Transcript Pediatric Brain Injury

Pediatric Brain Injury
•
•
Emotional Effects on Children and Youth
Strategies for Support
Deborah Ettel, PhD
[email protected]
Center on Brain Injury Research & Training
Overview
Incidence/Prevalence of Pediatric BI
 In the News
 Trauma

 Physiological sequelae
 Psychological sequelae

Trauma + brain injury: children, adolescents
 Cognitive, Behavioral, Emotional changes
 Risk Factors
• Strategies for Support
TBI: This is a low incidence
disability – why focus on it?
INCIDENCE AND
PREVALENCE
Brain injuries are not low incidence
BIAA
NATIONWIDE

1.4 -1.7 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
emergency departments following brain injury

Annual Incidence of TBI with disability
AN ESTIMATED 124,000 American civilians
NATIONWIDE- Annual BI
Incidence: 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)
Under-identification of children with
TBI
200,000
153,140
150,000
100,000
62,000
50,000
11,780
23,805
0
Children
hospitalized
for TBI/yr
19% need support for longerterm disability
Need spec
educ
support/yr
Cumulative
total K-12
need
support/yr
Total on Fed
Spec Ed
census 2007
“Reframed, the numbers nauseate. In America
alone, so many people become permanently
disabled from a brain injury that each decade they
could fill a city the size of Detroit……...
….Seven of these cities are filled already. A third of
their citizens are under fourteen years of age.”
From Head Cases, Stories of Brain Injury and its
Aftermath
Michael Paul Mason
2008 published by Farrar, Straus and Giroux
In the News: Risk for psychological problems
after brain injury
History of multiple concussions/ Chronic
traumatic encephalopathy(CTE)

Disease of the brain believed to be caused by repeated
head trauma resulting in large accumulations of tau
proteins, killing cells in regions responsible for mood,
emotions, & executive functioning.

Terry Long, NFL player, committed suicide June 7, 2005
by drinking anti-freeze after struggle with severe
depression.
Andre Waters, NFL player, committed suicide November
20, 2006 by gunshot wound after suffering from
depression.
Chris Benoit, Professional wrestler, committed suicide
after murdering his wife and child.
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Junior Seau committed suicide with a gun shot wound to the
chest in 2012 at the age of 43. National Institutes of Health (NIH)
concluded that Seau suffered from chronic traumatic
encephalopathy (CTE)
In the News:
Risk for psychological
problems after brain
injury? Domestic
violence, child abuse
Mindy McCready
Sarah Jane Brain Foundation, Patrick Donohue
Father, Founder
Public expectation of educators?
Know something about
working with children ,
families with brain injury
The First Word in Traumatic Brain
Injury
TRAUMA
Trauma: Physiological sequelae

“Traumatic injury is a disease process
unto itself. Biochemical changes occur
throughout the body in response to the
traumatic injuries, including in organs
distant from, and seemingly unconnected
to, the site of injury,”
Steven E. Ross, MD, Director of the Level I Trauma Center at Cooper
University Hospital.
Emotional psychological sequelae of trauma

“Traumatic events are extraordinary, not because they
occur rarely, but rather because they overwhelm the
ordinary human adaptations to life.” — Judith
Herman, Trauma and Recovery

