Common Causes and Effects of Traumatic Brain on Learning

Presented

By

Irene Opuka

and

James E. Monroe

Children and Adolescents

• It is also called head injury, or traumatic brain injury, or acquired brain injury.

• It is estimated that brain injuries to children between birth and 19 years of age annually result in:

7,000 deaths of children 150,000 hospitalizations Hospital care costing over one billion dollars 30,000 children becoming permanently disabled

Warm-up questions….

1. The major cause of severe TBI in school-aged children is:

• a. sports accidents

• b. motor vehicle accidents

• c. falls

• d. abuse

2. After experiencing a TBI, behavior problems may arise because the student is unaware of, or unable to understand, his/her deficits.

• a. true

• b. false

Sample Case: Preschooler

• Preschooler entering preschool just turned 3 years old.• Teacher complains the child is having problems socially, has emotional

breakdowns, attention problems, problems with transitions, problems remembering things, does not like to be touched at times, talks when not supposed to be talking.

• Parents want the child in a regular education setting, also sees child has hypersensitivity to loud sounds and complains it is the noisy classroom that causes this.

• What comes to mind first in terms of a disability? (Take 2 minutes to discuss with each other)

The Preschooler….

• Medical history: at 2 years of age, child had an accident – child fell head first onto a concrete floor hitting front of head. -- Child sustained a broken nose, swelling around the eyes, and brain damage. -- Child had seizures for 6 months, now under control with medication.

• Child is being considered for enrollment in a public preschool from child find services for 0 – 3 population.

Age is a strong predictor…

• Age is a strong predictor of the cause of brain injury in children: At least 80% of deaths from head trauma in children under two years of

age are the result of nonaccidental trauma Preschool age children are the 2nd highest risk group for brain injury Children between the ages of 6 and 12 are involved in twice as many

pedestrian/motor vehicle accidents as younger children Teenagers, 14 – 19 years old, are most susceptible to sports and auto-

occupant accidents. Two thirds of the children under age three who are physically abused

suffer traumatic brain injuries.

Facts & Statistics about TBI

• Over 1,000,000 children in the United States will sustain mild to severe brain injuries this year.

• Every 11 minutes one child in the United States has a brain injury which will result in permanent disabilities (30,000 children per year).

• The most frequently recorded diagnosis at the National Pediatric Trauma Registry is head injury.

• Almost one-half of the children who sustain winter sports injuries are diagnosed with head injury.

(National Pediatric Trauma Registry)

…./Facts

• Motor vehicle accidents are the number one cause of severe TBI in school-aged children. According to the National Pediatric Trauma Registry (NPTR), children using seat belts:

• a. had half the death rate• b. were less severely injured• c. were hospitalized for fewer days• d. spent less time in intensive care• e. were less likely to have head, neck, chest or face

injuries

Head Injury Causes

• Falls are the most common cause of minor head injury in children and adolescents, followed by motor vehicle crashes, pedestrian and bicycle accidents, sports-related trauma, and child abuse.

• The risk of brain injury varies with the severity of the trauma.

• Low force injuries (eg, short falls, hit by low speed or soft object such as toy or ball) have a low risk of brain injury.

(National Pediatric Trauma Registry)

…/Causes

• In comparison, incidents that have a higher risk of brain injury include:

High speed motor vehicle accidents** The rate of motor vehicle-traffic-related TBI is highest among adolescents ages 15 to 19 years.

Falls from great heights Being hit by a high speed, heavy, or sharp object

(e.g., baseball bat, golf club, bullet, knife) Inflicted injury (abuse), such as vigorous shaking,

typically causes severe injury

…/Causes

• Physical abuse is a leading cause of serious head injury and death in children aged 2 years or younger. The incidence of inflicted TBI in U.S. children is unknown.

• Abusive head trauma (AHT) is also known as nonaccidental head injury, inflicted head injury, or inflicted childhood neurotrauma.

• One subset is referred to as shaken baby syndrome, with a constellation of inflicted injuries in young children characterized by repeated acceleration-deceleration injury with or without blunt head impact.

• Child abuse is an important cause of death in children. Among child abuse fatalities, head injury is the leading cause of death in infancy.

• Mortality rates in series of cases of AHT range from approximately 15 to 25 percent.

(Sara Schutzman,2008)

Head injury symptoms

• A child's behavior and symptoms after a head injury depend upon the type and extent of the injury.

• The most common signs and symptoms include: Scalp swelling Loss of consciousness Vomiting Seizures Concussion

Groups at risk

• Injuries to children usually occur between noon and midnight and boys are twice as likely to be injured than girls.

• The two age groups at highest risk for TBI are 0 to 4 year olds and 15 to 19 year olds.

• Every year 475,000 cases of TBI occur in children aged from 0-14 years and 90 of TBI that occur every year are concussions or other forms of mild TBI.

