Traumatic Brain Injuries In Early Childhood

Traumatic Brain Injuries inEarly Childhood:Recognizing, Recovering, SupportingKathleen Deidrick, PhD and Eileen Bent, PhDThompson Center for Autism and Neurodevelopmental DisordersDepartment of Health Psychology, University of Missouri-Columbia

Training Provided by a Collaboration: University of Missouri-MO Head Start- StateCollaboration Office Missouri Head Start Association Thompson Center for Autism andNeurodevelopmental Disorders, University ofMissouri Columbia-Department of HealthPsychology Missouri Department of Health and SeniorServices-MO TBI Implementation PartnershipProject

Funding for this training is provided in part by:1.) H21MC06740 from the Department of Health andHuman Services (DHHS) Health Resources and ServicesAdministration, Maternal and Child Health Bureau. Thecontents are the sole responsibility of the authors anddo not necessarily represent the official views of DHHS.2.) Missouri Head Start State Collaboration Office

AcknowledgementMuch of the following information isadapted from “Understanding Studentswith Brain Injury,” a series of manualsdeveloped by the Center for Innovations inSpecial Education, University of MissouriColumbia.

Overview Typical DevelopmentBasic Brain AnatomyDefinition of Traumatic Brain InjuryMechanisms of Injury and Measuring SeverityRecoveryCognitive and Behavioral Impact of TBIHow to Help an Injured Child in Your ClassroomWhat to Do if a Child is Injured In Your CareHow to Recognize TBI in your Classroom

Typical Developmentand Basic Brain Anatomy

Basic Brain Anatomy

Basic Brain Anatomy

Basic Brain Anatomy

Basic Brain Anatomy

Basic Brain Anatomy

Basic Brain Anatomy

Basic Brain Anatomy Localized functions Connectivity and feedback loops Hierarchical organization

Basic Brain Anatomy

Basic Brain Anatomy

Traumatic Brain Injury:Definition and Prevalence

Traumatic Brain Injury Educational Category Defined By:– Acquired injury– Caused by an external force– Open or closed injury– Results in total or partial physical disability,psychosocial impairment, or both– Excludes: congenital, degenerative, or birthinjuries Contrast with Acquired Brain Injury

Estimated Average Annual Rates of Traumatic BrainInjury-Related Emergency Department Visits,Hospitalizations, and Deaths, by Age Group, UnitedStates, 2002-2006Children, older adolescents, andadults ages 65 years and olderare more likely to sustain a TBI1,400Per 100,0001,2001,000800600ED Visits400Hospitalizations200Deaths00-45-910-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75Age GroupFaul M, Xu L, Wald MM, Coronado V. Traumatic Brain Injury in the United States: EmergencyDepartment Visits, Hospitalizations and Deaths, 2002-2006. Atlanta, Georgia: Centers for DiseaseControl and Prevention, National Center for Injury Prevention and Control; 2010.

Estimated Average Annual Rates of Traumatic BrainInjury-Combined Emergency Department Visits,Hospitalizations, and Deaths, by Sex, United States,2002-2006In every age group, TBI rates arehigher for males than females1,600Per 910-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75Age GroupFaul M, Xu L, Wald MM, Coronado V. Traumatic Brain Injury in the United States: EmergencyDepartment Visits, Hospitalizations and Deaths, 2002-2006. Atlanta, Georgia: Centers for DiseaseControl and Prevention, National Center for Injury Prevention and Control; 2010.

Estimated Average Annual Rates of Traumatic Brain InjuryCombined Emergency Department Visits, Hospitalizations,and Deaths, by External Cause, United States, 2002-2006Falls are the leading cause of TBI.Rates are highest among ages0 to 4 and ages 75 and older.1,000Per 100,000800Falls600Struck By / AgainstMotor Vehicle400Assault20000-45-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75Age GroupFaul M, Xu L, Wald MM, Coronado V. Traumatic Brain Injury in the United States: EmergencyDepartment Visits, Hospitalizations and Deaths, 2002-2006. Atlanta, Georgia: Centers for DiseaseControl and Prevention, National Center for Injury Prevention and Control; 2010.

