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Children&
Brain Injury
Anastasia Edmonston MS CRC
TBI Projects Director
Maryland Mental Hygiene Administration
What We Will Talk About
• The big picture
• What about concussion and kids?
• Strategies
• Prevention tips
• State, regional and national brain injury resources
Definitions• Traumatic Brain Injury is an insult to the brain
caused by an external physical force• Diffuse Axonal Injury the tearing and shearing
of microscopic brain cells• Acquired Brain Injury is an insult to the brain
that has occurred after birth, for example; TBI, stroke, near suffocation, infections in the brain, anoxia
IDEA Definition of TBIFederal Public Law 101-476, 1990
……..an acquired injury to the brain caused by an external physical force resulting in total or partial functional disability or psychosocial impairment
or both that adversely affects a child’s educational performance……..
The Big Picture
The Brain Injury Quiz
• How many pounds is the adult brain? a) 7 lbs b) 3 lbs c) 1.5 lbs
• At what age is your brain fully mature? a) 16 b) 21 c) 25
• What is the last part of the brain to mature? a) temporal lobe b) brain stem c) frontal lobe
• Who has not had a traumatic brain injury? a) George Clooney b) Mike Wallace c) Jason Priestly d) Anne Hathaway
About 3.17 Million American civilians (more than 1.1% of
population, live with the consequences of traumatic
brain injuryCDC in Journal of Head Trauma
Rehabilitation 2008 (Vol. 23, No. 6, pp 394-400)
Limitations of Study• Does not include discharge records from
military and veteran affairs hospitals
• Does not include children under 15 years of age (from SC data)
• Does not include persons treated and released from emergency department or other healthcare setting, and those not treated in any healthcare setting following a blow to the head
NATIONWIDE
• 1.4 million Americans sustain a brain injury each year
• 50,000 do not survive their injuries• 235,000 are hospitalized• 1.1 million are treated and released from our
nations emergency department’s following a brain injury
• Annual Incidence of TBI with disabilityAN ESTIMATED 124,000 American civilians
NATIONWIDE-children ages 0-14
• 2,685 deaths
• 37,000 hospitalizations
• 435,000 emergency department visits (accounting for over 90% of emergency department visits in children 0-14 years old)
““Reframed, the numbers Reframed, the numbers nauseate. In America alone, so nauseate. In America alone, so
many people become many people become permanently disabled from a permanently disabled from a brain injury that each decade brain injury that each decade they could fill a city the size of they could fill a city the size of
Detroit……...Detroit……...
……..Seven of these cities are Seven of these cities are filled already. filled already. A third of their A third of their citizens are under fourteen citizens are under fourteen
years of age.”years of age.”
From Head Cases, Stories of Brain Injury and its Aftermath
Michael Paul Mason2008 published by Farrar, Straus and Giroux
In Maryland……..
• In 2000 there were 5,229 traumatic brain injuries
• 5% of all hospitalizations were TBI related
• 25% of all injury related deaths for ages 15-24 were TBI related
• 11% of all injuries to children 14 and under were TBI related CDC 2006
Why are the Numbers so Big?
• 30 years ago, 50% of individuals with TBI died, the number today is 22%
• due to:
• Improved medical technology and techniques
• Safety features such as car seatbelts, child safety seats and airbags
Simplified Brain Behavior RelationshipsFrontal Lobe• Initiation• Problem solving• Judgment• Inhibition of behavior• Planning/anticipation• Self-monitoring• Motor planning• Personality/emotions• Awareness of abilities/limitations• Organization• Attention/concentration• Mental flexibility• Speaking (expressive language)
Parietal Lobe• Sense of touch• Differentiation: size, shape, color• Spatial perception• Visual perception
Occipital Lobe• Vision
Cerebellum• Balance• Coordination• Skilled motor activity
Temporal Lobe• Memory• Hearing• Understanding language (receptive language)• Organization and sequencing
Brain Stem• Breathing• Heart rate• Arousal/consciousness• Sleep/wake functions• Attention/concentration
What happens in a TBI?
