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Traumatic Brain
Injury
March 2014
Carrie Childers, Ph.D., CCC-SLP
Financial Affairs
Office of the Bursar
Outline
• Background Information
• Physiology
• Team Involvement
• Functional Assessment
• Functional Intervention & Coaching
• Case Study
• Additional Considerations
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Severity
Length of Impaired
Consciousness
General Severity
Designation
0-to-60 minutes Mild
1-to-24 hours Moderate
1 or more days Severe
Deficits Deficits Exemplars
Physical • Vision
• Dizziness
• Fatigue
• Motor
Cognitive • Attention
• Memory
• Slow Processing
• Organization
Social-Emotional • Disinhibition
• Impulsivity
• Irritability
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Incidence for Birth to 14
Years
• 435,000 ER visits
• 37,000 hospitalizations
• ? unreported TBIs
TBI Verification Data –
United States
130,000+ 24,000
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Study Findings (Hux, Dymacek, & Childers, 2013)
• Up to one-third of students experience at least
one potential brain injury event before middle
school
• Subset of students with persistent deficits
unidentified, under-identified, or misidentified
– Misidentification may be especially common
among students verified for special education
services for disabilities other than TBI
• No consistent method of identification
WHY ARE KIDS SO DIFFICULT
TO IDENTIFY?
http://www.goodtoknow.co.uk/family/295871/
Free-fun-for-kids---14-Hide-and-seek
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Neurocognitive Stall (Chapman, 2006)
0
1
2
3
4
5
6
7
8
9
10
4 5 6 7 8 9 10
Perfo
rm
an
ce
Age
TBI
No TBI
Similarity to Other Disorders
http://www.health.com/health/
gallery/0,,20441463,00.html
http://parentsabcs.com/2012/06/19/tips
-to-handle-misbehavior-in-children/
http://www.school-
psychology.com.au/blog/learning-
disabilities-difficulties/
Behavior
Disorders
Learning
Disabilities
ADHD
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Subtlety Why does it matter?
http://feelitreal.com/2013/02/why-do-you-want-it/
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• Increased likelihood of
– Academic struggles
– Need for support and accommodation
– Difficulty with friendships (new/old)
– Decreased involvement in extracurricular
activities
Child Outcomes Adolescent Outcomes
• Increased likelihood of
– Poor secondary and post-secondary
outcomes
– Career path change
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What’s an SLP to do?
http://www.instant.ly/blog/2013/06/what-to-do-when-research-
agendas-conflict/
http://leonidzhukov.net/content/vis02/node10.html
1. Understand the Physiology (James F. Phifer, Ph.D.)
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A. Reduced Neural Circuit
Availability
• Fewer neural circuits to do the same jobs as
before.
Common Symptoms
Fatigue Headache
Irritability Social withdrawal
Poor concentration Poor multitasking
Memory Problems Poor attention
B. Lower Activation
Thresholds • Neurons are “leaky”
Common Effects
Stimuli Intolerance
- Photophobia
- Phonophobia
Distractibility
Easy Overstimulation Activation of Sympathetic
Nervous System
- Fight or Flight
- Homeostasis
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Implications
• What we often term “behavior” may, in fact,
be a physiological response mechanism.
• Educators need to be aware of physiological
changes and make modifications to a students’
school program, if necessary.
• Parents and students need education on the
effects of TBI on brain function and behavior.
C. Frontal Lobe Executive
Dysfunction
Start Stop
Initiation Impulse control
Motivation/Drive Inappropriate Social
Behavior
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What does this look like?
• Impaired social awareness
• Impaired awareness of deficits
• Impaired self-awareness/self-monitoring
Educational and Social
Implications?
http://en.wikipedia.org/wiki/Cafeteria
http://blog.ixl.com/2012/09/25/how-
do-you-manage-your-classroom/
http://buffbroad.wordpress.com/2010/01/1
3/the-lasting-horror-of-high-school-gym/
http://www.ynaija.com/opinion-what-
is-your-teen-really-doing-at-school/
http://realcomfortsystems.com/back-to-
school-tips-for-motorists/
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http://www.vrml.k12.la.us/family/parent_resources.htm
http://www.quellerfisher.com/hospital-negligence/
http://ealas.org/to-612/2013/06/meet-our-principal/
http://scienceforkids.kidipede.com/teachers/math.htm
http://www.missouriautismcoalition.com/special_education
http://tahlalalia.tumblr.com/
http://www.betweenthelinesbaseball.blogspot.com/
2. Get Involved 2. Get Involved (cont.)
• What will school look like?
