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What is EF influenced by?
- Structure inherent in the task (more structure reduces demand on EF)
- Novelty of task (more novelty increases demand on EF)
- Presence/absence of contextual cues (more cues=less demand)
- intelligence & motivation
What does problem solving involve?
- 1. Mental construction of problem (identification)
- 2. Generating possible solutions
- 3. Selecting the best solution (decision making)
- 4. Executing that solution (initiation)
- 5. Determining if the problem was solved (memory, motivation, attention)
- Also involves awareness and episodic memory (for identifying and generating)
In regards to problem solving:
How are TBI patients in analyzing problems?
How is their ability to generate solutions?
Are they thoughtful or impulsive when selecting solutions?
How does this impact their participation in society?
- Trouble coming up with more than one solution
- social problem solving is affected
What is abstract thinking/reasoning/gist? TBI patients often have problems with... (5) in this aspect.
- Going beyond concrete interpretation to synthesize information and apply stored knowledge
- Abstract/figurative interpretations (are literal)
- Sequencing information
- identifying relevant information
- organizing/categorizing information
- discriminating between similarities/differences
TBI patients also have poor self-awareness of deficits, aka ____. Awareness is not "all or none," but rather requires ___ skills. There are also emotional and/or cognitive components to consider, such as ___ or ___ vs. actual awareness issues. Lack of awareness is a negative prognostic indicator. There is also a strong correlation between awareness and caregiver burden. What are the 3 kinds of anosognosias?
- denial, avoidance
- Intellectual ("Yes, I have memory probs")
- Emergent (Capable of knowing when they experience problems)
- Anticipatory (knowing in advance when they might have difficulties)
Planning requires memory of scripts that contain information about the ___ order, ___, and ___ ___ of each step. It is arranged like semantic memories (e.g., activate one script, activate other semantically-related scripts). In TBI, there are problems with... (4)
- relative importance
- Temporal ordering of actions
- Script rule violations (e.g., stop script too soon)
- Problems determining relative importance of each step
- Sorting steps (which steps go with which scripts)
Debate on if it is a separate cognitive domain.
What are common components included in social cog?
What are hot social cog skills? What are cold? Problems with each?
- EF, emotion, perception, pragmatics
- Hot: Pick up and relate to emotional status
- Cold: TOM (make assumptions about thoughts)
- Problems with hot: ID facial expressions
- Problems with cold: TOM, inferencing
What is the definition of a mild head injury? What is the GCS score?
- One or more of the following:
- LOC <30 min
- PTA <24 hours
- Confusion or disorientation
- Other transient neurological abnormalities
What is the difference b/w concussion and mild head injury?
NONE. They are synonymous. Both have acute changes in the brain. Person can't go back to activity till a week or 2 later. Studies show damage in white matter at least 3 months after. In many individuals, this damage lasts a year.
Are the majority of TBI cases mild?
Repeated concussions/mild TBI increases risk between what? What is the technical term for this used with athletes and vets?
- Yes-- across all ages, 75%. 85% of vets are mild
- Progressive neurological diseases, especially AD
- A motor neuron disease similar to ALS
- Chronic traumatic encephalopathy
What are the primary causes of mild head injuries in middle-age adults? Kids & elderly?
- Sports-related injuries
What are physical, emotional/behavioral, and cognitive symptoms of a mild head injury?
- Physical: Headache, fatigue, noise and light sensitivity, loss of smell & taste
- Emotional/Bx: Depression, anxiety, easily irritated (usually bc they aren't educated on symptoms of mTBI), PTSD
- Cognitive: Concentration difficulties, mental slowness, problems in more demanding conditions (novel & complex)
What is recovery in mTBI like? To be in the PCS category, how long must symptoms remain? When are you more likely to show PCS?
- About 85% of mTBI patients will make full recovery within A year (15% have persistent problems, aka persistent post-concussive syndrome (PCS))
- Have to show continuation of at least 3 symptoms over 3 months (all previously discussed symptoms)
- If you've already had TBI, have pre-existing psychiatric disorder, or if you're a student
What is the definition of moderate/severe head injury? Moderate characteristics? Severe?