• Mechanism – Acceleration/Deceleration– Differential movement of partially
tethered brain within the skull• Results in:
– Bruising of the brain surfaceagainst rough areas of the skull
– Stretching and twisting of nerve axons
Skull Anatomy Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain:
Anatomy,Functions, and Injury
Bony ridges
The skull is a rounded layer of bone designed to protect the brain from penetrating injuries.
The base of the skull is rough, with many bony protuberances.
These ridges can result in injury to the temporal and frontal lobes of the brain during rapid acceleration.
Brain & SkullDr. Mary Pepping of the University of Idaho’s presentation The Human Brain:
Anatomy,Functions, and Injury
Injury to frontal lobe from contact with the skull
Diffuse Axon InjuryDr. Mary Pepping of the University of Idaho’s presentation The Human Brain:
Anatomy,Functions, and Injury
Can directly impact the major pathways of the brain.
RECAP:The Developing Brain
• Children’s brains do not reach their adult weight of 3 pounds until they are 12 years old
• The brain, and most importantly, the brain’s frontal lobe region does not reach it’s full cognitive maturity till individuals reach their mid twenties
The Developing Brain
• The Frontal Lobe houses our executive skills, these include; judgement, problem solving, mental flexibility, etc.
• The Frontal Lobe is very vulnerable to injury
• Damage to the Frontal Lobe any where along the developmental continuum can impact executive skill functioning
According to the USDE, in Maryland…….
Only 324 students out of 98,811with identified
disabilities were receiving services under a TBI
diagnosis in 2006. U.S. Department of Education, Office of Special Education Programs
7/17/06 httpt://www.ideadata.org/tables29th/ar_1-3.xls
Why the Gaps in numbers?
• Not all children experience lasting effects• The etiology of a student’s disability may be
unidentified or misunderstood• Student may be served under a 504 plan• Effects of a early brain injury may not be
expressed until the student is older• When the effects do surface, they may
diagnosed as having a learning disability, emotional disorder, or other disability
• Adapted from TBI and Educator’s Guide by the MD TBI Implementation Project and the BIAM 2003
Mild Traumatic Brain Injury (AKA concussion)
• Most common, 75%-85% of all brain injuries are mild
• Individuals experience a brief (<15 minutes)or NO loss of consciousness
• Post Traumatic Amnesia < 1hour• Normal neurological exam• 90% of individuals recover within 6-8
weeks, often within hours or days
The American Academy of Neurology:
“Concussion is a trauma-induced alteration in mental status that may or may not involve loss of consciousness. Confusion and
amnesia are hallmarks of concussion”
http://search.aan.com/vivisimo/cgi-bin/query-meta?input-form=simple&v%3Asources=AANNew&v%3Aproject=aan&query=concussion
Importance of Post Traumatic Amnesia
PTA is the period of time after injury when a
person is unable to lay down new memories
For Example...
“That first morning, wow, I didn’t want to move, I was thankful that
nothing’s broken, but my brain was all scrambled” Ryan Church, NYT 3/10/08
“All he remembers from the collision with Anderson is the
aftermath, being helped off the field by two people, although he said he did not know who they were until he saw a photograph
later” Ben Shpigel NYT reporter
Concussion and Kids-Sports
• In sports alone, 300,000 + concussions are “estimated” to occur annually
• For every 1 concussion in the NFL, there are 5,650 youth injuries
• Sports associated with concussion: soccer, football, lacrosse, hockey, horseback riding, cheerleading…….. Gerard Gioia, Ph.D., Children’s National Medical Center in remarks at the Brain Injury Association of MD conference 2005
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)
• 29,167 concussions suffered by US high school girl soccer players, 20,929 concussions suffered by high
school boy soccer players 2005-2006 (Time Magazine 2008)
• Female concussion rates in high school basketball were almost 3xs higher than among boys.
• In girls, symptoms take longer to resolve (NYT 10.2.07)
Quoted in TimeDr. Joseph Maroon
U of Pittsburgh Medical Center
“More-developed necks allow boys to better absorb
a blow to the head”
Implications for Children
• Children who incur a brain injury are twice as likely as other children to have a second brain injury within 6 months.
