Traumatic Brain Injury

Description

Other Names

Acquired brain injury
Post-concussion syndrome

Diagnosis Coding

Injuries to the head are reported using the ICD-10 S01 thru S09 codes [see Coding for Head Injuries (icd10data.com)] and exclude birth-related injuries. The following focus on brain injuries and their sequelae (indicated by the suffix "S").

ICD-10

S06.xxxS, Intracranial injury (multiple types specified by x’s), sequela

S09.8xxS, Other specified injuries of the head, sequela

F07.81, Postconcussional syndrome

Z13.850, Screening for traumatic brain injury

Z87.820, Personal history of traumatic brain injury

Coding details under S06 for the numerous types of intracranial injury can be found at  Coding for Intracranial Injury (icd10data.com).

Description

Traumatic brain injury (TBI), a form of acquired brain injury, can result when the head suddenly and violently hits, or is hit by, an object or when an object pierces the skull and enters brain tissue; the latter are called “open” injuries. TBI may result from motor vehicle accidents, sports accidents, falls, assaults (including child abuse), or gunshot wounds. TBI does not include injuries resulting from a tumor, stroke, primary hypoxia, degenerative disease, etc.

TBI is often classified as mild, moderate or severe, based on assessments at the time of presentation and during acute recovery over the first few weeks following the injury. Details can be found below under Clinical Classification. The correlation between severity and short- and long-term outcomes is variable, though poorer outcomes are generally associated with greater severity of acute injury. Hypoxia secondary to the injury and prolonged post-traumatic amnesia (PTA) are specific risk factors for more severe longer-term impact.

Sequelae of TBI range from very mild, inconsequential, and transient to severe, debilitating, and life-long. The more serious and persistent sequelae include cognitive deficits, behavioral and emotional disturbances, impacts on motor and sensory function, and somatic symptoms such as headache, fatigue, sleep disturbance, and chronic pain.

Prevalence

Inconsistent definitions of TBI and severity and lack of definitive diagnostic criteria make it difficult to determine the true incidence of TBI in children and the prevalence of long-term sequelae. Nevertheless, Zaloshnja et al. estimated that 145,000 US children (1 in 564) suffered long-term disability from TBI in 2005. [Zaloshnja: 2008] Using their varying estimates across age groups and adjusting for typical age distribution in pediatric practice [Bocian: 1999], the estimated prevalence of children with such sequelae in a pediatric practice is 1 in 3190.

The causes of TBI vary by age, with inflicted injuries being most common in infants, falls in children 0-4, and motor vehicle accidents in older children and adolescents (see Figure 2). Of all diagnoses of TBI in children, 96.6% are mild [Graves: 2015], as are 32% of those hospitalized for TBI. [Bowman: 2008]

The estimated incidence of pediatric hospitalizations associated with TBI in 2005 was 72.7 per 100,000. [Bowman: 2008] However, a prospective study published in 2008 found the average incidence of TBI in individuals 0-25 years, both hospitalized and non-hospitalized, to be 1.1-2.4 per 100 per year, higher than previous studies have suggested. [McKinlay: 2008]

Impact
Worldwide, TBI is “the leading cause of child death and long-term disability and among the most frequent causes of interruption to normal child development.” [Dewan: 2016] The median acute hospital cost for children 0-14 with TBI is around $8,000 [Hu: 2013]; higher for older adolescents. When compared with other injuries of similar initial acuity, the long-term care costs for TBI are higher regardless of the level of severity (mild to severe). [Schneier: 2006]

Figure 1: Rates of TBI-Related Emergency Department Visits by Age Group - United States, 2001-2010
Rates of TBI-Related Emergency Department Visits by Age Group - United States, 2001-2010
[Centers: 2017]

Figure 2: Percent Distributions of TBI-Related Emergency Room Visits by Age
Group and Injury Mechanism - United States, 2006-2010
Percent Distributions of TBI-Related Emergency Room Visits by Age Group and Injury Mechanism - United States, 2006-2010
[Centers: 2017]

Genetics

Though there are no known genetic associations with the occurrence of TBI, initial studies have identified genes that may influence recovery. An extensive study looked at the apolipoprotein (APOE) gene, which is thought to play an important role in synaptic repair, remodeling, and neuron protection. [Kurowski: 2012] In addition, studies in animals suggest that estrogen may play a role in recovery from TBI. [Asl: 2013] [Naderi: 2015]

Prognosis

The degree and impact of post-TBI disabilities depend on the extent of the injury, the area of the brain affected, and the age and general health prior to the injury. Recovery after childhood TBI relies on a number of complex and interrelated factors, making outcome difficult to predict and highly variable. [Beauchamp: 2013] Mild injuries generally result in few, if any, impairments, but complicated mild (clinically mild but with skull fracture or intracranial hemorrhage on CT scan), moderate, and severe injuries can cause a variety of cognitive deficits, including in intellectual function, attention, memory and learning, executive function, language, and visual motor skills. These deficits cause problems with functional skills and can affect educational and vocational abilities, especially in the post-acute period. [Beauchamp: 2013]

Most patients with a mild TBI will experience resolution of symptoms over time, however a subset of patients will have persistent somatic, cognitive, sleep, and emotional symptoms classified as post-concussion syndrome and may require outpatient follow-up. [Morgan: 2015]

Kerr, Zuckerman, Wasserman et al. (2017) conducted a cohort study from sports injury surveillance data identifying factors associated with post-concussion syndrome (PCS) among high school student-athletes, [Kerr: 2018] from which they drew the following practical implications:
  • The specific symptoms endorsed by high school athletes following concussion may be more important than total symptoms in determining risk of PCS; athletes who endorse symptoms of memory, concentration, sleep, balance, noise, and visual difficulty may have a higher chance of developing PCS than those who do not.
  • Contact level of the sport was not relevant in predicting the odds of PCS; PCS is seen in all athletes, both high- and low-contact sports.
  • Our findings, coupled with previous research, may suggest that high school student-athlete populations may have a greater prevalence of PCS than college student-athlete populations; thus, special attention should be given to the rigorous academic schedule and resources available to high school student-athletes in their return to school after a concussion.
While most mild injuries result in relatively few impairments, the impact of brain injury in children under 2 years of age may be easier to identify later in the toddler years making it important to screen this population regularly prior to school entry. [Pomerleau: 2012]

