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ANNOUNCER: Dr. Lyn Turkstra is a professor in the Department of Communication Sciences and Disorders at the University of Wisconsin-Madison, and a member of the UW-Madison Nurse Science Training
Program. Her research focuses on the relation of cognition to communication, particularly in the context of social communication in adolescence and young adults with traumatic brain injury. Dr.
Turkstra has published extensively on cognitive and communication function after TBI and has worked clinically with survivors of TBI for more than 20 years. Okay.
LYN TURKSTRA: Thank you very much.
AUDIENCE MEMBER: Yup.
LYN TURKSTRA: Can you hear me? Okay. I--after years of giving talks I still never wear an outfit that works really well for a lavalier mic. So, invariably I'll end up holding it and walking around
like I'm holding this. And if you see me limping I apologize because I seemed to have broken a bone in my foot which is fine, I can stand up fine but -- so if you see me kind of like hobbling around
up here, don't be alarmed. I'm sure it'll be fine. It's a good life lesson that if something hurts you should actually go to the doctor instead of putting it off for months and months and exercising
on it because then you end up in a boot. So, if your foot hurts see a doctor. I'm delighted to be here, especially delighted to be invited by BrainSTEPS. So, programs like BrainSTEPS are few and far
between across the United States, and you are so fortunate to have BrainSTEPS in this State. We had a very scale down version in the State of Wisconsin and the funding was cut when we had our big
nationally publicized budget cuts a few years ago. So, we really have different educational units around the state who have no funding support at all, but worked for so many years to develop the
program that they volunteered their time to keep trying to help students with brain injury. But that is no substitute for a program like BrainSTEPS. So, I hope for those of you who aren't BrainSTEPS
participants that you take advantage of this service in the future. It's funny for me to be invited to speak at a Low Incidence Institute about brain injury because it's not low incidence. But there
still is this idea, right? That brain injury only happens to a few children and adults. When we look for typical control subjects, so people without a brain injury for our research studies, that's
when we find the real prevalence because it's very hard for us to find a teenage boy who hasn't been knocked unconscious or even adults. It's hard to find somebody who hasn't had some mishap in their
lives. We just tested -- we just tested a young adult yesterday for a study that we're doing right now and he came in as a normal control and he said he had no history of brain injury even
concussion. So -- and then we have all the questions about -- we have a series of questions about whether you've ever fallen and hit your head or gone to the hospital for your head, things that I'm
sure you all if you work with students with brain injury, you ask this questions. And he said that he fractured his skull when he was a child, but he didn't have a concussion. So, if you all could
figure out how one can fracture -- hit someone hard enough to fracture their skull and not have a concussion, let me know. But that's -- because that's, you know, how that goes if the thinking is, oh
that's different, that's a separate issue. So, a lot of the fight that we've had in Wisconsin, which I think people are having around the country is getting recognition of the fact that even
concussion is a mild brain injury and so there's not two separate categories of injury concussion and then brain injury as something separate. So, it's great that you're all interested in knowing
more about this and I'm always happy to talk about adolescence. This is my favorite population to work with. My grant funding is with adults because it's very difficult to get grant funding for
adolescence. People -- by people, I mean grant reviewers, you adolescence is a real moving target. So -- because there are so many developments during that stage and adolescence are so strange
anyway. To try and figure out what's clinical and what's just typical adolescence is a really big challenge and so a grant reviewer said to me once, "You're studying social behavior and adolescence
with brain injury so you've taken the most complex behavior in the most heterogeneous population at the most difficult age. You have to get rid of one of those three variables." So, we are funded to
work with adults but this is really where my passion is. It's also great timing because I was just asked by a reporter to comment on a murder trial in Sheboygan Wisconsin. So, this made the national
news. I don't know if any of you heard about this. These are two young men, Nathan Paape and Antonio Barbeau. They're 13 years old and they're accused of brutally murdering their 78 year old
grandmother. The judge in the case said that he has never seen such a brutal crime. What happened was these two boys who were living in a group home went to her home, and apparently Antonio Barbeau
had a good relationship with his grandmother as recently as the week before. He'd been weeding her garden and picking things up for her at the store. So, this was really unexpected. They went to her
house to get money and they took a hatchet and a knife. And so when she said no to them at the front door and turned her back they hit her -- someone hit her because neither one of them is saying it
was them. So, someone hit her and they -- actually, the corner had to really pry the axe from her -- out of her head. So, really hit her hard and then kept hitting her and stabbing her until she died
and she was crawling away on the floor. So, this was a heinous crime. There -- there were -- there was a lot of discussion about whether they should be sentenced as adults, but they did not meet
criteria for adult sentencing. So, what that means in our state is that there's a limit on the number of years they can serve. I think it's 35 years in prison is the limit, 30 or 35 years in prison
is the limit they can serve. So -- and Paape had -- did a plea deal and talked about Barbeau. So, Barbeau's sentencing is coming up in a couple of weeks. So, the reason I'm talking about this if you
can guess is that Antonio Barbeau had a severe brain injury at 10. So according to his family, he was out of school for a year. So, it was a recognized injury by everyone. He was in rehabilitation
for some period of time, but he couldn't go back to school full time. Now again keep in mind we're in a state that has nothing and he's in an -- Sheboygan, Wisconsin which has even less of nothing
than the rest of the state. So, there are very few resources there. So, I don't know the details of this rehabilitation because the family is just putting together the brain injury with the behavior
problems now. So, what they said was he was home, not really in school full time for that year and his parents said he changed completely. That they used to be able to reason with him about things
and they couldn't reason with him. He had emotional outburst, a lot of behavior problems and that's what ended up with him being in this group home at 12. So, the question -- so he's -- he was found
guilty. That's not an issue. The issue now is about sentencing. And so what is the best -- best is a word one could use. What's the best sentence for this situation? And so the reporter said to me,
he called me -- call the University, asked for someone who did adolescent brain injury and got directed to me. And he said, "So, can a brain injury actually cause behavior problems?" That's the level
of understanding, right? That's a reporter too. That's someone who has actually done homework, talked to the family. And can those problems sort of emerge over time? So, this was all new to him. And
I was really pretty shock to have to tell you because this -- you know, you see this sort of gray area about how much is due to the brain injury versus other factors when it's a milder injury, but
when someone's injured so severely that they're out of school for a full year, you think that people are on the alert for problems coming up in the future, but apparently not. So, the parents have
now reached out to the Brain Injury Association and are trying to get educated about brain injury because they have a question about what the sentence should be and -- I don't know how it is here in
your state. I used to live in Ohio and we did a study at a Medium Security Juvenile Facility, and their budget had been cut so much, they had no services at all. So, the kids in prison didn't get
anything. There were no therapies. There was no physician so they couldn't have any of their medications unless they had epilepsy. So, you can imagine probably a third of those kids have ADHD and
they're now incarcerated with a bunch of rules, sitting around, talking all day with -- not being allowed to do anything else. So, I'm not sure if he goes to prison if he'll get anything. And so when
he gets out he will be so -- 30 and -- 43 years old, and a particularly sad part of this is his advocates here are his parents and they'll be probably deceased at that time. So, he'll -- by the time
he gets out there won't be anybody in the community who's really an advocate for him. And so what do you think is going to happen to him in prison? Will he get better? That would be a first. In
Madison, we have a very famous in legal circles, treatment facility call them the Mendota Juvenile Treatment Center. I was want to say Madison Juvenile Treatment Center. The Mendota Juvenile
Treatment Center, MJTC. It's the only one of it's kind in the country and MJTC takes the most violent criminal offenders. They're there for at a minimum of six months and up until a year and a half
ago in the history of MJTC they had a zero percent recidivism rate for murder. So, these are the most violent juvenile criminals and they had someone I understand -- we have a student placed there, a
grad student, someone I understand who left there, killed someone last October, but until then they had a zero recidivism rate. And it's an intensive program, it has a lot of behavioral therapy and
so it's the kind of program where I would want a child with brain injury to go because they have a lot of staff and they really understand the problem, but they also had their budget cut by 50
percent last year. So, I'm not sure how much longer they're going to be able to keep doing what they're doing. So -- and I don't mean to be political talking about budgets, but that's the reality,
right? Of the world we're living in, so. So anyway -- okay. So, I'm interested in your thoughts about this Antonio Barbeau case, what you think would be appropriate for this teenager. Feel free speak
AUDIENCE MEMBER: Those both are brothers, right?
AUDIENCE MEMBER: Both of them are brothers?
LYN TURKSTRA: Pardon?
LYN TURKSTRA: Well, they're not brothers. I think they're cousins.
AUDIENCE MEMBER: You know, I think that the crime was pretty heinous and just that there's two of them and...
LYN TURKSTRA: Oh, I'm sorry so -- microphone. My apologies. That was my first instruction from the videographer and I didn't do it. I can't -- I don't think...
LYN TURKSTRA: ...I can repeat the whole opinion though, but I I'll try my best.
AUDIENCE MEMBER: I talk pretty loud though.
AUDIENCE MEMBER: Is it on?
AUDIENCE MEMBER: I just think that because there are two of them, it's more premeditated. I mean whether of the brain injuries they are not -- you would -- you would hope I guess, or maybe it's just
LYN TURKSTRA: Okay.
me, that the brain injury didn't allow the control at the moment that the, you know, child needed. But when there are two and it's kind of planned out for money, it's a different story to make. So,
that's my side.
LYN TURKSTRA: Right. So, the issue is they -- it was premeditated in the sense they came with weapons and they wanted money, and so perhaps the brain injury -- I'm rephrasing for the videographer so
-- for the video purposes. So perhaps the brain injury was -- pushed the kid over the edge.
LYN TURKSTRA: But it doesn't -- and he was found guilty so it's not -- that's not a question. Yeah. Oh, sorry, microphone.
AUDIENCE MEMBER: Yeah.
AUDIENCE MEMBER: Oh, okay. Well, my first question was, was there a history of mental health issues prior to the crime?
LYN TURKSTRA: No. There was absolutely no history of mental health problems in this -- in Barbeau before this happened. And it was a marked change after the injury according to his parents.
AUDIENCE MEMBER: So, no documented history. I would just find it really difficult to accept that there wasn't something else going on besides the brain injury that he would commit such a brutal...
LYN TURKSTRA: Right.
AUDIENCE MEMBER: ...murder, first of all. But that's really complicated because he's going to be in society. So, this guy is going to get out of prison someday.
LYN TURKSTRA: Right.
AUDIENCE MEMBER: If he doesn't receive any intervention likelihood of him recommitting the crime or something equally as heinous is pretty high I would think.
LYN TURKSTRA: Right.
AUDIENCE MEMBER: So while -- my initial reaction is like no, like he should pay the price and he shouldn't be given accommodation or consideration because of any brain injury than the other side is
okay what are you going to do with him?
AUDIENCE MEMBER: Something -- we have to do something I think.
LYN TURKSTRA: Right.
LYN TURKSTRA: Right. So, I think this -- it's just...
AUDIENCE: [inaudible] the emotion.
LYN TURKSTRA: It's emotional and it's very interesting to think about that's why I post the question. There isn't an answer. Well, the court will figure out the answer. The judge -- because the judge
has already said it's the most heinous crime he's ever seen. I'm guessing that this adolescent is going to get the maximum sentence. So, I think that that -- I think that will happen. The family is I
believe going to try to get the brain injury introduced just a mitigating factor in this sentence so perhaps he can get some services. So that -- so I, you know -- so everyone I think would agree
that, first of all, this is not a totally impulsive crime. I think adolescent crime, unless there's a real history of conduct disorder in the adolescent, adolescent crime is almost always impulsive
because adolescents are impulsive. So, was it -- did -- was there good judgment there? No. Because probably if he talked to her nicely and persuaded her, she might have given them the money. So --
because they had a good relationship as I say up to a week before, Barbeau at least was had a good relationship with his grandmother and was over there helping her out on a weekly basis. That's the
other thing that's really odd about this. So -- yeah, sorry.
AUDIENCE MEMBER: I was just going to say one more thing. If media-wise this brain injury is taken into account and becomes a part of this case, it actually could be more difficult, I think for our
BrainSTEPS teams. A lot of times it's hard enough for us to get the districts to realize that concussion and brain injury is a legitimate injury that needs accommodation and needs help, and I would
think that a lot of them would be like, "Oh, yeah. Now, you just have to say you have a brain injury and you can get off easier from committing murder." Like the attitude...
LYN TURKSTRA: Right.
AUDIENCE MEMBER: ...towards it. I don't know if everyone else is like that too. Brenda.
LYN TURKSTRA: There's been a federal backlash against brain damage as a mitigating factor in crime, you might have heard for this reason in adults. So, the idea is that people are using this, using
MRI scan showing the person had old frontal lobe damage as a mitigating factor. The other concern and -- of mine that you I'm sure would share is that, you don't want people thinking that everyone
with a brain injury is going to go and murder someone and so I couldn't -- I can't tell you how many times I said this to the reporter and when he called me back the second time I said it again. This
99.9 percent of people with brain injury will never do something like this. So, this is not the brain injury causing the criminal behavior. There's no question about that, but yeah there are some
risks. Yes, Brenda? I'll let you have the last word before we move on. Yes.
BRENDA: Okay. In the State of Pennsylvania, I don't know it's like this everywhere, but if it's proven that you have a brain injury in your on death row, they won't...
LYN TURKSTRA: You can't be executed.
BRENDA: You can't be executed. So, yeah, that's something interesting.
LYN TURKSTRA: Interesting. Right. Oh, sorry. Yeah, go ahead.
AUDIENCE MEMBER: I actually worked in a maximum security prison and on death row in Pennsylvania, and there are a lot of people in those prisons with all sorts of issues. So, my thinking would be he
would -- he would not get any treatment in prison and he would only be worse when he got out. So, even though it was heinous and it was horrible he needs some kind of treatment while he's in prison.
AUDIENCE MEMBER: So if that could be an end result that would be really, really good.
LYN TURKSTRA: Right.
LYN TURKSTRA: Right. And that -- so that's where -- that's sort of where we ended up at least talking with the reporter. I think that's what the family is hoping for, that he can get some kind of
treatment while he's in prison. Not that it would affect his sentence, but that at least he would get some treatment, so when he gets out he's not as much of a danger to society. Yes?
AUDIENCE MEMBER: I also had a student where just this past year the kid had a brain injury and the parent had called me because the -- he -- the child was now starting to shoplifting, do things like
that, and getting into fights more where he hadn't before and he had a brain injury. And she'd called me because she said, "Is there anything I can do to take the judge?" So -- yeah whenever he's
LYN TURKSTRA: Interesting.
being caught to this...
AUDIENCE MEMBER: ...legal repercussions now and, you know, I told her to take a copy of his IP to show proof of his brain injury and take some documents along, you know, just to -- and I tried looking
for things on the internet for articles and things to -- like to see if there was anything to show, and I had a difficult time finding material to even give to her, but I told her to take what we had
written up and take that -- to take as consideration but I just think that...
AUDIENCE MEMBER: ...it was probably a lot more -- I mean that's on much lower level obviously because it wasn't murder but still -- and...
LYN TURKSTRA: Right.
AUDIENCE MEMBER: ...I encouraged her to...
LYN TURKSTRA: Well, now...
LYN TURKSTRA: Right.
AUDIENCE MEMBER: Exactly. I said to her too I've really encouraged her to go see a doctor again and get him into counseling and get him more therapy to help him, I said, before it does start to get
LYN TURKSTRA: Right. So to your comment about research literature, I could not find anything that talked about the likelihood of committing crime if a person had a brain injury. There are a lot of
studies looking at the prevalence of people with brain injury in the criminal justice system. So -- like on death row, or incarcerated individuals -- or we did a study, we did fact finding for the
State of Ohio where -- that's why I was in this medium security facility because we just walked in and asked kids if they'd ever been knocked unconscious and 50 percent of them had. So, we asked the
first hundred kids we saw and 50 of them had been knocked out. So, there's that kind of study but the really -- I wasn't able to find anything either. So, I think that that's -- I think that people
who do longitudinal studies like the TBI Model Systems Programs have the capacity to look and see to get those data to see how many people with brain injury end up in trouble and are there any
predictors of that, but we really don't know. So anyway -- oops sorry.
AUDIENCE MEMBER: That's okay. The--I think I have been speaking long enough. But anyway...
LYN TURKSTRA: Well, they're recording that's why they need the microphone.
AUDIENCE MEMBER: Mic. I think the other thing that -- I think the other thing that would actually...
LYN TURKSTRA: It's voice activated.
AUDIENCE MEMBER: Okay.
LYN TURKSTRA: Yes.
AUDIENCE MEMBER: Is it?
LYN TURKSTRA: Is it on? She's shaking her head. No, it's not on.
AUDIENCE MEMBER: Push the bottom.
LYN TURKSTRA: Push the bottom.
AUDIENCE MEMBER: Okay. Is that better? All right. I think the other thing that might be taken into consideration is the group home that he was placed in.
LYN TURKSTRA: Right.
AUDIENCE MEMBER: Because he moved from an environment of the caring supportive family into an environment that I would suspect was populated with kids who had already demonstrated some significant
behavioral issues, and so even though...
LYN TURKSTRA: Like this kid?
AUDIENCE MEMBER: Yeah.
LYN TURKSTRA: Who didn't have a brain injury.
