TBI can negatively affect a child’s functioning in home, school, community and social settings. Therefore, collaboration between parents, educators, health care providers, and others working with the child is needed to promote successful functioning following TBI.

Quick Facts

• Approximately 475,000 traumatic brain injuries (TBIs) occur in children <14 years old annually.1
• Children ages 0-4 years are at highest risk for TBIs.1
• There are an estimated 64,000 hospitalizations annually for TBI in children.2
• TBI in children may be been associated with $1 billion in total hospital charges annually.3
• Approximately 2 out of 5 traumatic brain injuries among children are associated with participation in sports and recreational activities.4,5
• TBI from unintentional trauma is one of the primary causes of death among U.S. youths.

Cognitive Development in Children

A basic understanding of brain development can be useful in understanding the potential effects of TBI in children. The following provides a general overview of cognitive development in children.

Birth to Age 2 years: Development initially focuses on functions essential for survival, including basic sensory and motor functioning. Significant development during this period also occurs in communication skills (verbal and non-verbal), developing representations of the environment (e.g., cause and effect) based on sensory and motor experiences, and establishing representations of human relationships based on interactions with caregivers. (For additional information on brain development, see the Zero to Three website.)

Age 2-5 years: Very basic sensory processing abilities (e.g., vision, hearing) develop to near adult-like levels, although analysis of complex information remains limited. Basic knowledge of language syntax is generally acquired by age 4. Memory systems are developing. The brain’s ability to inhibit and control impulses and emotions is limited.

Age 5-10 years: Advances occur in language complexity and in memory abilities. Increasingly complex language abilities are evident, both in expression and comprehension. The ability to inhibit and control behaviors and emotional remains limited relative to the adult, but is gradually improving. Source and autobiographical memory skills develop (e.g., recall of the context [e.g., when] of an event in memory).

Age 11-13 years: The ability to inhibit and control impulses and emotions increases during this period, coinciding with increasing activity in the prefrontal cortex. Notable changes occur in brain structure and chemistry during puberty. Declarative memory skills continue to develop.

Age 13+ years: Steady advances occur in other executive functions, such as working memory, selective attention, and problem solving; this may in part reflect increased connections between broad networks of cortical regions. Metacognition (one’s knowledge about one’s own thought processes/strategies) develops during this period. Ongoing gains in declarative memory occur. There continue to be structural and functional changes to the brain (e.g., connections between regions of the brain [reflected in white matter volume] may continue to develop through the 6th decade of life).

TBIs can cause different challenges for children depending on their developmental stage at the time of the injury.

Causes of TBI in Children

Falls

• There was a 62% increase in fall-related TBI seen in emergency departments among children aged 14 years and younger from 2002 to 2006.
• Falls cause half (50%) of the TBIs among children aged 0 to 14 years.
• Falls from less than 5 feet rarely result in severe brain injuries.
• Children who experience a fall at home seldom sustain fractures of the skull.
• Minor intracranial injuries without neurological deficits are more common.

Sports and Activity-Related Trauma

• Approximately 2 out of 5 traumatic brain injuries among children are associated with participation in sports and recreational activities.,
• The following 10 sports/recreational activities represent the categories contributing to the highest number of estimated TBIs sustained by children ages 14 and younger in 2009:
• Cycling
• Football
• Baseball and Softball
• Basketball
• Skateboards/Scooters
• Water Sports
• Soccer
• Powered Recreational Vehicles
• Winter Sports
• Trampolines

• In school settings, the potential risk for head injuries is increased in sports/activities where collisions are more likely to occur (e.g., playground activities, contact sports).
• Information about concussions in specific sports is available on the CDC website: http://www.cdc.gov/concussion/HeadsUp/sports_specific.html#1

• Some research has suggested that high school athletes may take longer to recover from concussion compared to college athletes.
• National Federation of State High School Associations (NFHS) and Centers for Disease Control and Prevention (CDC) have developed a free online training program for high school coaches.
• The training is designed to educate coaches and others involved in student sports about the importance of proper concussion recognition and management.
• See: http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000

• For additional information about Sports-Related TBI, see Special Populations – Athletes section.

Shaken Baby Syndrome (SBS)

• SBS is caused by violent shaking of a baby by the body, shoulders, arms, or legs.
• Because infants’ neck muscles are not fully formed, the shaking causes a whiplash effect.
• This whiplash effect can result in bleeding in the brain and/or in the eyes.

