BrainSTARS: Addressing a Double
Jeopardy! Situation
Jeanne E. Dise-Lewis, Ph.D.
Professor
University of Colorado School of Medicine
Director, Psychology Programs in Rehabilitation Medicine
Children’s Hospital Colorado
Jeanne.dise-lewis@childrenscolorado.org
Vilans Medical Education
June 7, 2012
A Few Facts
 Acquired brain injury is  There are more than
the leading cause of
2,600,000 children in the
death and disability for
U.S. who have survived
children in the U.S.
moderate-severe TBI
 ABI directly alters brain  Most of these children are
development, which in
not identified as having
turn affects:
ABI and do not have
access to accommodations
– personal development
(school, behavioral
– emotional development
treatment, community
– academic development
resources) that work
– social development
(Chapman, 2007)
Brain Injury in Childhood
Almost Always Results in These
Cognitive Symptoms:
Sensory-motor
changes
Language deficits
Poor Executive
functioning
organization
processing speed
mental flexibility
self-monitoring
Unevenness
Fatigue
Deficits in new
learning and memory
Social-emotional
changes
Brain Injury affects Behavior
 Child will express confusion and cognitive
problems behaviorally.
 Problems are worse at transitions and less
structured times/ less structrued environments.
 Impact of ABI most often felt on Executive
Control System.
 Typical discipline strategies (consequencesbased) and behavior accommodations are not as
effective.
Unmet emotional, learning and
social needs cause deficits in
behavior control and failure to
achieve typical adult
competencies
ABI and Developmental Stages
 Unlike other organs of the body, your brain needs
years and experience to mature
Cognitive, personal-emotional, and social abilities
emerge developmentally
 Abilities developed at one stage of life form the
foundation for more complex abilities
 Capacities in process of development, and those not
yet developed, are most vulnerable to brain injury
 The earlier the injury, the more pervasive the impact
on thinking, emotion regulation and behavior
• Abilities that are
just developing, or
have not yet
emerged, are the
most sensitive and
most likely to be
disrupted.
• These areas are
likely to be the
Achilles heel for a
child with an
acquired brain
injury, even after he
grows up.
Overall Brain Maturation
Slides courtesy of Ron Savage Ed.D.
Maturation of Temporal Region
Slides courtesy of Ron Savage Ed.D.
Developmental Pyramid:
Language
16-19: written language
12-16: reading comprehension
6 - 12: reading decoding
3 -6: expressive language
0 - 3: receptive language
The “Latent Effects” of Pediatric
TBI: Executive functions
 Phenomenon noted by  Children seemingly
Hendryx and Verdun
(1995 Journal of
Cognitive
Rehabilitation)
recovered from
early TBI (under
age 8) develop
serious problems in
learning and
executive control
many years later
(Savage, 1999)
Developmental Pyramid:
Executive Functions
16-19: reasoning, judgment
12-16: organization, working memory,
self and task monitoring
6 - 12: attention, initiation, planning
3 -6: mental flexibility, emotion regulation
0 - 3: cause/effect relationships, self-regulation
Executive Control Processes
Behavior Regulation
(in development
birth-age 6)
Impulse control
Mental flexibility
Emotion regulation
Metacognitive
(in development
ages 7-16)
Initiation
Planning
Organization
Working Memory
Monitoring (self and task)
What is BrainSTARS in its
essence?
 Parent Pediatric manual for the normal people in the
lives of children with moderate-severe ABI.
 Allows children to stay successful in normal settings.
 Holistic, integrated understanding of moderate-severe
Pediatric Acquired Brain Injury
– What happens after brain injury in childhood or
adolescence?
– Interaction effects on development
– What child guidance/teaching strategies are effective?
A comprehensive education
A collaborative model
A developmentally-focused resource
BrainSTARS Manual
Empirically developed and field-tested based on 50 teambased neuropsychological assessments.
Peer reviewed (Journal of School Psychology, 2004;
Journal of Head Trauma Rehabilitation, 2009, 2010)
Teaches regular people in child’s life to understand how a
child’s brain injury causes cognitive changes which ripple
out to affect behavior across many areas of development.
