TBI and ABI IN

CHILDREN“Working with students who have brain injuries through Transition.”

Andrea Buening

IL Special Projects Coordinator

The Independent Living Center

My EASY description ofhow the brain works:

• Consistency of soft jello• Millions of nerve cells• Brain sends messages back through the nerves

In MILLISECONDS the nerves transport messages to different parts of the brain.

Those messages travel to other parts of the brain for interpretation.

Then finally the brain sends out what it is, and what to do with it:

EAT it, JUMP over it, LOOK at it, or maybe CRY about it.

A person may concentrate on it, digest it, add it, subtract it, discuss it, prioritize it, or just ignore it.

The brain does it all and it’s amazing!

This is the brain and what it does:

The brain works out all the time. It depends on itself to make all things work together. It also depends on its owner to feed it and to care for it as it is a matter of life and death.

Children need help caring for their brain.

Brain injury (TBI) can happen to anyone. Children and older adults are at the highest risk

TBI – Traumatic Brain Injury

External force to the head

Closed or open (penetrating head injury)

Disrupts normal brain function

Did you know?

• An estimated 1.7 million people sustain a TBI annually.

• Children aged 0 to 4 years, older adolescents 15 to 19 years, and adults aged 65 years + are at the highest risk to sustain a TBI.

• Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years.____________________________________________________

Among children and youth aged 0 to 14 years in the U.S.:

****Each year traumatic brain injury results in an estimated****• 3,000 deaths• 29,000 hospitalizations• 400,000 emergency department visits.*

Statistics:

Classifications“Mild”

TBI - brief change in mental status or consciousness. (a mild concussion)

“Severe” Suggested by the length of time a person is unconscious or their “score” on either the Glasgow Coma Scale, or the Ranchos Los Amigos Cognitive Recovery Scale – e.g. (Is a 7-level scale for assessing early recovery in the brain injury rehabilitation setting.)

Mild brain injuries can result in temporary or permanent neurological symptoms

e.g. (GCS = Glasgow Coma Scale, PTA = Post Traumatic Amnesia, LOC = Loss of Consciousness)

Glasgow Coma Scale

Every brain injury is different, but generally, brain injury is classified as:

• Severe: GCS 3-8 (You cannot score lower than a 3.)

• Moderate: GCS 9-12

• Mild: GCS 13-15

Glasgow Coma Scale in Infants and Children vs. Adults

Causes of TBI in children

1. Shaken Baby – coup, contracoup

2. Any form of child abuse where the child’s head is involved

3. Playground accidents

4. Sports injuries

Shaken Baby Syndrome and Sports Concussions are in the news so brain injury awareness is increasing.

Abusive Head Trauma can be caused by direct blows to the head, dropping or throwing a child, or shaking a child. Head trauma is the leading cause of death in child abuse cases in the United States.

Childhood brain trauma can result in:

Learning and cognitive disabilities Behavioral disorders Blindness Paresis, or hemiplegia Trauma-induced seizure disorders Loss of motor control Communication disorders Hearing loss

Concussion and Kids-Sports• Football has the highest rate of concussions in high

school sports, girls soccer 2nd highest rate (New York times 10.2.07)

• 29167 concussions suffered by US high school girl soccer players, 20,929 concussions suffered by high school boy soccer players 2005-2008 (Time Magazine 2008)

• Female concussion rates in high school basketball were almost 3xs higher than among boys.

• In girls, symptoms take longer to resolve (NYR 10.1.07)

I invite you to read the,

"Interscholastic Youth Sports Brain Injury Prevention Act“ of 2011

DANGER SIGNS!Be alert for symptoms that worsen over time. Your child or teen should be seen in an emergency department right away if s/he has:

• One pupil (the black dot in the middle of the eye) larger than the other

• Drowsiness or cannot be awakened• A headache that gets worse and does not go away• Weakness, numbness, or decreased coordination• Repeated vomiting or nausea• Slurred speech• Convulsions or seizures• Difficulty recognizing people or places• Increasing confusion, restlessness, or agitation• Unusual behavior• Loss of consciousness (even a brief loss of consciousness should

be taken seriously)

If a child is taken out of the game, an assessment should be done by a professional.

