brain injury basics karen brewer, ph.d. clinical neuropsychologist

BRAIN INJURY BASICSBRAIN INJURY BASICS

Karen Brewer, Ph.D.Karen Brewer, Ph.D.Clinical NeuropsychologistClinical Neuropsychologist

UT Southwestern Medical CenterUT Southwestern Medical Center

Anatomy & Function of Anatomy & Function of Major Brain StructuresMajor Brain Structures

Frontal LobesFrontal Lobes Temporal LobesTemporal Lobes Parietal LobesParietal Lobes Occipital LobeOccipital Lobe CerebellumCerebellum Brain StemBrain Stem Corpus CallosumCorpus Callosum Limbic SystemLimbic System

Frontal LobesFrontal Lobes

Frontal LobesFrontal Lobes Executive functions:Executive functions:

PlanningPlanning OrganizationOrganization ““Remembering to remember”Remembering to remember” Self-monitoringSelf-monitoring

Higher-order thinking skills:Higher-order thinking skills: Problem solvingProblem solving ReasoningReasoning Cognitive flexibilityCognitive flexibility SequencingSequencing

Frontal LobesFrontal Lobes Higher-order thinking skills:Higher-order thinking skills:

JudgmentJudgment InsightInsight ““Reading between the lines”Reading between the lines”

Attention/working memoryAttention/working memory Motor functions – contralateral controlMotor functions – contralateral control Basal area:Basal area:

Bladder controlBladder control Taste/smellTaste/smell

Temporal LobesTemporal Lobes

Temporal LobesTemporal Lobes Memory:Memory:

Verbal memory – leftVerbal memory – left Visual memory – rightVisual memory – right

Auditory processing – both hemispheresAuditory processing – both hemispheres Language function (comprehension & Language function (comprehension &

expression) – usually leftexpression) – usually left 99% right-handers99% right-handers 90-95% left-handers90-95% left-handers

Parietal LobesParietal Lobes

Parietal LobesParietal Lobes Tactile sensation - contralateral Tactile sensation - contralateral

perception & integration of tactile perception & integration of tactile informationinformation

Right-left discriminationsRight-left discriminations Left: reading comprehension, Left: reading comprehension,

calculatingcalculating Right: visuospatial abilities (e.g., Right: visuospatial abilities (e.g.,

“mapping,” constructing) “mapping,” constructing)

Occipital LobesOccipital Lobes

Occipital LobesOccipital Lobes VisionVision Color perceptionColor perception

CerebellumCerebellum

CerebellumCerebellum Motor control & coordinationMotor control & coordination Connects to brainstemConnects to brainstem

Corpus CallosumCorpus Callosum

Corpus CallosumCorpus Callosum Connects the two cerebral Connects the two cerebral

hemisphereshemispheres Made up of huge tracts of white Made up of huge tracts of white

matter that carry messages from one matter that carry messages from one hemisphere to anotherhemisphere to another

Limbic SystemLimbic System

Limbic SystemLimbic System Amygdala – manages emotions Amygdala – manages emotions

(especially anger)(especially anger) Hypothalamus – manages hunger & Hypothalamus – manages hunger &

satiationsatiation Thalamus – major relay station for Thalamus – major relay station for

sensory input & integrationsensory input & integration

Brain StemBrain Stem

Brain StemBrain Stem Passageway between the brain and Passageway between the brain and

the spinal cordthe spinal cord Basic life support functions:Basic life support functions:

RespirationRespiration Heart rate/blood pressureHeart rate/blood pressure

Where all the cranial nerves Where all the cranial nerves convergeconverge

TBI Basic StatisticsTBI Basic Statistics

Annual incidence of head trauma in Annual incidence of head trauma in the United States - 2 million people the United States - 2 million people per year per year

Incidence of head injury steadily Incidence of head injury steadily increases until ages 15-25, then increases until ages 15-25, then declines; it rises again after age 60+. declines; it rises again after age 60+.

