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Preschool Traumatic Brain Injury: A Review for the Early Childhood Special Educator
Abstract
This article reviews an emergent area of traumatic brain injury (TBI) literature; namely, developmental outcomes of TBI sustained during the early childhood and preschool period. The developmental time period from birth through age 5 years is one of significant growth and maturity, particularly in the neurological development of the child. An injury to the brain can compromise the neurological integrity of the brain and can disrupt subsequent development and associated functions. A TBI may significantly impact how the child learns core academic skills, interacts with peers, expresses wishes, wants, and emotions, and may shape his or her role in the family. In addition to reviewing this important emergent area, this article addresses the available literature on the epidemiology of TBI in the preschool years, causes and neuropathological mechanisms, functional outcomes, and selected factors that affect outcomes. The review concludes with a listing of implications for the early childhood special educator.
... There exist a number of reviews on cognitive outcomes after pediatric TBI (Albicini et al., 2017;Albicini & McKinlay, 2018;Babikian & Asarnow, 2009;Babikian et al., 2015;Di Battista et al., 2012;Durish et al., 2018;Emery et al., 2016;Keightley et al., 2014;Lloyd et al., 2015;Lopes et al., 2013;Roberts et al., 2016;Trenchard et al., 2013). Some reviews focus on a subsample of TBI (e.g., mild TBI; Emery et al., 2016;Keightley et al., 2014; or nonaccidental TBI; Lopes et al., 2013), on a specific domain (e.g., social functioning; Rosema et al., 2012) or on a wide age range (e.g., 0 -18 years old; Babikian & Asarnow, 2009;Di Battista et al., 2012; or 0 -13 years old; Kennedy et al., 2017), but only two reviews include information on the specific effects of early TBI (Garcia et al., 2015;Wetherington & Hooper, 2006). Garcia et al. (2015) report that children who sustain TBI before the age of five years encounter difficulties such as externalizing behaviors, and attentional, language, and cognitive dysfunction (e.g., Intellectual Quotient [IQ], executive functioning). ...
... Garcia et al. (2015) report that children who sustain TBI before the age of five years encounter difficulties such as externalizing behaviors, and attentional, language, and cognitive dysfunction (e.g., Intellectual Quotient [IQ], executive functioning). Wetherington et al. (2006) suggest the presence of developmental changes and impairments in selected cognitive abilities, motor functions, and socio-behavioral skills. However, neither review was conducted systematically, and both reviews also included children older than six years, precluding specific conclusions concerning the effects of early TBI. ...
... These findings are congruent with a previous review by Garcia et al. (2015) that concluded that children who sustain early TBI encounter cognitive difficulties including intellectual, attention, language, and executive dysfunction. However, in their respective reviews, Garcia et al. (2015) and Wetherington and Hooper (2006) included children older than six years, ruling out the possibility of drawing any specific conclusions concerning the unique effects of early TBI. The findings of the current review clarify that difficulties in these domains are not solely driven by the results of older children. ...
There is increasing empirical focus on the effects of early traumatic brain injuries (TBI; i.e., before the age of six years) on child development, but this literature has never been synthetized comprehensively. This systematic review aimed to document the cognitive, academic, behavioral, socio-affective, and adaptive consequences of early TBI. Four databases (Medline, PsycNET, CINAHL, PubMed) were systematically searched from 1990 to 2019 using key terms pertaining to TBI and early childhood. Of 12, 153 articles identified in the initial search, 43 were included. Children who sustain early TBI are at-risk for a range of difficulties, which are generally worse when injury is sustained at a younger age, injury severity is moderate to severe, and injury mechanisms are non-accidental. Early childhood is a sensitive period for the emergence and development of new skills and behaviors, and brain disruption during this time is not benign. Research, clinical management, intervention, and prevention efforts should be further developed with consideration of the unique characteristics of the early childhood period.
... Still, this recovery largely depends on the type, location, and extent of brain damage, as well as other factors such as the individual variation in brain organization and age at the time of injury (Ewing-Cobbs & Barnes, 2002). Premorbid functioning also may be a strong predictor of outcome whereby having strong language skills pre-injury may serve as a ''protective factor'' for better recovery of language skills post-injury (Wetherington & Hooper, 2006), although this notion needs to be examined more thoroughly with empirical research studies. ...
... Assessing function in these other areas may help us understand language deficits in relation to other deficits related to TBI and also may facilitate appropriate intervention programming (Ewing-Cobbs & Barnes, 2002). Additionally, changes in language functioning may occur quickly among children with TBI, suggesting the importance of close monitoring and frequent reevaluation of language functioning to assess changes related to development or recovery and to develop appropriate programming based on the child's individual needs (Wetherington & Hooper, 2006). ...
The purpose of this article is to provide a current review of language functioning and deficits following traumatic brain injury (TBI), specifically among the pediatric population. This paper will: (a) outline the manner in which these deficits may impede functioning across environments; (b) review methods of assessing language functioning within this population; and (c) discuss empirically supported interventions to address noted language deficits as they present in pediatric TBI.
... [4] One explanation for this disparity is that MVAs often lead to diffuse axonal injury and severe, or even fatal, outcomes. Falls more commonly lead to focal insults because of translational forces, [27] with relatively better outcomes than those associated with MVAs. ...
Background:
Paediatric traumatic brain injury (PTBI) is a major public health problem. However, recent epidemiological data for PTBI in South Africa (SA) are lacking.
Objectives:
To establish a demographic profile of severe PTBI admissions to the Red Cross War Memorial Children's Hospital (RCWMCH) over a 5-year period, by investigating trends in annual admissions, age, sex, language, time and day of injury, and aetiology. Methods. This retrospective, descriptive, quantitative study included children admitted to the RCWMCH with severe traumatic brain injury (TBI) between June 2006 and April 2011, who required intracranial monitoring. We used the Division of Paediatric Neurosurgery's TBI database to identify cases for inclusion in the study and to gather demographic and injury information.
Results:
Descriptive statistics suggested that: (i) the number of annual admissions did not vary substantially across the study period; (ii) the peak admission age was 6 years; (iii) more boys than girls were admitted; (iv) the major mechanism of injury was pedestrian road traffic accidents; and (v) most injuries occurred on weekends. These results are discussed against the backdrop of international research on PTBI and reflect the extent to which epidemiological findings on TBI in high-income countries compare with those from low- and middle-income countries such as SA.
Conclusion:
The identification of aetiological factors and the description of demographic profiles of children sustaining TBI constitutes a basis for preventative policy administration and intervention strategies in SA.
... An early injury affects a developing brain that has not yet formed critical features necessary for mature function, potentially interrupting or hindering the developmental process. Some suggest that poorer outcomes in children injured early in life might be caused by the developing brain's greater susceptibility to diffuse brain insult, resultant abnormalities in neurogenesis, or resultant difficulties in acquiring new skills postinjury (18,70,71,98,99). Some researchers (70) have stressed the link between early developmental level and TBI; those injured very young demonstrate persistent deficits in academic skills (reading, decoding, comprehension, spelling, and arithmetic). ...
... An early injury affects a developing brain that has not yet formed critical features necessary for mature function, potentially interrupting or hindering the developmental process. Some suggest that poorer outcomes in children injured early in life might be caused by the developing brain's greater susceptibility to diffuse brain insult, resultant abnormalities in neurogenesis, or resultant difficulties in acquiring new skills postinjury (18,70,71,98,99). Some researchers (70) have stressed the link between early developmental level and TBI; those injured very young demonstrate persistent deficits in academic skills (reading, decoding, comprehension, spelling, and arithmetic). ...