• According to the researchers, factors included a “complex interaction between children and their social environments” (Pediatrics 2007 & Eric Nagourney of the NY Times 4/3/07)
Implications for Children
• Concussion and repeated concussions can occur from falls and sports injuries
• Most soccer concussions are due to hard falls or player collisions
• Secondary impact syndrome, a rare but potentially fatal result of two concussions within a short period of time
“The Faces of Brain Injury”
A short video by the Brain Injury Association of Florida
Brain Injury’s Impact on Physical Functioning….
Adapted from BIA Utah & BIA NJ
• Tired all the time/ Tires more quickly• Continuing headache (maybe accompanied by
nausea), may also be bothered by noise or light• Less active• Dizziness• Ringing in the ears• Slurred speech• Changes in balance, difficulty grasping objects• Bothered by light and noise• Sleep changes (can’t sleep, nightmares etc.)
Brain Injury’s Impact on Thinking.. Adapted from BIA Utah
• Memory, especially short-term memory
• Difficulty learning new information
• Trouble paying attention & staying on task
• Misses instructions
• Multi-tasking or splitting and dividing ones’ attention (aka “executive skills”) can be very challenging
Emotional and Behavioral Consequences… Adapted from BIA Utah
and NIA NJ
• Impulsive• worried and moody• flat affect or little change in emotion • Spends more time alone• Easily upset (teary, agitated, aggressive)• Self-centered of finding it hard to take another’s point
of view• Difficulty exercising good social judgement • Difficulty following daily routine at school and/or home
Possible Changes-Personality and Behavioral ...MD TBI Project
• Depression
• Social skills problems
• Mood swings
• Problems with emotional control
• Inappropriate behavior
• Inability to inhibit remarks
• Inability to recognize social cues
Possible Changes-Personality and Behavioral
• Problems with initiation
• Reduced self-esteem
• Difficulty relating to others
• Difficulty maintaining relationships
• Difficulty forming new relationships
• Stress/anxiety/frustration and reduced frustration tolerance
Children “Grow into Their Brain Injuries”(Gioia)
as children grow, more is expected, children with a history of brain injury may not be able
to meet the demands…….
Impact of an injury may not become apparent till years post injury and…not be
attributed to an earlier blow to the head
Recommended Supports and Services-The Ideal Pathway Following Concussion or Mild
Brain Injury-Childhood Injury
• Family and child is educated about the possible symptoms of concussion
• If symptoms emerge or persist following a concussion, appropriate referrals are made to a neurologist, pediatric neuropsychologist. Appropriate interventions and supports including outpatient speech, occupational and physical therapy are provided and coordinated with school personnel
• Exposure to situations where a second impact is a possibility is minimized
If Symptoms Persist and are Left Untreated….in children
• Teachers and family may notice irritability• Schoolwork suffers• Behaviors attributed to factors other than the brain
injury (family/peer problems, adolescence)• Child continues to experience problems, becomes
depressed/may begin to act out• Is at risk for academic/social difficulties• Is at risk for a subsequent brain injury, exacerbating
the above
If Symptoms Persist and are Left Untreated….in adults
• Job loss
• Mental Health Problems
• Relationships and supports erode
• At risk for Substance Abuse
• At risk for entry into the criminal justice system
Why Screen?What other TBI
Screening efforts have found
2000 Epidemiological Study of Mild TBI J. Silver of NYU, cited in WSJ by Thomas
Burton 1.29.08 http://online.wsj.com/article/SB120156672297223803.html?