TBI Basic StatisticsTBI Basic Statistics 500,000 people will require hospitalization, 500,000 people will require hospitalization,

and about 80,000 will suffer from some and about 80,000 will suffer from some level of chronic cognitive and/or physical level of chronic cognitive and/or physical disability. disability.

TBI is also the leading cause of death in TBI is also the leading cause of death in adolescents and adults under 45 years of adolescents and adults under 45 years of age, with an overall mortality rate of 25 age, with an overall mortality rate of 25 per 100,000.per 100,000.

TBI Basic StatisticsTBI Basic Statistics Boys are twice as likely to suffer a Boys are twice as likely to suffer a

brain injury as girls.brain injury as girls.

Men are injured twice as frequently Men are injured twice as frequently as women, but die due to head injury as women, but die due to head injury four times more often.four times more often.

TBI Basic StatisticsTBI Basic Statistics Brain Injury Severity Stats:Brain Injury Severity Stats:

76-85% are mild76-85% are mild 8-10% are moderate8-10% are moderate 6-13% are severe 6-13% are severe

TBI Basic StatisticsTBI Basic Statistics Most common causes of head injury – Most common causes of head injury –

all age groups:all age groups: Motor vehicle accidents (> 50%)Motor vehicle accidents (> 50%) Falls (21%)Falls (21%) Violence (12%)Violence (12%) Sports/recreational injuries (10%). Sports/recreational injuries (10%).

TBI Basic StatisticsTBI Basic Statistics

Health costs from TBI: estimated to Health costs from TBI: estimated to be $35 billion per year in the U.S.be $35 billion per year in the U.S.

Classifying Brain InjuryClassifying Brain InjuryPenetrating/Open TBIPenetrating/Open TBI Open TBIs are characterized by the Open TBIs are characterized by the

velocity and location of the missile at velocity and location of the missile at impact: impact: The higher the velocity of the missile, The higher the velocity of the missile,

the more severe the injury.the more severe the injury. The lower the path of the missile, the The lower the path of the missile, the

more severe the injury. more severe the injury.

Classifying Brain InjuryClassifying Brain InjuryClosed TBIClosed TBI Closed TBIs are classified as mild, Closed TBIs are classified as mild,

moderate, or severe, depending on moderate, or severe, depending on the neurological status of the the neurological status of the patient soon after the injury patient soon after the injury

Classifying Brain InjuryClassifying Brain Injury MildMild - GCS of 13–15, LOC of less than 30 - GCS of 13–15, LOC of less than 30

minutes, and/or PTA of less than 1 hour minutes, and/or PTA of less than 1 hour

ModerateModerate - GCS of 9–12, LOC of 1–24 - GCS of 9–12, LOC of 1–24 hours, and/or PTA of 30 minutes to 24 hours, and/or PTA of 30 minutes to 24 hours hours

SevereSevere - GCS of 8 or less, LOC of more 24 - GCS of 8 or less, LOC of more 24 hours, and/or PTA of more than 1 day hours, and/or PTA of more than 1 day

Mild Traumatic Brain InjuryMild Traumatic Brain InjuryMild Closed TBIMild Closed TBI (aka “concussion,” minor brain injury) (aka “concussion,” minor brain injury) Involves transient physiological disturbancesInvolves transient physiological disturbances May cause trauma to the scalp and/or cervical spine, May cause trauma to the scalp and/or cervical spine,

and, in some cases, contusions or hematomas and, in some cases, contusions or hematomas No obvious anatomic injury to the brainNo obvious anatomic injury to the brain Results from low-velocity head trauma and may Results from low-velocity head trauma and may

involve transient loss of consciousness and/or involve transient loss of consciousness and/or memory of events immediately before and after memory of events immediately before and after traumatrauma

Usually produces normal CT/MRI scans and Usually produces normal CT/MRI scans and neurologic assessmentsneurologic assessments