... Studies to date have documented little evidence for recovery of socio-emotional function after TBI, and frequently outcomes worsen over time (Bornhofen & McDonald, 2008;Ganesalingham et al., 2006;Yeates et al., 2004). This may be particularly true for children who sustain a brain injury during early childhood, as recent studies have shown that children who sustain TBI at early ages may actually be more vulnerable to long-term deficits (Anderson et al., 2004Catroppa et al., 2008;Chapman & McKinnon, 2000;Weatherington & Hooper, 2006). ...
A growing body of literature has documented evidence for emotion labeling (EL) deficits after traumatic brain injury (TBI); however, long-term effects of TBI on EL abilities, particularly among young children, are unclear. We investigated EL abilities and socio-emotional outcomes in 32 children with moderate-severe TBI, 23 with complicated-mild TBI, and 82 children with orthopedic injuries (OI), shortly after injury and at 18 months post-injury. All children were between 3:0 and 6:11 years of age at the time of injury. Repeated measures analyses indicated that all groups showed improved EL performance between acute and 18-month assessments, but that the moderate-severe TBI group improved at a slower rate than the OI group, so that the two groups showed significantly different performance at 18 months. Emotion labeling ability did not significantly contribute to the prediction of socio-emotional outcomes after controlling for pre-injury functioning. These results provide preliminary evidence of emerging EL deficits after early childhood TBI that are related to injury severity but that do not predict social and behavioral outcomes.
... One possible explanation of the comprehensive linguistic deficits found during the follow-up of children with TBI might be a poor premorbid linguistic capacity among these children. Wetherington et al. [27] suggest that strong language skills pre-injury may serve as a protective factor for better recovery of language skills post-injury and McDonald et al. [21] claim that 30% of adults with TBI have a history of academic failure. In the present study two of the children had a premorbid language diagnosis. ...
Objective:
The purpose of this study was to focus on two linguistic abilities, word retrieval (expressive language) and comprehension of vocabulary and grammar (receptive language), as well as to investigate to what extent long-term problems exist in these areas in children following traumatic brain injury.
Methods:
Two groups of children were studied retrospectively: twenty-four children with traumatic brain injury (TBI) and twenty-one children diagnosed with brain tumour. All children had been referred to the rehabilitation team for assessment. The children were between four and seventeen years old when assessed, with the assessments performed at least one year after the injury or brain tumour diagnosis. An established set of tests regarding word retrieval and comprehension of vocabulary and grammar was used, and the results were compared with normative test data.
Results:
In both clinical groups, significantly more children scored lower than the designated "normal" score than in the normative sample on tests measuring confrontation naming and phonological word retrieval. In addition, in the brain tumour group, more children demonstrated significantly lower results than normal performance on a test for semantic word retrieval. In the TBI group, significantly more children scored below the normal value on tests of word and grammatical comprehension when compared to the normative sample.
Conclusions:
This study confirms that word retrieval is an area of deficit in many children with acquired brain injuries one year or more after the injury occurred. The study also indicates that children with TBI may have persistent deficits in comprehension of both vocabulary and grammar.
... Specifically, children aged 2 to 7 years at the time of injury are more susceptible to deficits in expressive language, attention, and academic achievement compared with children injured at later ages (Anderson et al., 2005a;Barnes et al., 1999;Dennis et al., 1995;Ewing-Cobbs & Barnes, 2002;Ewing-Cobbs et al., 1989, 1997Morse et al., 1999;Verger et al., 2000). Researchers have speculated that the poorer outcomes in younger children may reflect a greater susceptibility to diffuse brain insult or abnormalities in neurogenesis, or a greater effect of injury on postinjury skill development (Anderson & Moore, 1995;Barnes et al., 1999;Ewing-Cobbs et al., 1997, 2004bTaylor & Alden, 1997;Wetherington & Hooper, 2006). ...
Previous studies have documented weaknesses in cognitive ability and early academic readiness in young children with traumatic brain injury (TBI). However, few of these studies have rigorously controlled for demographic characteristics, examined the effects of TBI severity on a wide range of skills, or explored moderating influences of environmental factors on outcomes. To meet these objectives, each of three groups of children with TBI (20 with severe, 64 with moderate, and 15 with mild) were compared with a group of 117 children with orthopedic injuries (OI group). The children were hospitalized for their injuries between 3 and 6 years of age and were assessed an average of 1 1/2 months post injury. Analysis revealed generalized weaknesses in cognitive and school readiness skills in the severe TBI group and less pervasive effects of moderate TBI. Indices of TBI severity predicted outcomes within the TBI sample and environmental factors moderated the effects of TBI on some measures. The findings document adverse effects of TBI in early childhood on postacute cognitive and school readiness skills and indicate that these effects are related to both injury severity and the family environment.
Due to their developmental status, children may be more susceptible than adults to the harmful effects of neurotoxins, whether this exposure occurs in utero through the mother’s use of teratogenic substances or postnatally within the child’s environment. Each of the chapters contributing to this volume provides a wealth of research-based information on academic and psychosocial outcomes associated with exposure to neurotoxins during critical developmental periods. In this concluding chapter we summarize some of the key findings from the previous chapters, identify several themes observed across chapters, and describe an agenda for future research in pediatric neurotoxicology.
Children and adult survivors of childhood-onset end stage kidney disease (ESKD) have a greater frequency of neurodevelopmental and cognitive challenges compared with the general population [1, 2]. The impact of this neurodevelopmental vulnerability persists into adulthood and contributes to manifestations such as a lower intelligence quotient (IQ) and lower frequency of post-secondary education compared with the general population [2]. The mechanisms responsible for the brain dysfunction observed with ESKD have not been established. The goals of this chapter are to review the acute neurologic complications of dialysis and to explore potential mechanisms leading to brain dysfunction, summarize known neurocognitive and neurologic findings, and consider possible management strategies for cognitive dysfunction in children affected by ESKD.
This study examined the impact of traumatic brain injury (TBI) in young children on executive functions and social competence, and particularly on the role of executive functions as a predictor of social competence.
Data were drawn from a prospective, longitudinal study. Participants were children between the ages of 3 years 0 months and 6 years 11 months at time of injury. The initial sample included 23 with severe TBI, 64 with moderate TBI, and 119 with orthopedic injuries (OI). All participants were assessed at 3 and 6 months postinjury. Executive functions were assessed using neuropsychological tests (Delayed Alternation task and Shape School) and parent ratings on the Behavior Rating Inventory of Executive Function and Child Behavior Questionnaire. Parents rated children's social competence on the Adaptive Behavior Assessment System, Preschool and Kindergarten Behavior Scales, and Home and Community Social Behavior Scales.
Children with severe TBI displayed more negative outcomes than children with OI on neuropsychological tests, ratings of executive functions, and ratings of social competence (η² ranged from .03 to .11). Neuropsychological tests of executive functions had significant but weak relationships with behavioral ratings of executive functions (ΔR² ranged from .06 to .08). Behavioral ratings of executive functions were strongly related to social competence (ΔR² ranged from .32 to .42), although shared rater and method variance likely contributed to these associations.
Severe TBI in young children negatively impacts executive functions and social competence. Executive functions may be an important determinant of social competence following TBI.