mod=googlenews_ wsj
• 5,000 interviewed
• 7.2% recalled a blow to the head w/unconsciousness or period of confusion
• Follow up testing found; 2x rate of depression, drug and alcohol abuse
• Elevated rates of panic and and obsessive-compulsive disorder
Findings from the Literature…Criminal Justice System
• Researchers at Indiana State University found that 83% of felons studied reported a head injury that predated their first encounter with the law (1998)
• Adults who had frontal lobe damage prior to age 8 exhibited recurrent impulsive and aggressive behavior
• 14% of the subjects in the Vietnam Head Injury Project with frontal lobe lesions engaged in fights or damaged property compared to 4% of controls without TBI
Domestic Violence TBI Findings
• Batterers fared worse on three neuropsychological indicators of cognitive functioning then a nonbatterer control group (Cohen et. Al 1999)
• Corrigan et.al., (2003) found that of 167 individuals treated for domestic violence related health issues, 30% experienced a loss of consciousness on at least one occasion, 67% reported residual problems that were potentially TBI related
• Valera and Berenbaum, (2003) assessed 99 battered women. Of these, 57 had brain injured related symptomatology
TBI Among Individuals with Persistent Mental Illness
• Kathleen Torsney (2004) found in one mental health treatment setting 13% of individuals served had a history of TBI
• These same individuals had been treated in various mental health settings but not received specific brain injury treatment
In Maryland- Screening Results from the MD TBI Post Demo II
Project-2005– Summary of TBI Incidence Among all Screened at 7
public mental health agencies in Frederick and Anne Arundel counties
– N=190– 39% no reported history of TBI (78)– 58.94% of individuals with a history of TBI (112)– 35.78% of individuals with a history of a single incidence of
TBI (68)– 23% of individuals with a history of 2 or more TBIs (44)
TBI ScreeningThe HELPS Brain Injury
Screening Tool(see handout)
The original HELPS tool developed by M. Picard, D. Scarisbrick, R. Paluck, 9.1991
Updated by the Michigan Department of Community Health
HELPS• Have you ever Hit your Head or
been Hit on the Head?
• Prompt individual to think about; TBI at any age, MVAs. Assaults, Sports injuries, Service related injuries, Shaken baby and/or adult
HELPS• Were you ever seen in the
Emergency room, hospital, or by a doctor because of an injury to your head?
• Explore the possibility of “unidentified traumatic brain injury” many do not present in medical settings
HELPS• Did you ever Lose consciousness or
experience a period of being dazed and confused because of an injury to your head?
• Remember, a LOC isn’t required for someone to develop symptoms subsequent to a blow to the head. “alteration of consciousness” AKA post traumatic amnesia (PTA). At this point, the interviewer may consider asking the individual if they have had multiple mild TBI
HELPS• Do you experience any of these Problems in
your daily life since you hit your head?• You want to know when any problems began
(or began to be noticed) Remember, lack of awareness is a hallmark of brain injury, you might ask if anyone close to the individual has made any observations regarding changes in function.
HELPS• Headaches• Dizziness• Anxiety• Depression• Difficulty
concentrating• Difficulty
remembering
• Difficulty reading, writing, calculating
• Poor problem solving
• Difficulty performing your job/school work
• poor judgement (being fired from job, arrests, fights, relationships affected)
HELPS• Any significant Sickness?• Acquired Brain Injury (ABI) can result in many
of the same functional impairments as traumatic brain injury (TBI). For example, brain tumor, meningitis, West Nile virus, stroke, seizures, toxic shock syndrome, aneurysm, AV malformation, any history of anoxic injury, e.g. heart attack, near drowning, carbon monoxide poisoning can all result in multiple deficits
Scoring the HELPS Positive for a possible Brain Injury when the
following three are identified:
• An event the could have caused a brain injury (YES to H, E, or S), and
• A period of loss of consciousness or altered consciousness after the injury or another indication that the injury was severe (YES to L or E), and
• the presence of 2 or more chronic problems listed under P that were not present before the injury.
Scoring the HELPS• A positive screening is not sufficient to diagnose
TBI as the reason for current symptoms and difficulties-other possible possible reasons need to be ruled out
• Some individuals could present exceptions to the screening results, such as people who do have TBI-related problems but answered “no” to some questions
• Consider positive responses within the context of the person’s self-report and documentation of altered behavioral and/or cognitive functioning
Additional comments and observations of the interviewer• Any visible scars?
• Walks with a limp?
• Uses a cane or walker?
• Has a foot brace?
• Limited use of one hand?
• Appears to have difficulty focusing vision?
• Difficulty answering questions?