Mild Traumatic Brain InjuryMild Traumatic Brain Injury May result in post-concussion May result in post-concussion

syndrome syndrome Disabilities due to posttraumatic Disabilities due to posttraumatic

headaches, dizziness, sleep headaches, dizziness, sleep disturbances, and inability to disturbances, and inability to concentrate and perform complex tasksconcentrate and perform complex tasks

Over time, PCS may cause anxiety, Over time, PCS may cause anxiety, depression, and/or other psychosocial depression, and/or other psychosocial problems problems

Moderate/Severe Moderate/Severe Traumatic Brain InjuryTraumatic Brain Injury

Associated with high velocity impact Associated with high velocity impact (e.g., motor vehicle accidents, assaults, (e.g., motor vehicle accidents, assaults, & falls)& falls)

Diagnosed when there is any one of the Diagnosed when there is any one of the following associated with a brain injury:following associated with a brain injury:

ContusionContusion HematomaHematoma HydrocephalusHydrocephalus Skull fracture Skull fracture

Diffuse Axonal Injury Diffuse Axonal Injury One of the most common and devastating types One of the most common and devastating types

of brain injury (Iwata et al., 2004), occurring in of brain injury (Iwata et al., 2004), occurring in almost half of all cases of severe head trauma.almost half of all cases of severe head trauma.

Results from the motion of the brain within the Results from the motion of the brain within the

skull, causing extensive damage to the axons skull, causing extensive damage to the axons (white matter). (white matter).

This can produce a wide spectrum of injuries, This can produce a wide spectrum of injuries, ranging from brief physiological disruption to ranging from brief physiological disruption to widespread axonal death. widespread axonal death.

Diffuse Axonal InjuryDiffuse Axonal Injury Secondary damage may occur after the initial injury:Secondary damage may occur after the initial injury:

Brain swellingBrain swelling Cerebral edema/Increased intracranial pressureCerebral edema/Increased intracranial pressure HypoxiaHypoxia Hematoma/hemorrhageHematoma/hemorrhage Metabolic abnormalitiesMetabolic abnormalities HydrocephalusHydrocephalus Fat embolismFat embolism Excessive release of excitatory amino acids (e.g., glutamate Excessive release of excitatory amino acids (e.g., glutamate

overproduction increases hypoxic injury to the hippocampus)overproduction increases hypoxic injury to the hippocampus) Oxidative free-radical productionOxidative free-radical production Disruption of neurotransmitters Disruption of neurotransmitters

Diffuse Axonal InjuryDiffuse Axonal Injury Delayed damage may occur as well:Delayed damage may occur as well:

White matter degenerationWhite matter degeneration Cerebral atrophyCerebral atrophy Development of posttraumatic Development of posttraumatic

hydrocephalushydrocephalus Development of posttraumatic seizuresDevelopment of posttraumatic seizures

QUIZQUIZAll things being equal (good pre-injury All things being equal (good pre-injury

health, no post-injury complications, etc.), health, no post-injury complications, etc.), which of the following people is most likely which of the following people is most likely to have the best outcome if he/she suffers to have the best outcome if he/she suffers a moderate brain injury?a moderate brain injury?

2-year-old2-year-old 22-year-old22-year-old 42-year-old 42-year-old

Common Cognitive Sequelae Common Cognitive Sequelae of TBIof TBI

Intellectual DeclineIntellectual Decline Verbal intelligence tends to be less vulnerable Verbal intelligence tends to be less vulnerable

to mild and moderate brain injuries.to mild and moderate brain injuries. Nonverbal intellectual abilities (e.g., Nonverbal intellectual abilities (e.g.,

Performance IQ) more often affected due to Performance IQ) more often affected due to problems with fluid problem solving and problems with fluid problem solving and decreased information processing speed.decreased information processing speed.

IQ tends to plateau 1-2 years after the injury, IQ tends to plateau 1-2 years after the injury, though improvements may be seen for up to 5 though improvements may be seen for up to 5 years.years.


