Transcript Slide 1

Traumatic Brain Injury
Update: Current Trends
in Assessment and
Intervention
=
Susan M. Wolf, Ph.D.
Executive Director
Wattle and Daub Consulting
10225 East Iris Road
Suite One
Mesa, Arizona 85207-3627
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Agenda
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Mr. Brain
Neurodevelopment
Epidemiology of injury
Understanding brain injury
Areas of impairment
Neuropsych assessment for disorders
Interventions in cognitive retraining
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Objectives
By the end of the training, the participant will:
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Be able to describe the neurodevelopmental
implications of childhood traumatic brain injury
and school functioning
Be able to identify cognitive-communication
disorders that can result from brain injury,
dependent upon the localization of injury.
Be able to explain their role(s) in relationship
to neuropsychological assessment and
cognitive retraining for children who have
sustained a brain injury.
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Mr. Brain
• Hemispheres
• Lobes
• Brain functions
• Executive Functions
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Mr. Brain
Brain Function
The brain is –
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Our personal, private universe.
What makes us distinctly human.
Our sensory processor.
Responsible for reasoning, language, complex
social relationships, and morality.
• Functioning as an interrelated whole; however
injury may disrupt a portion of its activity that
occurs in a specific part of the brain.
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Mr. Brain
Brain Function
The brain is –
• Most active organ in the body – uses the most oxygen; uses
20% of body’s blood supply; brain constantly active requiring
an uninterrupted flow of blood and oxygen; blood and
oxygen supply to the brain takes precedence over all other
organs of the body; when blood supply is interrupted –
neurons and neural networks die
• Brain is approximately 3 lbs in weight; 2% of total body
weight (adult); one trillion neurons
• Baby/child’s brain – 10% of body mass in a baby – 1/3 size
of adult brain – during first twelve months, brain cells
differentiate and begin developing neural connections.
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Cognitive Skills/Functions Associated with
Hemispheres of the Brain
Left Hemisphere – Logical
Words (spelling)
Verbal meaning
Vocabulary in language
Details – rules
Analysis
One-by-one selectivity
Step-by-step instructions
Sequential ordering
Cause and effect relationships
Learned facts
Letter-symbol associations
Abstract reasoning
Academically-learned information
Ideas
Serial/ordered structures
Self-verbalizations
Selective attention
Consciousness – reasoning
Scientific logic
Right Hemisphere – Aesthetic
Images, pictures, and colors – spatial
Music and feelings
Gestalt – whole/relational
Synthesis, comparisons
Simultaneous patterning
Whole process
Whole units
Analogies
Creativity – new combinations
Visual symbolism
Concrete
Practical – common sense knowledge
Patterns of things/theory
Random-without structure body language
Facial expression, tone of voice
Sustained attention
Meditation, spontaneous ideas, subconscious
Spiritual – mythical
Patterns of logical associations
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Used with Permission: Maureen Priestley 2004
Mr. Brain
Cerebral Cortex
• Both hemispheres are able to
analyze sensory data, perform
memory functions, learn new
information, form thoughts, and make
decisions.
• But each hemisphere acts upon
sensory information in a unique
manner.
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Mr. Brain
Left hemisphere –
• Concern is with discrete and concrete
pieces of information.
• Memory is stored in a language format.
• Helps an individual see details and keep
information organized.
• Helps the individual use language skills
(read, write, and speak) although each of
these skills is done in a different lobe of
that hemisphere.
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Mr. Brain
Right hemisphere • Memory is stored in auditory, visual,
and spatial modalities.
• Helps a person see “the whole” – the
“big picture” and to put things
together (e.g. recognize shapes).
• Supports artistic and musical skills
and abilities.
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Mr. Brain
Executive Function
• Executive Functions are housed in the frontal
lobes, one of the last areas of the brain to fully
develop. Refinement (differentiation and
integration) of the frontal lobes can continue into
the early 20’s.
• Executive Functions are highly dependent upon
normal neuro-development and the ability to
acquire higher level cognitive skills.
