Transcript Communication following an Acquired Brain Injury

Communication following
an Acquired Brain Injury
Sarah Chatterton, Independent Speech & Language
Therapist
Helen Cullimore, Speech & Language Therapist, Bristol
Royal Hospital for Children
[email protected]
Service Development for Paediatric ABI.
 ‘it has been shown that paediatric Brain Injury often does not
resolve completely and difficulties can persist or emerge
which may have an impact upon education and social
integration later in life’ (RCSLT Resource Manual for
Commissioning and Planning Services for SLCN, 2010).
 So..a care pathway is needed to recognise this – challenging
amongst community caseloads.
 Consequences: eg. of young people in custody, 65-70% will
have experienced a traumatic brain injury (Justice Secretary
Mr Grayling)
Cases referred at BCH..
 Severe – Moderate TBI, mostly RTA, falls.
(Severe GCS 3-8, >6 hrs LOC, Moderate GCS 9-12, 20 mins to 6 hrs LOC, Mild
GCS 13-15, 0-20 mins LOC)
 Tumour – Mostly posterior fossa
 CVA – due to AVM / FMD
 Meningitis / septicaemia /encephalitis (ADEM,
NMDA Receptor) / cerebral abscess
 Epilepsy surgery
 Inhalation burns
 Spinal surgery / foramen magnum decompression.
 Hypoxic Ischemic brain injury
 Cases admitted for diagnostic work up – some
eventually diagnosed as ‘non-organic’ cause for
symptoms.
GCS = Glasgow Coma Score, LOC = Loss of consciousness.
Pathways of management..
 Swallow / communication assessment, regular review &
advice. Resume premorbid function. Discharged with
advice & contact no.
 Discharged from hospital with ongoing SLT needs. Local
inpatient / community facilities sought – rarely adequate
if existing.
 Remain at BCH for ‘neurorehabilitation’ while medical,
home & social, therapy & education set up for discharge.
 Children discussed at weekly MDM & Discharge Planning
Meetings held for long-term / complex cases.
What happens if a developing brain is
injured?
At what stage did injury occur?
Assessment..
 Case History – Including development, pre-existing strengths /
weaknesses / disorders. Educational level / involvement of other
services.
 Pre-operative assessment in tumour cases where possible.
 Post ABI progress / observations.
 PTA status & ? Communication impairment affecting results.
 MDM information.
Communication Assessment…
 Informal & selected subtests appropriate tool. All
developmental but ABI tools exist (Tadworth Court have
some). Age ‘norms’ rarely useful (multiple factors affect
performance, peaks & troughs of function, often bares little
relation to functional performance, can be unnecessarily
disheartening to child & family if ‘bad’ and set unrealistic
expectations and inadequate support if ‘good’.
 Assessments include..CELF-4, Preschool CELF, Mount Wilga,
PALPA, Preschool Language Scales-3, Test of Word Finding,
BPVS, Phonological Screening Assessment, FDA, WHIM,
SMART, Functional Assessment of verbal reasoning &
executive strategies.
 Communication aids service /my small store via charity
funds! (Communication Aids have joined to one service, in
Bristol, Paeds still at Claremont School, Adults moved to
Cribbs Causeway with wheelchair services from Frenchay
Hospital).
Type and extent of changes
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Site and severity of injury.
Previous abilities and personality.
Stage of development at time of injury.
Impact of injury on emotional, physical, sensory and cognitive
functions.
 Support network for the individual and their family to aid
rehabilitation and reintegration.
Range of Communication Changes & Case Studies..
 Speech production-acquired dyspraxia, dysarthria, dysphonia.
May be so severe that little / no speech is possible (or if
tracheostomy& unable to use speaking valve). Communication
aids / non-verbal strategies may be needed. (cases DE, RW, CT,
SS)
 Receptive and expressive language (Spoken & written)-aphasia,
slowed processing, higher level & social language disorder, close
link with cognitive & behavioural impairments. (case JS)
 Cerebellar Mutism / Posterior Fossa Syndrome, Post Traumatic
Mutism. (TS)
 Cognitive Communication Disorders-beyond language, such as
effects of mood change, impulsivity, altered self esteem,
emotional lability, stress. (cases CW, BT, SR)
More on Cognitive Communication Disorders
 “Those communicative disorders that result from deficits in linguistic and nonlinguistic cognitive processes”
- The American Speech and Language-Hearing Association, 1988.
Continued..
 Common, persistent difficulty following TBI due to structures prone to injury (ie.
Frontal lobes)
 Even subtle problems can have a massive effect on functioning.
 Not necessarily accompanied by ‘aphasic’ type features, therefore, people may
do misleadingly well do well on standard language assessments.
Cognitive processes may include..
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Impaired attention, perception, memory.
Inflexibility, impulsivity, disorganised thinking.
Slowed processing of complex information.
Problems learning new information.
Inefficient retrieval of stored information.
Ineffective problem solving or judgement.