“…That's what trauma does. It interrupts
the plot. You can't process it because it
doesn't fit with what came before or what
comes afterward. …In most of our lives,
most of the time, you have a sense of what is
to come. There is a steady narrative, a feeling
of "lights, camera, action" when big events
are imminent. But trauma isn't like that. It
just happens, and then life goes on. No one
prepares you for it.”
― Jessica Stern, Denial: A Memoir of Terror
Emotionally traumatizing events – 3 common
elements
It was unexpected
Sudden, painful, potentially
life-threatening events
The person was
unprepared
There was nothing the
person could do to
prevent it from
happening.
Acute phase: What happens when people
experience trauma?
Shock and denial
• Normal protective reactions.
• Shock : a sudden, often intense disturbance of your
emotional state, leaves you feeling stunned or dazed.
• Denial: not acknowledging that something very
stressful has happened, or not experiencing fully the
intensity of the event. You may feel numb or disconnected
from life.
Amer Psychological Assoc
How we respond to trauma
American Psychological Association
Feelings : intense and
unpredictable
- more irritable than usual
Changes in thoughts & behavior patterns
-
Repeated and vivid memories of the
event
Flashbacks may occur for no
apparent reason
Recurring emotional
reactions
- Anxiety on anniversaries of the event
Interpersonal
relationships –
strained
Physical symptoms
- More conflict, frustration,
misunderstandings
- May have headaches,
stomachaches, body pain
Traumatic stress responses
Re-experiencing
“It pops into my mind.”
“Feels like it’s happening again.”
“I get upset when something reminds me of
it.”
Avoidance
“I block it out - try not to think about it.”
“I try to stay away from things that remind me
of it.”
Traumatic stress responses
Increased arousal/hypervigilance
“I am always afraid something bad will happen.”
“I jump at any loud noise.”
“I can’t concentrate, can’t sleep.”
Dissociation
“It felt unreal -- like I was dreaming.”
“I can’t even remember parts of it.”
Survivor [family, friends]
Complicated grief: numbness, detachment from
others, difficulty in accepting lost of skills, abilities,
memory surrounding event (Worden, 2009)
 Ambiguous loss: psychological loss of parts of previous
life, function, memory, participation (Boss, 2006); “a loved
one is physically present but psychologically absent “ Boss,
2004)
 Persistent ambiguity causes: confusion,
immobilization, exhaustion, continual state of heightened
awareness, fight-flight preparedness

Secondary trauma: emergency, medical events and
procedures: Why do medical events potentially lead to
traumatic stress?
• Challenge beliefs : the world is a safe
place; reminders of one’s own (and
child’s) vulnerability.
• Can be a realistic (or subjective) sense
of life threat.
• High-tech, intense medical treatment
may be frightening, & child or parent may
feel helpless.
• Uncertainty about course and
outcome.
• Pain or observed pain often involved.
• Exposure to injury or death of others
can occur.
Traumatic stress disorders after pediatric injury
Most children (and parents) do well psychologically after an
injury … some develop PTSD symptoms that persist for
many years
Almost 1 in 5 injured children and parents developed PTSD
symptoms that lasted more than four mo. and caused
impairment in their daily lives.
ASD symptoms: children 22%, PTSD symptoms :
children 17%
Winston, Kassam-Adams, et al. (2003). Screening for risk of
persistent posttraumatic stress in injured children and their
parents. JAMA 290: 643-649. months and cause distress.
Kids comments on trauma
“I thought I was going to die. Thought I must really
be hurt. I was so scared because my mom was not
there.”
“Doctors crowded around & stuck stuff on me & cut
my clothes off -- I didn’t know what was
happening.”
“In the hospital, in the middle of the night
they started pumping bright red stuff into
me. They were wearing protective
clothing -- that was pretty horrifying.
Then I got sick a couple of hours after and I
urinated bright red. There’s nothing
normal about that.”

“It all happened so quickly. I was ‘out
of it’ and in pain. The ride in the
ambulance was awful. I was given the
first treatment without being told
what was going on – that upset me
for a long time after that.”
Re-living traumatic stress
“Even now some things bring it all back.
Some smells, like being at the hospital, the
smell of metal pipes; seeing other people
that are sick. I only need one thing to
happen and then the day's practically
useless.”
Trauma + Brain Injury
SPECIFIC SEQUELAE
OF TRAUMATIC BRAIN
INJURY IN CHILDREN
BRAIN INJURY: Physical, physiological
processes

