Pediatric Traumatic Brain Injury

TBI is a major cause of death and disability in the United States. More than just an acute injury, TBI survivors can face a lifetime of impairment. Effects of TBI can include impaired thinking, memory, movement, sensation, altered psychological functioning, and decreased quality of life.  These impairments affect the survivor, their loved ones, and their community. Traumatic brain injury is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. 

Brain injuries are classified as mild, moderate or severe depending on variables such as the initial injury loss of consciousness (“LOC”), post traumatic amnesia (“PTA”), and coma length. The Glasgow Coma Scale (“GCS”) is a well-known clinical measurement tool used to score the individual’s level of consciousness from 0-15. GCS ratings correspond with severity; severe is 3-8, moderate is 9-12, and mild is 13-15.[1]

Classification of Brain Injury

TBI is a leading cause of death in the pediatric population either through motor vehicle crashes or assaults.^[2] For all age groups, motor vehicle crashes were the third overall leading cause of TBI-related ED visits, hospitalizations, and deaths (14%). In 2012, there were 329,290 children treated in U.S. emergency rooms for concussion or TBI related to sports or recreation.  In 2013, more than half of TBIs among children 0 to 14 years were caused by falls, while 1 in 5 were caused by being struck by or against an object. 

Controversy exists regarding the young brain’s ability to compensate for injury through neuroplasticity,^[3] versus the vulnerability of the young brain to unrecoverable insult, especially during intense developmental growth phases. Recent research suggests the young brain is vulnerable to severe injury and neuroplasticity does not prevent long term consequences. Age at injury and severity of injury apear to be major influences on a young brain’s recovery.

Age at injury is a predictor of cognitive and behavioral outcomes. The literature shows that cognitive and academic development is most at risk for those having a brain injury in infancy or early childhood, compared to middle childhood or adolescence.^[4] Children sustaining focal brain injury before age 2 show global deficits, while children injured when they are older show increasingly better function with increased age at injury, and are more like the average population. However, there is not a linear pattern of age and outcome for all functions of the brain. When considering behavioral outcomes, children ages 7-9 who sustained a brain injury performed worse than the 3-6 year old age group.^[5]

Severity of injury, as measured by the GCS, is an independent predictor of long term neurobehavioral outcomes. Children with severe brain injury show long-term deficits in language, memory, intellectual skills, and social skills. ^{[6], [7], [8], [9]}  Children with less severe brain injuries show evidence of age appropriate gains, for up to 10 years after injury.^[10] A child plateaus in function approximately five to ten years after brain injury, regardless of severity.^[11]  Lower pre-injury adaptive abilities, socioeconomic class, pre-injury educational performance, and altered family function also increase the risk for long-term neurobehavioral impairment.^{[12], [13]}

After the acute phase of assessment and stabilization, rehabilitation begins. A neuropsychologist can evaluate children over age 3 to determine the specific cognitive areas for rehabilitation. The neuropsychologist often makes treatment recommendations for therapists, educators, and family members to follow. Other professionals involved in the treatment of a child with brain injury are: pediatricians, neurologists, physiatrists, case managers, physical/occupational/speech/cognitive therapists, psychiatrists and psychologists. Effective treatment for pediatric brain injury is family centered and uses a variety of treatment approaches to meet the child’s needs.

• A restorative approach uses therapies to improve impaired function through retraining.
• A habilitative approach teaches skills that have not been developed due to immaturity.
• A compensatory approach uses the child’s strengths, task modifications and accommodations to minimize loss of function 
• A functional or contextual approach involves the child teaming up with educators, caregivers, and peers to accomplish functional goals.

Children with TBI often qualify for services from therapists within the public school system to promote a positive transition to mainstream classes and to encourage continued education.^[14] Cognitive, speech, physical and occupational therapists are integral participants of integrating the child into mainstream environments.

References

[1] Shepard Center, Atlanta, GA. Found at: https://www.shepherd.org/patient-programs/brain-injury/about/types-of-brain-injury/traumatic-brain-injury on 10/17/2017

[2] https://www.cdc.gov/traumaticbraininjury/get_the_facts.html

[3] Neuroplasticity: the brains ability to establish new neural connections to compensate for the injury.

[4] Taylor, G. Alden, J. (1997) Age-related differences in outcomes following childhood brain insults: An introduction and overview. Journal of the International Neuropsychological Society. 3, 555-567.

[5] Anderson, V. et al. (2009). Childhood brain insult: can age at insult help us predict outcomes? Brain. 132:45-56.

[6] Ibid. Anderson, V. et al. (2004).

[7]  Ibid. Taylor, G. Alden, J. (1997).

[8] Janusz, J., Kirkwood, M., Yeates, K., and Taylor, G. (2002). Social problem-solving skills in children with traumatic brain injury: long-term outcomes and prediction of social competence. Child Neuropsychology. 8(3): 179-194.

[9] Catroppa, C., Anderson, V. Morse, S., Haritou, F., and Rosenfeld, J. (2008). Outcome and predictors of functional recovery 5 years following pediatric traumatic brain injury (TBI). Journal of Pediatric Psychology. 33(7): 707-718.

[10] Ibid. Anderson, V. et al. (2004).

[11] Anderson, V., Godfrey, C., Rosenfeld, J., Catroppa, C. (2012). Predictors of cognitive function and recovery 10 years after traumatic brain injury in young children. Pediatrics.129 (2):e254-261. Found at http://aappublications.org.

[12] Ibid. Anderson, V. et al. (2004).

[13] Ibid. Catroppa et al. (2008).

[14] Pediatric Brain Injury found at http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942939&section=Treatment.

RPC provides a full array of economic damages services in personal injury cases for both plaintiff and defense attorneys. Our team includes life care planners, economists, a vocational expert, physicians and neuropsychologists. Our experts work together to create cohesive reports, while avoiding duplication of work and providing cost savings to attorneys.