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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.