Attention – Attention – Auditory & visualAuditory & visual Mediated primarily by the frontal lobesMediated primarily by the frontal lobes

Arousal Arousal Simple attention (e.g., focusing on what someone is Simple attention (e.g., focusing on what someone is

saying, ability to repeat numbers)saying, ability to repeat numbers) Sustained attention (maintaining focus for >5 Sustained attention (maintaining focus for >5

minutes) minutes) Selective attention (ignoring unimportant information Selective attention (ignoring unimportant information

while focusing on what is important)while focusing on what is important) Divided attention (attending to more than one thing Divided attention (attending to more than one thing

at a time; driving)at a time; driving)


Information Processing - Information Processing - making sense of making sense of information presented to the braininformation presented to the brain Mediated primarily by the frontal lobes and the Mediated primarily by the frontal lobes and the

white matter of brainwhite matter of brain Quality vs. speed issuesQuality vs. speed issues Visual information processingVisual information processing Auditory information processingAuditory information processing Working memory – requires manipulating Working memory – requires manipulating

information before processing it (e.g., multi-information before processing it (e.g., multi-step mental math problems)step mental math problems)


Verbal MemoryVerbal Memory Mediated by the left temporal lobe in >90% of Mediated by the left temporal lobe in >90% of

people (>95% right-handers; >85% left-people (>95% right-handers; >85% left-handers)handers)

Learning (storage), retrieval, & recognitionLearning (storage), retrieval, & recognition Contextual information (e.g., stories, conversations)Contextual information (e.g., stories, conversations) Noncontextual information (e.g., lists, isolated facts)Noncontextual information (e.g., lists, isolated facts) Symbolic information (e.g., math equations, spelling)Symbolic information (e.g., math equations, spelling)


Visual MemoryVisual Memory Mediated by the right temporal lobe in Mediated by the right temporal lobe in

most peoplemost people Learning, retrieval, & recognitionLearning, retrieval, & recognition

Contextual information (e.g., city streets, a Contextual information (e.g., city streets, a famous person’s face)famous person’s face)

Noncontextual information (e.g., an Noncontextual information (e.g., an unfamiliar item)unfamiliar item)


Reasoning/Problem-SolvingReasoning/Problem-Solving Mediated primarily by the frontal lobesMediated primarily by the frontal lobes Common deficit in TBI, but often not Common deficit in TBI, but often not

recognized by the patient.recognized by the patient. The area of function that often The area of function that often

distinguishes the children & adults that distinguishes the children & adults that adapt well post-injury from those who adapt well post-injury from those who do not.do not.


Abstract Thinking/Planning/OrganizationAbstract Thinking/Planning/Organization

Mediated primarily by the frontal lobes, Mediated primarily by the frontal lobes, especially the prefrontal corticesespecially the prefrontal cortices

Often quite impaired in persons who are Often quite impaired in persons who are brain injured, but not recognized until after brain injured, but not recognized until after hospitalization.hospitalization.


Speech/LanguageSpeech/Language Mediated by the frontal & temporal lobes Mediated by the frontal & temporal lobes

(usually left hemisphere)(usually left hemisphere) Frontal: language organization, naming, motor Frontal: language organization, naming, motor

controlcontrol Temporal: fluency, comprehension, spelling, Temporal: fluency, comprehension, spelling,

reading, calculation, prosodyreading, calculation, prosody In TBI, any or all of a survivor’s speech & In TBI, any or all of a survivor’s speech &

language skills can be affected, depending language skills can be affected, depending on the nature and severity of the damage.on the nature and severity of the damage.


Visuospatial FunctionVisuospatial Function Mediated by the right parietal lobeMediated by the right parietal lobe Involves understanding how objects fit Involves understanding how objects fit

together in space, part-whole relationshipstogether in space, part-whole relationships Impacts daily activities such as Impacts daily activities such as

navigating; also:navigating; also: Puzzle solving, art and play skills (creating Puzzle solving, art and play skills (creating

and/ or replicating objects in written or other and/ or replicating objects in written or other forms) – kidsforms) – kids

