Abstract 3 to 10

Bibliography 11 to 12

By John Simpson March 30, 2003

First of all, let us define acquired brain injury (AB.I.).

An acquired brain injury (AB.I.) is a disruption in brain functioning caused by an external trauma (e.g. motor vehicle crash or a fall), anoxic injury (e.g. heart attack or near drowning), infectious disease (e.g. meningitis), brain tumour, cerebral dysfunction (e.g. stroke), intercranial surgery, toxic exposure and other neurological disorders which predominately affect the central nervous system.

What is the incident rate in British Columbia? It is somewhere in the range of 7,000 to 12,250 but unfortunately, there is no registry, although a pilot project was done several years ago which proved how useful it could be. When it comes to children, please refer to tables one and two.

This shows, again, a huge range between 2,700 and 4,000 per year.

While the terms mild, moderate, and severe brain injury are frequently used to describe the "type" of injury the child sustained, these same descriptors often fail to tell us about outcome. Since children are less likely to lose consciousness after a blow to the head they are often thought to have fully recovered within days and weeks. However, over time children may experience significant cognitive and/or behavioral problems after only a minor blow to the head. In addition, as one searches the medical literature, there is no consistent definition of mild, moderate, or severe brain injury among physicians, psychologists, educators, etc. (Eichelberger et al, 1990).

Seventy percent (70%) of all brain injuries are classified as mild (RIA, 1994). Mild brain injury mayor may not involve loss of consciousness. In the mildest form the person has momentary confusion and disorientation that may resolve completely within a matter of seconds after the event. They may not be able to remember the impact or what happened immediately before the incident (retrograde amnesia). This type of injury usually resolves without further sequel except for some degree of permanent retrograde amnesia. Some individuals experiencing mild brain injury may also forget what happened immediately after the injury (post-traumatic amnesia) and their confusion may extend to minutes rather than seconds.

Most children with mild brain injuries experience a good recovery, however, I - 3% of these individuals may develop complications such as bleeding or swelling, requiring neurosurgical intervention. (Dacey and Dimen, 1989). Many children may continue to have post-concussive symptoms such as headache, fatigue, concentration/attention problems, dizziness, or blurred vision for up to three months after the initial injury.Children respond to mild brain injury differently than adults. Initially after the injury, they demonstrate more pronounced physical responses such as lethargy, nausea and vomiting (Snoeck et al, 1987). Therefore, vigilant observation and assessment is essential to detect subtle changes that may herald deterioration and serious complications.

Additionally, there are some individuals who will continue to experience persistent difficulties following a seemingly minor injury. Parents and teachers need to be aware of signs that may indicate persistent problems requiring attention such as any increases over the pre-injury baseline for fatigue, unexpected absences, inattentiveness, difficulty remembering, conflict with peers, inappropriate or disrespectful behaviors (Ylvisaker and Savage, 1994).

The role of health care professionals in the prevention, detection, assessment and management of mild brain injury is considerable. Taking the lead in the design and implementation of safety training programs, in-service education presentations, development of assessment checklists, follow-up observation tools, and tracking forms for early detection of performance problems, etc., can have a considerable impact on improving the quality of services and interventions offered in the school for these students and families. Coordination and integration with local hospital emergency rooms, physician offices, childcare centers, etc. can foster continuity in protocols and improved detection, appropriate recognition and treatment, community-wide.

Those with moderate brain injuries experience a loss of consciousness and post-traumatic amnesia, which usually subsides and resolves completely within 24 hours post-injury. Moderate brain injury is less common than mild or severe. While most individuals with moderate brain injury go on to experience a good recovery, many may be left with longstanding pronounced cognitive and psychosocial problems.

These individuals are particularly vulnerable because their quick dramatic hospital recovery (i.e., going from being unconscious to waking up and following command within 24 hours) is such a relief that it often times leads to false sense of security. The individuals seem quite well overall, but problems may develop later on when they are confronted with the demands of returning to home, school and the community.

Severe brain injury results in loss of consciousness, which may last for days, weeks, or months. Initially, the child may only move in response to deep pain. He/she may have signs of brain stem damage such as posturing and abnormal pupillary reactions. The child's hospital course may be complicated by the need for additional surgeries because of hematomas or increased intra-cranial pressure. The incidence of hematomas is lower for children than adults, but more children with severe brain injury have increased intra-cranial pressure (Shapiro & Marmarou, 1982: Bruce et al., 1978).

Severe brain injury may also result in blood pressure, heart rate, breathing and temperature regulation problems and seizures. Children tend to develop early seizures more frequently than adults, but that does not necessarily mean that the child will develop post-traumatic epilepsy (Shapiro, 1987).