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Mr. Brain
Executive Function
Executive Functions represent an individual’s:
• Capacity for self-control and direction, planning
and organization, mental flexibility, problem solving
skills, initiation and motivation.
• Ability to regulate one’s thoughts, emotions, and
behavior.
• Ability to “know where one is heading” as opposed
to having no idea of what the consequences will
be for volitional behavior.
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Mr. Brain
Executive Functions
Impaired Executive Functions
may interfere with a person’s ability to:
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Control emotions.
Benefit from experience.
Learn new information.
Understand “social cues”.
Be sensitive to the emotional needs of others.
To accomplish activities of daily living and to live
independently.
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Clinical Model of
Executive Functions
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Initiation and drive
Response inhibition
Task persistence
Organization
• Generative thinking
• Awareness
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Starting behavior
Stopping behavior
Maintaining behavior
Sequencing and
timing behavior
• Creativity, fluency,
problem-solving skills
• Self-evaluation and
insight
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Brain-behavior Relationships
• Neurodevelopment
• Brain-Behavior Relations
• Model
• New Learning
• Personality
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Neurodevelopment
• Vast difference between the adult brain and the
child’s developing one (size, structure,
networks).
• From birth to adolescence, the brain undergoes
dynamic change resulting in increasing
differentiation and integration.
• Brain development causes maturation in
thinking ability, behavior, emotional regulation,
and social capabilities.
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16 - 19:
Judgment
12 - 16:
The
Developmental
Pyramid
Integration/
Problem Solving
6 - 12:
New Learning/Attention
3 - 6:
Thinking/Emotion/Behavior
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Cause/Effect Relationships
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Key Points in Neurodevelopment
• Injury in childhood can result in an
underdevelopment of the brain functions of the
impacted areas.
• Abilities that are just developing or have not yet
emerged are the most sensitive and more likely
to be disrupted as a result of brain injury.
• These abilities and their associated areas of
function are likely to be the “Achilles Heel” for a
child with a brain injury, even after growing up.
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Brain Behavior Relationships
• It is through our brains that we experience
ourselves, the environment and understand
our relationships to and with others.
• Our experience of ourselves and our
environment is dependent on our brain’s
ability to receive, process, store, retrieve,
and transmit sensory information.
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Brain-Behavior Model
OUTPUTS
(motor, oral, written)
Concept formation, reasoning,
logical analysis
Language skills
Manipulations in
Active
Working Memory
Visual-spatial skills
Attention, concentration, memory
Inputs
Visual
Inputs Inputs
Auditory
Kinesthetic
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Brain-Behavior Relationships
New Learning
New learning is one’s ability to:
• Attend and concentrate on visual, auditory, and/or
kinesthetic input(s).
• Process information in active, working memory by
linking new information to visual, auditory, and/or
kinesthetic memory.
• Encode the new information:
– Hold it in memory for a short period of time.
– Integrate it into long-term memory.
• Retrieve the information when necessary:
– Timely.
– Accurately.
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Brain Behavior Relationships
What is Personality?
What does it mean when you say
someone is “reliable”?
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Brain-Behavior Relationships
Brain injury can impact a
person’s ability to store,
process, accumulate, and
retrieve information.
The extent to which the
brain is impaired is what
assessment and intervention
are all about.
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Understanding Brain Injury
• Epidemiology of Injury
• Types of Injury
• Concussion
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Incidence and
Prevalence of TBI
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TBI: Data and Research
Traumatic brain injury
is now classified as a
public health epidemic
in America.
Centers for Disease Control and Prevention. “Traumatic Brain Injury in the
United States: A Report to Congress.” (January 16, 2001).
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Incidence & Prevalence of TBI
• Someone in America will sustain a brain injury
every fifteen seconds.
720 people
during this
3 hour training
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TBI Incidence & Prevalence
2 million/year injured
1 million/year seek emergency care
270,000/year are hospitalized
50,000/year die from a TBI
75,000/year result in long-term disability
5.3 million Americans with significant disability
6.5 million Americans living with some effect
CDC figures as of 4/02
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‘00
The Real Statistics
‘99
‘98
Since 1992, on average
more than 5,000
Arizonans each year
sustain a TBI severe
enough to cause death
(20%*) or hospitalization.
