the basics of traumatic brain injury, its impact on children, and educational implications

The basics of traumatic brain injury,

its impact on children,and educational implications

Keith Owen Yeates, Ph.D.

Center for Biobehavioral HealthThe Research Institute at

Nationwide Children’s Hospital

Center for Biobehavioral HealthThe Research Institute at

Nationwide Children’s Hospital

Department of PediatricsCollege of Medicine

The Ohio State University

Why worry about pediatric TBI?

Annual incidence of hospitalization for head injuries = 200-300/100,000 children

#1 cause of pediatric death and disability in U.S.

Annual economic cost of pediatric TBI in the U.S. in the billions

More than 400,000 emergency room visits and hospitalizations per year.

TBI is very common among children

• > 1,000,000 TBI each year• > 250,000 hospital admissions annually• Accounts for > 10% of all emergency visits• Boys at higher risk than girls

– 2 to 1 for school-age children

• May vary with family socioeconomic status• Varies by severity

– 75-85% mild– 8-10% moderate– 6-13% severe

TBI especially common in young children and adolescents

Age differences in incidence & etiology

Durkin MS, et. al. 1998

Pediatric TBI: Etiology by Age

0

50

100

150

200

250

<1 year 1-4 5-12 13-16

Age group

Inci

den

ce (

case

s/10

0,00

0/yr

)

Other Accidental

Other Undetermined

Non-Gun Assault

Gun Assault

Transport

Fall

Age differences in causes of TBI

TBI can result in multiple injuries

• Primary injuries– Skull fracture– Contusion and laceration– Shear injuries

• Secondary injuries– Brain swelling and edema– Increased intracranial pressure– Mass lesions– Hypoxia and hypotension

TBI can result in delayed injuries

• Neurochemical cascade– Excessive free radicals– Excessive excitatory neurotransmitters– Disruption of cellular calcium homeostasis– Lactic acidosis

• Late effects– Post-traumatic hydrocephalus– White matter degeneration– Post-traumatic seizures

Outcomes of TBI

• TBI results in nearly 5,000 deaths annually

• TBI leaves > 17,000 children with permanent disabilities annually

• Multiple disabilities– Cognitive deficits– Emotional and behavioral problems– Impaired social and adaptive functioning– Declines in school performance

What happens after TBI?

• Neuropsychological outcomes– Alertness and orientation– Intellectual functioning– Language skills– Nonverbal skills– Attention and memory– Executive functions– Corticosensory and motor skills

• Academic performance– Less effect on achievement testing– More affect on classroom performance and

behavior

• Adaptive functioning • Social adjustment• Emotional and behavioral adjustment

Other outcomes after TBI

“Accidents” do happen!

But can we explain outcomes?

When and how does recovery occur?

• Developmental, biopsychosocial model• Multiple determinants

– Biological– Psychological– Environmental– Developmental

Developmental predictors

• Age of child at injury– Do young children have poorer outcomes?

• Time since injury– Does rate of recovery change?– How long can recovery take place?

• Age at assessment– Are some effects apparent only at

earlier/later ages?

Are children with TBI underserved in Ohio?

• In December 2002, 630 children classified as TBI • Incidence of childhood TBI resulting in

hospitalization = 180/100,000• Current population of children ages 5-17 in

Ohio = 2.1 million• 3,750 children with TBI annually in Ohio

– 450 to 600 in the moderate to severe range

• Overall prevalence in the thousands• Not recognized or identified…a “silent epidemic”

In contrast…autism

• In December 2002, 4,017 children designated autistic

• Prevalence– Autism 150/100,000– PDD spectrum 600/100,000

• Total number of children in Ohio– 3,500 with autism– 13,000 with PDD

• Autism much more likely to be provided with special education services than TBI, despite similar incidence

TBI is a challenge for educators

• Unique constellation of deficits – Attention– Memory– Executive functions– Behavioral regulation

• A moving target– Changes over time with recovery– Variability in outcomes

• Classroom performance affected more than academic achievement testing

Common problems in the classroom

• Tiredness and fatigue• Irritability, impulsivity• Aggressive behavior• Passive behavior• Inappropriate social behavior• Forgetfulness• Distractibility• Difficulty following directions• Poor organizational skills• Declines in grades

(From Wolcott, Lash, & Pearson, 1995)

Long-term academic achievement in children injured < 6 yrs

(From Ewing-Cobbs et al., 2006)

Reading problems: Slowed processing

(From Barnes & Dennis, 1999)

Math problems: Procedures, not facts

(From Ayr et al., 2005)

Longitudinal profiles of achievement

(From Fay et al., 2009)

Ohio Injury Follow-Up Project (1991-2002)