A person with severe brain injury overcomes serious life-threatening obstacles sometimes against all odds. Early in a person's recovery, he/she may struggle to recognize people, places and things. As the individual progresses and his/her confusion lessens, he/she learns or relearns how to eat, drink, move and communicate. Parents, friends and family are thrust unexpectedly into the strange and unfamiliar sight and sounds of intensive care, traveling through the ups and downs of an often times rocky rehabilitation course, and finally, arriving at the point they have been longing for -returning home. And returning home is another step in the child's ongoing recovery. Recovery is not a single event; it is a life process.

Taken from: An educator's Manual: What Educators Need to Know About Students with Brain Injury

Dr. Barry Willer in Ontario did some employment figures based on Stats Canada information. Unemployment statistics for British Columbia show that 75.5% of the brain injured are unemployed. 6.1 % work between 20 and 30 hours per week and 3.5% work less then 20 hours per week and 14.9% work 30 hours per week.

There has been research done in the United States, Australia and New Zealand that show for milder brain injuries if the right rehabilitation provided promptly without delay, 88% return to work, however, this is reduced to 12% if there is a delay of over 3 months.

Now look at how children and Young People are injured. Note the long-term disabilities. .

Not well, by and large, particularly if behavior problems are involved. Those that make it through school and can try going to college are also faced with problems. There is an excellent article, "Subtle Symptoms Associated with Self Report Mild Head Injury", Sidney J. Segalowitz and Sheila Lawson, published in the Journal of Learning Disabilities - Volume 28. No.5, May of 1995.

ABOUT THE AUTHORS: Sidney J. Segalowitz earned his Ph.D. at Cornell University in human development and teaches adult and child neuropsychology. Sheila Lawson earned her BA in Brock University in Canada and currently does research and assessment in developmental psychology and neuropsychology. Address: Sidney J. Segalowitz, Department of Psychology, Brock University, St. Catharines, Ontario L2S 3A 1. Canada or Email:

Refer back to the page 5: Then refer to Table 3 - long term disabilities and note the number that have behavioral problems.

Consider the following comments from Coastline Community College in California, which has a program specializing in the continuing education of those living with the effects of a brain injury.

There are further comments contained in the A.B.I. Handbook Serving Students with Acquired Brain Injury and High Education. The comments are as follows:

Deficits in psychosocial and behavioral functioning after acquired brain injury can be devastating. Of all the possible consequences, psychosocial and behavioral deficits can be the most damaging for long-term reintegration into home and community life. It is becoming increasingly clear in longitudinal studies after traumatic brain injury that behavioral and social deficits follow a longer, more complex pattern of change compared with physical and cognitive deficits. Therefore, it is critical to adequately understand the common types of psychosocial and behavioral disabilities frequently seen after brain injury. Whenever possible it is important to distinguish between the organic (i.e. due to damage to the emotional control or executive function units) or functional (i.e. reaction to the brain injury) nature of the problem. Unfortunately, this is not always easy to accomplish. In addition, psychosocial problems may have pre-existed the brain injury which further complicates the problem." Again, go back to the pages on consequences, pages 4 and 5 and pay particular attention to the problems, which are underlined. When it comes to adults who were working, the number reason for losing jobs is behavior and anti-social attitudes. Behavior, by the way, can be anything from poor hygiene to slugging the boss in the face. Again, look at Figure 3 and see the long-term disabilities.

We will look at how some children are injured, including babies. Shaken babies can have terrible outcomes. The following is an excerpt from a summary of presentations given at a conference on shaken babies.

In hospital-based studies presented at the conference, 15 percent to 32 percent of SBS victims died, and the majority of survivors had moderate to severe problems. Fewer than 10 percent to 15 percent were generally reported to have normal outcomes at short-term follow-up, with the long-term outcomes as yet unknown. Predators for mortality included a delay between infliction of injury and medical attention, age of the child (older than six months), presentation of the child in a comatose state and cerebral edema.

The limited data available, including anecdotal information from family members, indicated that sequelae among survivors included partial or complete loss of vision, hearing impairments, seizure disorders, cerebral palsy, sucking and swallowing disorders, developmental disabilities, hemiparesis, autism, emotional volatility, cognitive impairments, behavior problems including low tolerance for frustration and extremely short attention span, and permanent vegetative state.