Objective: To examine the contributions of demographic, injury, cognitive, and personality characteristics to psychosocial outcome 8 years after traumatic brain injury (TBI). Design: Multiple regression analyses were used to estimate the variance explained by putative "predictors" of psychosocial outcome. Participants: Thirty-nine TBI survivors and 39 family member informants. On the basis of Glasgow Coma Scale scores and Accident Injury Severity (head) ratings, the patients' brain injuries ranged from mild to critical in severity. Main Outcome Measures: One self-report measure combined putative markers of social role engagement, such as marital status and earned income. Another, based on informant ratings using the Katz Adjustment Scale, was conceptualized as reflecting behavioral adjustment. Results: Whereas cognitive functioning explained significant unique variation in social role engagement, it did not account for variance in behavioral adjustment. Conversely, whereas 3 personality trait ratings explained significant incremental variance in behavioral stability, only 1 did the same with respect to social role engagement. Conclusions: Social role engagement and behavioral adjustment appear to represent 2 related but distinguishable aspects of TBI outcome that are associated with different patient characteristics. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study provides a longitudinal follow-up of the behavioral adjustment of 45 children with mild, moderate, and severe closed head injuries. Two measures of behavioral adjustment, the Child Behavior Checklist (CBCL) and the Vineland Adaptive Behavior Scales (VABS), were obtained from a parent at the time of injury and at 6 and 12 months postinjury. The severely injured children obtained significantly poorer VABS scores than children with mild and moderate injuries over the year-long follow-up. In addition, on the CBCL, severely injured children had more school problems and engaged in fewer social activities than mild and moderately injured children. These results show that severe head injury in children was associated with declines in adaptive functioning, whereas scores for children with mild and moderate injuries did not differ, nor did they deviate from average levels at any follow-up interval.
Examined cognitive and motor performance during the subacute stage of recovery and 8 months postinjury in 21 infants and preschoolers who sustained a closed head injury (CHI). Children sustaining severe CHI, who exhibited impaired consciousness for at least 1 day, were impaired on measures of intelligence, motor, expressive language, and receptive language functions on the baseline and follow-up evaluations relative to children with mild-moderate injuries. Irrespective of injury severity, motor and expressive language functions were the most vulnerable to the effects of CHI. Results are discussed in terms of the rate of development of cognitive functions.
The purpose of the 23 year follow up study was to determine the relationship between trauma variables including measures of head injury and very long-term sequelae. The study included 159 individuals with a mean age 31.40 years, of whom approximately 90% were admitted to hospital with a mild head injury during childhood (mean age 7.96). Extent of head injury was determined by unconsciousness, neurological status, skull fracture, EEG, post-traumatic seizures and a composite measure. The composite measure of neurological variables was the best predictor of long-term outcome. In addition, IQ recorded in the post-acute phase was a reliable predictor of long-term outcome. Of the sample, 32.7% reported physical complaints and 17.6% reported current psychological/psychiatric problems unrelated to the head injury. Subjective sequelae (physical, intellectual and emotional) specified as due to the head injury were reported by 31% of the sample, and the sequelae were found to be related to the extent of the head injury and initial IQ. There were no discernible relationships between attribute variables including premorbid status and age with subjective sequelae. There were, however, significant relationships between subjective sequelae and objective, psychosocial measures of adaptation including educational lag, unemployment, current psychological/psychiatric problems and relationships with family members. Finally, there appeared to be continuity of complaints elicited during the five year follow up of the original project and current sequelae. The severity of the head injury was identified as the primary contributory factor in the reconstitution process and in the prediction of long term outcomes.
Neuropsychological outcome was evaluated in a prospective, longitudinal follow-up study of children age 4 months to 7 years at injury with either mild-to-moderate (N = 35) or severe (N = 44) traumatic brain injury (TBI). Age-appropriate tests were administered at baseline, 6 months, 12 months, and 24 months after the injury. Performance was compared on (1) Composite IQ and motor, (2) Receptive and expressive language, and (3) Verbal and Perceptual-Performance IQ scores. In comparison to mild-to-moderate TBI, severe TBI in infants and preschoolers produced deficits in all areas. Interactions between task and severity of injury were obtained. Motor scores were lower than IQ scores, particularly after severe TBI. Both receptive and expressive scores were reduced following severe TBI. Expressive language scores were lower than receptive language scores for children sustaining mild-to-moderate TBI. While severe TBI lowered both Verbal and Perceptual-Performance IQ scores, Verbal IQ scores were significantly lower than Perceptual-Performance IQ scores after mild-to-moderate TBI. Mild injuries may produce subtle linguistic changes adversely impacting estimates of Verbal IQ and expressive language. Within the limited age range evaluated within this study, age at injury was unrelated to test scores: The impact of TBI was comparable in children ages 4 to 41 months versus 42 to 72 months at the time of injury. All neuropsychological scores improved significantly from baseline to the 6-month follow-up. However, no further change in scores was observed from 6 to 24 months after the injury. The persistent deficits and lack of catch-up over time suggest a reduction in the rate of acquisition of new skills after severe TBI. Methodological issues in longitudinal studies of young children were discussed.
To characterize neuroimaging, physical, neurobehavioral, and developmental findings in children with inflicted and noninflicted traumatic brain injury (TBI) and to identify characteristic features of inflicted TBI.
Forty children, 0 to 6 years of age, hospitalized for TBI who had no documented history of previous brain injury were enrolled in a prospective longitudinal study. TBI was categorized as either inflicted (n = 20) or noninflicted (n = 20) based on the assessment of hospital and county protective services. Glasgow Coma Scale scores and neonatal history were comparable in both groups.
Acute computed tomography/magnetic resonance imaging studies and physical findings were evaluated. Glasgow Outcome Scale scores, cognitive development, and motor functioning were assessed an average of 1.3 months after TBI. chi2 analyses assessed differences in the distribution of findings in the inflicted and noninflicted TBI groups.
Signs of preexisting brain injury, including cerebral atrophy, subdural hygroma, and ex vacuo ventriculomegaly, were present in 45% of children with inflicted TBI and in none of the children with noninflicted TBI. Subdural hematomas and seizures occurred significantly more often in children with inflicted TBI. Intraparenchymal hemorrhage, edema, skull fractures, and cephalohematomas were similar in both groups. Retinal hemorrhage was only identified in the inflicted TBI group. Glasgow Outcome Scale scores indicated a significantly less favorable outcome after inflicted than noninflicted TBI. Mental deficiency was present in 45% of the inflicted and 5% of the noninflicted TBI groups.
Characteristic features of inflicted TBI included acute computed tomography/magnetic resonance imaging findings of preexisting brain injury, extraaxial hemorrhages, seizures, retinal hemorrhages, and significantly impaired cognitive function without prolonged impairment of consciousness.
This study assessed the behavioral outcome of 51 children with traumatic brain injury (TBI) up to 2 years following injury. Children with severe injuries, but not those with mild or moderate injuries, were reported by parents to have a greater incidence of behavior problems following TBI. Regression analyses indicated that the presence of a partner for the primary caregiver of the child and the acute emotional reaction of the parent to the injury were both predictive of child behavioral outcome, although not by 2-year follow-up. These findings suggest that parental coping resources may impact on the development of child behavioral sequelae following TBI, emphasizing the role of the family in the child's response and the importance of supportive intervention.
To examine the relative contributions of injury severity, level of physical and cognitive disability, child behavior and family function to short-term outcome 6 months following traumatic brain injury (TBI) in children.
Prospective, longitudinal, between-group design, comparing preinjury and postinjury measures of functional outcome across three levels of injury severity.
One hundred and twelve children, aged 2-12 years admitted to the Royal Children's Hospital, Melbourne, with a diagnosis of TBI. The sample was divided into three groups, according to injury severity: mild TBI (n = 31), moderate TBI (n = 52) and severe TBI (n = 29). Children with a history of neurologic, developmental and psychiatric disorder were excluded from participation.
Levels of postinjury functioning in the following domains: physical function, cognitive ability (incorporating intellect, memory and attention), behavioral and family functioning, and level of family burden.