- In coma >30 minutes
- Moderate: >30 minutes but <24 hours; PTA length- >24 hours but less than 1 week. GCS=9-12
- Severe: Coma longer than 24 hours, PTA longer than week, GCS=8 and below
What is recovery of moderate & severe like?
- Moderate: Not much data, but not as good
- Severe: 30% return to employment (but not necessarily same job they had)
What is speech like after mod-severe TBI? Why is speech challenging to address with TBI patients? What dysarthria is more common?
- Difficulty initiating vocalization (motor initiation)--BG, supplementary motor area
- AOS: Quickly remits or is severe & persistent
- Dysarthria: General estimate is 1/3 of TBI pts
- In TBI pts, the more severe dysarthria, the more severe cog deficits because underlying damage is more severe (subcortical damage)
- Challenging bc of awareness issues. Spastic Is more common because UMN are easier to damage
What is dysprosody? What is the most common deficit leading to least common?
- Excessive or not enough prosody
- Slow speech rate, decreased pitch variation, stress issues, reduced phrase length, prolonged pauses, decreased loudness variation
In the early stages of recovery (emerging from coma), what is language like? What recovers earliest?
Gesture and verbal comprehension recover first. Reading and writing recover at a slower rate
In the middle stages of recovery (PTA), what is the impact of confusion? The impact of impaired attention? Impact of memory?
- Language comprehension deficit in one in confusion (e.g., 1 step direction...higher command=more confusion). Writing deficit reflective of confusion (e.g., bizarre spelling errors)
- Confabulations, pragmatic skills (don't remember what you've said, who asked questions, etc.)
In the later stages of recovery (post-PTA), what are 3 common profiles?
- 1. Disorganized language secondary to cognitive deficits (most common)
- 2. Language disorder with minimal cog deficits
- 3. Residual cog deficits only
How frequently does aphasia occur after TBI? What is the recovery like for survivors with aphasia? People with aphasia due to TBI have better/worse recovery than those with aphasia due to stroke?
- Poor functional outcome, employability, higher disability, longer rehab stays
Anomia post-TBI is characterized by what? What is "language of confusion"?
- Slow processing time
- Old name for cog-comm disorders; representative of distinction b/w TBI deficits and aphasia
- pragmatics are challenging for TBI but often not in aphasia
What is the theoretical background of pragmatic deficits? what contexts are relative?
- ability to be sensitive and monitor communication environment (involving attn., memory., other EF skills); "top down processing"
- Social context (cultural, relationships)
- cognitive (awareness of shared knowledge, purpose of interaction, emotional cog status of partner)
- Physical context (e.g., location)
- Linguistic & nonverbal context (whats already been shared)
What is the importance of assessing/managing pragmatics?
re-integration and socialization, which are 2 predictors of recovery
What are sources of pragmatic deficits?
- Residual cog deficits (e.g., visual sustained attn., facial expression, physical context, etc.), problem solving (comm breakdowns)
- poor motivation
- lack of social knowledge (compromised TOM)
- impaired emotion perception (more in mod-severe cases)--difficulty perceiving negative emotions vs positive, difficulty discriminating and labeling
- poor executive control
- fewer social/communicative opportunities
What are comprehension deficits?
- Attention deficits (processing and picking up on contextual cues)
- memory deficits (remembering details of conversation, recalling information about partner)
- executive problems (picking out what's most/lease important, order of conversation), deductive reasoning, inferring
- visuospatial deficits (attending to cues in physical environment), body language, proxemics, metaphors (common in everyday living is no problem, less common are more difficult)
What are production deficits?
- nonverbal communication deficits (proxemics, kinesics aka body language, eye contact, affect)
- very context dependent (when assessing there is only one context (e.g., one partner in tx room)
What are some interactional deficits?
turn-taking (not enough or too much), conversational repair, communicative intents
What are propositional deficits?
- Content issues
- Topic management (selecting, maintaining)
- informativeness (confabulations)
- organization (sequential, organized, manner, directions, use of cohesion devices like conjunctions, pronouns)
- Abstract language
What are prerequisite skills to reading and writing? What are deficits in these areas?