Several presenters reported that SBS cases were not limited to any special group of people. Cases transcended gender, ethnicity, age and socioeconomic status. In both civilian and military populations, however, males were reported as perpetrators in 65 percent to 90 percent of cases of SBS. The most common perpetrator was the biological father of the victim, followed by boyfriends of mothers, then childcare providers. Although reports from Canada indicated that perpetrators were often teen fathers, data from the Untied States suggested that perpetrators were often adult males in their early 20s. When females were perpetrators, they were more likely to be baby-sitters or childcare providers than mothers. The reported age of perpetrators ranged from 13 to 65 years.

In the vast majority of cases in which a perpetrator was identified, he or she was with the victim when the child because symptomatic. In a number of cases involving a male perpetrator, histories suggested that he was caring for the baby for the first time. Some sentiment was expressed that even though violent force was involved, it did not suggest the perpetrator set out to hurt the child. Others said that a lay person would know that these forces are of such magnitude that they would hurt a child. The recommendation was made repeatedly that parents in particular, that they screen out males with a history of interpersonal violence in general, screening all child care givers was discussed as highly desirable." There are many pediatric neurologists who specialize in dealing with shaken babies who are convinced that many children who are identified with Attention Deficit Disorder learning disabilities have in fact been shaken babies but not severe enough to cause severe physical injuries. An example would be a child is shaken because he is crying and put down and he goes to sleep and that works, so the next time the child cries for a long time they do the same thing but each occasion is causing more and more damage. Then, of course, there is physical abuse; there are accidents during sport and violence between children as they group up.

The following information is from Head Smart Neighbors, Violence and Brain Injury Institute, Mary-Garrett Bodel, M.Ed., MSW.

Motor vehicle crashes are a major cause of brain injury and death in children ages five to nineteen. Three out of four motor vehicle crashes occur within 25 miles of home on roads where ~ the posted speed limit is 45 mph or less. Buckling a seatbelt saves an estimated 4,000 lives a year. Children are at risk as unrestrained occupants of motor vehicles and as pedestrians.

Children under nine years old have only one-third the peripheral vision of adults and they are shorter so that they can not see as far, nor are they as easily seen by motorists. Their hearing is not yet fully developed so that they can not accurately judge the direction of sounds and they tend to be impulsive and follow a single train of thought. If they begin to chase a ball into the street, they are more likely to complete that action than not, regardless of a changing situation. Common pedestrian injury scenarios include: a child darting into the street, a vehicle turning into the path of a child, a vehicle backing up into the path of a child, and a child dashing out from a school bus. Most children who are hit and killed by cars are playing in the street.

As many as 90% of bicycle fatalities involve motor vehicles. Children, ages ten to fourteen, are at the greatest risk of sustaining a bicycle-related head injury.

A bicycle helmet reduces the risk of serious brain injury by at least 88%. Common bicycle injury scenarios include: the cyclist failing to yield, a cyclist or a motorist failing to stop at a stop sign, a cyclist turning left in front of a passing car, and a cyclist riding against the traffic.

Falls constitute a serious cause of brain injury for children under five. In some communities, falls from open windows are a significant cause of brain injury and death. A child's head is at special risk in a fall from a window because of the head's size in relation to their body: little children topple out and fall headfirst. Screens are not designed to keep children in. Child guards for windows are recommended for families with small children. Falls are the most - common cause of playground injuries. Three- quarters of the children who die by falling from playground equipment die from a brain injury. Most playground-related brain injuries are sustained from falls off of playground equipment onto a hard surface. Appropriate surfacing - under climbing equipment greatly reduces the likelihood of serious brain injury. Proper surfacing includes wood mulch, wood chips, sand, gravel, and shredded tires. The most dangerous surfaces are asphalt and cement, closely followed by dirt and grass.

Each year there are around 82,000 brain injuries sustained as a result of recreational activities. Concussion is the most common consequence of brain injury in contact sports. A helmet helps protect your child's brain from injury while playing contact sports and in many other high-risk recreational activities.

Brain injury is the primary objective in boxing; 87% of all professional boxers have sustained brain injuries. Helmets do not protect boxers from serious brain injury because blows are primarily to the face. Fatalities can and do occur from repeated blows to the head. The American Academy of Neurology has called for a ban on boxing because of the death and disability caused by long-term multiple concussions.

About 100,000 concussions occur per year in the game of football, played at all levels, in the United States. In a given season, 10% of all college football players and 20% of all high school football players sustain brain injuries. Youth football has a lower rate of serious injury than high school and college level football.

Approximately 5% of soccer players receive a brain injury from head to head contact, falls, or being struck on the head with the ball. "Heading" or hitting the ball with the head is the riskiest activity; when done repeatedly, it can cause concussion. The risk is greater if a small child uses too large a ball. Girls are injured playing soccer more often than boys are. Serious consideration should be given to eliminating heading the ball in youth soccer leagues.

