![Page 1: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/1.jpg)
Paediatric Brain Injury Where are we now?
Dr Mary-Clare Waugh
Kids Rehab
BIA Sydney
10-11 November 2014
![Page 2: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/2.jpg)
ABI• Myths
• Evidenced based practice in Paediatric BI rehabilitation – deals with the myths!
• Inflicted head trauma follow up essentials
• What treatments are effective?
![Page 3: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/3.jpg)
Where are we now?
• Australia 22.6 m– NSW 7.3 m
• Sydney 4.6 m
– 1.84 m children 0-18 years
• Children’s Hospital at Westmead– 29,000 admissions /yr
– 13,000 day stays /yr
– 500 TBI kids admitted/yr
![Page 4: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/4.jpg)
Kids Rehab
• 3,500 children and adolescents with physical or cognitive disability
• 350 new referrals/year
• 1/3 new Brain injury
![Page 5: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/5.jpg)
![Page 6: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/6.jpg)
Kids Rehab model of care
• Family centred – Parent advisory group
• Multi- & interdisciplinary • Goal-directed• Co-ordinated care• Transition• Outreach including Telemedicine• From diagnosis to school leaving age• Based on the ICF framework
![Page 7: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/7.jpg)
ICF Framework WHO
![Page 8: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/8.jpg)
ABI Incidence
• Traumatic TBI
– MVA, falls, inflicted injury, sport injury
• Non-Traumatic BI
– Haemorrhage eg AVM
– Stroke
– Infections
– Demyelinating conditions
![Page 9: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/9.jpg)
Severity of TBI
• Mild Brain Injury coma scale 14-15
– >80% have a good outcome
• Moderate BI coma scale 9-13
• Severe BI coma scale 8 or less
– >60% have long term problems
![Page 10: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/10.jpg)
![Page 11: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/11.jpg)
Paediatric Coma Scales
![Page 12: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/12.jpg)
![Page 13: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/13.jpg)
![Page 14: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/14.jpg)
Severity of Brain Injury
• Post Traumatic Amnesia – State of confusion
– Continuous new memory
< 5 mins Very mild
5-60 mins Mild
1-23 hours Moderate
1-7 days Severe
1-4 weeks Very severe
>4 weeks Extremely severe
![Page 15: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/15.jpg)
Rancho Los Amigos Scales
![Page 16: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/16.jpg)
Physical Challenges• Headaches
• Cognitive Fatigue
• Physical Fatigue
• Seizures
• Medications
• Vision neglect reduced acuity
• Tinnitis
• Ataxia
• Motor difficulties
![Page 17: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/17.jpg)
ABI and Learning challenges
• Brain injury sequelae– Attention
– Motivation
– Initiation
– Processing speed
– Abstract thinking
– Exp and rec language
– Memory
– Reasoning
– Strategic thinking
– Self monitoring
![Page 18: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/18.jpg)
High School demands
• HS pre-requisites– Attention
– Motivation
– Initiation
– Processing speed
– Abstract thinking
– Exp and rec language
– Memory
– Reasoning
– Strategic thinking
– Self monitoring
![Page 19: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/19.jpg)
Social challenges
• Social skills difficulties
• Frustrations
• Disinhibition
• Aggression
• Labile mood
• Family functioning
![Page 20: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/20.jpg)
Sequelae of Paediatric ABI
• Learning/Cognitive
• Social /Emotional
• Behavioural
NETWORKS
• Working memory
• Attention
• Inhibitory control
• Sequencing
• Speed of processing
![Page 21: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/21.jpg)
Switch efficiency
controls
TBI
Caeyenberghs K et al 2014
![Page 22: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/22.jpg)
Paediatric Rehab challenges
• Heterogeneity of injuries
• Injury to a developing brain
– Interplay of age at injury and developmental level, ongoing development and mechanisms of recovery
• Functional and neuropsycholologicaloutcome measures for children
![Page 23: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/23.jpg)
ABI• Myths
• Evidenced based practice in Paediatric BI rehabilitation – deals with the myths!
