Transcript NEUROPSYCHOLOGICAL ASSESSMENT OF CHILDREN AND …

Traumatic Brain Injury in
Children and Adolescents
Katherine C. Nordal, Ph.D.
The Nordal Clinic
Vicksburg, MS 39183
[email protected]
Traumatic Brain Injury
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Injury to brain
External force
Total or partial disability or
psychosocial impairment
1 or more areas
Cognition, language,
memory, attention,
reasoning, abstract
thinking, judgment,
problem solving, sensor,
perceptual, or motor
abilities, psychosocial
behavior, physical
functions, information
processing, speech
TBI does NOT include
 strokes,
vascular accidents
 anoxic injuries, infections
 tumors, metabolic disorders
 exposure to toxic substances
Types of Brain Injuries
Open
brain injuries
Closed brain injuries
• 1. Diffuse
• 2. Focal
Severity of Brain Injury
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Mild: brief or no LOC,
nausea, signs of
concussion, GCS 1315, PTA < 1 hr, 50%75%
Moderate: coma < 6
hrs, skull fracture or
bleeding, GCS 9-12,
PTA 1-24 hrs
Severe: coma > 6 hrs,
PTA > 1 day, GCS 3-8
Glasgow Coma Scale (GCS)
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Eye Opening
• Spontaneous
• To speech
• To pain
• None
Best Motor Response
• Obeys command
• Localizes pain
• Withdraws from pain
• Abnormal flexion to pain
• Extension to pain
• None
Verbal Response
• Oriented conversation
• Confused conversation
• Inappropriate words
• Incomprehensible sounds
• None
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3
2
1
6
5
4
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2
1
5
4
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2
1
GCS Facts
8
is the critical score
 90% with scores less than or
equal to 8 are in a coma
 50% with scores less than or
equal to 8 at 6 hours will die
Post Traumatic Amnesia (PTA)
 Time
after coma when
person is still unable to form
new memories
 Measured by COAT or
GOAT
Rancho Los Amigos Scale
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Level I
Level II
Level III
Level IV
Level V
Level VI
Level VII
Level VIII
No Response
Generalized Response
Localized Response
Confused/Agitated
Confused/Inappropriate
Nonagitated
Confused Appropriate
Automatic, Appropriate
Purposeful, Appropriate
Epidemiology
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Who gets injured?
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TBI not randomly distributed
Predominately male
Lower SES
High family or life stress
Behavioral propensity toward risk taking
and high action levels
Epidemiology
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Who gets injured?
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3-8 year olds
15-29-year olds
Kid’s at greatest risk:
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HA/ emotionally disturbed/delinquent
Under 5, w/ prior adjustment problems, of
low SES, parents w/ problems
Risk Factors for TBI
 Prior
behavioral problems
 Family stress
 Family instability
 Crowded living conditions
 Prior TBI
Major Causes of Brain Injuries
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Infants: accidental dropping, physical
abuse, “shaken baby syndrome”
Toddlers and Preschoolers: falls, car
accidents, physical abuse
Elementary school children: car and bike
accidents, playground and recreational
accidents
Adolescents: car accidents, sports
injuries, assault
TBI: Some Statistics
 7,000
deaths of children
 >500,000 hospitalizations
 Hospital care costing over $1
billion
 30,000 children becoming
permanently disabled
TBI: Some Statistics
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The NHIF estimates that < 10% of all who survive
TBI receive adequate rehab to return them to selfsufficiency
TBI survivors requires between $4 and $9 M for a
lifetime of care
TBI accounts for about 16% of all pediatric
hospital admissions for children between the
ages of birth and 14
50% of battered children who survive a TBI suffer
permanent neurological, intellectual, and
psychological impairment
What Happens After
the Injury?