Violence, measured as assault, abuse, suicide and homicide, is a major cause of brain injuries in the United States. It is estimated that a woman is beaten every 12 seconds in the United States, which results in the leading cause of emergency room visits for women. Child abuse and firearms are two significant causes of brain injuries for American children, as well.

Sexual abuse has been identified by many professionals as a precursor to violent behavior. In the United States, as many as one in three children will be sexually abused before they reach the age of 18. A child is more likely to be sexually abused than to suffer a broken arm, or be hit by a car. As many as 85 - 90% of the cases involving sexual abuse are committed by someone the child knows, not strangers. As many as half of all sex crimes are committed by juveniles against younger children. Significant neuropsychological abnormalities have been detected in as many as 96% or more of the abuser samples studied.

I would like to draw your attention to the last sentence above, significant neuropsychological anomalies have been detected in as many 96% or more of the abuser samples studied. Now I would draw your attention to the bibliography and the article, Sex Offending as a psychosocial sequelae of Traumatic Brain Injury. Also in the bibliography you will see an article by John Limbert. B.M. B.CH. M.R.C.P., ~ Injury and Sexuality a Literature Review.

During public forums and support group meetings, families and people with brain injuries expressed their feeling that schools and Vocational Rehabilitation were not doing what they needed to do for children and adults, with brain injuries. Parents pointed out the extent to which special education 8 programs varied not only across different school districts, but also among I schools in the same district. At present, NH schools have only identified 49 children that have been given a disability coding of TBI. Both the Department of Education and the Division of Vocational Rehabilitation (VR) serve a disproportional number (compared with other disability groups) of individuals with brain injury and neither has designated staff for brain injury or expertise available at either the state or local level. VR services are further limited by the 18-month limit imposed by federal guidelines. No formal mechanisms or interagency agreements to collaborate with other agencies serving individuals with a brain injury have been developed (see the sections on Education and Employment for elaboration).

Although it is common for individuals with brain injuries to have coexisting mental illness and/or substance abuse problems, there are no formalized points of entry or processes for providing services to individuals with brain injuries through either the state's behavioral health or substance abuse' systems. It is not unusual to hear complaints from individuals that they have been denied services at a community mental health center or substance abuse treatment program and were told that they are not eligible for services because they have a brain injury."

Another typical experience of individuals with brain injuries is described by the term, "stimulus boundedness" which refers to the person's tendency to respond to the most immediate environmental stimulus. The primacy of the immediate environmental stimulus results in heightened distractibility. When the stimulus is irritating, threatening, or sexual in nature, the stage is set for an immediate and exaggerated response. (McAllister 1997).

A brain injury also increases the risk of developing a variety of psychiatric disorders. Depression is a common problem. Symptoms such as fatigue lack of interest, slowness, irritability, and sleep difficulties are common components of depressive syndrome and are reported by significant numbers of individuals. After sustaining a traumatic brain injury, as many as 25-30% of individuals will experience an even more serious form of depression classified as a major depressive disorder. Depressive syndromes in this population are often more difficult to treat, become worse over time, and may coexist with a complex mixture of other symptoms including rage attacks. Depressive syndromes following TBI are also associated with poorer outcomes and delayed recovery. Mania may also occur as a result of a brain injury, regardless of the severity of the injury, and over a wide range of post injury intervals. There may be a higher rate of relapse of symptoms, a higher percentage of irritable (as opposed to euphoric) moods, and assaultive behavior, which can be difficult to distinguish from the impulsively, irritability, and disinhibition seen as part of the more chronic characterologic changes in ABI. Anxiety disorders are also very common after an acquired brain injury and can include generalized anxiety disorder, panic disorder, obsessive compulsive disorder and post-traumatic stress disorder.

Prevailing attitudes that people with brain injuries are lazy, dependent or too disabled, serve to further isolate many people with brain injuries from their communities and negatively effect their self-esteem. Loss of jobs and informal support networks and the lack of public transportation sever what remaining connection people may have with their former lifestyles. People with a brain injury report that living in the community can be very lonely. Even their families feel cut off as friends drift away and their energies are redirected at simply getting through each day and week.

As persons with brain injuries return to their families and to their communities, they face many adjustments. "He's like a different person now" is the reaction of many family members as they see changes in personality, emotions and behaviors that are totally unlike the person they knew and loved before the injury. Learning how to create a new life involves creating a new "sense of self' for the person who has been injured.