Guides effective accommodations and interventions so
that child can continue to successfully participate in
home, school, and community.
Intended use: BrainSTARS
Manual
 A self-paced, stand-alone education about moderate-
severe ABI for “regular people” to use in normal
environments.
 11th grade reading level, tabs, spiral binding, lots of white
space, professional editing, multiple stopping points
within short chapters.
 Use like a cookbook– Neurodevelopmental clusters and
Index.
 Our hope: People would be able to understand their child
and modify their expectations/features of the environment
so that child could be successful in everyday settings in
which all children grow, learn and develop.
Effective TBI Intervention
 Educate school personnel and family; reestablish a team.
 Keep child functioning in everyday settings in which
his/her peers are learning, growing, and developing.
 Identify primary or underlying neurodevelopmental
deficits that are tanking the child’s performance.
– Especially MPS, executive functions, reading, new learning
 Remediate/ accommodate these deficits.
 Focus academic program on strengths.
 Identify and teach age appropriate play/ peer skills.
 Nurture hobbies and interests through which friendships
can develop.
Leap! And the net will appear
Infancy: Birth-3
Developmental Stage Characteristics:
 Regulation of sleep-wake patterns
 Sensory-motor integration
 No understanding of cause-effect or time relationships
 No self-other or person-environment distinction
 Symbiotic relationships with caregivers
Infancy: Birth-3
Developmental Disruptions post ABI:
 Disruption in ability to regulate state, arousal, sleep
 Does not understand sequential concepts or time
 Lability: moods shift dramatically and quickly
 Emotional reactions are unpredictable, "irrational,”
and extreme.
Infancy: Birth-3
Accommodations address Basic Self-Regulation
Setting: Constant supervision/ support/ modulation by adults
• Establish basic routines of sleep, nutrition, rest,
stimulation, and daily activities.
• Maintain calm and predictable environments.
• Incorporate calming routines in the schedule.
• Provide a point-person in each setting.
Preschool: Ages 3-6
Developmental Stage Characteristics:
 Robust understanding of single cause-effect relationships
 Learning of preschool concepts
 Concrete and black/white, good/bad, rigid thinking
 Cannot reconcile conflicting emotions simultaneously
 Developing (but fragile) ability to think before acting on
a feeling – Emotion Regulation
 Inability to take another person’s perspective (emotional
egocentrism) but can take turns
 Difficulty accepting a change in plans
 Focus is on self-control, “I can do it!” “I’m a big girl!”
Preschool: Ages 3-6
Developmental Disruptions post ABI:
 Behavior Regulation Executive functions: self-
monitoring, initiation, inhibition, shifting
 Rigid thinking and behavior
 Immediate expression of feelings without thinking
–
–
–
–
temper tantrums
lack of concern for danger and safety
aggressive behaviors
lability
 Poor acquisition of concepts
 Resistance to influence or direction from parents
 Anxiety
Preschool: Ages 3-6
Accommodations address Emotion Regulation
Setting: Close, continuous supervision, support, and
modulation moving to 1:1 when child is emotionally
aroused
 Provide continuous adult support.
 Teach student to stop and calm down before acting,
using role play, repetition, group activity.
 Create structure/ organization for student.
 Create, and teach use of, a visual schedule to increase
predictability.
 Anticipate and provide concrete assistance to get
through transitions.
Elementary School: Ages 6-12
Developmental Stage Characteristics:
 Ready to learn academic skills
 Initiation, self-monitoring, task monitoring
 Emotional focus on effort, intention as important
 Sense of self as hard worker, smart, good friend
 Responsibility, loyality, kindness, reasonableness,
and empathy
 Friendships based on shared interests
Elementary School: Ages 6-12
Developmental Disruptions post ABI:
 Academic skills: reading, spelling, math, new learning,
organization
 Poor performance despite hard work
 Difficulty “reading” social cues and others’ behavior
– Social ineptness or inappropriateness
 Behavior problems during unstructured times
 Initiation disorder
 Social isolation/withdrawal from peers
 Depression
 Sleep disturbance
Elementary School: Ages 6-12
Accommodations address Initiation, Monitoring and
Emotion Regulation
Setting: Group supervision/ start of school
 A point person in every setting.