Physical
Cognitive
Psychosocial
Behavioral/Emotional
Physical Effects
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Reduced stamina and endurance
Regulation of physical functions
Motor deficits, ataxia
Seizures and/or headaches
Skeletal deformities
Hormonal and body temperature changes
Dysarthria
Cognitive Effects
 Short
and long term memory
problems
 Intellectual functions hindered
 Attention and concentration
diminished
 Language difficulties
 Academic functioning reduced
Psychosocial Effects
 Depression
and anxiety
 Social withdrawal
 Feelings of worthlessness
 Guilt
 Loss of interest in school and
family activities
Behavioral Effects
Acting socially inappropriate..loss of
friends
 Being unaware of one’s impact on
others...may seek younger peers
 Irritable
 Impulsive and/or aggressive
 More emotional
 Unmotivated
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Emotional Effects
 Poorer
tolerance, more rigid
 Greater dependence,
insensitivity
 Flat affect, oppositional, blaming
 More demanding
 More labile, immature coping
Factors Influencing Outcome
Type of injury
 Medical complications
 Severity of injury: carries most weight
re: prognosis for recovery
 Premorbid functioning
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Gender and SES do not affect outcome
Pre-injury psychiatric d/o predictive of later
problems w/ severe TBI
Factors Influencing Outcome
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General principles:
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Not just the injury the brain sustains, but
the brain that sustains the injury
Understand the individual who has the
accident, the context in which he/she lives,
and will continue to live
Multifactorial influences on outcome at time
make “dose and response” seem
hopelessly out of proportion
Factors Influencing Outcome
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Age @ injury:
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@ > 5 y.o., age unrelated to severity of
neurocognitive deficits or rate of recovery
@ < 5 y.o., more severe long-term
neurocognitive deficits
May be difficult to determine severity of
injury w/ absence of baseline data-comparison w/ siblings, parents
Factors Influencing Outcome
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Pre-existing disorders
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Injury may interact w/ prior learning
disability, low intellectual capacity,
psychiatric d/o etc.
Addition of even a minor insult to
premorbidly compromised individual may
produce an apparent disproportionate
increment in disability
Factors Influencing Outcome
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Neurological damage more severe than
initially realized
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Overlooked due to other systemic injuries
requiring emergency attention, surgery,
long convalescence, etc. which put few
cognitive demands on patient
But, multiple injuries can also produce PCS
symptoms with no neurologic substrate
Factors Influencing Outcome
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Co-existing habit patterns
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Alcohol and substance Abuse
Previous head injuries
Produce difficulties in life functioning and ,
in some cases, make individual more
susceptible to negative outcome
Factors Influencing Outcome
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Family competence
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Well-functioning vs. barely tolerable
situation which is poorly managed
Injured child may increase strain in already
marginally coping family--produce more
negative consequences than neurological
event itself
Factors Influencing Outcome
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Recovery Rates
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Dependent upon severity--milder injuries
have faster recovery
More rapidly a function returns, better the
prognosis for that function
Major portion of recovery within first year
Note: there are different fields of
thought about TBI recovery rates
Factors Influencing Outcome
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Summary
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Neurocognitive and psychiatric residuals
for kids with mild or even moderate injuries
seem less clear and when injuries at this
severity level do produce deficits, recovery
seems to occur over a short (several
months) period of time
Pediatric TBI research is in its infancy-good longitudinal studies are needed
Factors Influencing Outcome
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Management of case
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Appropriate management of mild to
moderate injuries usually results in
successful re-integration to school
Inappropriate attribution of pattern of
neurocognitive variability to brain injury
may generate self-fulfilling negative
expectations, misattributions, anxiety
Neuropsychological Assessment:
Conceptual Approach
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Presenting problem
• Significant others as informants
• Child’s presentation colored by limitations
in conceptual capacity and self-awareness
• Consistency and contradictions in reports
• Pervasiveness/duration of symptoms
identity etiologic factors
Neuropsychological Assessment:
Conceptual Approach
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Collection of background information
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Records of injury/hospitalization
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Neurodiagnostics
Length of coma
Approximate length of PTA
Current Medications
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Anticonvulsants can adversely affect test results if
blood levels are high
Neuropsychological Assessment:
Conceptual Approach
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Collection of background information
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Premorbid history
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Medical
– prior TBI
– History of seizures
– Birth records
Psychiatric history
Comprehensive developmental history
Family history--trends re: ADD, LD
School history--attendance, testing, sped, etc.
Neuropsychological Assessment:
Conceptual Approach
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Appraisal of presenting problems and
collection of background information
provides an estimate of premorbid
functioning, determination of current
factors which might influence the
assessment process, and hypothesis
development about pattern/severity of
expected neuropsychological deficits
Neuropsychological Assessment:
Conceptual Approach
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Neuropsychological Examination
• Selection of assessment procedures
determined by nature of referral question,
child’s age, child’s physical and mental
capacities, and psychologist’s own
preferences
• Measures a full range of abilities necessary
for success in youth’s environments
Neuropsychological Assessment:
Conceptual Approach
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Assessment Domains
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General Intelligence
Academic Achievement
Motor Skills
Sensory, Perceptual, Constructional
Language/Speech
Auditory Attention/Information Processing
Visual Attention/Information Processing
Neuropsychological Assessment:
Conceptual Approach
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Assessment Domains
• Executive Functions/Problem Solving
• Memory
• Personality/Behavioral/Adaptive Skills
Assessment Instruments
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Neuropsychological Test Batteries
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Halstead-Reitan Neuropsychological Test
Battery for Older Children, 9-14 yrs.