AUDIENCE MEMBER: Yeah.
LYN TURKSTRA: And who for all we know is the one who actually committed the crime.
AUDIENCE MEMBER: So, in that situation I think there might have, you know, there could have been things that have led to...
AUDIENCE MEMBER: ...the environment, to change the environment, to change in...
LYN TURKSTRA: Right.
LYN TURKSTRA: Right.
AUDIENCE MEMBER: ...the groups that he was hanging out, you know, circulating with that might have led to what look like, you know, a predisposition to that kind of violent behavior.
AUDIENCE MEMBER: So the whole...
LYN TURKSTRA: Right. Right.
LYN TURKSTRA: And I think -- oh, sorry. I think those things were all considered in the verdict. So, all of these issues that everybody knew about I think came up, it's that the brain injury did not
really occur to the parents until very close to the trial date. So, well, we'll see what happens. You might see it in the news. Okay. So, that's great. I -- I'm happy that we had the -- this few
minutes to talk about this because I think that that highlights a lot of the issues that we deal within adolescence. So, the unpredictability and sometimes irrationality of adolescent behavior, the
issues of developing with a brain injury and what that means in terms of the types of functions that are supposed to be developing during adolescence, like executive function, and also just societies
understanding in general response to adolescent behavior, and the behavior of adolescents with brain injury. I've had the experience -- and you all have much more of this than have of having teacher
say, "Well, that kid just has an attitude problem." And so this is a battle we fight more with adolescence than any other age group because they're more likely to be obnoxious. So, with adults we
rarely have someone -- when someone goes to work with a brain injury say, "Oh, well, you know, he's just not trying hard enough." So, there are a lot -- we have a lot of challenges with this
population. So, I want to thank up front the many people who've worked on the research that I'm going to talk about today over the years. I'm going to talk about a lot of things that aren't research,
but I want to make sure I thank them first. The par teams here, when I did adolescent research -- I have done it over the last few years we did participatory action research which is a type of
research where the targets of the population are involved in all stages of the research. So, I'll show you an example of video clip coming up in a little bit and you'll see adolescents acting. So,
they told us what we should be testing, they acted out our videos and created our stimulus materials, they directed movies, they edited, they gave us feedback. So they -- these teams of adolescence
in Ohio and Wisconsin really directed the research that we did on typical adolescent behavior. When I started working with adolescence I thought I could go look up typical adolescent communication. I
thought there would be a place that you could see, you know, how fast they talk, how many times they change the subject, things like that, and there are no data about that, so I had to go back to
zero and actually ask teenagers what they thought. One grant reviewer said once, "This research is impossible because teenagers don't know themselves and what they need." Another bad public
perception. So, when you think about adolescents, I think the question that's on most people's mind is really, "Why?" Why do they do the things they do? So -- and I want to spend some time today,
quite a bit of time talking about typical adolescent development because I feel like in my training we had 10 minutes about that. So, most of my knowledge of adolescents came from adolescents with
problems, and I didn't really have -- I had a lot of myths in my mind about what was normal adolescent behavior and a lot of them aren't really true. So, I want to take some time and talk about that.
So, this is one of my pictures because I think it encompasses the beginning and the end of adolescence. So, the beginning of adolescence is when you're really humiliated by other people's behavior,
and the later stages of adolescence is where you're so preoccupied with sex that you don't care what anybody else thinks. So, that's the, you know, this is the mating in reproduction stage, that's
what they're supposed to be doing. I took this picture a few years ago when I was in Paris. So, I always joke that I was at the Louvre, and I was the only person who was taking photographs at the
back end of teenagers so -- and the back end of the Venus De Milo. So, I took this picture to make it appoint that adolescence hasn't really changed. You know, adolescents have not really changed.
They've always been making bad wardrobe decisions for millennia. So people say, "Oh, teenagers today are so bad." You know what, they are no worse than they were. In fact they're better than they
were years ago if you look at rates of volunteerism and adolescent crimes, smoking, littering, you know, things like that. Those things have actually improved over the last few decades so. They seem
really bad because we hear about the bad ones a lot in the news, but taken as a group and actually that's -- let me take that back, taken as individuals because when you put them in a group, it's
annoying. But taken as individuals, they're really no worse than they were. And I'm sure that Venus De Milo's parents were like, I can't believe you're going out with your butt showing. I wanted to
give you a little quiz because one of the points that I hope to make today that maybe transparent already to all of you is that we don't know anything about teenagers, we really don't. On an
individual level or on a group level we really don't. We are not cool and some of you are really young and you might think -- I'm looking at you especially youngsters, you might think you're still
cool. You are not cool. Right? As soon as you have a job it's over. And so there's nothing more embarrassing than an adult trying to seem cool. I sudden on a neuropsych eval -- and I'm not picking on
neuropsych. I sudden on a neuropsych eval at a very well known brain injury rehabilitation facility far away in the country, and the neuropsychologist was talking to an extreme snow boarder who'd
gone over an edge and, you know, had a brain injury, and this kid was still on PTA and then came in his chair and the neuropsychologist said -- who was my age by the way, he's sitting back in his
chair like this, "So dude, I bet you want to get back on that board, right? That's really grody." I was like, "Oh, my God." You should be thankful that kid is in PTA. Okay. So here's the quiz.
AUDIENCE MEMBER: I don't know if [inaudible]
LYN TURKSTRA: Yeah, I know you might not. Here we go. When you ask your daughter if she likes the new chicken dish you baked for dinner, she replies "It sick." This means...
LYN TURKSTRA: Right. It means good. Today, tomorrow it will mean bad.
AUDIENCE MEMBER: Good.
AUDIENCE MEMBER: Yeah.
LYN TURKSTRA: Your daughter calls you on her cell phone and says, "Can I make a re-question?" Huh? What? Yeah. Since you -- it was a bad cell phone connection that cracks me up. No, requesting
question at the same time. Which of the following words does not mean wonderful or awesome, tool, dope, tight?
LYN TURKSTRA: Everybody knows that one. OMG that just tells you how fast things are old because that's like so 2000. Okay. While driving your son and friends you overhear his buddy ask what your son
thinks of the new girl, he says, "She's fly." This cracks me up because where is fly from? Fly is from like the '60s.
LYN TURKSTRA: So -- yeah. So, it's recycled now. An individual who has a pessimistic attitude and is always talking about their friends is a?
AUDIENCE MEMBER: Oh.
LYN TURKSTRA: Exactly. Angst-filled teenager who dresses in black and looks like Goth basically, listens to alternative music is a?
AUDIENCE MEMBER: Emo.
LYN TURKSTRA: Good job. Is that -- did you said that, emo?
LYN TURKSTRA: All right. Emo. You pick up your son from school and he says, "I'm chilling."
AUDIENCE MEMBER: What is it called?
AUDIENCE MEMBER: [inaudible]
LYN TURKSTRA: Right. That's chill -- chillax, chill, that's also old. When Mark ask what the -- your son and his friend are checking out a new CD when Mark, his friend, asked what the music is like,
your son replies, "The lyrics were pretty HC." It does not mean heroin, what does it mean?
AUDIENCE MEMBER: Hardcore.
LYN TURKSTRA: Hardcore. Your daughter's best friend doesn't show up at the mall to meet her and Jane says it my b -- we all know that one, right? My bad. Your son and his friend are shooting hoops
when you ask if he'd like to stay for dinner your son's friend says, "I got to bounce."
LYN TURKSTRA: Right. You guys are doing pretty well. You see an IM between your daughter and her friend -- that tells you how -- that this is a couple years old. I just found its a few months ago but
AUDIENCE MEMBER: Keep going.
I guess it's a couple years old so -- yeah. This is what it means. How much of this do you understand?
AUDIENCE: All of it.
LYN TURKSTRA: All of it, way to go. Which is why it's changed now because as soon as parents understand it, it changes.
LYN TURKSTRA: Right. Because what's the point?
AUDIENCE MEMBER: Yeah.
LYN TURKSTRA: The point is to have a secret language your parents don't understand. So as soon as your parents understand it morphs. So, if you didn't get a hundred percent with no effort and even if
AUDIENCE MEMBER: Yeah. Yeah.
you did, you really aren't cool. So -- but the lesson is -- and we'll talk about this later this morning about intervention. The lesson is you really need to talk to other adolescents who know the
person with brain injury you're working with, to ask about the standards of behavior for the peer group. So many adolescents have talked to me about this, about how social life and social
inauguration is the piece that gets left out of rehabilitation and that's the focus in my lab so obviously I ask that question a lot. But I think one adolescent in my lab summed it up really well.
She said, "I wish someone had just talked to one of my friends to find out what was normal." Not brought her in to help and rehab, not showed her what I was doing, none of that stuff. Just talk to
her, to ask what kids my age were doing. And -- you know, it's such a self-conscious age, you don't want your friends coming in and seeing you necessarily when you're in rehab once the celebrity
thing is worn off. But just to talk to them and find out because the -- it -- even our common language or vernacular changes and -- but in adolescents it changes really, really fast. So the jokes,
the dress codes, all of that stuff changes so fast. You really need to talk to peers and find out what's going at this age, what are the things that people want to do. So adolescence -- so it's
defined as a transition, and that's what makes it hard to know about expectations because it's just defined as someone who isn't a kid and isn't a grown up and its something in between. And so at the
risk of saying this on video, it's like pornography people say, you know it when you'll see it. But nobody can really define it. Sorry, that's like a famous line. I didn't -- I don't want to refer to
pornography. Okay. So, there's fairly good agreement about the beginning of adolescence. So it generally in our society is thought to start with puberty. So, before the 21st century puberty started
around age 13 and now it's about age 10, and this is due to advances in nutrition. There had been talk -- there was talk a few years ago about hair products and girls whatever knowing. It's probably
not hormones in the milk, it's just better nutrition. Better nutrition means that puberty has come about a little bit earlier. So you all know people who had puberty before that or after that, so
everything I'm going to say today is average and there's going to be range for every single benchmark. So, that's the beginning. And it starts because of some pretty observable hormone
change--hormone changes. So in the hypothalamic pituitary axis, what happens is that the set point for stimulating the pituitary gland changes and you get this release of sex hormones. So, you have
had -- your body has -- had a set point for when you're going to go through puberty from birth. So, this is predetermined in your -- in your fetal development. But that -- what -- the time -- but it
isn't triggered until a certain point in development. And as you know, this triggering can be delayed by things, like children who are really underweight puberty can be delayed, or stress, or
chemotherapy, you know, or other medical treatments can mess around with what this is. But this is really already on track all throughout your development and so what happens is you get -- the
hypothalamus is stimulating hormones -- is releasing hormones that stimulate the pituitary gland which stimulates the gonads which causes release of androgens and estrogens, and then the levels of
those hormones are monitored by the hypothalamus. And so all of those things stimulate the body growth and development changes that are associated with puberty, they also stimulate an increase in
stress levels, so -- which is an interesting thing. So, puberty is biologically is a more stressful time. And we'll talk a bit more about other changes in puberty that might affect the behavior that
we see. So, why does the hypothalamic "set point" change? Well, as I said this is -- this biological clock is set genetically. People generally hit puberty around the time of their parents, somewhere
around the time of their parents. So, a lot of it is predetermined by your parents. There are also signals in the environment indicating that there are sexually available mates. So, you might want to
keep your 10-year-old locked up for -- this is probably the motivation behind same sex schools. Did you really think if you put them in an all girls' school or an all boys' school they won't meet
people of the opposite sex which is hilarious, right? You could put them -- literally locked in a closet and they would meet people of the opposite sex. Also as I mentioned, biological signals that
the organism is healthy enough to support pregnancy on the female side. So adequate weight, things like that. Interestingly -- so stress, illness, nutritional deficiencies, too much exercise,
thinness, all those things can delay the onset of puberty. But interestingly the onset of puberty is earlier in obese girls and later in obese boys. So, you can see that this is really about child
bearing. So -- because obese girls, it -- it's affects their child -- they have child bearing capacity earlier, they have earlier puberty, but for boys, I'm not sure what the rationale or the
evolutionary reason for that is. Maybe they're supposed to be out there hunting and gathering food and -- if they're obese they're not as able to do that [inaudible] I don't know what it is for boys.
But -- yes. So, this is the time course of hormone changes. So, this is actually for boys, but it looks the same for girls. So, what you get, is you get this little burst of hormone release, very
early in development. So for boys I think this is probably the maniac [inaudible] you know, when little boys are like running around screaming like maniac -- or boys--I mean certainly there's overlap
between boys and girls in that. But you get this prenatal burst that goes down all the way through the maniac [inaudible] and sort of settles down a little bit later in childhood. In girls this
little burst that you see, I think of it as the pink stage. So, you know right how girls go through that pink stage where everything has to be pink? And you think, "I'm a feminist. How did I have a
daughter who wants to have 20 Barbies." And then somehow they come out to the end of it and they're not pink anymore. So I think these early hormones probably correspond to that, but then look at
this puberty massive increase of sex related hormones. I've said before sometimes I think high school teachers should just not even bother, right? Because what is going on at this middle school and
high school stage? They're in a massive hormone storm and it's all about reproduction. So, there is nothing we can do about that speeding train. It is what it is. We do all start life as girls. So
embryologically we all start as girls. And then there are hormone levels that change brains from girl brains to boy brains. So, overall if you look at brains of boys and girls, men and women they're
almost identical. They have small changes. It turns out the small changes are kind of important, but our brains really are pretty similar. So, what happens is at around eight weeks of gestation,
eight weeks until the pregnancy, you get circulating testosterone levels and that masculinizes the brain and I'll talk a little bit later about -- well in a couple of slides about sex differences.
But that--you get the impression that boys and girls start to differ at puberty, but really it's not at puberty. They're really -- those changes are already starting in utero and then you get
activation of those changes at puberty. So, what are all those hormones doing? Well, these are the things you all know. So, you see rapid acceleration in growth, increases in height and weight.
Interestingly, hands and feet grow faster than the trunk. I have a picture on my cell phone. I might -- maybe I'll put it up after the break, of my niece. She weighs -- I don't know 55 pounds or
something. She's like this tall. She's the skinniest little kid, and her feet are this big. She is totally out of control of her limbs. Her sister who's also -- they're two years apart so they're
going through the same stage. Her sister is this tall now, she is 10 and -- my family is pretty tall. And my brother said he has a picture of his daughter crossing the finish line in a race and she's
got like her arms are over here and for something like -- she has no idea where anything is. So, it's a very physically awkward stage so you have to feel sorry for them because they really are
growing super fast and you know your brain the ability to control your limbs is at -- having to adapt on a daily basis to this increase in body size and things being out of proportion. So you get
development of primary sex characteristics including gonads, testes and ovaries, and then development of secondary sex characteristics, changes in body composition. So girls start developing more a
shape. Guys get really muscular, increased strength and tolerance. This is the strongest age. So adolescents are the strongest age. You can see that in Olympic sports. So endurance sport like
running, you tend to see people pick later in their 20s even into their 30s but strength sports -- strength and agility sports usually it's late teens into the 20s. And so there's no -- there's
nothing new developing at puberty. It's just things are being turned on so to speak. Okay. So, let's talk about stages of development. So when we talk about adolescence, people who work with
adolescence usually talk about three different stages of adolescence. Early adolescence which is about 10 to 13 years corresponding roughly to about middle school or some people call it junior high
school, so about grade six, seven, eight. And then middle adolescence, which is 14 to 17 years, so more or less the high school age. Late adolescence, which is 18 to 21 years thereabouts, which is
about the college age, and then there's this term, I used to call it emerging adulthood. Ages 18 to 25 years when people make the transition into adulthood. So, this is changing. So, people now are
talking about adolescence as ending at around age 25. So, developmental people study adolescent development are generally saying about 25 and a lot of that has been driven by growing knowledge about
frontal lobe maturity. So, that's really where a lot of it is coming from. So, I think -- yeah, I have this here. How do we know when it's over? So, there is not a definition of the end of
adolescence. So people agree that around the onset of puberty is the beginning, but there is no definition of the end. So, it may just be interminable. So, the end of adolescence is really mostly
cultural. So, in our culture, we have some benchmarks of the end of adolescence. Like that you're emotionally independent from your parents. I asked my students this, the undergrads, "How many of you
call your mom when you get a bad grade?" It's like everybody. You know, how many of you are financially independent from your parents? Yeah, that's a parent, right? No, they are not. Mckay Sohlberg
who is the first author on the book that we have published, her last daughter left home last year out of high school to go to college and she said, "You know, my children are emancipated and it's
kind of a sad moment having an empty nest." A I said, "Honey..."