(Centers for Disease Control and Prevention)

…/At risk groups

• Males also account for two thirds of childhood and adolescent TBI. The great majority of head injuries are caused by road-traffic accidents, falls, sports and assaults, but the proportion of injuries due to each cause varies according to age group.

• Falls and domestic accidents are much more common in the elderly, whereas assaults, sports injury & industrial injuries are more common in younger men.

• Physical abuse is a leading cause of serious head injury and death in children aged 2 years or younger.

Are children less vulnerable than adults?

• Children are just as vulnerable as adults. • It takes much longer for the effects of trauma to be seen in a

child. • Preschoolers with injuries to their frontal lobes often look fine

within a few weeks or months.• When a child’s brain is injured it can have long-term

devastating effects on the child and his/her ecosystem.• Educators are usually directly involved with helping children

with brain injuries adjust to the effects of their injuries on their functional skills and learning disabilities (NPTR, October 1993, Fact Sheet #2).

Common Problems Following TBI

• Rate of Recovery– Generally accepted that children/adolescents recover

more fully from illness than adults– The younger a person was when brain injury occurred the

more likely they would recover fully– Long term deficits as a result of that injury– At no age can one safely say a child/adolescent will

recover fully due to plasticity of the brain or other factors.

– Receiving adequate structure and rehabilitation following an injury.

– Structure and stimulation may be in their best interest.– One area in which children/adolescents does seem to

surpass adults is in survival from head injury.– Children/adolescents seem more likely to leave the ICU

alive than adults.

• Physical Problems following TBI– Children/adolescents experiencing TBI are often medically

stable.– Medical follow-up or medications.– Will experience seizures as a result of their injury.– Anticonvulsant medications (Phenobarbital, Delantin, or

Tegretol)– Discontinues within a few weeks or months after their

injury.– Movement difficulties or problems with sensation.

– Double vision is common and usually improves over several months and returns to normal.

– Hemiplegic, the inability to move one side of the body, is relatively uncommon.

– Problems with balance and coordination are often seen and may last longer than other motor difficulties.

– Difficulty participating in physical education class due to the balance and coordination difficulties.

– Take care of themselves as one would expect.

Cognitive Difficulties

• To the extent that the brain controls our cognitive abilities, any thinking skill can be affected by TBI.

• While a child/adolescent may exhibit one, two or several of the following deficits, it is unlikely that a child/adolescent will exhibit all of them.

• TBI is unique in the sense that the same cognitive systems are not affected in any two children/adolescents, which makes the educational program difficult to formulate.

• Deficits in attention and concentration– After TBI children/adolescents may be noted to be more

distractible and unable to establish and maintain a focus of attention.

– Such children may need constant reminding to stay on task and very specific directions as to what is expected of them.

– They often cannot complete more than one task at a time and even then may require prompting.

– In many respects, these children are similar to people with ADD.

• Memory Deficits– Recall information, from prior to injury so they do not

forget the things they have learned in school previously, their family members, their friends, or where they live.

– This is somewhat deceptive, however, since the problems they encounter is often with new learning.

– They are unable to learn new things as one would expect of the average child/adolescent.

• Problems with reasoning– Difficulties in reasoning vary with the age of the student.– With a very young child/adolescent very little in the way of

reasoning is expected, whereas with adolescents much more is anticipated.

– The problems with reasoning often relate to difficulties in planning, organization, and predicting what is to happen.

– Unable to shift to other solutions even though the problems my require such a shift.

– Require much more guidance and structure than the average student.

– The consequences of their actions need to be explained very clearly and any shift in the type of material presented has to be explained.

• Slowed processing– Slow in responding to questions.– Longer to understand directions and generate a response.– Slow in their physical abilities

• Language problems– Aphasia (the absence of language)– Problems might not be noticed– Word finding difficulties– Immature fashion– Comprehending longer instructions

• Problems with academic skills– Dyslexia or dyscalculia (an inability to do arithmetic)– Require review of basic concepts and information – Review of materials– Student return to school with academic skills– Difficult to understand the presence of apparently intact

academic skills that there may still be significant brain injury that is going to affect school performance.

• Behavioral/Emotional Difficulties– Difficult to separate the two.– Behavioral problems and behavioral difficulties.– Direct reflection of the brain injury.

• Restlessness– Fidgety – Move about without permission– No adequate response– Unable to be still– Focusing and directing their energy– Severe attention difficulties– Unable to focus or maintain attention adequately– Very distractible

• Failure to comply with instructions– May not complete assignments on time– Forget to do assignments– Desist in a certain behavior and the student persists– Difficulty with language comprehension– Cannot adequately focus his/her attention on directions– Memory

• Irritability towards the teacher and other students– Somewhat less inhibited in their emotional responses– May cry more easily or exhibit irritability– Anger more easily– Unable to take joking– May snap– Problems getting along with peers

• Withdrawing physically from others– Stay back of the crowd– Remain silent and unobtrusive– Very nervous and unwilling to participate– Sense of being overwhelmed– Withdrawal

• Turning in sloppy or incomplete work– Writing is skewed– Poorly spaced– Stop in mid-thought– Fine motor skills and coordination may be impaired– Attention problems– Difficulty in monitoring themselves– Poor memory

• Fatigue– Extremely tired within a relatively short time– Increased concentration– Great deal more effort– Quickly

• Lack of motivation– May sit quietly at their desks and stare into space– Require constant prompting – Simply lack the drive to perform– Association between motivation and outcome– May not perceive that they will do better if they exhibit

more effort.