The more comorbidities a child has, the lower their functional status will be after TBI. The most common comorbidities are mental disorders, such as anxiety, post-traumatic stress, and depression. [Zonfrillo: 2013] Emotional, behavioral, adaptive and social difficulties are common in TBI survivors and have major implications for long-term and adult outcomes . [Beauchamp: 2013] However, “…the vast majority of children suffering TBI achieve a good clinical outcome.” [Dewan: 2016]

Roles Of The Medical Home

Important roles of the medical home for patients with TBI include:
  • Assuring continuity of care by evaluating the needs of the patient and the family before and after discharge from the hospital or rehabilitation facility
  • Coordinating care with multiple providers to optimize the value added by each, minimize duplication of tests and unnecessary treatments, and enhance patient/parent understanding and engagement.
  • Providing prescriptions for medications and therapies. Advise patients/parents to avoid all medications other than those prescribed by you or a referring physician and to make certain all providers have an up-to-date list of current medications, including over-the-counter and other substances (e.g. herbal remedies). Work with the patient's rehab specialist to determine therapy prescription needs and who is responsible for them.
  • Helping the family identify local, state, and national resources
  • Providing letters of medical necessity for resources and referrals
  • Listening to parents and helping them cope with problems as they arise

Practice Guidelines

No guidelines for management of children with TBI following discharge from the initial hospitalization have been published. The guideline below is for acute care of children with TBI:

Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, Carson S, Chesnut RM, Ghajar J, Goldstein B, Grant GA, Kissoon N, Peterson K, Selden NR, Tasker RC, Tong KA, Vavilala MS, Wainwright MS, Warden CR.
Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition.
Pediatr Crit Care Med. 2012;13 Suppl 1(Jan):S1-82. PubMed abstract

Helpful Articles

PubMed search on rehabilitation and management of traumatic brain injury in children: articles over the past year

Brands I, Stapert S, Köhler S, Wade D, van Heugten C.
Life goal attainment in the adaptation process after acquired brain injury: the influence of self-efficacy and of flexibility and tenacity in goal pursuit.
Clin Rehabil. 2015;29(6):611-22. PubMed abstract

Dewan MC, Mummareddy N, Wellons JC 3rd, Bonfield CM.
Epidemiology of global pediatric traumatic brain injury: qualitative review.
World Neurosurg. 2016;91:497-509.e1. PubMed abstract

Goldsworthy R.
The effect of traumatic brain injury on caregivers.
Spotlight on Disability Newsletter. 2015; (March). American Psychological Association; http://www.apa.org/pi/disability/resources/publications/newsletter/201...

Rashid M, Goez HR, Mabood N, Damanhoury S, Yager JY, Joyce AS, Newton AS.
The impact of pediatric traumatic brain injury (TBI) on family functioning: a systematic review.
J Pediatr Rehabil Med. 2014;7(3):241-54. PubMed abstract

Clinical Assessment

Overview

Because the initial evaluation and management of the injury are generally accomplished in the inpatient setting and the diagnosis is rarely in question, this section will discuss ongoing assessment, including of potential secondary sequela. The approach will vary depending on the severity of injury, the age of the child, and the presence of pre-existing and co-morbid conditions.

Pearls & Alerts

Predicting recovery

Although it is difficult to predict the extent of recovery in a child soon after a TBI, Time to Follow Commands (TFC), a standard measure of injury severity performed during the inpatient stay, was found to predict self-care, mobility, cognitive, and overall function at time of discharge from inpatient rehabilitation. [Suskauer: 2009] The Children's Orientation and Amnesia Test (COAT), also administered as an inpatient, includes assessment of PTA. [Ewing-Cobbs: 1990]

Repeated concussion

Over the last decade, it has become evident that successive concussions, as well as repetitive sub-concussive blows, have lasting physiological effect. [Choe: 2016] A history of concussion increases an individual’s probability of having a future concussion and prolongs the duration of significantly abnormal cognitive functioning. [Shrey: 2011] Research suggests "that cumulative exposure to sub-concussions, defined as 'a cranial impact that does not result in known or diagnosed concussion,' can lead to neurocognitive deficits and structural and functional brain abnormalities detected on advanced neuroimaging studies.” [Ellis: 2016] [Bailes: 2013]

Screening

For Complications

Standard developmental screening for deficits in development, learning, problem solving, and general functioning may identify subtle sequelae/deficits or problems that the family attributes to other causes. See Developmental Screening Tools (AAP)

Standard mental health screening tools should augment the general clinical assessment and focused surveillance questions. [Beauchamp: 2013] Information and tools related to screening and assessment for these concerns can be found on these Portal pages:

Presentations

New onset or changes in behavior or mood that suggest conduct disorder or mood disorder (depression/anxiety), change in academic performance, or sleep disorder may be due to distant sequelae from a TBI, though they may not be readily recognized as such. Cognitive testing by a speech therapist/pathologist or neuro-psychologic testing may be helpful to differentiate potential causes. Onset of seizures has been reported up to 10 years after a TBI.

Clinical Classification

No formal classification exists for the longer-term sequelae of TBI. Acutely, TBI is often classified as mild, moderate, or severe, based on assessments in the first days or weeks following the injury. The Glasgow Coma Scale (GCS) is the gold standard for primary assessment, based on level of consciousness. Duration of loss of consciousness/coma and the severity of symptoms also contribute to the severity assessment. Duration of post-traumatic amnesia (PTA), characterized by a loss of memory for events surrounding the injury, disorientation, confusion, and significant cognitive impairment, offers further assessment of severity. Resolution of PTA in the pediatric patient is defined as achieving two consecutive passing scores on the Children’s Orientation and Amnesia Test (COAT). (See [Ewing-Cobbs: 1990] and [Iverson: 2002]; the latter includes the COAT questions and response norms by age).

