A developmental perspective
informs a framework of
self-awareness following
Traumatic Brain Injury in
childhood
21 June 2017
Dr Lorna Wales, Research Professional Lead
Outline of session
• Overview of PhD
• Development of self in typical development
• New definition for self-awareness after brain injury
• Conceptual framework of self-awareness
Acknowledgements
University of Warwick
• Medical School
• Supervisors – Dr Carol Hawley, Dr Peter Sidebotham
• Advisor – Dr George
The Children’s Trust
• Funding
• Managers
• Mentors – Dr Carolyn Dunford, Dr Jenny Jim
Participants and families
Introduction
Poor self-awareness
• TBI
• Rehabilitation
Lack of engagement
• Long term
Poor outcomes
Definition
Following a TBI, individuals may have difficulty
“understanding that they have deficits, anticipating the
impact of those deficits on function and assessing their
occupational performance in relation to those deficits”
Dirette et al 2008, p44
Young children
I’m amazing,
look how high I
can jump
Middle childhood
Well I’m not as good as
Jonah at sums, but I
always get picked first
for the team
Adolescence
I don’t
understand
Rationale for PhD
Start from typical development and build up or start with adult
models and try out into childhood?
Brain maturation
Adult literature and models assume a fully developed system
PhD aim
To gather quantitative and qualitative longitudinal data from
children and young people who have experienced a moderate
to severe traumatic brain injury in order to understand their
level of self-awareness.
A moment in time and change over time
PhD study
Methods
n=15
Moderate/severe Traumatic Brain Injury
Age 4-18yrs at injury; 1 year post-injury
Design
Longitudinal (4 visits over 2 years)
Mixed methods (QUAN+QUAL)
Case study
PhD study - measures
• Self-report
• Parent/teacher/therapist report
• Typical development measures–
−Harter Scales,
−Self-Understanding Interview
• Clinical measures
−Knowledge Interview for Children (KIC)
−Strengths and Difficulties Questionnaire (SDQ)
−Children’s Cooking Task
−Executive Function Map
Discrepancy
Key findings
Thematic analysis of interview data
Aspirations
Discrepancy – self v other AND self v norm
Beliefs
No children had agreement across all domains when compared
Being different
to others and compared to norms
Brain injury
Greatest discrepancy self-other was social and behavioural
Greatest discrepancy self-norm was school/learning and physical
Characteristics
Participation
Age at injury
Interpersonal interactions
Four of the cases with the greatest amount of discrepancy were
and relationships
the youngest
Older children more likely to make reference to their injury
Change over time
Harter pen portraits
All 10 cases had positive change in at least one domain
Becoming more closely aligned to age matched norms
Children more than 2 years post injury more likely to make
reference to their injury
Proposal
A new definition
A conceptual framework
Definition
Self-awareness of deficits following a brain injury
in childhood is a dynamic and complex construct.
At its earliest level it is an adult-supported
reflection of ability in the physical domain.
Through maturity and recovery there is an ability
to appreciate a range of deficits across domains,
and anticipate their effect on functional
performance.
Wales 2016
AGE and RECOVERY
Self-awareness knowledge Acquisition of cognitive and metacognitive skills
1.There is a relationship in typical
development between a child’s age and their
ability to understand and retain knowledge
2. In typical development, the pre-school
child is able to demonstrate autobiographical
memory with the development of language
3.Young children typically find it more difficult
to integrate autobiographical memories,
behaviours and experiences
4.Typically developing children mature from
concrete thinking that is context dependent
in early and middle childhood to abstract
thinking in adolescence
5.Young children are typically concerned with
the physical domain in early childhood.
6.Typically developing children have little
knowledge of how the body works in early
childhood, and may have inaccurate
knowledge
Self-awareness in context
Developmental shift from EXTERNAL to INTERNAL feedback and support
1.Children require knowledge and experience
of how tasks should be performed
Self-awareness in the future
2.Typically developing children have to learn
about strategies ,and when to employ them
Towards anticipatory awareness
Development of executive function, creativity and imagination
3.Typically developing children rely on external
monitoring in early childhood.
1.Prospective memory skills are required to manage future
events.
2.Creativity and imagination develop through childhood
3.Young people learn to integrate and apply knowledge to
future events independently in adolescence
4.Typical development of executive function (planning,
organizing, shift in attention, cognitive flexibility) has not
developed in younger children and stabilizes in middle
childhood (8-11years).