‘97
‘96
‘95
‘94
‘93
‘92
* estimate
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Incidence & Prevalence of TBI
Who is at risk?
• Close to 1/3 of those surviving
brain injury are children and
teens.
• Males are 2 times more likely to
sustain a TBI compared to
females.
• Risk of traumatic brain injury is
highest in adolescents and
young adults.
• Second highest risk group is
adults older than 75 yrs.
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Incidence & Prevalence of TBI
How are they injured?
• Motor vehicle crashes
account for 50% of all
traumatic brain injuries.
• Falls are the second leading
cause and the most prevalent
cause among the elderly.
• Violence, particularly from
firearms, ranks third.
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Incidence & Prevalence of TBI
TBI Research
While the behavioral effects of
child abuse have been
understood for many years, it
is only recently that we have
begun to recognize the
impact of trauma on the
physiological development of
a child’s brain.
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Incidence & Prevalence of TBI
TBI Research
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As a result of growing up with violence in their
homes, many children have neurological deficits
caused by repeated blows to the head and face
(most common area hit), and by the chemical
reaction to prolonged stress.
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Brain alterations caused by shock and trauma of
witnessing violence, for both women and children,
is a negative outcome of violence in the home.
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Incidence & Prevalence of TBI
TBI Research
These hidden injuries may result in:
Depression
Delinquency
Anxiety
PTSD
Aggression
Impulsiveness
Hyperactivity
Mood regulation
Impulse control
Suicidal ideation
Communication difficulties
Substance abuse
Planning and problem solving difficulties
Brain Injury Source, Winter 1998, Volume 2, Issue 1, pages 12 – 13
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Understanding Brain Injury
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Understanding Brain Injury
Brain Anatomy
Quick overview (from the outside in):
• Outside - Bony skull
• Inside
– Brain tissue – gelatinous substance – firm
jello consistency.
– Brain wrapped in thick covering (dura) that
protects and segments the brain.
– Within the covering, the brain “floats” in
cerebrospinal fluid. It surrounds the brain,
and under normal circumstances, cushions
the brain from contact with its hard, spiny
shell.
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Understanding Brain Injury
Brain Injury Types
Congenital Brain Injury
Acquired Brain Injury
Traumatic
Brain Injury
Closed
Head
Injury
Open
Head
Injury
Non-traumatic
Brain Injury
Savage, 1991
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Understanding Brain Injury
Non-Traumatic
• Examples of non-traumatic brain injury from
medical conditions include:
– infectious disease (e.g., meningitis, encephalitis)
– brain tumor
– cerebral-vascular dysfunction (e.g., stroke, cardiac
disorders)
– intercranial surgery
– toxic chemical or drug reactions (e.g., lead
poisoning, carbon monoxide poisoning).
– anoxic/hypoxic episodes.
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Understanding Brain Injury
Hypoxia/Anoxia
• Near drowning.
• Suffocation.
• Other injuries (cardio or
pulmonary) can reduce blood
flow and oxygen to the brain.
• Lack of oxygen/blood flow for
more than 3 - 4 minutes
causes generalized damage.
• Suicide attempts.
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Understanding Brain Injury
Traumatic
A traumatic brain injury (TBI) is a result of:
• Blunt or penetrating trauma to the head
such as a fall or gunshot wound.
• Coup – Contrecoup injury from
acceleration - deceleration forces such
as motor vehicle crashes or shaken baby
syndrome.
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Understanding Brain Injury
• Primary injury (immediate impact)
– Skull fracture (O)
– Hematomas (C)
– Anoxia/hypoxia (C)
– Contusions (C)
– Axonal shearing (C)
• Secondary injury (reaction to impact)
– Secondary tissue damage/necrosis
– Increased intracranial pressure
– Increased internal temperatures
– Swelling/inflammatory response
– Intracranial infection
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Understanding Brain Injury
COUP - CONTRECOUP Injury
LifeArt: Williams & Wilkins
http://www.lifeart.com
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Shaken Baby Syndrome
Violent shaking or sudden impact may cause excessive brain movement
and damage bridging cerebral veins.