A clear dose-response relationship for physical and cognitive outcomes was found, with severe TBI associated with greater impairment of physical, intellectual, memory and attentional function. For psychosocial outcome, results were less clearly linked to injury severity. Preinjury behavioral and family functioning were closely related to postinjury function in these domains, with an interaction identified between family function and child behavior at 6 months postinjury. Family functioning remained unchanged postinjury, although level of burden was high, and predicted by injury severity, functional impairment and postinjury behavioral disturbance.
These results suggest ongoing functional problems for the child and significant family burden 6 months following TBI. The nature and severity of physical and cognitive problems are most closely related to injury severity, with family functioning and child behavior better predicted by psychosocial and premorbid factors.
Physical abuse is a leading cause of serious head injury and death in children aged 2 years or younger. The incidence of inflicted traumatic brain injury (TBI) in US children is unknown.
To determine the incidence of serious or fatal inflicted TBI in a defined US population of approximately 230 000 children aged 2 years or younger.
All North Carolina children aged 2 years or younger who were admitted to a pediatric intensive care unit or who died with a TBI in 2000 and 2001 were identified prospectively. Injuries were considered inflicted if accompanied by a confession or a medical and social service agency determination of abuse.
Incidence of inflicted TBI. Multivariate logistic regression models were used to compare children with inflicted injuries with those with noninflicted injuries and with the general state population aged 2 years or younger.
A total of 152 cases of serious or fatal TBI were identified, with 80 (53%) incurring inflicted TBI. The incidence of inflicted traumatic brain injury in the first 2 years of life was 17.0 (95% confidence interval [CI], 13.3-20.7) per 100 000 person-years. Infants had a higher incidence than children in the second year of life (29.7 [95% CI, 22.9-36.7] vs 3.8 [95% CI, 1.3-6.4] per 100 000 person-years). Boys had a higher incidence than girls (21.0 [95% CI, 15.1-26.6] vs 13.0 [95% CI, 8.4-17.7] per 100 000 person-years). Relative to the general population, children who incurred an increased risk of inflicted injury were born to young mothers (< or =21 years), non-European American, or products of multiple births.
In this population of North Carolina children, the incidence of inflicted TBI varied by characteristics of the injured children and their mothers. These data may be helpful for informing preventive interventions.
The social outcomes of pediatric traumatic brain injury (TBI) were examined in a prospective, longitudinal study that included 53 children with severe TBI, 56 with moderate TBI, and 80 with orthopedic injuries, recruited between 6 and 12 years of age. Child and family functioning were assessed at baseline, at 6- and 12-month follow-ups, and at an extended follow-up a mean of 4 years post injury. Growth curve analyses revealed that pediatric TBI yields negative social outcomes that are exacerbated by family environments characterized by lower socioeconomic status, fewer family resources, and poorer family functioning. After controlling for group membership, age, race, socioeconomic status, and IQ, path analyses indicated that long-term social outcomes were accounted for in part by specific neurocognitive skills, including executive functions and pragmatic language, and by social problem-solving. Deficits in these domains among children with TBI are likely to reflect damage to a network of brain regions that have been implicated in social cognition.
To examine executive processes in young children with traumatic brain injury (TBI), we evaluated performance of 44 children who sustained moderate-to-severe TBI prior to age 6 and to 39 comparison children on delayed response (DR), stationary boxes, and spatial reversal (SR) tasks. The tasks have different requirements for holding mental representations in working memory (WM) over a delay, inhibiting prepotent responses, and shifting response set. Age at the time of testing was divided into 10- to 35- and 36- to 85-month ranges. In relation to the community comparison group, children with moderate-to-severe TBI scored significantly lower on indexes of WM/inhibitory control (IC) on DR and stationary boxes tasks. On the latter task, the Age x Group interaction indicated that performance efficiency was significantly reduced in the older children with TBI relative to the older comparison group; performance was similar in younger children irrespective of injury status. The TBI and comparison groups did not differ on the SR task, suggesting that shifting response set was not significantly altered by TBI. In both the TBI and comparison groups, performance improved with age on the DR and stationary boxes tasks. Age at testing was not significantly related to scores on the SR task. The rate of acquisition of working memory (WM) and IC increases steeply during preschool years, but the abilities involved in shifting response set show less increase across age groups (Espy, Kaufmann, & Glisky, 2001; Luciana & Nelson, 1998). The findings of our study are consistent with the rapid development hypothesis, which predicts that skills in a rapid stage of development will be vulnerable to disruption by brain injury.
This is the third symposium to be published in JINS. The idea for the symposium arose following the presentation of a group of papers on pediatric head injury at the February 1996 meeting of the International Neuropsychological Society in Chicago. During that paper session, speakers shared not only their research data, but also the methodological and conceptual dilemmas involved in evaluating the consequences of head injury in children. Several of these dilemmas occur as themes throughout the set of articles presented in the symposium.
Objective To study identified rates of long-term behavior problems
in children with traumatic brain injury (TBI) compared to children with only
orthopedic injuries and risk factors and correlates for new behavior problems
following TBI. Methods Sample included children with severe TBI (n =
42), moderate TBI (n = 41), and orthopedic injuries only (ORTHO;n = 50). The
baseline assessment measured child behavior, adaptation, and
neuropsychological, academic, and family functioning. Follow-ups were
conducted at 6 and 12 months and at an extended follow-up a mean of 4 years
after injury. Results The prevalence of caseness, defined as elevated
behavior problem ratings, was higher in one or both TBI groups than in the
ORTHO group at each follow-up (e.g., 36% of severe TBI group, 22% of moderate
TBI group, and 10% of ORTHO group at extended follow-up). Most instances of
postinjury-onset caseness at the extended follow-up were evident within the
first year after TBI. Predictors were severe TBI, socioeconomic disadvantage,
and preinjury behavioral concerns. Concurrent correlates included weakness in
working memory and adaptive behavior skills, poorer behavior and school
competence, and adverse family outcomes. Conclusions Postinjury-onset
caseness is persistent, risks are multifactorial, and correlates include child
dysfunction and family sequelae.
Language skills undergo rapid development during the early childhood years, so that by the time children start school they are competent communicators with well established syntactic, semantic and pragmatic abilities for their age. Little is known about the effects of traumatic brain injury (TBI) on the acquisition of these language skills during the early childhood years. This study used a prospective, cross-sectional design to compare the language abilities of young children following their head injury. Fifteen brain injured children, aged between 4-6 years, were divided into three injury groups depending on severity of injury, i.e. mild, moderate and severe, and compared with a matched community control group. They were assessed within 3 months of sustaining their injury on a range of expressive and receptive language tests, and free speech conversation samples, which were analysed pragmatically and syntactically. Results indicated that the severe group performed most poorly on language tasks. It is suggested that linguistic evaluation is an important component of follow up at least for the severe head injured population.
Older views of the functional developmental plasticity of the developing central nervous system (CNS) focused on the protective effect of a young age at the time of insult. In these views, a younger rather than an older age at onset was thought to produce fewer and/or less severe symptoms and a more rapid recovery. More recently, neurobehavioral outcome has been studied in a variety of medical conditions that affect the developing CNS; at the same time, new investigative techniques, such as brain imaging, have elucidated the biological basis of structural and functional brain plasticity. In consequence of a better understanding of the structural and functional consequences of developmental CNS insults, a body of research has emerged that is shaping a new view of functional developmental plasticity, in which neurobehavioral outcome is set by the biological risk associated with a medical condition and moderated by age and development, the time since onset of the condition, and the reserve available within the child, family, school, and community.
