In your years of work and service, what is the most significant change in recognizing and treating pediatric ABI that you have seen?
The conventional thinking about pediatric acquired brain injury (ABI) used to be that the child’s brain was incredibly resilient to trauma, because it was much more “plastic” than the adult brain and could grow new cells and circuits that enabled the child to overcome the effects of brain injuries. This thinking turned out to be based on very little evidence. It was 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 (focal damage) in the motor cortex of their brains, the part of the brain responsible for generating skilled voluntary movements. From these studies professionals postulated that children just “bounce back” from brain injuries and that the “younger you are, the better you do.”
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, who followed the progress of human preschoolers and elementary school children, who suffered a brain injury of equivalent severity and charted their neuro-cognitive development over time. One of their 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 and that children younger than seven years old did worse over time than those who suffered a brain injury when they were older than seven. The research showed that the younger the child at the time of the brain injury, the more likely she would grow up with severe, permanent deficits. This is because the developing brain of the toddler is the very foundation of the intellectual house that will be built through preschool, grades K-12 and college. Significant damage to that foundation will cause big problems with the house erected upon it. The difficult part is that the damage may not be immediately apparent and will manifest itself sporadically at critical junctures of later life. Today, the longitudinal studies by Drs. Vickie Anderson, Harvey Levins, Goran Horneman and Ingrid Emanuelson, Linda Ewing-Cob and others have showed us that many “children with brain injuries grow to become adults with brain injuries.”
What do you think is the most important current need for children and youth with brain injuries?
In terms of injury versus disease, brain injury is still the leading cause of death and disability in most countries for children and youth (WHO). Many countries lack medical resources and long term supports for these young people and, even for those countries with good healthcare resources, there is most often a lack of coordinated care between medical facilities, schools, communities and families.
Our universal mission should be to Prevent, Identify, Treat and Cure brain injuries for all children and youth and their families. In addition, by an international group of experts, working with the Sarah Jane Brain Foundation, developed a set of Guiding Principles:
- Principle 1: Brain injuries can be prevented and controlled. Primary prevention entails preventing new injuries, secondary prevention involves reducing the severity of injuries, and tertiary prevention is decreasing the frequency and severity of disability.
- Principle 2: The developmental stage of the child/young adult at the time of injury and recovery across the lifespan must always be considered, and all treatments and interventions should be implemented by individuals with pediatric training and special expertise in brain injury.
- Principle 3: Providers and all professionals should adhere to the principles of family- and person-centered care, engaging the family and child/young adult themselves in a collaborative process for setting and achieving treatment goals.
- Principle 4: Early identification of brain injury is critical to improving long-term outcomes.
- Principle 5: Best clinical practices need to be determined based upon evidence from research and then standardized to be effective and efficient.
- Principle 6: Children’s recoveries are strongly influenced by their environmental contexts (home, school, community). Beyond early hospitalization, interventions to improve outcomes for children and young adults with brain injuries must occur in the settings in which children and young adults with brain injuries live and function (school, home, and community), and must involve the “everyday people” in these settings such as parents/caregivers, teachers, and peers.
- Principle 7: Interventions for children and young adults with brain injuries must acknowledge the overlap among different disability populations in terms of treatment needs and useful interventions.
- Principle 8: Research should use a variety of methodologies to examine hypotheses regarding recovery and intervention (prospective, naturalistic follow-up studies, randomized controlled trials, single subject experiments, qualitative studies, and animal models).
- Principle 9: Interventions for children with brain injuries occur at multiple levels (e.g., physical, medical, psychological, family, school, community) and across a continuum of care (e.g., acute care, rehabilitation, re-entry, and ongoing educational, social, and vocational life). Research on the effectiveness and efficacy of intervention should link both vertically (i.e., across levels) and horizontally (i.e., across the continuum of care), must follow children and families long-term, recognize that needs are likely to change over time, use functional outcome measures, and measure generalization to a variety of functional contexts of application.
- Principle 10: Interventions for children with brain injuries occur across a developmental spectrum that varies according to age at injury, time since injury, and age at intervention. The effectiveness and efficacy of any intervention may vary as a function of these developmental parameters because of critical variations both in neural developmental and environmental contexts.
- Principle 11: Proper brain injury training and education for future medical and educational professionals should be integrated into current graduate and medical school programs in order to ensure continuity of care is taught to those just entering the medical or educational profession.