Shaking Exerts
10x g Force
Impact Exerts
300x g Force
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Understanding Brain Injury
Concussion
• May or may not result in a loss of consciousness.
• Clear structural damage may or may not be
present on radiographic/imaging studies.
• Can result in dysfunction in the absence of
structural damage.
• Dysfunction may not be evident until the tasks or
demands of the environment present the individual
with challenges for which s/he may not be able to
compensate.
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Understanding Brain Injury
Concussion: Common Symptoms
• EARLY SYMPTOMS
– Headache
– Confusion
– Dizziness
– Nausea with or without
vomiting
– Disorientation to time
and place
– Slow to respond or
follow instructions
– Being uncoordinated
• LATE SYMPTOMS
– Persistent headache
– Poor attention and
concentration
– Memory dysfunction
– Vision disturbance
– Ringing in the ears
– Anxiety and depressed mood
– Irritability
– Intolerance to loud noise
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Understanding Brain Injury
Concussion Related Issues
• For children and adolescents, whose brain
development is ongoing, the effects of a
concussive brain injury may be distinct from
those seen in adults.
• Repeated concussions, such as sports injuries or
repeated incidents of abuse can have cumulative
effects.
• Symptoms related to post-concussive syndrome
can have significant life-long impairments and
debilitating effects on those who survive them.
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Understanding Brain Injury
Concussion: Common Symptoms
• Second Impact
Syndrome (SIS)
– 2nd concussion while
still symptomatic
– Can occur within
hours, days or
weeks
– May lead to lifelong
impairments
• Post-Concussion
Syndrome
– Effect of repeated
concussions
– Cumulative neurologic
and cognitive deficits
– More concussions, more
risk
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Understanding Brain Injury
• Mild (70-80%), moderate (10-15%), and
severe (5-7%) brain injury are the clinical
terms used to describe the “type” of brain
injury the person sustained. (e.g. Glasgow
Coma Scale, Rachos Los Amigos Scales)
• However, these same descriptors often
fail to tell us about the “functional
outcome” (long-term prognosis) of the
injury.
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Areas of Impairment(s)
after Injury
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What Does TBI Look Like?
• Functional Impacts
• Personality and
Emotional Impacts
• Psychological and
Behavioral Impacts
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Functional Impacts of TBI
• Impaired Mobility
• Impaired Body Functions
• Impaired Sensory Experiences
• Impaired Cognitive Functioning
• Impaired Communication
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Functional Impacts of TBI
• Impaired mobility
– Paralysis (partial or full)
– Hemiparesis
– Spasticity, contractures
– Balance and equilibrium
– Gait challenges
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Functional Impacts of TBI
• Impaired body functions
– Swallowing difficulties
– Temperature control
– Changes in other voluntary controls (motor)
– Changes in involuntary controls
– Seizures
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Functional Impacts of TBI
• Impaired sensory experiences
– Vision
– Hearing
– Smell
– Taste
– Touch
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Functional Impacts of TBI
• Impaired cognitive functions
– Decision making and executive functioning
– Attention/Concentration/Distractibility
– Memory (active, short-, long-term)
– Organization
– Judgment and reasoning
– Mental fatigue, lowered pain threshold
– Self-awareness and metacognition
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Functional Impacts of TBI
• Impaired communication
– Understanding language (e.g., aphasia, auditory
speed of processing concerns, limited verbal
memory or attention)
– Speaking and producing language (e.g.,
anomia, confabulation, tangential, fragmentation,
devoid of content)
– Speech patterns (e.g., perseveration, hyperverbal
speech, cocktail language)
– Poor pragmatics (e.g., poor turn taking, poor
topic maintenance, reduced sensitivity to partner)
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Functional Impacts of TBI
• Impaired pragmatics is CRITICAL !
