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These program materials and the works comprising it are protected by

copyright. Copyright © 2022. The Sydney Children's Hospitals
Network (Randwick and Westmead) (Incorporating The Royal
Alexandra Hospital For Children). All rights reserved.
No part of these materials may be reproduced, or any other use made of Brain Injury
them, without the express written permission of the copyright holder.
Dr Mary-Clare Waugh
Kids Rehab
The Children’s Hospital Westmead

© Sydney Children’s Hospitals Network

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Learning Outcomes ABI

• Trauma
– Fall
1. To understand the range of presentations and – Shaken baby syndrome • Stroke or infarct
functional deficits in traumatic brain injury (TBI). – Assault
– MVA • Infection
2. To understand the interventions available in the – Gun shot – Meningitis
– Encephalitis
management and rehabilitation of TBI • Hypoxia – Abscess
3. To have an approach to the long term – Seizures
• Toxins
– Metabolic
complications of TBI – Near drowning
– Lead
– Etc
– ALTE
4. To have an understanding of likely outcomes of • Encephalopathy • Haemorrhage
TBI. – Hypertensive – AVM
– Liver failure

© Sydney Children's Hospitals Network © Sydney Children's Hospitals Network

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Brain Injury
ABI Overview
• Trauma
– Fall • Injury assessment
– Abusive Head Trauma • Stroke or infarct • Brain areas and function
(SBS) – Tools
– Assault • Infection • GCS
– MVA – Meningitis • PTA • Neuropsychological
– Gun shot – Encephalitis • Rancho LAS assessment
– Abscess • Outcomes
• Hypoxia – Challenges
– Seizures • Toxins
– Lead • Abusive Head • Treatments
– Metabolic
– Etc Trauma / Shaken – Environmental
– Near drowning Baby Syndrome
– ALTE • Haemorrhage – Drugs
• Encephalopathy – AVM
– Hypertensive • Follow up process
– Liver failure

© Sydney Children's Hospitals Network © Sydney Children's Hospitals Network

5
These program 6
materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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Glasgow Coma Scale

Paediatric
Coma Scale
• GCS Modifications for age PCS
– 0-6 months 10/15 maximum achievable
– 6-12 mo 12
– 1-2 yr 13
– 2-5 yr 14
– >5 yr 15
• Paed Coma scales

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Paediatric
PCS
Coma Scale

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Brain Injury = Loss of consciousness

PCS
• Mild BI coma scale (13)14-15
– >80% have a good outcome

• Moderate BI coma scale 9-12 (13)

• Severe BI coma scale 8 or less

– >60% have long term problems

© Sydney Children's Hospitals Network © Sydney Children's Hospitals Network

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These program 12
materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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Severe TBI Severity of Brain Injury

• Loss of Consciousness >1 hour • Post Traumatic Amnesia
• Assessment of coma – State of confusion
– Coma score ≤8/15 at 4/24
– abnormal coma score at one week – Continuous new memory
• Post Traumatic Amnesia < 5 mins Very mild
– 24 hours = severe
5-60 mins Mild
– very severe >7 days
– Modifiers PICU, drugs, fits etc 1-23 hours Moderate
• Brain Imaging 1-7 days Severe
– DAI, focal lesions, raised ICP, 1-4 weeks Very severe
hypoxia, deep lesions >4 weeks Extremely severe

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Post Traumatic Amnesia Scale PTA Scale

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PTA pictures Question 1

Which of the following statements is true about the
Westmead Post Traumatic Amnesia Test?
• Naming
• New memory A. Can be used with 5 year old children
B. Is not valid if done repeatedly
C. Evaluates new memory formation
• PTA testing after D. Assesses immediate recall of information
age 7 years E. Is not predictive of later outcomes following a
traumatic brain injury