Reitan-Indiana Neuropsychological Test
Battery for Children, 5-8 yrs
Luria-Nebraska Neuropsychological Test
Battery for Children, 8-12 yrs
NEPSY
Assessment Domains
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General Intellectual Measures
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Purposes
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Overall IQ will be a benchmark for other
comparisons
Identify cognitive strengths/weaknesses
Formulate diagnostic decisions
Plan intervention strategies
Assessment Domains
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General Intellectual Measures
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IQ and brain injury
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Full Scale IQ is the most reliable and valid score
from a psychometric viewpoint
Verbal abilities recover more rapidly
With severe TBI, PIQ’s are lowered and deficits are
persistent at 5 years post-injury (slowed reaction
time, deficits in problem solving and novel tasks)
Coding, PC, BD distinguish the severely injured; no
differences with PA and OA
VIQ-PIQ patterns map recovery of function
Assessment Instruments
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General Intelligence
• Wechsler Preschool and Primary Scale of
Intelligence-Revised (WPPSI-III), ages 3-7
• Wechsler Intelligence Scale for Children,
Third Ed. (WISC-IV), ages 6-16 yrs
• Wechsler Adult Intelligence Scale, Third
Ed. (WAIS-III), ages 16+ yrs
Assessment Instruments
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General Intelligence
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Kaufman Assessment Battery for Children
(K-ABC), ages 2.5-12.5 yrs
Leiter International Performance Scale
McCarthy Scales of Children’s Abilities,
ages 2.5-8.5 yrs
Stanford-Binet Intelligence Scale, 4th Ed.,
ages 2-23 yrs
Assessment Instruments
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General Intelligence
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Woodcock-Johnson Psycho-Educational
Battery-Revised: Tests of Cognitive
Abilities, ages 3-80 yrs
Test of Non-Verbal Intelligence, 2nd Ed, 585 yrs
Columbia Mental Maturity Scale (CMMS),
3.5-9 yrs
Assessment Domains
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Academic Assessment
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Profile strengths/weaknesses
Measures must be comprehensive
Skill based deficits (lack of knowledge) vs.
performance based (execution of skills and
abilities that may be present) deficits
Assessment Domains
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Academic Assessment
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Academic Performance and Brain Injury
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Difficulty with new/novel material
Slowed information processing
Poor independent work efforts
Problems with higher order cognition: generalization,
abstraction, organization, planning, strategy
generation
Written language particularly susceptible--as an
emerging skill that is not well consolidated
Assessment Domains
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Academic Performance and TBI
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With moderate to severe injuries, reading, writing
and math affected and increased need for sped
Even with milder injuries, academic performance
can be affected
REMEMBER: Skills demonstrated on individual
assessment may not be commensurately
demonstrated in the classroom (performance based
deficit)--where rapid attention, organization, and
retrieval are required
Assessment Instruments
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Academic Achievement
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Kaufman Test of Educational Achievement,
6-18 yrs
Wechsler Individual Achievement Test
(WIAT-II), 5-adult
Woodcock Johnson Psycho-Educational
Battery: Tests of Achievement, 2-90 yrs
Wide Range Achievement Test (WRAT3),
5-Adult
Assessment Instruments
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Academic Achievement
• Key Math Diagnostic Arithmetic Test,
Grades 1-6
• Gray Oral Reading Test, 7-18 yrs
• Stanford Diagnostic Reading Test, Grades
1-12
• Peabody Individual Achievement Test
(PIAT-R), Kg-H.S.