Persons with brain injuries and their families report that they constantly encounter stereotypes that they are retarded because of their slow cognitive abilities or mentally ill because of behavioral changes. The invisible nature of a cognitive or behavioral impairment is harder for those unfamiliar with brain injury to comprehend. This ignorance and inexperience perpetuates stereotypes about persons with brain injury in the community, such as, "I don't see why he can't get a job"; "He doesn't look disabled to me"; or "I don't want my daughter going over to their house, I've heard him yelling and have seen how he acts".

These attitudes can pose the greatest barrier to persons with brain injuries in their local communities and affect everything from finding a job to having a social network. There is a tremendous need to raise public awareness about brain injury at every level from prevention through the impact on families and what services are needed to help people put their lives together again.

Absolutely in no way. Just a few examples. You are all aware of the Gove Inquiry following the tragedy of Matthew Vaudreuil. It is interesting to note that there are about three lines in the three volumes of the report that show Verna had a brain injury when she was 3 years old when she fell off her father's shoulders and hit her head (Vol. I, page 13). Doctors told her father that the fall may have resulted in learning disabilities. Verna believes that the fall caused her speech impediment and partial hearing loss. Reading the report, it is clear that she was typical of someone living with the affects of a brain injury.

Another case, a boy of 13 playing with his brothers and sisters, had a fall and was knocked out cold for a period of time. His mother sought help but was told there was none available. As a young adult he sought help again and was told the funding had run out for the year. Subsequently, a serious crime was committed and the young man ended up the Forensic Psychiatric Institute. Attempted suicide led to further brain damage. It was at that time some funding was found to provide a better quality of life.

Drinking alcohol at age 11, a very good athlete, brain injured driving his own car whilst impaired at 16. Was in a coma for two months and had no rehabilitation. Worked at a few jobs for various periods of time, one for 7 years. It was alcoholism and a back injury that finished his working life. He did have a run in with the law but is now a very good member of society.

On the other side of the coin, there are those who are too nice and constantly being taken advantage of. One young man, who had his own apartment, was talked into using it as a brothel by a girl he met on the streets. Because of lack of companionship, especially female companionship, for a young man, they will turn to anyone who shows the slightest affection. Several are HIV positive, some have Aids and some have died.

Research done in a hospital in California showed that approximately 50% of the adults admitted with a brain injury had previous neurological problems, which included brain injury as children etc.

Certainly not! If anything, particularly when it comes to schooling, the situation is deteriorating, not improving.

Most certainly not! We do not have the same benefits for those who sustain a brain injury and this is particularly true with children because they are more likely not to be injured in a motor vehicle crash. There are programs available, if there is funding. The funding sources are basically; Insurance Corporation of British Columbia, Workers' Compensation Board and Victim Services. There is a little more funding but this is never guaranteed for those 19 and over who may have no funding source. As I have said to the Ministry for Children and Families on more than one occasion, I've become convinced that they put with criticism when the child in care dies, the rest they are quite willing to serve in the Justice System.

When a child or adult is in the Criminal System because of their brain injury, many of them simply cannot participate in group programs. It is very common for a person living with a brain injury not to be able to cope with more than 2 or 3 individuals at a time. Therefore, to expect them to cope in bigger groups is not going to happen, they wont participate, they will eventually get out having served their time but they will not have been adequately "rehabilitated".

1. A case management system for children, youth and adults operated by the Brain Injury Association and funded by either directly Victoria or joint funding from different ministries for each region.

2. There needs to be prevention.

3. There needs to be recognition and help as soon as possible.

4. There needs to be separate behavior programs for children, youth and adults. This is not to mean that one facility could provides all the behavioral support but there needs to be one for children, one for youth and one for adults.

5. When youth get into trouble with the law, there needs to be better programs rather than the traditional ones.

6. When inmates are incarcerated, prior to incarceration they need to be screened for brain injury and deficits and appropriate programs within the system set up. See screening tool attached to Appendix.

7. When inmates are released, there needs to be a follow-up program which provides financial support for living expenses, supervised living to begin with, job opportunities and medical follow-up.

8. Education: this really should be number one on the list because if children and youth are not getting an education, then absolutely nothing is going to change. Like it or not, we need special schools for the brain injured.

9. Speech and language evaluations and treatment must be available to children and adults when there is any hint of a problem.

10. Housing is also vital. Ranging from supportive housing to 24 hour supervised living.

Facilitating the access of a patient to appropriate rehabilitation and support programs, and coordination of the delivery of services. This role may involve liaison with various professionals and agencies, advocacy on behalf of the patient, and arranging for purchase of services where no appropriate programs are available. .

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