Table 1 below integrates the several factors used to determine severity of brain injury. Mild TBI, can be further classified as uncomplicated or complicated, the latter having skull fracture or intracranial hemorrhage on CT scan. A diagnosis of mild TBI does NOT require loss of consciousness. [Management: 2009]

The World Health Organization (WHO) Collaborating Centre Task Force on Mild TBI states that key criteria for identifying persons with a mild TBI include at least one of: confusion, disorientation, loss of consciousness less than 30 minutes, post-traumatic amnesia (PTA) for less than 24 hours or other transient focal neurologic abnormalities, and a GCS score of 13 to 15 after 30 minutes of presentation to a health care facility. [Centers: 2015]

Most patients with a TBI will experience resolution of symptoms over time, however a subset of patients will have persistent somatic, cognitive, sleep, and emotional symptoms classified as post-concussion syndrome and may require outpatient follow-up. [Morgan: 2015]

Table 1: The Management of Concussion Adapted from VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury
The Management of Concussion Adapted from VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury
Source: [Management: 2009]

Comorbid Conditions

Cognitive dysfunction, mood disorders/anxiety, ADHD, hemiplegia, muscle spasms, seizures, and conduct disorder are known sequelae of TBI and may persist indefinitely. In general, these disorders should be managed as they would from any cause, with consideration of cognitive abilities and executive functions. Specific cognitive deficits to address include:
  • Attention
  • Learning and memory
  • Executive functions, such as planning and decision-making
  • Language and communication
  • Reaction time
  • Reasoning and judgment

History & Examination

The aims of the initial post-discharge assessment are to determine the extent of the trauma, obtain details about the inpatient course, evaluate current problems and functioning, and to develop a plan for management. This can take some time, particularly if the primary care clinician was not involved in the inpatient stay.

Family History

Is there a family history of neurological conditions? Any family members who have experienced TBI? This may offer insight into prior knowledge and understanding of the condition and may elicit fears or optimism to guide ongoing education and communication.

Pregnancy Or Perinatal History

Primarily relevant to help identify possible pre-existing neuro-behavioral deficits.

Current And Past Medical History

Background: explore pre-existing problems, particularly previous brain injury and/or seizures. Did the child have developmental delay, psychiatric or behavioral problems, or cognitive problems before the injury? Did the child have a baseline ImPACT assessment prior to the injury?

Related to the acute injury, the following details may help you understand the injury and its impact on the child and family:
  • What were the circumstances surrounding the trauma?
  • What was the nature of the injury?
  • Was the injury witnessed?
  • Did the child lose consciousness? For how long?
  • What was initial Glascow Coma Scale?
  • What, if any, other injuries did the patient suffer?
  • Did the patient have any seizures at the time of injury?
  • What treatment was given post-injury?
  • Was a CAT scan or MRI performed?
  • Were C-spine films done?
  • Was the child admitted to an ICU? If so, for how long?
  • Was the child intubated? If so, for how long?
  • Did the child receive inpatient rehabilitation? If so, for how long?
  • What is the first thing the child remembers after the accident?
  • Did the child receive a cognitive evaluation (usually by a Speech/Cognitive Therapist)?
Since discharge from the hospital:
  • What medications is the child taking?
  • Ask the child and then the parent by what percentage has the child returned to pre-injury status? What is hindering the child from being 100%?
  • Ask them to prioritize the top three challenges and delve into each for clarification.
ImPACT (Immediate Post-Concussion Assessment and Cognitive Test) is a computerized test administered by a licensed professional and is commonly used in sport-related concussion. Although you may not be able to administer the full ImPACT, the following questions will assist in focusing the assessment and developing the treatment plan:
Is the child having
  • Headaches (if present, consider evaluation by an optometrist with experience in TBI)
  • Nausea
  • Vomiting
  • Balance problems
  • Dizziness
  • Trouble falling asleep
  • Fatigue
  • Sleeping too much
  • Sleeping too little
  • Drowsiness
  • Light sensitivity
  • Noise sensitivity
  • Irritability and agitation
  • Sadness
  • Feeling nervous
  • Feeling more emotional
  • Numbness or tingling
  • Feeling too slow
  • Mentally “foggy”
  • Difficulty concentrating
  • Memory problems
  • Visual or reading problems (if present, consider evaluation by an optometrist with experience in TBI)
Functional status (assess relative to child's age and condition):
  • Eating; is the child having difficulty maintaining or gaining weight?
  • Bathing
  • Dressing
  • Bowel/bladder function
  • Fine motor skills
  • Mobility
  • Communication and comprehension
  • School and developmental milestones
  • Which therapies is the child receiving?

Periodic screening for mental health problems may be very useful. (See Depression , Initial Diagnosis and Anxiety Disorders, Initial Diagnosis for screening tools.)

Developmental And Educational Progress

Assess educational status before and after injury for the following:
  • Grade/school/academic program
  • Presence of physical, emotional, or learning challenges
  • Receiving special accommodations or modifications (504, IEP plans)
  • Level of academic performance. Assess for changes.

Maturational Progress

Assessment of pubertal status is important, particularly for understanding the social impact of any resulting disabilities. [Webb: 2014] [Casano-Sancho: 2017]
  • Have menses begun or resumed since accident?
  • Was the adolescent sexually active prior to injury?
  • Is the adolescent sexually active now? Is birth control/protection being used?

Social And Family Functioning

Psychiatric disorders after TBI are correlated with pre-injury family functioning, family socio-economic class and functioning, and a family history of psychiatric problems. [Rashid: 2014] A family history of mood disorder, migraine, and other psychiatric illness increases the likelihood of post-concussion syndrome. [Morgan: 2015]

Are there medical or social challenges that may hinder the parent in providing for the ongoing needs of the child? Is there a history of depression, alcoholism, etc. in the child or family that might hamper recovery? Is there family support available? Ask about school and relationship problems (within the family and with peers).

Physical Exam

General

Assess mental status, including wakefulness, alertness, interaction, ability to follow commands in an age-appropriate manner, attention span for age, and memory. Assess speech and language: Are expressions of wants and needs and response to circumstances age appropriate? Compare current exam with previous exam. Except as related to associated injuries, aspects of the exam not mentioned below should be normal.

Vital Signs

Blood pressure

Growth Parameters

Ht | Wt | BMI

Extremities/Musculoskeletal

Look for contractures, assess range of motion.

Neurologic Exam

Perform developmentally-appropriate exam with special attention to:
  • Tone, especially spasticity,
  • Strength,
  • Reflexes,
  • Gait/posture,
  • Balance and coordination

Testing

Sensory Testing

Obtain or review hearing and vision screens; repeat if concerns arise.

