Evaluation and Treatment Planning in Children with TBI

By: Enrico Castelli, MD, Bambino Gesù Children’s Hospital, Rome – Italy

Traumatic brain injury (TBI) is the most common cause of acquired disability in developmental age. Several epidemiological studies report that the incidence of TBI is approximately 200 cases in 100000 children. TBI in children is mild in 81% of the cases, moderate or severe in 14%, and fatal in 5%. Approximately 20% of survivors have severe disabilities. Given that TBI often produces life-long effects, it is certainly among the most important chronic neurologic illnesses.

Importantly, the survival rate of children who have suffered TBI is increasing, partly as a result of the improved acute and resuscitative medical and surgical treatment received immediately following the injury. The increase in the survival rate is accompanied by a corresponding increase in the morbidity rate, which leaves children with significant difficulties. The complexity of signs we have to deal with to perform a comprehensive assessment of injured adults and achieve rehabilitation is further complicated by the age factor in children  as it plays an important role. Frequently these problems are multiple and complex and have implications for the physical and scholastic achievement and social interaction of injured patients.

Cognitive Development

The development of intelligence requires progressive neuroanatomic pathways maturation and structural differentiation. The brain takes years to achieve functional maturity. Therefore, the effect of TBI can be different at different ages. Early brain lesions interfere with basic neuronal organization, neuroanatomic pathways maturation and structural differentiation; they determine a worse outcome compared to analogous lesions in adult people. Early brain lesions compromise the differential registration and detailed analysis of environmental sensory stimuli and the formation of comparative associations with similar past representations retrieved from widely distributed fragmentary long-term memory stores and with signals that represent the on-going elaboration of current autonomic/homeostatic states.

These complex functions require different brain lobes activity and an intricate series of anatomical interconnections basically linking the prefrontal cortex with the hippocampus of temporal lobes, the posterior parietal cortex and the neocerebellum and, more generally, connecting different cortical areas at a local, interregional and interhemispheric level. Indeed, these brain areas and their anatomical interconnections are impaired by multiple lesions caused by TBI, both by focal injury (that mainly involves the frontal and temporal lobes, regardless of the site of injury) and by diffuse injury (when the white matter of the corpus callosum, the internal capsule and the regions of the superior cerebellar peduncles are mainly involved). This results in impairment of cognitive development and of basic neuropsychological functions.

Psychological Disorders

Emotional and relationship disorders are often associated with TBI. Variables predicting new psychiatric disturbances in children with TBI include most importantly severity of injury, but also their pre-injury behavior, intellectual level and psychosocial circumstances. As reported in recent literature, other factors are important for predicting the onset of psychiatric problems, namely lifetime psychological disorders, family psychiatric history, family function, socio-economic class, pre-injury intellectual function and behavioral-adaptive function. The actual role of another possible predicting factor of psychopathology, namely the age at injury, is not clear.

However, neurobehavioural functions in children under 5 years of age are generally more compromised and difficult to define owing to the lack of standardized diagnostic instruments. The most frequent psychological disorders following TBI in children are attention deficit hyperactivity disorders (ADHD), oppositional defiant disorders, separation anxiety disorders, anxiety disorders, poor control of emotion (depressed mood and hypomania), and obsessive-compulsive disorders. An important component of morbidity after TBI in children may involve not only new psychiatric disorders, but the recurrence and/or exacerbation of pre-injury disturbances.

Family Involvement

The impact of TBI on family relationships is significantly correlated with perceived behavioral and affective symptoms and changes in the quality of life. It underlines the importance of providing relatives of TBI patients with information about the consequences of the injury. Particular emphasis must be given to behavioral and emotional disturbances so as to teach relatives how to better deal with them. Emotional disturbances generally cause more distress because they tend to persist longer than physical disabilities. During the acute phase family members often react with shock and denial. The first reaction is multifaceted: they oscillate between denial and expectation of full recovery to depression, as it becomes evident that deficits are long-lasting.

There are important psychological reaction differences between adult and child care-givers. While the adult post-traumatic care-giver experiences emotional, sexual, financial, family changes, the child care-giver often faces the loss of future hope and dreams. Shortly after injury, denying the patient problems may be a normal reaction to an intolerable situation.

However, self-denial may become a serious obstacle to family readjustment if it is not addressed during rehabilitation. Care-givers often develop dysfunctional family and community interaction by exclusively focusing on the child’s needs and isolating him from social life. When persistent, unhealthy coping strategies can compromise the interaction and mental health of all family members. Family therapy can often provide crisis families with helpful information, structure and support.

Multidisciplinary Evaluation

The clinical assessment, the rehabilitative program and the evaluation of sequelae after TBI require the use and the co-ordination of multiple competencies. Head injury evaluation in children is complicated by the contemporary development of cognitive and psychological functions and personality organization. Assessment and process of rehabilitation must be multidisciplinary, whereby specific problems are addressed by experts. A multidisciplinary approach permits a comprehensive assessment, facilitates the identification of main rehabilitative goals and makes the management of rehabilitative program easier.