• Answers are unorganized and/or rambling
• Becomes easily distracted, agitated or is emotionally labile
What you are looking for…..And Why
• Any visible scars?Walks with a limp?Uses a cane or walker?Has a foot brace?Limited use of one hand?Appears to have difficulty focusing vision?Difficulty answering questions?Answers are unorganized and/or ramblingBecomes easily distracted, agitated or is emotionally labile
Strategies for supporting children with persistent
symptoms
Strategies to enhance learning are included in a child’s IEP or in
a 504 planSome examples to support those
with brain injury related challenges include with or with
out an IEP or 504 plan... (For more information on IDEA & 504 plans go to
resource section of this handout)
Strategies-Physical-for Children
• Visual aides (large print, screen adapters, scanning aides)
• Built in rest periods in daily schedule• Structure and simplify the classroom
environment (predictable schedule, reduced clutter, consistent cues, written classroom rules)
• Tailor assignments and homework (3 ten minute verses one half hour assignments)
• Adapted from TBI and Educator’s Guide by the MD TBI Implementation Project and the BIAM 2003 & BIA Utah
Strategies-Cognitive
• Calendar/keep schedule predictable
• Planner vs. loose paper
• Laptop/computer• Tape recorder• Timer/timer watches• Untimed testing• Alternative testing
• Use of a reader or note taker (buddy)
• Highlighter• Books on tape/film
adaptation• Strategic scheduling• Break
tasks/assignments into steps
Strategies Continued• Encourage active
listening strategies e.g paraphrasing back to speaker the information, especially when it is novel
• Special seating• Place visual cues in
environment (calendars etc.)
• Use of an FM system (headphones that directly link child to the teacher to screen out distractions)
• Text reader programs• Retention in long term
memory is enhanced by the three R’s Repeat, Rehearse, and Review
• Checklists
Uses of Strategies at Home and When Navigating the
CommunityWatch this clip from the movie
“The Lookout”What are the strategies he uses to
compensate for memory, organization, etc.
“The Only Cure for Brain Injury is
Prevention”
Strategies for Prevention
Prevention
• Car safety
• Helmet use
• Sports
• Violence reduction
Car Safety• Parents and caregivers-DRIVE THE POSTED
SPEED LIMIT• Drivers-insist all adult passengers wear
their seatbelts. An unrestrained adult in the event of an accident can be transformed into an unguided missile that can injure or kill a child passenger (same goes for dogs, buckle them up too!)
• Don’t drink and drive, reaction time can deteriorate after only two drinks
Car Safety for Child Passengers
• Children up to 14 years of age or younger need to sit in the back seat and properly restrained for their age, weight and height.
• Children 40-80 pounds should sit in a booster seat. This enables the belt to sit properly, low and tight across the top of the thighs Kids in Safety Seats website
Car Safety for Child Passengers
• Although car manufacturers recommend not to place children 12 or under in the front seat with an air bag, research suggests that no child under 14 should sit in the front seat with an airbag. (Pediatrics
2005)
• At 14, the maturation of the bones and muscles is sufficient to tolerate the impact of a deployed airbag
The Good News!
Because of increased use of seat belts, and placement of children in the backseat, it is
estimated that from 1995-2001, 1,700 lives were saved!
Report by the Air Bag and Seat Belt Safety Campaign 2005
Helmets & Sports• Brain injuries cause more deaths than any
other sports injury• Research shows that 85% of bicyclists head
injuries can be prevented by a bicycle helmet• Always wear a helmet when biking, playing,
football, baseball (at bat), horseback riding, in-line skating, ice skating, roller skating, avoid “heading” the ball when playing soccer (Brain Injury of America website www.biausa.org)
Violence Prevention
• Keep guns unloaded and locked up
• Keep bullets locked up in a separate location
• Explain to children the difference between the violence they may see on TV and the real harm that guns can do (BIAA website, www.biausa.org.)
