Traumatic Brain Injury in Children and Adolescents Katherine C. Nordal, Ph.D. The Nordal Clinic Vicksburg, MS 39183 [email protected].

TraumaticTraumatic Brain Injury in Brain Injury in Children and AdolescentsChildren and Adolescents

Katherine C. Nordal, Ph.D.Katherine C. Nordal, Ph.D.

The Nordal ClinicThe Nordal Clinic

Vicksburg, MS 39183Vicksburg, MS 39183

[email protected]@vicksburg.com

Traumatic Brain InjuryTraumatic Brain Injury Injury to brainInjury to brain External forceExternal force Total or partial disability or Total or partial disability or

psychosocial impairmentpsychosocial impairment 1 or more areas1 or more areas Cognition, language, Cognition, language,

memory, attention, memory, attention, reasoning, abstract reasoning, abstract thinking, judgment, problem thinking, judgment, problem solving, sensor, perceptual, solving, sensor, perceptual, or motor abilities, or motor abilities, psychosocial behavior, psychosocial behavior, physical functions, physical functions, information processing, information processing, speechspeech

TBI does TBI does NOTNOT include include

strokes, vascular accidentsstrokes, vascular accidents anoxic injuries, infectionsanoxic injuries, infections tumors, metabolic disorderstumors, metabolic disorders exposure to toxic substancesexposure to toxic substances

Types of Brain InjuriesTypes of Brain Injuries

Open brain injuriesOpen brain injuriesClosed brain injuriesClosed brain injuries

• 1. Diffuse1. Diffuse

• 2. Focal2. Focal

Severity of Brain InjurySeverity of Brain Injury

Mild: brief or no LOC, Mild: brief or no LOC, nausea, signs of nausea, signs of concussion, GCS 13-concussion, GCS 13-15, PTA < 1 hr, 50%-15, PTA < 1 hr, 50%-75%75%

Moderate: coma < 6 Moderate: coma < 6 hrs, skull fracture or hrs, skull fracture or bleeding, GCS 9-12, bleeding, GCS 9-12, PTA 1-24 hrsPTA 1-24 hrs

Severe: coma > 6 hrs, Severe: coma > 6 hrs, PTA > 1 day, GCS 3-8PTA > 1 day, GCS 3-8

Glasgow Coma ScaleGlasgow Coma Scale (GCS)(GCS) Eye OpeningEye Opening

• SpontaneousSpontaneous 44• To speechTo speech 33• To painTo pain 22• NoneNone 11

Best Motor ResponseBest Motor Response• Obeys commandObeys command 66• Localizes painLocalizes pain 55• Withdraws from painWithdraws from pain 44• Abnormal flexion to painAbnormal flexion to pain 33• Extension to painExtension to pain 22• NoneNone 11

Verbal ResponseVerbal Response• Oriented conversationOriented conversation 55• Confused conversationConfused conversation 44• Inappropriate wordsInappropriate words 33• Incomprehensible soundsIncomprehensible sounds 22• NoneNone 11

GCS FactsGCS Facts

8 is the critical score8 is the critical score 90% with scores less than or 90% with scores less than or

equal to 8 are in a comaequal to 8 are in a coma 50% with scores less than or 50% with scores less than or

equal to 8 at 6 hours will dieequal to 8 at 6 hours will die

Post Traumatic Amnesia (PTA)Post Traumatic Amnesia (PTA)

Time after coma when Time after coma when person is still unable to form person is still unable to form new memoriesnew memories

Measured by COAT or Measured by COAT or GOATGOAT

Rancho Los Amigos ScaleRancho Los Amigos Scale

Level I Level I No ResponseNo Response Level IILevel II Generalized ResponseGeneralized Response Level IIILevel III Localized ResponseLocalized Response Level IVLevel IV Confused/AgitatedConfused/Agitated Level VLevel V Confused/Inappropriate Confused/Inappropriate

NonagitatedNonagitated Level VILevel VI Confused AppropriateConfused Appropriate Level VII Level VII Automatic, AppropriateAutomatic, Appropriate Level VIII Level VIII Purposeful, AppropriatePurposeful, Appropriate

EpidemiologyEpidemiology

Who gets injured?Who gets injured?• TBI not randomly distributedTBI not randomly distributed• Predominately malePredominately male• Lower SESLower SES• High family or life stressHigh family or life stress• Behavioral propensity toward risk taking Behavioral propensity toward risk taking

and high action levelsand high action levels

EpidemiologyEpidemiology

Who gets injured?Who gets injured?• 3-8 year olds3-8 year olds• 15-29-year olds15-29-year olds

Kid’s at greatest risk:Kid’s at greatest risk:• HA/ emotionally disturbed/delinquentHA/ emotionally disturbed/delinquent• Under 5, w/ prior adjustment problems, of Under 5, w/ prior adjustment problems, of

low SES, parents w/ problemslow SES, parents w/ problems

Risk Factors for TBIRisk Factors for TBI

Prior behavioral problemsPrior behavioral problems Family stressFamily stress Family instabilityFamily instability Crowded living conditionsCrowded living conditions Prior TBIPrior TBI