What do think the future holds for care and treatment of children with ABI?
Firstly, we must focus our research efforts on finding a “cure” for brain injury, as well as investigate new treatments that embrace technology. For example, computer engineers are all ready researching and searching for ways in which to document an individual’s life. New memory devices are currently being developed in an effort to blend brain technology with computer technology. Of course this is only a research and development project right now, but hopes of coming up with programs that can organize photographs, paper records and other materials from the brain into a programmable computer that a consumer can run are high.
This would work like an external computer that will support an individual’s life history. There are many researchers now working on systems to records every conversation that a person has and send it to a computer database via text. Individuals with memory problems would definitely benefit from programs such as these. Those who want to pass down family stories may also see the light at the end of this tunnel. For those people with memory debilitating deficits and diseases this could be a dream come true. Imagine the possibilities of having all your memories recorded.
Another possible treatment is "Brain cap" technology which allows users to turn their thoughts into motion. Dr. José 'Pepe' L. Contreras-Vidal and his team at the University of Maryland have created a non-invasive, sensor-lined cap with neural interface software that soon could be used to control computers, robotic prosthetic limbs, motorized wheelchairs and even digital avatars. Dr Contreras-Vidal even feels we are on track to develop, test and make available to the public, within the next few years, a safe, reliable, noninvasive brain computer interface that can bring life-changing technology to millions of people whose ability to move has been diminished due to paralysis, stroke or other brain injury or illness.
At the neuro-cellular level, the work of Dr. Virginia Lee at the University of Pennsylvania, whose research provides the first direct and compelling evidence that tau fibrils alone are entirely sufficient to recruit and convert soluble tau within cells into pathological clumps in neurons, followed by transmission of tau pathology to other inter-connected brain regions. This new model of tau pathology spread provides an explanation to account for the stereotypical progression of Alzheimer's and other related tauopathies by implicating the cell-to-cell transmission of pathological tau in this process. Can we eventually “untangle” brain trauma?
The future of finding a cure for brain injury and treatment to reverse the effects of brain injury is in front of us. We just all need to continue to fight for the resources to fund brain injury research.
Bio: Ronald Savage
Dr. Ron Savage has worked with children, adolescents and young adults with neuro-developmental disabilities (i.e., acquired brain injuries, autism, developmental disabilities and other neurological disabilities) for over 40 years. He is currently the President of the Sarah Jane Brain Foundation. Dr. Savage is also Chairman and Co-Founder of the International Pediatric Brain Injury Society (IPBIS). He is the immediate Past Chair of Chairman of the North American Brain Injury Society (NABIS) and Editor of Brain Injury Professional. He is on the Board of Governors for the International Brain Injury Association (IBIA). Dr. Savage served as Executive Vice President for the Bancroft Neurosciences Institute and directed the pediatric services division for Bancroft NeuroHealth in New Jersey. He is the former Senior Vice President of Behavioral Health and Rehabilitative Services at The May Institute in Massachusetts and the former Director of Clinical Services for Rehabilitation Services of New York.
Dr. Savage has taught at the elementary and secondary school level as a special educator, as well as positions at several colleges and universities including Professor of Education (tenured) at Castleton State College, Clinical Professor of Neurology at the University of Medicine and Dentistry of New Jersey, and Associate Professor of Psychology at Rutgers University. He also held adjunct academic appointments at Tufts University, Department of Rehabilitation Medicine; Northeastern University, Department of Psychology; and The George Washington University, School of Education. Dr. Savage served on the Editorial Board of the Journal of Child Neurology. He was a Founding Member and Chief Examiner of the Academy for the Certification of Brain Injury Specialists (ACBIS).
Dr. Savage is the former Chairperson of the Pediatric Task Force for the Brain Injury Association of America; the past Co-Chairperson of the International Pediatric Task Force for the International Brain Injury Association; and serves on several professional advisory boards across the country. In 1989-90, Dr. Savage spearheaded the campaign to include traumatic brain injury (TBI) in Public Law 101–476: Individuals with Disabilities Education Act. He also worked with the Emergency Medical Services for Children (EMSC) training programs; the Office of Special Education and Rehabilitation Services of the United States Department of Education; the Professional Advisory Task Force for the National Council on Disability for the United States Congress; and the advisory board for the Traumatic Brain Injury Act.