The clinical evaluation consists in collection of clinical history, assessment of clinical features, neurophysiological recording, neuroimaging, sensory and perceptual evaluation, cognitive and psychological examination, in order to be tailored to the severity and complexity of the deficits. By no means does each child need an extensive multidisciplinary evaluation. The frequent presence in post-traumatic children of a sensory impairment, mainly of visual function, can determine sensory deprivation or, more often, input analysis alteration.

The processing of distorted sensory inputs may produce errors in the understanding of cognitive rules and concepts. Therefore, the sensory impairment may lead to a worse prognosis in relation to cognitive development. A neurophysiological and neuroradiological assessment provides important prognostic factors such as SEP alteration and brain lesion site and severity.

The backbone in the evaluation of cognitive disorders is a clinical assessment of the deficit first, and  then appropriate neuropsychologic and language tests that provide a quantitative score. A battery of psychometric tests must be selected that allows comparison of single item scores at different ages to verify the cognitive outcome, study the relationship between tests and specific brain areas and to verify patient's higher-order executive processes.

We must define the possible behavioral troubles and family and social relationships difficulties too. Mood, emotional and relational states are assessed by standardized tests, free game observation and clinical interview.

Rehabilitation Planning

Assessment is followed by the identification of main rehabilitative goals and then young patients begin training in different rehabilitative sectors.

In the acute phase rehabilitation of developmental and adult patients does not appear to be different. Nevertheless, we believe that it is fundamental that one of the parents, usually the mother, stays with the child. All team members, therapists, nurses and teachers must have a long-lasting experience of work with children. Moreover, rooms, rehabilitative areas and the different parts of the building must be furnished accordingly.

The main early rehabilitative goals are:

  • to wean patient from endotracheal and nasogastric tubes
  • progressive withdrawal of drugs used to control neurovegetative crises and drug management of possible behavioral disorders
  • drug management of epilepsy
  • to avoid sensory overstimulation of the patient but ensure a soft and affective environment, regulated by day-night cycles in order to facilitate the new acquisition of sleep - wakefulness rhythms
  • to avoid undesirable postures and secondary lesions such as muscular contractures, pressure sores and preserve muscular strength and a good joint range of motion
  • to provide patients with all useful facilities
  • to stimulate progressive awareness and start cognitive rehabilitation
  • to provide the family with psychological support.

Initially, the child is treated in bed but when the basic clinical features have stabilized, the patient is carried out of the room and rehabilitation continues in specific treatment rooms. Treatment and stimulation must not overload the child, because usually his attention and information processing abilities are reduced in span and duration.

Therefore, we must treat him more often every day for short periods. In successive phases, when the patient’s abilities are recovering, the main aim of rehabilitation is the achievement of the optimum level of recovery, compatible with lesions severity, and of a general well-being favoring re-entry into school and social environment as much as possible.

The rehabilitative techniques used and their main goals are as follow:

  • Physical therapy must achieve the maximum physical recovery and independence in ADL
  • Sensory and perceptual rehabilitation is mainly directed to neurovisual and low vision training, and multisensory stimulation. Children with post-traumatic lesions of the VIIIth nerve usually need low-hearing and balance training.
  • Speech therapy goals range from training in feeding, chewing and swallowing to rehabilitation of word articulation, augmentative communication, aphasia disorders, writing, reading and independent communication.
  • The cognitive training of children under 4 years of age or with severe intelligence deficits may lead to better results if psychomotor techniques are used that are oriented to sensorimotor training, basic spatial and time skills, and symbolic play. Children over 5 years need neuropsychological rehabilitation progressing from training of basic functions to integrated and independent use of cognitive functions. These goals can also be achieved using specific softwares, oriented both to facilitation of motor, communicative and sensory disabilities and to training of neuropsychological functions.
  • Occupational therapy mainly aims at improving the autonomy level, training in ADL, and adaptation to home and school places.

Furthermore, the child is put in small groups of peers with similar disability level. The group is managed by an educator, in collaboration with a psychologist with behavioral-cognitive competencies. This stimulating environment facilitates the recovery and the creative and integrated use of functions, reduces behavioral and relationships disorders and favors an increase in the child’s self-esteem. Even after less serious injuries family support and counseling, as well as medical care, become very important. The team must address the changing needs of the child during rehabilitation, and this can only be achieved if team members communicate and work effectively as a unit.

After the initial intensive rehabilitative treatment children are discharged and they re-enter into community and schools. The re-introduction into school should be well planned, with ancillary support if necessary. Usually, all patients need a follow-up throughout the developmental period, with periodic re-assessment of clinical features and outcome, and up-dating of rehabilitative planning. Different intensive outpatient rehabilitative periods are planned if the team members, after the follow-up, believe that they could be useful.  The same rehabilitative periods are organized even if the services near the child’s home cannot provide all necessary facilities.

In conclusion, TBI children have disorders that change over time and throughout clinical phases. In the acute phase, the patient mainly needs medical care, but then rehabilitation takes the first place. Over the years, the primary need of a post-traumatic patient is an existential project. The management of head-injured patients requires a co-ordinate and multidisciplinary team work. 

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