Major Causes of Brain InjuriesMajor Causes of Brain Injuries

InfantsInfants: accidental dropping, physical : accidental dropping, physical abuse, “shaken baby syndrome”abuse, “shaken baby syndrome”

Toddlers and PreschoolersToddlers and Preschoolers: falls, car : falls, car accidents, physical abuseaccidents, physical abuse

Elementary school childrenElementary school children: car and bike : car and bike accidents, playground and recreational accidents, playground and recreational accidentsaccidents

AdolescentsAdolescents: car accidents, sports : car accidents, sports injuries, assaultinjuries, assault

TBI: Some StatisticsTBI: Some Statistics

7,000 deaths of children7,000 deaths of children >500,000 hospitalizations>500,000 hospitalizations Hospital care costing over $1 Hospital care costing over $1

billionbillion 30,000 children becoming 30,000 children becoming

permanently disabledpermanently disabled

TBI: Some StatisticsTBI: Some Statistics

The NHIF estimates that < 10% of all who survive The NHIF estimates that < 10% of all who survive TBI receive adequate rehab to return them to self-TBI receive adequate rehab to return them to self-sufficiencysufficiency

TBI survivors requires between $4 and $9 M for a TBI survivors requires between $4 and $9 M for a lifetime of carelifetime of care

TBI accounts for about 16% of all pediatric TBI accounts for about 16% of all pediatric hospital admissions for children between the hospital admissions for children between the ages of birth and 14ages of birth and 14

50% of battered children who survive a TBI suffer 50% of battered children who survive a TBI suffer permanent neurological, intellectual, and permanent neurological, intellectual, and psychological impairmentpsychological impairment

What Happens After What Happens After the Injury?the Injury?

PhysicalPhysical

CognitiveCognitive

PsychosocialPsychosocial

Behavioral/EmotionalBehavioral/Emotional

Physical EffectsPhysical Effects Reduced stamina and endurance Reduced stamina and endurance Regulation of physical functionsRegulation of physical functions Motor deficits, ataxiaMotor deficits, ataxia Seizures and/or headachesSeizures and/or headaches Skeletal deformitiesSkeletal deformities Hormonal and body temperature changesHormonal and body temperature changes DysarthriaDysarthria

Cognitive EffectsCognitive Effects Short and long term memory Short and long term memory

problemsproblems Intellectual functions hinderedIntellectual functions hindered Attention and concentration Attention and concentration

diminisheddiminished Language difficultiesLanguage difficulties Academic functioning reducedAcademic functioning reduced

Psychosocial EffectsPsychosocial Effects Depression and anxietyDepression and anxiety Social withdrawalSocial withdrawal Feelings of worthlessnessFeelings of worthlessness GuiltGuilt Loss of interest in school and Loss of interest in school and

family activitiesfamily activities

Behavioral EffectsBehavioral Effects Acting socially inappropriate..loss of Acting socially inappropriate..loss of

friendsfriends Being unaware of one’s impact on Being unaware of one’s impact on

others...may seek younger peersothers...may seek younger peers IrritableIrritable Impulsive and/or aggressive Impulsive and/or aggressive More emotionalMore emotional UnmotivatedUnmotivated

Emotional EffectsEmotional Effects Poorer tolerance, more rigidPoorer tolerance, more rigid Greater dependence, Greater dependence,

insensitivityinsensitivity Flat affect, oppositional, blamingFlat affect, oppositional, blaming More demandingMore demanding More labile, immature copingMore labile, immature coping

Factors Influencing OutcomeFactors Influencing Outcome

Type of injuryType of injury Medical complicationsMedical complications Severity of injury: carries most weight re: Severity of injury: carries most weight re:

prognosis for recoveryprognosis for recovery Premorbid functioningPremorbid functioning

• Gender and SES do not affect outcomeGender and SES do not affect outcome• Pre-injury psychiatric d/o predictive of later Pre-injury psychiatric d/o predictive of later

problems w/ severe TBIproblems w/ severe TBI


General principles:General principles:• Not just the injury the brain sustains, but Not just the injury the brain sustains, but

the brain that sustains the injurythe brain that sustains the injury• Understand the individual who has the Understand the individual who has the

accident, the context in which he/she lives, accident, the context in which he/she lives, and will continue to liveand will continue to live

• Multifactorial influences on outcome at time Multifactorial influences on outcome at time make “dose and response” seem make “dose and response” seem hopelessly out of proportionhopelessly out of proportion


Age @ injury:Age @ injury:• @ > 5 y.o., age unrelated to severity of @ > 5 y.o., age unrelated to severity of

neurocognitive deficits or rate of recoveryneurocognitive deficits or rate of recovery• @ < 5 y.o., more severe long-term @ < 5 y.o., more severe long-term

neurocognitive deficitsneurocognitive deficits• May be difficult to determine severity of May be difficult to determine severity of

injury w/ absence of baseline data--injury w/ absence of baseline data--comparison w/ siblings, parentscomparison w/ siblings, parents


Pre-existing disordersPre-existing disorders• Injury may interact w/ prior learning Injury may interact w/ prior learning

disability, low intellectual capacity, disability, low intellectual capacity, psychiatric d/o etc.psychiatric d/o etc.