- Auditory and visuoperceptual abilities (sounding out words)
- Reasoning and organizing
- Access to linguistic and nonlinguistic knowledge (reading words and interpreting from memory)
- drawing on past experiences (memory)
- Spelling errors, incomplete sentence construction and/or poor syntax, reading problems (especially long, complex material), organization problems)
- **if you use an aphasia battery to assess this patients, you may miss their errors b/c aphasia batteries assess at word and sentence level, which are typically easier for TBI patients. more complex material like paragraphs are harder.
define emotional and behavioral disorders.
- Overt actions that result in socially maladaptive interactions b/w the patient and environment
- families report this as most distressing. also challenging for assessing and treating, as well as diagnosing. If someone has an undiagnosed hearing loss, they might have behaviors
What are common emotional/behavioral deficits?
- disinhibition of aggression (easily irritated, argumentative)
- Impulsivity (reduced capacity to control and monitor bx; could be inhibition issues, problem-solving, attn., easily distracted)
- Inflexibility (rigid in scheduling, difficulty with seeing others' points of view)
- paranoid symptoms (misinterpret other ppls' comments and actions; accusatory and uncooperative; associated with temporal lobe damage)
- depression (important prognostic indicator)
- inappropriate sexual behavior
- self-centered, egocentric
- immature behavior
- poor frustration/tolerance (more common in speech and language disorders, associated with dysinhibition, can relate to too difficult or too simple tasks)
- noncompliance (refusing to come to tx, won't participate/adopt strategies)
- substance abuse
Explain 'episodic dyscontrol'
Type of disinhibition of aggression that is pathologic. They just 'fly off the handle.' Might be related to seizure activity. Frequently associated with damage to the temporal lobe.
Which emotional/behavioral deficit is most common? What can it arise from? At what point in recovery does it occur? Why is it important to recognize this deficit? Why is it difficult to identify?
- brain injury (organic, NTs), reaction to brain injury, and/or premorbid characteristics
- various stages; acutely, discharge, plateau phase are examples
- TBI patients are at greater risk for depression and twice as likely to commit suicide
- Awareness issues, affect/prosody, social isolation, sleep disturbances, concentration issues (i.e., many signs of depression are also effects of TBI in general)
How can you manage noncompliance?
- check goals/activities and make sure they're functional and motivating for client
- allow the patient nd family to be involved in goal setting
- make sure stimuli/activities are age and culturally appropriate
- see if clients are really aware and if not, target that first
What is ptsd? What are symptoms? Who are at greater risk?
- 'anxiety' disorder
- neurological changes can take place (e.g., decreased hippocampal size)
- hypervigilance, depression, sleep disturbances, nightmares, irritability, negatively affects cognitive abilities
- People with pre-existing emotional diagnosis wit history of substance abuse, personality traits (those who externalize blame), more common in mild vs. severe
What is frontal lobe syndrome? What are characteristics of it?
- changes in personality and behavioral profile
- lack of insight/anosognosia, decreased or lack of initiation
The 2 well-described frontal syndromes are (1) frontal poles/dorsolateral region damage and (2) orbitofrontal damage. explain the characteristics of each.
- (1) "pseudodepression"; arousal disorder; apathetic, flat affect; disorganization of bx sequences; difficulty shifting sets (perseveration), problems self-monitoring (in general, this is a significant drive deficit)
- (2) "pseudopsychopathic"; excess drive; disinhibition (eloping, distractible, impulsive), mania (strong emotion/shift quickly, 'invincible', flight of ideas and might not sleep for days), talk excessively and tangentially
- Bilateral damage=worse symptoms and more difficult to manage
What are secondary reactions to tbi? (brief)
acceptance of disability, denial of disability, accident neurosis, reaction of caregivers, social isolation
what is accident neurosis?
experiencing symptoms that should've responded to treatment but didn't; psychogenic--person not aware that they're contributing to symptoms; example: when insurance/litigation is settled, symptoms subside--NOT malingering or faking symptoms
how do the reactions of caregivers affect secondary reactions?
patients pick up on when people are avoiding them so may become depressed, socially isolated, aggressive, have attention getting behaviors). Look at how the staff is interacting with the client.
What is the #1 problem reported post-tbi (besides depression)?
What are causative factors to explore when assessing?
- Lesion location (brainstem--decreased arousal, limbic structures--regulation of emotion, frontal lobe damage--frontal lobe syndrome)
- person (pre-existing ED/bx disorder? pre-morbid personality)
- context (when do you see issues?)