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Brain tissue reacts to trauma -> with biochemical, physiological
responses.
Substances within the cells , flood the brain causing more damage,
destroy more brain cells = secondary cell death.
In severe injuries, may have loss of consciousness (LOC): a few minutes,
hours, several weeks ,or even months. Lengthy LOC = coma.
Negative changes in respiration and motor functions.
Neurons do not mend - new nerves do not grow in ways that lead to
full recovery. Some areas of brain remain damaged, and the functions
controlled by those areas may become challenges for person
Simplified summary of traumatic brain injury (TBI)-associated cellular injury
cascades. Events are triggered at time of injury –
full process continues over hours to weeks after injury.
Brain regions vulnerable to damage in a typical traumatic brain injury (TBI); (B)
Relationship of vulnerable brain regions to common neurobehavioral sequelae
associated with TBI. Bigler E. Structural imaging In: Silver J, McAllister T,Yudofsky S, eds. Textbook of Traumatic
Brain Injury. Washington DC: American Psychiatric Press; 2005:87
Complex interdependencies, processes influence functional
outcomes
Compared post-injury psychiatric disorders children
with TBI and OI:
Novel psychiatric disorder occurred significantly
more frequently in the TBI (32/65; 49%)
than the OI (7/53; 13%) group.
Not accounted for by:
pre-injury lifetime psychiatric status
pre-injury adaptive functioning
pre-injury family adversity
family psychiatric history
socioeconomic status
injury severity, or
age at injury.
Max,Wilde, Bigler, MacLeod,Vasquez, Schmidt, Chapman, Hotz,Yang, Levin, Psychiatric
Disorders After Pediatric Traumatic Brain Injury: A Prospective, Longitudinal, Controlled Study .
The Journal of Neuropsychiatry and Clinical Neurosciences 2012;24:427-436.
10.1176/appi.neuropsych.12060149
Preschool vulnerable time for MTBI
At age 14 to 16 years, children hospitalized for MTBI during preschool
years were significantly more likely to show symptoms of:
Attention deficit/hyperactivity disorder (odds ratio = 4.2),
 Conduct disorder/oppositional defiant disorder (OR=
6.2),
 Substance abuse (OR= 3.6)
 Mood disorder (OR= 3.1) but not anxiety disorder.
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Preschool MTBI associated with persistent negative effects on
psychosocial development. Preschool years vulnerability
period following MTBI.
McKinlay, Audrey PhD; Grace, Randolph PhD; Horwood, John MSc; Fergusson, David PhD; MacFarlane,
Martin FRANZCR Adolescent Psychiatric Symptoms Following Preschool Childhood Mild Traumatic Brain
Injury: Evidence From a Birth Cohort
Social dysfunction after brain injury
WHY?
 Social skills not localized, mediated by an integrated neural network.
 Neural networks susceptible to disruption with TBI.
 Early development, a brain injury can disrupt this neural network while
it is in the process of being established, resulting in social dysfunction.
RISK FACTORS for SOCIAL DIFFICULTIES:
 Younger age at insult
 pathology to frontal regions and the corpus callosum
 social disadvantage
 family dysfunction
Social Function in Children and Adolescents after Traumatic Brain Injury: A Systematic Review 1989–
2011 Rosema, Crowe, Anderson. Journal of Neurotrauma. May 1, 2012, 29(7): 1277-1291. doi:10.1089/neu.2011.2144.
Possible Changes-Personality
and Behavioral ...MD TBI Project
Depression
Emotional
control
problems
Social skills
problems
Sadness, hopelessness, loss of enjoyment,
withdrawal, isolation,
Mood swings, lability
Emotion may not match occasion (laughing at
something sad)
Emotions not always tied to events, triggers,
seem random
Inappropriate behavior
Inability to inhibit remarks
Inability to recognize social cues, facial
expressions
Possible Changes: Personality and
Behavior MD TBI Project
Problems with initiation
Reduced self-esteem
Difficulty relating to others
Difficulty maintaining relationships
Difficulty forming new relationships
Stress/anxiety/frustration and reduced frustration
tolerance
Top three recommendations for anyone
working with a child or family with brain
injury:
LISTEN.
LISTEN.
LISTEN.
You will not be heard until the
family knows they have been heard.
 Your first meeting should be 5 to 1
ratio of listening to talking.
 Time spent building a trusting
relationship early will save time,
increase progress & efficiency later
 Making up the spelling test is not
the most important thing on the
parent’s agenda