• Inflicted head trauma follow up essentials
• What treatments are effective?
![Page 24: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/24.jpg)
Myths for Paediatric BI
Better to have a brain injury when you are young.
![Page 25: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/25.jpg)
Fact about Paed BI
Good evidence that the earlier you have a brain injury the worse outcome especially cognitive and behavioural outcomes
Long term cohort studies IQ and executive
function
– Mckinlay A 2010+
– Anderson V 1997 2001 2006 2008 2009 … 2014
– Lidzba K 2009
– Webb C 1996
– Yeates KO 1997 2010 2012
– Jaffe KM 1993+
– Taylor HG 1995 +
– Many more
![Page 26: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/26.jpg)
Myths for Paediatric BI
A student is in the average IQ range can learn new material well.
![Page 27: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/27.jpg)
Myths for Paediatric BI
Children don’t have strokes.
![Page 28: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/28.jpg)
Fact about Paediatric BI
Children do have strokes.
– 7 per 100,000 children,
– Gomes et al 2014 review 16 articles• ADHD symptomatology most common
• Emotional dysregulation, anxiety, and mood instability
• Location of lesion vs networks to determine outcomes
![Page 29: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/29.jpg)
Myths for Paediatric BI
Recovery will take about a year.
![Page 30: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/30.jpg)
Facts about Paediatric BI
Recovery takes many years
– Stability only reached at brain maturity
Limond et al 2014
![Page 31: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/31.jpg)
Myths for Paediatric BI
Brain cells don’t regenerate
Stems cells are proven to work in acquired brain injury
![Page 32: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/32.jpg)
Fact about Paediatric BI
Neurons do regenerate
Not all regenerated cells are fully restored
Stem cells are effective for a small number of brain conditions
More research is needed www.hli.ualberta.ca
![Page 33: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/33.jpg)
Myths for Paediatric BI
• A brain scan will always diagnose the injury
![Page 34: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/34.jpg)
Specific areas lead to specific problems
• Networks now much more prevalent
• Language is not just Broca and Wernicke areas but a network
![Page 35: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/35.jpg)
Tractography
• 12 yr boy TBI
![Page 36: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/36.jpg)
Myths for Paediatric BI
• Neuroplasticity does not exist
![Page 37: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/37.jpg)
Neuroplasticity
• Brain at birth 25% of adult size
• By 2 years 75% and adult size at 10 yr
• Motor and sensory areas develop first
• Frontotemporal development – 0-6 years
– 17-25 years
![Page 38: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/38.jpg)
Neuroplasticity
• Neglect and stress shape brain development– ABI can knock out key areas and influence later networks
• Brain changes thru life – Synaptic pruning ↓ grey matter and myelination↑ white
matter
![Page 39: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/39.jpg)
ABI• Myths
• Evidenced based practice in Paediatric BI rehabilitation – deals with the myths!
• Inflicted head trauma follow up essentials
• What treatments are effective?
![Page 40: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/40.jpg)
TBI severity in an infant• Difficult lack of coma
scores that are easily done
• MRI brain assists– Diffuse axonal injury
• Infants behaviour – Irritability
– Play and interaction
– Time to return to “normal”
![Page 41: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/41.jpg)
Outcome after Shaken baby syndrome• Predictors of severity of
outcome
– retinal haemorrhages
– intracranial lesions
– early neurological signs
– deceleration of head circumference or brain growth
![Page 42: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/42.jpg)
Non Accidental Head Injury
• Lack of clear history of the injury type and time
• Difficulties with follow up
• Connecting with the family
• Moving homes in out of home care
• Early follow up can look “ok”
• Fall off the radar
• Lost to follow up
• Morbidity 59-100%
Barlow et al 2004
![Page 43: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/43.jpg)
NAHI essentials
• Earlier recognition
• Long term follow up
• Networks
• Centralised registers
• Standardised data collection
• Tracking
Kelly P et al 2009
![Page 44: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/44.jpg)
ABI• Myths
• Evidenced based practice in Paediatric BI rehabilitation – deals with the myths!