© Sydney Children's Hospitals Network © Sydney Children's Hospitals Network

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These program 18
materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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TBI severity and TBI severity and

worse outcome worse outcome
• Earlier age at injury
• GCS or Coma score • Lower • < 7 yr, < 4 yr
• LOC • Longer • Prior knowledge and experience to draw on later in life =
cognitive reserve
• Brain abnormalities on • More lesions and
scanning deeper in location • Premorbid ability
• Co-morbidities
• Hypoxia, ICP • More or higher
• Post traumatic • Longer • Family functioning
amnesia PTA • dysfunctional
• Coma duration • Longer • SES
• Lower

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Ranchos Los Ranchos Los

Amigos Scale Amigos Scale
Level 1 - NO RESPONSE: Level 4 - CONFUSED, AGITATED:
Level 2 - GENERALIZED RESPONSE: • Combative
• Non purposeful responses; • Confusion;
• First reaction may be to deep pain; • Reacts to own inner confusion
• May open eyes
• Not seem to focus. Unable to co-op, brief attention to env.

Level 3 - LOCALIZED RESPONSE: Level 5 - CONFUSED, INAPPROPRIATE,

NON-AGITATED:
• Inconsistent responses • Alert; responds to commands;
• Reacts in a more specific manner • follows tasks
• May follow simple commands. • does not learn new information
• Need structure
Need total assistance
Symptomatic management Need maximal assistance, rehab can start
Respond to family

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Ranchos Los Ranchos Los

Amigos Scale Amigos Scale
Level 7 - AUTOMATIC APPROPRIATE:
• Robot-like behaviour,
Level 6 - CONFUSED APPROPRIATE: • Minimal confusion, needs structure;
• Follows simple directions; • Poor judgement, problem-solving and planning skills;
• Needs cueing;
• Serious memory problems Need minimal assistance, can learn new tasks
• Does self-care tasks Level 8 - PURPOSEFUL APPROPRIATE:
• Some awareness of self and others. • Learns new activities and can continue
without supervision
• Defects in stress tolerance, judgment;
abstract reasoning
Need moderate assistance
Some carry over with rehabilitation process Stand-by assistance Modified Independent, functional

© Sydney Children's Hospitals Network © Sydney Children's Hospitals Network

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These program 24
materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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Question 2 Traumatic Brain

Outcome following a severe traumatic brain injury can
Injury Outcomes
be best predicted by which of the following
parameters?
• Infant brain at birth 25% of adult size
• By 2 years 75%
A. Age at the time of brain injury • Adult size by 10 years
B. Glasgow Coma Score at presentation • Frontotemporal dev.
– 0-6 years
C. Length of time unconscious
– 17-25 years
D. Post traumatic amnesia length of time
• Head circumference
E. Extent and depth of lesions in the brain on imaging – ~ brain growth

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TBI severity Brain development

in an infant

• Difficult • Neuroplasticity – much written about

• MRI assists however younger is NOT better but worse
– Diffuse axonal injury
• Infants behaviour • Neuroplasticity enables better recovery for
– Irritability focal injuries but not diffuse injuries
– Play and interaction – raised intracranial pressure
– Time to return to “normal” – shearing injuries DAI
• Long term follow up

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Outcome after Shaken

Neuro-cognitive stall
baby syndrome

• Plateau of abilities – Predictors of severity of

– Lack of skills to facilitate outcome
learning in the classroom or • retinal haemorrhages
playground • intracranial lesions
• early neurological signs
• Grow into their deficits • AND……..
• Problems then emerge – DECELERATION OF BRAIN
GROWTH

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29
These program 30
materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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Shaken Baby
Syndrome
Question 3
A severe traumatic brain injury in an infant is often
associated with which of the following?
• Follow up suggests
50% “ok”
• Very few long term A. Immediate stagnation of developmental milestones
studies >5 yrs B. Later emergence of problems as the child develops
• Difficulty following the C. A better outcome when compared with older
whole cohort children and a similar TBI
• Most >60%, do badly D. Normal head growth
• Long term follow up E. Typically a good outcome
required

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Simone now 12 years Simone - Progress

