20Q: Addressing the Needs of Children and Teens with Traumatic Brain Injury

From the Desk of Ann Kummer

In the last decade, there has been increased attention in both the media and also among healthcare providers regarding the potential long-term effects of concussions following traumatic brain injury (TBI). Perhaps this began with the publication of multiple studies that found high rates of chronic traumatic encephalopathy (CTE) in former football players who experienced multiple concussions. Of course, football players are not the only ones who have long-term neurological disorders secondary to concussions. Children who experience TBI as a result of sports injuries or accidents also have concussions that result in neurological disorders. The common neurological sequelae of concussions include abnormal behavior, confusion, mood swings, problems with cognition, and communication disorders. Fortunately, Dr. Angela Ciccia, an expert on this topic, has agreed to answer our questions regarding the management of these residual issues in children and teens through this 20Q article.

Angela Ciccia, PhD, CCC-SLP is an associate professor in the Department of Psychological Sciences at Case Western Reserve University. Her research focuses on factors that impact children’s ability to develop communication skills in the presence of a developmental neurogenic disorder and also their ability to recover communication skills from an acquired neurogenic insult or injury. She is also interested in the use of novel service delivery models (including telemedicine) to enhance access to rehabilitation and support services for these children. Dr. Ciccia is the author of multiple research publications and book chapters on habilitation and rehabilitation of neurogenic disorders. She has also done numerous national presentations on these topics. In 2017, she received the Distinguished Member Award of the American Congress of Rehabilitation.  

In this 20Q article, Dr. Ciccia answers questions regarding the prevalence of TBI and concussion in children and teens, and the communication issues that occur as a result. She provides very valuable information about the treatment of these neurologically-based communication issues and the role of the speech-language pathologist in the rehabilitation process. I think you will really like this article!

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Addressing the Needs of Children and Teens with Traumatic Brain Injury

Angela Ciccia

1. How many children and teens have a brain injury every year? Are these mostly children with concussion?

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children and teens, impacting at least 1.8 million children annually in the United States (Haarbauer-Krupa et al., 2018). An estimated 283,000 are seen in emergency departments in the United States each year specifically for sports- or recreation-related TBI. Approximately 45% of these are sustained in contact sports. Many of these cases are relatively mild in nature (Sarmiento, K., Thomas, K., Daugherty, J., Waltzman, D., Haarbauer-Krupa, J.K., Peterson, A., Haileyesus,T., Breiding,M., 2019) Approximately 1:220 children and teens with TBI are seen for specifically mild TBI (Meehan & Mannix, 2010). While these are high numbers, it is assumed that these underestimate the true incidence of TBI as many do not seek care through emergency departments or medical centers.

2. Are there certain groups of youth that have the highest rates of brain injury? What are the most common causes?

The highest incidence rates for pediatric TBI overall occur in those who are 0-4 years of age, followed by those 15-19 years old (Haarbaurer-Krupa et al, 2018). In TBI of all severity, for children 0-4 years old, falls have been the most common mechanism of TBI followed by non-accidental trauma (i.e., abuse specific trauma). For those 15-19 years old, motor vehicle accidents have been the most common mechanism. Within mild TBI sustained from sport and recreational activities, males continue to have twice the occurrence of TBI and those aged 10–14 and 15–17 years having the highest rates in sports- and recreational-related TBI. This could potentially be related to higher participation in contact sports for males in this age range (Sarmiento et al, 2019). It is important to note that while many youth experience TBI during sports, injuries can occur in all type of recreational and daily life (i.e., play) activities.

3. What type of cognitive and language problems can children and teens have after brain injury?

There is a wide range of cognitive-communication challenges that occur after TBI, with deficits occurring in attention, memory, executive function, and language and social communication in higher demand contexts (e.g., conversation, reading textbooks, and situations with high social demand). It is also important to understand that these areas of deficit may not look as significant on structured, standardized assessment but become more apparent in everyday settings with multiple demands occurring at once (e.g., listening to a teacher, taking notes, and trying not to pay attention to the students sitting next to you that is tapping their pen). While the severity of these challenges is often directly related to severity of injury, it is possible for a person to have more severe cognitive-communication issues than would be expected based on TBI severity alone, likely because of the effect of compounding demands. Interventions should be targeted towards an individual’s specific profile of strengths and needs along with possible environmental modification of barriers that together would support improved performance (Togher et al, 2014).

