Long-term (sematic)

memory• Episodic memory• Prospective memory• Planning• Awareness of behavior

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Intervention Approaches after BITime-based shifts in responsibility

• Environmental modifications

• Behavioral strategies• Cues, prompts, and

checklists• Teaching task-

specific routines• Pharmacological

interventions

• Cognitive-behavioral interventions

• Metacognitive/self-regulatory strategies

• Training in use of compensation strategies

• Practice at task management

• Awareness training and psychotherapy

Primarily EXTERNAL Primarily INTERNAL

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Some Old Principles of Intervention (Revisited)

• Observe, Observe, Observe• Gain insight into individual’s level of “readiness” (capacity) to

participate• Honor the chasm between pre- and post-morbid self (many

are very aware of the differences)• Identify strengths, assets, interests before focusing on deficits

and impairments• Have heightened awareness that this population presents

with more psychological and behavioral issues• Make tasks contextually relevant and meaningful• Look to modify the environment and task demands (your

expectations) rather than focusing on “change” in the individual with brain injury

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Sidebar: External Compensatory Aids

• Careful needs assessment (with multiple sources of input) regarding the client’s needs and constraints– Organic factors (relevant physical/cognitive)– Personal factors (psychosocial/environmental)– Situational factors (contexts for aid use)

• Options for external aids– Written planning systems– Electronic planners– Computerized systems– Auditory/visual symbol systems– Task-specific aids (post-it notes, bulletin boards, phone

dialers, calculators, refrigerator magnets)

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Sidebar: External Compensatory Aids

• Adequate preparation for training a client to use– Patience with clients and caregivers (everyone needs

reinforcement!)– Evaluating awareness issues (can procedures work?)– Breaking down the use of an aid into component parts– Anticipating the contexts in which the aid will be used

• Training methods– Effective instructional techniques (academic, functional)– Errorless Instruction (Baddeley & Wilson, 1994; Evans, 2000)– Prompting (with rapid and gradual fading cues)

• Monitoring client’s progress

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Review of Intervention Handouts

• Memory Theory Applied to Intervention• Functional and Prospective Memory• Working with Complex Attention• Managing Dysexecutive Symptoms• Working to Improve Unawareness

• Research and Contemporary Publications and Resources

1 traumatic brain injury update: current trends in assessment and intervention = susan m. wolf,...

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