• MVA @16/12 • Early Griffiths Developmental

• Severe TBI assessments
– skull fracture – 2 years “within normal limits”
– right hemiplegia, – 3 years “within normal limits”
– blind • Vision “normal”
• Intensive care 5 days, • Psychometric. Assessments:
• Hospital 4 weeks – 5 years age IQ low average ~85
– 8 years age IQ now <70

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Simone : Year 3 Brain Injury Sequelae

• Special School placement – Motor – Cognitive

– impaired new learning • Ataxia • Attention
– poor self monitoring • Motor dyspraxia • Concentration
– Impulsive • Dysphagia dysarthria • Executive function
– very poor attention • Hemiplegia • Memory
– very poor motor planning • Quadriplegia • Fatigue
– no sight words
– Language – Behavioral
– no spontaneous writing except name
• Executive
– very poor problem solving
dysfunction
• Socially isolated • Higher language
– Social
– Very vulnerable deficits
– No sense of humour/danger • Word finding – Family functioning

© Sydney Children's Hospitals Network © Sydney Children's Hospitals Network

35
These program 36
materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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Brain Injury Brain areas and

Sequelae function Frontal lobes
– Motor – Cognitive
• Ataxia • Attention • Language Brocas area
• Motor dyspraxia • Concentration – Expressive aphasia
• Dysphagia dysarthria • Executive function – non fluent,
• Hemiplegia • Memory – poor repetition
• Quadriplegia • Fatigue • Gait apraxia
– Language – Behavioral • Conjugate eye gaze
• Executive
dysfunction • Incontinence
– Social
• Higher language • Memory
deficits – Retrieval and acquisition
• Word finding – Family functioning (storage Temporal)

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Brain areas and Brain areas and

function Frontal Lobes function Parietal lobes
• Sensory
• Drive • Visuospatial
• Neglect
• Initiation
• Apraxias
• apathy motivation insight • ideomotor “pretend to brush
your teeth”
• Emotion • dressing - shoes on before
• Mood disinhibition irritability sox!
• impulsiveness aggressive • Constructional – cant draw
intersecting shapes
• Cognitive executive • Gerstmanns Syndrome
• Filtering planning switching flexibility • Dominant hemisphere (L)
• Left right disorientation,
problem solving word finding attention dyscalculia/acalculia, finger
concentration perseveration rigid agnosia, dysgraphia/agraphia

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Brain areas and At Brain Injury Clinic F/U ask about

function Temporal
lobes
• Upper quadrantanopia • Abnormal play / initiation
• Prosopagnosia • Behaviour characteristics
• Auditory processing • Flexibility, rigidity
• Smell
• Self regulation/ lability/ anger
• Wernickes = language
comprehension, receptive aphasia
• Danger awareness
• Storage of memory • Fatigue, headache
• Emotional control and expression • Family dynamics / coping /
• Depression understanding

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41
These program 42
materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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Assessments: Executive Functions

Neuropsychological
Assessment • Goal directed behaviour
• Deficits cause impairment in otherwise intact individuals
• Evaluate cognitive • self monitoring
functions: • initiating
– perception • inhibition (stopping)
– speed of processing • mental inflexibility
– motor functions • planning & organisation
– attention • problem solving
• abstract reasoning (concrete)
– language
– memory
– executive functions

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43 44

“Memory” Attention deficits

– alertness or arousal
• Impairments can occur in
• disconnected, withdrawn, sleep
– encoding constantly
– new learning (acquisition)
– selective attention
– working memory
• attending to speaker
– retention/long term storage
– sustained attention
– retrieving information
– can be material/modality specific • perseverance; task maintenance
– divided attention
• Implications for classroom
• listening while performing a task

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Mental status Social cognitive

and cognition • Mood
– low, labile
• General knowledge - PM etc
• Calculation - Serial sevens • Personality changes
• Concentration - 100-7 Count backwards – drive, sense of humour
• Insight - Find a stamped letter? Get lost?
• Language - Fluent ? Word finding • Cognitive fatigue
• Judgment - What to do if…?
• Behaviour
• Memory short/long - Recall an address
– aggression,
• Memory and comprehension – temper control,
• Speed of processing - Lists – disinhibition,
• Abstract thinking - Explain a proverb – hyperactivity,
• Intellect – flexibility

