2018 Traumatic Brain Injury Conference: Connecting the Dots After TBI May 12, 2018

1. Neuropsychological
Assessment Following
Pediatric TBI
MARISSA E. CAREY, PHD
NEUROPSYCHOLOGY GROUP OF WEST VIRGINIA PLLC
MORGANTOWN, WV
2018 Traumatic Brain Injury Conference:
Connecting the Dots After TBI
May 12, 2018

2. Objectives
 What is neuropsychology and what is a
neuropsychologist?
 What is a neuropsychological evaluation?
 Who needs a neuropsychological evaluation?
 What to expect on the day of evaluation?
 What to expect after the evaluation?
 Brief review of TBI types and factors that affect
neuropsychological recovery in children
 Review neurobehavioral changes often associated
with TBI
 Case examples

3. What is Neuropsychology?
 Clinical Neuropsychology (NAN, 1991)
“…defined as the study of brain-behavior
relationships based on the combination
of knowledge from basic
neurosciences, functional
neuroanatomy, neuropathology, clinical
neurology, psychological assessment,
psychopathology, and psychological
interventions.”

4. What is a
Neuropsychologist?
 Clinical Neuropsychologist (APA Div. 40, 1989)
“A professional psychologist who
applies principles of assessment and
intervention based upon the scientific
study of human behavior as it relates
to normal and abnormal functioning of
the central nervous system.”

5. What is a Clinical
Neuropsychologist?“…a professional within the field of psychology with special
expertise in the applied science of brain-behavior relationships.
Clinical neuropsychologists use this knowledge in the assessment,
diagnosis, treatment, and/or rehabilitation of patients across the
lifespan with neurological, medical, neurodevelopmental and
psychiatric conditions, as well as other cognitive and learning
disorders. The clinical neuropsychologist uses psychological,
neurological, cognitive, behavioral, and physiological
principles, techniques and tests to evaluate patients’
neurocognitive, behavioral, and emotional strengths and
weaknesses and their relationship to normal and abnormal
central nervous system functioning. The clinical
neuropsychologist uses this information and information provided
by other medical/healthcare providers to identify and diagnose
neurobehavioral disorders, and plan and implement intervention
strategies.” - NAN Position Paper, 2001

6. Minimum Training Criteria
 A doctoral degree in psychology from an accredited university
training program.
 An internship, or its equivalent, in a clinically relevant area of
professional psychology.
 The equivalent of two (full-time) years of experience and
specialized training, at least one of which is at the post-
doctoral level, in the study and practice of clinical
neuropsychology and related neurosciences. These two years
include supervision by a clinical neuropsychologist.
 A license in his or her state to practice psychology and/or
clinical neuropsychology independently.
 At present, board certification is not required for practice in
clinical neuropsychology.

7. What is a Neuropsychological
Assessment?
 Comprehensive evaluation includes:
 Cognitive Assessment
 Intellectual function
 Language
 Visual-spatial/Visual-perceptual skills
 Attention
 Memory
 Processing Speed
 Abstract reasoning/ executive function
 Motor and sensory exam
 Academic achievement
 Behavior/Mood Assessment
 Personality Assessment

8. Use of Personality/Behavior Measures
in Neuropsychological Evaluations
 Psychiatric and neurological symptoms that may overlap include:
 Decreased attention
 Decreased learning/memory
 Word-finding difficulties
 Changes in judgment
 Reduced awareness
 Impulsivity
 Affective disturbance
 Social withdrawal
 Difficulty expressing ideas
 Decreased cognitive efficiency

9. What to Expect from an
Assessment
 This is an all day affair
 6 to 8 hours
 Gather comprehensive history including medical/injury
history
 Get collateral reports from family, teachers, etc.
 Comprehensive and integrated report
 Follow-up face-to-face feedback session with
patient/family

10. What to Expect in a
Neuropsychological Report
 Thorough review of patient history
 Behavioral Observations
 List of Measures Used
 Written explanation of test results by domain
 Summary of findings and diagnoses
 Recommendations for school, medical follow-up, other
treatment interventions

11. Who Needs a
Neuropsychologi
cal Assessment?

12. Statistics
 Over 2.8 million sustained a TBI in the U.S. in 2013:
 >50,000 deaths
 280,000 hospitalized
 2.5 million treated and released from ER
 75% of TBIs are concussions or mild TBI
 Among children ages 0 to 14 years, TBI results in an estimated:
 2,685 deaths
 37,000 hospitalizations
 435,000 ER visits annually
 Most treated and released (91.5%)
 >248,000 ER visits for sports or recreation-related injuries (57% increase
in last decade) for age<19 years

13. More Statistics
 80,000 to 90,000 people with TBI experience
permanent disability from their injury each year
 An estimated 5.3 million Americans – about 2% of
the population – currently live with disabilities
resulting from brain injury (CDC)
 Traumatic brain injury is the leading cause of death
and disability among children and young adults
under age of 44.
 4th leading cause of death overall (accounts for 1/3
of all injury-related deaths).