Objective
To provide biomedical researchers and clinicians with information regarding
and recommendations for effective rehabilitation measures for persons who
have experienced a traumatic brain injury (TBI).Participants
A nonfederal, nonadvocate, 16-member panel representing the fields of
neuropsychology, neurology, psychiatry, behavioral medicine, family medicine,
pediatrics, physical medicine and rehabilitation, speech and hearing, occupational
therapy, nursing, epidemiology, biostatistics, and the public. In addition,
31 experts from these same fields presented data to the panel and a conference
audience of 883 members of the public. The conference consisted of (1) presentations
by investigators working in areas relevant to the consensus questions during
a 2-day public session; (2) questions and statements from conference attendees
during open discussions that were part of the public session; and (3) closed
deliberations by the panel during the remainder of the second day and part
of the third. Primary sponsors of the conference were the National Institute
of Child Health and Human Development and the National Institutes of Health
Office of Medical Applications of Research.Evidence
The literature was searched through MEDLINE for articles from January
1988 through August 1998 and an extensive bibliography of 2563 references
was provided to the panel and the conference audience. Experts prepared abstracts
for their conference presentations with relevant citations from the literature.
The panel prepared a compendium of evidence, including a patient contribution
and reports from federal agencies. Scientific evidence was given precedence
over clinical anecdotal experience.Consensus Process
The panel, answering predefined questions, developed their conclusions
based on the scientific evidence presented during the open forum (October
26-28, 1998) and in the scientific literature. The panel composed a draft
statement that was read in its entirety and circulated to the experts and
the audience for comment. Thereafter, the panel resolved conflicting recommendations
and released a revised statement at the end of the conference. The panel finalized
the revisions within a few weeks after the conference. The draft statement
was made available on the Internet immediately following its release at the
conference and was updated with the panel's final revisions.Conclusions
Traumatic brain injury results principally from vehicular incidents,
falls, acts of violence, and sports injuries and is more than twice as likely
to occur in men as in women. The estimated incidence rate is 100 per 100,000
persons, with 52,000 annual deaths. The highest incidence is among persons
aged 15 to 24 years and 75 years or older, with a less striking peak in incidence
in children aged 5 years or younger. Since TBI may result in lifelong impairment
of physical, cognitive, and psychosocial functioning and prevalence is estimated
at 2.5 million to 6.5 million individuals, TBI is a disorder of major public
health significance. Mild TBI is significantly underdiagnosed and the likely
societal burden is therefore even greater. Given the large toll of TBI and
absence of a cure, prevention is of paramount importance. However, the focus
of this conference was the evaluation of rehabilitative measures for the cognitive
and behavioral consequences of TBI. Evidence supports the use of certain cognitive
and behavioral rehabilitation strategies for individuals with TBI. This research
needs to be replicated in larger, more definitive clinical trials and, thus,
funding for research on TBI needs to be increased.
Infants and preschoolers sustaining traumatic brain injury represent a distinct group in terms of injury characteristics, medical management, and outcome. Although the majority of traumatic brain injuries occurring during early childhood are mild, severe injuries are associated with high rates of mortality and morbidity. The less favorable neurobehavioral outcome frequently identified in infants and preschoolers in relation to outcome in other pediatric age groups is likely due to the high rate of inflicted injury in young children. Inflicted injury often subjects the brain to rotational acceleration-deceleration forces that produce diffuse damage, leading to a high rate of death or persistent disability.
(C) Williams & Wilkins 1995. All Rights Reserved.
Objective : To examine the pre- and postinjury patterns of behavioral and psychosocial adjustment in children with moderate to severe traumatic brain injury, and to identify variables that predict adjustment outcome.
Design: Premorbid and follow-up parental ratings of children's adjustment were compared. Outcome predictor variables were identified through stepwisc regression analysis.
Setting: Pediatric program at a regional comprehensive rehabilitation center.
Patients: 50 children with moderate to severe traumatic brain injury, selected from a 36-month series of consecutive clinical inpatient referrals.
Measure: Achenbach Child Behavior Checklist.
Results: Premorbid behavioral or psychosocial deficits were no more common than in the general population. Level of psychosocial adjustment deteriorated significantly after traumatic brain injury (P<.0001). Significant predictors of psychosocial adjustment at followup included premorbid psychosocial adjustment (P<.01), diffuse lesion on computed tomography/magnetic resonance imaging scan (P<.001), and length of coma (P<.10).
Conclusions: Postinjury psychosocial impairments are common in children with moderate to severe traumatic brain injury and are related to injury severity. In the majority of the cases, such problems cannot be attributed exclusively to premorbid dysfunction
(C) Williams & Wilkins 1996. All Rights Reserved.
Head injuries in children under the age of 3 years have not been extensively studied, due in part to the lack of an objective tool for neurological assessment. We have developed a Children's Coma Scale (CCS) by modifying the verbal response subscore of the Glasgow Coma Scale (GCS) to overcome this limitation. When applied prospectively to children under 3 years of age, we found the CCS to be useful in predicting outcome. During the 5-year study period from 1981 to 1985, there were 738 patients with head injuries (0–16 years) admitted to the Children's Memorial Hospital in Chicago, including 318 (43.1%) less than 3 years of age. Initial data demonstrated the following observations. The most common mechanism of injury was a fall (75.5%). Although a brief loss of consciousness (LOC) was reported in three-fourths of the patients, prolonged LOC of more than 6 h was uncommon (16/318, 5.0%). The classically described lucid interval was seen in only 7 children (2.2%) and was not a reliable indicator of epidural hematoma. Post-traumatic seizures developed more commonly in children under 2 years of age (15.7%) than in older children (11.6% under 3 years of age, 9.6%, entire group), (P
Head injury in the youngest age group is distinct from that occurring in older children or adults because of differences in mechanisms, injury thresholds, and the frequency with which the question of child abuse is encountered. To analyze some of these characteristics in very young children, the authors prospectively studied 100 consecutively admitted head-injured patients 24 months of age or younger who were drawn from three institutions. Mechanism of injury, injury type, and associated injuries were recorded. All patients underwent ophthalmologic examination to document the presence of retinal hemorrhages. An algorithm incorporating injury type, best history, and associated findings was used to classify each injury as inflicted or accidental. The results confirmed that most head injuries in children younger than 2 years of age occurred from falls, and while different fall heights were associated with different injury types, most household falls were neurologically benign. Using strict criteria, 24% of injuries were presumed inflicted, and an additional 32% were suspicious for abuse, neglect, or social or family problems. Intradural hemorrhage was much more likely to occur from motor vehicle accidents and inflicted injury than from any other mechanism, with the latter being the most common cause of mortality. Retinal hemorrhages were seen in serious accidental head injury but were most commonly encountered in inflicted injury. The presence of more serious injuries associated with particular mechanisms may be related to a predominance of rotational rather than translational forces acting on the head.
The psychological effects of nonneurologic trauma on children are poorly recognized. We hypothesized that physical trauma in children, with or without head injury, would result in substantial and persistent psychological and behavioral abnormalities. Using a short telephone survey followed by a detailed behavioral checklist, we studied psychobehavioral dysfunction in children who had experienced trauma either with or without minor head injury (n = 40 each) as well as in a comparative group of children after emergency appendectomy (n = 80). Substantial behavioral disability was identified by the detailed checklist in 35% and 28% of children without and with head injury, respectively, but in none after appendectomy. Dysfunctions included phobias, major scholastic difficulties, rage attacks, and episodic depression that continued for a long period. Even in the 67% of children who eventually fully recovered, the duration of symptoms after the time of injury was an average of 19 months. Demographics, socioeconomic status, severity of injury, and length of hospitalization did not correlate with dysfunction, and these traumatized children's siblings had no reported history of trauma or psychological difficulties. Thus, parental opinion about behavioral dysfunction appears sensitive and specific and is therefore a useful screening index. These results suggest that injured children, even after minor trauma, may suffer substantial and long-lasting behavioral changes to a degree hitherto unrecognized.