• Addition of even a minor insult to Addition of even a minor insult to premorbidly compromised individual may premorbidly compromised individual may produce an apparent disproportionate produce an apparent disproportionate increment in disability increment in disability


Neurological damage more severe than Neurological damage more severe than initially realizedinitially realized• Overlooked due to other systemic injuries Overlooked due to other systemic injuries

requiring emergency attention, surgery, requiring emergency attention, surgery, long convalescence, etc. which put few long convalescence, etc. which put few cognitive demands on patientcognitive demands on patient

• But, multiple injuries can also produce PCS But, multiple injuries can also produce PCS symptoms with no neurologic substratesymptoms with no neurologic substrate


Co-existing habit patternsCo-existing habit patterns• Alcohol and substance AbuseAlcohol and substance Abuse• Previous head injuriesPrevious head injuries• Produce difficulties in life functioning and , Produce difficulties in life functioning and ,

in some cases, make individual more in some cases, make individual more susceptible to negative outcomesusceptible to negative outcome


Family competenceFamily competence• Well-functioning vs. barely tolerable Well-functioning vs. barely tolerable

situation which is poorly managedsituation which is poorly managed• Injured child may increase strain in already Injured child may increase strain in already

marginally coping family--produce more marginally coping family--produce more negative consequences than neurological negative consequences than neurological event itselfevent itself


Recovery RatesRecovery Rates• Dependent upon severity--milder injuries Dependent upon severity--milder injuries

have faster recoveryhave faster recovery• More rapidly a function returns, better the More rapidly a function returns, better the

prognosis for that functionprognosis for that function• Major portion of recovery within first yearMajor portion of recovery within first year

Note: there are different fields of Note: there are different fields of thought about TBI recovery ratesthought about TBI recovery rates


SummarySummary• Neurocognitive and psychiatric residuals Neurocognitive and psychiatric residuals

for kids with mild or even moderate injuries for kids with mild or even moderate injuries seem less clear and when injuries at this seem less clear and when injuries at this severity level do produce deficits, recovery severity level do produce deficits, recovery seems to occur over a short (several seems to occur over a short (several months) period of timemonths) period of time

• Pediatric TBI research is in its infancy--Pediatric TBI research is in its infancy--good longitudinal studies are neededgood longitudinal studies are needed


Management of caseManagement of case• Appropriate management of mild to Appropriate management of mild to

moderate injuries usually results in moderate injuries usually results in successful re-integration to schoolsuccessful re-integration to school

• Inappropriate attribution of pattern of Inappropriate attribution of pattern of neurocognitive variability to brain injury neurocognitive variability to brain injury may generate self-fulfilling negative may generate self-fulfilling negative expectations, misattributions, anxietyexpectations, misattributions, anxiety

Neuropsychological Assessment: Neuropsychological Assessment: Conceptual ApproachConceptual Approach

Presenting problemPresenting problem• Significant others as informantsSignificant others as informants• Child’s presentation colored by limitations Child’s presentation colored by limitations

in conceptual capacity and self-awarenessin conceptual capacity and self-awareness• Consistency and contradictions in reportsConsistency and contradictions in reports• Pervasiveness/duration of symptoms Pervasiveness/duration of symptoms

identity etiologic factorsidentity etiologic factors

Collection of background informationCollection of background information• Records of injury/hospitalizationRecords of injury/hospitalization

• NeurodiagnosticsNeurodiagnostics• Length of comaLength of coma• Approximate length of PTAApproximate length of PTA

• Current MedicationsCurrent Medications• Anticonvulsants can adversely affect test results if Anticonvulsants can adversely affect test results if

blood levels are highblood levels are high



Collection of background informationCollection of background information• Premorbid historyPremorbid history

• MedicalMedical– prior TBIprior TBI– History of seizuresHistory of seizures– Birth recordsBirth records

• Psychiatric historyPsychiatric history• Comprehensive developmental historyComprehensive developmental history• Family history--trends re: ADD, LDFamily history--trends re: ADD, LD• School history--attendance, testing, sped, etc.School history--attendance, testing, sped, etc.