Inappropriate social behaviour.
Impaired executive functioning.
How does this manifest?
 Inability to filter out distractions / attend to a task.
 Difficulty understanding and remembering spoken information.
 Difficulty understanding jokes, puns sarcasm, hints, metaphors.
 Rambling, imprecise language with poor sequencing and topic
maintenance.
 Repetitive or inappropriate conversation, and poor turn taking.
Swallow Assessment…
 Most Paediatric assessments not appropriate to acute ABI. Use
Frenchay Dysphagia Profile, observation and description to get
cranial nerve & functional profile (FOTT assessment tools sometimes
used).
 Videofluoroscopy infrequently needed but if so, done at Bristol
Children’s Hospital.
? Developmental stage…
 Pre-surgery swallow and speech assessments done where possible
particularly for posterior fossa tumours.
Inpatient Rehabilitation..
 Often via and with family, play team, school room staff, links with OT / PT.
 Communication – Computer based (REACT /Step by Step aphasia therapy,
speech viewer, ‘speech sounds on cue’ dyspraxia prog easy games, ziko
world, spot on games), strategies, card / board /object games / tasks.
 I Pads increasingly used – multiple uses.
 Swallowing – FOTT, chewy pouches & tubes, messy food play, texture,
taste, temp, feeding style / tools.
What happens in Rehabilitation?
gadgets
photos
drink
Joint
sessions
FUN !
noise
games
Mirror
Assessment
Tools
food
Take Aways…
 Self Advocacy DVD
“Personally I think that dvd was huge in his transition
back to school and helped show the professionals that
took over to understand Seb and what he finds
difficult.
We have found it useful to watch and measure
progress against, as it's incredible and sometimes
when you see small bits each day you forget how much
they equate too.
We also used the dvd to explain to a new autistic child
in his year Sebs story. He was quite mean at points
saying "he didn't care he had been in hospital " etc and
this just helped explain the seriousness of his accident
and injuries”.- Seb’s Mum
 Tip Card
 Reports
 Communication / ‘get out’ cards
 Ideas for therapy & strategies in school / at home.
Out patient rehabilitation
A continuation of inpatient rehabilitation...
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Intensive therapy
Blocks of therapy
Programme setting with review
Monitoring with advice
It may be needed for many years
with each stage of development
presenting new challenges
 It needs to be delivered across all
environments to ensure consistency
and generalisation of skill.
 Skills may need to be taught in each
environment individually.
Common features of the community ABI paediatric
caseload
 Spiky profile
 Variability in skills over time
 Comprehension very dependent on
levels of fatigue and attention
 Word finding difficulties
 Rigidity of concept formation
 Difficulty learning time concepts
 Difficulties with abstract language
 Conversation initiation
 Disinhibition when speaking
 Sensation changes within the mouth –
affecting eating and drinking and / or
saliva management
 Oro-motor control changes – affecting
eating and drinking and/ or speech
and /or saliva management
Conversation initiation
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iPad – calendar apps
Photo boards / visual displays
Photo key rings
Strategies – looking around the room /
at the person speaking to for ‘clues’
about what to say
Context dependent scripts
Question cards
‘Wh’ question words
Games in which need to ask questions:
Guess who, 20 questions, Headbanz
Role play
Scaffolding of conversation
Music
Adapted speaking circles
Sensory oro-motor skills
 Use of tactile tools to address
difficulties in sensation, oro-motor
weakness or difficulties in planning
the movements of the tongue, lips,
soft palate etc.
 Detailed assessment and specific
and finely graded programme is
developed.
 Programme needs to be delivered
on a daily basis approx 15-20 mins
per day
Useful References…
 Children With Traumatic Brain Injury – a parent’s guide. The special needs
collection. Ed. Lisa Schoenbrodt. Woodbine House 2001.
 Pediatric Traumatic Brain Injury, Proactive intervention. Jean L Blosser & Roberta
DePompei.Singular Publishing Group, Inc.1994
 Head Injury Rehabilitation, Children & Adolescents. Mark Ylvisaker. College Hill
Press 1985.
 Lash publications
 Head Injury, A Practical Guide. Trevor Powell. Winslow 1994.
 Living Skills for the Brain-Injured child and Adolescent. Julie M Buxton & Kelly B
Godfrey. The Speech Bin,inc. 1999.
 The Source for Pediatric Dysphagia. Nancy B Swigert. LinguiSystems 1998.
References continued…
 Acquired Neurological Speech/Language Disorders in Childhood. Bruce E
Murdoch. Taylor & Francis 1990.
 Feeding and Swallowing Disorders in infancy. Lynn Wolf & Robin Glass.
Therapy Skill Builders 1992.
 Eating and Drinking Difficulties in Children. A Guide for Practitioners. April
Winstock. Speech mark 2005.
 Communication, How Communication Changes over Time. ‘Tip Card’ leaflet.
Roberta DePompei & Jean Blosser. Lash & Associates Publishing/Training inc.
1998.