– Part-time or full time?
– Regular education or special education?
– Class schedule?
– Breaks?
• What will the school’s response be to –
– Behavioral outbursts?
– Inappropriate social interactions?
– Impaired disability awareness?
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3. Conduct Functional
Assessments • Ongoing, contextualized, collaborative,
hypothesis-testing assessment (OCCHTA)
– Ongoing
– Contextualized
– Collaborative
– Hypothesis-testing
4. Provide Functional Intervention (Ylvisaker & Feeney, 1998)
A. Scope of Intervention
B. Integration of intervention: Collaboration
C. Orientation of Intervention: Deficits &
Strengths
D. Service Delivery: Settings and Activities
E. Providers of Service: Involvement of
Everyday Communication Partners
F. Source of Control
G. Intervention Procedures
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Why Functional Intervention?
• Fallacy of decontextualized cognitive
retraining:
1.Performance of task T involves the use of
cognitive process P.
2.Repeated performance of task T results in
improved performance of task T.
3.Therefore, repeated performance of task T, will
result in improved process P.
http://www.dennis-yu.com/i-play-video-games-for-a-living-now-sorta/
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A. Scope of Intervention
• Real-world goals in real world contexts.
• Collaboration
– SLP, psychologist, and cognitive rehab.
• Self-control (executive function) focus
http://www.rhl.org/blog/blog/classes/the-8-worst-classroom-
companions/2697/
B. Collaboration
• Acknowledge professional uniqueness and
overlap
• Integrate assessments & plans for intervention
– Cross-disciplinary documents
• Include individual and significant others
thenatureofbusiness.org/
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C. Deficits and Strengths
• Build on existing strengths via
– Facilitation of success in functional activities
– Apprenticeship procedures (chaining, shaping)
– Compensatory strategies
• Antecedent supports ensure success
throughout intervention
• undesirable behaviors and ↑ desirable
• Self-esteem
D. Settings and Activities
• Real world needs in real world contexts
– Functional communication, social, and cognitive
skills
• Communication and behavioral services
delivered in
– Meaningful social groups
– Settings that mirror where skills will be used
• Everyday routines
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E. Everyday Communication
Partners
• All individuals are service providers
• Rehab. specialists train providers
– May be SLP
govcareers.about.com/
www.degreesfinder.com/
www.ccso.charlestoncounty.org/
F. Source of Control
• Final goal = self-control
– Decision making
– Strategic thinking
– Behavior self-regulation
– Flexible thinking
• Individual with TBI is involved
– E.g., goal selection, progress monitoring, creating
solutions
http://coaching-journey.com/2012/10/i-can-do-model/
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G. Intervention Procedures
• Goal: acceptable range of behaviors that may
vary in effectiveness
• ABC – modifying behaviors
– focus on antecedents
• Contingency Management
– Positive vs. negative consequences for desired
behavior
– Natural contingencies vs. artificial rewards
• Apprenticeship
Functional Intervention
should…
• Be personally relevant
• Address behavior
• Focus on communication
• Improve executive function
• Increase organization and memory
• Include pharmacology
• Provide staff orientation and integration
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5. Be A Coach-Partner
http://www.avca.org/education-resources/coaching-education/
5. Be a Coach-Partner
• Session 1
– Individual shares challenges
• Problem-solves with SLP
– Individual & therapist make a plan
–The individual tries out strategies in
meaningful environments
• Changes to environment, self, and
learning
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5. Be a Coach-Partner (cont.)
• Session 2
– Individual shares performance, barriers,
problems
• Problem-solves with SLP to ID possible
solutions and strategies
– Individual and therapist make a plan
– Individual tries new/modified strategies
in meaningful environments
Case Study • John Smith, 8 years old, experienced a moderate
traumatic brain injury (TBI) following an ATV
accident. He returned to school six months after
his injury. When the IEP team met, John’s teacher
noted that he exhibited distractibility throughout
the day, defiant behavior that escalated during
English class, difficulty with new learning, and
memory problems.