LYN TURKSTRA: "They'll be back." There is no empty nest. They just recycle back into your home year after year, right? And then they have kids and then the grandkids are recycling back into your home,
AUDIENCE MEMBER: They'll be back.
there's no emancipation. So, if you think about those benchmarks, you can understand why people are talking about adolescence as not ending at 21. So, it's really more like 25. And I think that that
should affect our expectations. One of the places where I see it really making a huge difference is in where people go in rehab. So, you know, like a 21-year-old would go to an adult facility for
rehab and have nothing in common with anybody in that facility. We see young people who go to group homes, even nursing homes if they really have severe impairments and feel like they're stuck there
with a bunch of old people. A girl who's 19 said to me once when I was working in rehab, "I am so sick of talking about fishing." Right? She could not have cared less. And so, I think if you think
about adolescence ending at 25, it really has implications for a lot of things in rehabilitation. Also -- and I -- this is something just to -- for shadows, I mean, that we'll talk about later in
terms of treatment, I do not send young adults with brain injury to support groups because I think it's a completely different developmental stage. I would not have a 23-year-old go to a brain injury
support group with a bunch 40 year olds who are sitting around talking about how their lives suck. Sorry, I said that on video tape. Edit better. Sorry, I am a Mark Ylvisaker and Tim Feeney
offspring, and so I have the potty mouth that they endorsed, right? You have to have a potty mouth if you work in brain injury. One thing has been identified as a possible biomarker for the end of
adolescence and that's sleep changes. So, when you're in adolescence -- adolescents can sleep pretty much 20 hours a day. Um, but at some point, you can't anymore. And so there was one study that
proposed that this might be the biomarker for the end where you start to sleep in a more adult-like sleep schedule and not -- so adolescents will tell you, "Oh, I don't sleep 20 hours a day. I'm
really sleep-deprived." Well, yeah. It's not about how much you do sleep, it's how much you could and they really could sleep around the clock. On my street, Saturday morning at 7:30, I was awoken by
expletive. That heard, shouting outside my window, kids on skateboards with no helmets, of course. It's like the tri-fact, they're swearing, it's 7:30 in the morning, and they're not wearing helmets.
And I was thinking, "Why do I have the only adolescents on the continent who are up at 7:30 on a Saturday morning? They're supposed to be sleeping until 12:00." So, a lot of different disciplines
have defined the end of adolescence. I'm just saying this to you to say that you can't -- we don't really have a hard and fast rule about when it's over. So, people in biology will say that end of
adolescence is when you can sexually reproduce. And I don't think any of us would agree with that. But that's been a biological definition. Parents might say, when they're out of the house and
they're detached from us and affiliated with their peers, we have voting, you know, legal requirements, and you notice the ages are all different and it's confusing. So, there's an age when you can
smoke, when you can drink, when you drive, when you can serve in the military, when you can rent a car without paying a ton of money, they're all different ages. And so every sort of constituent has
a different definition of the end. But it does make a really big difference to our expectations for behavior. Adolescents are developing in different domains. So, they're learning about who they are.
And this again is one of the challenges with brain injury as an adolescent is just in the process of figuring out their identity when it can change. So, they're just beginning to know their strengths
and limitations and have a feeling of accomplishment. They're also separating from their parents and sort of having their first intimate relations with peers, having sexual feelings we've talked
about and then being able to evaluate their own performance. So, these are all different spheres in which adolescents are developing. And again, different groups have sort of defined what they think
is causing adolescent behavior. So, some people think it's all biological that everything you see in teenagers is driven by hormones and that you can't do anything about it. It just is the way it is.
And so that's kind of the extreme biological view which is there's -- it's a stressful horrible time because you have all this stress hormones and everything, and so you can't really do anything
about it. But there are a lot of other views, and I think it's good to know about them because they affect things like sentencing in the courts. So, some people believe that adolescents are the way
we are -- are the way they are because we let them. Right? So, they think, you know, people who say that ADHD is on the rise because parents are more permissive and less structured? It's that. So,
there are a lot of people out there who believe that our culture has created adolescence as a time of, you know, acting out an impulsive behavior and that we cuddle children for too long, and because
of that they're not expected to be responsible. You've probably heard this or even maybe said it. I know my parents certainly said it to me at -- when I was 21 I was expected to be out of the house,
with a job, starting a family. And so there are those views about adolescence. And so I think it's good to know when you're interacting with people in the general community what their perception is
about what they think is causing the behavior because it's going to influence how willing they are to do things like make accommodations. So let's talk about what's actually going on during
adolescence. And just to give you a heads up, we will probably take a break at around -- somewhere between 10:00 and 10:15 this morning if that's okay with everybody. But feel free to get up anytime.
It's not school. Okay. So, this is a wonderful cartoon of adolescent brain development, there's an animation available online that you can see. And what you can see -- so it starts at age five on the
-- on your upper left and goes down to age 20 on the lower right. The color coding represents areas of the brain that are changing. So, the purple areas are the areas that are changing and changing
last. So, this is the right side of the brain on the top row and the top of the brain on the bottom row. On the bottom row, you can see that eyes would be up. So, the frontal lobes are at the top of
the image and the back of the brain is at the bottom. So, one thing to note, the most purple is the occipital lobe and our visual cortex is the most plastic and changeable part of the brain. So, it
continues developing throughout our lifespan. It's really interesting, but you know this if you wear glasses. Because you wake in the morning without your glasses, you can see better than after
you've put your glasses on if you take them off. That's plasticity of the visual cortex. So, we do an experiment when we do neuroscience outreach where kids put on prism glasses. I don't know if
you've ever seen that. And then they have to throw bean bags at a target and prisms move the target over in your visual field so they miss at first and then they can hit the target right on. That's
plasticity of the visual cortex. So, it's a very changeable, malleable part of the brain. So, that change is very late. But you can also these major frontal lobe changes going in to the 20s. So, as
we say about the frontal lobes, they are last in, first out. So, they continue developing into the late 20s but they start to decline early in the 40s. And so if you are between 27 and 40, you should
really enjoy this moment. So -- of course the brain functions as an interconnected unit. So it's not like you, you know, it's over when you're 40. But the frontal lobes do tend to be very sensitive
to aging changes because the frontal lobes have a very protracted developmental sequence. They're vulnerable to a lot of things. So they're -- frontal lobe development is vulnerable to a lot of
environmental factors for example so -- and you'll see this -- again, I'm over simplifying because the brain is all connected, but kids who grow up in a very unstructured environment where they don't
have a lot of good education and, you know, meaningful input and things like that, may not develop the same capacity for higher abstract thinking as other kids. So, the frontal lobes are sensitive to
input all along those -- that develop -- developmental trajectory. That's not just a brain injury type of input but also things like nutritional status, drugs, like ecstasy, you know, things like
that. So, those -- because that system is still developing, anything that happens through that age can really affect its development. So, it's probably one of the most sensitive parts of the brain to
anything going wrong from the ages of five up to thirty. So there are a couple of main categories of changes in adolescent brains. So, there are structural changes. What happens in the brain is that
-- you probably heard this, that at birth, you are born with more neurons that you need and more connections that you need, and then you prune back in the first couple of years of life. So, you have
this massive proliferation of connection, synapses among neurons in the brain and then they prune back in the first two years based on your experience. But what people didn't talk about until the
last -- oh, I don't know -- few decades, is that, there's another massive way of synaptogenesis or connection of new -- creation of new synapses in the pre-adolescent years and then more pruning. So,
this is another time where the brain is really sensitive to environmental input. Like from nine to thirteen where the brain itself is actually changing regardless of what the teenager is doing. So,
when I first read about this when I was a grad student I was really excited because I think sometimes people write off adolescence for therapy because they figure, you know, especially from speech
pathology point of view, they figured, if you haven't fixed it by seven, it's not going to be fixed. But this is really a time -- an age where there's a lot of sensitivity to input so you can --
there's still a lot you can do for a teenager. So, I think the notion that it's kind of over in terms of changing the brain in development by the time a child is seven, that was driven by miscoded
old research and that's not really true at all. So, there is this other period of proliferation of synapses and then pruning again. So, you also get an increase in white matter. So, white matter is
the myelin covering of neuron axons. So, what that means basically is that the brain is functioning more efficiently as a unit. So, you get better connection among parts of the brain. What you see if
you look at imaging studies of children versus adolescence is less brain to do the same thing. So, more -- which people interpret as more efficiency, in efficiency of thinking, efficiency of moving.
So, when people say that young kids are clumsy, I always think, "Well, yeah, they're clumsy because their brains are not full developed." And so you don't expect a small child to be able to do very
fine motor things like writing because they don't really have the fine motor coordination. So, that is all developing that -- speed and efficiency of moving and thinking is developing into the
adolescent years. Functionally, you see a decrease in cortical metabolic rate, and that's what I mean by less brain to do the same thing. So, which may mean more efficiency. And I'm also going to say
another word about this. There's something that happens during the teenage years with dopamine in the brain. And I'm going to come back to that when we talk about why adolescents take risks. So,
neurotransmitters in the brain function differently in adolescence than they do in childhood. And you have probably seen this if you've seen children with ADHD. So, a child with ADHD looks very
different than an adolescent with ADHD, looks very different than an adult with ADHD. So -- and ADHD meds often have to be changed a lot around puberty. So, a kid might have been on something, on the
same med and been pretty stable from, you know, say they were diagnosed at age seven or eight, and they were well-maintained on some medication they were on at, you know, seven, eight, nine. At 10
and 11 that drug might not be working anymore or it might work differently. So, neurotransmitter systems in the brain actually function differently during the teenage years. So, a lot of drugs have
unpredictable effects in adolescence and this is like you saw, you know, like, the suicide risk of anti-depressant drugs and things like that. So, the adolescent brain is not responding to
medications the same way. And that has some big implications for their behavior. So, as I said, we're going to come back to that when we talk about behavior. So, I'm going to go through and talk
pretty specifically about these developmental stages. So, that's kind of a big picture of what's going on, but I want to talk about the individual developmental stages. But I have to give a few
caveats. This is one of my favorite photographs. It's from Laurence Steinberg's book Adolescence. If you're looking for a book about adolescence just to have on your shelf to look stuff up about
anything, about physical changes, hormones, social changes, life or whatever, I would get this book. There's a newer edition. This is the old edition that the photo is from. But the newer -- newest
edition is only a couple years old. Laurence Steinberg is the world's expert on adolescence. He has single-handedly published most of the literature on the adolescent brain and its effect on
development and how that placed out in criminal courts as well and in risky behavior. So, the reason I love this picture is that these adolescents are all the same age. Right? Isn't that true? So --
and you might look and say, "Who was I?" Right? Which were -- which one were you? I was not that girl. I wanted to be that girl. I'm still not that girl. And so -- but yeah, so we have this boy who
shaved in 9th grade, right? And so -- yeah, so they are also -- as I mentioned before, there's a variety of when people hit those developmental benchmarks and the brain changes are like the body
changes. Some adolescents are really introspective and mature when they're 13 and some are still not introspective and mature when they're 30. So they're -- people -- adolescents are going to be
different. And as you know, if you work with adolescents with brain injury, one of our challenges is trying to figure out where this kid would be on his or her trajectory. So you can't say, is this
kid's behavior normal compared to everybody else because it's such -- you know, they're all so different at that age. You have to say, "Based on how this kid was before the injury like Barbeau, you
know, the parents have this 10 year history of him being right on his developmental benchmarks and then they see a departure, but it's his departure. So, sure he turned out to be like this other kid,
the Paape kid, but they didn't start in the same place. That's a big caveat. The second one, this is a bell curve. All of the things that are developing in adolescence are variable in the general
population, you know, it's like grammar development, development of grammar. Everybody except for people with the language impairments develops grammar the same way. And everyone generally gets the,
you know, good grammar by whatever age, seven or eight along the same line. For executive function, it is not true. There's a huge range of executive function in the general population. One of the
tasks that neuropsychologist often use for executive function, the Delis-Kaplan Executive Function System has no cut-off for abnormal. There's no -- there's no -- you know, you usually give a tests
in like two standard deviations below the mean is the cut off for a typical performance or something that? There's no cut-off in that test. Because there are always going to be people who do very
well and people who do very poorly. So, this is a real diagnostic challenge for us. Social behavior, a lot of which is driven by executive function and it's also a very variable in the general
population. So, some people are good at it, some people are not good at it. And so that makes it a challenge. The third caveat is this, right? So, as I mentioned earlier, our brains are almost
identical, but not exactly identical. I never wanted to believe in differences between males and females because you're mostly women here you know what that always means is that women aren't as good.
Right? Whenever when it -- ever -- whenever anyone says there's a difference between men and women, it always is in favor of men. So, I always wanted us to be just the same, but after doing this
research for, you know, 20 plus years, I have to admit, there are differences between males and females. Now, again, back to the bell curve, there's a huge range. So, there are girls who are more
masculine and girls who are more feminine. There are males who are masculine and males who are more feminine. So, there's a range but there's still are some things that are different. I loved this
cartoon. This is from Zits, the comic strip, if you ever are looking for funny cartoons for the teens you work with. I was doing this -- our participatory action groups in Ohio and the girls were
over here talking and the guys were over here talking. And the guy -- if you get a group of teenage boys together, they will talk about relationships in five minutes. It's hilarious. Like, they have
this reputation as never talking about stuff. First of all, they talk all the time and they talk about relationship. So, the girls -- the guys were talking about this look so if -- your benefit over
here. You know the look? But women in the room, will know what that look is. The guys were, like, no idea. No idea. And one boy said, "Ma'am, we're just really happy when anyone talks to us." It was
so cute. So, I thought, you know, you have to acknowledge that there probably are some differences and we have seen in my lab, in adolescents and adults pretty consistent differences in social
perception between males and females, and I'll show you a little bit of those data later. But we did one study in adults that if you look at percent accuracy on the social perception task, it was
woman, woman with brain injury, man, man with brain injury. So, there are differences. And these are brain differences that might be related. So, you can see -- and I'm not sure, I might have a
pointer. Yes, I do. No, I don't. Okay. You can see in the solid lines are boys, that hash lines are girls. This is development on the top of the amygdala which is a part of the brain that's involved
in fear, aggression, those kinds of emotions and the only thing to pay attention to in this pictures is that you can see that from early puberty to late puberty, the size of it goes up in the boys
and it's about the same in the girls. And that maps right on to testosterone level. So, as testosterone levels go up in puberty, amygdala size gets bigger. And that's the part of the brain that is
involved in aggression. So, does that all make sense? And then the left cortex which is involved in language, you can see from early to late puberty is being pruned in girls. And remember pruning is
generally thought to be a good thing in the brain, so getting more efficient. So you can see that it's decreasing in size in the girls, not changing in the boys. And that that goes along with the
testosterone levels in the boys as well. So, that girls' testosterone levels in boys and girls, that girls -- it's a function of brain changes. So, it's like -- in puberty, if you look again, it's an
average. Everyone is different. But if you look over all, you will see aggressive behaviors often increasing in boys and language and communication and social behaviors improving in girls during the
puberty stage. So the -- as I -- that -- as I sort of alluded too in that slide, physical cognitive and social changes go along with those changes in the brain. So, you saw the dots were all over the
place, so a lot of variability across people. Big changes, sex-based differences, related more or less to the timing of puberty. So, a lot of stuff is happening. And this is when I want to come back
to dopamine. Another feature of the adolescent brain is that it's a reward-seeking brain. And you might have heard about this because it's been in the media a lot in the last year. So, the adolescent
brain is very sensitive to rewards including drugs that affect dopamine systems in the brain. So, drug is a reward, but also social reward. So, social reinforcement is extraordinarily powerful during
the adolescent years. And Steinberg proposed this dual system account of adolescence to explain why adolescents do the stupid things they do. And so -- and I'll -- and I'll talk about that in a sec.