4. Don’t most children who have had a concussion get better in a couple of weeks?

Children and teens recover in a different way than adults, which is thought to be related to neurologic and behavioral developmental issues. While adults often recover in about two weeks, children and teens often take about one month to recover with approximately 20-30% showing persistent symptoms for many months after injury and possibly longer (Davis et al, 2017).  Once a child or teen has symptoms over one month, it is important that they are seen by a concussion specialist (if they have not already done so) to guide the ongoing recovery process. It is important to note that very little is known about concussion and concussion recovery for children younger than 12 and therefore, how different age groups with TBI should be specifically treated has yet to be documented. Also, children and teens who have other areas of concern prior to the TBI (e.g., language-learning disability, ADHD, anxiety) are at risk for prolonged recovery and should be monitored more closely.

5. It seems like there is a lot of focus on high school athletes in the TBI literature. What do we know about other groups?

There is an overall paradox in pediatric TBI. On one hand, TBI in childhood has a high incidence rate. On the other hand, there is very little assessment and intervention research in TBI for children under 12 years of age which makes evidence-based service provision challenging (McCrory et al., 2017; Ludine, Ciccia & Brown, 2019; Sarmiento et al, 2019). Additionally, we know that children who experience a mild, moderate, or severe TBI before entering formal schooling are not likely to be identified in preschool settings or to receive support services at least 1 year after injury (Haarbauer-Krupa, Lundine, DePompei, & King, 2018) meaning that children could have unidentified TBI-related problems at the time of school entry.

6. Why would a speech-language pathologist need to be involved with children and teens with mild TBI?

The current standard of care of pediatric TBI uses an interdisciplinary team approach (Lumba-Brown et al, 2018) that can include physicians, nurses, athletic trainers, allied health professionals (physical therapy including vestibular and balance therapy, occupational therapy, speech-language pathology), neuropsychologist, educators, and intervention specialists. Based on the scope of practice and preferred practice patterns, the speech-language pathologist is uniquely suited to optimize social and academic success for the cognitive, language, and communication challenges that can occur after pediatric TBI. Additionally, speech-language pathologists are often in natural environments for children and teens (i.e., school) where environmental modifications to support the student’s success is so important.

7. Is it true that speech-language pathology services after brain injury should be provided in a medical setting like an outpatient hospital clinic?

While it is true that medical management is the initial focus for TBI intervention (Lumba-Brown et al, 2018), this part of the recovery journey represents only a small component of the recovery processes.  After a child receives medical services, the child will return to school and will actually spend more time in an academic environment during their recovery process than in a medical setting.

School speech-language pathologists have a unique advantage in that they can provide intervention within a child’s functional environment which is thought to be an important component for intervention when someone has cognitive challenges (Togher et al, 2014). In fact, using the functional environment is a central tenant of evidence-based cognitive rehabilitation (Sohlberg & Turkstra, 2011). In the school environment specifically, a speech-language pathologist is a vital member of the team who can help to create the individualized education plan (IEP), provide cognitive-communication assessment and treatment, lead education and training regarding cognitive-communication deficits for educators and parents, and advocate for students during the return-to-learn process (Coreno & Ciccia, In press). Additionally, the school-based speech-language pathologist is in a unique position to be able to monitor a student with TBI especially given the changing demands of the school environment over time.

8. Are there a lot of co-occurring language and learning needs in children and teens who sustain a TBI?

Yes, it does appear that in the pediatric TBI population broadly there is a high co-occurrence of pre-existing learning disabilities of many varieties including Attention Deficit Hyperactivity Disorder, headache, and mental health concerns such as anxiety and depression. This co-occurrence can complicate recovery so that those with these conditions have a protracted recovery requiring more medical, rehabilitative, and educational interventions (Haarbauer-Krupa, J., et al, 2018a). Additionally, a new on-set of co-occurring conditions is also common after TBI.

