Introduction to Pediatric Traumatic Brain Injury

By Jeanne Dise-Lewis, Ph.D.

Edited by Jeannie Topkoff, B.S.

Every year, more than 1,000,000 children living in the United States have had a traumatic brain injury (TBI) and in Colorado, it is estimated that about 6,000 children per year acquire a brain trauma. Brain injury is the leading cause of both death and disability in childhood and adolescence. Because of the tremendous growth in medical technology and knowledge, the emergency medical response is now of such high caliber that the large majority of children survive their brain injuries. At the same time, the length of stay in critical care and rehabilitation in the hospital has decreased significantly over the past ten years, resulting in an influx of children who have sustained serious brain injuries back to the care of their families, teachers, and primary care pediatricians. The result of these changes is the following: Greater numbers of children survive TBI More children survive very serious TBIs Children arrive in the hospital rehabilitation service sicker and more impaired cognitively Children spend less time in hospital rehabilitation programs Children return home and to their public schools at an early stage of TBI recovery The responsibility for ongoing care, including rehabilitation, often falls primarily on the childs natural caregivers: family, pediatrician, and school personnel

While the largest cause of TBI is involvement in motor vehicle accidents, other sources include: Non-accidental trauma Falls Near-drowning Stroke Sport-related injuries The severity of injury is related to several factors, predominately: Glasgow Coma Scale Length of amnesia for the events surrounding the accident Altered mental status MILD TBI Although it is commonly believed that the sequelae of mild TBI do not persist, both the follow-up and quality of data available on children with mild brain injuries are inadequate. In addition, recent reports of the latent effects of mild pediatric TBI have suggested that the assumption of no lasting impact may be in error. In particular, deficits in executive functions processes such as: Self-monitoring Attention Initiation Inhibition have been documented. Other deficits have also been associated with mild TBI: Difficulty with mood regulation

 Slow rate of mental processing Verbal retrieval weakness Conceptual reasoning deficits These deficits are thought to result from subtle disruption in the frontal lobes at sensitive period so f growth, the effects of which are not apparent until later in life. It is very important that parents report of these subtle changes in mood , personality, or behavior following a a head injury be taken seriously. Children suspected of having a mild TBI should be followed closely and should have the benefit of evaluation and consultation. It appears clear that brain injuries of a moderate or severe degree result in a host of physical, cognitive, behavioral, social and emotional ramifications, which are likely to persist with some degree of permanence. NEUROLOGICAL SEQUELAE OF PEDIATRIC TBI The most commonly reported medical problems include: Sleep disturbances Fatigue Headaches Typically, all three symptoms are noticed early in the recovery period, if they are going to occur at all. Usually, sleep patterns become more regular and less disrupted as the weeks go by; failure to re-establish a normal sleep-wake cycle spontaneously may indicate the need for assistance with medication or psychological assessment and treatment for Post Traumatic Stress Disorder (PTSD). Occasionally, headaches become an ingrained, long-lasting problem, with daily occurrences. Rebound headaches, a continuous headache-cycle, can be caused by over-reliance on acetaminophen or ibuprofen and may require management by a a neurologist. Mental and/or physical fatigue is almost universally reported by individuals recovering from brain injury; children typically sleep longer at nighttime and also require after school naps. Stamina for recreational activities is often quite diminished. SENSORY AND MOTOR SEQUELAE TBI is associated with a variety of physical sensory, perceptual, and motor abnormalities. The primary reported symptoms include: Loss of balance, coordination, motor planning abilities Difficulty accurately perceiving sensations from fingers Difficulty maintaining awareness of body positions Blurred or double vision Hyper-sensitivity to sounds, tastes, smells, or loss of smells Visual-perceptual distortions Disturbances in the sensory and motor systems, besides requiring intervention in their own right, also affect the childs energy and availability for higher order cognitive activity. COGNITIVE/EMOTIONAL FUNCTIONING