And then girls being a little bit different. So the reward-seeking brain. It turns out during adolescence, especially between about age 10 and about 13 to 16 years, on every kind of measure you can
ask adolescents about risk, taking risks and seeking rewards, the scores will go up during this period of time. And so, Steinberg has a model for that. And I think that the -- that behaviors led us
to some beliefs about why we think it happens. And I was interested to hear from him -- he came and spoke in Wisconsin last year, that a lot of the beliefs I had about why adolescent reward-seeking
behaviors go up, all -- a lot of my beliefs were wrong. So, here -- I like you to think about true or false for these questions. So, some people think that adolescents do stupid things because they
just don't reason like adults do. They're just not capable of that kind of higher level reasoning. So, there's something fundamentally difference -- different about their information processing in a
way they reason. So, I'm guessing a lot of you might think that. I certainly thought that before, and that turns out to be not true. Interesting if you ask them objectively to reason through
problems, they do it exactly the same as adults. So, there's really difference between adolescents and their ability to know something is right or wrong. So, for Barbeau, for him to be able to say --
if you would said to him -- as you know with your students with brain injury, even after brain injury, "Is it a good thing for you to go over to your grandmother's house with an axe to try and get
money?" He would say no, right? It's a bad thing. So, it's not a reasoning problem. The second thing you hear a lot is the adolescents just don't see the risks. They don't appreciate that if you wear
seatbelt it's a good thing, or they think their invulnerable. And this invulnerability is a -- this is something I've said a lot over the years. Well, it's not true. So, if you ask adolescents about
risk, they're just as scared of stuff as we are. Which is really interesting because I always thought there was this myth, this immortality myth that adolescents thought that they -- nothing would
happen to them. They're really no worse at adult -- than adults. And like adults, they can over estimate how dangerous something is. So again, if you sit down and talk to them, they can tell you what
all the risks are. It's not in the knowing that the issue comes up. The other thing is, do they like risks, are they -- are they less risk-averse? So, are they more concerned with negative
consequences than adults? No, it's not true. So, even when they did studies where they made the negative consequences greater, adolescents would still -- would respond just like adults did and be
less likely to take risks. So, why is it then that they do these things? Well, one thing is dopamine. So, as dopamine -- something about circulating dopamine levels go up during puberty and dopamine
is a neurotransmitter in the brain that's -- that is -- or the neurotransmitter of reward. So, a lot of drugs like cocaine that are associated -- that are rewarding for people and are addictive act
on dopamine systems, and the adolescent brain is very, very sensitive to that. So, it actually changes its chemistry in a way that makes it crave reward and benefit from it more than we do. So -- and
in terms of social reward for example, if you get an A in Grade 10, it has more of an impact on you than if you get an A in college. And that has more of an impact on you than if your boss says good
job to you when you're, you know, in your 30s and 40s. So, there's something about social rewards and drug types of rewards. Food rewards. Any kind of rewarding behavior. A loud noise, music you
like, whatever it is that the brain craves and is more responsive to at that age. Independence of the kid's ability to reason. The other thing is this whole sex related hormone change includes an
increase in hormone called oxytocine. That's associated with bonding because this is the mating age, right? So, you have a brain that's sensitive to reward and a brain that wants to bond with other
people who are potential reproductive partners. And of course the 13-year-old doesn't think, "I need a potential reproductive partner." They are just attracted to other people in a way that they
don't really understand. So, there's a lot social bonding. Well, the combination of those two things, Steinberg has argued is risky behavior. So, being really responsive to peers, and peer social
reward, and having a brain that just responds to reward in general makes an adolescent behave stupidly especially in the presence of peers and it was shown beautifully in this study. So, this is a
study where -- it's a simulation, it's a video game simulation. So, they have the adolescents sit in a simulator and they saw -- this is it. It's not really fancy. It's not like, you know, like
virtual reality. They're just watching a screen. And in the top left, you can see the different screens. So, basically there -- it's like a car and they're driving and there's a road ahead of them
and there's one stoplight. And the stoplight is going to be green, red or yellow. If it's red, they have to stop, if it's green, they can go, if it's yellow, they can either choose to run the light
or stop. If they run the light, there's some probability that they'll get hit by another car. So, the two outcomes of running a light are either crash or success. The crash, it's hard to see, but
it's this fractured windshield. So, what they look at was the probability -- and all the adolescent can do, they can't steer at all, all they can do is hit the brakes or not hit the -- or hit the
gas, that's it. So, they looked at the likelihood that adolescents would stop on the yellow and avoid the crash. And what they saw was that if you look at risky decisions, when adolescents were
alone, which is the blue, the number of times they had ran the light in blue, they look just like adults. But if you put them with a peer, that's the red bars. So, as soon as there's a peer in the
room. Likewise if you look at the number of crashes, blue when they're alone, they look exactly like adults. But when there's a peer in the room, the number of crashes increases. Interestingly, this
was true even if the experimenter said a peer was in another room watching and the kid couldn't see them. Just the idea of a peer watching increase the probability of risky behaviors. And this shows
evidence that reasoning is not the problem. So, making risky decision, they could reason through it, they're sitting there, but put them in an environment where there's peers doing something else,
and then that whole reasoning thing goes right out the window. We had another criminal case that I was asked to help with in Wisconsin where an adolescent shot a drug dealer. So, this was a suburban
kid, great family, no problems, a bunch of kids got together, decided to buy drugs and then someone had the genius idea to take a gun so that the drug dealer couldn't rip them off. They had never
done anything like this apparently. They didn't know how drug deals work. That the other person's unlikely to rip you off and cheat you. Anyway, the kids all started, they got into an altercation
with the drug dealer, they passed around the gun. This kid fired it, shot the drug dealer and is serving life in prison for that when he was 15. And the lawyer contacted me because this peer data had
come out. And she said -- he's sentence to life because he was sentenced before the new guidelines that -- it's 30 years or 35 years maximum. So he's in life -- he's in for like real life. No
possibility parole. And so she said, "I think -- could we argue that the peer influence was a mitigating factor." I mean, this was not a pre-meditated crime because they didn't plan to shoot him.
They just took the gun in case he'd attack them or whatever. And it's, again, not clear who really shot the drug dealer, but probably this kid. So anyway, that's another extreme example, but peers
are everything. And I think sometimes we might underestimate that when we address kids' needs with brain injury when they go back to school. I think we may underestimate the peer influence. So, this
is Steinberg's account of why adolescents do stupid things. He says, if you look at the top, that reward-seeking has a bump in that lower graph in adolescent years. But frontal lobe function and
executive control is errors -- this is impulsivity, so that's the opposite of control. The errors are getting lower and lower at a slower pace. So, you have this window of time where -- and then this
is not a very good graph, where the -- it's -- to say it simply, it's like the frontal lobes haven't caught up with the reward system. Does that make sense? So, when you're young, you have immature
behavioral control, but you also have a brain that isn't really sensitive to peer influence and isn't really risk-seeking. Then you have this period where you're slowly getting better self- control
but you have a massive increase in reward-seeking and peer influence. And then self-control gets better and better and it settles back down again and then you're an adult. So, it's that imbalance
between your ability to control your behavior and your brains need to have stimulation and peer feedback. Now, there are -- according to Steinberg's research, there are some sex-based differences,
but I don't believe them and I'll tell you why. So in this task, what Steinberg did was he asked teens to say whether they were influenced by peers in specific risk behaviors like smoking and
drinking. And the boys said that they were more influenced or less able to resist than girls. So, you can see, girls said they were easily able to resist peer influence more often than boys. Boys are
the lower line. But I think they asked about peer influence on the wrong things. I think girls have peer influence on different things than smoking and drinking. Because when they talked about risky
behavior in teenagers, they always say smoking, drinking and sex. I mean, those are like the -- or substance use, smoking and sex are the three things. But I think girls will do -- are influenced by
peers on their hair, their clothes, their, you know, how they talk to other friends, who they socialize with or don't socialize with. So, I think that girls probably are as influenced. It's just if
you ask different questions. And teenage girls -- that comes from teenage girls. I think that teenage girls are very sensitive to what their peers think. And so, look, we've had suicides from --
right? From girls getting bullied so obviously, they're very sensitive to what peers think. And I put this -- it's not important to read this whole thing, but I put this up, this is from Steinberg to
say -- mostly for the chicken and egg at the bottom. He talks about teens having an imaginary audience. They think everybody is watching them and everyone is monitoring all their behavior and it's
true. They are. And he said that makes it kind of a chicken and an egg question. You see an adolescent with the brain injury and they have a problem, so is it the brain injury or did the adolescent
behavior lead them to have the brain injury in the first place? So, which comes first? Okay. So, this might be a good time to take a break. Because we're going to talk about specific benchmarks in
development so let's take a 15 minute break and we'll come back at 10:15. Okay. So, we're going to move on and talk about specific adolescent developments. And so in different categories and then
translate that into what happens in brain injury. So, these are the main categories of cognitive developments in adolescence. So, the first thing on the list is just expanded knowledge. So, kids are
in school so they're learning a lot more information. So, that's something that continues all through childhood, adolescence and adulthood as well. The second thing I want to mention is improvements
in executive function, and I've talked about this a little bit already. The third here is speed of processing which I also mentioned in relation to myelination of the brains, so better information
transmission in the brain in general, faster thinking, better inauguration of information. And the last related to executive function on here is working memory. So again, with the difference to the
neuropsychologist in the room, different people define executive functions differently and in -- for a while, they became kind of a wastebasket of term of everything, planning, programming,
organizing, sequencing, whatever it is. But I like this conceptualization of executive function. It divides executive functions into three main types of functions. One is control. So, control over
your emotions, control over your thoughts, control over your behavior. The second is abstraction; so being able to get out of the moment, being able to take the non-literal meaning of something to
get a joke, to see the big picture. And the third is having a sense of time, which people consider an aspect of executive function. So, for example, you know about how long it takes you to get ready
in the morning, you have a general idea of how much time you need to set aside to do things. You also have a timestamp on your memory so that you have a notion of what you did yesterday versus two
years ago. You have that sort of sense of time. Humans as organisms are terrible at time estimates. So, we're not really biologically equipped to tell time very well. So for example, if I said to you
I want you to tell me when a minute is up but I didn't let you count, you couldn't do it. So we don't really -- time is not really that important for us. So it's not that you have a minute to minute
sense of time but you do have this kind of notion of what was recent past versus distant past. This is something you'll see sometimes in children and adolescents with brain injury, that they don't
really have a good sense of when something happened and they sort of merge a bunch of past things together. So you also might see individuals with intellectual disabilities. This is another thing you
don't really see, this acute sense of time. It does post a challenge obviously in crime, so this is one of the issues that's come up in these court cases is that if you have someone who doesn't have
good sense of what happened when. You also see sense of time problems in TBI prospectively, so that people have difficulty planning ahead to make sure they have enough time to get something done
because they don't estimate how long it's going to take them very well. It's a big problem for students with TBI. So, these three categories of executive function are developing during adolescence.
So, of course, you have to be able to control your own time more and more as an adolescent, as you're developing. So by the time I see them as undergrads, I am not calling them if they're late for
class, right? So they need to be able to get to class on their own. They need to be able to register and I -- even though I try and help them see what's important to study for the test, I'm not going
to give them the level of detail you'll get in 6th grade. So you're learning how to control yourself and your own behavior, control your emotions and you're learning to delay gratification, another
common problem for people with brain injuries. So one of the things you learn as an adolescent is I'm going to study now in 9th and 10th grade so I can get in to college. That's big delayed
gratification, or I'm saving up my allowance to buy something next month, something that's impaired in a lot of kids with brain injury who do not have the ability anymore to either perceive that
there's a need for delayed gratification or just can't stop themselves from doing whatever they want to do at that particular moment. So the developments in abstraction during adolescence usually
show up as teenagers really starting to get to know themselves and their strengths and limitations. So I'll have students come as undergrads at 18 and not really know how to study because they don't
really know how to study because they don't really know how they learn and that's a process that sometimes they get to learn, one hopes, through their undergrad. Some of them come from high school
already knowing that. We see a lot of students who underline or highlight everything in a book, right? Because they don't know that doesn't work. So these are the things that are developing through
adolescence, being able to understand your own strengths and weaknesses and starting to see yourself as an adult. So, starting to see sort of like going from wanting to play for the NBA or WNBA to
realizing you didn't make the high school team, so you're probably going to have to have a plan B job. I see this in our -- we were joking about this yesterday, the UW Madison basketball teams, if
you look at the -- what the majors are of the students, so especially on our boys basketball team, which is a really highly ranked basketball team, they're all communication majors, communication
studies because they think they're going to be broadcast journalist later because they're going to the NBA, all of them. And then they're going to be broadcast journalist. And it's funny because the
girls, if you look at the women's basketball team which is not very good at all, their majors are like business, engineering, you know, because they all know pretty much by that time that there's not
going to be a professional future basketball for them, so. So this is what you're learning as an adolescent. Also, abstraction includes understanding complex social situation and social dynamics that
are not stated. For example, you, you know, you learn which teacher you can approach for what, right? And so what you -- how you can negotiate with your parents to get things that you want? You learn
how to read a room to figure out if peers are going to accept you or not accept you. And a lot of these you practice with your friends, especially your best friend you practice a lot of these skills
of, you know, of figuring those things out. But a lot of them, you just have to develop as part of your development of abstract thinking. The third sense of time as I said is really -- you see more
in adolescence in school, so kids having a better ability to plan, how much time they need to do things and to have a better sense of what happened when in the past. So language developments you see
during adolescence are related to cognitive developments. So you see an increased use of peer specific and school specific vocabularies, so that goes along with the [inaudible] of learning. Complex
syntax emerges during adolescence, so complex for those of you who aren't speech pathologist, which is probably all of you. So complex -- oh, sorry most of you. Thank you. Any else -- others speech
pathologist in the room? All right then. My peeps. What happens in adolescent language is that sentences become more grammatically complex but stay the same length. So be -- the difference between
saying, "I went to the gym and then I exercised and then I had a shower and then I went out with my friends," to saying, "before I went out with my friends, I was at the gym and since I worked out, I
had to have a shower." So, you see, I've moved the clauses around and put a bunch of different complex words in it and that takes working memory to understand because you have to be able to hold all
that in your mind, but that's what adolescents are doing. So in very little kids, they say, you know, they say a word then two words then three words then a short little sentence. By the time they're
about three or four, counting the number of words doesn't tell you anything about development. So in adolescence, what tells you about development is subordination of clauses so this convoluted
sentences ad using words like more over. Hold on. I am plugged in. Oh, it would help if I turn the power bar on. Okay. Not on reserve power anymore, that's good. Development of genres, so another
school-based language term. So, a genre is a type of language. So being able to have like write a short story or give an argument in a debate or be able to tell a narrative, tell a joke, this, you
know, learning all these different kinds of communication that happens during adolescence and then being able to use language flexibly. So what that means is I'm not going to talk smack with my
teacher. And we noticed this a lot with adolescence we interviewed who were starting to enter the workforce. So once you start to get a part-time job, then you have to be able to talk to co-workers,
boss, employees -- sorry, customers, right? So you have to be able to adjust your language code the way you talk, the style of your language to all these different partners. One of my recently
graduated PhD students, Peter Meulenbroek, did his dissertation on return to work for adults with brain injury, and Peter found that one of the most significant predictors of return -- of successful
return to work was this task he developed where you had to leave a phone message. So, in this task, you had to leave a message about some upcoming event for a boss, a co-worker, and a subordinate and
what he found was the thing that discriminated people from brain injury from people without brain injury was -- sorry. They were all people from brain injury, people with brain injury, people who are
successfully employed versus not successfully employed was use of politeness words, so that people who are not successfully employed did not use as many politeness terms on the phone. And this was
like a two-minute task. So we had five hours of neuropsych testing and a two-minute telephone task and the two-minute telephone task turned out to be the most predictive. So, again, these sort of
social nuances of how you talk to different people are really important. This is important I think for us for assessment because often when an adolescent goes back to school, we don't think about
assessing them with these different kinds of partners. So if you're looking at how they communicate, you probably look with you as the clinician, maybe you look at the teacher, but you don't really
look to see how do they talk to the teacher and then another student? Can they make that change? You know, a lot of kids with brain injury are pretty -- are okay in a small dose. But a lot of the
reason thery'e annoying to people is because they can't code-shift and so they're that -- they're that same person all the time there, right? So they're like funny and disinhibited but they're funny
and disinhibited in class and at home all the time. They don't turn it off, and that turning it off is really about being flexible on how you talk to different people. And we'll talk a bit more about
pragmatics right now. So social developments during adolescence are pivotal as you can imagine, and sometimes people say to me I think adolescent social skill, it's a -- they're -- that's an
oxymoron. They don't have any social skills. So one of the things I'm hoping that you take away from today is that I convince you that adolescent social life is incredibly complicated and adolescents
have to be really, really skilled to navigate it. And so I'm going to give you an example. I'd like to do this as a quiz when we have males and females in the audience. So I would like to have a
male, you know who you are, volunteer to tell me what they think is going on in this picture. Yes?
AUDIENCE MEMBER: I think the guy was speaking in a friendly way with the girl in pink and this other girl knows that she doesn't like it.
LYN TURKSTRA: Wow. That was awesome. That is a total girl answer. That's fantastic. How about you other guys, did you...
AUDIENCE MEMBER: That was balancing.
LYN TURKSTRA: Yeah, that's right. You have the perfect balance.
AUDIENCE MEMBER: So I [inaudible] I'm building up that side.
LYN TURKSTRA: All right. It's bias when you work with -- because you work with people, you know what I mean. You work with people.
AUDIENCE MEMBER: [inaudible]
LYN TURKSTRA: Oh, for heaven sakes, you should have disclosed your profession first. How about you other guys, what did you think? Did you think the same thing? Yeah, he's not going to say it now. Did
you think the same thing?
AUDIENCE MEMBER: No. He probably doesn't want to be there. He looks kind of bored.
LYN TURKSTRA: Right. So typically -- in -- again, bell curves, overlapping distributions, many males will look at the scenario and not really get that story. I've had a couple of gentlemen say that
that guy is looking at that girl's butt, which didn't occur to me, I have to say. So, yes. So this picture indeed is just as you described. So, it's meant to show these two were together and this
girl is feeling, what?
AUDIENCE MEMBER: Angry.
LYN TURKSTRA: And why?
AUDIENCE MEMBER: She likes him.
LYN TURKSTRA: Rejected. Exactly she's feeling rejected. So if you didn't read that right away, don't worry about it because it's for teenagers and so -- but in order to figure out the message, you
have to do very complex information processing. So first of all, you've got to be able to just get the scene, like the physical layout of people, so that these two are standing closer together than
this person and actually this, if you could see it, the -- it wasn't in the frame of the picture but they're holding hands so that's kind of -- but you could kind of project that they're holding
hands. You have to be able to read their emotions. So, a lot of people say bored for him. I think he's probably guilty. And then this girl upfront, what do you think is her facial expression?
AUDIENCE MEMBER: Self satisfaction.
LYN TURKSTRA: Self satisfaction. That's right. It's not -- uh-oh, she has a smug look. Boy, you are really good.
AUDIENCE MEMBER: I'm a psychologist.
LYN TURKSTRA: You're a psychologist. She's looking smug. This woman -- this girl's looking irritated. The first time I showed this picture -- and the reason I show it at talks is because it was at
Neurosurgery Grand Rounds and they asked me to come and talk about pediatric brain injury and this was like a few years ago now, about four five years ago. And the neurosurgeon in front row put his
hand up, you know, he -- and as soon as he did that, I was like, you were that kid, right? That's why you're a neurosurgeon because you were that kid. Anyway, he said that -- that's the guy's mom.
