Psychological Therapy for Paediatric Acquired Brain Injury

Innovations for Children, Young People and Families

Jenny Jim, Esther Cole

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781000228007
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Children, young people and families living with an acquired brain injury (ABI), whether through accident, illness, injury or abuse, are rarely offered psychological therapy, and yet the benefits of such interventions can be profound. This important new book, providing a selection of practice examples and insights from frontline practitioners, will be essential reading for any paediatric therapist or clinician.

Beginning with a "life story" of the brain where emphasis is placed on how brain development is fundamentally related to its environment, the book offers key background knowledge before showcasing the core topics of assessment, psychological formulation and intervention. It features a range of therapeutic models, includes direct and indirect work, group work and family therapy, with settings varying from inpatient neurorehabilitation to community work and the transition to education. The long-term needs of those in the criminal justice system are also addressed. The closing chapters focus on the debate around effective outcome measurement and outline a vision for better services.

Elevating the voices of our children, young people and families living with ABI, this pioneering book will provide practitioners with the confidence to work collaboratively across a range of children and young people with disorders of consciousness or communication to those with behaviour that challenges others to manage. It offers new ways to understand both children's pasts and their futures, and will be essential reading for anyone in the field.

Part I

Getting started

Chapter 1

“My life story” by the brain

Jenny Jim

Making concepts simple: using language and metaphor

I have written two chapters from the perspective of the brain speaking, “‘My life story’ by the brain” (Part I) and “Narrative-inspired interview with the brain” (Part II). The aim was to help introduce complex concepts around brain development and brain injury to readers using simple, accessible language. I believe in making complex concepts user-friendly; otherwise, knowledge can be lost to language. Stories seem to me to be a natural forum open to children and adults alike, allowing us to connect to our innately creative and fantastic imaginations.

Story lines and characters can be used to form a bridge between semantic knowledge and our natural ways of weaving meaning in conversation and stories. “Mini-worlds” can capture enormous detail, as long as meaning connects the details together. I wanted both chapters to demonstrate this idea. I hope they will be a springboard to others to use fun and creative means to connect crystallised knowledge to our natural ways of making meaning in our lives together.

For instance, another project I am currently developing with Jon Ettey, a doctorate student, uses narrative principles to personify and externalise the different lobes of the brain so that children and adults can better hold on to their functions, their vulnerabilities and what they need from themselves and others to recovery from injury. “The Lobe Family” will be one of the first (if not the first) theoretically and therapeutically grounded psychoeducational packages co-constructed directly with children with an acquired brain injury (ABI). Each character will have a personality demonstrating the main functions of the lobe and will “talk” to the user. The way they interact will demonstrate what we know about the development of the brain and principles of connectivity, plasticity, environmental-dependency/expectancy and effects of rehabilitation.

All of these resources can be used with children and adults to increase their mastery of knowledge that forms a solid basis for understanding and reclaiming their own agency in a situation where they may often feel stripped of their role and expertise. In Part II, “The Narrative-inspired interview with the brain” purposefully does not include academic references but follows the work of Michael White (2007) as a basis for the questions the fictitious narrative therapist uses. I felt that making this more explicit, in the actual interview, deflated its emotional impact. “ ‘My life story’ by the brain”, as a more complex endeavour, required endnotes throughout, as I felt this would enhance the reading and rigour of the chapter. The Brain will now talk you through its “life story” from birth to old age.

Conception to birth: the worm in the womb

I was born just three weeks after conception. Funny to think that I began life as a plate and then a tube!¹ When I look at my electron microscopic baby pictures, I cringe, as I resemble a fat earthworm. Thank goodness they didn’t have social media back then. I develop at the “head” of the worm, and the “tail” then becomes the spinal cord. Together, we are the central nervous system, the figurative and literal “backbone”; of our minds and bodies.

The spinal cord gets off the blocks fast and begins to develop its first synapses² by week five. This allows the first movements of my embryonic body just a week later and at ten weeks even more refined actions, such as hiccupping and sucking my thumb. I am more of a slow burner when it comes to ripening, playing the “long game” as they say. In this game of “heads or tails”, this flip is always rigged to “Tails”.

Whilst I may mature at a slower rate, I am still rapidly generating my brain cells³ and by week five, I have formed three bulgy areas of my wormy and tube-like self, towards my front, middle and back. Two weeks later, the front and back areas have both divided into two.⁴ These each become more intricate with time. It’s rather like building a house and making sure the floorplan and basic wiring is down so that all rooms are connected. Of course, the house needs a water supply, so I make four interconnected internal chambers that produce my favourite eau de vie,⁵ the supply of which extends into the space between me, my skull and the canal in the spinal cord.

Incidentally, within the walls of my two biggest chambers is also where I manufacture my brain cells. I make two varieties of brain cells: the vocal communicating neurones and their support act, the glia. To say I run a busy production line would be a slight understatement given that I usually make up to 80–100 billion of each variety of brain cell in the womb!⁶ I issue each neurone with its own passport and travel itinerary so it can immediately migrate from its place of birth to a specific destination.⁷ By week 24, I have almost all my neurones made.

Returning to my house-building metaphor, my front rooms are by far the largest because I need a lot of cells to make my most complex areas. Also known as my “cerebrum”, it is the prime location that I invest in to become my cerebral hemispheres. I guess you could see them as my HQ offices.