Blunt and penetrating force injuries to the brain constitute an enormous public health problem. If a child or young adult survives a moderate or severe brain injury, there is a strong likelihood of a lifetime of physical and mental impairment as well as tremendous economic and social impact on the family. The magnitude of this problem has only been recently appreciated, yet many questions on the causes and short- or long-term outcomes remain unanswered. One conclusion is clear: prevention is the best solution, but information on the nature of the brain injury, exposure factors, and effectiveness of countermeasures is incomplete. We sought to summarize certain basic epidemiological data on brain injuries in infants, children, adolescents, and young adults as well as findings on incidence of brain injury and current data on demographics and risk factors. We also estimated disability and person-years of life lost from brain injuries and highlight the value of helmets as a countermeasure for several exposures to head injury.
The outcomes of 97 children with severe closed head injuries referred to a regional rehabilitation center were studied. Patients were divided according to referral source and age (less than 6 and greater than or equal to 6 years). Patients referred from more distant sources had worse outcomes in terms of cognition, motor ability, and brain atrophy for both age groups. Children 6 years of age and older had better cognitive, motor, and brain atrophy outcomes than younger patients for each referral origin. These results do not support the hypothesis that the youngest children have the best recovery after profound closed head injury. All abused children were younger than 6 years of age; compared to other age-matched, closed head injury patients, these children had significantly worse cognitive and motor abilities.
Head injuries in children under the age of 3 years have not been extensively studied, due in part to the lack of an objective tool for neurological assessment. We have developed a Children's Coma Scale (CCS) by modifying the verbal response subscore of the Glasgow Coma Scale (GCS) to overcome this limitation. When applied prospectively to children under 3 years of age, we found the CCS to be useful in predicting outcome. During the 5-year study period from 1981 to 1985, there were 738 patients with head injuries (0-16 years) admitted to the Children's Memorial Hospital in Chicago, including 318 (43.1%) less than 3 years of age. Initial data demonstrated the following observations. The most common mechanism of injury was a fall (75.5%). Although a brief loss of consciousness (LOC) was reported in three-fourths of the patients, prolonged LOC of more than 6 h was uncommon (16/318, 5.0%). The classically described "lucid interval" was seen in only 7 children (2.2%) and was not a reliable indicator of epidural hematoma. Post-traumatic seizures developed more commonly in children under 2 years of age (15.7%) than in older children (11.6% under 3 years of age, 9.6%, entire group), (P less than 0.001). Oculovestibular reflex and bilateral fixed dilated pupils had the most reliable correlation with outcome. Other brain-stem reflexes were less useful.(ABSTRACT TRUNCATED AT 250 WORDS)
The author reviews the empirical evidence on the psychological sequelae of brain damage in childhood, concluding that brain injury causes a markedly increased risk in both intellectual impairment and psychiatric disorder. The risk is related to the severity of the brain damage, but there is little indication of locus effects. Psychiatric disorder is probably most likely to occur when there is abnormal neurophysiological activity; to some extent it may be influenced by the nature of the basic medical condition. Psychiatric consequences of brain injury are also substantially affected by the child's pre-injury behavior, psychosocial circumstances, and cognitive level. However, there are few psychological sequelae that are specific to brain damage.
This study describes the effect of mild head injury in preschool children on aspects of their cognitive performance in the year after injury and at the age of 6.5 years, with particular reference to the development of reading skills. Mild head injury was defined by diagnosis at a hospital emergency department of a head injury which was not severe enough to need admission for observation. Seventy eight such children were compared with a group of 86 with a minor injury elsewhere. The groups had similar developmental, family, and socioeconomic status. There were no differences in cognitive tests soon after the injury, but at six months and one year children with mild head injury scored less than controls on one test, solving a visual puzzle (visual closure); they were also more likely to have had another mild head injury. At 6.5 years of age they still scored less than controls, reading ability was related to their visual closure score at one year, and they were more likely to have needed help with reading. Mild head injury seems to be able to produce subtle but significant changes which can affect school performance.
To examine changes in family functioning from injury to 3 years after pediatric traumatic brain injury; to determine factors most predictive of family outcomes at 3 years and variables that promote positive outcomes and changes over time.
Prospective cohort study.
Two regional tertiary care centers: cases followed for 3 years into community.
Families of 81 children, ages 6 to 15 years, who sustained closed head injury and loss of consciousness (mild = 43, moderate = 20, severe = 18), consecutively enrolled over 15 months.
Family Environment Scale, Family Assessment Device, Family Inventory of Life Events, Health Insurance Survey-General Well-Being, NYU Problem Checklist for Significant Others, Family Interview Rating Scale, Family Global Assessment Scale. All were obtained initially and at 3 months, 1 year, and 3 years postinjury. Predictor variables were selected from the instruments above, as well as from the parent and teacher versions of the Child Behavior Checklist, socioeconomic status, and injury severity.
Preinjury functioning was the best predictor of 3-year outcomes. Fewer changes in family functioning were reported over 3 years in the mild or moderate groups, whereas more deterioration occurred in the severe group. At 3 years, one third to one half of parents in either the moderate or severe groups reported medium to high strain in 19 of 34 problem areas. Low levels of family control and high levels of expressiveness correlated with better outcomes for severe group. Positive change for the severe group was marked by better preinjury levels of communication, expressiveness, problem solving, use of resources, role flexibility, greater activity orientation, and less conflict, control, and stress. Preinjury variables and severity explained from 26% to 69% of the variation in 3-year outcomes.
Families at risk for poorer outcomes can be prospectively identified and should be supported and encouraged in their efforts to develop new coping resources.
Nonaccidental injury accounts for nearly one quarter of all hospital admissions for head injury in infancy, and is associated with significant morbidity and mortality. Long-term outcome in survivors, however, has been incompletely studied. In this series, 84 infants 2 years of age and younger with the shaking-impact syndrome consecutively admitted to a single hospital between 1978 and 1988 were identified. A questionnaire detailing current medical, developmental, and behavioral status was developed, and attempts were made to locate the 62 children surviving the acute injury. Family instability and strict confidentiality restrictions precluded locating the majority of children, but 14 children with demographic and injury characteristics similar to those of the overall group were contacted at an average of 9 years after injury. Seven children were severely disabled or vegetative, 2 were moderately disabled, and 5 had a good outcome. Of the latter group, 3 had repeated grades and/or required tutoring. Acute factors associated with poor outcome included unresponsiveness on admission, need for intubation, age less than 6 months, and bilateral or unilateral diffuse hypodensity on CT scan. All children with bilateral diffuse hypodensity and loss of gray-white differentiation on CT scan remained blind, retarded, nonverbal, and nonambulatory in spite of aggressive medical and surgical management. This study suggests that the majority of children surviving the shaking-impact syndrome suffer major permanent morbidity, and that acute factors predicting long-term outcome may help guide aggressiveness of care.
This article examines the evidence that the effect of head injury on young children may differ from that in adults, in that while in the latter the pattern is of deficits that recover with time since the accident, this is not necessarily the case with very young children. In this group, there may be no evidence of any deficit in the early days or weeks after injury, but the children may fail to develop some skills as quickly as children who have not had a head injury. Results from a series of studies of MHI in preschool children carried out over a more than 10-year period from Auckland Hospital and recently published studies of pediatric MHI from other groups are reviewed. It is concluded from a comparison of these data that there is a need for long-term prospective studies designed within a developmental framework to clarify the issue.