5.According to the adult definition of self-awareness, an
adult can integrate knowledge of deficits across domains ,
and anticipate their effect on functional performance
AGE and RECOVERY
Self-awareness knowledge Acquisition of cognitive and metacognitive skills
1.There is a relationship in typical development
between a child’s age and their ability to
understand and retain knowledge
2. In typical development, the pre-school child is
able to demonstrate autobiographical memory
with the development of language
3.Young children typically find it more difficult to
integrate autobiographical memories, behaviours
and experiences
4.Typically developing children mature from
concrete thinking that is context dependent in
early and middle childhood to abstract thinking in
adolescence
5.Young children are typically concerned with the
physical domain in early childhood.
6.Typically developing children have little
knowledge of how the body works in early
childhood, and may have inaccurate knowledge
AGE and RECOVERY
Self-awareness knowledge Acquisition of cognitive and metacognitive skills
Self-awareness in context
Developmental shift from EXTERNAL to INTERNAL feedback and support
1.Children require knowledge and
experience of how tasks should be
performed
2.Typically developing children have to
learn about strategies ,and when to
employ them
3.Typically developing children rely on
external monitoring in early childhood.
AGE and RECOVERY
Self-awareness knowledge Acquisition of cognitive and metacognitive skills
Self-awareness in context
Developmental shift from EXTERNAL
to INTERNALin
feedback
and support
Self-awareness
the future
Towards anticipatory awareness
Development of executive function, creativity and
imagination
1.Prospective memory skills are required to manage
future events.
2.Creativity and imagination develop through
childhood
3.Young people learn to integrate and apply
knowledge to future events independently in
adolescence
4.Typical development of executive function
(planning, organizing, shift in attention, cognitive
flexibility) has not developed in younger children and
stabilizes in middle childhood (8-11years).
5.According to the adult definition of self-awareness,
an adult can integrate knowledge of deficits across
domains , and anticipate their effect on functional
performance
AGE and RECOVERY
Self-awareness knowledge Acquisition of cognitive and metacognitive skills
1.There is a relationship in typical
development between a child’s age and their
ability to understand and retain knowledge
2. In typical development, the pre-school
child is able to demonstrate autobiographical
memory with the development of language
3.Young children typically find it more difficult
to integrate autobiographical memories,
behaviours and experiences
4.Typically developing children mature from
concrete thinking that is context dependent
in early and middle childhood to abstract
thinking in adolescence
5.Young children are typically concerned with
the physical domain in early childhood.
6.Typically developing children have little
knowledge of how the body works in early
childhood, and may have inaccurate
knowledge
Self-awareness in context
Developmental shift from EXTERNAL to INTERNAL feedback and support
1.Children require knowledge and experience
of how tasks should be performed
Self-awareness in the future
2.Typically developing children have to learn
about strategies ,and when to employ them
Towards anticipatory awareness
Development of executive function, creativity and imagination
3.Typically developing children rely on external
monitoring in early childhood.
1.Prospective memory skills are required to manage future
events.
2.Creativity and imagination develop through childhood
3.Young people learn to integrate and apply knowledge to
future events independently in adolescence
4.Typical development of executive function (planning,
organizing, shift in attention, cognitive flexibility) has not
developed in younger children and stabilizes in middle
childhood (8-11years).
5.According to the adult definition of self-awareness, an
adult can integrate knowledge of deficits across domains ,
and anticipate their effect on functional performance
Conclusions
 Children have an interrupted development of self-awareness following a TBI
 Measuring self-awareness is challenging
 Degree of self-awareness deficit related to age
 Ongoing changes of self-awareness over time
 Using developmental framework gives more insights than adult literature alone
 Message for goal setting
Take home messages
Think child
Age at injury
Less reliance on adult literature
Learn child development
Thank You
[email protected]
@WalesLorna
Harter pen portraits
Early to middle childhood
Middle adolescent
I have a lot of friends, in my neighbourhood, at
school, and at my church. I’m good at schoolwork, I
know my words, and letters, and my numbers. I can
run fast, and I can climb high, a lot higher than I
could when I was little and I can run faster, too. I can
also throw a ball real far, I’m going to be on some
kind of team when I’m older. I can do lots of stuff
real good. Lots!
At school, I’m serious, even studious every now and
then, but on the other hand, I’m a goof-off too,
because if you’re too studious, you won’t be popular.
So I go back and forth, which means I don’t do that
well in terms of my grades. But that causes
problems at home, where I’m pretty anxious when
I’m around my parents. They expect me to get all
A’s, and get pretty annoyed with me when report
cards come out.
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