• Classroom Interventions– Decrease excess stimulation– Quite places– Calm behavior reinforced– Changes in the physical setting

– A class size of 10 is the upper limit for a child/adolescent returning to school after TBI who is exhibiting attention difficulties.

– Optimally, a class size of five would be even better with as much individualized attention provided as possible.

– Individual work stations would be helpful at school for children/adolescents with TBI.

– Avoid placing children/adolescents with TBI in classrooms in close proximity to a great deal of activity.

– Seating a child/adolescent with TBI close to the teacher would be appropriate for several reasons.

– It is often beneficial for the child/adolescent with TBI to stay in the same classroom as much as possible.

• General teaching ideas– Children/adolescents with TBI benefit from as much

individualized attention as possible. – The teacher should anticipate having to repeat

directions/comments and review past materials more often than with the average student.

– The teacher should anticipate having to repeat directions/comments and review past materials more often than with the average student.

– It is often more effective to redirect inappropriate behavior on the part of children/adolescents with TBI than to discuss it with them, particularly within the context of a classroom situation.

– As a teacher, do not underestimate the impact of positive reinforcement.

– Working with computers is appropriate but likely requires greater attention on the part of the teacher than with the average student.

– Children/adolescents with TBI require more frequent rest breaks than the average student due to rapid fatigue.

– On a daily basis, the child/adolescent with TBI should write down homework assignments in a designated notebook.

– If class changes are involved, it would be appropriate to write down the student's schedule and post it on the front of the homework assignment notebook.

– Due to motor slowness, the TBI child/adolescent may have difficulty getting to classes on time if there are class changes.

– Many TBI individuals cannot write fast enough to keep up with notes in class.

– It is often beneficial when teachers give instructions one step at a time. The next instruction should be provided only after the preceding one is completed.

– To avoid sloppiness on papers turned in, the teacher could provide a specific format that is to be followed by the TBI student and others as well.

– Because of the frustration experienced by many students with TBI, it would be helpful if the teacher would learn to recognize early signs of irritability and intervene at that point.

– Children/adolescents with TBI, due to reasoning difficulties, frustration, and disinhibit, may behave in socially inappropriate ways.

– Inappropriate behavior occurs it is important that teachers not just correct the behavior by noting its inadequacy.

– Children/adolescents with TBI often do not respond well to embarrassment or teasing, particularly in group situations.

– Use of visual cues with a TBI student may be appropriate since they do not interfere with the ongoing class process and do not draw attention to the TBI student, which the latter may find embarrassing

– If there are to be any changes in the school routine for the child/adolescent with TBI, it is important that, if possible, the student be notified in advance.

– Consistency in the classroom is extremely important to children/adolescents with TBI.

– Use of humor may be very important to the recovery of the TBI child/adolescent.

– As a general rule, teachers should plan on having more contact with the parents of the TBI student than parents of the average student.

– When it comes to behavioral or emotional problems the teacher should set realistic goals in addressing the problem.

– Children/adolescents with TBI often do not cope well with decisions due to reasoning difficulties.

• Curriculum Issues– Placement of a TBI student in a curriculum is often one of

the more difficult decisions that has to be made.– The classroom teacher can consult with a rehabilitation

team, including a speech therapist and neuropsychologist, as well as specialists in the school system.

– It should also be recognized that placement in a particular curriculum or program may be short lived for the TBI student since progress is evident over time.

– An initial placement in special education services, such as for children/adolescents with learning disabilities, provides a smaller class size and the attention of teachers who are accustomed to learning difficulties.

– For those students who might need a review of material from previous school years, it is often uncertain as to where to start. As a general rule, it is logical to start approximately two grade levels below the level of ability existing prior to the injury and then review material in a sequential fashion

– The teacher needs to be sensitive to the presence of gaps in recall which will require more review and study time.

– Testing of children/adolescents with TBI is often a very difficult experience due to their slowness, memory difficulties, and problems in expressing themselves.

References

• Schutzman, S. (2008). Head injury in children [Online]. Up-to-date for Parents.

Retrieved March 9, 2010, from http://www.utdol.com/patients

• Centers for Disease Control and Prevention. What is Traumatic Brain? [Online].

Retrieved March 9, 2010, from http://www.cdc.gov/ncipc/tbi

• National Pediatric Trauma Registry (NPTR). Facts and Statistics about TBI.

[Online]. http://guest1.altec.org/ndsp/traumatic_brain_injury/FS.html