Appraisal of presenting problems and Appraisal of presenting problems and collection of background information collection of background information provides an estimate of premorbid provides an estimate of premorbid functioning, determination of current functioning, determination of current factors which might influence the factors which might influence the assessment process, and hypothesis assessment process, and hypothesis development about pattern/severity of development about pattern/severity of expected neuropsychological deficitsexpected neuropsychological deficits


Neuropsychological ExaminationNeuropsychological Examination• Selection of assessment procedures Selection of assessment procedures

determined by nature of referral question, determined by nature of referral question, child’s age, child’s physical and mental child’s age, child’s physical and mental capacities, and psychologist’s own capacities, and psychologist’s own preferencespreferences

• Measures a full range of abilities necessary Measures a full range of abilities necessary for success in youth’s environmentsfor success in youth’s environments


Assessment DomainsAssessment Domains• General IntelligenceGeneral Intelligence• Academic AchievementAcademic Achievement• Motor SkillsMotor Skills• Sensory, Perceptual, ConstructionalSensory, Perceptual, Constructional• Language/SpeechLanguage/Speech• Auditory Attention/Information ProcessingAuditory Attention/Information Processing• Visual Attention/Information ProcessingVisual Attention/Information Processing


Assessment DomainsAssessment Domains• Executive Functions/Problem SolvingExecutive Functions/Problem Solving• MemoryMemory• Personality/Behavioral/Adaptive SkillsPersonality/Behavioral/Adaptive Skills

AssessmentAssessment InstrumentsInstruments

Neuropsychological Test BatteriesNeuropsychological Test Batteries• Halstead-Reitan Neuropsychological Test Halstead-Reitan Neuropsychological Test

Battery for Older Children, 9-14 yrs.Battery for Older Children, 9-14 yrs.• Reitan-Indiana Neuropsychological Test Reitan-Indiana Neuropsychological Test

Battery for Children, 5-8 yrsBattery for Children, 5-8 yrs• Luria-Nebraska Neuropsychological Test Luria-Nebraska Neuropsychological Test

Battery for Children, 8-12 yrsBattery for Children, 8-12 yrs• NEPSYNEPSY

Assessment DomainsAssessment Domains

General Intellectual MeasuresGeneral Intellectual Measures• PurposesPurposes

• Overall IQ will be a benchmark for other Overall IQ will be a benchmark for other comparisonscomparisons

• Identify cognitive strengths/weaknessesIdentify cognitive strengths/weaknesses• Formulate diagnostic decisionsFormulate diagnostic decisions• Plan intervention strategiesPlan intervention strategies


General Intellectual MeasuresGeneral Intellectual Measures• IQ and brain injuryIQ and brain injury

• Full Scale IQ is the most reliable and valid score Full Scale IQ is the most reliable and valid score from a psychometric viewpointfrom a psychometric viewpoint

• Verbal abilities recover more rapidlyVerbal abilities recover more rapidly• With severe TBI, PIQ’s are lowered and deficits are With severe TBI, PIQ’s are lowered and deficits are

persistent at 5 years post-injury (slowed reaction persistent at 5 years post-injury (slowed reaction time, deficits in problem solving and novel tasks)time, deficits in problem solving and novel tasks)

• Coding, PC, BD distinguish the severely injured; no Coding, PC, BD distinguish the severely injured; no differences with PA and OAdifferences with PA and OA

• VIQ-PIQ patterns map recovery of functionVIQ-PIQ patterns map recovery of function

Assessment InstrumentsAssessment Instruments

General IntelligenceGeneral Intelligence• Wechsler Preschool and Primary Scale of Wechsler Preschool and Primary Scale of

Intelligence-Revised (WPPSI-III), ages 3-7Intelligence-Revised (WPPSI-III), ages 3-7• Wechsler Intelligence Scale for Children, Wechsler Intelligence Scale for Children,

Third Ed. (WISC-IV), ages 6-16 yrsThird Ed. (WISC-IV), ages 6-16 yrs• Wechsler Adult Intelligence Scale, Third Wechsler Adult Intelligence Scale, Third

Ed. (WAIS-III), ages 16+ yrsEd. (WAIS-III), ages 16+ yrs


General IntelligenceGeneral Intelligence• Kaufman Assessment Battery for Children Kaufman Assessment Battery for Children

(K-ABC), ages 2.5-12.5 yrs(K-ABC), ages 2.5-12.5 yrs• Leiter International Performance ScaleLeiter International Performance Scale• McCarthy Scales of Children’s Abilities, McCarthy Scales of Children’s Abilities,

ages 2.5-8.5 yrsages 2.5-8.5 yrs• Stanford-Binet Intelligence Scale, 4th Ed., Stanford-Binet Intelligence Scale, 4th Ed.,

ages 2-23 yrsages 2-23 yrs


General IntelligenceGeneral Intelligence• Woodcock-Johnson Psycho-Educational Woodcock-Johnson Psycho-Educational

Battery-Revised: Tests of Cognitive Battery-Revised: Tests of Cognitive Abilities, ages 3-80 yrsAbilities, ages 3-80 yrs

• Test of Non-Verbal Intelligence, 2nd Ed, 5-Test of Non-Verbal Intelligence, 2nd Ed, 5-85 yrs85 yrs