Mechanisms of Injury

Mechanisms of Injury

Mechanisms of Injury Primary Mechanisms Secondary Mechanisms

Mechanisms of InjuryGlascow Coma Score(also Pediatric Glascow Coma Score)EyesRate 1-4VerbalRate 1-5MotorRate 1-6

Measuring Injury SeverityGlascow Coma ScaleMild13-15Moderate9-12Severe3-8

Measuring Injury Severity Post-Traumatic Amnesia– Period of confusion following a TBI– Includes disorientation– Inability to remember continuous eventsoccurring after the injury Children’s Orientation and Amnesia Test(COAT)

Recovery Process

Initial ck abilitationSchoolRe-Entry

Inpatient Team MembersPhysicians and NursesPhysical TherapistOccupational TherapistSpeech/Language ogist Psychiatrist Social Worker Learning Specialist

Initial ck abilitationSchoolRe-Entry

RecoveryNumber of Symptoms54321Baseline1 monthAdapted from Taylor et al., 20103 months6 months9 months12 months

Factors nmentalFactors

Severity of the Injury

Severity and CognitiveRecoveryTrends in neurocognitive outcomes and recovery over timeFrom Babikian & Asarnow, 2009

Concussion Headache Dizziness Fatigue Sleep problems Sensitivity to light Forgetfulness Concentration Mood problems Controversy about long-termeffects Subset of children showsignificant and persistingcognitive, behavioral, emotionalproblems– Younger children– More serious injury– Worse functioning beforeinjury– Worse family functioning

Post-Concussive Symptoms9%12%15%From Yeates et al., 2010

Factors nmentalFactors

Child FactorsChild’s AgeChild’s FunctioningBefore the Injury

Factors nmentalFactors

Environmental FactorsFamilyFunctioningResources andSocioeconomic StatusSupportAdjustment

Cognitive and BehavioralImpact of TBI

Impact of TBIPhysical/SensoryCognitiveBehavioralEmotional

Physical and Sensory Problems Fatigue and sleep problemsHeadachesSeizuresBladder/bowel problemsTemperature regulationOrthopedic problems Vision problemsHearing problemsSensory sensitivityMotor problems

Cognitive CommunicationAuditory Workingattention memoryOrganizing verbalresponsesVisual-spatial g written edDividedOrganizingattentionKeeping on topicBody lexibilityDiscoursePersonal ye contactSocialinformationprocessing

Effects on IQFrom Anderson, Catroppa, Morse, Haritou, & Rosenfeld, 2009

Cognitive CommunicationAuditory Workingattention memoryOrganizing verbalresponsesVisual-spatial g written edDividedOrganizingattentionKeeping on topicBody lexibilityDiscoursePersonal ye contactSocialinformationprocessing

Behavior ProblemsImpulsivityPoor JudgmentSelfRegulationLow MotivationLethargic

Emotional ProblemsDepressionEmotionRegulationAnxietyMood ChangesAnger andIrritability

Impact of TBIPhysical/SensoryCognitiveBehavioralEmotional

Academic Problems Reading Number concepts andarithmetic Writing Academic facts

Math AchievementAdapted from Ewing-Cobbs et al., 2004

Spelling AchievementAdapted from Ewing-Cobbs et al., 2004

Reading RecognitionAchievementAdapted from Ewing-Cobbs et al., 2004

Social ProblemsAggressionLonelinessPoor SocialProblem-SolvingBossinessSuggestibility

Adaptive ProblemsSelf CareSelf DirectionSafety SkillsSelfRegulation

Working with a Childwith TBI

Educator’s Role Integral team member Collaborate with otherservice providers andparents Frequent monitoring Appropriateaccommodations andsupports

Parent’s Role Watchful attention Communicate with allproviders Advocate for supports andservices Provide support andencouragement Attend to family’s well-being

Supporting the tention,LearningandMemory

HealthPlan Obtain needed informationfrom child’s medicalproviders Schedule medicationadministration Provide neededaccommodations to addressphysical limitations Develop a written plan

Schedule Modified schedule Alternate physical andacademic activities Scheduled breaks

Structure Structure Predictability Routines– Visual Schedule– Instructional Routines