Assessment Instruments
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Academic Achievement
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Nelson Denny Reading Test, Grades 9+
Test of Early Written Language, 3-10 yrs
Test of Written Language, 7.6-17 years
Test of Written Expression, 6.5-14 years
Assessment Domains
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Motor & Sensory Functions
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Difficulties usually resolve within 6 months;
mildly injured match controls at 6 mos
With severe TBI, simple and complex
motor speed deficits @ 1- & 2-yr. f/u
With younger kids see problems with:
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fine motor coordination/tremors
rapid alternating movements
visual-motor integration
Assessment Domains
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Motor and Sensory Functions
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Extracurricular motor movements after 10
y.o. indicate dysfunction with motor
inhibitory system
Sensory errors--for lateral comparisons
Rule out peripheral injuries, difficulty with
focused attention
Assessment Instruments
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Sensory, Perceptual, Constructional
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Bender Visual Motor Gestalt Test, 4+ yrs
Benton Visual Retention Test, 8+ yrs
Halstead Reitan subtests, 5+ yrs
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Sensory imperception
Tactile finger recognition
Fingertip number writing
Tactile form recognition
Assessment Instruments
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Sensory, Perceptual, Constructional
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Tactual Performance Test (TPT), 5+ yrs
Perceptual-Motor Assessment for Children,
4-16 yrs
Developmental Test of Visual-Motor
Integration (Beery VMI), 3-18 yrs
Judgment of Line Orientation, 7+ yrs
Test of Visual-Perceptual Skills, 4-12 yrs
Assessment Instruments
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Motor Skills
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Bruininks-Osteresky Test of Motor
Proficiency, 4.5-14.5, w/ disabilities
Developmental Test of Visual-Motor
Integration (Beery VMI), 3-18 yrs
Grooved Pegboard and Purdue Pegboard
Wide Range Assessment of Visual-Motor
Abilities. 3-17 yrs
Assessment Domains
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Attention
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Levels of Attention: Arousal; Vigilance,
attention span; Perseverance;
Distractibility; Inhibitory processes
Attention is: Simple alertness & attention
span; Sustained attention or vigilance;
Divided attention
Direct measures & qualitative observation
Assessment Domains
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Attention
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Common problem with TBI
W/ severe injury, in young children: HA and
poor attention span up to 5 yrs. post-injury
Deficits in concentration & speeded
performance @ 1yr for all severity levels
(studies do not universally support this)
Assessment Instruments
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Auditory Attention/Information Processing
Speed
Auditory Continuous Performance Test (ACPT), 611 yrs
• Conner’s CPT, 4+ yrs**
• Goldman-Fristoe-Woodcock Selective Attention
Test
• Gordon Diagnostic System, 4+ yrs**
• Test of Variable Attention (TOVA)**
**denotes need for computer or special testing
equipment
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Assessment Instruments
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Visual Attention/Information Processing
• Wechsler Scales: Digit-Symbol Coding;
Symbol Search; Cancellation Test; Picture
Completion; Picture Arrangement
• Trail Making Test, Part A
• Ruff 2 & 7 Selective Attention Test
• Symbol Digit Modality Test, 8+yrs
• Nelson Denny Reading Test, Reading Rate
Assessment Domains
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Language/Speech
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Deficits increase w/ TBI severity
Expressive abilities more susceptible than
receptive:
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Description of object functions
Repeating words, sentences
Word fluency
Writing to dictation
Copying sentences
Object naming
Assessment Domains
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Language/Speech
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Global deficits (mutisms, aphasias) with
severe injuries, under 5 y.o., do improve
with recovery
Speculated that type of deficit is related to
language skills in primary ascendancy at
time of injury
Comprehensive Evaluation from Speech &
Language Pathologist
Assessment Instruments
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Language
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Aphasia Screening Test of HRB, 5+ yrs
Boston Naming Test, 6+ yrs
Clinical Evaluation of Language Functions
(CELF), Kg-H.S.
Controlled Oral Word Association, 6+ yrs
Illinois Test of Psycholinguistic Abilities
(ITPA), 2yrs,4mos-10yrs,3mos
Assessment Instruments
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Language
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Peabody Picture Vocabulary Test (PPVT-R), 2.5+
yrs
Test of Language Development (TOLD-2), 4-12
yrs
Utah Test of Language Development, 3-9 yrs
WIAT-II Oral Expression, Listening
Comprehension subtests, Kg-Adult
WISC-IV Verbal Comprehension Index,6+ yrs
Assessment Domains
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Memory
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Assess: Immediate and delayed recall of
story passages; visual recall; spatial
memory; verbal retrieval of newly learned
material; recognition memory
Mildly to moderately impaired TBIs usually
recover in 6-12 months
Severely impaired show deficits @ 12 mos
Assessment Domains
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Memory
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Adolescents show a stronger recovery of
verbal memory deficits
Young children are very unstable in their
performance from one memory test to
another--may be a result of their failure to
employ useful learning strategies
Assessment Instruments
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Memory
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Wide Range Assessment of Memory and
Learning (WRAML), 5-17 yrs
Children’s Memory Scale (CMS), 5-16 yrs
Wechsler Memory Scale-III (WMS-III), 16+
Children’s Auditory Verbal Learning Test
(CAVLT-2), 8+ URS
Test of Memory and Learning, 5-19 YRS
Assessment Instruments
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Memory
• California Verbal Learning Test-Children’s
Version (CVLT-C), 5-16 yrs
• Memory/Localization Scores from TPT
• Benton Visual Retention Test, 8+ yrs
• Rivermead Behavioral Memory Test, 5+yrs
Assessment Domains
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Executive Functions require:
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integration of motor, perceptual, attention,
memory, and learning skills.