Imaging

Review previous scans. Although a non-contrast CT scan indicates the presence of hemorrhage or edema, MRI provides a much clearer picture and shows subtle changes. Imaging needn't be repeated unless the patient has acute changes in mental status. Note: MRI/CT scans look at structural anatomy of the brain and spinal cord. Subtle and/or chemical changes may not be radiographically evident and functional changes may not be reflected on the MRI/CT. Focus should be on the functional status which may evolve over time. In general, imaging results will not alter the treatment plan. [Haghbayan: 2016]

Other Testing

Consider EEG if seizures are suspected after the first week post-injury (note, the longer the patient goes without a seizure, the less likely he/she is to develop post-traumatic seizures).

Subspecialist Collaborations & Other Resources

Pediatric Physical Medicine & Rehabilitation (see Services below for relevant providers)

Often helpful in monitoring physical, emotional, behavioral issues, spasticity and generally key to devising and implementing a rehabilitation plan.

Pediatric Neurology (see Services below for relevant providers)

As needed for the treatment of seizures, may also follow patients with traumatic brain injury, depending on local expertise.

Pediatric Orthopedics (see Services below for relevant providers)

As needed for orthopedic issues relating to spasticity or injuries.

Pediatric Gastroenterology (see Services below for relevant providers)

As needed for problems related to feeding.

Speech - Language Pathologists (see Services below for relevant providers)

To evaluate language, content, memory, speech, and feeding-related functions.

Occupational Therapy, Pediatric (see Services below for relevant providers)

To evaluate visual perception and processing, handwriting, upper extremity strength and coordination, activities of daily living and fine motor skills.

Physical Therapy (see Services below for relevant providers)

To evaluate gross motor function, balance, lower extremity strength and coordination.

Educational Advocacy (see Services below for relevant providers)

To assess learning disabilities and develop a plan for re-integration into school.

Neuropsychiatry/Neuropsychology (see Services below for relevant providers)

To assess cognitive abilities. Sometimes available during initial hospitalization, often not done until 3 to 6 months post traumatic injury and repeated every 2 to 3 years as needed.

Pediatric Ophthalmology (see Services below for relevant providers)

Refer to an ophthalmologist or optometrist with experience in evaluating children with TBI if headaches, reading, or vision are identified as problems.

Treatment & Management

Overview

The need for intervention (physical, emotional, cognitive, educational) in children with TBI should be reassessed periodically as the patient recovers cognitively, physically, and from other post-injury problems, such as headaches and attention deficits. A pediatric physiatrist (Physical Medicine and Rehabilitation physician, we currently have no Pediatric Physical Medicine & Rehabilitation service providers listed, please search our Services database for related services) can help coordinate a multi-disciplinary team.

The focus of care for children following TBI is to restore independence in mobility, communication, and self-care (feeding, grooming, toileting) through rehabilitation. Rehabilitation should be consulted early (even while the patient is in the intensive care unit) to begin planning care based on the extent of injury, the family situation, and available resources. Early and regular communication between the rehab team and the primary care physician can optimize follow-up and outcomes. Follow up with primary care should occur one to weeks after discharge from the hospital.

Pearls & Alerts

Depression is common after TBI

Up to 50% of brain-injured children present with specific behavioral problems and disorders, which may emerge shortly or several years after injury and often persist and even worsen with time. [Li: 2013] The frequency varies with age at brain injury and the degree of injury. [Beauchamp: 2013] Depression following TBI may appear as a deterioration in ability and should be considered in follow-up visits by the medical home. A child with previous mental health issues will likely have greater need for mental health services than before the injury. [Max: 2015] Jimenez et al. found that Hispanic children were less likely to receive needed mental health services. [Jimenez: 2017]

Initial family education

In the emergency room, the focus for children with concussion or mild TBI is often ruling out more serious injuries. Having found none, children and families may be discharged without education on consequences of mild TBI, such as changes in mood and/or concentration, learning problems, headaches, and sleep problems. Follow-up with a physiatrist or neurologist, depending on local expertise, can be helpful. [Yeates: 2009] [Taylor: 2015] [Scholten: 2015]

How should common problems be managed differently in children with Traumatic Brain Injury?

Growth Or Weight Gain

Assess for and monitor weight gain/status in the child with any mobility impairments. While a childhood obesity screen (Childhood Obesity ) is helpful, it is important to also look at endocrine function as a causative factor for weight gain.

Development (cognitive, motor, language, social-emotional)

Ongoing developmental assessment is important as “Brain injury affects the process of development. Abilities that are just emerging are very vulnerable; therefore, are most likely to be disrupted. Skills established a one stage form the foundation for later-developing abilities, a brain injury acquired early in life can affect the appearance of skills at later periods of life.” [Dise-Lewis: 2002]

Common Complaints

A number of problems, common in children in general, may be signs/symptoms of TBI-related sequelae and deserve focused attention:
  • Physical:
    • Headaches
    • Sensitivity to light and noise
    • Visual changes
  • Cognitive:
    • Difficulty with school, usually related to difficulty with memory and impaired executive functioning (initiation, planning, organizing, paying attention)
  • Behavioral:
    • Increased frustration
    • Short fuse
    • Decreased tolerance
    • Difficulty with sibling relationships
  • Sleep:
    • Difficulty initiating and maintain sleep
    • Fatigue from lack of sleep

Systems

Neurology

Attending to neurologic sequelae of TBI is the primary focus of acute and long-term management.