I put most of the grey cell bodies of my neurones on the outer layer of the hemispheres – i.e. grey matter. Scientists named this the “cortex” – the Latin word for tree bark because of the grooves they saw. Underneath my grey matter are the tails of my neurones that will eventually look white when they are covered in fat – i.e. white matter.⁸ I have to mention that I am careful to shrink wrap myself⁹ and, of course, ensure an oxygen supply to all my rooms.¹⁰

You could say I am a natural architect rather than avant-garde, I follow a similar genetic building plan to other brains, so I put things where they seem to make sense and rarely get maverick with my blueprint.¹¹ However, this doesn’t stop me from adding my individual sparkle by customising my rooms and how well they are connected to one another. A big influence on my overall interior structure and design are the experiences I am exposed to. I’ll talk more about this later.¹²

Once I have my cells in place, I can get my vital jobs done. Firstly, I decorate the back rooms, which are the seat of control of all my critical reflexes (this area is known as the brainstem). The moment I finish furnishing this room and do the lights-on “big reveal” is like flicking the switch for “autopilot mode” – it means I no longer have to worry about controlling things such as breathing, how fast my heart beats and the pressure that blood is pumped through my body. By the end of the second trimester (week 28), my brainstem is almost completely mature, which means my foetal body stands a chance of surviving outside of the womb.

Once I am sure my autopilot mode is in place, I get to work on the “thinking” part of my brain so I can learn about the world I am in. Scientists discovered that if they crept up and startled me with loud noises, I would eventually learn to ignore their silly games.¹³ Honestly, sometimes I think they assume I am just resting on my laurels as if in some kind of suspended animation, but I am busy studying – learning all about my mother: her smell, her heartbeat and her voice.¹⁴,¹⁵

Of course, I can’t say that I am consciously doing this – conscious thinking comes later when my cerebral cortex comes online. You might have noticed that I have been decorating my house from back to front, a bit topsy-turvy, but when you think about it, the tail also came before the head, so I guess when it comes to my story, it is one that doesn’t follow expectations.

Throughout my time in the womb, I must make sure I get enough folic acid; otherwise, the “head” of my tube never closes, and this would be the end of me (technically before I am even born!).¹⁶ If the “tail” does not seal, then the spinal cord will grow without the protection of the spine.¹⁷ Also, infections, malnutrition or drug/chemical exposure can wreak havoc on my newly born neurones that are hitchhiking¹⁸ across to their forever homes and so are particularly vulnerable to attack.

Another thing I must mention before I tell you about my next big life event is that I haven’t quite told you my story from the very beginning. Scientists are now reliably informing me that long before I start emerging as a plate, the “instruction manual and programme of works” for my development have already been influenced, not only by the genes of my parents, but the life experiences of my mother^{19, 20} in particular.

Birth: eviction to exuberance

I was evicted from my lovely womb-home when I was ready enough to live without it.²¹ What a shock to be “outside” and having lots of new sounds, smells and things I could see! I had to get used to my body not being supported by the comfort of my bathing liquid, and it was very scary at first. Luckily, I had learnt the smell, voice and heartbeat of my mother, so I knew I wasn’t really alone. But I do have to admit that it took a while to really learn I was safe – because I was so dependent on my parents, I made sure they were close, by crying (a lot) so that I was gradually convinced that they hadn’t forgotten about me. Flashing a few winning smiles²² seemed to make them forget the pain of those early days.

I weigh around 1 pound now, and my neurones are so excited by the world around them that they can’t stop talking to one another. I am using up energy like nobody’s business, and by the time I am 1-year-old, I am at young adult levels of power; this increases exponentially so that by the time I am 3, I am sapping 2.5 times adult levels!²³ This is perhaps not surprising because in these years, I am producing 700 new neural connections every second!²⁴ Scientists call this time my “exuberant period”. At an almost unimaginable rate, my cerebral cortex bursts into life – like the crescendo of a thousand New Year’s Eve fireworks displays, my neurones make up to two million new synapses every second.²⁵ Anything that happens to me makes a big impression. Scientists describe this as “plasticity”²⁶ – repeated experiences can easily become part of my “go-to” templates about the world²⁷

Because I don’t yet know what things are going to be important to me, I employ a “wide-net” strategy and try to lay down the building blocks for as many memories as possible. I am glad I spent a lot of time making my neurones (approximately 86 billion of them!) before I was evicted, as now they bolt into action like a spread of runners in a relay team, each having migrated in strategic locations forming highways across my landscape of interiors.

Networks are laid down between my neuronal cell bodies in parallel with me insulating the tails of the neurones. Just like cabling a wire, the fat²⁸ I put down means the messages relay faster and more efficiently.²⁹ These networks are like the first imprints of my experiences,³⁰ and the more the routes are run the more distinct they become. I put on a lot of weight after I am out of the womb because of this. In fact, I lay down so many networks, as a baby I have twice as many connections than an average adult.³¹

The early years equations

Brains + love = development

Bowlby³² was right when he said the first 18 months of life are inordinately important to a person’s sense of belonging in this world. At this time, I am constructing my templates of how I expect to be treated, by whom and how I can get my needs met. This is my neural blueprint for relationships for the rest of my life.

If my parents spend time getting to know me and my foibles,³³ a remarkable thing happens – my gelatinous being becomes synchronised with theirs.³⁴ Our brains communicate, and their affection shapes the fundamental development of the rest of my nervous system. Brain role models help me understand my emotions and bring peace to my networks. One particularly important “room” I develop only after I am out of the womb is just for understanding people and emotions.³⁵ Given that this is the basis of empathy, it makes sense that I can’t develop this on my own.³⁶ I sometimes think about what it would be like if I was born without toys, days out, people talking to me, enough milk and love...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Dedication
• Contents
• List of illustrations
• Editors’ acknowledgements
• About the editors
• List of contributors
• Preface
• Series editors’ foreword
• Experts by Experience Reflections – Jackie Solaiman
• Introduction
• Part I Getting started
• Part II Innovations in psychological therapy
• Part III What differences can we make?
• Experts by Experience Reflections on the Book – Jackie Solaiman
• Appendix: Theory-practice links in “Narrative-inspired interview with the brain”
• Name index
• Subject index