– Pragmatics transcend isolated word and grammatical
structures (discourse in social context)
– Pragmatics is an interplay of cognitive and affective factors
and decreased self-awareness also plays a role
– People with TBI often exhibit normal linguistic skills but
have difficulty adapting communication to specific contexts
– Poor pragmatics do not spontaneously improve over time
(Snow, Douglas, Ponsford (1998))
– Poor pragmatics leads to social isolation and because it is
critical to community reintegration, clinicians have begun to
prioritize assessment and treatment of deficits.
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Uniqueness of Injury:
Predictability Challenging
• Very specific areas of impairment may exist sideby-side with high-functioning areas
– Example: high intelligence but slow visual or auditory
processing of information
– Example: language skills age-appropriate but
significant working memory impairment
• Location of injury can help determine (to some
extent) the type(s) and severity of impairment
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Impact:
Organic-based Personality / Emotional Changes
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Disinhibition
Suspiciousness
Impulsivity
Lack of awareness of deficit
and unrealistic appraisal
Reductions in or lack of the
capacity for empathy; inability
to experience emotions
Childlike emotional reactions
or behavior
Uncontrolled laughing or
crying; mood swings
(emotional lability)
Preoccupation with one’s own
concerns (egocentrism)
Poor social judgment
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Rage reactions
Euphoria
“Flat” affect
Agitation
Reduced or altered sense of
humor
Low frustration tolerance
Misperception of other
people’s facial expressions
/intentions; inability to perceive
emotions
Hyper-sexuality or hyposexuality
Catastrophic emotional
reactions
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Impact: Psychological / Behavior
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Depression
Anxiety
Panic
Shame
Humiliation
Grief
Loss
Sadness
Irritability and aggressiveness
Deep sense of anger over
what has happened
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Resentment
Blame
Hopelessness and despair
Helplessness
Reduced self-esteem
Withdrawal from social contact
Increased sense of dependency
on others
Psychologically-based denial or
minimization of problems
Defensiveness
Pre-occupation with the past
Unrealistic expectations of family,
friends, co-workers
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Functional Impacts of TBI
"Left to fend for themselves, the
survivors of traumatic brain
injury, already confused by their
inability to be the people they were
prior to the injury, now face the
daunting task of demonstrating
that an injury they do not
understand and cannot
comprehend is producing the
confusion they cannot
communicate."
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Questions
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Assessment
• Psychoeducational
Evaluation
• Neuropsychological
Evaluation
• Formal and Informal
Assessment Discussion
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Psychoeducational Assessment
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Referral Question
Family History
Medical/Developmental History
Educational History
Primary Language
Educational/Cultural Limitations
Classroom or Other Observation
Assessment Battery (Tests Used)
Testing Observation and Student Interview
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Psychoeducational Assessment
(cont.)
• Discussion of Results
• Summary
• Recommendations: Educational/Learning
Implications
• Referral (i.e., neuropsychologist, clinical
psychologist, etc.)