• Teach children to walk away from conflict
Resources
Brain Injury Association of America
1-800-444-06443
www.biausa.org
Resources
Brain Injury Association of Maryland
410-448-2924
www.biamd.org
Resources Centers for Disease Control
Wonderful, free tool kits
• Heads Up: Concussion in high school sports- a tool kit for for coaches, parents and athletes http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm
• Head Up: Concussion in Youth Sports Tool Kit http://www.cdc.gov/ConcussionInYouthSports/default.htm
Resources/References• "Brain Injury Partners: Navigating the School
System”a collaboration of the National Institute of Child Health and Development and the Brain Injury Association of America.
• “Brain Injury: A Guide for Families About School” Published by the BIA of New Jersey, includes an excellent discussion on how the IEP and 504 plans can support students with brain injury http://www.bianj.org/publications-on-brain-injury
• Slides 17-19 adapted from Dr. Mary Pepping of the University of Idaho’s presentation The Human Brain: Anatomy,Functions, and Injury
Resources/References• http://www.bianys.org/learnet/. A website full of
information on strategies for children, teachers and clinicians on how to problem solve around various brain injury related issues. Created by the NIA of New York State
• Brain Injury Resource and Information Network of Tennessee www.tndisability.org/brain
• Brower MC, Price BH. Neuropsychiatry of frontal lobe dysfunction in violent and criminal behavior: a critical review. Journal of Neurological and Neurosurgery Psychiatry 2001;71:720-726.
Resources continued...
National Safe Kids Campaign
www.safekids.org
1301 Pennsylvania Ave., N. W.
Washington D.C. 20004-1707
202-662-0600
Resources continued...
Kids in Safety Seats
1-800-370-SEAT, call for information as well as for a car
seat safety check
Resources continued...
The Safe Concussion Outcome Recovery & Education Program
(SCORE)
At the Children’s National Medical Center
Washington DC202-884-2429
National Center on Secondary Education
and Transition
www.ncset.org
Resources
Specialized Health Needs Interagency Collaboration
(SHNIC)
Kennedy Krieger Institute
410-502-8419
Lash and Associates Publishing/Training
www.lapublishing.com
Information and ReferralBrain Injury in Children and Adults
Books, pamphlets and tip sheets on various aspects of brain injury can be purchased, the website also offers
many articles that can be downloaded for free
National Dissemination Center for Children with
Disabilities
www.nichcy.org/pubs/factshe/fs18txt.htm
Publications Available from Lash & Associates
•Pay Attention! Attention Training for Children Ages 4-10. 2nd edition, Jennifer Thomson and
Kimberly Kerns. Resource for professionals and families working with children following TBI, brain tumors, and ADHD•Getting A-Head of Concussion. Phil Hossler and Ron Savage. For school nurses, parents, pediatricians, and coaches. Discusses the signs of concussion and how to monitor at home and in the classroom
Recommended Reading
• I am the Central Park Jogger: A Story of Hope and Possibility by Trisha Meili, 2003
• Every Good Boy Does Fine: A Novel by Tim Laskowski, 2003
• Over My Head: A Doctor’s Own Story of Head Injury from the Inside Looking Out by Claudia Osborn, 2000
Recommended ViewingFilm released by Miramax in 2007
The LookoutStarring Joseph Gordon-Levitt, Jeff Daniels,
Matthew Goode and Isla Fisher
Aside from being a great bank heist movie, this movie realistically depicts the struggles of a
young man living with the aftermath of a traumatic brain injury he suffered as a high
school senior
Appropriate movie to share with teenagers, brings home the message of brain injury
prevention without preaching
Brain Injury Training
Available free of charge for human service professionals, agencies and advocacy groups in:•Frederick•Washington•Montgomery•Baltimore•Howard•Anne Arundel County• All counties on Maryland’s Eastern Shore•Contact Anastasia Edmonston 410-402-8478
A Product of the Maryland TBI Partnership Implementation Project, a collaborative effort between
the Maryland Mental Hygiene Administration, the Mental Health Management
Agency of Frederick County and the Howard County Mental Health Authority
2006-2009
Support is provided in part by project H21MC06759 from the Maternal and Child Health Bureau (title V,
Social Security Act), Health Resources and Services Administration, Department of Health and Human
Service Please Copy and Distribute Widely
