The Developing Brain after TBI: Predicting Long Term Deficits and Services for Children, Adolescents and Young Adults

By: Ronald C. Savage, Ed.D., President, North American Brain Injury Society

Traumatic Brain Injury (TBI) is a leading cause of death and disability in children, adolescents and young adults around the world (WHO, 2009). It is also internationally recognized that TBI can have a negative impact on continued brain maturation and development in young people as they get older and grow into their adult years (Lehr and Savage, 1991; Klonoff et al, 1993; Anderson et al, 1997, 1999, 2000, 2004, 2005, 2009; Hanaoka et al, 1998; Savage, 1999; Benz et al, 1999; Ewing-Cobbs et al,1998, 2003, 2006; Chapman et al, 2001,2003, 2007; Jang et al, 2002; Poogi et al, 2003; Hawley, 2003; Jonsson et al, 2004; Bauer and Fritz, 2004; Yeates et al, 2005; Ducrocq et al, 2006; Horneman and Emanuelson, 2009). A particular challenge for physicians, clinicians and therapists is accurately predicting the long term effects of TBI on young people so that services and supports can be organized before deficits worsen and/or young people fail altogether. Understanding TBI in this population as a developing disability over time can help better manage this disease-like process. This article discusses current neuroscience research regarding brain development and the cumulative indicators related to TBI recovery in order to help professionals better predict the long term needs of children, adolescents and young adults with TBI.

Premise:   Young peoples’ brains are developing, maturing organs

Neuroscientists have learned what parents have always known, that the brains of children, adolescents and young adults are not static, but rather develop in leaps and spurts throughout childhood and well into the mid-twenties of young adulthood (Hudspeth et al, 1992; Somsen et al, 1997; Hanaoka et al, 1998; Evans, 2006; Waber et al, 2007).  In addition, physicians, clinicians and therapists now have the advantage of being able to “look inside the brain” using advanced neuroimaging technology (e.g., fMRI, MRI with DTI, PET) to better understand brain growth, maturation and functioning (Conturo, 1999; Gogtay et al, 2004; Evans, 2006), as well as specific brain damage after TBI. These studies have enabled us to further confirm the different developmental milestones that children, adolescents and young adults go through, and that these milestones are reached at various ages and stages in their lives. 

The significance of these findings for TBI treatment specialists (i.e., physicians, clinicians and therapists) is that it allows us to view brain damage resulting from TBI alongside typical brain development. As such, we can then investigate the relationship amongst various TBI deficits alongside the individual’s age and developmental stage at the time of the injury and project what this means functionally as the individual gets older. It further allows us to analyze the relationship amongst various brain regions (i.e., frontal, temporal, occipital, parietal, limbic, brain stem) that sustained specific damage and the resulting deficits (e.g., the relationship between frontal-temporal damage and executive functioning deficits) and, thus, prescribe services and supports for the individual in the future (e.g., job training, independent living supports, behavioral treatment). 

Current neuroscience research has identified that children, adolescents and young adults pass through five neuro-developmental stages between birth and 21+ years (Hudspeth et al, 1992; Somsen et al, 1997; Gogtay et al, 2005; Evan, 2006; Waber et al, 2007).   Chart 1 is a composite graph of research on brain development in young people and summarizes the percentage of brain maturation (i.e. brain growth, increased neuro-connections, pruning and refinement) for typically developing children, adolescents and young adults. 

CHART 1:


(Savage, 1999)

 

Table 1 reflects neuro-developmental stages and brain functioning

Newborn to 6 years:

  • During this period of overall rapid brain growth, all regions of the brain – those governing frontal executive, visuospatial, somatic and visuoauditory functions – show signs of synchronous development.
  • Children perfect such skills as the ability to form images, use words and place things in serial order.  They also begin to develop tactics for solving problems.

Ages 7 to 10 years:

  • The sensory and motor systems continue to mature in random up to about age seven and a half, when the frontal executive system begins accelerated development.
  • The maturation of the sensory motor regions that begins at about age six peaks just as children begin to perform simple operational functions such as determining weight and logical-mathematical reasoning.
  • By age ten, while visual and auditory regions of the brain mature, children are able to perform formal operations such as calculations and perceive new meaning in familiar objects.

