Traumatic brain injury (TBI) among children is a significant health problem as indicated by the high rate of emergency department (ED) visits, hospitalizations, and deaths in the United States, as well as increased risk for long-term negative effects, such as changes in cognition and behavior, that can notably impact a child’s learning, school, and recreational participation [1-4]. Current methods of surveillance that rely on administrative healthcare datasets may underestimate the true prevalence of TBI among children because these data sources identify those seen for care in hospital settings, but do not capture those who seek care elsewhere or do not seek care at all. National parent surveys show that among the 6–17-year-old age group, 5.4 % of parents reported their child has a suspected TBI within his /her lifetime. In this group, 88.6% sought care from a physician or other healthcare provider [5].
When describing young children’s brains, many people have said “Their brains are “plastic”, and they will be “fine” after a traumatic brain injury (TBI). However, research is now reporting effects of a brain injury in infants, toddlers, and preschool children that shows that young children can have long term effects. The most we know about adult outcomes for children is that there is a high rate of a childhood history of TBI in those in the prison system, an outcome we do not want to see for children. Recent reports based on national TBI screening in the justice system estimate that the TBI prevalence among criminal justice-involved populations is between 44.6% and 60.0%, much higher than that of the general population [6,7]. Similarly, an examination of youth recently admitted to the justice system showed a high incidence of TBI (50% of males; 49% of females), which may have contributed to criminal justice system involvement [6,7]. While the association between TBI and involvement in the justice system is well-documented, less is known about why this relationship exists.
Currently much of the focus on children is about adolescents who experience a sports related concussion, partly because of Return to Play (RTP) policies enacted in all 50 US states. However, injury mechanisms vary across the age groups and include other mechanisms such as falls, struck by an object, and motor vehicle crashes [8]. The majority of concussions reported were sustained by children 6 years of age and older primarily via SRR activities, as previously reported; thus, concussion prevention in athletic settings is important to ensure safety for all children in sports and recreational activities. Importantly, these findings also show that approximately 30% of youth 0-17 years of age sustain concussions from activities other than sports [8].
Children younger than 5 years old have the highest incidence of emergency department visits for TBI at a time that is just beginning the development of cognitive, motor and sensory skills. The signs and symptoms in young children during the clinical assessment are different than those observed among older children since their symptoms are typically observed and reported by parents. Recent reports describe concussion symptoms in young children can include sleep issues, increased irritability and crying, vomiting, toilet training regression, decreased appetite, and headache [9]. The effects of early childhood TBI can include higher prevalence of chronic health conditions, education and therapy needs, and functional difficulties such as activity limitations and poor coordination [9].
Research has also indicated that a brain injury is a chronic health condition which is also reported in children with effects that can extend beyond initial medical care [10]. Most of what we learned was due to unmet needs [10,11]. Current services are insufficient because there is often a discrepancy between the need for pediatric rehabilitation and school services, receipt of those services, communication between models of care, and an inadequate understanding among parents about the need for therapy and educational support following discharge from acute medical care [3,4,12].
A challenge in the field is how to determine when children have fully recovered from their injury from a clinical, functional, and neurophysiologic perspective. Although long term studies of children are limited, emerging research demonstrates that TBI effects can persist throughout childhood and span into adulthood [4,7,13].
Compared with adults, children have the greatest risk for long-term consequences from a TBI. Their vulnerability for changes in brain development and neuropsychological impairment that impacts academic and social outcomes supports a critical need for follow-up care beyond the acute injury. There is an essential need to optimize coordination between healthcare and educational systems of care [3].
Providing education and supporting healthcare providers, caregivers, and teachers of children is critical not only to address the child’s medical and educational needs but also recognizing the unique challenges families face. Education is also needed for Emergency Department and Pediatric Physicians about diagnosis, education for parents and caregivers, and follow-up. We need to recognize that brain injuries occur in children, monitor them over time and ensure that care if provided when needed.
The author has previously received funding for pediatric TBI projects from NIDILRR and Children’s Healthcare of Atlanta. This commentary was written without funding.
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