Traumatic brain injury, then and now. (research reflections).

Summertime, and the livin' is ... dangerous. Most children are home from school, and many zip along sidewalks and streets on bicycles, skateboards and in-line skates. So, too, do newly licensed teenagers and, presumably, seasoned drivers cruise the roadways. Accidents happen. And the result is often more than a sprained wrist or ankle.

The National Pediatric Trauma Registry in the United States tracks data on the more than 80,000 children who sustain trauma each year. According to Ronald Savage, an expert in traumatic brain injury (TBI), just as many children recorded in this databank sustained traumatic brain injury as fractures.

How many children suffer head trauma? A lot! Published estimates place the incidence of significant head trauma between 200 and 300 per 100,000 children and adolescents, or between 54,000 and 81,000 per year in the US. That number is probably even higher since symptoms of brain injury are similar to other categories in special education that are more familiar to school personnel. Many children with TBI are incorrectly classified by registries or databanks in special education as being learning disabled, developmentally disabled, emotionally disturbed or as having attention deficit hyperactivity disorder.

The term "traumatic brain injury" refers to a specific type of disability that occurs after birth (usually, but not always, due to accident or abuse); in fact, it is sometimes referred to as "acquired brain injury," as opposed to something with a genetic or "unknown" cause.

The consequences of TBI depend heavily on the type of injury, on the part of the brain where the injury occurred and on the age of the child. At one time it was assumed that children would recover better and more quickly if the accident occurred in early childhood, in the belief that brain plasticity would aid in recovery. Now it is recognized that younger children, ages birth to five years, have a more difficult time recovering because their brains are injured during a period of rapid brain growth and maturation. Indeed, since older adolescents and young adults have simply had a longer time living and coping with daily events, they have more practical knowledge and experience to help compensate for an injury to the brain. This new knowledge makes the fact that the majority of brain injuries occur in children under the age of 10 even more cause for concern. Incidentally, twice as many boys as girls sustain a traumatic brain injury.

What are some of the common causes of TBI? The national registry on brain injury, mentioned above, reports that most pediatric TBI injuries result from motor vehicle collisions (27.1%) and falls (26.5%), like the one Jack, and so many others in classic nursery rhymes, took. Yet the number of brain injuries resulting from bicycle accidents (9.7%) or sports (5%) is also daunting. In an infant TBI is usually due to either child abuse or a fall.

Do certain activities place a child at risk? Despite their propensity to recover skills more quickly, older children and youth are more likely to engage in sports, a widespread risk factor for head injury. In the old days, coaches and even parents were quick to dismiss head injuries as "bell ringers" or just as part of the game. Today we are well aware that playing sports can carry a risk of concussion, a mild form of brain injury. Football is not solely to blame, although it is certainly the main culprit. High risk is also associated with ice hockey, rugby, martial arts, soccer and horseback riding.

James Kelly and Ronald Savage have written eloquently about how best to evaluate concussions in sports, whether--or when--the athlete should re-enter the sport, and what parents and educators should be aware of when the athlete returns to play. Their report draws on data from the Centers for Disease Control and Prevention estimating 300,000 sports-related concussions in the US each year.

Kelly and Savage provide explicit guidelines for determining whether to return an athlete, or a child, to the game. For example, according to their guidelines, after a grade 1 or mild concussion, an athlete can be returned to play only if he or she is symptom-flee at rest, or symptom-free with exertion within 15 minutes of the injury. In a grade 2 or moderate concussion, the individual should refrain from sports for at least a week. In a grade 3 concussion, which is the most severe, there is typically a loss of consciousness; thus, return to play should occur after a minimum one-month recovery. However, there are exceptions and caveats even to these guidelines, allowing more or less rest and recommendations for follow-up examination.

In an extensive review of neuropsychology's contribution to understanding brain injury during sports, Ruben Echemendia and Laura Julian propose that neuropsychological tests may be more useful than traditional neuroimaging techniques because they can detect subtle losses in an athlete's attention and concentration. Echemendia and Julian also note that these traditional neuroimaging techniques, such as computerized tomography (CT) and magnetic resonance imaging (MRI), may not detect abnormalities, even when the injured child or his parents report somatic complaints or cognitive impairment following the concussion.

Most parents (and educators and coaches for that matter) are not aware of post-concussion syndrome, which refers to repeated concussions over an extended period of time. Obviously, the more frequent the concussions, the greater the likelihood that there will be neurological, cognitive and/or behavioral deficits in the child or young adult.