Visual Scheduleshttp://www.do2learn.com/

Visual isual-schedule.html

Instructional Routines Getting the child’s attentionExplain the activityModel the activity (“I’ll do it”)Children do activity with teacher (“We do it”)Child does activity alone (“You do it”)Teacher gives feedbackReview

Avoid overstimulationAttention– Designated quiet space– Remove unnecessarymaterials Look for signs of fatigue– Give breaks as needed Keep instructions simple Present information ininteresting, active ways

Brisk Pace– Slower pace for new materialLearningandMemory Check in with child Small chunks of informationover several days Frequent repetition andreview Present information in morethan one way

Anticipate problems andtriggersBehaviorSupports– Transitions and changes– Unstructured activities– Time of day/fatigue Set up the environment forsuccess– Reduce stimulation anddistraction– Provide breaks– Re-direct the child– Give reminders and cues

Give lots of specific positivereinforcementBehaviorSupports– I like how you kept yourhands to yourself– Great job asking for help Formal behavior plan– Increase appropriatebehaviors– Decrease negative behaviors Functional BehaviorAssessment

Additional Supports andServices Individual therapy Cognitive rehabilitation Building coping skills Family counseling Improving family functioning Family problem-solving

When a Child Is Injuredin Your Care

What to Do if a Child isInjured in Your Care Follow standard firstaid procedures Make sure the child isevaluated by aphysician

What to Do if a Child isInjured in Your Care When did the injury occur?What did the child hit his/her head on?How did it happen?What part of the child’s head was injured?How did the child behave after the injury?–––––Loss of consciousnessSeeming dazed, confused, or disorientedPeriods of blank staring and/or frank seizureVomiting and/or headacheIrritability, fussiness How long did any changes in behavior last?

Recognizing TBIin Your Classroom

How to Recognize TBIin Your Classroom Any child who showsa change inbehavioral orcognitive functioningshould be evaluated Changes in behaviorfollowing a knownhead injury warrantspecialty attention

How to Recognize TBIin Your Classroom Notable changes may include:– Irritability or moodiness– Fatigue– Withdrawn behavior– Impulsivity– Complaints of headaches– Trouble learning new information– Slow speed of processing

References Anderson, V., Catroppa, C., Morse, S., Haritou, F., & Rosenfeld, J. V. (2009). Intellectualoutcome from preschool traumatic brain injury: A five-year prospective, longitudinalstudy. Pediatrics, 124, 1064-1071.Babikian, T., & Asarnow, R. (2009). Neurocognitive outcomes and recovery afterpediatric TBI: Meta-analytic review of the literature. Neuropsychology, 23, 283-296.Ewing-Cobbs, L., Barnes, M., Fletcher, J. M., Levin, H. S., Swank, P. R., & Song, J. (2004).Modeling of longitudinal academic achievement scores after pediatric traumatic braininjury. Developmental Neuropsychology, 25, 107-133. Fau, M., Xu, L., Wald, M.M., & Coronado V. (2010). Traumatic Brain Injury in the UnitedStates: Emergency Department Visits, Hospitalizations and Deaths, 2002-2006. Atlanta,Georgia: Centers for Disease Control and Prevention, National Center for Injury Preventionand Control. Taylor, H. G., Dietrich, A., Nuss. K., Wright, M., Rusin, J., Bangert, B., et al. (2010). Postconcussive symptoms in children with mild traumatic brain injury. Neuropsychology,24, 148-159.Yeates, K. O., Taylor, H. G., Rusin, J., Bangert, B., Dietrich, A., Nuss, K., et al. (2009).Longitudinal trajectories of postconcussive symptoms in children with mild traumaticbrain injuries and their relationship to acute clinical status. Pediatrics, 123(3), 735-743.

Resources Centers for Disease Control and Prevention– http://www.cdc.gov/traumaticbraininjury/ Brain Injury Association of America– http://www.biausa.org/ Brain Injury Association of Missouri– http://www.biamo.org/new page0.aspx LearnNet– http://www.projectlearnet.org/

Basic Brain Anatomy Definition of Traumatic Brain Injury Mechanisms of Injury and Measuring Severity Recovery Cognitive and Behavioral Impact of TBI How to Help an Injured Child in Your Classroom What to Do if a Child is Inj