child to manage multiple simultaneous
demands, often w/ speed & accuracy
requirements, engaging multiple input &
output modalities, and incorporating
feedback
Assessment Domains
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Executive Functions (Self-management)
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Frontal lobes particularly susceptible to
injury
Much of frontal areas do mature during
childhood
Frontal Lobe Syndrome: alertness;
appetite; sleep; irritability; distractibility;
impulsivity; social problems; attention
difficulties; academic production
deficits;poor planning
Assessment Instruments
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Executive Functions/Problem Solving
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Children’s Category Test, 5-16 yrs
Porteus Mazes, 3-12 yrs
Raven’s Progressive Matrices, 5-17 yrs
Wisconsin Card Sorting Test (WCST), 6.5+
Delis-Kaplan Executive Function System
(D-KEFS) subtests
Trail Making Test, Part B
Assessment Domains
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Psychosocial Functioning
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W/ mild injuries: no increased risk for
psychiatric disturbance although may have
early change in temperament and other
transient behavioral symptoms
W/ severe injuries (i.e., PTA> 7 days): >2X
rate of psychiatric d/o @ 4mos. & f/u
regardless of sex, age, or social class
Assessment Domains
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Psychosocial Functioning
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Types of behavioral disorders mimic
general population except for grossly
disinhibited social behavior w/ very severe
injuries
Pre-existing behavioral d/o and adverse
psychosocial histories are additive rather
than interactive
Assessment Domains
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Psychosocial Adjustment
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Poor social adjustment with severe injuries:
studies range from 25% @ 1 year to >50%
at 3- and 5-yr follow-up
Significant declines in adaptive behavior
seen @ 1 yr post-injury
Severely injured children carry w/ them
substantial and continuing risk factors
Assessment Domains
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Psychosocial adjustment
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Denial of personal awareness of deficits
may result in more dangerous and risktaking behaviors
Disinhibition, impulsivity,aggressiveness,
and irritability may make maintaining old
relationships and establishing new
relationships difficult
Assessment Instruments
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Personality/Behavioral Measures
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Brown Attention Deficit Disorder Scales,
12+ yrs
Attention Deficit Disorders Evaluation
Scales (ADDES)
Conner’s Rating Scale, 3-17 yrs
Achenbach CBC/TRF, 2+ yrs
Devereux Scales: Parent (DSMD, 5+) and
School (DBRS, 5+)
Assessment Instruments
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Personality/Behavioral Measures
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Minnesota Personality InventoryAdolescent
Millon Adolescent Clinical Inventory (MACI)
Adolescent Psychopathology Scale (APS)
High School Personality Questionnaire
(HSPQ), Children’s Personality
Questionnaire (CPQ), Early School
Personality Questionnaire (ESPQ)
Assessment Instruments
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Personality/Behavioral Measures
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Manifest Anxiety Scale for Children
Children’s Depression Inventory
Reynolds Children’s Depression Scale
Reynolds Adolescent Depression Scale
Beck Depression Inventory, 13+
Assessment Instruments
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Personality/Behavioral Measures
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Children’s Personality Questionnaire
(CPQ)
Behavior Rating Profile, 6.5-18.5 yrs
Personality Inventory for Children (PIC)
Trauma Symptom Checklist for Children
(TSCC), 8-16 yrs
Adaptive Behavior Rating Scales, if
needed
TBI Evaluation Schedule
Do SERIAL evaluations
 Initial evaluation within 6 months
 Follow-up @ 1-yr intervals w/ mild to
moderate TBI
 Follow-up @ 6-month intervals w/
severe TBI
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