• SBS can result from shaking alone and from an impact (with or without shaking).
• Very young babies (ages 0-4 months) are at greatest risk for SBS.
• An estimated 25% of babies who are shaken violently die from the injuries they sustain.
• In infants, inflicted trauma or abuse is the #1 cause of death and disability.
• Initial signs of SBS may include:
• Extreme irritability
• Decreased activity — lethargy, no smiling or vocalizing
• Feeding changes — poor sucking or swallowing, decreased appetite
• Neurological signs — difficulty breathing, seizures, eyes not tracking movement

• Physical examination of infants with SBS may reveal:
• Subdural hemorrhage
• Retinal bleeding
• Epidural hemorrhage of the cervical cord
• Gripping marks (bruises) on chest and/or shoulders
• Tearing injuries of the throat and neck muscles

Inconsolable crying is the #1 trigger for Shaken Baby Syndrome.

Support and education for parents can reduce occurrence of Shaken Baby Syndrome.

Consequences of TBI in Children

The effects of a TBI will differ depending on the age of the child when the injury occurred.

As with adults, more severe brain injury is associated with greater likelihood of cognitive and behavioral difficulties. (See TBI Basics: Mechanisms of Injury, Injury Severity).

Research suggests that younger age at injury (< 7 years) is associated with increased risk of long-term difficulties.

• Some believe this may be because older children have developed more skills prior to the TBI.
• TBIs may affect existing abilities and can also impact the development of emerging abilities. In general, new learning and emerging learning abilities are more likely to be affected by TBI.
• As a result, some effects of the TBI may be more immediately impairing (e.g., problems with new learning), while others may not be observed until later (e.g., problems with complex problem solving, behavioral inhibition, etc.).

• The challenges experienced by a child with TBI may change over time, so ongoing monitoring of cognitive and behavioral development is essential.

Physical/Medical Consequences

Long-term medical problems may or may not occur following TBI. As with all TBI-related difficulties, the type and severity of difficulties will depend on multiple factors related to the nature and severity of the TBI. Potential problems include:

• Fatigue
• This can include lowered alertness and/or decreased endurance.
• This is often the most common complaint, particularly in the early period following recovery from TBI.

• Headaches/pain
• Particularly in the early recovery period, headaches may be a common complaint.

• Motor/coordination difficulties
• Slowed gross motor skills (e.g., slowed walking/running).
• Problems with fine motor dexterity (e.g., problems writing)
• Difficulties with coordinating complex motor tasks (e.g., problems engaging in sports-related activities such as batting, accurate throwing, catching)

• Seizures
• Children may develop seizures as a result of injury to brain tissue.
• Once correctly diagnosed, medications are often effective in managing seizure activity.

Cognitive Consequences

Cognitive difficulties experienced by children are similar to those observed in adults (see TBI Basics, Cognitive Symptoms). Specific symptoms may include problems with:

• Memory
• Encoding (learning) new information at the same rate as peers
• Being able to learn as much new information as peers
• Being able to recall/retrieve information that was encoded
• Retaining information as the complexity of the material increases

• Attention/concentration
• Sustaining attention for long periods of time
• Ignoring distractions (e.g., noise in the environment)
• Keeping focused on one task until it is completed
• Concentrating on visual information and/or auditory information

• Planning/Organization
• Organizing items in his/her environment
• Knowing where items are (e.g., books, homework)
• Organizing his/her time
• Effectively planning how much time is needed to complete tasks
• Planning a strategy for completing multi-step tasks
• Language
• Communicating by speaking and/or writing
• Being able to retrieve desired words to communicate thoughts
• Having fluid, fluent speech
• Writing difficulties (e.g., may be due to problems with expression, organization and/or manual dexterity)
• Comprehension of spoken and/or written language
• Having difficulties understanding a complex set of statements (e.g., multi-step instructions in class)
• Being able to make interferences based on discussions and/or information provided by others

• Thinking Speed
• Quickly comprehending information being presented
• Completing written assignments in class and at home
• Responding as quickly as his/her peers (e.g., to questions in class)

• Visual-Spatial difficulties
• Having difficulties with spatial orientation
• Understanding/recalling relative locations of places within the school
• Experiencing difficulties with visual tracking
• Following line across the page when reading
• Finding objects that have been misplaced

• Intellectual functioning
• For younger children (< 7 years), lowered global intellectual functioning (IQ) may occur
• For older children (8+ years), IQ may seem unchanged, except for slowed processing speed
• IQ may appear to “decline” with age due to a widening gap between the injured child and same-aged peers associated with slowed development

Behavioral/Emotional Consequences

Emotional and behavioral changes experienced by children with TBI are often one of the more significant sources of difficulties/stress in families and in school settings.

