Childhood (or paediatric) acquired brain injury (ABI) is the term given to any injury to the brain that occurs during childhood but after birth and the immediate neonatal period. It excludes injuries sustained as a result of genetic or congenital disorder. It also excludes those resulting from birth traumas such as hypoxia or conditions such as foetal alcohol syndrome. It encompasses both traumatic and non-traumatic (or atraumatic) injuries.
Pediatric acquired brain injury (PABI) is the number one cause of death and disability for children and young adults in the United States." and affects mostly children ages (6-10) and adolescent ages (11-17) around the world. The injury can be traumatic or non-traumatic in nature, and most patients never return to normal following the injury. There are many different symptoms such as amnesia, anhedonia, and apraxia. Currently there isn't a cure for the injury. PABI effects the family of the patient also, because the families of the patient will need to adapt to the new changes they will experience in their child. It is recommended that the families decide to gain as much information as they can about the injury and what to expect by going to different program events and meetings.
Traumatic injuries could include a blow to the head; gunshot; stabbing; crushing and excessive vibration / oscillation. This can be caused by shaking or sudden deceleration. Traumatic injuries might but do not necessarily have to involve an open wound or penetration of the skull or of the meninges - an 'open head' injury.
Non-traumatic injuries could include those caused by illnesses, such as tumours, encephalitis, meningitis and sinusitis. They could also be caused by infections such as septicaemia; events such as anoxia and hypoxia occasioned by strangulation or near drowning, lead toxicity, and substance misuse.
Symptoms and signs
Some symptoms that result from an acquired brain injury are amnesia, anhedonia, and apraxia.
Amnesia "Childhood amnesia is the inability to remember one's own childhood." Researchers found that some everyday activities such as speaking, running, or playing a guitar, cannot be described or remembered.
Anhedonia A child that is diagnosed with anhedonia would lack interest in some usual activities, such as hobbies, playing sports, or engaging with friends. It's very essential for a child to be able to enjoy fun childhood activities because it can help them build a social life, and easily interact with others. Not being able to do these things at a young age will only make it harder to adapt as the child gets older.
Apraxia
"Apraxia is the inability to execute learned purposeful movements, despite having the desire and the physical capacity to perform the movements." In this case, the child could have still have the memory of doing a usual activity such as riding a bike, but still not be able to accomplish the movement.
Prevalence and impacts The prevalence of ABI amongst school-aged children in the UK is estimated to be in the region of 1 in 30, based on admissions to A & E, although some professionals consider it to be much higher, as a child can be admitted to A & E with another more urgent injury, which is considered to be of overriding concern at the time.
It can be tempting to assume that an injury acquired in childhood is likely to have a more positive long term outcome than one acquired during adulthood. It could be assumed that a child or adolescent could have a better chance of developing compensatory strategies whilst still at the stage where significant development and learning is taking place. If the injury is in any way significant this is often not the case.
The inherent 'plasticity' of the brain can occasionally mean that areas damaged beyond healing can relocate their function to other undamaged areas (the so-called 'Kennard principle') and there are documented cases where this has indeed happened. However, it is frequently the case that the functions associated with the damaged areas never fully develop and these deficits can present as significant disabilities or difficulties in later life.
A significant proportion of the prior learning and the development of skills which has already taken place within an adult's brain can often be retained post injury. However, a brain at the earlier stages of development, if damaged, might never develop the capacity to learn those skills, leading to subsequent difficulties that could manifest themselves physically, socially, emotionally and educationally.
Neurocognitive Problems Delayed physiological responses post-TBI can lead to neurodegeneration in various parts of the brain in both chronic and severe cases in children. The parts of the brain that have been proven to be affected include: the hippocampus, amygdala, globus pallidus, thalamus, periventricular white matter, cerebellum, and brainstem. As a result, this can lead to behavioral and cognitive problems in child development. Behavioral changes have been characterized as "externalizing" and "internalizing" problems. Externalizing problems include different forms of aggression, hyperactivity, and impulsivity. The most common of these problems result from changes in attention and focus, such as ADHD. Internalizing issues include psychiatric problems such as short-term and long-term depression, anxiety, personality disorders, and post-traumatic stress disorder (PTSD). Several variables can determine the outcome of behavioral problems in children post-TBI. For example, children that are already have behavioral issues before injury are more likely to develop long-term cognitive problems. Another important factor is the severity of the injury, which can be a predictor of how long behavioral symptoms last and if they will increase over time.