Acute phase
Trauma interferes with attention,
comprehension, memory, cognition,
executive function: organizing, planning
 Parents often say medical personnel
didn’t tell them anything – they likely did
- but don’t remember it

Parents key resources for child’s
emotional recovery after injury
GOOD TO KNOW:
 Parent and child reactions to injury
connected -- severity of ASD or PTSD
symptoms is correlated between child
and parent.
 Hard for parents to assess child’s
psychological responses to injury
 May under- or over-estimate child’s
distress compared to their child’s own
report of symptoms.
Strategies for Support
Acute phase
 Post-acute phase

Complex influences on child recovery
•Harvey S. Levin, PhD , Gerri Hanten, PhD. Department of Physical Medicine and Rehabilitation, Baylor College
of Medicine, Houston, Texas
9 things NOT to say to a person with a
brain injury
1. You seem fine to me.
2. Maybe you’re just not trying hard enough
(you’re lazy).
3. You’re such a grump!
4. How many times do I have to tell you?
5. Do you have any idea how much I do for you?
6. Your problem is all the medications you take.
7. Let me do that for you.
8. Try to think positively.
9. You’re lucky to be alive.
Marie Rowland, PhD, EmpowermentAlly
BrainLine
APA trauma guidelines : Acute phase
Immediately after trauma: Match care to child needs and phase of
recovery
Attend first to basic needs: safety, shelter, reuniting family
Assess initial responses and arrange to follow up over time
Help parents to:
– accurately assess child’s symptoms and needs
– help child manage psychological symptoms and pain
– promote positive social interactions for child
– manage their own reactions
Support parent, family, and community efforts to:
◦ provide safe, developmentally appropriate, culturally responsive recovery
environment
◦ reduce ongoing exposure to stressors/secondary traumas
◦ reestablish normal roles and routines
◦ activate support among kinship networks and spiritual and community
systems
APA guidelines for tx children youth after
traumatic event(s): Post-acute phase
Any time after trauma
Allow children to express feelings if they want to
Help parents and other key adults to be aware of and manage their own
reactions, listen to and understand the child's reactions
Assess risk factors for persistent adverse reactions
Assess needs that may warrant intervention, such as severe or persistent
distress, numbing, or impairment , reduced capacity of family/community to
support child, self-destructive or violent behaviors
APA trauma response guidelines
Be Aware of Potential Pitfalls
Assuming that all children will respond to trauma in the same way
Pathologizing early distress or reactions
Conveying the message that trauma exposure inevitably results in
long-term psychological damage
Assuming that all trauma-exposed children will have long-term
damage or need treatment
Creating situations in which trauma-exposed children have little
choice or control
Forcing children or parents to tell their story (but remember to
listen carefully when they do)
Ignoring your own stress from trauma-focused clinical work
POST-INJURY
What types of emotional, behavioral,
psychiatric symptoms, or disorders?
Anxiety: Some causes and strategies for
reducing
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Caused by difficulty reasoning, concentrating when probsolving, feeling overwhelmed
Too many demands, time pressure,
Harder in situations with high demand for attention &
processing – crowded environments, heavy traffic, lots of
noise
TO REDUCE:
• Reduce environmental demands,
unnecessary stress,
• Modify schedule, early dismissal from class,
more time between classes, peers helper
• Reassurance, structured activities,
counseling, systematic desensitization, peer
helper
Acute Stress Symptoms or Disorder
Post-Traumatic Stress Disorder
• Frequent monitoring by supportive staff member
• Regular check-in plan with family
• All staff involved with student , knowledge of potential signs,
symptoms of PTSD
• Action plan for acute symptoms, nurse, counselor, family
• Modifications allow for “breaks” from class
Depression
WHAT?
 Feeling sad, worthless, sleep or appetite disruption (too much,