Driving, directional sense - adults Driving, directional sense - adults

Common Physical Sequelae Common Physical Sequelae of TBIof TBI

Motor DysfunctionMotor Dysfunction Swallowing problemsSwallowing problems Speech problems (e.g., dysarthria) Speech problems (e.g., dysarthria) Hemiparesis, spasticity, or rigidityHemiparesis, spasticity, or rigidity Coordination/balance problems due to either Coordination/balance problems due to either

cerebral or inner ear disruptioncerebral or inner ear disruption Ataxia – damage to cerebellumAtaxia – damage to cerebellum Tremors – damage to basal ganglia or Tremors – damage to basal ganglia or

thalamusthalamus


Sensory DysfunctionSensory Dysfunction Anosmia (inability to smell)Anosmia (inability to smell) Hearing lossHearing loss TinnitusTinnitus Visual problems – field cuts, diplopia, even Visual problems – field cuts, diplopia, even

blindnessblindness Proprioception difficulties (position sense) Proprioception difficulties (position sense) VertigoVertigo Stereognosis deficits (recognition of items by Stereognosis deficits (recognition of items by

touch)touch)


Seizures – 5-9% of severe BI Seizures – 5-9% of severe BI survivorssurvivors

Hydrocephalus – usually requires Hydrocephalus – usually requires surgical shuntingsurgical shunting

Emotional Sequelae of TBIEmotional Sequelae of TBIThe emotional disturbances associated The emotional disturbances associated

with TBI include: with TBI include:

Mood disordersMood disorders Anxiety disordersAnxiety disorders PsychosisPsychosis Behavioral problems Behavioral problems

Emotional Sequelae of TBI:Emotional Sequelae of TBI:DepressionDepression

Major depression occurs in at least 25% of Major depression occurs in at least 25% of patients with TBI.patients with TBI.

Feelings of loss, demoralization, and Feelings of loss, demoralization, and discouragement seen soon after injury are discouragement seen soon after injury are often followed by symptoms of persistent often followed by symptoms of persistent dysphoria. dysphoria.

Fatigue, irritability, suicidal thoughts, Fatigue, irritability, suicidal thoughts, anhedonia, disinterest, and insomnia are seen anhedonia, disinterest, and insomnia are seen in a substantial number of patients 6–24 in a substantial number of patients 6–24 months or even longer after TBI.months or even longer after TBI.

Emotional Sequelae of TBI:Emotional Sequelae of TBI:Mania/Bipolar DisorderMania/Bipolar Disorder

Mania after TBI is less common than depression but Mania after TBI is less common than depression but much more common than in the general population much more common than in the general population (about 9% of patients).(about 9% of patients).

Changes in mood, sleep, and activation may Changes in mood, sleep, and activation may manifest as irritability, euphoria, insomnia, manifest as irritability, euphoria, insomnia, agitation, aggression, impulsivity, and even violent agitation, aggression, impulsivity, and even violent behavior.behavior.

Positive family history of affective disorder and Positive family history of affective disorder and subcortical atrophy prior to TBI are added risk subcortical atrophy prior to TBI are added risk factors.factors.

Mania is often seen in patients with right-Mania is often seen in patients with right-hemispheric limbic structure lesions. hemispheric limbic structure lesions.

Emotional Sequelae of TBI:Emotional Sequelae of TBI:Anxiety Anxiety

Anxiety disorders are common in patients with TBI Anxiety disorders are common in patients with TBI and range in frequency from 11%–70%.and range in frequency from 11%–70%.

All variants of anxiety disorders are seen, but TBI All variants of anxiety disorders are seen, but TBI patients often experience generalized "free-patients often experience generalized "free-floating" anxiety associated with persistent worry, floating" anxiety associated with persistent worry, tension, and fearfulness.tension, and fearfulness.

Increased activity of the aminergic system and Increased activity of the aminergic system and decreased activity of the GABA inhibitory network decreased activity of the GABA inhibitory network is the proposed mechanism for the clinical is the proposed mechanism for the clinical manifestation of anxiety.manifestation of anxiety.