• NIH-funded study at multiple sites– Rainbow Babies and Children’s Hospital,

Cleveland– Children’s Hospital, Columbus– MetroHealth Medical Center, Cleveland– Children’s Hospital Medical Center, Akron

• Investigators– H. Gerry Taylor (PI), Keith Yeates (Columbus PI),

Shari Wade, Dennis Drotar, Terri Stancin, Sue Klein, Elaine Borawski, George Thompson

Study design

• Two groups hospitalized for:– Moderate to severe TBI – Orthopedic injuries (OI)

• Assessed children and their families– Baseline, 6 months, 12 months, and

4 years post-injury

• Collected information about pre-injury and post-injury educational programs and placements from parents and schools

Participants

Variable Severe TBI Moderate TBI Ortho

Number 42 42 50

Age at injury 9.7 ± 2.1 9.5 ± 1.8 9.4 ± 1.9

% male 79 69 60

% single parent 40 32 42

% white 76 76 56

Days hospitalized 12.9 ± 9.3 6.7 ± 7.1 14.6 ± 14.1

Behavior in school: Standardized ratings

(From Yeates & Taylor, 2006)

Behavior problems vs. academic skills as predictors of classroom performance

(From Yeates & Taylor, 2006)

Going back to school: Days of school missed and part-time re-entry

05

10152025303540

Ave

rage

num

ber

Group

Days of school missed

0

5

10

15

20

25

Perc

ent

Group

Part- time return to school

Severe TBI

Moderate TBI

OI

Post-injury grade retention

0

5

10

15

20

25

Perc

ent

Group

Severe TBI

Moderate TBI

OI

Rates of special education placement

0

10

20

30

40

50

60

Perc

ent

Pre-I njury 6M Follow-

Up*

12M Follow-

Up*

Extended

Follow-Up*

Time

Severe TBI

Moderate TBI

Ortho

Group

TBI SLD DH SBH OHI S/ L0

2

4

6

8

10

12

Num

ber

Classifi cation

Types of special education programs

Are all needs being met?

• Identified children with deficits after TBI– Behavioral adjustment– Adaptive behavior– Neuropsychological functioning– Academic skills

• Children with deficits not provided special education– 45% at 6 months post-injury– 36% at 4 years post-injury

• Unmet needs behavioral and neuropsychological

Teachers are not always aware

(From Hawley et al., 2004)

The importance of transition services

(From Glang et al., 2008)

Predictors of achievement:Neuropsychological testing

(From Ewing-Cobbs et al., 2004)

Predictors of special education placement

• Pre-injury – Behavioral adjustment– Academic performance

• Baseline– Language and writing skills

• Extended follow-up– Behavioral adjustment– Social competence– Adaptive behavior– Cognitive skills

• IQ, language, memory, working memory, attention, executive functions

– Arithmetic skills

(From Taylor et al., 2003)

What is needed systemically?

• Increased awareness– Teacher education– Staff training in schools

• Better methods of identification– Yearly screening– Links to local hospitals

• STEP project

• Better methods of assessment– Neuropsychological evaluation

• Studies of effectiveness of intervention

What to do?Individualized educational planning

• Active experimentation is needed to identify best plan

• The educational plan requires ongoing review

• Inclusion in regular classrooms and routines is valuable

• Educational success depends heavily on social reintegration

Evidence-based instructional approaches

(From Glang et al., 2008)

• Direct instruction/cognitive strategy instruction– Systematic, explicit instruction and practice– Consistent instructional routines– Effective task analysis– Systematic introduction and modeling of component

skills– Use of scaffolding/guided practice– Rapid instructional pacing– Teaching to mastery (criterion referenced instruction)– Consistently high rate of success– Teaching of generalizable strategies– Planned and programmed generalization– Frequent and cumulative review

Evidence-based instruction: I

(From Ylvisaker et al., 2001)

Evidence-based instruction: II

Evidence-based instruction: III

Educational, behavioral, and social interventions: I

Educational, behavioral, and social interventions: II

Educational, behavioral, and social interventions: III

Summary

• TBI results in substantial disruption of education• Many children with TBI have disabilities likely to

affect their school performance• Many children with TBI receive special

education services, but many have unmet needs– Many not identified– Many mis-classified– Limited scope of services

• Need for intervention is early and ongoing

An ounce of prevention....

Websites of interest

• Brain STEPS (http://www.brainsteps.net/_orbs/about/)

• LEARNet (http://projectlearnet.org/)• BrainSTARS (

http://www.thechildrenshospital.org/conditions/rehab/camps/brainstars.aspx)

• Students with TBI - Thriving Beyond Injury (http://olrs.ohio.gov/ASP/TBISpecialEd.asp)

• Brain Injury Partners (http://free.braininjurypartners.com/page/0100/)