Ages 11-17 years:

  • This stage primarily involves the elaboration of the visuospatial functions, but it also includes maturation of the visuoauditory regions.  Successive maturation of the visuoauditory, visuospatial and somatic systems reach their maturation peak within one-year intervals of each other.
  • Young people enter the stage of dialectic ability.
  • Youth in this age range are able to review formal operations, find flaws with them and create new ones.
  • Meanwhile, the visuoauditory, visuospatial and somatic systems of the brain continue developing.
Ages 18-21+ years:
  • During the final stage of childhood development, starting around 17-18 years, the region governing the frontal executive functions matures and continues into the mid-twenties.
  • Young adults begin to question information they are given, reconsider it and form new hypotheses incorporating ideas of their own, and developing a sense of self.
  • Young adults are planning to continue their education or training, work competitively, live on their own, actively participate in their community, have mature relationships with others, and become fully functioning adults in charge of their own lives.
(Savage, 1999)

 

In addition, neuroscience research has further identified that different regions of the brain (i.e., frontal-temporal region, temporal-central region, occipital-parietal region) have different periods of developmental maturation. While the brains of young people are developing in overall unison and harmony, certain brain regions have their own particular stages of growth and maturation. For example, the frontal-temporal brain regions have two peak maturation periods, from birth to age 6 years (e.g., think about the so-called “terrible two’s”) and also from 17-18 years into early adulthood.  Chart 2 below summarizes frontal-temporal brain region development in young people.

CHART 2:

 

(Savage, 1999)

Such information regarding neuro-development is particularly important when we evaluate infants, toddlers and preschoolers with TBI who have sustained injuries to their frontal-temporal lobes. For example, preschoolers with injuries to the frontal-temporal regions of their brains may look “medically fine” within a few weeks or months after injury (e.g., they can walk, talk, eat, sleep), however, as they get older and their brains mature, new cognitive, behavioral and motor deficits often emerge. When we consider that the greatest percent of brain maturation occurs in the child’s early years (Birth – 5 years), we can more fully understand that injury to a child’s brain before age 5 years often has devastating consequences because the injury occurred at a peak time in neurological maturation.  Consider the poor outcomes of infants and toddlers who suffer severe head trauma from being “shaken and impacted”, i.e. shaken baby syndrome (Berger, 2008).  Ewing-Cobbs and colleagues (2003) have proposed that recovery from severe brain injury may be limited to the skills that were already established at the time of injury.  Furthermore, the recovery of previously acquired skills may not necessarily ensure continued development of new and later emerging skills or skills in a rapid state of development at the time of injury (Andrews et al, 1998; Anderson et al, 2000, 2005; Chapman et al, 2001, 2004; Hanten et al, 2002, 2004; Ewing-Cobbs, Barnes and Fletcher, 2003; Antsey et al, 2004; Levin et al, 2004, 2005; Malec et al, 2006; Cole et al, 2008 ).  Lastly, young people, unlike adults, have limited cognitive reserve. Therefore, children who sustain TBI have little prior knowledge and/or prior life experiences to draw upon to support their recovery, especially cognitive and behavioral functioning, and develop compensatory strategies.

Premise: neuroplasticty is more complicated than we previously thought

We now understand from multiple longitudinal studies of young people with brain injuries (Lehr and Savage, 1991, Ewing-Cobbs et al, 1997; Hanaoka et al, 1998; Savage, 1999; Anderson et al, 1999, 2000, 2004, 2005; Chapman et al, 2001; Ewing-Cobbs et al, 2003; Yeates et al, 2005; Max, et al, 2006; Levin and Hanten, 2005; Gizza, 2005), that neuro-plasticity is much more complicated than we previously thought. The conventional thinking regarding TBI in young people was that the child’s brain was incredibly resilient to trauma because it was much more “plastic” than the adult brain, i.e., that other parts of the brain would take over for damaged parts. While neuro-plasticity may enable individuals to recover better from focal injuries (e.g., strokes, aneurysms, piercings), it most likely does not apply to more complicated brain injuries like diffuse brain injuries, shearing injuries, and injuries to multiple brain regions (e.g., frontal-temporal injuries).

Interestingly, the original thinking on neuro-plasticity was based on very little evidence.  It was originally published by Margaret Kennard in 1936 in the American Journal of Physiology and is known as the Kennard Principle.  Kennard took a group of chimpanzees and created lesions (i.e., focal damage) in the motor cortex of their brains, the part of the brain responsible for generating skilled voluntary movements.  After a period of brief observation, she found that younger chimps were more likely to recover their ability to perform a skilled action than the older ones.  She attributed this to the fact that the younger chimps were still growing.  Kennard developed her findings into a universal principle that she applied to human children and adults.  In retrospect, that research was hardly a solid basis for making the generalization that all human children were more likely than adults to overcome the cognitive, motor, emotional, psycho-social and behavioral consequences of a TBI.  Kennard noted later that, after long term observation of the chimps, the younger chimps she originally described as fully recovered, developed problems with spasticity and motor control later in their lives as their brains matured and then were required to perform more complex motor tasks. 

Beginning in the mid 1990’s, researchers began accumulating data that directly challenged the validity of the so-called Kennard Principle.  The data was acquired by such persons as Marjaleena Koskiniemi, Jeanette White, Barbara Benz and Cynthia Bealieu, Linda Ewing-Cobbs and Vicky Anderson who followed the progress of preschool and elementary school children who had sustained a TBI of equivalent severity and charted their neuro-cognitive development over time.  These studies showed that children younger than four years of age did worse over time than those whose TBI occurred when they were older than four years old. Furthermore, those children younger than seven years old did worse over time than those who suffered a TBI when they were older than seven.  Such research provided evidence that younger children were at the time of their TBI, the more likely children will grow up with severe, permanent deficits. 