Right-hemispheric lesions are more often Right-hemispheric lesions are more often associated with anxiety disorder than left-sided associated with anxiety disorder than left-sided lesions. lesions.

Emotional Sequelae of TBI:Emotional Sequelae of TBI:PsychosisPsychosis

0.7%–9.8% of patients with TBI develop 0.7%–9.8% of patients with TBI develop psychotic symptoms. psychotic symptoms.

Psychotic symptoms following TBI often Psychotic symptoms following TBI often manifest as frank delusions, hallucinations, manifest as frank delusions, hallucinations, and illogical thinking. and illogical thinking.

The psychotic features may be acute or The psychotic features may be acute or chronic, transient or persistent, and may or chronic, transient or persistent, and may or may not be associated with mood may not be associated with mood disturbances. disturbances.

Both right and left hemispheres have been Both right and left hemispheres have been implicated in the genesis of psychotic implicated in the genesis of psychotic symptoms. symptoms.

Emotional Sequelae of TBI:Emotional Sequelae of TBI:AdynamiaAdynamia

Ten percent of TBI survivors have Ten percent of TBI survivors have apathy without depression apathy without depression (adynamia) and 60% have adynamia (adynamia) and 60% have adynamia with some degree of depression.with some degree of depression.

Adynamia may be secondary to Adynamia may be secondary to damage of the mesial frontal lobe. damage of the mesial frontal lobe.

Emotional Sequelae of TBI: Emotional Sequelae of TBI: Stages of Grief for Patients & Stages of Grief for Patients &

FamiliesFamilies Shock and disbeliefShock and disbelief AngerAnger Sorrow/grievingSorrow/grieving GuiltGuilt DepressionDepression

(helplessness/hopelessness)(helplessness/hopelessness) DenialDenial AcceptanceAcceptance

Behavioral Sequelae of TBIBehavioral Sequelae of TBIADULTS & KIDS:ADULTS & KIDS: Irritability/angry outburstsIrritability/angry outbursts Impulsivity Impulsivity Aggressive acting out/misbehaving OR passive behavior/adynamia Aggressive acting out/misbehaving OR passive behavior/adynamia DepressionDepression Sexually inappropriate behaviorSexually inappropriate behavior Social immaturitySocial immaturity Fatigue Fatigue Drug/alcohol abuseDrug/alcohol abuse

KIDS:KIDS: Poor or lower gradesPoor or lower grades Difficulty following directions at home & at schoolDifficulty following directions at home & at school

Behavioral Sequelae of TBI:Behavioral Sequelae of TBI:Other factors that have been found to Other factors that have been found to

be important in poor emotional & be important in poor emotional & behavioral outcomes after TBI:behavioral outcomes after TBI:

Marital discordMarital discord Poor interpersonal relationshipsPoor interpersonal relationships Problems at work/schoolProblems at work/school Financial instabilityFinancial instability

Interventions for TBI Interventions for TBI SurvivorsSurvivors

Cognitive Rehabilitation: Cognitive Rehabilitation: A therapeutic approach designed to improve A therapeutic approach designed to improve

cognitive functioning after central nervous system cognitive functioning after central nervous system insult. insult.

Restorative trainingRestorative training: retrains or alleviates problems : retrains or alleviates problems in cognitive functioning; reinforces or re-in cognitive functioning; reinforces or re-establishes previously learned patterns of behavior establishes previously learned patterns of behavior

Compensatory Compensatory training: establishes new training: establishes new mechanisms to compensate for impaired cognitive mechanisms to compensate for impaired cognitive functions functions


Research in adult cognitive rehabilitationResearch in adult cognitive rehabilitation Rehab may be provided by neuropsychologists, Rehab may be provided by neuropsychologists,

OTs, PTs, etc.OTs, PTs, etc. Generally shows efficacy of CR, especially for Generally shows efficacy of CR, especially for

rehab of attention, memory, and executive rehab of attention, memory, and executive functions.functions.