• Columbia Mental Maturity Scale (CMMS), Columbia Mental Maturity Scale (CMMS), 3.5-9 yrs3.5-9 yrs


Academic AssessmentAcademic Assessment• Profile strengths/weaknessesProfile strengths/weaknesses• Measures must be comprehensiveMeasures must be comprehensive• Skill based deficits (lack of knowledge) vs. Skill based deficits (lack of knowledge) vs.

performance based (execution of skills and performance based (execution of skills and abilities that may be present) deficitsabilities that may be present) deficits


Academic AssessmentAcademic Assessment• Academic Performance and Brain InjuryAcademic Performance and Brain Injury

• Difficulty with new/novel materialDifficulty with new/novel material• Slowed information processingSlowed information processing• Poor independent work effortsPoor independent work efforts• Problems with higher order cognition: generalization, Problems with higher order cognition: generalization,

abstraction, organization, planning, strategy abstraction, organization, planning, strategy generationgeneration

• Written language particularly susceptible--as an Written language particularly susceptible--as an emerging skill that is not well consolidatedemerging skill that is not well consolidated


• Academic Performance and TBIAcademic Performance and TBI• With moderate to severe injuries, reading, writing With moderate to severe injuries, reading, writing

and math affected and increased need for spedand math affected and increased need for sped• Even with milder injuries, academic performance Even with milder injuries, academic performance

can be affectedcan be affected• REMEMBER: Skills demonstrated on individual REMEMBER: Skills demonstrated on individual

assessment may not be commensurately assessment may not be commensurately demonstrated in the classroom (performance based demonstrated in the classroom (performance based deficit)--where rapid attention, organization, and deficit)--where rapid attention, organization, and retrieval are requiredretrieval are required


Academic AchievementAcademic Achievement• Kaufman Test of Educational Achievement, Kaufman Test of Educational Achievement,

6-18 yrs6-18 yrs• Wechsler Individual Achievement Test Wechsler Individual Achievement Test

(WIAT-II), 5-adult(WIAT-II), 5-adult• Woodcock Johnson Psycho-Educational Woodcock Johnson Psycho-Educational

Battery: Tests of Achievement, 2-90 yrsBattery: Tests of Achievement, 2-90 yrs• Wide Range Achievement Test (WRAT3), Wide Range Achievement Test (WRAT3),

5-Adult5-Adult


Academic AchievementAcademic Achievement• Key Math Diagnostic Arithmetic Test, Key Math Diagnostic Arithmetic Test,

Grades 1-6Grades 1-6• Gray Oral Reading Test, 7-18 yrsGray Oral Reading Test, 7-18 yrs• Stanford Diagnostic Reading Test, Grades Stanford Diagnostic Reading Test, Grades

1-121-12• Peabody Individual Achievement Test Peabody Individual Achievement Test

(PIAT-R), Kg-H.S.(PIAT-R), Kg-H.S.


Academic AchievementAcademic Achievement• Nelson Denny Reading Test, Grades 9+Nelson Denny Reading Test, Grades 9+• Test of Early Written Language, 3-10 yrsTest of Early Written Language, 3-10 yrs• Test of Written Language, 7.6-17 yearsTest of Written Language, 7.6-17 years• Test of Written Expression, 6.5-14 yearsTest of Written Expression, 6.5-14 years


Motor & Sensory FunctionsMotor & Sensory Functions• Difficulties usually resolve within 6 months; Difficulties usually resolve within 6 months;

mildly injured match controls at 6 mosmildly injured match controls at 6 mos• With severe TBI, simple and complex With severe TBI, simple and complex

motor speed deficits @ 1- & 2-yr. f/umotor speed deficits @ 1- & 2-yr. f/u• With younger kids see problems with:With younger kids see problems with:

• fine motor coordination/tremorsfine motor coordination/tremors• rapid alternating movementsrapid alternating movements• visual-motor integrationvisual-motor integration


Motor and Sensory FunctionsMotor and Sensory Functions• Extracurricular motor movements after 10 Extracurricular motor movements after 10

y.o. indicate dysfunction with motor y.o. indicate dysfunction with motor inhibitory systeminhibitory system

• Sensory errors--for lateral comparisonsSensory errors--for lateral comparisons• Rule out peripheral injuries, difficulty with Rule out peripheral injuries, difficulty with

focused attentionfocused attention


Sensory, Perceptual, ConstructionalSensory, Perceptual, Constructional• Bender Visual Motor Gestalt Test, 4+ yrsBender Visual Motor Gestalt Test, 4+ yrs• Benton Visual Retention Test, 8+ yrsBenton Visual Retention Test, 8+ yrs• Halstead Reitan subtests, 5+ yrsHalstead Reitan subtests, 5+ yrs

– Sensory imperceptionSensory imperception– Tactile finger recognitionTactile finger recognition– Fingertip number writingFingertip number writing– Tactile form recognitionTactile form recognition