9. Are there differences in the types of difficulties children have depending on their age at injury?

Historically, it has been thought that the earlier a child sustains a TBI the better than the outcome. However, we now understand that there appear to be critical windows during which sustaining a TBI could lead to worse outcomes.  For example, the early and middle teen years represent an important developmental window for the pre-frontal cortex (an area with major contributions in attention, memory, and executive function). When a TBI occurs during these years, cognitive skills are especially vulnerable when compared to the same injury occurring either at a younger or older age.

10. What are the resources available that focus on explaining evidence-based interventions for children and teens with TBI? 

The CDC published evidence-based guidelines on the diagnosis and management of pediatric mild TBI in 2018 (Lumba-Brown, et al. 2018). These recommendations list five major points:

1. Not routinely imaging pediatric patients to diagnose mild TBI
2. Using validated, age-appropriate symptom scales to diagnose mild TBI
3. Assessing for risk factors for prolonged recovery
4. Providing patients with instructions on returning to activity customized to their symptoms
5. Counseling patients to return gradually to non-sports activities after no more than 2– 3 days of rest.

To help implement these recommendations, the CDC created educational tools that are available at https://www.cdc.gov/HEADSUP.

Additionally, a consensuses statement on Concussion in Sport was created at the 5^th International Conference on Concussion in Sport held in Berlin (McCrory et al, 2017; details below). The Oratorio Neurotrauma Foundation has created the Living Guideline for Diagnosing and Managing Pediatric Concussion which can be found at: https://braininjuryguidelines.org/pediatricconcussion/.

The area of pediatric TBI has been receiving increased attention in both research and clinical practice and so best-practices are updated regularly; therefore, it is important for speech-language pathologists working with children and teens with brain injury to review resources for updated guidelines regularly.

11. What is the difference between return-to-activity/play and return-to-school/learn protocols?

Return to play is a set of guidelines that are directed toward gradually increasing physical activity without causing increases in concussion symptoms such as headache, vision changes, and fatigue. While completing a return to play protocol, children and teens are monitored closely for worsening symptoms, and the plans are then adjusted specifically for the individual.

Return to school guidelines are similar in that it follows a titrated return to activities without causing an increase in concussion symptoms, but in this case, the focus is on academic activity. As in return to play, the student is monitored for worsening symptoms with increasing academic demands, and the plan is adjusted accordingly.

The most current recommendations indicate that children and teens should not fully return to play until they have successfully returned to school (e.g., Davis et al, 2017).

12. What is the current return-to-school/learn protocol?

The 2017 Concussion in Sport Consensus Group published current return-to-school (RTS)/learn guidelines (McCrory et al., 2017). Overall, there are four stages in the RTS process that should occur for at least a 24-hour period before returning to school. These guidelines are as follows:

• A brief stage of rest during the acute phase, that is the first 24-48 hours after injury
• Daily home activities (e.g., reading, writing, screen time) that do not give the child symptoms beginning for 5-15 minutes as tolerated without symptom exacerbation and working up to typical home activities
• School activities outside of the classroom (e.g., homework, reading) gradually increasing tolerance for activities
• Return to school part-time that includes the graduate introduction of school work which maybe include partials days and/or increased breaks during the school day gradually increasing tolerance for activities
• Return to school full time by gradually increasing time in the classroom (i.e., reducing breaks or modified attendance) until a full academic schedule is achieved and work is caught up

The RTS process is often carried out by an interdisciplinary team that can include the managing physician, athletic trainer (where applicable), school nurse, teacher/s, school psychologist, speech-language pathologist, social workers, intervention specialist, OT and PT (for visual and vestibular concerns), and the student and the parent/caregiver. The RTS process includes daily check-ins and symptom reporting along with regular classroom observations/monitoring to verify self-report. The time to complete the RTS process can vary widely from 1-2 weeks to months depending on the students. For some students, a prolonged RTS process will trigger a referral for evaluation for full special education support.

13. What types of assessments should speech-language pathologists use for cognitive-communication assessment after pediatric TBI?