Establish S.A.F.E guidelines:
  • Sleep: 8-10 hours of sleep per night, and rest breaks in the daytime. Avoid screen time 1 hour prior to bed.
  • Activity: Initially your child will need rest, and to “keep two feet on the ground” until cleared by a physician. While the child gradually increases his or her activity, caution to avoid re-injury is important. Recommended activities during recovery include taking walks, playing board games, spending time in a chair. If the activity causes headaches or other symptoms, return to previous level of activity.
  • Food/Fluids: It is important to stay hydrated while the brain is healing to help prevent headaches and dizziness, drinking enough to keep their urine clear. Encourage a healthy diet of lean protein, whole grains, fruits/vegetables and limit processed/high sugar foods.
  • Environment: Provide a calm, quiet environment. Monitor overstimulation and tolerance of the environment. Set limits for total screen time during recovery.
Return to driving:
  • If the adolescent has a driver’s license or learner’s permit, return to driving needs to be discussed and seatbelt use reinforced.
  • The parent may want to provide supervised driving practice to assess reaction time and judgement.
  • If visual changes or deficits are present, these should be addressed before driving.
  • If the adolescent developed seizures that are being treated with an antiepileptic, a neurologist will need to make recommendations for return to driving.
  • Consider a driving evaluation from a specialized occupational therapist. If deficits are identified, the physician may need to complete a functional driving evaluation.
Address residual health problems:
  • Headaches: common following a head injury. While the duration of headaches is unknown, it is a potential symptom of post-concussive syndrome, which can potentially last 12-24 months, and is the most common acute post-injury symptom. Following the SAFE guidelines is a conservative but effective treatment for headaches. While exposure to light and noise can trigger or exacerbate headaches a plan for progressive tolerance to these stimuli needs to be established. [Starkey: 2018]
  • Vision: monitor for decreased visual acuity, diplopia, strabismus, visual field deficits. Visual changes may also be due to cortical injury and resulting decreased convergence. Vision therapy, with a specialized OT or optometrist with training in neuro-vision services, may be useful. Review hospital/clinic records for previous screening.
  • Hearing: refer to an audiologist for concerns about conductive or sensorineural hearing loss. Review hospital records for audiology screening.
  • Spasticity: patients may have varying degrees of spasticity from damage to the motor areas of the brain or descending white matter tracts. The primary care physician should monitor progress and coordinate care with the family and physiatrist.
  • Seizures: Anticonvulsants are generally discontinued a week after injury if no new seizures are reported. The risk of post-traumatic epilepsy is 7-12% for up to 10 years following TBI. [Krach: 2015] The more severe the injury the more likely the patient will develop seizures. For detailed information to help with those patients with persistent seizures, see Seizures/Epilepsy.

Subspecialist Collaborations & Other Resources

Pediatric Physical Medicine & Rehabilitation (see Services below for relevant providers)

Children with TBI should be followed by physiatry, and associated therapies, as well as their medical home to optimize recovery and treat complications.

Pediatric Neurology (see Services below for relevant providers)

Consider a referral to pediatric neurology for seizures or intractable headaches.

Pediatric Ophthalmology (see Services below for relevant providers)

Refer to ophthalmology for visual problems.

Audiology (see Services below for relevant providers)

Refer to audiology for hearing deficits.

Physical Therapy (see Services below for relevant providers)

Physical therapy is an important part of the rehabilitation process.

Occupational Therapy, Pediatric (see Services below for relevant providers)

Occupational therapy will help the child relearn activities of daily living following TBI.

Speech - Language Pathologists (see Services below for relevant providers)

Children should be referred to speech/language therapy after TBI if they have problems with aphasia, attention, etc.

Musculoskeletal

Hypertonicity (spasticity and dystonia): Children with spasticity due to TBI may develop contractures. The management of spasticity includes both surgical and non-surgical interventions. If spasticity is severe, it may interfere with the child's functional abilities, make hygiene difficult, and cause discomfort. These may result from the spasticity itself or from secondary contractures and pressure sores. Spasticity may worsen when the patient is ill or upset. Treatment, generally provided by a physiatrist-led team, includes therapies and orthopedics. Realistic expectations are key to successful therapy.

Non-surgical interventions may include:
  • Therapies - physical and occupational.
  • Positioning aids (to help the child sit, lie, or stand) - if the child isn't sitting by him/herself, a corner chair, tumble form, wheelchair, or other positioning aids enable a seated position for feeding and optimal hand use during play and activities of daily living (ADLs).
  • Braces and splints to prevent deformity and to provide support or protection. May be used during the day or night to provide stretch and optimal positioning across joints.
  • Wheelchairs, either manual or power, may be needed for mobility.
  • Standers/walkers to allow standing (weight bearing may help prevent osteoporosis, allow full lung expansion, stretch hamstrings, and allow children to be on-level with peers) and supported walking (for those needing help with balance and support for walking).
  • Medications:
    • Oral: although oral antispasmodic agents may cause excessive sleepiness, they are often tried because they are non-invasive. Examples are baclofen (Lioresal), tizanidine, diazepam (Valium) or clonazepam (Klonopin). Valium before sleep is helpful in some patients and may not cause daytime drowsiness. [Mathew: 2005] Despite limited experience in pediatrics, modafinil (Provigil) [Murphy: 2008] and tizanidine (Zanaflex) may improve function of children with spasticity. Doses should be titrated to avoid weakness and excessive hypotonia.
    • Injections: botulinum toxin A (Botox) or (Dysport) and phenol injections are used to treat and prevent contractures that lead to tight ankles (difficulty walking) and hygiene problems (hip adduction contractures). These injections are usually combined with physical therapy, splinting, or casting to optimize impact. [Pattuwage: 2017]
Surgical interventions may be used to manage the complications of spasticity or to decrease spasticity and/or dystonia:

Subspecialist Collaborations & Other Resources

Pediatric Orthopedics (see Services below for relevant providers)

Children with spasticity after TBI should be referred to orthopedics for management of spasticity and related orthopedic complications.

Pediatric Physical Medicine & Rehabilitation (see Services below for relevant providers)

Physiatry will manage the different treatment options available for spasticity after TBI including initial evaluation and management of a baclofen pump.

Pediatric Neurosurgery (see Services below for relevant providers)

Neurosurgery, in conjunction with Pediatric Physical Medicine & Rehabilitation, will perform a baclofen trial and the pump insertion surgery.

Nose/Throat/Mouth/Swallowing

Swallowing dysfunction (dysphasia) may manifest as drooling, salivary pooling (with resultant malodorous breath and increased risk of dental caries), malnutrition, choking, coughing after drinking and/or frequent pneumonias. Generally, children with swallowing problems should receive therapy from a speech therapist (or, in some locations, an occupational therapist) who can evaluate swallowing function and safety, determine if interventions (e.g., oral therapy, special feeding techniques, improved feeding position) might lead to improvements in function, and determine the safest and most efficient textures for eating. If dysphagia is a problem, diets using pureed foods and thickened liquids may be necessary to prevent aspiration. See Power Packing, Thickening Liquids & Pureeing Foods, and Aspiration/Chronic Lung Disease.

Drooling: Many parents will choose not to treat drooling due to concerns about side effects of medication or surgery. Drooling in the older, socially-aware child can be very embarrassing and create barriers to important social interactions. See Let's Talk About Series for Pediatric Brain Injury and Associated Issues (Intermountain Healthcare) for resources and information about specific treatments.