Sensory, Perceptual, ConstructionalSensory, Perceptual, Constructional• Tactual Performance Test (TPT), 5+ yrsTactual Performance Test (TPT), 5+ yrs• Perceptual-Motor Assessment for Children, Perceptual-Motor Assessment for Children,

4-16 yrs4-16 yrs• Developmental Test of Visual-Motor Developmental Test of Visual-Motor

Integration (Beery VMI), 3-18 yrsIntegration (Beery VMI), 3-18 yrs• Judgment of Line Orientation, 7+ yrsJudgment of Line Orientation, 7+ yrs• Test of Visual-Perceptual Skills, 4-12 yrsTest of Visual-Perceptual Skills, 4-12 yrs


Motor SkillsMotor Skills• Bruininks-Osteresky Test of Motor Bruininks-Osteresky Test of Motor

Proficiency, 4.5-14.5, w/ disabilitiesProficiency, 4.5-14.5, w/ disabilities• Developmental Test of Visual-Motor Developmental Test of Visual-Motor

Integration (Beery VMI), 3-18 yrsIntegration (Beery VMI), 3-18 yrs• Grooved Pegboard and Purdue PegboardGrooved Pegboard and Purdue Pegboard• Wide Range Assessment of Visual-Motor Wide Range Assessment of Visual-Motor

Abilities. 3-17 yrsAbilities. 3-17 yrs


AttentionAttention• Levels of Attention: Arousal; Vigilance, Levels of Attention: Arousal; Vigilance,

attention span; Perseverance; attention span; Perseverance; Distractibility; Inhibitory processesDistractibility; Inhibitory processes

• Attention is: Simple alertness & attention Attention is: Simple alertness & attention span; Sustained attention or vigilance; span; Sustained attention or vigilance; Divided attention Divided attention

• Direct measures & qualitative observationDirect measures & qualitative observation


AttentionAttention• Common problem with TBICommon problem with TBI• W/ severe injury, in young children: HA and W/ severe injury, in young children: HA and

poor attention span up to 5 yrs. post-injurypoor attention span up to 5 yrs. post-injury• Deficits in concentration & speeded Deficits in concentration & speeded

performance @ 1yr for all severity levels performance @ 1yr for all severity levels (studies do not universally support this)(studies do not universally support this)


Auditory Attention/Information Processing Auditory Attention/Information Processing SpeedSpeed• Auditory Continuous Performance Test (ACPT), 6-Auditory Continuous Performance Test (ACPT), 6-

11 yrs11 yrs• Conner’s CPT, 4+ yrs**Conner’s CPT, 4+ yrs**• Goldman-Fristoe-Woodcock Selective Attention Goldman-Fristoe-Woodcock Selective Attention

TestTest• Gordon Diagnostic System, 4+ yrs**Gordon Diagnostic System, 4+ yrs**• Test of Variable Attention (TOVA)**Test of Variable Attention (TOVA)****denotes need for computer or special testing **denotes need for computer or special testing

equipmentequipment


Visual Attention/Information ProcessingVisual Attention/Information Processing• Wechsler Scales: Digit-Symbol Coding; Wechsler Scales: Digit-Symbol Coding;

Symbol Search; Cancellation Test; Picture Symbol Search; Cancellation Test; Picture Completion; Picture ArrangementCompletion; Picture Arrangement

• Trail Making Test, Part ATrail Making Test, Part A• Ruff 2 & 7 Selective Attention TestRuff 2 & 7 Selective Attention Test• Symbol Digit Modality Test, 8+yrsSymbol Digit Modality Test, 8+yrs• Nelson Denny Reading Test, Reading RateNelson Denny Reading Test, Reading Rate


Language/SpeechLanguage/Speech• Deficits increase w/ TBI severityDeficits increase w/ TBI severity• Expressive abilities more susceptible than Expressive abilities more susceptible than

receptive:receptive:• Description of object functionsDescription of object functions• Repeating words, sentencesRepeating words, sentences• Word fluencyWord fluency• Writing to dictationWriting to dictation• Copying sentencesCopying sentences• Object namingObject naming


Language/SpeechLanguage/Speech• Global deficits (mutisms, aphasias) with Global deficits (mutisms, aphasias) with

severe injuries, under 5 y.o., do improve severe injuries, under 5 y.o., do improve with recoverywith recovery

• Speculated that type of deficit is related to Speculated that type of deficit is related to language skills in primary ascendancy at language skills in primary ascendancy at time of injurytime of injury

• Comprehensive Evaluation from Speech & Comprehensive Evaluation from Speech & Language PathologistLanguage Pathologist


LanguageLanguage• Aphasia Screening Test of HRB, 5+ yrsAphasia Screening Test of HRB, 5+ yrs• Boston Naming Test, 6+ yrsBoston Naming Test, 6+ yrs• Clinical Evaluation of Language Functions Clinical Evaluation of Language Functions