• Inflicted head trauma follow up essentials
• What treatments are effective?
![Page 45: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/45.jpg)
Treatments• Many ………… • Constraint induced movement therapy
• Bimanual training • Strengthening, • Electrical Stimulation• Treadmill training• Virtual reality• Transcranial magnetic stimulation • Motor imagery• Mirror therapy• Cognitive rehabilitation +++• Pharmacotherapy• Adjunctive therapies • Computer based brain training
![Page 46: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/46.jpg)
ICF Framework WHO
![Page 47: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/47.jpg)
ICF Framework WHO
Brain injury
![Page 48: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/48.jpg)
ICF Framework WHO
Brain injury
Diffuse axonal injury
![Page 49: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/49.jpg)
ICF Framework WHO
Brain injury
Diffuse axonal injury
Walking Talking
Thinking ADLs
Writing
![Page 50: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/50.jpg)
ICF Framework WHO
Brain injury
Diffuse axonal injury
Home School
Community Groups
Walking Talking
Thinking ADLs
Writing
![Page 51: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/51.jpg)
What matters?
• Intensity matters
• Timing of intervention matters
• Type of intervention also matters
• Measurement matters
– What tool and when
![Page 52: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/52.jpg)
Intensity of programs
• Adult stroke units
• Dedicated Brain injury units
• Animal studies
• CP studies
• Magic Camps
![Page 53: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/53.jpg)
Brain Training $8b industry
• Practice
• Rest
• Sleep
• CVS fitness /exercise
• Nutrition
• Reduced multitasking
• ? transferability
![Page 54: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/54.jpg)
Animal and human studies • Exercise
– Helps academic cognitive function in children (Hillman 2010) and elderly (Colcombe and Kramer 2003, Erikson 2011)
• Computer based training– Evidence emerging
• Compensatory mechanisms– ?best for the severely
injured brain
![Page 55: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/55.jpg)
Training the brain
• Neuroplasticity of child’s brain
– To what extent
– Which techniques work
– Laboratory or community based
– Which skill to target first
– Is there any risk of harm?
Bryck RL and Fisher PA 2012
![Page 56: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/56.jpg)
Treatment of ABI• Start early • Enriched environment• Maximise intensity
• Ensure it is the right treatment for the family and the developmental level of the child.
• Constraint induced movement therapy
• Bimanual training • Strengthening, ES• Treadmill training• Virtual reality• Transcranial magnetic
stimulation • Motor imagery• Mirror therapy• Cognitive rehabilitation • Pharmacotherapy• Adjunctive therapies
![Page 57: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/57.jpg)
Cognitive Rehabilitation Therapy
• Relearning cognitive skills lost or altered through ABI
– Education about weaknesses and strengths.
– Process Training, retraining or practicing
– Strategy Training or compensatory strategies
– Functional Activities Training in real life.
![Page 58: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/58.jpg)
Neurocognitive Interventions • Behavioural support
• Specific skills training egerrorless learning and rehearsal for a secure base
• Maximise core skills like working memory and inhibitory control
• Cognitive function training –flexibility and metacognition
• Independence training to use above skills
D. Indep.
C. Cognitive training
B. Remediation
A. Compensatory strategies
Psychosocial systemic foundations
Limond et al 2014
![Page 59: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/59.jpg)
Recovery post ABI
Limond et al 2014
![Page 60: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/60.jpg)
Ensuring best practice
• Data data data– Severity of injury: Coma scales PTA
– Outcome measures: weeFIM, Neruopsych, functional outcomes,
• Research
• Measure
• Review
![Page 61: Dr Mary-Clare Waugh - The Children's Hospital at Westmead - Paediatric Brain Injury - Where Are We Now?](https://reader034.vdocuments.mx/reader034/viewer/2022052206/557d62a3d8b42abf3d8b52b9/html5/thumbnails/61.jpg)
Thank you