Assessment should include both formal (e.g., standardized assessments) and informal (e.g., patient interview, observation) age-appropriate measures to determine the impact of higher-order cognitive and cognitive-communication deficits in functional environments. Standardized assessments that are familiar to speech-language pathologists that can be used for children and teens with TBI include a comprehensive language assessment such as the Comprehensive Assessment of Spoken Language-2 (CASL-2) paired with measures of cognitive performance such as the Behavior Rating Inventory of Executive Function-2 (BRIEF-2) and Student Functional Assessment of Verbal Reasoning and Executive Strategies (Student FAVRES). Informal assessments can include classroom observation (e.g., observing a student’s notetaking during lecture or the student’s participation in a group activity) and comparison of pre- and post-injury academic work (see Coreno & Ciccia, In Press for additional details). Additionally, the Cognitive-Communication Checklist for Acquired Brain Injury (CCCABI) is a useful screener for this population.

14. What is the current evidence-based practice recommendations in the area of family/caregiver focused interventions?

In a recent systematic review (Laatch et al, 2019), family and caregiver focused interventions were found to have a high level of evidence and should be considered a “core” component for pediatric TBI intervention. These interventions take a variety of forms, but overall involve specific education and training for “everyday people” who are directly engaging with the child with TBI to support cognitive and emotional control issues that can be persistent post-TBI. These interventions focus on educating and coaching the family to modify the environment and their own behaviors to best support their child/sibling with TBI. Interestingly, many of these interventions were designed to be conducted via telehealth.

15. What are the current evidence-based practice recommendations in the area of attention interventions?

The Laatch et al. (2019) systematic review identified that direct attention training, specifically Attention Process Training (APT), should be considered a practice standard in pediatric TBI intervention. APT is a structured program that is clinician-led and computer/technology supported (lapublishing.com). It should be noted that this standard should be applied to moderate-severe TBI as not enough testing is yet available to determine its application to a mild TBI population. 

16. What are the current evidence-based practice recommendations in the area of memory interventions?

The Laatch et al. (2019) systematic review identified the Amsterdam Memory and Attention Training for Children (AMAT-C) as a practice standard for pediatric TBI intervention. This approach uses process-specific attention and memory training paired with metacognitive strategy training. The AMAT-C has also been studied in the school setting.  Additionally, the Strategic Memory Advanced Reasoning Training (SMART) focuses on enhancing gist reasoning intervention and has shown positive improvements, although listed as a practice guideline rather than a practice standard because of the level of evidence.

17. What are the current evidence-based practice recommendations in the area of executive function interventions?

The Laatch et al. (2019) systematic review identified the use of the Counselor Assisted Online Problem-solving (CAPS) Intervention as a practice standard. While these studies were conducted in an online format, it would be reasonable to apply this to traditional treatment. Additionally, metacognitive skills/strategy training (defining the problem, generating alternatives, implementing strategies, evaluating the outcome; Goal-Plan-Do-Review) was considered to be a practice guideline. Additionally, Goal Management Training (GMT) has emerging positive evidence in pediatric TBI and so could be reasonably applied in this population.

18. What types of school accommodations are used after TBI?

After TBI, students may present with a variety of challenges in the classroom. This could include difficulty responding quickly during classroom discussion, completing real-time written material (e.g., writing prompts, notetaking, and open-ended response options on exams), understanding complex and abstract classroom discussions, meaningfully contributing to group assignments that are completed during class, and difficulty managing real-time social interactions (Coreno & Ciccia, In Press). Academic accommodations should strive to address these challenges. Examples include the use of self-paced learning, organizational and external memory aids, breaking assignments into smaller chunks, use of a notetaker, speech-text support for writing activities, and modified assignments. The most important component of the accommodations is that they are individualized, and flexible, to address the student’s needs throughout recovery.

19. Do all children and teens with TBI need to be in special education?

No, not all children and teens need special education in the form of an Individualized Education Plan following their TBI (Haarbauer-Krupa et al, 2018b), rather many that require support longer than one month after their TBI could benefit from a 504 plan. For some children, informal academic accommodation and modification may only be needed for a short period of time and therefore would not warrant either a 504 or IEP. Regardless of severity, it has been documented that all children and teens with TBI benefit from a coordinated transition from medical to educational services. Unfortunately, this does not always happen and can hamper the outcome (Haarbauer-Krupa et al, 2018b).

20. As a speech-language pathologist, should I be looking for ways to expand services for children and teens with TBI in my community and if so, how can I do that?

