TBI
346 - Psychology of Exceptional Children
(3-3-15)
I. Brain Injury in Children and Adolescents
A. Ascending reticular systems (brain stem)
arousal/(editing)
B. Limbic systems (subcortical)
arousal/attention/(editing)
biological drives (basic instincts)
emotional behavior/reinforcement
temperament (possibly)
consolidation of verbal learning/memory
C. Cortex
sensory unit: processing input
posterior: temporal, parietal, & occipital lobes
motor unit: executive functions, "pause and plan"
frontal: frontal lobe
arousal/attention/(editing)
forming plans
executing plans
verifying results
CDC's National Center for Injury Prevention and Control estimated in 2003 that 5.3 million U.S. citizens (2% of population) was living with disability as the result of a traumatic brain injury. Each year an estimated 1.5 million Americans sustain a TBI. Motor vehicle accidents account for the largest group of TBI leading to hospitalization.
Prevalence of TBI and resulting disability in Children and Adolescents
San Diego County Cohort, 1981 (Kraus et al., 1990)
study population was defined by presenting (alive) at a hospital ER with a head injury; severity was assessed with the Glasgow Coma Scale
Dead at scene/DOA 5%
Severe brain injury 6%
Moderate brain injury 8%
Mild brain injury 82%<1 year of age 4%
1-4 year of age 15%
5-9 year of age 19%
10-14 year of age 20%
15-19 year of age 43%male: 293.0 per 100,000
female 137.9 per 100,000
incidence of brain injury 2.1 times higher for malesExternal causes of brain injuries:
Motor vehicle 37%
Falls 24%
Assault 10%
Sports/recreation 21%
other 8%Estimate of national disabilities:
assumptions:
1. overall incidence rate of hospitalized brain injured person in U.S. of 210 per 100,000 persons aged 0 to 19 years
2. U.S. population of 74,255,000 persons aged 0 to 19 years in 1986
3. severity proportions of 86% mild, 8% moderate, and 6% severe
4. in-hospital case-fatality rates of 0%, 2%, and 42% per 100 patients, respectively, by severity
5. disability rates (any neurologic limitation or disability on hospital discharge) of 10%, 90%, and 100% for mild, moderate, and severe brain injury
then:
About 29,000 persons aged 0 to 19 years have a resultant disability each year from brain injury.
25 years later (Quayle, Holmes, Kuppermann, and others, 2014, p. 1945)
looked at 43,399 children from <2 years to 17 years of age in 25 PECARN ER dept's from 2004 through 2006
falls most frequent "mechanism of injury" for children under 12 years of age
assaults, sports activities, and motor vehicles crashes most frequent causes in adolescents
Impact of TBI in children and adolescents
Acute (short term) effects
Cognitive
language, especially fluency
memory
intelligence
cognitive flexibility
attention and concentrationEmotional/Behavioral
lability of emotions, emotional regulation
frustration tolerance
painChronic (long term) outcome
Cognitive
Decline in Intellectual Functioning
strong dose-effect relationship
severity: Glasgow Coma Scale, Post-Traumatic Amnesia
Memory
Attention & Concentration
Neurological
Motor problems: incoordination, tremor, fatigue
Post Traumatic Seizure Disorder
Emotional/Behavioral/Personality
Exacerbation of premorbid problems
Emergence of "novel" psychiatric symptoms/disorders
Psychiatric disorders 3.6 x baserate (Rutter et al., 1970)
threshold effect evident
Few specific sequelae, social disinhibition may be one exception
ADHD symptomatology not uniquely characteristic of TBI outcome
Brain injury in youth acts as a nonspecific risk factor for emotional/behavioral problems
Vulnerability to disruptive influences:
Fatigue/Illness/Stress/Drug effects and side effects
Variable affecting the outcome of TBI in children and adolescents
Age at time of lesion (how old was the child when injured)
In general--better outcomes with older age at injury
Age of lesion (how much time has passed since in injury)
Severity of lesion
In general--better outcomes with milder injuries
Measures of severity
Glasgow Coma Scale
The Glasgow is a commonly used rating scale for assessing cognitive status in a medical setting.
Measures of posttraumatic amnesia
Galveston Orientation and Amnesia Test (GOAT)
On-Field Cognitive Testing of "mild" sport injuries and possible concussion
University of Pittsburgh Medical Center, Sports Medicine, Sports Concussion Program
Nature of the lesion
focal lesions:
penetrating wounds
strokes
tumorsdiffuse (generalized) lesions:
CHI (closed head injury)
toxic effects
infectious processes
metabolic disorders
History of head injury
the cumulative history of head traumas may be one variable contributing to variability of outcome in individual cases
Subject variables
Youth with good premorbid histories (good social adjustment, academic strengths, higher tested intelligence) tend to fair better after head injuries than children with premorbid risk factors
ABI versus TBI
Acquired Brain Injury: refers to traumatic brain injuries as well as nontraumatic brain injuries, such as strokes, other vascular accidents, infectious, disease, and toxic processes
Children with a variety of neurological diseases and disorders can experience problems in school and social adjustment, and would be covered under the “Other Health Impaired” provisions of IDEA.