It has been argued that young children's brains are "plastic," and may sustain substantial brain insult with little loss of function. Recent research suggests that this notion may not apply for generalized cerebral pathology. The present study aimed to evaluate this proposition using a sample of 73 young children, divided into 3 groups: severe head injury (HI; N = 17); mild-moderate HI (N = 32); and noninjured controls (N = 24). Preinjury screening established equivalence across groups for age, sex, preinjury ability, behavioral adjustment, socioeconomic status, and family functioning. Children were evaluated as soon as possible postinjury, and again 12 months postinjury, in three domains: intellectual ability, language, and memory. Results indicated that severe HI was associated with substantial, persisting difficulties in all areas. In contrast, children with mild-moderate HI experienced fewer difficulties, and often performed similarly to controls, both acutely and 12 months postinjury. There was no evidence of differential recovery of function associated with injury severity, with performance increments consistent across groups and probably due to either age-appropriate developmental gains, or test-related practice effects. Poorer outcome at 12 months postinjury was predicted by injury severity primarily, with earlier age at injury, and premorbid ability associated with outcome in specific domains.
Narrative discourse and intellectual functioning were examined 3 years following traumatic brain injury (TBI) in children 1 to 8 years of age at the time of injury. The language-impaired TBI group (n = 9) had language deficits during the subacute stage of recovery; their performance was contrasted with that of a TBI comparison group equated on neurologic and demographic variables that did not show subacute language impairment (n = 8) and a sibling comparison group (n = 9). The language-impaired TBI group had lower Verbal and Full-Scale IQ scores and produced fewer words and utterances than the sibling group on a story retelling task; their stories were characterized by fewer complete referential and lexical ties and more referential errors, indicating difficulty conjoining meaning across sentences. The language-impaired TBI group recalled approximately one-third of the propositions needed to maintain the story theme and made more errors sequencing the propositions than either the TBI or the sibling comparison groups. Group differences were not obtained on the Performance IQ scores or on measures of rate or fluency of speech production, mazes, use of conjunctives, or naming errors. The discourse deficiencies of children with TBI and acute language impairment were most pronounced at the level of cognitive organization of the text reflecting text macrostructure and were least apparent at the level of lexical and sentential organization reflecting text microstructure. Results are discussed in terms of the vulnerability of developing language abilities to disruption by brain injury.
To study adaptive functioning after severe traumatic brain injury (TBI).
Case-control study.
A university hospital and three regional and four community hospitals.
A consecutive series (n=24) of children age 5 through 14 years who suffered severe TBI were individually matched to subjects who sustained a mild TBI and to a second group who sustained an orthopedic injury with no evidence of TBI.
Standardized adaptive functioning, intellectual, psychiatric, and neuroimaging assessments were conducted on average 2 years after injury.
Severe TBI was associated with significantly (p < .05) lower Vineland Adaptive Behavior composite, communication, and socialization standard scores and lower Child Behavior Checklist parent-rated social competence scores compared with children with orthopedic injury. Severe TBI and mild TBI subjects were significantly (p < .05) more impaired than orthopedic subjects on teacher-rated adaptive function. Family functioning, psychiatric disorder in the child, and IQ were significant variables, explaining between 22% and 47% of the variance in adaptive functioning outcomes.
Severe TBI is associated with significant deficits in child adaptive functioning. This association appears to be mediated by family dysfunction, child psychiatric disorder, and intellectual deficits.
Recent studies suggest that plasticity does not benefit outcome when diffuse cerebral pathology of the young child's brain is concerned. Thirty-three patients with severe traumatic brain injury (TBI) at preschool age were followed-up until adulthood. After the age of 18 years, a thorough neurological, neuropsychological and social evaluation, including detailed patient history and assessment of identity, was made by the team. When the youngest patients were 21 years old, the study was completed, with a questionnaire assessing employment status and ability to live independently. Twenty-seven per cent of the patients worked full time, 21% had subsidised work, 37% lived independently at home and 15% needed help with every-day functions. Tests measuring speed, executive and memory functions were significantly associated with vocational outcome, as was the sense identity, which was independent of the test scores. The results support the recent reports on the vulnerability of a young child's brain to early trauma. The study also strongly suggests that the final assessment of outcome after childhood TBI should be done in adulthood.
Traumatic brain injury (TBI) may have a profound impact on a child's ongoing development. Various risk factors have been found to predict outcome, but considerable variability remains unexplained. This study used a prospective, longitudinal design to examine recovery of memory function following TBI within the pre-school period. Forty-four children with TBI were divided according to injury severity (mild, moderate, severe), and compared to age and SES matched healthy controls (n = 26). Children were evaluated acutely and at 12 months post-injury using the Rivermead Behavioural Memory Test for Children. Results failed to show a clear dose-response relationship between injury severity and memory function during the acute phase of recovery. However, this relationship developed over time, with greater memory impairments evident for children with more severe TBI by 12 months post-injury. Children with mild TBI exhibited few memory problems.
The present longitudinal case study was designed to investigate the possibility that a traumatic brain injury (TBI) occurring during the second year of life, while significant lexical and grammatical competencies are emerging, could have an impact on subsequent language development. Thus, the language development of a very young girl (BL) who suffered a TBI at the age of 17 months was monitored for 6 months following the injury. Different procedures were used to measure her lexical and grammatical development: monthly parental checklists, free-play sessions and word-learning tasks. BL's results were compared with two control groups (n = 5 and 9) matched for age and gender. Overall, the results are consistent with the classical view of acquired language disorders in children: despite an initial decrease in the use of her premorbid vocabulary, BL showed no durable significant impairment on any measure of lexical or grammatical development.
Traumatic brain injury (TBI) may have a profound impact on a child's ongoing development. Various risk factors have been found to predict outcome, but considerable variability remains unexplained. This study used a prospective, longitudinal design to examine recovery of memory function following TBI within the pre school period. Ninety-six children with TBI were divided according to injury severity (mild, moderate, severe), and compared to age and SES matched healthy controls (n = 35). Children were evaluated acutely and at 6,12 and 18 months post-injury using intellectual and memory measures. Results showed a relationship between greater injury severity and poorer intellectual ability. This dose-response relationship was not clearly evident for memory function within the acute phase of recovery, but developed over time, with greater memory impairments evident for children with more severe TBI by 12 months post-injury. Children with mild TBI exhibited few memory problems. Findings are discussed in the context of theories of plasticity and recovery of function.
Older views of the functional developmental plasticity of the developing central nervous system (CNS) focused on the protective effect of a young age at the time of insult. In these views, a younger rather than an older age at onset was thought to produce fewer and/or less severe symptoms and a more rapid recovery. More recently, neurobehavioral outcome has been studied in a variety of medical conditions that affect the developing CNS; at the same time, new investigative techniques, such as brain imaging, have elucidated the biological basis of structural and functional brain plasticity. In consequence of a better understanding of the structural and functional consequences of developmental CNS insults, a body of research has emerged that is shaping a new view of functional developmental plasticity, in which neurobehavioral outcome is set by the biological risk associated with a medical condition and moderated by age and development, the time since onset of the condition, and the reserve available within the child, family, school, and community.
This article represents the work of the National Association of Medical Examiners Ad Hoc Committee on shaken baby syndrome. Abusive head injuries include injuries caused by shaking as well as impact to the head, either by directly striking the head or by causing the head to strike another object or surface. Because of anatomic and developmental differences in the brain and skull of the young child, the mechanisms and types of injuries that affect the head differ from those that affect the older child or adult. The mechanism of injury produced by inflicted head injuries in these children is most often rotational movement of the brain within the cranial cavity. Rotational movement of the brain damages the nervous system by creating shearing forces, which cause diffuse axonal injury with disruption of axons and tearing of bridging veins, which causes subdural and subarachnoid hemorrhages, and is very commonly associated with retinal schisis and hemorrhages. Recognition of this mechanism of injury may be helpful in severe acute rotational brain injuries because it facilitates understanding of such clinical features as the decrease in the level of consciousness and respiratory distress seen in these injured children. The pathologic findings of subdural hemorrhage, subarachnoid hemorrhage, and retinal hemorrhages are offered as "markers" to assist in the recognition of the presence of shearing brain injury in young children.