Explain the treatment in:
Education & involvement of staff & family
Coping & stress management techniques
- Restraints if bx is harmful, apathetic, close supervision, contextual factors
- Explaining that issues are d/t tbi not out of spite; educate teachers, colleagues, classmates too
- Drugs for arousal, for example
- "Talking therapy"; programs available
- Examples are taking breaks if they're getting upset
What are causes of TBI in children?
0-4 years? Older kids?
Why are boys morel likely to have a TBI?
- Accidents at home (falls, bed)
- More sports-related
- MVA (because they're driving)
- Child abuse
- "bigger risk takers" and "not as supervised"
What is more of an issue in regards to pathophysiology in TBI in kids?
Skull is not as rigid so there can be more shearing than adults; speed and impact are not usually issues
What are the 2 recovery hypotheses in kids with TBI?
Greater plasticity (greater recovery potential). This is an oversimplification because it depends at what point in development damage occurs. Example-myelination of frontal lobes continues until early 20's. Some say age 7 is cutoff and if you have damage before, worse prognosis. Others say 4 years.
Reorganization: Limited; RH can only take over so much and something will suffer.
What are predictor variables in kids with TBI?
- Injury severity (time in coma, PTA)
- Lesion characteristics (frontal lobe involvement=worse prognosis)
What are special considerations with kids with TBI?
- Delayed onset of some deficits (developmentally or until demands are greater)
- Long-term effects can be cumulative (e.g., coding deficits aka learning will become bigger as they advance in school)
- Differences in each developmental stage (follow up at minimum every 2 years until maturity, or 30 years old. This isn't always followed)
What are motor and sensory impairments in kids with TBI?
Same as adults, but children generally show better recovery in these domains. They are, however, at risk for physical problems not seen in adults, such as different leg lengths
What are cognitive deficits in kids following a mild TBI? What are issues with this domain?
- 85% will have problems; 15% persist
- Assessments aren't as sensitive as adult population. Structured vs. unstructured tests. Kids w/ mild TBI might have some behaviors, but MRI shows there is more activation than their peers, indicating they're using more neural resources to work harder
What are cognitive deficits in kids following moderate/severe TBI?
- Vulnerable to all.
- Memory: WM, LTM
- Language (lexical semantics, discourse productions, A/C difficulties when WM demand is greater, pragmatics, reading/writing)
- EF (but know the typical developmental pattern)
- Visuoperceptual problems
What are factors to consider with behavioral problems in kids after TBI?
- Consider behaviors pre-morbidly
- More variability than adults
- Pre-injury personality, family coping, impact of being hospitalized, social circumstances, family cohesion, poor body image, social isolation
- Acting out, low self-esteem and depression
Outcomes in kids with TBI?
emotional/behavioral issues have more impact in functional outcomes than physical and cognitive
What is the scholastic performance of kids with TBI?
- reading is more impaired than that in adults
- moderate/severe at risk for long term deficits in reading, math, and other academic areas
- ¼ put in SpEd
- Undiagnosed mild TBI may explain unexplained academic difficulties
What are family issues/considerations regarding kids with tBI?
- Pre-trauma family functioning (marital harmony)
- Adjusting goals, guilt for accident, other stressors, not a good understaning of consequences of TBI
- Changes in parental handling (overprotective, hesitant to discipline, overzealous, inadequate education of parent)
- Sibling left out of the education process and might act out if they aren't receiving attention; anger
Name some federal legislation and accreditation for kids with TBI?
- Public Law 101-476 (IDEA)
- Expanded Definitions of Intellectual and Developmental Disabilities (each state has their own)
- Concussion legislation (education on how concussions should be managed)
Who would be team members for a kid with TBI?
ST, OT, PT, neuropsych, nurses, primary care doctor, surgeon, family members and patient, psychologist, psychiatrist, social worker, audiologist, teachers, optometrist, VR
Why do you do a case history ?
What are some information sources?
What type of information should you get?
- Yields information to pick assessment procedures; not many tats that look at contextual factors (who model)
- Interview, medical records, feedback/observations from other team members and self
- Medications, social adjustment, ethnocultural/demographic, background, legal issues, history of drug/alcohol abuse, etc.