Chapter 18: Major and Mild Neurocognitive Disorders Due to Traumatic Brain Injury

Description

• Traumatic brain injury (craniocerebral trauma) is defined either:

  • As an occurrence of injury to the head that is documented in a medical record, with one or more of the following conditions attributed to head injury:

    • Observed or self-reported decreased level of consciousness

    • Amnesia

    • Skull fracture

    • Objective neurological or neuropsychological abnormality

    • Diagnosed intracranial lesion

  • Or as an occurrence of death resulting from trauma, with head injury listed on the death certificate, autopsy report, or medical examiner’s report in the sequence of conditions that resulted in death.

Cognitive Domains

• Complex attention

• Executive function

• Learning and memory

• Language

• Perceptual-motor

• Social cognition

Social cognition

Difficulties in social cognition are one of the newer areas of understanding. Social cognition includes the ability to recognize emotions properly and theory of mind, which is the ability to consider another person’s mental state or point of view.

Perceptual-motor

Any difficulty in sensory perception or sensory processing may be included under the realm of a perceptual-motor deficit. Problems with visual perception, visuo-construction, and apraxias (inability to initiate or complete motor responses) and agnoses (inability to name or recognize objects)

Language

Language deficits include both expressive and receptive communication difficulties. Deficits may include various aphasias, such as word-finding problems, lack of fluency, and improper use of grammar and syntax.

Learning and memory

Learning and memory deficits range from difficulty with implicit and immediate memory to very-long-term memory impairment for autobiographical information.

Complex attention

Deficits in sustained attention, divided attention, selective attention, and speed of cognitive processing.

Executive function

Deficits in executive function, also frequently identified as executive dysfunction, may include difficulties with planning, problem solving, decision making, error correction, inhibition, and cognitive flexibility.

Determining the nature of the injury (Assessment)

• Glasgow Coma Scale (GCS)

• Children’s Coma Scale

• Rancho Los Amigos Scale

• Abbreviated Injury Score/Injury Severity Score (AIS/ISS)

Abbreviated Injury Score/Injury Severity Score (AIS/ISS)

More commonly used in clinical settings, the Abbreviated Injury Score/Injury Severity Score (AIS/ISS) has been updated (AIS 98) to better assess children. The AIS score for the head is empirically correlated with GCS and has been shown to be a useful measure of TBI severity

Rancho Los Amigos Scale

The Rancho Los Amigos Scale is a 7-level scale for assessing recovery in rehabilitation settings for those recovering from TBI related disorders

Children’s Coma Scale

The Children’s Coma Scale (CCS) is a modification of the Glasgow Coma Score designed for use with children less than 4 years of age although it is not as popular. Subscales assessing eye opening and motor response are identical to the GCS, although verbal response and behavioral aspects applied to younger individuals are adjusted in the CCS.

Glasgow Coma Scale (GCS)

The GCS categorizes severity of TBI into one of three levels; mild, moderate or severe; and can be a useful indicator of severity in adults and some youth, but is not considered useful in children 0 through 4 years of age.

Interviews

• Birth history—length of pregnancy, complications, use of forceps, mother’s health during pregnancy, mother’s exposure to any chemicals or medications, and mother’s use of drugs or alcohol.

• Developmental history—age at which critical developmental milestones were reached and any type of developmental delays or interventions. Critical milestones include those for walking, speech development, and potty training.

• Medical history—any medical or physical interventions, surgeries, or injuries the child has sustained. List of current and past medications. History of allergies, food sensitivities, and of course, head injuries of any type or intensity. Also include sleep history, sleep routine, history of insomnia, and sleep disturbances.

• Family history—any history of mental retardation, developmental or intellectual delay, academic difficulties, substance abuse, and mental health history for parents, siblings, biological grandparents, and biological first cousins.

• Academic achievement—current achievement levels, grades, study habits, test scores, and behavioral issues

• Social-emotional functioning—what the child’s daily mood or disposition is; how well he or she handles changes in routine; number of peers; how well he or she interacts with peers, adults, and authority figures; level of child’s prosocial behaviors; handling of disappointments; and leisure time activities.

• For known head injuries—age of head trauma, method of injury, any loss of consciousness (LOC), length of LOC, any memory deficits, changes in child since injury, learning difficulties, and triggers to any emotional or behavioral outbursts.

• Mental status examination—a mental status examination assesses a child’s orientation to time, place, self, and purpose. Some structured, copyrighted measures attempt to provide normative information based on age and level of education. Other elements of a mental status examination assess a child’s verbal fluency, memory, and cognitive flexibility at an age-appropriate level. Use of similar formats and noncopyrighted measures should also provide valuable insight to the child’s cognitive functioning