Attentional-inhibitory control and social-behavioral regulation are two outcome domains commonly impaired after childhood closed head injury (CHI). We compared neuropsychological tests of attentional-inhibitory control (vigilance, selective attention, response modulation) and social discourse and intentionality (inferencing, figurative language, and speech acts) with parent ratings of attention and behavioral regulation in relation to four injury-related variables: age at CHI, time since CHI, CHI injury severity, and frontal lobe injury moderated by CHI severity. Participants were 105 school-aged children in the chronic stage of CHI, divided into mild, moderate, and severe injury severity groups, and further subdivided according to frontal lobe injury. Outcome indices were imperfectly correlated in the group as a whole, although several relations between neurocognitive tests and parent ratings were observed within CHI subgroups. Different domains of cognitive function had different predictors. For attentional-inhibitory control, age at injury and time since injury were most predictive of outcome; for social discourse, predictors were injury severity and frontal lobe injury moderated by injury severity. Variability in cognitive outcome after childhood CHI is not random, but appears related to age, time, and biological features of the injury.
To explore the possibility that gender has a moderating effect on memory after pediatric traumatic brain injury (TBI).
Controlled group study. Gender effects between and within groups were evaluated by means of effect size comparisons and hierarchical regression analysis.
Regional rehabilitation center.
Seventy children with TBI, selected from a 4-year series of consecutive referrals, and 70 demographically matched controls.
Screening version of the Wide Range Assessment of Memory and Learning (WRAML-S) and the Wechsler Intelligence Scale for Children-Third Edition (WISC-III).
Boys with TBI performed worse than girls with TBI, and worse than their counterparts in the control group, on the WRAML-S. There was no gender effect in the control group. Gender explained an additional 9% of the variance in WRAML-S performance over and above injury severity and age variables. However, gender differences were largely attenuated when speed of information processing, as assessed by the WISC-III, was used as a covariate.
The effect of TBI on children's memory appears to be moderated by gender and may be mediated by speed of information processing.
There is significant disagreement among medical professionals regarding the mechanisms for infant brain injury. This disagreement is due in part to the failure by some to acknowledge and incorporate known biomechanical data and models into hypotheses regarding causes. A proper biomechanical understanding of the mechanisms of traumatic brain injury (TBI) challenges many published and testified assumptions regarding TBI in infants and children. This paper analyzes the biomechanical relationship between the causes of TBI in infants and children, and their physiological consequences. Loading characteristics, injury parameters and criteria, scaling, failure characteristics, differences between infants and adults, and impact due to falls are described and discussed in the context of the laws of mechanics. Recent studies are critiqued with reference to their contribution to an understanding of brain injury mechanisms. Finally, methods for improving our currently incomplete knowledge of infant head injuries, and their mechanisms, consequences and tolerances are proposed. There is an urgent need for close collaboration between physicians and biomechanicians to objectively and scientifically evaluate infant head injuries to further define their mechanical bases, and to assist in their diagnosis and treatment.
As infants develop skills that allow for increasing independence in social and cognitive domains, they acquire the ability to identify goals, sequence behaviors to carry out goals, and to flexibly use strategies for attaining goals in both social and independent play contexts. Little is known about how brain injury in young children may disrupt the precursors to such executive processes. In this study, we examined social and cognitive competence in 25 infants ages 3 to 23 months who sustained moderate to severe traumatic brain injury (TBI) secondary to physical abuse and in 22 healthy community comparison children. Children with TBI were evaluated an average of 1.6 months after the injury. A toy-centered activity with the examiner was used to capture joint attention and social behavior and an exploratory toy play situation was used to measure independent goal-directed play. The inflicted TBI group showed significant reduction in both social and cognitive domains relative to the comparison group. Canonical correlation analyses disclosed that inflicted TBI was associated with reduction in (a) initiation of social interactions, (b) responsiveness to interactions initiated by the examiner, (c) positive affect, and (d) compliance. The groups performed comparably on indexes of gestural and verbal communication and for the occurrence of negative affect. Joint attention was an area of vulnerability for the TBI group in both social initiation and response contexts. Although general cognitive and motor scores were lower in the inflicted TBI group, the complexity of independent toy play did not differ across groups. Early brain injury causes significant disruption in behaviors regulating initiation and responsiveness in social contexts. Longitudinal follow-up will characterize the long-term consequences of early disruption in joint attention and other behaviors on the development of social and cognitive precursors to executive processes.
In a prospective longitudinal study, academic achievement scores were obtained from youth 5 to 15 years of age who sustained mild-moderate (n = 34) or severe (n = 43) traumatic brain injuries (TBI). Achievement scores were collected from baseline to 5 years following TBI and were subjected to individual growth curve analysis. The models fitted age at injury, years since injury, duration of impaired consciousness, and interaction effects to Reading Decoding, Reading Comprehension, Spelling, and Arithmetic standard scores. Although scores improved significantly over the follow-up relative to normative data from the standardization sample of the tests, children with severe TBI showed persistent deficits on all achievement scores in comparison to children with mild-moderate TBI. Interactions of the slope and age parameters for the Arithmetic and Reading Decoding scores indicated greater increases over time in achievement scores of the children injured at an older age, but deceleration in growth curves for the younger children with both mild-moderate and severe TBI. These results are compatible with the hypothesis that early brain injuries disrupt the acquisition of some academic skills. Hierarchical regression models revealed that indexes of academic achievement obtained 2 years following TBI had weak relations with the duration of impaired consciousness and socioeconomic status. In contrast, concurrent cognitive variables such as phonological processing and verbal memory accounted for more variability in academic scores. Given the significant and persistent decrement in basic academic skills in youth with severe TBI, it is clear that head-injured youth require intensive, long-term remediation and intervention not only of the academic skills themselves, but also of those cognitive abilities that support the development and maintenance of reading and math.
Young children with special needs Columbus, OH: Prentice-Hall. Individuals with Disabilities Education Improvement Act (IDEA): Analysis of changes made by
- S R Hooper
- W Umansky
Hooper, S. R., & Umansky, W. (Eds.) (2004). Young children with special needs (4th ed.). Columbus, OH: Prentice-Hall. Individuals with Disabilities Education Improvement Act (IDEA): Analysis of changes made by P.L. 108–144 (2005). CRS Report for Congress, Retrieved January 22, 2006 from http://www.cec.sped.org/pp/docs/CRS AnalysisofNewIDEAPL108–446.pdf.
Early preliminary linguistic analysis
- S Morse
- F Haritou
- K Ong
- V Anderson
- C Catroppa
- L Rosenfeld
Morse, S., Haritou, F., Ong, K., Anderson, V., Catroppa, C., & Rosenfeld, L. (1999). Early preliminary linguistic analysis. Pediatric Rehabilitation, 3, 139–148.
Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths
- J A Langlois
- W Rutland-Brown
- K E Thomas
Langlois, J. A., Rutland-Brown, W., & Thomas, K. E. (2004). Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths (1995–2001). Atlanta, GA: Center for Disease Control and Prevention, National Center for Injury Prevention and Control. Retrieved January 1, 2005 from http://www.cdc.gov/ncipc/pub-res/TBI_in_US-04/TBI_ED.html.
Growth and development
- S R Hooper
- C Mills
Hooper, S. R., & Mills, C. (2004). Growth and development. In S. R. Hooper, & W. Umansky (Eds.), Young children with special needs (4th ed., pp. 38–89). Columbus, OH: Prentice-Hall.