Presentation

Self-awareness, or insight, is the ability to accurately appraise one’s self and personal abilities. Following a brain injury, children may have difficulties with self-awareness (insight) and recognising their own difficulties arising from the injury. This often results in children overestimating their abilities. For example, they may fail to remember information but not recognise that they have difficulties with their memory.

While there is limited research available on self-awareness following brain injury in children, in adults, it is shown that impaired self-awareness results in reduced motivation for rehabilitation, and poorer functional outcomes. Impaired awareness is also associated with reduced safety and increased need for supervision and support in adults. While impaired self-awareness can be protective in the short-term, with lack of awareness acting as a buffer from emotional distress, it can result in emotional difficulties in the longer-term.

In children, impaired self-awareness is more likely to occur with injuries sustained at a young age and with more severe injuries. Impaired awareness tends to improve with increased time since injury, particularly as individuals re-engage in their usual activities.

Considerations for intervention

When working with children, it is worth considering what they have been told so far in relation to their injury and it’s impact on their functioning. Lack of information may present as lack of awareness.

Some children may also engage in the psychological process of denial, actively avoiding discussing their injury and/or subsequent difficulties, to protect themselves from emotional distress (at an unconscious level). This is usually accompanied by signs of emotional distress (e.g. becoming stressed or agitated when discussing their injury or associated difficulties). This is most appropriately managed through referral for psychological intervention.

A child’s awareness of their injury and difficulties should be assessed soon after their injury was sustained. Regular assessments should also take place thereafter if reduced awareness is suspected.

A child’s awareness is always determined by their self-report compared to someone else’s report or an objective measure. This can be done through discussion or by obtaining feedback during therapy as to what they think they are doing well and, conversely, what they are finding difficult, compared to a therapist’s observations or knowledge.

Formal assessment measures can also be useful, such as the Paediatric Awareness Questionnaire. Other measures in which parental reports can be compared to child self-reports are also useful.

Careful consideration may need to be given to how and when to try enhancing a child’s awareness, due to the potential emotional impact. However, a child’s self-awareness may need to be improved before formulating goals and commencing therapy, in order to assist with motivation and engagement.

It is also worth considering parental awareness of the child’s difficulties, and the need to support parents’ awareness and emotional functioning alongside supporting the child.

Recommended treatment approaches

• Children with reduced awareness are likely to require increased supervision, particularly with regard to safety (e.g. a child attempting to ride their bike very soon post-injury, despite significant physical deficits and risk of injury).
• Children should be provided with information on their injury and its impact on their functioning. This should be done in developmentally appropriate ways, such as discussion and social stories.
• Monitor emotional well-being, particularly as children return to their usual activities.
• Encourage self-reflection.
• Give specific feedback on a child’s task performance – one of the most powerful tools for doing this is via video recording (e.g. iPad) immediately after performance on a task.
• Balance feedback on difficulties with feedback on what a child is doing well.
• Try to link feedback on a child’s difficulties with ways they can improve. Later, reflect on gains that are subsequently made.
• Balance easily achievable tasks in therapy with more challenging tasks.
• Refer on for more specific psychological support if a child has significant ongoing difficulties with awareness that are impacting on their functioning, or if they are having significant emotional impact.

Contact us

Queensland Paediatric Rehabilitation Service
Queensland Children’s Hospital
Level 6, 501 Stanley Street, South Brisbane 4101
t: 07 3068 2950
t: 07 3068 1111 (general enquiries)
f: 07 3068 3909
e: qprs@health.qld.gov.au