1. A developmental perspective informs a framework of self-awareness following Traumatic Brain Injury in childhood
21 June 2017
Dr Lorna Wales, Research Professional Lead

2. 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

3. Acknowledgements University of Warwick The Children’s Trust
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

4. TBI Rehabilitation Long term Introduction Poor outcomes
Poor self-awareness
TBI
Lack of engagement
Rehabilitation
Poor outcomes
Long term

5. 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

6. I’m amazing, look how high I can jump
Young children
I’m amazing, look how high I can jump

7. Middle childhood
Well I’m not as good as Jonah at sums, but I always get picked first for the team

8. Adolescence
I don’t understand

9. 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

10. 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

11. 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

12. 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

13. Key findings Harter pen portraits Thematic analysis of interview data
Aspirations
Beliefs
Being different
Brain injury
Characteristics
Participation
Interpersonal interactions
and relationships
Discrepancy – self v other AND self v norm
No children had agreement across all domains when compared to others and compared to norms
Greatest discrepancy self-other was social and behavioural
Greatest discrepancy self-norm was school/learning and physical
Age at injury
Four of the cases with the greatest amount of discrepancy were the youngest
Older children more likely to make reference to their injury
Change over time
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
Harter pen portraits

14. Proposal
A new definition
A conceptual framework

15. 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

16. Self-awareness in context
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
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.
Self-awareness in 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

17. 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

18. Self-awareness in context
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.

19. Self-awareness in context Self-awareness in the future
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
Self-awareness in 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

20. Self-awareness in context
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
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.
Self-awareness in 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

21. 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

22. Less reliance on adult literature Learn child development
Take home messages
Think child
Age at injury
Less reliance on adult literature
Learn child development

23. Thank You
@WalesLorna

24. Harter pen portraits
Early to middle childhood 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!
Middle adolescent 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.

25. The Children’s Trust | Presentation Title Name DD Month 2016