Traumatic Brain Injury and Mental Health in Children

Traumatic Brain Injury and Mental Health in Children and Adolescents Maria Butler, Psy. D. Stephanie Terracciano, Psy. D.

Agenda v Overview of TBI in children and adolescents v Cognitive, behavioral, and social effects v Effects on family functioning v Factors influencing presentation • Child variables, age at injury, contextual, injury variables, family environment v Intervention

Types of Brain Injury Congenital and Perinatal (no period of normal development) Perinatal (e. g. , birth stroke) Congenital (e. g. , PKU) Acquired (following a period of normal development) Non-traumatic (internal occurrence e. g. , tumor) Traumatic (external physical force) Open (e. g. , gunshot) Closed (e. g. , fall)

Traumatic Brain Injury (TBI) v “A TBI is caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain” (Centers for Disease Control and Prevention, 2016) v A leading cause of disability and death in children and teens (Thurman, 2014)

Risk Factors For TBI v Sports: Contact sports v Age: Children and elderly v Sex: Males between the ages of 15 and 30 (Centers for Disease Control and Prevention, 2016)

(Centers for Disease Control and Prevention, 2016)

Classification System of TBI Severity (Bodin & Yeates, 2010) Severity GCS LOC PTA Mild 13 -15 <30 minutes <1 hour Moderate 9 - 12 30 minutes – 1 -24 hours Severe 3 -8 > 24 hours

Cognitive Problems • Problem solving • Comprehension of abstract language • Word retrieval • Expressive language organization • Pragmatics (Yeates et al. , 2002) • • • Executive functions Memory Attention Concentration Information processing Sequencing

Cognitive Impairments v Tend to improve slowly (6 -18 months) with greatest rate of improvement in first 12 months v Kids often deny their cognitive problems due to lack of insight v May not be noticeable to others which may cause anxiety or frustration (Yeates et al. , 2002)

Behavioral and Emotional Changes v May occur as direct result of injury v Inability to express him/herself appropriately v Decreased language production v Concrete thinking and poor insight may interfere with compliance or ability to respond to interventions v Frustration about being in the hospital and missing family v Loss of former self (Li & Liu, 2013)

Emotional Lability 1) Resulting from new deficits in executive control and a lowered frustration tolerance 2) Result in the loss of emotional sensitivity to others and ability to modulate high emotions and behavior 3) Feelings are generally appropriate with exception of brief episodes of strong affective expression (Lezak, Howieson, Bigler, & Tranel, 2012)

Externalizing Behavior Problems v Inattention, disinhibition, distractibility, etc. • 30 -50% of children developed symptoms after TBI (Schachar, Levin, Max, Purvis, & Chen, 2004) v Learning and generalizing behavioral strategies may be more challenging v Aggression and conduct problems (Ganesalingam, Sanson, Anderson, & Yeates, 2007; Li & Liu, 2013)

Internalizing Problems: Anxiety v Anxiety, obsessions, and compulsions are common v Internalizing symptoms are more likely to emerge six months after TBI than other medical traumas v Cognitive problems associated with TBI mimic OCD symptoms. • Perseveration due to executive dysfunction v Damage to similar brain areas are implicated in primary OCD and OCD after TBI - frontal and subcortical regions (Konigs et al. , 2016; Li & Liu, 2013; Luis & Mittenberg, 2002)

Internalizing Problems: Depression v Lack of energy, irritability, agitation, etc. v Hard to differentiate between symptoms of TBI vs. somatic manifestations of depression v Depression increased baseline → 6 months → 1 year (Kirkwood et al. , 2000) As physical and cognitive symptoms decrease, psychiatric concerns may worsen (Noggle & Pierson, 2010)

Internalizing Problems: Trauma- and Stressor-Related Disorders v Overlap of symptoms between PTSD and TBI v PTSD symptoms at 1 year associated with self-reported anxiety and depression one month after the injury (Gerring et al. , 2002) v Emotional reactivity symptoms more common than re-experiencing symptoms due to posttraumatic amnesia (Luis & Mittenberg, 2002)

Personality Change v Examples: Social insensitivity or hypersensitivity, emotional dulling/blunting, mild euphoria with diminished anxiety v Occurs in up to 60% of patients with severe TBI (Max, Robertson, & Lansing, 2001) v Persistent personality change 2 years after severe TBI is associated with IQ but not psychosocial variables v Apathy different from loss of interest associated with depression (Max et al. , 2006)

Social Effects v Decline in social function following TBI with limited improvement one year post-injury (Rivara et al. , 1993) v TBI between ages 6 and 12 years associated with deficits in higher order problem solving and social reasoning skills four years post-injury (Janusz, Kirkwood, Yeates, & Taylor, 2002) v Associated with injury to frontal lobes which achieve maturation in mid-20 s v At risk for peer rejection, victimization, substance use, etc. (Bigler, 2013; De. Rosier & Lloyd, 2010; Mayes et al. , 2015)

