Transcript Welcome Value Team: Surgical Efficiency On

Traumatic Brain Injury in Children
and Adolescents
Justin J. Boseck, PhD, CBIS
Trinity Health
Minot, North Dakota
• Brain Injuries = Bad
• Knowledge about brain
injuries = Good
Overview
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Neuroanatomy
Neuroplasticity
Childhood TBI
Questions to be Addressed
Treatment
– Neuropsychological Assessment
– Neurorehabilitation
– Assistive Technology
Neuroanatomy
Neuroanatomy
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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
Incidence in American per 100,000
1200
1000
800
600
per 100,000
400
200
0
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
>75
Neural Development
There are 5 distinct brain maturation milestones
that have been identified through
neuropsychological testing, MRI, and EEG11.
% Maturation
8
6
4
% Maturation
2
0
2 to 3
7 to 8
12
19
Thus, injury to a child’s brain before the age of 3 is
devastating to brain development
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 selfcontrol?
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
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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
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Agenda books
Binders
Color Coding
File Folders
Calendars
Post-it Notes
Assistive Technology
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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
References
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Wahlstrom, D., & Luciana, M. (2011). Functional neuroanatomy of the cerebral cortex. In A. Davis (Ed.).
Handbook of Pediatric Neuropsychology, New York, NY: Springer Publishing.
Bhatnagar, S.C. (2008). Neuroscience for the study of communicative disorders (3rd ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.
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.
Lezak, M. D., Howieson, D. B., & Loring, D. W. (2004). Neuropsychological assessment. New York, NY:
Oxford University Press.
Brain Injury Association of America. (2009). Facts about traumatic brain injury. Retrieved online at:
http://www.biausa.org/aboutbi.htm.
National Head Injury Foundation, 1986
Lash, M. (2009). The Essential Brain Injury Guide: Edition 4.0. Vienna, VA: Brain Injury Association of
America.
Zitnay, G.A. (2005). Lessons from national and international TBI societies and funds like NBI RTT. Acta
Neurochivica Supplementum 93:131–133
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,
Academy of Certified Brain Injury Specialist’s Essential Brain Injury Guide, 4th Edition.
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.
References
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16.
17.
18.
19.
20.
21.
22.
23.
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.
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.
Harley, J.P., Allen, C., Braciszewski, T.L., Cicerone, K.D., Dahlberg, C., Evans, S., Foto, M.,
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.
Mateer, C.A., Raskin, S. (1999) Cognitive rehabilitation. In Rosenthal, M., Griffith, E.,
Kreutzer, J.S., Pentland, B. (eds.): Rehabilitation of the Adult and Child with Traumatic Brain Injury.
Philadelphia: FA Davis, pp. 254–270.
Danes, S. M. (2011). Family Problem Solving. From
www.extension.umn.edu/distribution/familydevelopment/00072.htm
Wade, S. (2011). The impact of TBI on family functioning: Models of family-centered intervention to
improve family and survivor adaptation. Presentation for BIAA.
Mirotta, M. (2012). APP Attack. Assistive Technology Presentation.
Semrud-Clikeman, M., & Bledsoe, J. (2012). Traumatic Brain Injury in Children and Adolescents. In A.
Davis (Ed.), Handbook of Pediatric Neuropsychology, Springer Publishing.
Starling, Sirotnak, Heisler, & Barnes-Eley. (2007). Inflicted skeletal trauma: The relationship of
perpetrators to their victims. Child Abuse and Neglect, 31, 993-999.
Draper, Ponsford, & Schonberger. (2007). Psychosocial and emotional outcomes 10 years following
traumatic brain injury. Journal of Head Trauma Rehabilitation, 22, 278-287.