And she's mad at him and I said, "Oh, honey, I'm so sorry." And then he said we don't get out very much. So -- and I realized everyone they talk to wears a mask, right? So what do they really see in
terms of people's emotions? Anyway, so -- no, not his mom. So she does look a little bit older. I mean, this is the range of adolescent development, right? These guys are all the same age, but they
don't look the same age. So you have to be able to pull all of that together plus you have to call on your old knowledge about relationships, right? To figure that I can imagine a situation or
remember a situation where someone gets dumped in favor of someone else. So -- and this is a still photograph that we've just talked about for four minutes. This is happening in a millisecond. Every
millisecond, this is changing and this is what adolescents have to do. This is the kind of stimulus they have to read. Yeah?
AUDIENCE MEMBER: I don't want say it, the next part is the guy is at risk because she's about to whack him. She doesn't realize that.
LYN TURKSTRA: It's -- you know what? It's really funny you say that, so that comment was for the videographer, the guy is at risk because she's about to hit him. I asked this -- this is one of our
teen video groups. I asked them in the group, do you ever touch each other, like hit each other or whatever, lay hands on each other? Because people talk about that inappropriate touching with
individuals with brain injuries, so I said, "Do you, as a group, do you ever do that?" And they were like, "Ew, no, we don't." Three minutes later, she whacked him. I mean, they were just laugh...
AUDIENCE MEMBER: So with the left hand.
LYN TURKSTRA: They were laughing and...
AUDIENCE MEMBER: The left hand in the back of the head...
LYN TURKSTRA: Oh, is that what you think that's what that is? No, they were just laughing about something and she really, really whacked him on the side of the arm. And so -- yeah. So I don't think --
I don't -- I don't think she's mean -- lining up to whack him there, but they do. Adolescents have a lot of physical contact with each other. So, anyway this is the adolescent world. This is a tiny,
tiny little snapshot literally of what adolescent life is like. So it's not that easy. So we tried to develop stimuli to assess social perception. So, when I was talking earlier about social
perception developing during adolescence, this is what I was talking about, this kind of thing, not just being able to look at a face and say happy or sad, but to look at a face in a room with other
people all showing emotions and talking and background noise and everyone has an agenda. So you have to understand the agenda of everyone, like that kind of processing is what an adolescent has to do
every minute of everyday. So we created some videos with -- this is another one of our par teams, to try and capture some adolescent behaviors that adolescents thought were important and this is one
of them. So -- and this is that video. The videographer is going to edit it out because I don't want -- what he said? Did the guy on the right get it?
AUDIENCE: No, he did not.
LYN TURKSTRA: No. So this is what I mean by abstract thinking during adolescence and so the -- this is sarcasm comprehension. And so in a typical test that you would see, and you might if you ever
work with kids with autism, you might see this because this is theory of mind that's tested in autism a lot. They'll say what did he think about what he said about that teacher? But that sentence is
too complicated especially for kids with memory problems, and so we just say this. Did he mean what he said and did the other guy get it? And so this is one of the staples of adolescence is
comprehension of figurative language and things like sarcasm. So non-literal language, it's really, really important. We did a study a few years ago where we compared adolescents and adults, just
typical adolescents and typical adults and then those with brain injury on sarcasm comprehension and the teenagers were better at it than the adults because I think that's all they do, that's like
the main form of communication in adolescence is sarcastic. So how did they get there to have these fantastic skills? This is just a quick overview. This is my husband. His name's Erwin Montgomery.
He's a famous neurologist and he moved to Greenville, PA recently, so you may see him in Pennsylvania. He does deep brain stimulation and they're building a center for neuromodulation in Greenville
so that's what he's there for. Sometimes I'm afraid to go to sleep in case I would have electrodes. And this is our granddaughter a couple of years ago. Okay. So when kids are really little, what
they do is they say what they think, right? In their head out there mouth, no editing or anything else. But as you grow up and you develop executive functions for example and social perception, it
gets to be more complex. So what you have to do is you understand people and the person you're talking to in the context that influences your perceptions of the role -- this is S as Speaker, L as
Listener here, so the role of the other person, is this a superior that I need to be nice to, is this someone who's a peer I can be casual with, then you recode what you wanted to say for the
audience. So like me editing my potty mouth. So I'm saying this is a professional venue, I'd be inappropriate for me to swear and I'm on video, so I have to really watch what I say. So I code it for
myself but then I recode it for all these other constraints then I send the message, but then I'm also watching all of you and so if I saw that you were sleeping, I would really try to liven it up or
something like that. And so I'm using that feedback all the while I'm having to put some effort into not just saying what I want. A teenager said to me once she said it doesn't really matter if the
other person is listening because the point is just for me to talk. And so -- don't you ever feel like that if you work with adolescents? Right? That's pretty much it. So -- yeah. So you have to put
some effort into that and these two circled areas are the areas that are developing -- our areas that are developing a lot. They develop a lot through childhood, but especially in adolescence so for
executive function, your ability to really control your behavior so that you can shape your communication to suit the audience and what we call social cognition which is the thinking involved in
social interactions. In autism, then they call it social thinking, mentalizing, there's a whole bunch of terms for it so -- and this is actually what we study in my lab. So, you need to able to read
the other person and just to refer back to the hormones again, this is some of our data. So, you can see these are typical, tedious for typically developing females and males, and you can see that
non-verbal like you is almost identical between the males and females but in everyone of the social measures and language in general, girls have it's -- a smidge of an advantage. So it's a
significant difference but it's not a huge difference. So pragmatic language or social language, faux pas is that highest form of social cognition development or theory of mind development. So faux
pas is, you know, you say something and then you realize, oh, I shouldn't have said it. We say like making a joke about cheese to someone from Wisconsin. So you say it and then you look at their face
and you realize, oh, man, I shouldn't have said that and then trying to fix it. So that takes pretty sophisticated theory of mind because you have to read their expression and realize that what you
have said has affected their thinking in a negative way. And also that you can say something else that can change their thinking back to positive. So that faux pas takes executive function, it takes
social cognition and it's thought to be the highest form of social thinking in teens. So you can see that girls are a little bit better than boys all the way through. So I want to talk a little about
how these changes, the developments in executive functions, social cognition, memory relate to the developmental benchmark's different stages. But I don't want to do a brain overclaim. So you know
there's a tendency you see an imaging picture and everything lights up in color and they say this is the seed of consciousness in the brain or something like -- because it has a picture. So we don't
really understand how hormones translate into dating. You know, there are many steps in between. So I gave you an oversimplified picture of big things that are happening, but I don't want to brain
overclaim those Steinberg's expression. Okay. So I -- so I want to just run back through the big picture developmental stages events at different stages. So pre-adolescence, that's the younger year,
that's the middle school years, mostly defined by physical growth. At this age, adolescents, because they're learning about themselves, are very opinionated but do not have good reasoning skills,
right? No one is more opinionated than a 12 year old. They know how you should parent, right? They know how teacher should teach. They know how all their friends are behaved, but their biggest reason
for all it is because I said so, right? Or because I think so. So they really are not good at abstract reasoning. This is a stage where they need a lot of privacy. So again all this big body changes,
hormone changes, things that are, you know, kind of unpredictable. So I have these kids with ear buds in because this is the sort of I need to be alone in my room with my door shut and my iPad and --
because I need privacy. Of course in brain injury what happens to privacy? Out the window. Also big need to be an insider at this age, you want to be exactly like everybody else. Same clothes, same
everything. I asked a kid once about going back to school after his brain injury and I said "What was the hardest thing about going back after being out a year?" And he said "Guess jeans weren't in
anymore." So really, and he had some pretty significant problems. Early adolescence, usually people think of that as around the end puberty so secondary sexual characteristics, big focus at this
stage in high school on physical appearance. So physical appearance is really, really important and, again, this is the mating age so that's normal. There, you know, there are things that happen
after brain injury like ataxic gait, gaze deviations, you know, kids [inaudible] the sixth nerve will have a sixth nerve weakness and they just feel so disfigured and different from their peers
because of this little tiny physical changes and I think we all need to really pay attention to that, to physical appearance. It might seem trivial to us, but it's really the currency of social
interaction in high school. If you work with kids with developmental disabilities, you might have observed this that parents who dress their kids well when they have developmental disabilities and
put some effort into the kids having like the cool hair or a pierced ear or something like that, that those kids can be more socially accepted than other kids. And so I have said one, although it's
heretical, that if I had $500 to spend on an adolescent with brain injury and it was my therapy or the gap, I might go to the gap. Because if you think of long term, what's going to help them be more
socially accepted, a change in physical appearance might count more than my freaky speech therapy that might not work anyway. It might work but -- we'll talk about that. They're also having -- this
is the BFF stage, so high school is really important for BFFs. I've seen some kids with brain injury who had a pretty good outcome just because they had one person who they could really trust, who
helped manage their behavior in a socially appropriate way. Sometimes, when we put kids back in school, we'll say you can -- you can hire your study, you know, your note taker or whoever, so they can
pick a popular kid and, you know, like have that one person they can practice with. There was a study done many years ago that showed that positive feelings about yourself coming out of high school
could be achieved with just one really close friend. You didn't need to have a ton of friends. So just having one person with whom you could practice your intimacy skills and who accepts you not
matter what you do. This one kid, his friend used to say to him when he was acting inappropriately in public, his friend would say, "Don't be such a retard." And even though I completely disagree
with that terminology, it fits with the peer social jargon and it was a way to shape this kids behavior without making him look really conspicuous. So having one good friend is really good. Kids are
also starting to see themselves and think about the future. Late adolescence is all about independent living. So you're trying to get them out of the house and now they want to be different than
everybody else. So they've gone from, right, from a uniform in 7th grade where every kid is wearing the same shoes to in high school where it's like I'm an individual. We did -- we asked teenagers
what -- to describe the cliques and crowds, you'll see some of the data in a minute. The cliques and crowds there are in high school. And every adolescent, brain injury or no brain injury, could go
through and say "Oh, they're stoners. They're skaters." There's like the -- whatever they are, you know, goths, emos, and then we would say "What group are you in?" Every single adolescent, but one
said I get along with everybody and that was replicated in a national study where they asked adolescence and they all said I get along with everybody because I'm my own person. I can't be
categorized. I'm an individual. One girl said "I'm a drunk," so she's the only one. I was like [inaudible]. A drunk, she said I'm a drunk. So, I was like "Good for you." So, yup. So, anyway, so they
-- yeah, they really want to be individuals but they still have inconsistent execution of ideals. It's very typical for an adolescent to not live up to their expectations from them -- for themselves.
Don't you remember this? Where you felt like, man, I screwed up again. I could still -- honestly, it's such an emotional age and so stressful I can still remember thinking today, I am going to talk
to a boy like X and then the end of the day thinking I didn't do it, you know, or I'm going to be whatever. I'm going to be shyer or more outgoing or something like that and not living up to your
expectations. The funniest example I have was from one of our focus groups, again, with apologies to the camera. This girl in a focus group was talking to another girl and she said "That girl, Susan,
she's like totally a bitch. She's always talking about people behind her back." Isn't that awesome? That is late adolescence in a nutshell right there. So she was kind of there but not totally there.
And your community has very high expectations for you in managing your own behavior right at the stage. So, when you put it all together, this is how adolescence should end. So you should have
elaborate and abstract knowledge about yourself. You should be able to control your own behavior and your emotions. You should be separated from your family and really affiliating with your peer
group and not relying on your family for everything. And you should have very sophisticated interaction skills so you should have very sophisticated social perception and social behavior. And at the
end of all of that development, you should have a sense of who you are and a feeling that there's somewhere in the world that you belong. It might not be where you eventually end up, but you have a
feeling that I am a college student. I am in the National Guard. I am a hockey player or whatever it is, you have a feeling of yourself. And as you know, in brain injury, all of this can go wrong. So
this is a -- these are two guys who had dramatic brain injury and I wanted to include adolescents with brain injury on our part teams to shoot videos. So I had these two guys come in and they just
giggled for two straight hours. There's no -- so they're not in a video because they were just goofing off. So I'm talking about TBI but the principles apply to acquire brain injury in general as you
all know. So, you know, there are -- the brain is a very complex organ, but there are certain themes that occur across kids no matter what. Executive function problems really are sort of the hallmark
of almost all adolescent disabilities. So ADHD and adolescence is an executive function disorder. Kids with schizophrenia in adolescence have impairments in executive function. Kids with specific
language impairment who have language-based learning disabilities when they're young have executive function language-based problems in adolescence and they're scoring in the normal range on
standardized test, language test. So because adolescence is all about developing executive function, it tends to be the sign -- problems in this [inaudible] intend to be the sign of many, many
different disorders. There was talk with new DMS-5 of having things reorganized along in executive function domain especially because even autism, if you look at high functioning autism, there are a
lot of executive function problems, but as the two physiologists know, that didn't happen. So but it is kind of a theme when you're working with teens, so this role apply no matter what. So brain
injury, first off all, has some biological effects on pituitary function and I mention this because there's a national move to talk about brain injury as a chronic disease, which, Brenda, you might
have come across. So many of us around the country trying to have people think of brain injury as a chronic disease because what tends to happen is you go and see a trauma surgeon or a neurologist or
whatever acutely, but that's not the person who follows you up, it's your family doc. They don't know about the brain injury. So there are things that happen to you over development that nobody ask
about. So didn't know for example that woman with disabilities are more likely to die from cancer because they don't get Pap test and routine exams and mammograms. So, there are things you have to
think about when someone has a brain injury in terms of their general health. So, about 30% of children with brain injury have abnormal pituitary function five years after injury. So you have to
think that that's going to affect things like puberty when the injury happens before adolescent development. So they need to have that followed up, they need to see an endocrinologist or at least
have their family doc look at their hormone levels because that can be affected. The most common problems are growth hormone deficiency and changes in puberty, other problems include hormone
deficiencies, diabetes, which is more common in children with brain injury, hypothyroidism, which you probably have seen this. You've seen kids and adolescents who have more sever brain injuries,
have problems with weight management after the injury. So you know how initially they're burning like 6000 calories a day so they really lose weight in the first few days and weeks after injury and
then sometimes in the later stage, you'll see they have trouble keeping weight off, sometimes that's actually hormone dysfunction. Every hormonal access can be affected after TBI in children, and so
they need to have hormones assessed serially by the doctor, so if you're seeing kids like that, I recommend that you send them to their family physician. I didn't -- I really didn't know about that
until this year and so I put it in sort of this public awareness. I think it's good for all the students you serve who have disabilities to make sure that they're having those kinds of basic health
things checked. Okay. So in terms of brain structures and functions, you all know this really well especially those of you who work in brain steps, there are some big changes we often see, most
accidents are this way and so most damage is here so you see atrophy of the frontal lobes, interrupted frontal lobe development, also diffuse axonal injury, which we use to not be able to see but now
with new imaging techniques, you can actually see loss of white matter tracks connecting different parts of the brain. You see bigger ventricles of the brain, the cavities in the brain because of
less brain so they expand to fill the space. Decreased volume of the corpus callosum, so the big track that connects the two sides of the brain, you can imagine because it's very tough, these fibers
are very tough that when the brain's moving like this, the fibers get sheered. So this corpus callosum that communicates between the two halves of the brain often is damaged. And then in the chronic
stage, you can see loss of gray matter in the brain even with a normal scan in the acute stage. And so this is something we've seen -- I will see it in research because I see people so many years
later, but often, they don't get scanned. So someone -- especially a child will have diffuse axonal injury, they'll do a CT at the scene and not see anything, right? They'll do an MRI at a week,
still not really see anything. The kid will seem okay [inaudible] physical problems they'll send them home, two years later they're showing up with more and more problems. Sometimes, at that point,
when you look, you can actually see changes in the brain because those brain changes were at the microscopic level and they were still evolving over the first weeks. And so you can see long term
changes in the brain. We just -- most people just don't get scanned. Particularly after moderate to severe TBI, you see reduced growth of the corpus callosum, reduced volume of the hippocampus,
that's the structure in the brain that you need for learning. So that structure can be smaller. If a person also had high intracranial pressure, that's ICP, so if at the time of the injury, their
intracranial pressure was high, you see a disproportionate amount of damage to the memory systems of the brain and if you think about brain anatomy, this makes sense because those structures are all
sitting around the ventricles, they're really tiny and the brain is a closed system. So if something gets big, something else is getting compressed. So if they have increased intracranial pressure
and it's pushing the brain against the outside -- the inside of the skull and the ventricles are getting bigger and they're squishing that brain that's all around the ventricles, that's the
hippocampus system and so if a kid had high intracranial pressure, they're more at risk for having profound memory problems after their injury, profound problems with new learning. In the very
extreme cases, if a child has a very severe, very early injury, they may not even develop executive function and social cognition. So this was a case report of two teenagers, I think they were both
16 when this was published, A was ran over by a motor vehicle at 15 months, and B had a right frontal tumor at 3 months. This situation of A run over, can't you just see it? Because 15 is the
crawling age, right, crawling and walking, so they were probably run -- ran behind the car or something who ran over. So if you look at the top, you can see the two eyes -- sorry, oh, I can -- I know
what I can do. You can see here, this is a frontal view. See two eyes, here's another frontal view. These are frontal views and then you can see a side view of the brain. Here's the front and the
black is what's missing. You can see it here, this is top-down view, so the eyeballs are right here and right here, and you can see all this black, which is that the frontal lobes here are missing,
big parts of the frontal lobes are -- they never developed. So the brain damage was so severe they never developed. And you can see the same here in this child here, the brains are flipped, so that
the front is in the middle so you can see this black part is here were there's no brain. And you could see this big resection here where there's no frontal lobes on that side of the brain. These two
teenagers were described as sociopaths. They had never developed moral reasoning, never. So -- and this, as I've said, is the very extreme case where they had good other intellectual function, but
very profound deficits in moral reasoning and executive function. Typically, if a kid had a very severe injury, they'd have other cognitive impairments, you wouldn't see that. But these kids were up
walking around, doing fine in school and just had no moral reasoning. And I, you know, I've been working in brain injury, I'll always it say more than 20 years from now on, so, you know, it's a few
more than 20, but I'm going to stick with 20 forever. I've only ever seen one adolescent like this, only one who looked right in my face and said, "My mother is so annoying I'm going to shot her."