(CELF), Kg-H.S.(CELF), Kg-H.S.• Controlled Oral Word Association, 6+ yrsControlled Oral Word Association, 6+ yrs• Illinois Test of Psycholinguistic Abilities Illinois Test of Psycholinguistic Abilities

(ITPA), 2yrs,4mos-10yrs,3mos(ITPA), 2yrs,4mos-10yrs,3mos


LanguageLanguage• Peabody Picture Vocabulary Test (PPVT-R), 2.5+ Peabody Picture Vocabulary Test (PPVT-R), 2.5+

yrsyrs• Test of Language Development (TOLD-2), 4-12 Test of Language Development (TOLD-2), 4-12

yrsyrs• Utah Test of Language Development, 3-9 yrsUtah Test of Language Development, 3-9 yrs• WIAT-II Oral Expression, Listening WIAT-II Oral Expression, Listening

Comprehension subtests, Kg-AdultComprehension subtests, Kg-Adult• WISC-IV Verbal Comprehension Index,6+ yrsWISC-IV Verbal Comprehension Index,6+ yrs


MemoryMemory• Assess: Immediate and delayed recall of Assess: Immediate and delayed recall of

story passages; visual recall; spatial story passages; visual recall; spatial memory; verbal retrieval of newly learned memory; verbal retrieval of newly learned material; recognition memorymaterial; recognition memory

• Mildly to moderately impaired TBIs usually Mildly to moderately impaired TBIs usually recover in 6-12 monthsrecover in 6-12 months

• Severely impaired show deficits @ 12 mosSeverely impaired show deficits @ 12 mos


MemoryMemory• Adolescents show a stronger recovery of Adolescents show a stronger recovery of

verbal memory deficitsverbal memory deficits• Young children are very unstable in their Young children are very unstable in their

performance from one memory test to performance from one memory test to another--may be a result of their failure to another--may be a result of their failure to employ useful learning strategiesemploy useful learning strategies


MemoryMemory• Wide Range Assessment of Memory and Wide Range Assessment of Memory and

Learning (WRAML), 5-17 yrsLearning (WRAML), 5-17 yrs• Children’s Memory Scale (CMS), 5-16 yrsChildren’s Memory Scale (CMS), 5-16 yrs• Wechsler Memory Scale-III (WMS-III), 16+Wechsler Memory Scale-III (WMS-III), 16+• Children’s Auditory Verbal Learning Test Children’s Auditory Verbal Learning Test

(CAVLT-2), 8+ URS(CAVLT-2), 8+ URS• Test of Memory and Learning, 5-19 YRSTest of Memory and Learning, 5-19 YRS


MemoryMemory• California Verbal Learning Test-Children’s California Verbal Learning Test-Children’s

Version (CVLT-C), 5-16 yrsVersion (CVLT-C), 5-16 yrs• Memory/Localization Scores from TPTMemory/Localization Scores from TPT• Benton Visual Retention Test, 8+ yrsBenton Visual Retention Test, 8+ yrs• Rivermead Behavioral Memory Test, 5+yrsRivermead Behavioral Memory Test, 5+yrs


Executive Functions require:Executive Functions require:• integration of motor, perceptual, attention, integration of motor, perceptual, attention,

memory, and learning skills.memory, and learning skills.• child to manage multiple simultaneous child to manage multiple simultaneous

demands, often w/ speed & accuracy demands, often w/ speed & accuracy requirements, engaging multiple input & requirements, engaging multiple input & output modalities, and incorporating output modalities, and incorporating feedbackfeedback


Executive Functions (Self-management)Executive Functions (Self-management)• Frontal lobes particularly susceptible to injuryFrontal lobes particularly susceptible to injury• Much of frontal areas do mature during Much of frontal areas do mature during

childhoodchildhood• Frontal Lobe Syndrome: alertness; appetite; Frontal Lobe Syndrome: alertness; appetite;

sleep; irritability; distractibility; impulsivity; sleep; irritability; distractibility; impulsivity; social problems; attention difficulties; social problems; attention difficulties; academic production deficits;poor planningacademic production deficits;poor planning


Executive Functions/Problem SolvingExecutive Functions/Problem Solving• Children’s Category Test, 5-16 yrsChildren’s Category Test, 5-16 yrs• Porteus Mazes, 3-12 yrsPorteus Mazes, 3-12 yrs• Raven’s Progressive Matrices, 5-17 yrsRaven’s Progressive Matrices, 5-17 yrs• Wisconsin Card Sorting Test (WCST), 6.5+Wisconsin Card Sorting Test (WCST), 6.5+• Delis-Kaplan Executive Function System Delis-Kaplan Executive Function System

(D-KEFS) subtests(D-KEFS) subtests• Trail Making Test, Part BTrail Making Test, Part B


Psychosocial FunctioningPsychosocial Functioning• W/ mild injuries: no increased risk for W/ mild injuries: no increased risk for

psychiatric disturbance although may have psychiatric disturbance although may have early change in temperament and other early change in temperament and other transient behavioral symptomstransient behavioral symptoms