too little), loss of interest and pleasure , difficulty
concentrating, thoughts of death, suicide
 Struggles with adjustment to temporary or lasting disability,
 Biochemical and physical changes in brain from injury
TO DO:
 Set up check-in w/supportive staff member as needed
 Discuss psych evaluation with family, pediatrician, psychiatrist,
counselor
 Family support, counseling, cog behavior therapy, behavioral
activation, create opportunities for positive social interaction
 Frequent monitoring signs of self-harm, aggression, suicidal
ideation
Temper outbursts and irritability
“Short fuse,” “Flying off the handle” easily, being irritable or having a quick
temper.
Children and adolescents with TBI may frequently be irritable.
May yell, use bad language, throw objects, slam fists into things, slam doors, or
threaten or hurt family members or others.
What may cause temper outbursts and irritability?
Injury to parts of brain controlling emotional expression
Frustration, dissatisfaction with changes in life from injury ;
loss of skills, friends, independence.
Feeling isolated, depressed, misunderstood
Difficulty concentrating, remembering, expressing oneself
or following conversations may cause frustration
Tiring easily
Pain.
Hart & Ciccerone 2002
What can be done about
temper problems?
Reduce stress, decrease irritating situations, remove some of the
triggers for irritability
Set up the child for success
Teach basic anger management skills: self –calming strategies,
mindfulness stress reduction, relaxation, deep breathing cues, better
communication methods, instructional sequence for high ratio success
(mastery learning, direct instruction)
After outburst, when calm, discuss possible triggers, problem solve
alternate acceptable responses – set stage for success, ” What else
could you do if this happens? Then, model, practice, & support
appropriate routines for problem-solving “ What are 2 things you could
do if you need help? Ex: raise hand, take a break, ask a peer
Work with a psychologist, mental health professional familiar with TBI
issues, including medications
Changing your own and others’ reactions to
temper outbursts
Don’t take it personally – it really isn’t about you. What looks like
willfulness, challenging your authority may be due to brain injury: difficulty
initiating, attention control or memory problems, inappropriate social skill
Learn and use de-escalating strategies, firm and calm
communication/rules about acceptable behavior, non-confrontational
attitude; neutral body language, non-punitive, don’t box child in a corner
during crisis, allow face-saving
Use good behavior management strategies for unacceptable behavior
(keep self and others safe, tell child specifically what is unacceptable,
provide child choices, don’t argue or engage, speak in a calm voice, don’t
give in to demands etc.)
INTERVENTION for emotional sequelae
from pediatric TBI?
Limited high quality, experimental research on
intervention efficacy and effectiveness for emotional
sequelae of pediatric TBI
Evidence-based intervention
Better tx outcomes:
1. Cognitive behavioral therapy
2. Family-based therapy, family involvement,
parent coaching, intensive therapy
3. Psycho-pharmacology - medications
Wade and Yeates
Example: Shari Wade, Keith Yeates interventions
Online Family Problem Solving – RCT, intensive
therapy support, parent coaching, video, 14 direct
intervention sessions, Improvement in internalizing
difficulties . Most benefit to children of lower SES,
and those age > 11 yrs.
Wade SL, Oberjohn K, Burkhardt A, Greenberg I. J Head Trauma Rehabil
2009; 24: 239–47.
Trauma-Focused Cognitive Behavior Therapy
[Evidence-based]
TF-CBT:
• works for children who have experienced any trauma, including
multiple traumas.
• is effective with children from diverse backgrounds.
• works in as few as 12 tx sessions.
• has been used successfully in clinics, schools, homes, residential
treatment facilities, and inpatient settings.
• works even if there is no parent or caregiver to participate in tx
• works for children in foster care.
• has been used effectively in a variety of languages and countries
2 goals you can help children and
adolescents achieve
Resilience