• Psychometric Summary (Explanation of Scores)
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Neuropsychological Evaluation
• Background Information
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Reason for referral
Diagnosis
Onset of injury, neurophysical insult(s)
Medical history, pre-injury status
Developmental, school history
Psychosocial status
Previous psychological, neuropsychological, or
educational evaluation findings
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Neuropsychological Evaluation
• Behavioral Observations
• Alertness and orientation and awareness of
circumstances
• Memory
• Attention, concentration
• Task persistence, fatigue
• Speed of processing and performance
• Speech-language
• Judgment, reasoning
• Affect, mood
• Test behavior
• Self-monitoring of performance, approach, effort
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Neuropsychological Evaluation
• Findings
– Overall cognitive and intellectual functioning
– Sensory/motor functioning
– Attention and concentration
• Basic, complex, independent
– Memory
• Immediate, over trials, delay, recognition, verbal/non-verbal
– Language and Auditory Processing
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Cognitive/verbal subtests (complexity input/output)
Word/speech fluency measures
Aphasia screening
Speech sounds / rhythm patterns
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Neuropsychological Evaluation
• Findings
– Constructional abilities / Visual-perceptual Motor
• Design copying tasks
• Wechsler performance subtests
• Figure drawing
– Analysis and Synthesis of Complex Information / Shifting Set
– Academic Assessment
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Reading
Spelling
Math
Writing
– Personality / Behavioral / Social Assessment
– Adaptive Behavior Assessment (Functional)
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Neuropsychological Evaluation
• Impressions
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Summary of deficits and impairments
Summary of intact areas of functioning and strengths
Comparison to reported level of pre-injury functioning
Contributing factors to performance
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Impulse control
Attention / distractibility
Flexibility
Fatigue
Speed
Awareness of deficits
– Impact on development, learning, social, emotional,
vocational
– Specific needs
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Neuropsychological Evaluation
• Recommendations
– School programming /
Vocational programming
– Therapy needs
– Compensation strategies,
adaptations, accommodations
– Psychosocial intervention(s)
– Re-evaluation (need for and
timing of)
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What critical role can SLPs
play in neuropsychological
evaluation?
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Comprehensive Assessment
• Formal (standardized) evaluation tests
• Informal measures such as modified test
procedures and non-standardized tasks
• Clinical observations
• Simulated situations
– Provides information on strengths and
limitations as well addressing the unique
treatment needs of the client
Frank & Barrineau (1996) Jrnl of Med Spch-Lng Path, 4(2) 81-101.
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GROUP DISCUSSION
• Identify formal
(standardized) and
informal
assessments that
you have used or
can use to ascertain
impairments in the
following areas:
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Sustained attention
Divided attention
Short-term memory
Long-term (sematic)
memory
Episodic memory
Prospective memory
Planning
Awareness of behavior
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Intervention Approaches after BI
Time-based shifts in responsibility
• Environmental
modifications
• Behavioral strategies
• Cues, prompts, and
checklists
• Teaching task-specific
routines
• Pharmacological
interventions
Primarily EXTERNAL
• Cognitive-behavioral
interventions
• Metacognitive/selfregulatory strategies
• Training in use of
compensation
strategies
• Practice at task
management
• Awareness training and
psychotherapy
Primarily INTERNAL
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Some Old Principles of Intervention
(Revisited)
• Observe,
Observe, Observe
• Gain insight into individual’s level of “readiness”
(capacity) to participate
• Honor the chasm between pre- and post-morbid self
(many are very aware of the differences)
• Identify strengths, assets, interests before focusing on
deficits and impairments
• Have heightened awareness that this population
presents with more psychological and behavioral issues
• Make tasks contextually relevant and meaningful
• Look to modify the environment and task demands (your
expectations) rather than focusing on “change” in the
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individual with brain injury
Sidebar: External Compensatory Aids
• Careful needs assessment (with multiple sources of
input) regarding the client’s needs and constraints
– Organic factors (relevant physical/cognitive)
– Personal factors (psychosocial/environmental)
– Situational factors (contexts for aid use)
• Options for external aids
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Written planning systems
Electronic planners
Computerized systems
Auditory/visual symbol systems
Task-specific aids (post-it notes, bulletin boards, phone
dialers, calculators, refrigerator magnets)
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Sidebar: External Compensatory Aids
• Adequate preparation for training a client to use
– Patience with clients and caregivers (everyone needs
reinforcement!)
– Evaluating awareness issues (can procedures work?)
– Breaking down the use of an aid into component parts
– Anticipating the contexts in which the aid will be used
• Training methods
– Effective instructional techniques (academic, functional)
– Errorless Instruction (Baddeley & Wilson, 1994; Evans, 2000)
– Prompting (with rapid and gradual fading cues)
• Monitoring client’s progress
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Review of Intervention Handouts
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Memory Theory Applied to Intervention
Functional and Prospective Memory
Working with Complex Attention
Managing Dysexecutive Symptoms
Working to Improve Unawareness
• Research and Contemporary Publications and
Resources
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