Subspecialist Collaborations & Other Resources

Speech - Language Pathologists (see Services below for relevant providers)

The therapist involved with swallowing and feeding issues.

Occupational Therapy, Pediatric (see Services below for relevant providers)

In some locations, OTs may have the most expertise in swallowing and feeding issues.

Pediatric Gastroenterology (see Services below for relevant providers)

Evaluate and manage gastric tubes and nutrition; may collaborate with dietician to monitor caloric needs related to growth.

Pediatric Otolaryngology (see Services below for relevant providers)

Key to assessing anatomic and some functional disturbances in swallowing; may perform surgical treatments and interventions for excessive drooling.

Mental Health/Behavior

Children with a TBI may have behavioral problems that can interfere with social and emotional development. These may include difficulty with sustaining attention, mood stability, depression, and anxiety. These may be challenging to address and may lead to social difficulties, particularly in the school setting. See Returning to School after a Traumatic Brain Injury. Behavior problems are exacerbated by fatigue, stress, frustration, and external stimuli such as bright lights and loud noises. For more information, see Traumatic Brain Injury Survival Guide and Behavioral Changes Following a Brain Injury.

Evaluation and treatment by physiatrists, neuropsychologists, psychiatrists, or psychologists with experience with TBI can be helpful. Ask parents, the patient (if appropriate), teachers, care providers, and therapists to complete the Behavioral Checklist for Patients with TBI (PDF Document 50 KB) to identify specific problems. When working with the families of children with TBI, the medical home should help families prioritize the issues on which to focus.

Patients may be discharged on stimulant medications for attention and memory problems; their efficacy is still unclear but they may be helpful in selected patients, particularly those who had ADHD before the injury. [Huang: 2016] [Spritzer: 2015] Other psychotropic drugs may be prescribed to address problems with behavior, attention, and learning. [Williamson: 2016] Behavior modification has also been used to address the personality and behavioral effects of TBI. [1998 Consensus Statement - Rehabilitation after TBI (NIH Conference) (PDF Document 920 KB)] Depression is common after TBI and should be watched for by families and screened for in the medical home. See Depression Tool Kit (MacArthur Foundation Initiative on Depression and Primary Care) and Prescribing SSRIs for Depressed Children and Adolescents.

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (MD) (see Services below for relevant providers)

For the treatment of behavioral problems and mood disorders following TBI.

Neuropsychiatry/Neuropsychology (see Services below for relevant providers)

For behavioral evaluation and management, including cognitive problems after TBI.

Sleep

Lack of sleep interferes with the healing process, affects memory, causes irritability, and generally makes head injury symptoms worse. It can also contribute to depression and anxiety. The child may:
  • Go to sleep easily but wake up often
  • Have difficulty falling asleep
  • Suffer from fatigue during the day
  • Have disruption of day/night sleep cycles
  • Be awakened easily by minimal stimuli, such as soft noises
Complete a sleep assessment to assess severity and potential approaches:
  • When do you lie down to sleep?
  • How long does it take you to fall asleep?
  • How many times do you wake up during the night?
  • What time do you get up?
  • Do you feel rested upon awakening in the morning?
  • How often/how long do you nap?
First, ensure that families are following good sleep hygiene measures, including having the child:
  • Go to bed at the same time every night even on weekends
  • Avoid caffeine and chocolate, especially in the evening
  • Avoid exercise or stimulating activity late in the evening
  • Keep the bedroom at an even, moderate temperature and dark and quiet
  • Avoid napping during the day
  • No screen time 1-2 hours prior to bedtime
  • Establish a routine for bedtime which may include: bath, stories, reading, journaling, and if using medications, administer as part of the “winding down” routine, stimulation should be avoided after medications have been given.
If hygiene measures are insufficient, medications for short- or long-term may be helpful. See Medications for Sleep.

Having the parent/child track sleep patterns is useful in guiding management. See Sleep History Questionnaire (PDF Document 20 KB).

Subspecialist Collaborations & Other Resources

Pediatric Sleep Medicine (see Services below for relevant providers)

Very helpful in the assessment and management of sleep problems following TBI.

Gastro-Intestinal & Bowel Function

Constipation is common in children with impaired mobility. Symptoms may include unexplained irritability, vague abdominal pain, loss of appetite and/or intolerance of feeds. Encourage a healthy diet including fruits, vegetables, lean protein, whole grains, and adequate water intake. If the child receives feedings via G-tube, consider prescribing a formula with added fiber. For medical management of constipation, see the Portal’s Constipation, Treatment & Management module.

Subspecialist Collaborations & Other Resources

Pediatric Gastroenterology (see Services below for relevant providers)

Helpful for patients with intestinal motility problems or constipation that do not respond to typical measures implemented in the medical home.

Learning/Education/Schools

The medical home should assist the family in planning and negotiating for educational needs following TBI. An education consult may have been obtained during the child’s hospitalization. His/her school may have been contacted regarding severity of the brain injury.

It may be appropriate to order a neuropsychological evaluation at least 6 months after the event to assess the child’s learning style and abilities. This information can be used in collaboration with the school to make the most appropriate accommodations or modifications to the school program.

The medical home should advocate for early involvement of the education team for evaluation for needed services. Returning to school may provoke anxiety, the medical home can assist the child/parent in setting a plan for gradual reintegration into the school community.

The school may request a letter from the medical provider specifying modification/accommodations needed for the child. See Traumatic Brain Injury: A Guidebook for Educators (University of the State of New York). Other helpful resources include:

Subspecialist Collaborations & Other Resources

Pediatric Physical Medicine & Rehabilitation (see Services below for relevant providers)

Generally well-connected with local school systems and able to advise families regarding options and the most efficient and effective approaches to seeking accommodations and assistance.

Family

It is important to understand the stressors that affected children and their family may face after leaving the hospital. The transition home can be overwhelming for the entire family system. Challenges may include, but are not limited to:
  • Adequate insurance coverage for required medical/therapeutic services
  • Providing constant supervision as needed for the child
  • Transportation to appointments/therapies
  • Managing the child’s medical needs such as medication, nutrition, and daily cares
  • Adjustments/home modification, as needed
  • Coordinating with the school for modifications/accommodations
  • Changes in lifestyle, work routine, and leisure activities
  • Changes in family/marital roles and responsibilities
  • Emotional adjustments and changes in expectations/hopes
The medical home should help the family by suggesting financial resources, support groups, counseling and/or psychotherapy for the patient and/or family. Local brain injury associations and support groups can be a resource for the patient and family. They help with education, resource allocation, and can connect the patient and family with support groups.