But…studies have been limited by small sample But…studies have been limited by small sample size, failure to control for spontaneous recovery, size, failure to control for spontaneous recovery, and the unspecified effects of social contact. and the unspecified effects of social contact.

Funding has been very difficult to obtain.Funding has been very difficult to obtain.


Support GroupsSupport Groups For SurvivorsFor Survivors For Caregivers/Family membersFor Caregivers/Family members

Individual/Group TreatmentIndividual/Group Treatment Emphasis is on adaptation to illness & Emphasis is on adaptation to illness &

compensatory strategiescompensatory strategies Medications may also be helpfulMedications may also be helpful

Tips for Working with/Tips for Working with/Living with TBI SurvivorsLiving with TBI Survivors

DODO Positive, encouraging Positive, encouraging

statementsstatements Be empatheticBe empathetic Use humor in a Use humor in a

positive and positive and supportive mannersupportive manner

DON’TDON’T Expect typical Expect typical

“social exchanges” “social exchanges” ArgueArgue


DO Encourage client to Encourage client to

write things downwrite things down Keep things simple; Keep things simple;

build at the person’s build at the person’s raterate

Emphasize important Emphasize important informationinformation

SLOW DOWNSLOW DOWN Allow time for Allow time for

responseresponse

DON’T Rush


DO Be concrete—clear & Be concrete—clear &

directdirect Offer to repeat what Offer to repeat what

was saidwas said Encourage questionsEncourage questions Ask the child to repeat Ask the child to repeat

back information givenback information given Limit options from which Limit options from which

the child must choosethe child must choose

DON’T Speak for the Speak for the

child or try to “fill child or try to “fill in” what he/she is in” what he/she is trying to saytrying to say

Talk down to the Talk down to the childchild


DO Gently help kids get back Gently help kids get back

“on track” if there is a long “on track” if there is a long lull in conversationlull in conversation

Gently help kids get back Gently help kids get back “on track” if they ramble “on track” if they ramble off topicoff topic

If child gets “off track,” say If child gets “off track,” say “I’m confused/getting “I’m confused/getting lost.” lost.”

Occasionally summarize or Occasionally summarize or restate what children are restate what children are saying or askingsaying or asking

DON’T Interrupt Interrupt (unless child (unless child

has strayed far from the has strayed far from the topic)topic)

Say “You are Say “You are rambling/off topic”rambling/off topic”


DO Set clear Set clear

boundaries if boundaries if inappropriate inappropriate remarks are made remarks are made (be firm yet (be firm yet respectfulrespectful))

Respond to Respond to inappropriate ideas, inappropriate ideas, but maintain focus but maintain focus of discussionof discussion

Provide support and Provide support and reassurancereassurance

DON’T Overreact Overreact Be offended or react Be offended or react

in anger to in anger to exaggerated or exaggerated or inappropriate inappropriate responsesresponses

Take inappropriate Take inappropriate responses personallyresponses personally

Be judgmentalBe judgmental


TYPICAL EVENTS THAT MAY CAUSE AGITATION/FRUSTRATION:TYPICAL EVENTS THAT MAY CAUSE AGITATION/FRUSTRATION: Being told ‘no’ oftenBeing told ‘no’ often Difficult tasks Difficult tasks Loud/competing noise Loud/competing noise Too much stimulation Too much stimulation Abrupt changes in routineAbrupt changes in routine Feeling stupidFeeling stupid ConfusionConfusion


IF AGITATION INCREASES:IF AGITATION INCREASES:

Change the subject to something Change the subject to something non-threatening non-threatening

Re-direct survivor’s attention Re-direct survivor’s attention Ask if survivor needs to take a break Ask if survivor needs to take a break Stay calm & supportiveStay calm & supportive


Finally…Finally…Don’t forget to take care of Don’t forget to take care of

yourself!yourself!

If the caregivers/providers are not If the caregivers/providers are not OK, then the survivor will not be OK, then the survivor will not be

OK.OK.

QUESTIONS?QUESTIONS?

brain injury basics karen brewer, ph.d. clinical neuropsychologist

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