Consequences of Moderate to Severe TBI
Cognitive Difficulties
Many different models of cognitive function are available in the literature.
Authors such as Adamovich (1985), Sohlberg and Mateer, (1989) and Ylvisaker (1985) have provided us with
valuable frameworks for conceptualizing this most difficult-to-understand area.
The following is a brief summary of some of the cognitive problems associated
with acquired brain injury. More information is available in our resource section.
Arousal
Following injury to the brain, particularly the reticular
activating system, the child will have difficulty maintaining and sustaining
arousal. This may also be noticed as the child returns
to school and seems to have difficulty "getting going" in the morning and
maintaining arousal for increasing lengths of time despite cognitive demands.
Attention
Some of the most common problems following ABI involve
attention. These difficulties result from mild as well as severe injuries and
are generally significantly worse during the initial phase of recovery,
improving over time. Attention is a complex system involving several levels,
which emerge as the child recovers. Problems with higher levels of attention
will be more evident as the student returns to
school and is challenged by increased
cognitive demands. In order for treatment to succeed, it is important to
understand the various levels of attention and their implications.
- Focused Attention: The ability to demonstrate attention to a stimulus,
whether visual, auditory, tactile or other sensory modalities
- Sustained Attention: The ability to maintain attention to a task. As
expected, this is most important for recalling new information. Initially, the
length of time on a task will be very short and will expand as the child
recovers.
- Selective Attention: The ability to respond to a stimulus in the presence of
competing stimuli (e.g., in the classroom or home environment)
- Alternating attention: The ability to alternate between tasks and resume an
activity once interrupted
- Divided Attention: The ability to do more than one thing at a time; the type
of attention required to drive a car and take notes in a class, for example
Memory
A child must use several types of memory to function in daily
living, learn new information, communicate with others and appreciate life by
relating to past events. Research is showing us that memory is not located in
just one center of the brain but rather responds to the interconnections between
many areas. It is a highly complex system that involves active and passive, or
conscious and unconscious, involvement. The following are examples of frequently
referred to types of memory. We must realize that we do not rely on just one
type of memory but incorporate many aspects into our working memory. Memory is
what anchors us to our past and helps us create new ideas.
- Immediate Memory: The ability to recall information immediately after seeing
or hearing it
- Short-Term Memory: The ability to recall information after a delay
- Long-Term Memory: The ability to recall information after an extended period
of time
- Recall: The ability to remember information without any cues; the type of
memory required for answering factual and essay questions
- Retrieval: The ability to retrieve information relying on cues such as
fill-In-the-blank and multiple questions
- Prospective Memory: The ability to recall events or activities into the
future, resulting in follow through on a task
- Procedural Memory: The ability to complete the steps involved in doing a
task without involving verbal or visual memory
- Verbal Memory: The ability to recall information related to an individual
through written or spoken words
- Auditory Memory: The ability to recall information heard
- Visual Memory: The ability to recall things seen
Organization
A process whereby the child shows an ability to categorize,
classify and sequence objects and activities, organization is often impaired in
the brain-injured child. He may have difficulty describing likes and differences
in objects, sequencing steps in an activity or keeping to a schedule without
frequent cueing.
Executive Function
A TBI can adversely impact a variety of executive
functions within the affected child.
- Goal Selection: The ability to generate or choose, as defined by appropriate
future objectives; requires anticipation (Sohlberg and Mateer, 1989) and a sense of
intention
- Planning/Sequencing: The ability to develop a scheme to reach intended
objectives; includes the ability to correctly order the steps involved in
generating a plan and encompasses organizational skills
- Initiation: The ability to behaviorally begin an action
- Execution: The ability to carry out or follow through with intended actions;
the behavioral correlate to planning. Execution comprises the skills involved in
carrying out planning/organizational schemes.
- Time Sense: The ability to estimate the passage of time and monitor one's
performance within time constraints; a specific application of planning and
execution. The rationale for distinguishing time sense as a separate scale was
based on the high frequency with which problems in time management were reported
as a primary obstacle to community reentry. As such, time management was often
an important treatment objective.
- Awareness of Deficits: An individual's level of awareness and understanding
of existing impairments after injury, including knowledge of how impairments
will impact daily functioning and acceptance of the need to compensate for and
accommodate deficits
- Self-Monitoring: The ability to self-evaluate and modify one's own behavior
in response to information gleaned from the environment, including the ability
to detect and correct one's own errors
Reasoning
In this higher-level, more complex process of the brain, the
child is required to take information he has, organize it, identify a central
theme or main point, draw conclusions based on that information and/or gather
all the details and develop the "big picture" from those pieces. Reasoning
requires the use of abstract thinking, an understanding of figurative language
and the ability to develop alternative actions for a situation or creative uses
for objects.
Problem Solving
This component of cognition involves a number of
executive functions. The problem must first be identified. Goals must then be
selected, strategies for achieving them devised and applied, progress analyzed,
modifications made and results evaluated.