Traumatic Brain Injury in Children and Adolescents

Justin J. Boseck, PhD, CBISTrinity 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 adults1.

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 internally2

• 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 mechanisms3

• 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 brain4

Pediatric Acquired Brain Injury

Pediatric Acquired Brain Injury • Leading cause of death and disability for Americans under

the age of 3521

• 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

0.0 - 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

>750

200

400

600

800

1000

1200

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 EEG11.

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

2 to 3 7 to 8 12 1901234567

% 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 abuse22

– 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**• As 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 complexity.

• “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 injury23

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 Enable 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 themselves15

Goals of Neurorehabilitation

• Return children to their communities and daily activities

• Help children adapt to the expectations of the community

• Help 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

• Areas 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

References1. 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, 19867. 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 93:131–1339. 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, 4th 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.

References12. 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.htm19. 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, 993-999. 23. Draper, Ponsford, & Schonberger. (2007). Psychosocial and emotional outcomes 10 years following traumatic

brain injury. Journal of Head Trauma Rehabilitation, 22, 278-287.