The cognitive, emotional, and behavioral problems associated with TBI are often less obvious than the physical symptoms, and they also are likely to be more individualized. The type and severity of problems depends both on the severity of injury and also on the childs stage of development at the time of injury. In general, previously learned behaviors and knowledge are recovered most quickly and robustly. Therefore, other things being equal, early brain injuries (acquired during infancy or preschool years) create more significant impact on both cognitive and behavioral functioning than do injuries acquired at a later stage of development (adolescence, for example). However, the emotional and social impact of TBI increases with age, adolescents feeling it most acutely and being prone to serious depression during recovery. Brain injuries acquired during childhood or adolescence almost always result in: Unevenness among cognitive abilities Reduced rate of mental processing speed Diminished organizational abilities Mental inflexibility Difficulty self-monitoring and regulating emotional experiences These neuropsychological problems, in turn, produce: Spotty acquisition of new information Mental fatigue Stress Poor frustration tolerance Confusion Psychological, emotional and behavioral problems are often misinterpreted as being under the childs control in some way, reflecting poor motivation, lack of effort, or lack of care. Often, others will reassure the childs parents that these attitude problems are normal, or that they will outgrow them. This rarely happens, unless the underlying connections with the brain injury are well understood and appropriate remedial accommodations are made. TBI UNDER THE AGE OF 10 In young children, the most commonly reported problems in this arena are behavioral and include: Temper tantrums Unpredictable swings of emotion and displays of emotion Non-compliance Resistance to change Impulsive, aggressive, and/or dangerous behavior For the young child with a TBI, important interventions include: Increasing clarity and structure Emphasizing healthy routines regarding nutrition, sleep, and activities Providing supervision Creating multiple opportunities to learn appropriate behavior

Once parents and caregivers understand the essential problems their child is facing, it is often quite possible to make significant change in these troubling symptoms. TBI DURING ADOLESCENCE Children whose TBI occurs in adolescence have a different task to face in recovery, and their symptoms are usually more subtle. By adolescence, behavioral control should be well established and the youngster has a solid foundation of academic, as well as personal and social, competencies. The older child can draw on his/her fund of previously learned information in school, and teachers may not recognize the impact of the head injury on the ability to learn new material. Slow rate of mental processing and difficulty organizing and managing complex information are two very common sequelae of TBI. These deficits make it very difficult for the adolescent to function in the quick-paced and complex world of the middle or high school classroom. For adolescents, the post-injury return to school and social activity can be very confusing, agitating, and disappointing. Activities that once were routine now require thought, planning, and assistance. The adolescent feels overwhelmed by the pace of material being presented in class and feels discouraged by her inability to keep up with the demands to process multiple sources of information simultaneously. She often worries that these symptoms mean that school will never again be an arena of success. The adolescent may be unable to resume such responsibilities as babysitting siblings and monitoring and tracking his own schoolwork. He may lack judgment or be unable to think quickly and efficiently on his feet. This loss of ability to function in the routine roles and responsibilities of teenage life is very distressing to the teenager as well as to his/her parents and siblings. Because typical adolescent social life is spontaneous, with few clear rules and little predictability, the youngster with a TBI can become easily overwhelmed in the social arena; afraid of making a mistake which would call attention to their problems, they often withdraw and lose the support of their peer group. Finally, adolescents often have some early notions regarding vocational interests, further education, and maybe even a specific career. They have developed coping strategies, including participation in sports and physical activities. Their injury may prevent or diminish their involvement in such activities, further increasing the stress they feel and contributing to their loss of social support. INTERVENTIONS When adults experience a TBI, there are many sources for cognitive rehabilitation, including adult vocational rehabilitation, disability insurance, and general medical insurance. This availability of funding sources has spawned a variety of treatment programs for adults and hs resulted ion advances in knowledge regarding the mechanisms of TBI and the process of cognitive recovery in adults. For children, however, the cognitive ramifications of a TBI often are viewed as educational, and public school teachers are expected to provide the cognitive rehabilitation for children through the IEP process. Teachers assess the childs academic difficulties, behavioral problems, and motivational deficits, and apply strategies which they have used with other populations of

children (e.g., mental retardation, Attention Deficit Disorder, or emotional disturbances). However, while many symptoms may be the same, there are very fundamental and significant differences in the root causes of school and behavior problems in the case of TBI, and traditional interventions are rarely effective. It is important for parents and care providers of children with a history of brain injury to know that their children are eligible for individualized educational programming and support services in school, no matter what their I.Q. or achievement test scores indicate. Support services and interventions, which are very important for children who have had a TBI and their families, are offered at specialty care centers. These services and interventions include: Medical consultation and follow-up Multidisciplinary neuropsychological evaluation (including psychology, learning, speech/language, social work, OT and PT specialties) Consultation with families and school personnel Support groups for children and their parents Cognitive rehabilitation treatment groups Psychological treatment