• Personality changes
• Families often report their child’s personality has changed
• The child may be seen as more or less outgoing, irritable, active, etc.
• The child may demonstrate changes in interests (e.g., loss of interest in previously enjoyed activities).

• Emotional distress
• Symptoms of depression and/or anxiety are not uncommon following childhood TBI.
• They may directly result from changes to the brain.
• They may reflect difficulties adjusting to difficulties since the TBI.
• Symptoms experienced may be influenced by circumstances surrounding the injury.
• Depression is the most common emotional reaction to TBI in older children and adolescents.
• Anxiety may manifest in general nervousness or restlessness in children of all ages.
• Adaptation to change in the person’s sense of self, or self-identity, can be a source of distress for older children and adolescents.

• Difficulties with Social Relationships
• Problems with skills associated with effective interpersonal communication, including:
• Turn-taking skills
• Use of appropriate eye contact
• Awareness of and respect for interpersonal space
• Awareness and appropriate use of non-verbal communication skills (e.g., gestures, facial expressions, body language)
• Difficulties understanding nuances in social relationships

• Executive function difficulties
• Problems inhibiting automatic (sometime inappropriate) responses
• Increased impulsivity in behaviors and decision-making
• Problems with judgment
• May lead to increased suggestibility (ability to be led or influenced by peers)
• Heightened emotional lability
• Increased irritability
• Problems with frustration/anger management
• Decreased motivation and/or interest (apathy)

Returning to School following TBI

When should planning begin for a return to school following TBI?

When a child sustains a mild TBI, treating healthcare providers may recommend a brief period of rest (e.g., lasting a week or less) prior to returning to school, particularly if the child is experiencing physical symptoms (e.g., headaches, dizziness). Contact with the school and the child’s teacher shortly after the injury occurs and then again prior to a return to school is essential so that the school is prepared to be alert for possible residual symptoms once the child returns to school

For children sustained a moderate to severe TBI requiring hospitalization and rehabilitation, preparations for returning to school may begin in acute inpatient rehabilitation or during outpatient rehabilitation. Schools may be able to provide educational materials that can be completed by the child in the rehabilitation program. Typically a gradual resumption of school work is recommended depending on the child’s progress. As treatment goals are met and therapies are phased out, the treatment team can make recommendations regarding therapies and accommodations that may be helpful in school setting.

Who should be involved in planning for a child’s return to school following TBI?

A successful return to school following a TBI is most likely to occur when there is coordinating planning by the treatment team, family members and school personnel working with a child with TBI. Decisions about the pace of resuming school activities, as well as what types of work should be attempted by the child at what points during recovery, are typically made by the rehabilitation team (e.g., physician, speech therapist, psychologist) in conjunction with the child’s family.

As the child approaches readiness to return to school, the rehabilitation team may provide specific recommendations regarding school-based interventions and accommodations. School personnel may be invited to attend a team meeting in the rehabilitation setting to discuss planning for the child’s return to school.

What can be done if the child has ongoing difficulties from the TBI?

Prior to returning to school, the treatment team can work with the parents and school in determining whether the child would benefit from an Individual Education Plan (IEP) or a 504 Plan. According to the Individuals with Disabilities Education Act (IDEA), cognitive and behavioral difficulties associated with the diagnosis of TBI qualify individuals for an IEP and special education services in public schools.

What information is contained in an Individual Education Plan (IEP)?

How is a 504 Plan different from an IEP?

A 504 Plan may be implemented if the child with TBI does not meet criteria for an IEP but could benefit from some accommodations within the school setting. Potential accommodations may include allowing extra time for the child to travel from one class to the next (to accommodate mobility issues), and reducing the number of items on tests (to accommodate slowed processing/motor speed).

Management Strategies

There are many different possible ways to help children with TBI function well in school settings. With assistance, children (particularly older children and adolescents) can learn to use compensatory strategies for their TBI-related cognitive difficulties.

In addition, there are numerous strategies that teachers can use to help a child with TBI. Because each child with TBI will have a unique set of weaknesses and strengths, it is essential that strategies are tailored to the child’s need. Potentially useful strategies may include:

• Strategies involving the classroom environment
• Ensuring the student is sitting near the teacher or the teacher's assistant.
• Adhering to a consistent schedule.
• Having well-defined sets of procedures for classroom activities.
• Relying on clear instructional routines.
• Maintaining a separate space where there are fewer distractions for the child to use during test-taking and/or seatwork.
• Minimizing clutter in the classroom and potential distractions.
• Providing a quiet place for children to go if they become over-stimulated.
• Providing scheduled rest breaks to assist with management of fatigue.
• Offering periods of small group instruction.
• Identifying specialized instruction strategies that can helpful for the child with TBI (e.g., errorless learning, direct instruction).