It is important that parents, teachers and other professionals who work with the child monitor his or her cognitive, behavioral and physical changes for six to eight weeks following an injury. Fortunately, with a first injury, no permanent negative effect is likely, and full recovery of the injured child is expected. But, because a child active in sports can have four or more different coaches during high school, parents must be responsible for being aware of their child's injury history and making sure each new coach is also kept apprised.

Does a child's "special need" immunize him at all from further traumatic brain injury? Sadly, no. In fact, some children with special needs are at even higher risk for injury than children in the general population. For example, children whose behavior is characterized by inattention, impulsivity, hyperactivity, highly disturbed reactions, aggression, irritability and/or depression are less likely to be tuned into what is going on around them. They are more likely to engage in risky or careless behaviors--such as stepping in front of a moving vehicle--which can lead to injury.

Researcher Jenny Sherrard and her colleagues in Australia recently published results of a large-scale study on injury risk in about 500 young people ages 4 to 18 years with an intellectual disability. The investigators used data collected across two time periods five years apart, which allowed them to calculate risk factors over time. Parents answered questionnaires about the child's development and behavior and about family functioning and economic status. The authors identified three risk factors highly associated with injury: having epilepsy, which increases the likelihood of falls; having clinically significant levels of behavioral or emotional problems; and having an overly sociable temperament (e.g., attempting more risky activities without a full understanding of the consequences). Clearly, acquiring a brain injury in addition to another disability constitutes a double-whammy for both the child affected and his parents.

How is the family affected by a traumatic brain injury? The caretaking environment provided by parents, the extent of family involvement in rehabilitation, overall family functioning and the appropriateness of a child's educational program upon re-entry to school are all paramount in determining the long-range impact of TBI. Several recent studies by a team of researchers at Case Western Reserve University and Ohio State University (led by H. Gerry Taylor, Keith O. Yeates and colleagues) report on both short- and long-term outcomes for children with TBI. In all cases, children who have moderate or severe TBI and were from socially advantaged homes (whereby parents have higher incomes, more resources and, potentially, fewer family stressors related to the parents' health or work) had lower risk of depression and lower rates of other new psychiatric disorders following injury. These studies determined that "environmental advantages" are critical for predicting positive outcomes in children after injury.

Furthermore, siblings seem to adjust well to having a brother or sister with a serious TBI, as reported in a study by Mary McMahon and her colleagues. These researchers hypothesized that siblings of affected children might have more "acting out" or behavior problems, as well as more "acting in" problems, such as depression or poor self-concept. However, their studies found that there were no significant differences in these areas when, 3 to 18 months after the original injury, the siblings were compared to their classmates. With only 12 siblings involved, this was a small, but clinically useful study. Is this really good news? You bet--because parents can be in control of providing a positive and supportive family environment for both the child with the TBI and any siblings.

Is it possible to pick up all the pieces after a traumatic brain injury? It is heartening to know that rapidly developing technology can better detect brain abnormalities and pinpoint areas of functioning--such as social skills, the management of emotions, mathematical processing and reading--that might be negatively affected. At a more practical level, rehabilitation and education efforts have also advanced, and there is growing awareness of TBI among public school personnel. Promising interventions used successfully with children with learning or cognitive disabilities also seem to work with TBI. For example, "self-monitoring" techniques taught to children with TBI have proven effective for increasing on-task behavior, task accuracy and even improving social skills. If Humpty Dumpty had lived today, it is likely that the neurosurgeons, psychologists, rehabilitation specialists and special education teachers would be pretty successful in putting him back together again.

A list of studies referred to in this Research Reflections may be obtained by e-mailing requests to: [e-mail].

Dr. Jan Blacher is a Professor in the School of Education at the University of California, Riverside, where she has been a researcher for more than 25 years. She is currently the principal investigator of the UC Riverside Families Project, a study of families of children with severe disabilities. Over 600 families have been involved in the Families Project research; their participation has contributed to our knowledge about family coping, the cultural context of retardation, dual diagnosis and the transition to adulthood. Dr. Blacher has developed Research Reflections as a forum for communicating exclusively with parents. The purpose of this column is to provide "news you can use." She is eager to read your reactions to Research Reflections and any suggestions you might have. Send e-mail to: [e-mail].