We are also aware that as young people’s brains develop, the world around them also becomes more complex and sophisticated.  Learning in school becomes more difficult, social and behavioral expectations increase, and the adult world of competitive work, relationships and independence looms before young people.  In other words, if we thought algebra was challenging in secondary school, try marriage, and if we thought that history studies were difficult, try competitive work. Thus, traumatic brain injury needs to be understood as a “developing phenomenon” in young people and we need to compare and contrast current research on brain development in young people with current longitudinal research studies in TBI.

Premise: young people with TBI often fall further and further behind their peers

We are now recognizing that young people who have severe brain injuries may be at risk for manifesting a “neuro-cognitive stall” during a second phase of brain recovery.  This neuro-cognitive stall as defined by Chapman (2007) is a halting or slowing in later stages of cognition, social, and motor development beyond a year after brain injury.  Thus, despite sometimes remarkable recovery during the first year after a TBI, young people appear to “hit a wall” or plateau and not meet later developmental milestones.  In addition, this neuro-cognitive stall may emerge despite the individual seeming to have recovered cognitive abilities commensurate to one’s pre-injury level (Chapman, 2007). 

Chapman (2007) has graphically represented neuro-cognitive stall in Chart 3 by comparing normal brain development with latent stage brain development after TBI.

CHART 3:

 

(Chapman, 2007)

Understanding the long term deficits related to TBI in young people and recognizing that “recovery” after TBI has a vector-like trajectory (i.e., a moving and changing force) can help treating physicians, clinicians and therapists predict the supports services that the individuals and their families will need at different points in time.

Savage (2005) found similar profiles for children and adolescents with TBI by tracking and graphing their progress over several years. By comparing chronological age with intellectual age, various TBI profiles emerged that showed initial recovery curves followed by plateaus in functioning and, in some cases, further declines in functioning when compared to typically developing peers (i.e., mental and chronological age develop in tandem). Charts 4 and 5 below profile two children with TBI with different recovery curves.

Angelique was an above average student in school when she sustained a severe TBI at age 9 years, including injury to her frontal-temporal brain regions, in a motor vehicle crash. After extensive inpatient rehabilitation and outpatient services, Angelique returned to school. At first her prior knowledge helped her to keep up with her peers even though her performance was weaker than before her TBI. Yet, after several months her cognitive problems, particularly with attention, working memory, processing speed, and organization, were inhibiting her new learning and she started to fall further and further behind her peers. Angelique was placed in special education services for the remainder of her school years. The chart below represents Angelique’s learning trajectory over time.

CHART 4:

 

(Savage, 2005)

 

Mawan was slightly behind his peers in language functioning when he sustained a TBI at age 5 years, including diffuse injury, shearing injury and damage to his brain stem, when he fell three stories from his apartment complex. Mawan’s TBI was so severe that he continued to immediately decline after his TBI and had poor outcomes in cognitive, behavioral and physical functioning. Mawan’s school and family placed him in a private, post-acute brain injury rehabilitation program where he could receive intensive therapies every day to maintain his current status. The chart below represents Mawan’s learning trajectory over time.

CHART 5:

 

(Savage, 2005)

 

As Angelique and Mawan progressed over their school years, they both fell further and further behind their peers and new deficits emerged in their cognitive and behavioral functioning.

Summary

By using current neuroscience research regarding brain development in children, adolescents and young adults and correlating it with the cumulative effects of TBI, clinicians can better predict the long term needs and support services for this population. TBI in children, adolescents and young adults is a developing disabilitythat needs to be managed in order to avoid potentially worsening deficits.

 

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References for charts:

  1. reference for Charts 1 and 2, and Tables 1 
    Savage RC. The Child’s Brain – Injury and Development, Lash and Associates Publishing, Wake Forest, NC, 1999.
  2. reference for “neuro-cognitive stall chart”
    Chapman SB.  Neurocognitive stall: a paradox in long term recovery from pediatric brain injury.  Brain Injury Professional, 3(4): 10-13, 2007.
  3. reference for “neuro-developmental” charts from 
    Savage, Ronald C. “The utilization of allostatic load theory to predict long term deficits in children/adolescents with TBI” presented at North American Brain Injury Society conference. October, 2007. www.nabis.org.

Contact Information

Ronald C. Savage, Ed.D., President
North American Brain Injury Society (NABIS)
Chairman, International Paediatric Brain Injury Society (IPBIS)
480 West Euclid Ave
Haddonfield, NJ 08033
856.816.0427