14. Who’s at Greatest Risk?
 Males are about 1.5 times as likely as females to sustain a TBI
 Males 3x more likely to die from TBI
 The two age groups at highest risk for TBI are 0 to 4 year olds and
15 to 19 year olds
 Assault leading cause of TBI death in 0-4 year olds
 MVA leading cause of TBI death in 5-24 year olds

15. Types of TBI
 Penetrating head injury
 Closed head injury
 Includes concussion
 Most injuries result in focal damage
 CHI often results in diffuse damage as well caused by:
 Brain moving back & forth inside bony
skull
 Frontal and temporal lobes most
susceptible

16. Skull Anatomy
Frontal Bone
Sphenoid Bone
Temporal Bone
Occipital Bone
Cribiform Plate
Foramen Magnum
www.gwc.maricopa.edu
Optic Foramen

17. Primary Injuries
 Impression - direct contact between
stationary head and some physical force ->
skull fracture
 Acceleration-Deceleration - impact with a
moving head (i.e., falls, MVAs)
 Rotational - occur when skull stopped by
impact but brain continues to move in the
skull
 Tearing/bruising of blood vessels -> focal contusion or
hemorrhage (most occur in frontal and temporal cortices)
 Shearing/straining of WM nerve fibers -> diffuse axonal injury

18. Mechanisms of Injury
In a coup injury, a blow to the rear of the skull
results in an injury to the anterior of the brain. In a
contracoup injury (right), the brain recoils and
strikes the posterior skull as well injurying it twice.
Lateral views showing motion of head and neck
during whiplash injury.
www.braininjury.com

19. Secondary Injuries
 Follow initial trauma
 Brain swelling
 Cerebral Edema
 Increased intracranial pressure
 Ischemia/Hypoxia
 Mass lesions (hematoma)
 Epidural hematoma - blood collect in space between dura and skull
(usually associated with skull fracture)
 Subdural hematoma - blood collects in space between dura and
arachnoid membranes (tearing of veins in sagittal sinus)
 Intracerebral hematoma - occur within brain parenchyma
 Neurochemical changes
 Brain herniation

20. Delayed Pathology
 White matter degeneration
 Cerebral atrophy/ Ventricular enlargement
 Posttraumatic hydrocephalus
 Posttraumatic seizures
 Occurs in 3-9% of children with TBI
 Younger children more vulnerable to this
 More common in penetrating injuries/ depressed skull
fractures (incidence of 10%)
 Most occur within 2 years of injury

21. Neurobehavioral
Consequences
 Alertness/Orientation - mostly acute changes
 IQ - fluid intelligence and processing speed
 Language - subtle language deficits, pragmatics, discourse
 Nonverbal skills - visual-constructional
 Attention and memory - encoding, storage and retrieval
 Executive function - planning, concept formation, mental flexibility,
inhibitory responding, metacognition
 Sensory and motor skills
 Academic achievement - more related to demographic variables than
cognitive/behavioral variables
 Adaptive function/Social skills and judgment
 Behavioral adjustment/Personality changes
 Emotional disturbance – depression and anxiety common

22. Long Term Recovery
 Concussion symptoms resolve in 7-10 days in majority of cases
 May be up to 3 weeks in children and adolescents
 Persistent symptoms beyond this referred to as Post-Concussive
Syndrome
 Persistent symptoms 3 months post-injury following an
uncomplicated mild TBI is uncommon
 For moderate to severe injures more variable
 The more severe the higher probability of LT impairments and persistent
disability
 Recovery can take more than 12 months

23. Plasticity in Recovery?
 Neuroplasticity refers to the changes that occur in the
organization of the brain, and in particular changes that
occur to the location of specific information processing
functions
 Model argues that young children sustain less severe
structural damage and fewer functional deficits
compared to older children and adults
 May be true for focal TBI, but not clear if applies to more
diffuse injury
 Evidence suggests that early injury disrupts normal
development with cumulative deficits over time

24. Anderson, et al., Pediatrics 2005;116:1374–1382
Recovery of global intellectual skills over 30
months after
TBI for children sustaining TBI from birth to 12
years.

25. Trajectories for verbal IQ (A) and performance IQ
(B) over 30 months after TBI.
Anderson, et al., Pediatrics 2005;116:1374–1382

26. Reasons for Referrals Following
TBI
 Document cognitive/ behavioral consequences of TBI
 Attention and memory difficulties
 Behavior problems
 Mood disturbance
 Personality changes
 Academic problems
 Track injury recovery/developmental progress
 Assist with return to play or school determination
 Differential diagnosis

27. Referral Sources
 School
 Family
 Primary Care Doctors
 Neurology
 Psychiatry
 Other Medical Specialties
 Rehabilitation Services
 Legal Services/Court System

28. How to Make a Good
Referral
 Do NOT just write “diagnosis clarification”
 Do NOT just write a list of diagnoses
 DO formulate a question
 Current concerns
 Assess for???
 Helpful to know current medical and psychiatric
diagnoses, medications
 A recent progress note or intake note helpful

29. Case Examples