The Cog Queen
AN INTERVIEW WITH DIANA REESE
Rehabilitation after brain injury can make all the difference in how successful a patient is in reclaiming parts of their former life. This is one of the key reasons Headstrong proudly supports the work of SameYou a charity that prioritizes making neurorehabilitation more widely available to brain injury survivors. So when we heard about a dynamic speech-language pathologist who specializes in young TBI patients and is nicknamed “The Cog Queen” (for cognitive), we were intrigued!
Introduce yourself to our readers!
My name is Diana Reese. I have been a speech language pathologist for a children’s hospital for 11 years. I work primarily outpatient, but I will also work inpatient on a PRN basis. I am a mom with three kids. I enjoy playing piano, hiking, and biking. Most of my spare time is spent going on small outings with my kiddos.
What started you down the path of working with brain injury patients?
I have had a special interest in TBI since the beginning of my career. It started when I was assigned a patient who had discharged from the hospital after a stroke. She needed physical therapy, occupational therapy and speech therapy to assist in her recovery. I became really invested in this patient and her journey. It served as a catalyst and I started to specialize more in this patient population. I think I enjoy this population because there is so much potential for growth. We get these patients and families at a really vulnerable time; they are dealing with a lot of loss and stress. In rehab we get to be their hope and their cheerleaders. I enjoy working with this patient population because so much of what we do is really functional and practical.
When you consider your experiences of the last decade, what do you consider the biggest obstacles facing brain injury survivors?
There are many challenges with this population. One is the sense of loss. Many of these patients are grieving the loss of their former selves. It is difficult to let go of what should have been and grow to accept where you are. These patients can be more volatile and have more difficulty controlling their emotions. As a speech therapist there are more things that we are trying to assess in this population than in many other populations we serve. We look not only at language and articulation, but we are also looking at memory, attention and executive functioning. It makes evaluation and treatment more challenging, but I believe it is also more fun.
You’ve specialized in younger patients.
I enjoy pediatrics because I feel that it is where I can make the greatest impact. Kids have their whole lives ahead of them. When we intervene young, we can really make a difference.
Among the patients you see, what are the most common causes of TBI?
Causes of TBI vary according to age. In really young kiddos the primary cause is falls. Unfortunately, non-accidental trauma or abuse could be the cause of a TBI. In older kiddos it is more frequently sports injuries or motor vehicle accidents.
When I was growing up, head traumas that didn’t involve dramatic symptoms--like fractured skulls-- were treated as an ordinary part of growing up. The widespread understanding that concussions can be MAJOR brain injuries has come into public consciousness largely because of professional athletes, notably the NFL. Where do concussion patients fit into your work?
I frequently see sports injuries and concussions. One of the things I frequently stress to these families is to know your limits and try not to push past them. Listen to your body. Headaches, fatigue and nausea are signals from your brain that indicate when you need to rest. The kiddos who recover best from concussion are the ones who are able to balance work and rest. You need some of both. Sleep is very important to your recovery, but so is mild activity.
Walk us through the process of evaluating a brain injury patient. What should a parent or caregiver expect?
So the process is different based on the acuity of the patient or how recently they were injured. For kiddos on the inpatient end, we will typically take a quick history and get an understanding of what the kiddos were like prior to their accident. Sometimes we are called in to assess swallowing and oral skills to make sure these kids are safe to eat and drink appropriately. Diet recommendations are usually our first encounter. We will also assess what is their current communication status. Communication and eating safety are the first priority. When kids are able to attend to tasks, we will give a test to get an idea of attention, memory, processing speed and language skills as compared to other kids their age. At the time of the evaluation, we formulate goals we hope they can accomplish during their hospital stay.
I can imagine that meeting a brain injury patient on an outpatient basis presents its own challenges because it is often assumed that once the acute stage of an injury is over (ER visit or doctor’s office visit, initial symptoms end) that a patient is fine. You might not see a patient until some time has lapsed after the injury.
On the outpatient end, we will typically take a case history and get an idea of the areas of impact. We try to focus on how the injury is affecting the patient functionally. We usually do some level of standardized testing to assess memory, attention, problem solving and language skills and we will give questionnaires to assess the executive functioning skills. Executive skills are a set of thinking skills that allow us to meet challenges and accomplish goals. Executive functioning skills include planning, organization, ability to regulate emotions, self-awareness and regulation, task initiation, flexibility and persistence to goals. We ask questions regarding each of these questions so that we can make a plan to give strategies to help in areas of deficit.
Once therapy is underway, how do you help your patients adapt to their post-injury lives?
Every child that comes into therapy is given a set of goals. We will choose games and other activities related to their goals. For example, if a child is working on memory, we will select games and activities that require the child to memorize some pictures, names or words. We will walk the child through a strategy to make memory easier and more manageable as we play the game. Other times, we may actually do something more functional. I will frequently work with kids on keeping their planners and help them prioritize assignments they have been given at school. I frequently ask kids to bring me their backpacks and their school assignments and I will give strategies to help them manage their assignments more efficiently, so they aren’t getting too overwhelmed. We will sometimes make a plan for more long-term assignments. Everything is tailored to the specific needs of the child. We try to collaborate with parents so that we understand what is most important to them and set our goals accordingly. At my hospital, the parents are part of the session. Parents are given a home program to help them carry over things learned in therapy to the home setting.
One of the challenges I’ve observed in the brain injury population is that often, the challenges they face, aren’t immediately obvious to the casual observer. How do you help caregivers/parents better support the brain injury patients in their lives?
I think that a common misconception regarding kiddos with brain injury is that they are being lazy or they are being stubborn. Unfortunately, TBI is frequently a hidden disability. People may set their expectations too high and when kids lash out or struggle, we assume they are being obstinate. I’ve read several books and taken some courses from a man named Ross Greene. He writes about what he labels “The Explosive Child.” His philosophy is “Children do well if they can.” What he then says is that if something is not going well, we need to discover the can’t. I think this applies beautifully to all children, but especially those who have suffered a TBI. I find that when we treat kids that are demonstrating difficult behaviors with empathy, scaffold them where we need to, we can see these behaviors improve substantially. I would say the vast majority of the TBI patients I have worked with are really great kids that just need some help and support to succeed in school and at home. They have typically been very sweet and grateful for someone taking an interest and investing in them.