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47
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materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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Question 4 Treatments for BI

“Executive function” on neuropsychological
assessment relates best to which of the following • Depends on the impairments and the
skills? goals of treatment
– Environmental
A. Expressive and receptive language – Targeted deficits
– Diet = no preservatives
B. Goal directed problem solving
– Effalex – fish oils
C. Visuospatial skills – Sleep/melatonin
D. Attention and concentration skills
E. Short term memory span and digit recall • Medications

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Drug treatment trials Management BI

• Stimulants
– Ritalin
– Dexamphetamine • Educate
– Atemoxetine – family school others
– Strattera
• Antidepressants • Repetition and rewards
– Sertraline Fluoxetine
– Tricyclics • Reduce cognitive load
• Mood stabilizers • Modify curriculum
– Tegretol
– Epilim • Targeted programs
– Lamotrigine
• Antipsychotics
– Cognitive therapy
– Respiridone • Reading
– Halloperidol • Memory
– Thioridazine
– Olanzapine • Diary use, personal organisers
– Lithium

© Sydney Children's Hospitals Network © Sydney Children's Hospitals Network

51 52

Behavioural & Social family

Emotional Sequelae
• Respite/family support
• Parents report significant – Exhaustion from need to
behavioural problems in 75% continually supervise
of cases
– Getting stuck • Social reintegration (child,
• Social problems family, peers)
– poor communication • Parental job change
– lack of friends
• Evidence of post-traumatic
– rejected by others stress
– bullying/teasing – child, parents, sibs

© Sydney Children's Hospitals Network © Sydney Children's Hospitals Network

53
These program 54
materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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Family coping Long term outcome

– Premorbid factors • Multiple cognitive sequelae
– Unfavourable family – Can change over time as the
circumstances exacerbate child develops
problems from BI • Impaired
– Pre-injury functioning, life events – Social functioning
and stressors predict post-injury – Emotional function
adjustment – Behaviour control
– Family dysfunction and injury- • Impact on family functioning
related burden associated with
cognitive and academic outcome • Physical status often reasonable
– Dyspraxia motor planning

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Question 5 Acknowledgements
Long term follow up after a severe traumatic brain injury is
recommended because:
Children and Families of the
A. Immediate performances may change as the child
Rehabilitation Department at the Children’s
develops Hospital at Westmead
B. Transition periods e.g. starting school raise new issues
related to learning following the TBI
C. Families and teachers need differing levels of support
to promote independence of the child as they develop
D. This allows for early intervention around an issue
before it becomes irreversible.
E. All of the above

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57 58

Abbreviations Abbreviations
• ABI Acquired brain injury
• ALTE Acute life threatening event • IQ Intelligence quotient
• AVM Arteriovenous malformation • LOC Loss of consciousness
• MPH Methylphenidate
• BI Brain Injury
• MRI Magnetic resonance imaging
• CBZ Carbamazepine
• MVA Motor vehicle accident
• DAI Diffuse axonal injury
• PTA Post traumatic amnesia
• DEX Dexamphetamine • Rancho LAS Rancho Los Amigos Scale
• F/U Follow-up • SES Socio-economic status
• GCS Glasgow coma scale • TBI Traumatic brain injury
• ICP Intracranial pressure • TCA Tricyclic antidepressants

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59
These program 60
materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
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Contact

service@schp.org.au schp.org.au (02) 9933 8600

Copyright

These program materials and the works comprising it are protected by copyright.
Copyright © 2022. The Sydney Children's Hospitals Network (Randwick and Westmead)
(Incorporating The Royal Alexandra Hospital For Children). All rights reserved.
No part of these materials may be reproduced, or any other use made of them,
without the express written permission of the copyright holder.

61

These program materials and the works comprising it are protected by copyright which is owned by or licensed for use by SYDNEY
CHILDREN’S HOSPITALS NETWORK (“SCHN”). No part of these materials may be reproduced, or any other use made of them,
without the express written permission of SCHN.
11