WHEN NERVE CELLS ARE DAMAGED

• Messages to and from the brain are interrupted• Any combination, All, or NONE of the following may

occur• The child may not

see taste smell have balance tolerate lights tolerate stimulation noise tolerate ANY stress

These are PHYSICAL impacts

The most common consequence of brain injury is

IMPAIRED MEMORY

POSSIBLE Affected cognitive skills

Possible consequences cont.Cognitive Impairments

• short term memory deficits

• impaired concentration

• slowness of thinking

• limited attention span

• impairments of perception

• communication skills

• planning

• writing

• reading

• judgment

MORE possible consequencesEmotional Impairments

• mood swings• denial• self-centeredness• anxiety• depression• lowered self-esteem• sexual dysfunction• restlessness• lack of motivation• difficulty controlling emotions

Possible consequences

Physical Impairments

speech vision hearing headaches motor coordination spasticity of muscles paresis or paralysis seizure disorders balance fatigue

A little Science and Anatomy

Maturation of the Prefrontal cortex

The Prefrontal Cortex

The prefrontal cortex is one of the last regions of the brain to reach maturation. This delay may help to explain why some adolescents act the way they do. The so-called “executive functions” of the human prefrontal cortex include:

Focusing attentionOrganizing thoughts and problem solvingForeseeing and weighing possible consequences of behaviorConsidering the future and making predictionsForming strategies and planningAbility to balance short-term rewards with long term goalsShifting/adjusting behavior when situations change

We don’t see these develop until the child is a teenager.

In a child with a brain injury, they may not develop at all.

Cognition is a term referring to the mental processes involved in gaining knowledge and comprehension. These processes include thinking, knowing, remembering, judging, and problem-solving. These are higher-level functions of the brain and encompass language, imagination, perception, and planning.

Adolescent Brain Development

Neural pruning

If a teen is routinely doing music, sports, or academics, those are the connections that will be hard wired. If they’re lying on the couch or playing video games or MTV, those are the cells and connections that are going to survive.

Experiential and rote learning continues and is necessary for the child with a brain injury.

Brain DevelopmentResearch shows the brain develops until age 22

1.

Why do children experience such dramatic consequences from brain injury if their brain has plasticity?

1. Age at injury and Fund of knowledge

2. Brain development and functioning

3. Experiential learning

4. Undeveloped brain functions

Interruption in development?

Children do not always “look” like they have a brain injury. Be aware of a possible injury.

As they grow and mature, they are introduced to more complex skills and have more social demands.

Researchers found that children may cope better at school since it is a highly structured environment.

They show difficulty in a more independent and less structured modern working environments.

• attention deficit and fatigue• impaired planning and problem solving, • lack of initiative, • inflexibility, • impulsiveness,• irritability and temper tantrums, • opposition, • socially inappropriate behavior

LOOK FOR

IDENTIFICATION OF POSSIBLE BRAIN INJURY

Provide

• Structure• Rest periods• Watch for frustration• Have realistic expectations• Evaluate frequently • Communicate with parents!• At age 14, begin looking at Transition

Teacher Directives• Make your expectations clear• Stay focused on the task• Praise effort, not outcome• Say, “Try again”• Ask questions and give choices• Speak with respect, calmly and firmly• Describe and model the behavior you want• Pick your battles

Work on Attention and Concentration• Seat the student where there are few distractions• Use materials appropriate to the child’s attention span• Use cues to redirect attention (verbal and non-verbal)• Use a timer• Use highlighters to draw attention• Provide well placed rest periods

Strategies

Organization• Keep your daily schedules consistent (Routines are necessary)• Use a daily assignment book or planner• Keep materials organized in one place• Break tasks into manageable steps and write the steps on cue

cards.• Set interim deadlines for long-term projects• Use notebook system, not loose paper.

Memory and Comprehension• Use active listening strategies• Use study guides or other study strategies• Provide opportunities for sufficient practice and review to

increase acquisition and retention• Organize materials graphically (illustrations, visual cues, graphs)• Muse memory aids (assignment books, cue cards)• Use mnemonics• Relate information to personal experience

Initiating Tasks• Use a prosthetic initiator such as a watch, sign, or pager• Identify peer buddies to work with the student• Engage in highly structured activities• Review tasks and responsibilities• Check for understanding prior to the beginning of an activity

Rigidity/Inflexibility• Prepare student in advance for new situations, transitions,

changes in routine• Provide an explanation for the changes• Use alerting signals and reminders (“In 5 minutes, we will

leave for music class”)• Refer to the student’s schedule to identify the next activity• Have the student repeat back what is going to happen next

Strategies to help children with brain

injuries

Educating Children and Youth who have brain injuries

Recommended reading

Students with Brain Injury: Challenges for Identification, Learning and Behavior in the Classroom

Katherine Kimes, Ed.D., Marilyn Lash, M.S.W. and Ron Savage, Ed.D.