• Strategies related to the presentation of information
• Providing oral directions/instructions also as visual and/or written instructions.
• Offering regular clarifications/reminders as needed.
• Maintaining written agendas/”To Do” lists for the child, so that the teacher, child and parents can refer to this as needed.
• Presenting information in smaller “chunks,” with extra breaks if needed.
• Avoiding the presentation of information until the child and class are giving their undivided attention.
• Allowing the child to repeat the information/instructions to ensure he/she understood.
• Avoiding use of figurative language.

• Strategies for promoting good behavior
• Providing regular, ongoing feedback regarding class performance and behavior.
• Seeking opportunities to praise good work and behavior!
• Using a behavioral plan if needed, to reduce unwanted behaviors and promote positive behaviors.
• Providing opportunities for success, by ensuring that classroom expectations are appropriate given the child’s abilities, can promote self-esteem and good behavior.
• Analyzing task demands and environmental factors that may impact behavior.

• Other strategies
• Becoming knowledgeable about TBI, to promote effective interactions with the child and appropriate planning for school success.
• Working with the parents to provide them with support, to learn from them what strategies may be working in the home, and to understand as much as possible about the child
• Exercising consistent patience with the child.
• Ensuring expectations for the child’s academic and behavioral functioning match the child’s abilities.
• Continuing to modify strategies for working with the child, as well as the child’s IEP or 504 Plan, as his/her abilities and needs are likely to change over time.

Prevention of TBI in Children

The primary causes of TBI in children include sports-related injuries, falls, motor vehicle accidents, and intentional trauma (Shaken Baby Syndrome). The following are some strategies that can be used to reduce the risks of TBI in children:

• Enforce use of helmets. Activities/sports where helmets should be worn include:
• Bicycling
• Skateboarding, skating, rollerblading, riding scooters
• Sledding
• Skiing
• Football
• Hockey
• Horseback riding

• Make sure children play only where it is safe.
• Look for playgrounds that have soft surfaces (e.g., mulch, sand) underneath climbing equipment.

• Supervise young children while playing.
• Attend to safety in the home.
• Block off stairs with safety gates
• Ensure windows are secure (e.g., install window guards)
• Lock firearms and bullets in secure place when not in use.

• Promote safety in motor vehicles.
• Ensure infants and young children always use appropriate car seats.
• Use seatbealts.
• Keep children in the backseat of cars at least until age 13.

• To reduce incidence of SBS, promote training for parents in caring for their child and dealing with frustrations associated with parenthood.
• Healthcare providers can offer guidance.
• Programs such as Parents as Teachers in Missouri can be helpful.

Resources

Heads Up to Schools — Know Your Concussion ABCs

A component of the Centers for Disease Control Heads Up initiative, this flexible set of materials, developed for professionals working with grades K-12, will help you identify and respond to concussions in an array of school settings. http://www.cdc.gov/concussion/HeadsUp/schools.html

Heads Up - Concussion in Youth Sports
A component of the Centers for Disease Control Heads Up initiative, this provides important information on preventing, recognizing, and responding to a concussion. Information is available for coaches, parents, and athletes. http://www.cdc.gov/concussion/HeadsUp/youth.html

Heads Up – Concussion in High School Sports
A component of the Centers for Disease Control Heads Up initiative, this material is designed to help coaches, parents and athletes correctly identify and respond to sports-related concussions. http://www.cdc.gov/concussion/headsup/high_school.html

National Center on Shaken Baby Syndrome
This not-for-profit organization is dedicated to offering training to prevent the occurrence of Shaken Baby Syndrome. Training is aimed at professionals who work with SBS cases, as well as parents and those working with parents to prevent SBS. http://www.dontshake.org/

Child Brain Injury Trust
This is a charity within the United Kingdom offering support and education on the topic of brain injury in children. They have several publications written for children with TBI and for their families that can help with understanding and preparing for the experience of having a TBI. http://www.cbituk.org/information-children-young-people

LEARNet Problem Solving System and Resource Website
This website was developed by the Brain Injury Association of New York. Included on this website are lists of problem behaviors seen in children with TBI; these are connected to information about possible causes for these behaviors, as well as potential solutions. There are videos as well as written descriptions of common strategies for dealing with TBI-related cognitive and behavioral difficulties in children. http://www.projectlearnet.org/index.html