The medical home should work with the family to monitor how the child functions in the community and how the family is coping. Children may have behavior problems after a TBI and act-out. They may have anxiety and/or post-traumatic stress disorder. Sometimes a child who is functioning well at first presents with behavior or adjustment problems later. Pre-injury function, injury severity, parent mental health and child self-esteem all contributed significantly to predicting social and behavioral outcomes. [Catroppa: 2017]

Complementary & Alternative Medicine

There is strong evidence that combining complementary and integrative medicine with conventional medical care with portions of alternative medicine is safe and effective in treating traumatic brain injury. Complementary and integrative medicine strives to be patient centered in its approach to combine modern medicine and healthy lifestyle practices by treating mind, body and spirit together. Complementary and integrative medicine includes traditional Chinese medicine (acupuncture, tai chi, Qigong, yoga), essential oils, manipulative therapies, nutraceuticals (essential oils, omega-3 fatty acids, zinc, vitamin D, vitamin B3, creatine and curcumin) and mind-body practices (deep breathing, relaxation, meditation). [Drake: 2017] [Hernández: 2016]

Questions from Clinicians

When can the child return to school?

If the child is able to tolerate sitting in a chair or has had therapy; start with 1-4 hours of school while progressively increasing time in class. Limit screen time, promote 8-10 hours sleep nightly, and adequate hydration, while monitoring for worsening headaches, tolerance of light, and feelings of being overwhelmed. It may be beneficial to meet with the school counselor/teachers and evaluate the need for 504 accommodations allowing for rest periods and decreased workload (extended due dates, lighter homework assignments, and test taking accommodations). See Let's Talk About Brain Injuries: A Guide for Teachers (Intermountain Healthcare) (PDF Document) and Let's Talk About Brain Injuries: A Guide for Teachers (Spanish) (Intermountain Healthcare) (PDF Document 1.4 MB).

When should I try medications to help manage impaired attention, focus, and impulsivity?

If attending cognitive/speech therapy is not effective in reducing impaired executive functioning deficits, such as decreased attention and focusing abilities, then typical dosing for medications to treat attention/focusing can be initiated and titrated to effect. It is important to monitor changes in appetite and sleep when starting these medications.

When should I consider ordering a neuropsychological evaluation?

Neuropsychological testing is usually discussed with the parents/child 1-3 months following TBI, it is typically not completed until after at least 6 months post injury and/or when the child has plateaued in their recovery. Considerations for repeating the test every 2-3 years post injury allows for changes due to recovery/development and identifies strengths in learning which can be incorporated into their 504/IEP allowing the child to be the most efficient learner they can be.

When can the child/adolescent return to increased activity (progression from “Two-Feet on the Ground”)?

Generally speaking, these are the accepted guideline: Each child needs to be evaluated as the child progressively returns to sports and other typical age-appropriate activities.

  • Mild TBI: With normal CT scan and no skull fractures; two feet on the ground for 1 month.
  • Complicated Mild TBI: Intracerebral bleeding or skull fracture; two feet on the ground x2 months.
  • Complicated Mild TBI: Intracerebral bleeding and skull fracture; two feet on the ground x3 month.
  • Moderate/Severe TBI: Two feet on the ground x3-6 months depending on restoration of balance and vestibular function, it may not be recommended to return to high contact sports, such as football, wrestling, motor cross.
As the child/adolescent returns to activity, promote 8-10 hours sleep nightly and adequate hydration, while monitoring for worsening headaches, tolerance of light, and feelings of being overwhelmed, as these may indicate the child needs to return to last level of tolerated activity.

Emphasize safe activities the child can do while recovering as staying active will promote recovery. See Let's Talk About Brain Injury: Keeping Your Child Safe After a Head Injury (Intermountain Healthcare) (PDF Document) and Let's Talk About Brain Injury: Keeping Your Child Safe After a Head Injury (Spanish) (Intermountain Healthcare) (PDF Document).

Issues Related to Traumatic Brain Injury

Constipation and Depression offer information about these common co-morbid conditions.

Resources

Information for Clinicians

Traumatic Brain Injury (CDC)
Educational initiatives and campaigns for clinicians, parents, educators, coaches, and individuals including children with TBI. Free, downloadable materials and fact sheets; Centers for Disease Control and Prevention.

Brain Trauma Foundation
Education for health care professionals and first responders who treat brain injury. Guidelines for pre-hospital management, surgical management, and acute medical management of severe TBI in infants, children, and adolescents.

Traumatic Brain Injury (NINDS)
Overview and links to publications and relevant organizations - not pediatric-specific; National Institute of Neurological Disorders and Stroke.

Center for Outcome Measurement in Brain Injury (COMBI)
Information about measurement scales that are currently being developed and tested such as: Agitated Behavioral Scale (ABS), Disability Rating Scale (DRS), and a Family Needs Questionnaire (FNQ).

Traumatic Brain Injury Model Systems (National Data and Statistical Center)
Research and dissemination efforts of the Traumatic Brain Injury Model Systems (TBIMS) program; funded by the National Institute on Disability and Rehabilitation Research (NIDRR).

Heads Up to Health Care Providers (CDC)
Provides physicians with information for assessment of mild TBI and helps guide the management and recovery of patients of all ages although some information pertains to very young children; Centers for Disease Control and Prevention.

Helpful Articles

PubMed search on rehabilitation and management of traumatic brain injury in children: articles over the past year

Brands I, Stapert S, Köhler S, Wade D, van Heugten C.
Life goal attainment in the adaptation process after acquired brain injury: the influence of self-efficacy and of flexibility and tenacity in goal pursuit.
Clin Rehabil. 2015;29(6):611-22. PubMed abstract

Dewan MC, Mummareddy N, Wellons JC 3rd, Bonfield CM.
Epidemiology of global pediatric traumatic brain injury: qualitative review.
World Neurosurg. 2016;91:497-509.e1. PubMed abstract

Goldsworthy R.
The effect of traumatic brain injury on caregivers.
Spotlight on Disability Newsletter. 2015; (March). American Psychological Association; http://www.apa.org/pi/disability/resources/publications/newsletter/201...