• Using the principles we discussed, identify how
you would assess one of John’s deficit areas and
design an intervention based on your “findings”
from the assessment.
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Additional Considerations
Severe Speech Deficits
• Evaluate intelligibility
• Explore augmentative or alternative forms of
communication
• Train individual, family, and school personnel
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Mild TBI/Concussion
Acute (up to 3 days post-injury)
– Student and Parent/Guardian Education
• Understanding of event and implications
– When to transition back to school
• Need for rest (physical and cognitive)
– Time of rapid change
• Avoid elaborate accommodation plans
– Athletics
• Asymptomatic (behavior, cognition, physical)
– At rest and with exertion
• Unremarkable neurological exam & Neuroimaging (Kirkwood, Yeates, Taylor, Randolph, McCrea, & Anderson, 2008)
Mild TBI/Concussion
Post-Acute (4 days to 3 months)
• Continue student & parent/guardian education
• Abbreviated neuropsychological testing
– 2+ weeks post , if symptomatic
• Educational profile information
– History of areas of strength/weakness
– Current academic status
• Teachers continue to monitor
– Informal vs. Formal but brief education plan
• Athletics – psychosocial effect of injury (Kirkwood et al., 2008)
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Mild TBI/Concussion
Post-Acute (4 months +)
• Continue student & parent/guardian education
• Formal Neuropsychological evaluation
• Formal educational evaluation and services, as
needed
• Athletics and return to play
– Expert opinion – avoid high-risk activities
• Persistent deficits: At same risk as when first injured
– Cost-benefit analysis of psychosocial and physical
benefits (Kirkwood et al., 2008)
Resources • “SAFE Child” brain injury screening tool
– Available online
• Brain Injury Association of America
– http://www.biausa.org/
• The REAP project – New York State
– Concussion/Mild TBI information and checklist
– http://bianys.org/children.htm
• Brain Injury Survival Kit: 365 Tips, Tools, &
Tricks to Deal with Cognitive Function Loss
– Cheryle Sullivan, M.D.
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References
• Deidrick, K. K. M., & Farmer, J. E. (2005). School reentry following traumatic
brain injury. Preventing School Failure, 49(4), 23-33.
• DePompei, R., & Bedell, G. (2008). Making a difference for children and
adolescents with traumatic brain injury. Head Trauma Rehabilitation, 23(4), 191-
196.
• Glang, A., Todis, B., Thomas, C. W., Hood, D., Bedell, G., & Cockrell, J. (2008).
Return to school following childhood TBI: Who gets services?
NeuroRehabilitation, 23, 477-486.
• Glang, A., Tyler, J., Pearson, S., Todis, B., & Morvant, M. (2004). Improving
educational services for students with TBI through statewide consulting teams.
NeuroRehabilitation, 19, 219-231.
• Kirkwood, M.W., Yeates, K.O., & Wilson, P.E. (2006). Pediatric sport-related
concussion: A review of the clinical management of an oft-neglected population,
Pediatrics, 177, 1359-1371.
References
• Kirkwood, M.W., Yeates, K.O., Taylor, H.G., Randolph, C., McCreas, M., &
Anderson, V.A. (2008). Management of pediatric mild traumatic brain injury: A
neuropsychological review from injury through recovery., The Clinical
Neuropsychologist, 22, 769-800.
• Phifer, J.F. Rehabilitation of the adult with TBI: Strategies to facilitate successful
community participation [PowerPoint slides]. West Virginia Center for Excellence
in Disabilities Conference, Huntington, WV, February 2014.
• Ylvisaker, M. (1998). Traumatic brain injury rehabilitation (2nd ed.). Boston:
Butterworth-Heinemann.
• Ylvisaker & Feeney (1998). Collaborative brain injury intervention: Positive
everyday routines. San Diego: Singular.
• Ylvisaker, M., Todis, B., Glang, A., Urbanczyk, B., & Franklin, C. (2001).
Educating students with TBI: Themes and recommendations. Journal of Head
Trauma Rehabilitation, 16, 76-93.