And lacked follow-through, thankfully. But who really had no conscience, had no -- so that's really the extreme. So most kids are going to be in between that fine and that extreme in terms of having
poor executive function and not great social perception. I'm at this slide, and just a reminder that the brain developments in adolescence turn out to be partly fostered by social interaction. So
adolescents with more social interactions actually have better brain development in some parts of the brain. And I just put this picture just for fun because it's an -- it's an adolescent white rat
that's trying to get alcohol and it just reminded me of the lengths that teenagers will go to, to get alcohol. Yeah, I feel like that -- I don't know where he smelled it from the other side of the
room. He was like trying to get himself in the jar. So anyway the -- that those brain changes that happen after brain injury might be mitigated in some way by social interaction, we don't know that.
So in a normal adolescent brain, social interaction actually is positive for brain development during the adolescent years. And remember I said how you have this big wave of new synapses and pruning
during the pre-adolescent years, so socialization is very important to brain development at that time. So we don't know about brain injury, but it's possible that by being socially isolated after a
brain injury, it might actually have negative affects on further brain development, which is an important thing to remember. So I mentioned executive function problems, one of the things that -- a
concept that's come up recently is this notion of cognitive stall. Now, this is still being debated. So the idea is that physical function recovers really well and kids have learning problems, but
their memories will sort of recover a bit and then they're behind in school because they're not learning as fast as their peers and then they'll always be slower, but they'll continue to learn new
things so they'll be behind their peers, but they're still going in this direction. Well Sandy Chapman's group in Texas put forth this idea of cognitive stall What she said is, if you damage the
frontal lobes enough, these kids will stick at this level. So they'll have some recovery of executive function and that's it, that it's not that they keep going only the slope is lower, that they
might actually never develop some of those executive functions. And so as I say, it's debated, so -- especially in the last year, people have shown some data that doesn't exactly look like that, but
I think you do see -- we do see kids where they seem to have a pretty good recovery of executive function and all their other cognitive functions for the first few months. And then it really slows
down and then their -- they still seem child-like when they're older than -- you know, when they should have got better, they still seem to have concrete thinking and poor self-control and poor
verbal reasoning, so it's possible they could kind of stick at that age. And the reason that we talk about it is because it has service implications, right? Because a lot of times, these kids are out
of services by the time you notice that, it's two years, three years down the line. Or we see them in college where this is the first time they really have problems because they sort of scrape by all
through high school, but then they can't do the independent multitasking that you have to do in college and they just can never do it. So one of the cognitive effects might be just stalled cognition.
I think I might skip over some of the memory stuff I was going to talk about because I'm guessing you know that the most. The one thing that I just want to talk about is this, which is working
memory. And I'm sorry this is not in your slides. So working memory is one of the most difficult to -- difficult aspects of cognitive impairment I think to get a handle on in everyday living, so I
wanted to talk about it just for a minute. So working memory which we use to call short term memory is just your ability to -- it's this mental work space you use to keep things in mind, in your
attention. So for example, if you're listening to a really long sentence, you're keeping the beginning parts in your head long enough to get to the end so you understand the whole sentence. If you're
planning your day, you probably sit and think, okay, I have to do this and I have to do this and I have to go here and I have to go there, that's in your working memory, so it's what your consciously
paying attention to. This cognitive function working memory in this mental work space, you can manipulate things like with planning your day you can kind of juggle things around. And there's this
certain number of manipulations you can do and there's also a certain amount of space. So the space people think of this as the seven plus or minus two, short term memory span space. But it's not
just that kind of space that's computational space too. Probably it's -- I'm probably not doing a very good job explaining it. Let me try an example. Someone tell me a sentence about how they got
here today. Somebody who didn't stay here, because that'll be an easy one, did anybody drive from offsite today? Okay. How -- tell me about how you got here in one sentence.
AUDIENCE MEMBER: I got in the car, drove onto the onramp, exited on the 322 and turned on the Innovation Parkway.
LYN TURKSTRA: Perfect. Okay. I got in the car, got on the onramp, drove on 322 and exited on Innovation Parkway? Probably missed the highway there. Okay. So that sentence has a certain length, that's
the seven plus or minus two span for you to keep it on your mind, but it also -- you have to do a lot of mental operations to make it make sense. For example, if someone says I got on the onramp,
what does that mean?
AUDIENCE MEMBER: To get on the highway.
LYN TURKSTRA: Get on the highway, but you didn't say highway, highway is implied. So you have to do a little retrieval out of your long term memory to think, oh, onramp means highway, likewise 322,
right? It doesn't mean anything by itself. You have to know the area and you have to know the highway, then you said Innovation Parkway, and you said that at the end which implies that this place is
off Innovation Parkway, but you would have to know that so see how there's a space amount with the length of the sentence, but there's also a computation amount that you need to do because you need
figure out all those things that are in the sentence. Working memory is very, very commonly impaired after brain injury, but the way it's often tested, and the neuropsychologist will know this, not
by neuropsychologist but by other people, it's often tested just by span. I'm got to say something, you say it back to me. So when you say a kid has short term memory problem when they go back to
school, people will say, well, I said a phone number and they said it back to me so it's not a problem. That's not the problem. The problem is how they use those working memory resources to do
thinking and how they can keep things in their attention without being distracted. You'll see neuropsychologist will ask people to do, like say numbers backwards, you know, in reverse order or
there's -- on the children's memory scale, which I don't think anybody uses anymore, they have to -- kids have to say a1, b2, c3 all the way to z. So they have to keep track of what letters they've
already said. So this is a common problem in people with brain injury. Some people have limits -- some people with brain injury have limitations in space, some have limitation in computation and you
don't know who is which. You really rely on your neuropsychologist to help you figure that out because the accommodations are different. So if a child has enough space but they can't process fast
enough to keep it all in their head, you would slow it down. So some -- for some kids, they really -- it's a mental processing problem, not a space problem. So you slow it down for them, but slowing
down doesn't work for every kid because some kids't can actually keep that many elements in their mind, so for them, they need it just in smaller bits, so you can't make a general statement to say
for all kids with brain injury in the classroom, you have to say things more slowly. They really have to be tested and then you have to think about how that translates into an accommodation, does
that make sense? And I see recommendations a lot for say things slower or whatever, but it just doesn't work for every child. So Audrey Holland and I did a study again, it's so funny because I
skipped over a slide I was going to show you, oh, actually I have it, I'm going to skip past it. That's a study we just are submitting for publication and it's like I've come full circles since 1998.
Anyway, that's an adolescent working memory. So what we did is we took here a test called the test of adolescent language which the SLPs might be familiar with, it has a subtest where you say I'm
going to tell you three sentences and I want you to tell me which two mean about the same thing. So -- and they're spoken. So obviously, this is a working memory test because you have to keep all
three sentences in mind. So what we did is we create -- and it's called a test of understanding grammar. So it's meant to test grammar, but we thought this is a memory test, this is not a grammar
test. So we did two things, first of all, we made an analogous version with only two sentences and said do this mean about the same thing or not, which test the same thing. And then we had a
condition where we just said is this sentence grammatical or not. And we compared kids with brain injury, black bars and the control group. And what you could see is, this is the toll, so this is the
three sentences, two sentences, one sentence. You can see that the typical kids didn't have a problem even -- in the regular version of the test, so it's testing grammar for kids who don't have
memory problems. But for kids who have memory problems, it's testing memory. So on grammatically judgment, they were the same or they were not statistically different from typical kids, little bit
worse for two sentences and way worse for three. Further, the errors they made were always -- not always, were just proportionately when the correct answer was b and c. So if the correct answer was a
and b, they could get it right because it was the first two sentences. But if the correct answer was b and c, they had to wait to listen to keep a in mind, b in mind, c in mind, reject a go back,
compare b and compare c and that was where they made the mistakes. And so I think that we have to give a lot of thought to working memory impairments and how they affect classroom performance. There
was a paper a few years ago by a psychologist, I think his name is Larry Shultz, Shutz or Shultz, who talked about how multiple choice questions really hurt students with brain injury because they
have a hard time keeping all those -- all that bits of information in mind. I see teachers at the black board giving complex multi step commands to students about when assignments are due, right? Or
even when they're teaching, things go, not just quickly but also in big, complex chunks of information, part of this is a communication style. My sentence structure is really difficult for a person
with working memory problems to understand because I tend to have a lot of embedded clauses and a lot of garden paths. To give you an example, I went to a TBI support group once and I said, I was
asking the group members to give me some pointers about how to teach my students. But did I ask it that way? No. I said, so I wonder if you guys could think about like let's say if you were out in
public and you know someone was interacting with you or like what kinds of things do you think I should, like for my students in the classroom, okay, you could forget it? They were lost after four
words. And so Roberta DePompei, there's a nice book that I'm sure Brenda knows by Jean Blosser and Roberta DePompei called Proactive Interventions, students with TBI returning to school I think. They
have a self -- a communication style questionnaire that you can do yourself to find out if you're helping or not. And I really like that because I think it makes you as a teacher or someone working
with the student with brain injury really makes you think. And the recommendations in that inventory are not just for students with TBI because working memory problems are pretty darn common among
other students, again, kids with ADHD have working memory problems for slightly different reasons. So having someone go through and do the communication style inventory and see if they're speaking in
a way that's hard would be good. Yeah?
AUDIENCE MEMBER: Can you repeat the name...
LYN TURKSTRA: Yes, so the book is by Blosser, B-L-O-S-S-E-R, and DePompei, D-E-P-O-M-P-E-I. And it -- I think the first part of the title is Proactive Intervention and the second edition was published
a few yeas ago now maybe, five or six years ago maybe.
AUDIENCE MEMBER: It's blue.
LYN TURKSTRA: It's blue. It's a blue book. Your long term memory is good.
AUDIENCE MEMBER: So I have one other question, I'm sorry.
LYN TURKSTRA: Yeah.
AUDIENCE MEMBER: Do you have any recommendations or tests that look at the -- are there anything that [inaudible] to the different types, like whether it's a storage or [inaudible] or, you know, space
problem and memory or...
LYN TURKSTRA: Right. So your neuropsychologist -- and even educational school psychologists are getting -- are becoming more likely to give those kinds of test, so I would -- I would defer to my
psychology colleagues about testing that I think, so I'm a very neuropsychologically oriented speech language pathologist and I still don't think my student should be testing that stuff because I
don't think we have the tools for it.
AUDIENCE MEMBER: I think some really of our tests are influenced by so many other factors. We call the test the language test that really the four of them are much more an assessment of memory or, you
know, especially like getting out of their processing thing. But most of the districts that I work with, they're doing that standard, you know, working memory index with the number score number
AUDIENCE MEMBER: And if they score okay, and then they totally just want to dismiss the whole memory issue and I am also trying to say no, I think there's something there but...
LYN TURKSTRA: Right.
LYN TURKSTRA: There's something more into it.
AUDIENCE MEMBER: ...they won't show me and [inaudible] sometimes.
LYN TURKSTRA: I know. Use the mic. She's saying -- I will read -- I will summarize that. So this is a common challenge for many of us, is that in a school district, the school psychologist might give
a limited neuropsychological assessment have normal [inaudible] for the kids who's scoring the typical range. And because the tests are not designed for kids with acquired brain injury and so you
will have a student who you know is really struggling in class, but it's not showing up on the test. We have the same issue with language testing because our language tests are confounded because
they often have cognitive demands, so what you end up testing is cognition and it still -- some kids -- I published a paper on the self three. Or three -- I think it was a three. It's a self three
showing that it missed most kids with brain injury because it's not looking for those problems. So from a language standpoint, I tend to use the CASL, the Comprehensive Assessment of Spoken Language
for -- just for the SLPs in the room. I like the CASL because it has test rather than subtest, so on a typical standardized test, if there are subtests, they are not normed independently so you can't
report subtest scores. This drives psychologist crazy because specially speech pathologist will pull subtest from here or there and give them to a person with brain injury and then report the scores.
You cannot report the scores of subtest unless they were standardized on their own. There's a huge variation in the normal population on this subtest. PsychCorp, before it was Pearson, sent me the
standardization data for the self three and I was shocked at the raw score range in typical kids. I mean, there were 16,000 kids in that sample. There were kids who are getting a raw score of three
and a raw score of eighteen on some of the subtest, that's in the typical population. So you can't interpret subtest scores, but CASL was standardized as test. And the thing I like about it is it has
basic language skills and then it has higher level language skills, so it has inference and it has pragmatic judgment. That's actually been the most useful subtest for us is pragmatic judgment. And
they have statistics on the likelihood of a difference between those two tests. So that when you have a child who has a focal deficit in some area, you can see it. The other thing I like about it is
the self force is also good. The thing I like about the CASL is a test into the gifted range. So we have a lot of students who's ceiling out on test because they were gifted students before the
injury and it goes right up into the gifted range and right down into a very low functioning range, so I like the range on the test. So from a language point of view, the self authors paid good
attention to cognitive confounds in four, in version four. So they really did try and get rid of some of the memory load of the items, but it's -- we've taken a test that's spoken and giving it in
writing and seeing even typical kids gets better score so, you know, you can't -- I was the lead author on standardized test guidelines for TBI and we reviewed pediatric and adult test. Anything
recommended for SLPs to use or for evaluation of communication we refer -- we reviewed a lot of neuropsych test as well and the biggest challenge was that many of these tests were never developed
with people with brain injury in mind. So you can't really interpret the data. A good example is the test of language competence which SLP sometimes use to measure pragmatics. This is a test that
kids will do poorly on for a totally different reason than the test was intended to measure. So the first item -- the first subtest is meaning is -- ambiguous meanings, so I say the elephant was
ready to lift and how could you interpret that? The elephant was ready to lift. There's two ways to interpret it.
AUDIENCE MEMBER: The elephant's going to be lifted or the elephant could lift something.
LYN TURKSTRA: Exactly. So the elephant was ready to be lifted or the elephant could lift something. That is a test of cognitive flexibility. So kids with TBI tend to score poorly on that subtest, but
it's not because of a language problem. It's because to shift mental sets from one interpretation to another interpretation can be a challenge for kids with executive function impairments. So they'll
score poorly on a test but for the wrong reasons, which gets them the wrong diagnosis and that gets them the wrong accommodations. One other thing to mention is for those of you who might work with
adults or might know some adult test, there is a speech pathology test called The Functional Assessment of Verbal Reasoning and Executive Skills which is a great language-based executive function
test and the adolescent version is coming out. So it's F-A-V-R-E-S, like Brett Favre. So F-A-V-R-E-S, and if you type F-A-V-R-E-S, communication test or something, you'll get to the website and
you'll see. It's just getting ready to go to the printer, so I'm really looking forward to that because it has kids do a lot of reading and writing and I feel like for higher functioning kids, we
don't really have a good test of reading and writing that's demanding enough to look like school. But it's very sort of school-like. So that's hopefully coming out very soon. I am going to skip over
this study we just did in the interest of time. I just want to talk a little bit about social perception and social behavior. And I want to make sure that I leave lots of time for questions. So I've
tried to talk about intervention all the way through and kids with TBI all the way through, so you shouldn't feel like, oh, when are going to get to the intervention section because I hope I
intersperse that through out. But I do want to talk about this because I think that there are some ways we can address it with the students we have in pretty simple ways and I think this can be a
very debilitating impairment. So, as I mentioned, there's been a lot of interest in recent years in this idea of social l cognition or social thinking, mentalizing, whatever you want to call it,
driven entirely by autism, right? So the increased profile of people with autism has made everyone pay more attention to how well someone can read other people and think about their thoughts. So
there are two main aspects -- there are two main parts of social cognition that people talk about a lot. One is recognizing emotion from people's facial expressions, so emotion recognition. And one
is theory of mind that as I saw a lot of you are nodding about theory of mind because you've heard about it from autism. So theory of mind is the idea that you have -- you understand that other
people have thoughts different from yours, not just that, but that you understand that their thoughts influence their behavior. So that when I see you acting like a jerk, I can think I bet you're mad
because this happened to you 10 minutes ago and that's causing you to act out, that is theory of mind. There is still debate about this whether this is a special social function or whether it's some
product of executive function and other things, but it seems to be a special thing that humans and non-human primates can do, possibly dogs but no other animal species so, yes, I don't know what it
is about dogs. Apparently, dogs are the only animal species that can catch a yawn from a human and give a yawn to a human. So there's something about dogs, but anyway so this seems to be unique to us
to be able to do this and we start doing it very, very early in development. One of the tests for autism is the first birthday test, that if you work in autism, you might have heard of people started
to -- Geraldine Dawson was the researcher, they started to go back and look at videos from children's first birthdays and they would look to see if the child looked around at other people or just
looked at the cake. And so that social referencing, that's a precursor to drawing attention. These are the things that are impaired in autism. So people started talking about whether this was a
problem in brain injury. You can see why it came up, right? Because you see people with brain injury don't seem to take the other person into account very well. Their behavior doesn't seem to be
appropriate, they miss jokes, things like that, so there were questions about could they have a theory of mind impairment. And when I started do -- so I've been doing pragmatics-related research for
years, but I started looking at theory of mind about 10 years ago and I did not believe that you could lose it. I just didn't believe it. I could see in autism where you didn't develop it. Or
schizophrenia, people have impairments in theory of mind, but I just couldn't see it in TBI but every single study we do, we keep turning up problems. And we've tried to control for executive
function and in working memory and all these different things but we still, no matter what we do, are finding people with brain injury who actually have lost theory of mind. And even if they haven't
lost it, they have impairments in it. So this is a test that comes from autism. It's called the eyes test. Reading the Mind in the Eyes, it's by Simon Baron-Cohen, who's a knight, so Sir Simon
Baron-Cohen in the UK, who's been a pioneer in autism research and funnily enough for a person who's an expert in social behavior is the cousin of Sacha Cohen who's Borat. It's hard to believe that's
the same family. Anyway, what Simon -- the question in Autism was, if people with autism don't read other people's expressions very well, is it because they don't look at their eyes, right? So you
notice this thing that kids with autism often don't look at the eyes of the other person, there's a lot of this kind of therapy going when they're really little to get them to look at the eyes. So,
they created a test with just eyes to work out if you make them look at eyes then do they get it right. So this is a series of photographs of eyes and there are four words around the outside and the
child or adult chooses a word that best represents what the person was thinking feeling. So what do you think about this person?