Effects of TBI on Family v Increases risk for psychological symptoms in family v Family goes through grieving process when recovery slows down and child starts to miss expected developmental milestones v Sibling reactions to TBI • Jealousy, anger, behavioral problems (Potter et al. , 2011; Root et al. , 2016; Wade et al. , 2008)

Factors Influencing Post-Injury Presentation v Children’s brains are in a constant state of change and development v During periods of rapid growth, the brain may actually be more vulnerable to damage (e. g. , TBI, anoxia, or toxins) v Injury impacts skills currently in the process of being acquired as well as those skills that have yet to be developed (Anderson, Spencer-Smith, & Wood, 2011; Garcia et al. , 2015; Li & Liu, 2013)

Factors Influencing Post-Injury Presentation: Course of Symptoms v Although adults normally exhibit symptoms days to months after an injury, a child may not exhibit deficits until years post injury v When children reach a stage of greater autonomy and higher cortical demands, deficits may be magnified v Greatest challenges are typically seen in ability to learn new information and develop socially appropriate behaviors (Anderson, Spencer-Smith, & Wood; 2011; Garcia et al. , 2015; Li & Liu, 2013)

Factors Influencing Post-Injury Presentation: Course of Recovery (Chapman, 2006)

Factors Influencing Post-Injury Presentation: Age v Under age 6 years = more internalizing behaviors v Age 6 years or older = more externalizing symptoms v Adolescents = higher incidence of BOTH internalizing and externalizing behaviors v Pre-morbid functioning is a strong predictor of post-injury functioning (Dykeman, 2003; Geraldina et al. , 2003)

Factors Influencing Post-Injury Presentation: Contextual v Family Resources • Strong family support and good family mental health are correlated with resilience • Lack of family resources (e. g. , low SES) is correlated with poorer social and cognitive outcomes (Holland & Schmidt, 2015)

Factors Influencing Post-Injury Presentation: Contextual v Parenting Style • Punitive and permissive parenting • Correlated with higher incidence of behavioral problems and poorer cognitive outcomes following TBI (Li & Liu, 2013) • Warm parenting • Correlated with fewer internalizing and externalizing behaviors (Wade et al. , 2011) Favorable parent behaviors do not show a moderating effect on behavior 12 -18 months post-injury (Yeates, Taylor, Walz, Stancin, & Wade, 2010)

Factors Influencing Post-Injury Presentation: Contextual v Family Functioning both pre- and post-injury • Family coping style and ability to manage the injury are stronger predictors of recovery in comparison to quality of family environment pre-injury (Li & Liu, 2013) v Family Environment • Chronic family stress correlated with higher incidence of long-term social issues

Factors Influencing Post-Injury Presentation: Contextual Variables v Injury Variables – type and severity v Duration of coma, PTA, and alteration in consciousness may inform neurobehavioral outcome (Yeates, 2010) v Lesion burden correlates with morbidity (Babikian & Asarnow, 2009)

Rehabilitation following TBI v Intervention should be initiated as soon as possible v Requires a multidisciplinary approach v Goals are to: • Improve function • Maximize potential • Prepare for community and school re-entry • Train skills necessary for future learning (Penn, Rose, & Johnson, 2009; Thomas, Apps, Hoffman, Mc. Crea, & Hammeke, 2015)

Reduce Overstimulation v Turn down lights v Close door to room v No electronic stimulation (no phones, computer, television) v Turn down/off radio v Limit number of visitors v Speak one at a time in a low, slow voice v Provide simple direction and provide time for response – you may need to repeat v Do not argue with the child

Psychological Treatment v Individual and family approach v Intervention should be individualized (e. g. , CBT) v Consider psychiatric comorbidities and pre-existing mental health problems v Environment should promote positive behaviors (Noggle & Pierson, 2010; Warschausky, Kewman, & Kay, 1999)

Family Support v Address impact of TBI on family v Help family understand changes in child v Provide education about needs both in community and at school (Semrud-Clikeman, 2010)

Family Interventions v Resources: Obtaining information about educational programs or community agencies that may facilitate their child’s recovery. Help to foster a home-school partnership v Self-care: Encouraging parents to use resources such as respite care when necessary v Ensure parents that it is not an “all or none” process (Semrud-Clikeman, 2010)

Return to School v Children may be incorrectly perceived similarly to those with learning disabilities • There may not be consistent overall patterns of deficits as seen in individuals with learning disabilities v Weaknesses in attention and behavioral regulation may be more evident • Teach emotional regulation as child may be more prone to temper outbursts or stress • The child may need information simplified • The child may not understand that what they do leads to something else Individualized Education Program (IEP) should be in place (Dykeman, 2003)

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