Ability to experience disruptive event, life-threatening and
continue to maintain relatively stable life, with flexibility
Self-determination
• Taking charge of one’s own life to the extent possible,
setting personal goals for recovery, independence, future
Suggested readings: Reviews and Summaries
Horowitz L, Kassam-Adams N, & Bergstein J. (2001). Mental health aspects of emergency medical
services for children: Summary of a consensus conference. Journal of Pediatric Psychology, 26: 491502.
Kassam-Adams N & Fein J. (2003). Posttraumatic stress disorder and injury. Clinical Pediatric Emergency
Medicine, 4: 148-155.
Saxe, G, Vanderbilt, B, Zuckerman, B. (2003). Traumatic stress in injured and ill children. PTSD Research
Quarterly, 14 (2): 1-7. Available at www.ncptsd.org/publications/rq/rq_list.html
Translational research Neurobiological consequences of traumatic brain injury Thomas W. McAllister, MD
Dialogues Clin Neurosci. 2011;13:287-300.
Adolescent Psychiatric Symptoms Following Preschool Childhood Mild Traumatic Brain Injury: Evidence
From a Birth Cohort McKinlay, Audrey PhD; Grace, Randolph PhD; Horwood, John MSc; Fergusson,
David PhD; MacFarlane, Martin FRANZCR Section Editor(s): Caplan, Bruce PhD, ABPP
Zatzick, Df, & Grossman, DC, Association between traumatic injury and psychiatric disorders and
medication prescription to youths aged 10-19, Psychiatry Service, 2011, 62(3): 264-271
Jonathon Silver MD Psychiatric News | December 07, 2012 Volume 47 Number 23 page 26-28
American Psychiatric Association
Kimberley A. Ross1, Tom McMillan1, Tom Kelly2, Ruth Sumpter1, Liam Dorris1,3*Friendship, loneliness and
psychosocial functioning in children with traumatic brain injury, Brain Injury, 2011, Vol. 25, No. 12 ,
Pages 1206-1211 (doi:10.3109/02699052.2011.609519)
Yvette Alway , Adam McKay , Jennie Ponsford & Michael Schönberger (2012): Expressed emotion and its
relationship to anxiety and depression after traumatic brain injury, Neuropsychological Rehabilitation:
An International Journal, 22:3, 374-390
RossKA . Dorris, L McMillan, T 2011, A systematic review of psychological interventions to alleviate
cognitive and psychosocial problems in children with acquired brain injury Developmental Medicine &
Child Neurology a 2011
C. Konrad, A. J. Geburek, F. Rist, H. Blumenroth, B. Fischer, I. Husstedt, V. Arolt, H. Schiffbauer and H.
Lohmann (2011). Longterm cognitive and emotional consequences of mild traumatic brain injury.
Psychological Medicine, 41, pp 11971211 doi:10.1017/S0033291710001728
Resources continued
Dikmen SS, Bombardier CH, Machamer JE, Fann JR, Temkin NR (2004). Natural history of depression in
traumatic brain injury. Archives of Physical Medicine and Rehabilitation 85, 1457–1464.
Koponen S, Taiminen T, Portin R, Himanen L, Isoniemi H, Heinonen H, Hinkka S, Tenovuo O (2002). Axis I and II
psychiatric disorders after traumatic brain injury : a 30-year follow-up study. American Journal of Psychiatry
159, 1315–1321.
Temkin NR, Corrigan JD, Dikmen SS, Machamer J (2009). Social functioning after traumatic brain injury. Journal
of Head Trauma Rehabilitation 24, 460–467.
Vanderploeg RD, Curtiss G, Luis CA, Salazar AM (2007). Long-term morbidities following self-reported mild
traumatic brain injury. Journal of Clinical and Experimental Neuropsychology 29, 585–598.
The Psychiatric Sequelae of Traumatic Injury Richard A. Bryant, Ph.D.; Meaghan L. O'Donnell, Ph.D.; Mark
Creamer, Ph.D.; Alexander C. McFarlane, M.D.; C. Richard Clark, Ph.D.; Derrick Silove, M.D. Am J
Psychiatry 2010;167:312-320.
Spina, S., Ziviani, J., & Nixon, J. (2005). Children, brain injury, and the resiliency model of family adaption. Brain
Impairment, 6, 33-44.
Medical Events & Traumatic Stress in Children and Families. Center for Pediatric Traumatic Stress
Winston, Kassam-Adams, et al. (2003). Screening for risk of persistent posttraumatic stress in injured children and
their parents. JAMA 290: 643-649.
Center for Pediatric Traumatic Stress The Children’s Hospital of Philadelphia Room 1492, 3535 Market34th Street
and Civic Center Boulevard Philadelphia, PA 19104
www.cbirt.org