AUDIENCE MEMBER: Panicked.
LYN TURKSTRA: Probably panicked. One of the features of the eyes test is that none of the answers seem right, but we all seem to agree on them so I know it's a very strange test. I heard recently that
this is -- that for English people, that this is probably Prince Philip, the queen's Consort, and that -- because people know him, they tend to say arrogant, so a lot of the photographs are taken
from catalogues, so they're models. So we call it the cover model test because it has a lot of models with this beautiful eyes. Anyway, so lo and behold, people with brain injury have a lot of
impairments in basic emotion recognition and in theory of mind. The videotape I showed you earlier with the three boys sitting at the table, this kind of video, we've shown impairments in adolescence
with brain injury. We have also done two studies now showing that these impairments can be reflected in how they talk, which was really interesting. So we did a study where we compared kids with
brain injury who scored well in theory of mind versus who didn't, so they were all kids with brain injury and then we compared them to typical teenagers who also scored well in theory of mind and we
looked at how often they use words about other people's thinking in their conversations and it was less often. So when you hear the comment that someone is egocentric, I wonder if part of it is
they're not reading other people, they're not talking about other people's thoughts, perhaps they're not thinking about other people's thoughts at all. And so I think that we need to be assessing
this, we don't have a test for it. So there is no standardized for it, even in autism there's no standardized test. So I would recommend -- there isn't one emotion recognition test, but it's not for
kids and it's not very good. So I would recommend trying to assess this informally in your students with TBI if you have the opportunity to do that, you may do it with photographs and magazines, you
could do it with your own facial expressions. It's not standardized, but some of the problems we've seen have been pretty obvious problems. For example, we have had adolescence with TBI who confused
angry for happy. Actually I shouldn't happy because happy everybody can do. But like angry for sad, that's a common one, sad versus angry. And you could make those different facial expressions. So I
think that this could have huge consequences for behavior problems. So we have seen people who don't do this very well in situations where -- and they're making another person uncomfortable and they
yet -- they seem to seek -- they keep seem to do it, I could try it again. They seem to keep doing what they're doing over and over and not changing their behavior in response to the other person's
expression or maybe they can't read it. All of the tests we've done have been in isolation like this. So if someone has a problem like this, how is it in a room with multiple speakers where
expressions are changing? So I think we need to take it into account and I really encourage you to think about it, these social perception problems because they're showing up a lot. I just want to
mention though apropos of treatment that -- so that's social perception, which everybody should be able to do and which I encourage you to scream. Social behavior is another thing. So social behavior
in everyone is really variable and I want to mention this study just because I have kind of a soapbox about eye contact. So you hear a lot in brain injury that people don't make good eye contact and
they maybe should have eye contact treated. Like staring at me, showing me really good eye -- so this is a study that we did a few years ago where we had teenagers talking to either one of us or a
friend. The first -- so there's 16 participants with brain injury down here and -- I'm sorry, these are typical -- these are typical teens and these are teens with TBI on that side I think. I may
have a TBI label, right. Those are teens with TBI on that side, so there are 16 and 16 and they're matched for age, sex, race, and partner type. I think the first eight participants are talking to a
friend and the second eight are talking to a researcher. So this is while they're talking. And they're talking about whatever. They're just having a conversation. They're talking about the movie. So
we counted second, millisecond by millisecond whether they looked at the other person. You can see that when a typical person is talking, they're only looking at the other person around 40 percent of
the time. When you're talking, you don't look at the other person's eyes. It's weird. You shouldn't. Because you can't think about what you want to say and process their facial expression at the same
time, right? So you tend to look like a baton, that's what we say, like passing a baton, it's like I went to the store today and I bought, blah, blah, blah, blah, and now it's your turn. So I'm going
to look back at you. I'm going to check that you're understanding, so I'm going to kind of look back and forth. You don't look all the time. If you tell someone about good eye contact, they're going
to over generalize. So it's only about 30 or 40 percent of the time. Here's the TBI group. The mean in the TBI group is identical to the mean in the typical group, but they are all over the map. So
there are some kids who are not looking at all when they're talking. I think maybe those kids are having a hard time coming up with what to say, because there is a correlation between looking at the
other person and your processing load. The harder you have to think, the less you can look. And so if I make those bottom two kids look more, maybe they can think less. At the top, we have -- at the
very top right, one of the kids who was that photograph of the giggly teenage boys with brain injury who looks 100 percent of the time. And why do you think he does that? Somebody told him. There is
a social skills curriculum for adolescents, there is a unit on eye contact, it says a good listener is someone who sits up straight and looks at the other person. So, he has abandoned listening. You
just can't do it. So he just looks a hundred percent of the time. This is the same data for listening. Even listening, you only look around 60 percent of the time even when the other person is
talking. And so, again, there's the mean for the typicals and here's the kids with TBI. A lot of them are looking more when they're listening, which is good, right? They probably need as much of the
non-verbal information as they can get, so they're looking a lot. I maybe would be concerned about the low people on this side, although there's a low kid over there too. He's probably shy because
maybe they're missing some information, but there's no general rule about eye contact. And as I'll say in a little bit, I think treating is just silly. It's really complicated. We're just analyzing
data from a study where we showed people with brain injury videos of people talking and we ask them to hit the key when they could take a turn, and the typical adults, this is on adult side, typical
adults are all hitting the key at very similar times, but people with brain injury are all over the map in when they hit the key. They're even reading the cues about when to take a turn. And, you
know, turn-taking cues it's like you look, intonation goes up, you turn toward the other persons, all of these cues that all have to happen at the same time for you to pick up, ah, I could interrupt
here or I'm not interrupting if I jump in here. And so people aren't even able to do that like you -- to try and treat this is kind of crazy, but it gets treated a lot. So if you -- in your school
area, if you see someone who says that they're doing the social skills curriculum for adolescence and they're training eye contact, please tell them to stop, just stop. So overall, we've seen teens
who even though they're doing well overall in cognitive function and on academic language test, the still are having pragmatic problems. We've seen as I said the social cognition problem reflected in
conversations, but in a lot of data, and we've analyzed a lot of adolescents with brain injury, we have not seen significant differences in the routine kinds of social behaviors, like social
greetings or whether you sit facing the other person or not, you know, like things like that that tend to get trained, that's not where we really see the difference. We see the differences in these
sophisticated timing kinds of problems that are really not that amenable to treatment. So despite having differences in cognitive function and social cognition, the real eye opener for me when I
started doing this research was that in many, many ways, when it comes to beliefs and understanding of the world, adolescence with TBI are just like their peers without TBI and they want to be the
same. They don't want to be different and anything we do, I know I'm singing to the choir here, anything we do that makes them feel different is really going against where they are in development.
And so, when we ask adolescents with brain injury, they could say the different kind of cliques. They would say I get along with everyone. I don't have a particular group. They said -- when we asked
them, how would you make a person feel good? They would say compliment them on how they did in the game or compliment them on their outfit or I would pick them up to go to a party. That's a big
thing, right? If someone goes out of their way to include you in a social event, that's huge. So they could say all those things. They don't have a knowledge problem. Again, a lot of these social
skills curricula are really knowledge-based for students with intellectual disabilities. And so they're like teaching you how to be social. And kids with brain injury know all that stuff. I mean,
that's -- unless they'd really severe injury really young. And we only -- in our studies, we always have kids who were older than four when they were injured because that's when Theory of Mind is
developed, so I -- because you include kids in brain steps who were injured between zero and two. You might have kids you didn't. But most of the kids we see did develop these things. So this isn't
where we saw problems. And in high school, we still saw our kids saying that they felt there was a place they belonged. And I think that's really important for those of you who work with adolescents.
We've really come to believe that the effects, the social isolation effects of brain injury are not experienced until kids are out of high school, because social life is structured in high school and
you're in class with other kids. Once you get out of high school, you have to self-structure social interactions; and so we feel that sometimes kids are not prepared to do that because they've had it
done for them by the system and their families while they're in high school, so they don't really have the skills to be able to create their own social networks after high school. So we also -- if
you ask people who work in peds brain injury and many of you do, I think most people will say that all the pre-injury friends are gone by about two years. I think that's what most people estimate,
about two years. So if the kid's only getting services for a couple of years, they're also not prepared for a losing -- loss of friends later on. So they still at that stage feel like they fit in but
in the studies we've done, we had a bunch of adolescents with brain injury who said they thought communication skills were really important. And we did that to them because we gave them speech
therapy and so we convinced them that communication skills were important. So that's an iatrogenic difference between our peers. Our peers don't really care about that stuff. We found that
adolescents with brain injury didn't comment as much about being good listeners, and we did find out a lot of them were aware that they weren't fitting in socially. And I don't know if that's been
your experience as well. They might not know at the moment what they did was wrong but they have a sense that this is not the way their life was before. And older they get, the more of a sense of
that they get. One of the students who actually is getting her master's degree right now in Rehab Psych, who we worked with as an undergrad, she said that it took her four years -- so she was injured
at 18. She said it took her four years post-injury to have an opinion, because she was at the age of developing metacognitive skills, and because she had such a severe injury and she did pretty bad
frontal lobe injury, her abstract thinking like that was really impaired. And so it took her years before she had enough awareness to have an opinion about things. Well, by four years, she was beyond
all services, right. I mean, she had moved, she'd gone to college, nobody had access to her old medical records. And so, I think there's some things for the future that we need to be really thinking
about in terms of social preparation. So I feel like Voc Rehab, you know, there are rules and laws about getting Voc Rehab involved but we don't really talk much about how to peer a student for their
social future and things that they might like to have. So studies of adolescents with brain injury have shown major changes in career plans, which you can expect, and as you all know parents being
involved for longer than they are for typical kids, sometimes out of guilt because they let this accident happened in the first place, sometimes because they're concerned about what's going to happen
to the kids and social isolation. So we have the situation where a lot of kids with brain injury where they think of themselves as being like they were before. They think of the world the same way
but they can't read the world very well. So you can imagine what that does for your self-image because you're -- you keep doing the wrong thing and you don't really understand why. And maybe you're
not capable of reading the world to understand why. There's a young adult who comes to speak to my class who we've worked with for the last four years since his accident. And if you ask him, he says
he has really great social skills, and he's charming but he's only charming for about 10 minutes and then he's kind of annoying. And so for him, it's like, "Why don't I have any friends?" You know,
he sees himself as having good social skills. He knows he could talk to about what it takes to have good social skills but he -- it's -- there's a mismatch between his perception of himself, his
ability to understand the world and his ability to read the world. So I think for us to overall TBI Effects include that. So just to summarize where we've been so far this morning, there are a lot of
basic brain developments that occurred during adolescence that are disrupted by brain injury. Even mild brain injury can disrupt these developments. And the things that we think of as "frontal lobe"
functions including executive functions, social cognition are particularly vulnerable mostly because these things are developing during the adolescence. So even if the person didn't have a focal
frontal injury, if they had diffuse axonal injury, that can affect the connectivity of this whole developing system so they can look like they had a "frontal lobe" injury even if they didn't. So they
don't need to have a scan with the focal lesion. In fact, Mary Kennedy, who Brenda was saying you're using her approach with college students in Pittsburg. Mary Kennedy's research show that executive
function problems were correlated with white matter loss not frontal lesions. So a kid doesn't have to come in with a focal something on a scan to have these kinds of problems. This is what's
happening at adolescence, so this is where the problems are going to be. In typical development, there's a lot of heterogeneity, so our model is really to think about where the child has been and
expect where they might be rather than comparing them to peers. I do, do peer testing because we do a lot of things at aren't norm, so I will ask them to bring a peer in for testing because I feel
like, then I'm getting a perspective of someone else in their same social group. And kids tend to affiliate with other kids and have the same sort of shared social belief system and shared language
and things like that; and so peer testing has been very useful. Again, the person -- the peer with TBI, we don't say, "Oh, we need your friend to come in and evaluate you." Right? We're having the
friend also come in because we want to [inaudible] more about the peer group. Many adolescents are not reading social cues and that might be reflected in the language they use but they still view
themselves as normal. So just to finish up to summarize things I've said already about intervention, this is our hero, right, Jenny McCarthy. Oh, my gosh. Really? She was at ASHA one year. Do you
guys know that, the SLPs? Did you -- is that before you were in SLP maybe? It's probably like six years ago. Now, she was at ASHA signing autographing copies of her book.
AUDIENCE MEMBER: Oh, my gosh.
LYN TURKSTRA: It was so embarrassing that she was there. I was like, "Please don't let the media come and see that Jenny McCarthy is signing books at ASHA." Like, it's so hard for us to get over this
image we have. So anyway, she endorses a whole product line for treating social cognition. So, does intervention work? First of all, we have almost no data about any kind of intervention for
adolescents with brain injury or children, almost no data at all. So see, my aforementioned comments about grant reviews. So we don't really know a lot about what works, but they are some general
principles that we know don't work. So this is Mr. Laser Vision that I mentioned earlier. So treatment of these complex social behaviors tends to make kids like robots. They tend to learn them as
procedures and then they overuse them. This is so true in the autism literature. If you look at kids -- I'm not talking about early intervention the first three or four years of life. I'm talking
about teenagers. You see teenagers -- I've reviewed this literature and I can tell you, anyone can be trained to learn a behavior. Right? A monkey can be trained to learn a behavior. But what you end
up with this, these kids who have these chunks of behaviors that are not really connected to anything in a social world, and you put them in therapy so that they get to have a really good knowledge
of how bad they are. So Sloane Burgess is a faculty member at Kent State and she was a Ph.D. student of mine, and she came from autism from the teach program. And she did -- she studied adolescence
self-perception of kids with autism, and she said, "I wonder if we're making these kids experts at how impaired they are in therapy, in -- and the teenagers." If that's what are function is that
we're pulling them out and we're just showing them all these things that they can't do, then we're training them on social skills that they're not going to be able to generalize effectively anyway.
So we don't want these kids. In terms of rehabilitation of executive function, we have really good evidence in adults that we can train compensatory strategies, and we can help people learn how to
think differently and how to manage their environments to improve their performance. No data on kids. So, you know, to developing system, we don't really know how it works. And some things might not
be amenable to treatment. A lot of this "neuroplasticity" which is worth an entire other talk, talk about computerized programs. My other's still boxed at the moment. They talk about
"neuroplasticity, neuroplasticity", but the prefrontal cortex and its connections may be the least plastic part of the brain. So, you know, occipital cortex keeps changing every moment of everyday.