• W/ severe injuries (i.e., PTA> 7 days): >2X W/ severe injuries (i.e., PTA> 7 days): >2X rate of psychiatric d/o @ 4mos. & f/u rate of psychiatric d/o @ 4mos. & f/u regardless of sex, age, or social classregardless of sex, age, or social class


Psychosocial FunctioningPsychosocial Functioning• Types of behavioral disorders mimic Types of behavioral disorders mimic

general population except for grossly general population except for grossly disinhibited social behavior w/ very severe disinhibited social behavior w/ very severe injuriesinjuries

• Pre-existing behavioral d/o and adverse Pre-existing behavioral d/o and adverse psychosocial histories are additive rather psychosocial histories are additive rather than interactivethan interactive


Psychosocial AdjustmentPsychosocial Adjustment• Poor social adjustment with severe injuries: Poor social adjustment with severe injuries:

studies range from 25% @ 1 year to >50% studies range from 25% @ 1 year to >50% at 3- and 5-yr follow-upat 3- and 5-yr follow-up

• Significant declines in adaptive behavior Significant declines in adaptive behavior seen @ 1 yr post-injuryseen @ 1 yr post-injury

• Severely injured children carry w/ them Severely injured children carry w/ them substantial and continuing risk factorssubstantial and continuing risk factors


Psychosocial adjustmentPsychosocial adjustment• Denial of personal awareness of deficits Denial of personal awareness of deficits

may result in more dangerous and risk-may result in more dangerous and risk-taking behaviorstaking behaviors

• Disinhibition, impulsivity,aggressiveness, Disinhibition, impulsivity,aggressiveness, and irritability may make maintaining old and irritability may make maintaining old relationships and establishing new relationships and establishing new relationships difficultrelationships difficult


Personality/Behavioral MeasuresPersonality/Behavioral Measures• Brown Attention Deficit Disorder Scales, Brown Attention Deficit Disorder Scales,

12+ yrs12+ yrs• Attention Deficit Disorders Evaluation Attention Deficit Disorders Evaluation

Scales (ADDES)Scales (ADDES)• Conner’s Rating Scale, 3-17 yrsConner’s Rating Scale, 3-17 yrs• Achenbach CBC/TRF, 2+ yrsAchenbach CBC/TRF, 2+ yrs• Devereux Scales: Parent (DSMD, 5+) and Devereux Scales: Parent (DSMD, 5+) and

School (DBRS, 5+)School (DBRS, 5+)


Personality/Behavioral MeasuresPersonality/Behavioral Measures• Minnesota Personality Inventory-Minnesota Personality Inventory-

AdolescentAdolescent• Millon Adolescent Clinical Inventory (MACI)Millon Adolescent Clinical Inventory (MACI)• Adolescent Psychopathology Scale (APS)Adolescent Psychopathology Scale (APS)• High School Personality Questionnaire High School Personality Questionnaire

(HSPQ), Children’s Personality (HSPQ), Children’s Personality Questionnaire (CPQ), Early School Questionnaire (CPQ), Early School Personality Questionnaire (ESPQ)Personality Questionnaire (ESPQ)


Personality/Behavioral MeasuresPersonality/Behavioral Measures• Manifest Anxiety Scale for ChildrenManifest Anxiety Scale for Children• Children’s Depression InventoryChildren’s Depression Inventory• Reynolds Children’s Depression ScaleReynolds Children’s Depression Scale• Reynolds Adolescent Depression ScaleReynolds Adolescent Depression Scale• Beck Depression Inventory, 13+Beck Depression Inventory, 13+


Personality/Behavioral MeasuresPersonality/Behavioral Measures• Children’s Personality Questionnaire Children’s Personality Questionnaire

(CPQ)(CPQ)• Behavior Rating Profile, 6.5-18.5 yrsBehavior Rating Profile, 6.5-18.5 yrs• Personality Inventory for Children (PIC)Personality Inventory for Children (PIC)• Trauma Symptom Checklist for Children Trauma Symptom Checklist for Children

(TSCC), 8-16 yrs(TSCC), 8-16 yrs• Adaptive Behavior Rating Scales, if Adaptive Behavior Rating Scales, if

neededneeded

TBI Evaluation ScheduleTBI Evaluation Schedule

Do SERIAL evaluationsDo SERIAL evaluations Initial evaluation within 6 monthsInitial evaluation within 6 months Follow-up @ 1-yr intervals w/ mild to Follow-up @ 1-yr intervals w/ mild to

moderate TBImoderate TBI Follow-up @ 6-month intervals w/ Follow-up @ 6-month intervals w/

severe TBIsevere TBI

Traumatic Brain Injury in Children and Adolescents Katherine C. Nordal, Ph.D. The Nordal Clinic Vicksburg, MS 39183 [email protected].

Documents

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