Yes! Overall, children and teens with TBI report a high level of unmet and unrecognized need with about 20-30% of parents reporting unrecognized or unmet need even long after the initial injury (Haarbauer-Krupa et al, 2018a). Pediatric speech-language pathologists can educate other professionals and advocate for this population in their institutions and community to help address this service gap. Medical and school speech-language pathologists who work within the same community can partner together to try to identify barriers and opportunities that would be workable with available resources.  Additionally, speech-language pathologists can consider how to improve identification of youth with TBI to help ensure that all children who need services are able to obtain access.

​References

Brown, J, O'Brien, K, Knollman-Porter, K, & Wallace, T. (2019). The Speech-Language Pathologists' Role in Mild Traumatic Brain Injury for Middle and High School–Age Children: Viewpoints on Guidelines From the Centers for Disease Control and Prevention. American Journal Of Speech-Language Pathology, 28(3), 1363-1370. doi: 10.1044/2019_ajslp-18-0296

Coreno, A & Ciccia, A (In Press). Supporting students with TBI: A clinically-focused tutorial for Speech-Language Pathologist. Seminars in Speech-Language Pathology.

Davis, G, Anderson, V, Babl, F, Gioia, G, Giza, C, & Meehan, W et al. (2017). What is the difference in concussion management in children as compared with adults? A systematic review. British Journal Of Sports Medicine, 51(12), 949-957. doi: 10.1136/bjsports-2016-097415

Haarbauer-Krupa, J, Lee, AH, Bitsko, RH, Zhang, X, & Kresnow-Sedacca, M (2018a). Prevalence of parent-reported traumatic brain injury in children and associated health conditions. JAMA Pediatrics, 172(11), 1078. https://doi.org/10.1001/jamapediatrics.2018.2740

Haarbauer-Krupa, J, Lundine, JP, DePompei, R, & King, TZ (2018b). Rehabilitation and school services following traumatic brain injury in young children. NeuroRehabilitation, 42(3),259–267. https://doi.org/10.3233/NRE-172410

Laatsch, L, Dodd, J, Brown, T, Ciccia, A, Connor, F, & Davis, K et al. (2019). Evidence-based systematic review of cognitive rehabilitation, emotional, and family treatment studies for children with acquired brain injury literature: From 2006 to 2017. Neuropsychological Rehabilitation, 30(1), 130-161. doi: 10.1080/09602011.2019.1678490

Lumba-Brown, A, Yeates, KO, Sarmiento, K, Breiding, MJ, Haegerich, TM, Gioia, GA, Timmons, SD (2018). Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatrics, 172(11), e182853. https://doi.org/ 10.1001/jamapediatrics.2018.2853

Lundine, J, Ciccia, A, & Brown, J (2019). The Speech-Language Pathologists' Role in Mild Traumatic Brain Injury for Early Childhood–, Preschool–, and Elementary School–Age Children: Viewpoints on Guidelines From the Centers for Disease Control and Prevention. American Journal Of Speech-Language Pathology, 28(3), 1371-1376. doi: 10.1044/2019_ajslp-18-0295

McCrory, P, Meeuwisse, W, Dvorak, J, Aubry, M, Bailes, J. & Broglio, S et al. (2017). Consensus statement on concussion in sport—the 5^th international conference on concussion in sport held in Berlin, October 2016. British Journal Of Sports Medicine, bjsports-2017-097699. doi: 10.1136/bjsports-2017-097699

Meehan, WP, & Mannix, R (2010). Pediatric concussions in United States emergency departments in the years 2002 to 2006. The Journal of Pediatrics, 157(6), 889–893. https://doi.org/10.1016/j.jpeds.2010.06.040

Sarmiento, K, Thomas, K, Daugherty, J,  Waltzman, D, Haarbauer-Krupa, JK, Peterson, A, Haileyesus, T, Breiding, M (2019). Emergency department visits for sports- and recreation-related traumatic brain injuries among children – United States, 2010-2016. MMWR Morbidity  Mortality Weekly Report. 68:10, 237-242.

Togher, L, Wiseman-Hakes, C, Douglas, J, Stergiou-Kita, M, Ponsford, J & Teasell, R et al. (2014). INCOG Recommendations for Management of Cognition Following Traumatic Brain Injury, Part IV. Journal Of Head Trauma Rehabilitation, 29(4), 353-368. doi: 10.1097/htr.0000000000000071