Examples include childhood cancers, CNS infectious diseases, seizure disorders, and environmental toxins.
Brain Tumors
Childhood cancers are relatively rare but occur at all age groups. Brain tumors account for about 20% of these cases—approximately 1200 to 1500 new cases each year.
Treatment protocols often involve radiation therapy, chemotherapy, and/or surgical interventions. Outcomes vary from death to being cancer-free at 5-year follow-up.
With increased survival of childhood brain tumors, the “late effects” of treatments, especially irradiation, have received increasing attention. Declines in intelligence and memory, and poor academic progress have been reported. The clearest risk factors for poor outcome are earlier age for cancer (and treatment) onset, amount of radiation, extent of the tumor, and medical complications.
Leukemia
Acute lymphocytic leukemia (ALL) is the most common type of cancer in childhood, it accounts for 80% of the cases of leukemia in children.
95% of children with ALL survive their initial episode and 55% continue in remission 5 years after treatment. Age at diagnosis and initial white blood cell count (WBC) are strong predictors of remission and survival—children with high WBC and <2-years-old or >10-years-old have poorest prognosis. As risk factors/severity of illness increases—aggressiveness of treatment increases with associated “late effects of treatment” in survivors: learning and academic problems.
Meningitis—inflammation of the meninges (protective layers) of the CNS (brain and spinal cord). Bacterial meningitis is the most common form.
Sequelae depend on the age of onset, infectious agent, speed of diagnosis, severity of infection, and treatment used. Outcome varies from no identified residual effects to severe retardation, learning problems, and neurological handicap.
Encephalitis—generalized inflammation of the brain. Viruses are frequently the infectious agent. As with meningitis, the outcome varies from good to poor.
CNS involvement is estimated to be high in children who are HIV positive. Severe cases may be classified as AIDS Complex Dementia.
Epilepsy is often considered the most common neurological disorder of childhood, occurring in 1% to 2% of the population. Seizures can occur secondary to a number of etiological factors, or with no know cause. “Febrile” seizures (caused by a high temperature—above 102 degrees F) may occur once without any subsequent episodes. “Prodomal” [before the seizure] and “postictal” [after the seizure] effects may include irritability, lethargy, confusion, or behavior problems. Some, not all, individuals may experience an “aura” immediately prior to the seizure. Some, not all, individuals may show repetitive behavior [“automatisms”] during the seizure—lip smacking, hand flapping, eye blinking, etc.
Partial Seizures
Partial seizures do not involve loss of consciousness, but may evolve into generalized seizures.
Simple partial seizures involve focal discharges/symptoms.
Complex partial seizures involve an impairment of consciousness.
Generalized Seizures
Generalized seizures involve the entire brain and are associated with a loss or impairment of consciousness. 3 general patterns:
Febrile
Absence seizures (“petit mal”)
Tonic-clonic (“grand mal”)
Partial Seizures
temporal lobe seizures, Partial Complex Seizures
Associated features of seizures disorders in youth
Because of the various types of seizure disorders and different etiologies, the population of children and adolescents with seizure disorders is very heterogeneous.
Lower tested intelligence, academic problems, learning problems, and behavior problems are statistically over represented in the population of individuals with seizures disorders. Very likely these comorbid problems are caused by the same underlying neurological abnormality or dysfunction which causes the seizures.
The most likely (modal) young person you know with a seizure disorder is just like you!
Fetal Alcohol Syndrome (FAS)
FAS refers to a pattern of growth deficiency, facial anomalies, & CNS dysfunction caused by prenatal exposure to alcohol. Children with FAS often show delayed development, overactivity, motor clumsiness, attention deficits, learning problems, mental retardation, and seizure disorders. There may be comorbid diagnoses of MR, ADHD, LD, and other behavior problems.
An overall incidence of 1-3 per 1000 live births is cited but the actual prevalence varies greatly with community and local cultural norms.
Various thresholds for “safe use” have been discussed. Varying results may, in part, reflect individual differences in vulnerability of some fetuses. Between 7 and 28 drinks (1 oz. of alcohol) per week the relationship between consumption and neurobehavioral sequalae become increasingly strong.
ADHD and intellectual limitations are often diagnosed in children with FAS. Problems with attention, adaptive behavior, academic achievement, and language skills are often reported. However, it is often difficulty to disentangle the effects of FAS from environmental effects: many children with FAS come from chaotic homes where alcohol and other drugs are used by the parents. Poor prenatal and neonatal care, neglect, abuse, inadequate nutrition, inconsistent parenting
Lead Poisoning
Exposure to even low levels of lead can cause cognitive and behavioral problems in children. Children with acute lead encephalopathy show severe medical symptoms—seizures, lethargy, ataxia, nerve palsy, and increased intercranial pressure. These can lead to death in severe cases; and in survivors: epilepsy, motor paralysis and spasticity, blindness, mental retardation, attention deficits and hyperactivity
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