You can grow new neurons and hippocampus, not totally clear they have functional connections but you can grow them. But think about the highest function of the brain that requires -- like an
orchestra, every single instrument in the orchestra needs to be playing together, and each instrument needs to be playing well. So to think that you could repair that is a bit like cutting a phone
cable and putting a Band-Aid on it. You know, we are only at the infancy of understanding how the brain changes and response to injury and rehab. So didactic treatment where I'm training your
abstract thinking, when I'm having you practicing proverbs or whatever it is, we really don't have any evidence in adults that that works. Most of the evidence in adults is if someone has a memory
problem, a declare of memory problem, we capitalize on their spare procedural learning, so they learn a lot of strategies and habits. We do a lot of environmental modification. We do a lot of
think-aloud protocols, you know, like, "I will check my work. I'll check my work. I'll check my work for kids, so they learn how to check their homework." So I'm not sure what the sitting-down during
therapy is, the thing for kids with -- for adolescents with brain injury. But there are few general principles, and these are not evidence-based; these are my opinion and there are evidenced-informed
because we don't really good evidence. The first is "Just Do It". So people think adolescents don't deserve treatment. They need to get therapy. And by therapy, I mean they need to see someone who
can help them navigate what's going on. I don't mean -- again, it doesn't have to be across the desk with the computer program. But people write them off and they shouldn't be written off. I know I'm
singing to the choir. You guys would never write them off, but they should be seen. The second is, think about a peer mentoring model. So if you look at the literature on students with disabilities,
you'll see that there's been a big upswing in interesting peer mentoring types of models. And I think peer mentoring can be very effective for social problems in particular. Just to give you an
example, Julie Haarbauer-Krupa was -- she's currently at the CDC but she was at Children's Hospital in Atlanta. And Julie runs a two-week summer program for teens with TBI. And I was involved with
Julie when she first was setting the program up, and we set up a peer mentoring in the program. So there were 10 kids with brain injury, mostly boys, and we have undergrad volunteers who work in the
program as coaches. And the volunteers are trained. They're actually trained for the SLPs and a combination of Hannon and Ylvisaker's principles of behavior intervention. So they're trained in how to
model appropriate social behavior and think out loud. For example, there was a guy, the first -- the second year of the program, who was very physically impaired and he wanted to get the attention of
the girl sitting beside him. And so he put his hand in her purse and took something out of her purse. And she just wasn't happy. So the coach said, "You know, if I wanted the girl to pay attention to
me, I probably do acts." And the coaches, because they were a little bit older and they were college students, were cool. So they were more effective at delivering the intervention. And Shari Wade
and Gary Beadle and I submitted a grant in the spring to set up a social coaching network that's phone-based, smart phone-based. Shari has developed the teen online problem solving curriculum tops,
which is only a research available now. It's not commercially available. So -- but what we want to do is to put on the phone. Put the top steps so the kids learn how to manage their behavior through
tops. It's really a strategy training but they also can talk to a peer, and so we can skype them to a peer. And then the peers don't have to be there. They can be anywhere in the country. So that's
-- so cross your fingers that, you know, we get funded to do that. But we really like the peer mentoring model and we really like peers who are a little bit older, say, college students because
they're not in the classroom with the kids and that could be embarrassing whereas slightly older person gives you some social points because they are -- they do have that cool factor. Adolescents
need immediate reward. So they need to -- they need to have something that works right away. An SLP in Australia -- I was there as a visiting scholar, once said to me, "If you can't show them, you
can't help in the first 10 minutes, you've lost them." So I think -- and that makes sense if you think of the reward system in the brain. And so you need to be able to show them right away how you
can make a change that makes a difference. For example, I was working with this girl who's injured at 12 and I saw her at 18, because she just could not -- she was having a lot of problems with her
family and couldn't get a job. She'd been fired five times. So anyway, she would not take notes. She was a great note-taker and she would not take notes in a meeting. And so I tried for like, a
couple of weeks to say it's a good think, you know, make the intellectual argument. And finally I said, "Okay. We're collecting data," so one of my students came up with three stories. I said I'm
going to read you the story. Don't take notes." She didn't take notes. Then I asked her fact questions. She got 10% correct. Then I read it. She took note. She got 80% correct. Then I read another
one. She took note. She got 10% correct. So it's like I -- she needed to have the data right that minute. At the end of it, she said, "I don't feel like taking notes." But she knew that note-taking
was an option for her. So, yes. So it has to be rewarding and we have to quit like, talking about stuff so ironic because I've spent the whole morning talking. There's a lot of talking that goes on
in therapy sessions and perhaps it's just speech pathologists who do this. But about how are we going to solve this problem? Or let's discuss what you just did and whether that was appropriate. And
you know, people with declarative memory problems need to just practice. There needs to be a lot of practicing and not a lot of talking. So one of the homeworks of brain injury is this dissociation
between knowing the right thing to do and doing it, right? That's executive function problems. So I find a lot of interventionist talking about what you would do if, what we call what-if type
questions. That does not translate into doing. So I feel like in our treatment sessions and even in school, kids need to have high frequency practice of the right thing and less discussion. And if
perhaps having had adolescents' helps because I realize that adults to adolescents sound like the adults in Charlie Brown, "Wa, wa, wa, wa, wa, wa, wa." So you feel like you're just doing the
greatest job explaining and that's what they're hearing, "Wa, wa, wa, wa, wa, wa." Right? So you kind of have to just do it. I mentioned that it's a chronic disease. So you have to think about the
long term. And we have to be prepared to assess and treat chronic problems. I'm going to skip this framework that we use. Except to say this is the -- this is the World Health Organization framework,
International Classification of Functioning, Disability and Health. Oh, this was the book that McKay and I have on cognitive rehab. Again, no data for kids so I'm not telling you, you should buy it.
But in the book, this is the framework we use for setting goals. So, when we're working with adolescents, we say, "What is the social participation goal and how can I get there?" We don't say,
"What's the social impairment and how can I train it?" So if we have -- if I'm working with an adolescent who doesn't have any friends then having friends -- having a friend is going to be the goal.
And maybe the way to get to that goal is by joining a special interest club instead having something at school, you know, something that crosses age groups, or maybe it means belong to a church group
or something like that. So we're -- we always start with the social inclusion. And that's not a school model. You know, the school IEP model is very skills-based but for adolescents, that's not
really as relevant anymore. You know, you have to -- you know when they get close to ending school, people are good about this work-wise. They'll say, "Well, the -- you know, the goals can be
employment or college or something." But socially, I don't think we use this framework. I think we might say they have socially inappropriate behavior, so we're going to teach them good turn-taking
or fewer behavior problems in the classroom or something like that, but we really need to -- or at least, I believe, again, this is evidence-informed. You can take it as you wish, but I think we need
to think about participation level goals and working backwards. So if it happens that they are depressed, you could treat the depression instead of trying to treat turn-taking when depression might
be the biggest predictor or for us in Wisconsin, we're a rural state. So we have a lot of kids who just can't get anywhere to socialize with other people. And so maybe some, you know, some kind of a
safe online-based interaction as where they're going to get their social inclusion because teens need social input, social reward, and they need to take risks. There's a teen brain injury program in
Ireland and they take the kids out in their teen summer program. They take the kids out on speedboats with lifejackets because they want them to have a risk experience in a protected way. So, I mean,
they need to have these elements. There are normal elements of development. So that's my take-home message. And that is that look that girls give for the guys in the room. Anyway, great. We have a
few minutes for questions. For questions, we do need to use the mike. I know that was a lot of information. Yes. Here it comes.
AUDIENCE MEMBER: You didn't talk too much about Brain STEPS. And I was just wondering, you know, what your part in it is in that.
LYN TURKSTRA: My connection with Brain STEPS is that Brenda from Brain STEPS invited me to come here.
AUDIENCE MEMBER: Sure. So we -- every year at the Low Incidence Institute, Brain STEPS had -- we formed the TBI strand, so usually it's two days. It was yesterday and then today. But if you want any
information about Brain STEPS -- are you familiar with Brain STEPS?
AUDIENCE MEMBER: Okay. Good.
AUDIENCE MEMBER: Yes.
AUDIENCE MEMBER: I have two psychologists in our -- in our district in Hampton has a nice book.
AUDIENCE MEMBER: A BrainSTARS manual?
AUDIENCE MEMBER: Can we get one of those?
AUDIENCE MEMBER: So you can buy one if you -- there's something called the BrainSTARS manual. It's available by the Children's Hospital of Colorado, and it's about $75, $80 or something like that.
It's a good manual for, like, if a child has fine motor difficulties or if they have -- no, not fine motor. More things like attention. You know, you noticed that the child is having problems with
their attention. It will give you some quick fixes to try. And there's also a nice section that talks about, you know, the brain and what happens during brain injury. So it's a good resource.
AUDIENCE MEMBER: Really? It was nothing. Correct.
AUDIENCE MEMBER: And it's indexed...
AUDIENCE MEMBER: And then it has all that belongs for education.
AUDIENCE MEMBER: Yeah. I think that would be it.
AUDIENCE MEMBER: Is it blue? And yellow?
AUDIENCE MEMBER: It's kind of [inaudible]
AUDIENCE MEMBER: It is blue.
AUDIENCE MEMBER: Yeah. So it's a good book.
AUDIENCE MEMBER: No. No. Yeah. It has like cognitive processes, things like that. We brought her in to speak a couple of years ago to the Low Incidence Institute, the author of that book. But that's a
AUDIENCE MEMBER: [inaudible] fine motor...
good resource for schools to have. All of our Brain STEPS teams have -- all of our team members have that book also. Yeah. But I'd be happy to talk to you afterwards if you have any other questions.
LYN TURKSTRA: I -- also, I just wanted to mention LEARNet. So, LEARNet is a website by the Brain Injury Association of New York state, and it was originally developed by them with Mark Ylvisaker
before he passed away, and LEARNer is a really good resource for everybody. So, it has handouts for teachers. It has things for parents and it has things for kids. And LEARNet is kind of a problem
solving system. And so, you can go there and -- it's by the problem that the student is showing. So, if the student is showing X in the classroom, it goes through kind of the differential diagnosis
and says -- it says here a possible medication side effects, here a possible executive function effects. It's not for a casual user because like, everything Mark did is really dense. So, it has a lot
of information on it. So, I'm not sure I would necessarily recommend it to a teacher to just go and look on the website because I think it's -- can be a bit of a challenge. But, yeah, the LEARNet
problem solving system is a really nice resource. And it has a lot about behavior management because that was Mark Ylvisaker and Tim Feeney's specialty. So, when students are having problems in the
classroom, it has some really nice resources for that. Yes?
AUDIENCE MEMBER: It's actually more of a comment bound...
LYN TURKSTRA: Oh, great.
AUDIENCE MEMBER: ...question, so...
LYN TURKSTRA: My assistant will bring you the microphone.
AUDIENCE MEMBER: Okay. So, I actually have spent my entire career of education and, now, Brain STEPS leader for team leader for the state. But I'm also a brain injury survivor. And I have a daughter
who's a post-concussive -- has been identified with post-concussive syndrome. But in terms of commenting on the -- one of the things you said about they don't have the skills to create social
networks and I think something that became painfully aware for us this year is her transition from high school to college was just overwhelming. I mean she had other stuff to deal with. We lost both
of my parents, but the biggest thing is she had no idea how to create those social networks. And at the same time that she was really trying to redefine herself socially, because the injury occurred
when she was a junior in high school. So, you know, I think even with all of my -- you know, I've worked in the field of autism for the last 12 years, so even though I had a ton of expertise around
those lines, there were still things that we were not able to do or not able to support. And it really wasn't until she really crashed in her freshman year in college that it became how much the
overall injury had kind of impacted her ability to form and create those friendships. The other piece of it that I thought was very interesting is that she didn't want to be disclosing.
LYN TURKSTRA: Right.
AUDIENCE MEMBER: Because she didn't want other people to think, you know, she was...
AUDIENCE MEMBER: ...just trying to -- yes. She was trying to establish these new relationships with people that she didn't know, and she didn't want to be disclosing with regard to the struggles that
LYN TURKSTRA: Because she was less then.
she was having, all of those other kind of things. So, she was essentially trying to really work through all of them without a support system or a network to be able to do it. So, I think it's
something that those of us who are Brain STEPS team members when we're dealing with adolescents who are in that stage that they're getting close to transition to college, make sure that everybody has
got that item on the table as well to be able to think about.
LYN TURKSTRA: That is great -- thank you so much for sharing that. That is a great -- both of those are great comments. And I thought the not wanting to disclose is really critical for all students
with disabilities at the college level, except for students with autism who seem fine with clean disclosing; not surprisingly but...
AUDIENCE MEMBER: Well, she disclosed to the -- to the school.
LYN TURKSTRA: But it -- But it -- even to the...
AUDIENCE MEMBER: But she did not disclose to...
LYN TURKSTRA: To her friends.
AUDIENCE MEMBER: ...her friends.
LYN TURKSTRA: But even to the school though, we have a big challenge with students in college wanting to -- because they feel in some way that they're past it now. They got to college and they don't
really want to be identified as different or they don't want people to perceive they're getting special treatment. But, yes, for friends it's really so, you know, your wits are the most highly valued
thing in our society. Everybody is okay with saying that they're hobbling around on a boot. But to say anything about your cognitive abilities is really difficult for anybody. And so, obviously she
has great theory of mind because she was really concerned about what other people were thinking.
AUDIENCE MEMBER: Yeah. One of the things that she said that I thought was very insightful. You know, when your kids grow up, sometimes you're surprised about what they're actually really thinking. But
one of the things that she said -- because we actually got to the point where she did really need to seek, you know, therapeutic interventions and some other things. And she said one of the questions
that her psychologist to ask her was, you know, how did she deal with change. And she said, "Well...," she goes, "...I really think that I like change and I'm really looking forward to exciting
adventure." She's an International Studies major. So, she really has plans for a lot of things. She goes, "But obviously I'm delusional because...," she goes, "...look at where I am right now." So, you
know, it was -- it, you know, so, it -- but it was a huge internal struggle for her to be able to try. And, you know, the other thing is that we also found was she has support from the Office Of
Disability Services. She tried to connect with the counselor. She was doing all of the right things that she needed to do. But one of the counselor on campus said, "Well, you're just having an
AUDIENCE MEMBER: And it was really -- I mean, in some terms she really was because she was really trying to have to define herself as this new person. But, you know, that shift and all of those other
LYN TURKSTRA: Right.
things that were impacted by the injury were significantly contributing to that. It wasn't just that she went off to college.
LYN TURKSTRA: Right. So one thing that all of you know that's been a frustration -- a bit of a frustration for us in our student with brain injury is that the supports that are available at the
college level, first of all, you know, they're on a voluntary basis, so you have to request them. They're no longer right like they are under IDEA. The second thing is that they -- in our office, the
McBurney Center at UW Madison has a great national reputation. It's a wonderful center but they do -- until this year, they have not had anyone who understood about managing executive function
problems. And so, their model tends to be to give out worksheets, you know, tips and pointers. And this -- if it worked, the students would never need to go there in the first place. So, we have had
a process of trying to help them support students with TBI who have memory and executive function impairments, because their model is not a fit for most of our students. Yes. Oh, you got the mike up
here. Sorry. Last question then I will liberate you for lunch.
AUDIENCE MEMBER: Actually, it's more of a comment. I just wanted to validate. I work with -- in a rehab center and we deal with adults. Sometimes they come in as late teens. And in one particular
case, I found it very interesting which you said about the presence of peers increases risky behavior. We have a gentleman who had a car accident at 17. He was still in high school. And when he had
the car accident, he killed one gentleman which was his girlfriend's brother. He lived but he was on a vent and in a medically induced comma for six months. And he is on our facility. We have both a
residential and a clinic environment. He's been in our residence ever since then. He just had his 30th birthday.
LYN TURKSTRA: Oh, my gosh.
AUDIENCE MEMBER: And he -- one of the things they have to do is they have to come up with goals. And so, one of his goals was to present to high schools, and he created a PowerPoint of presenting to
high schools across Pennsylvania. He started last year at Hershey in Elizabethtown. And he talked to the kids about the fact. He said, you know, he starts out and says, "How many of you plan to go to
college one day? How many of you plan to get married? How many of you plan to have kids?" And then, of course, all the kids, you know, raised their hand meekly. He said I had those same dreams. And
he said, "I wasn't doing drugs. I wasn't drinking. I was just showing off for my friends." And so, it truly does what you said about increasing a risky behavior by being a part of the peers. It
really is true.
LYN TURKSTRA: Yeah.
AUDIENCE MEMBER: And his injury has left him or he has no alternatives. He is in our facility because he can't remember if he took his meds. He can't remember day to day for his daily living
activities. And yet, he works hard to give back by doing these presentations to other teenagers across the -- across the county and across the state, so that he can hopefully help to influence them
better decisions, so.
LYN TURKSTRA: That's a wonderful use of his time and energy. Thank you for sharing that. You might -- I understand Kevin Pearce's movie is now out on HBO. And you can download it on Netflix. So Kevin
Pearce was the Olympic snowboarder, who had a severe brain injury and then went to Craig Rehab. And he -- he's -- it's -- apparently, it's a wonderful movie but his story as family is awesome. He has
a brother with a developmental disability. And so, the family really knew the therapy world. And so, I recommend that as well if you're looking for something for your teens to watch. It -- well, it
-- Kevin Pearce -- if you go to Kevin Pearce -- it's P-E-A-R-C-E, if you go to Kevin Pearce's website. I think they have a link to it. I'm sorry, I can't remember the name.
AUDIENCE MEMBER: I think it's The Crash Reel.
LYN TURKSTRA: Oh, thank you.
AUDIENCE MEMBER: What's it called? Crash Reel?
AUDIENCE MEMBER: I think it's The Crash Reel.
LYN TURKSTRA: It's called...
LYN TURKSTRA: The Crash Reel. That is exactly it. Well, thank you everyone for your attention this morning.