Signs and Strategies for Educating Students with Brain Injuries

Marilyn Lash, M.S.W., Gary Wolcott, M.Ed., and Sue Pearson, M.A.

Resources• Slide Share www.slideshare.net

• CDC Centers for Disease Control Injury Prevention & Control: Traumatic Brain Injury http://www.cdc.gov/TraumaticBrainInjury/

• Brain Injury Association of America http://www.biausa.org/brain-injury-children.htm

• Traumatic Brain Injury.Com http://www.traumaticbraininjury.com/symptoms-of-tbi/ranchos-los-amigos-scale/

• About Education http://psychology.about.com/od/cindex/g/def_cognition.htm

• Undiagnosed Brain Injuries in youth and adults, Michael P. Mozzoni, Ph.D.,/B.C.B.A. and Marilyn Lash, M.S.W.

• ABC News http://www.abc.net.au/news/2012-04-17/neuroplasticity-and-early-intervention3a-q26a/3952432

• Brain Injury Association of America http://www.biausa.org/FAQRetrieve.aspx?ID=43913

• Brain Injury.Com http://www.braininjury.com/children.shtml

• Lash and Associates, Publishers http://www.lapublishing.com/home.php

• Supporting Students with Brain Injuries, Susan M. Rivers, EdS, Director, TBI Training Institute University of South Carolina School of Medicine Columbia, South Carolina

Questions?

Materials for parents of children with brain injuriesNational Institute of Child Health and Human Development (NICHD)http://www.nichd.nih.gov

Family, friends, and caregivers speaking out on behalf of children with special health care needs, addressing policy, managed care, advocacy-training for parents, publications available.http://www.familyvoices.org

The Sarah Jane Brain Foundation – The Mission is to create a model system for children suffering from all Pediatric Acquired Brain Injuries.http://www.thebrainproject.org/

Shaken Baby Alliancehttp://www.shakenbaby.com

Parents and Special Educationhttp://www.parentpals.com

National Information Center on Children and Youth with Disabilities – Includes TBI fact sheetshttp://www.sst13.org/wp-content/uploads/2014/11/TBI-Basics-Powerpoint.pdf

Interesting site with forms you can downloadhttp://free.braininjurypartners.com/page/0100/

The mission of PACER Center (Parent Advocacy Coalition for Educational Rights) is to expand opportunities and enhance the quality of life of children and young adults with disabilitieshttp://www.pacer.org/about/

Neuroscience for Children – Helping students and teachers learn more ab out the nervous systemhttp://faculty.washington.edu/chudler/neurok.html

Materials for teachers and school personnelOffice of Special Education and Rehab Serviceshttp://www.ed.gov/about/offices/list/osers/nidrr/index.html

NICHCY is nw the National Dissemination Center for Children with Disabilities, funded by the U.S. Department of Education, Office of Special Education Programs (OSEP). The site contains material useful in discharge packets for guiding families as they learn about the law and about access to programs for kids.http://www.nichcy.org

National Database of Educational Resources on Traumatic Brain Injuryhttp://www.tbicommunity.org/html/tbiresources/b_advancequeryItem.asp

George Washington School hosts an educational clearinghouse on postsecondary education for individuals with disabilities. Support from the U.S. Department of Education enables the clearinghouse to serve as an information exchange about educational support services, policies, procedures, adaptations, and opportunities at American campuses, vocational-technical schools, and other postsecondary training entities.http://gsehd.gwu.edu/

Council for Exceptional Childrenhttp://www.cec.sped.org

Exceptional Educational Services – Especially for children with Acquired Brain Injury includes power point presentation and article on how to assess children with mild brain injury. http://www.helpingkidsbrains.com/

Family and Advocates Partnership for Education – includes info on IDEA and laws. http://www.fape.org/

School Psychology Resources Online http://school-psychology.org/

Technical Assistance Alliance for Parent Centers – useful publications to print http://www.taalliance.org/

The Brain Injury Guide and Resources - Missouri braininjuryguide@health.missouri.edu