Statistically about 54% to 63% of children develop novel psychiatric disorders about 24 months after severe TBI, and 10% to 21% after mild or moderate TBI, the most common of which is personality change due to TBI. The symptoms may last for 6 to 24 months on average. Development of PTSD is common (68%) in the first few weeks post-injury with a decline in the course of 2 years. In cases of severe TBI about one third of children develop depressive disorder. Children with severe TBI also have some effects on working memory, visual immediate memory, and more prominent consequences in intellectual functioning, executive functioning (including speed processing and attention), and verbal immediate and delayed memory. Some recovery is observed during the first 2 years post-injury. Children with moderate TBI only show some decline in attention and problem solving, but larger effects in visual immediate memory. The superior frontal lesions correlate with the type of outcome, but more importantly, subcortical network damage may affect the recovery due to the lesions in white matter tracts. Children with severe TBI are at higher risk for not achieving developmentally appropriate gains and not catching up with peers at school due to the crucial stage of learning at which their neural networks are disrupted by the injury.
Behavior In children and adolescents that have an acquired brain injury, the cognitive and emotional difficulties that come about from their injury can negatively impact their level of participation in home, school and other social situations. This puts the patient at a disadvantage because they won't be nearly as social, or able to participate in a school setting as an ordinary child would. Involvement in social situations is important for the normal development of children as a means of gaining an understanding of how to effectively work together with others. Group work is a huge factor in academics today, and the child's ability to work within groups will be ineffective. Furthermore, young people with an acquired brain injury are often reported as having insufficient problem solving skills. This has the potential to hinder their performance in various academic and social settings further. It is important for rehabilitation programs to deal with these challenges specific to children who have not fully developed at the time of their injury.
Potential general effects The effects can range from the relatively mild to the catastrophic but all will, to some degree, affect the child's ability to function within an educational and / or social setting. Educational attainment and quality of life indicators for young adult survivors of childhood acquired brain injury are significantly lower than those of an uninjured peer group.
Because a child's brain is a 'work in progress', deficits caused by an injury sustained at one age might not become apparent until much later, as the damaged areas become relevant to the child's expected developmental milestones. This is known as the 'sleeper effect' and where adults observing the child are unaware either of the injury itself or of the potential effects of an ABI, this can often lead to a misattribution of the failure to achieve academically and socially as 'laziness', 'teenage tantrums' and 'going off the rails'.
It is evident that damage to specific areas of the brain can result in whole areas of knowledge, skills and abilities being lost, sometimes irrevocably. However, it is also often the case that although some cognitive abilities can be left intact, (including the ability to retrieve, process and manipulate information) and much prior learning can remain, a child can be prevented from developing academically and socially because of other, more functional, deficits.
Potential social disadvantage There are many ways in which a child with an ABI can become socially disadvantaged and alienated from his or her peers following an injury and the following are only indicative of the problems that might follow reintroduction to their peer group.
A common sequela of brain injury is a much reduced ability to process information and therefore to respond to it promptly. This can mean that a child is unable to keep up with the conversational flow of a group of friends and can be slower than the rest of the group to pick up on jokes and 'banter', leaving him/her feeling frustrated and left behind. However caring and well meaning, the friends can also find it difficult to accommodate this new slowness into their usual give and take, resulting in the affected child being alienated and left out.
Another effect often seen as a result of damage to the vulnerable frontal lobes of a child's brain is 'disinhibition' or a reduced ability to inhibit an impulse to say or do something long enough to calculate whether it's the correct or appropriate thing to say or do. Research shows that adolescence is the time when the frontal lobe areas of the brain - the areas that govern the ability to manage one's behaviours - develop enough to allow a child to begin to 'grow up' and start to inhibit their initial impulses.
Disinhibition can lead to a child saying apparently hurtful or aggressive things to peers, leading to antagonism and embarrassment. It can also be the case that because of this, a child with an ABI will be less able to inhibit their responses to other provocations, such as adult authority, resulting in apparent 'bad' behaviour, leading their friends (or their friends' parents) to view them as unsuitable companions. Disinhibition can also lead to sexually harmful behaviour, particularly when coupled with a lowered sense of risk and danger and a child with a brain injury can often become vulnerable to exploitation by peers or by strangers.
A reduced ability to access and to process language and therefore to 'word find' appropriately can result in an increased inclination to use a more readily accessible word - such as a swear word or a more aggressive word - and this can obviously alienate and concern friends, who could interpret this as anger or aggression.
Potential emotional effects