 Create functional, context-based, multisensory learning
experiences.
 Provide a “warm-up” before tests, classwork,
introduction of new material.
 Assess and accommodate for reading inefficiencies.
 Reduce amount of coursework and homework to fit a
reasonable, preset time limit.
 Develop recreational skills and hobbies; group learning.
 Respond quickly to signs of depression
Early Adolescence: Ages 12-16
Developmental Stage Characteristics:
 Metacognitive executive functions, concrete
problem solving
 Abstract reasoning Extremism
 Increasing self-awareness: what I am like, what I
am good at
 Beginning identity development -- negative
comparisons
 Responsibility; able to care for self, baby-sit, paid
jobs
Early Adolescence: Ages 12-16
Developmental Disruptions post ABI:
 Judgment and reasoning difficulties
 Reduced ability to manage age-appropriate
independence and responsibilities
 Uncertainty about self/abilities
 Increased "frustration" response
 Withdrawal from peers and limited social
involvements
 Depression
Early Adolescence
Accommodations address Metacognitive
executive functions and Emotion Regulation
Setting:brief periods of complete personal responsibility,
babysitting
 Teach planning, organization, and problem solving.
 Educate student about his/her cognitive profile.
 Increase communication between home and school regarding




assignments, tests, and upcoming topics.
Use videos, movies, field trips to create context and familiarity
with new school topics.
Provide increased adult support; use educated peer buddies.
Structured group activities around area of interest.
Identify clear roles and responsibilities at home and school.
Late Adolescence: Ages 16-19
Developmental Stage Achievements:
 Capacity for spontaneous appropriate behavior in
situations requiring judgment, weighing of
consequences, and decision-making
 Solid sense of own identity based on positive
identification and realistic appraisal of
competencies, liabilities, interests
 Development of vocational plans and goals
 Social sophistication
 Emancipation from home
Late Adolescence: Ages 16-19
Developmental Disruptions post ABI:
 Poor decision-making, judgment, thinking “on your
feet”
 Reduced processing speed, organization of complex
tasks, new learning
 Interaction between specific deficits and career goals
 Interference in developmental drive toward
independence/separation
 Social awkwardness and disturbance of sexual behavior
 Fatigue
 Depression
Late Adolescence: Ages 16-19
Accommodations address Metacognitive executive
functions and Emotion Regulation
Setting: Formal operations, abstract reasoning;
Extended periods of complete personal responsibility/
driving
 Teach planning, organization, and problem solving.
 Educate student about his/her cognitive profile.
 Identify roles and responsibilities within the competence of your




adolescent at home/school.
Provide a forum for expression of feelings.
Develop coping skills appropriate to varied settings.
Focus on solid understanding of more limited content in
academic curriculum.
Use areas of strength and interest to develop vocational goals and
competencies.
Comparison of Impairment Ratings
Pre and Post BrainSTARS Consultation
1
2
3
4
Neurodevelopmental Skills
Post
Pre
Post
Pre
Post
Pre
Pre
Pre
IMPAIRMENT RATING
90
80
Transient 70
60
Mild 50
Moderate40
30
Significant20
Severe 10
Post
No
Impairment
5
Leap! And the net will appear
Leap! And the net will appear
Leap! And the net will appear
Leap! And the net will appear
Leap! And the net will appear
Referenced Works
 Davis AS (2004). Review of BrainSTARS: brain injury– strategies for
teams and re-education for students. Journal of School Psychology, 42;
87-92.
 Dise-Lewis JE, Lewis H, & Reichardt CS. (2009). BrainSTARS: Pilot
data on a team-based intervention for children who have traumatic
brain injury. Journal of Head Trauma Rehabilitation, 24(3), 166-177.
 Glang A and Todis B (2010). Contextually based interventions for
pediatric brain injury rehabilitation. Journal of Head Trauma
Rehabilitation.