Rashid M, Goez HR, Mabood N, Damanhoury S, Yager JY, Joyce AS, Newton AS.
The impact of pediatric traumatic brain injury (TBI) on family functioning: a systematic review.
J Pediatr Rehabil Med. 2014;7(3):241-54. PubMed abstract

Clinical Tools

Assessment Tools/Scales

Behavioral Checklist for Patients with TBI (PDF Document 50 KB)
Questionnaire for parents, patient, teachers, and care providers. Assists in identifying key behavioral problems and narrowing the focus of treatment; Primary Children's Rehabilitation Program.

Sleep History Questionnaire (PDF Document 20 KB)
14 day sleep tracker and 1-page questionnaire about sleep routines and behavior.

Sleep Log (PDF Document 31 KB)
One-page chart to help parents record a child's sleep status and the effects of sleep interventions.

Glascow Coma Scale (PDF Document 93 KB)
Scoring system used to describe the level of consciousness in a person following a traumatic brain injury.

Rancho Levels of Cognitive Functioning Overview (PCH) (PDF Document 40 KB)
A 2-page summary describing the typical levels of recovery after brain injury; Pediatric Brain Injury series from Primary Children's Hospital.

Patient Education & Instructions

Let's Talk About Series for Pediatric Brain Injury and Associated Issues (Intermountain Healthcare)
Search the patient education library to find PDFs in Spanish and English for topics related to TBI. Examples include: Safety after Brain Injury; Acquired Brain Injury Characteristics; Sleep and Brain Injury; Selective Dorsal Rhizotomy; Mild Traumatic Brain Injury; Dysphagia; Brain Injury Severity and Measurement; Power Packing; Thickening Agents; and Brain Injury and a Healing Environment.

Cognitive Functioning Scale: A Guide for Family and Friends (Rancho Los Amigos National Rehabilitation Center) (PDF Document 1.7 MB)
Thirteen-page booklet that explains the cognitive and behavioral levels of recovery after a brain injury.

Let's Talk About Baclofen Pump (Intermountain Healthcare) (PDF Document)
Description of the benefits, risk, care, and use of a baclofen pump for spastic muscle relaxation.

Let's Talk About Baclofen Pump (Spanish) (Intermountain Healthcare) (PDF Document)
Hablemos Acerca De Bomba de Baclofen. Spanish description of the benefits, risk, care, and use of a baclofen pump for spastic muscle relaxation.

Let's Talk About Selective Dorsal Rhizotomy (Intermountain Healthcare) (PDF Document)
Description of the benefits, risks, and care after a selective dorsal rhizotomy (SDR) procedure for muscle spasticity.

Let's Talk About Selective Dorsal Rhizotomy (Spanish) (Intermountain Healthcare) (PDF Document)
Hablemos Acerca De Rizotomia Dorsal Selectiva. (RDS) Spanish description of the benefits, risks, and care after a selective dorsal rhizotomy (SDR) procedure for muscle spasticity.

Let's Talk About Brain Injuries: A Guide for Teachers (Intermountain Healthcare) (PDF Document)
Description of student behavior changes after a traumatic brain injury.

Let's Talk About Brain Injuries: A Guide for Teachers (Spanish) (Intermountain Healthcare) (PDF Document 1.4 MB)
Lesiones del cerebro: Una guía para profesores. Spanish description of student behavior changes after a traumatic brain injury.

Let's Talk About Brain Injury: Keeping Your Child Safe After a Head Injury (Intermountain Healthcare) (PDF Document)
Description of why a child needs greater supervision after a traumatic brain injury (TBI) and how parents can help the child.

Let's Talk About Brain Injury: Keeping Your Child Safe After a Head Injury (Spanish) (Intermountain Healthcare) (PDF Document)
Lesión cerebral: cómo mantener a su niño seguro después de una lesión en la cabeza. Spanish description of why a child needs greater supervision after a traumatic brain injury (TBI) and how parents can help the child.

Let's Talk About Brain injury: Creating a Healing Environment (Intermountain Healthcare) (PDF Document)
Description of how to create a calm environment for a child with a Traumatic Brain Injury (TBI) including triggers, signs of being overwhelmed, and steps to prevent agitation.

Let's Talk About Brain injury: Creating a Healing Environment (Spanish) (Intermountain Healthcare) (PDF Document)
Hablemos Acerca Lesión Cerebral: Cómo Crear un Ambiente Curativo. Spanish description of how to create a calm environment for a child with a Traumatic Brain Injury (TBI) including triggers, signs of being overwhelmed, and steps to prevent agitation.

Let's Talk About Sleep After a Brain Injury (Intermountain Healthcare) (PDF Document)
Description sleep problems, signs of those problems, and helping a child with a Traumatic Brain Injury (TBI) sleep better.

Let's Talk About Sleep After a Brain Injury (Intermountain Healthcare) (PDF Document)
Hablemos Acerca Dormir Después de una Lesión cerebral. Spanish description sleep problems, signs of those problems, and helping a child with a Traumatic Brain Injury (TBI) sleep better.

Toolkits

Heads Up: Brain Injury in Your Practice (CDC)
Practical clinical information and tools, including a booklet on diagnosis and management of a mild TBI; an ACE; a care plan to help guide a patient's recovery; fact sheets in English and Spanish on preventing concussion a palm card for the on-field management of sports-related concussion; and a CD-ROM with downloadable kit materials and additional mild TBI resources.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Traumatic Brain Injury (MedlinePlus)
Offers an overview and an extensive compilation of links to reliable websites and organizations related to TBI; National Library of Medicine and National Institutes of Health.

Traumatic Brain Injury (NINDS)
Information about traumatic brain injury, treatment, prognosis, clinical trials, organizations, and publications; National Institute of Neurological Disorders and Stroke.

TBI Resource Guide (CSN)
Comprehensive list of national , informational, educational, and organizational resources related to traumatic brain injury; Children's Safety Network.

Traumatic Brain Injury (Center for Parent Information & Resources)
Parent-focused page about TBI, includes information about education.

Brainline Kids – Helping Kids with Brain Injury
BrainLine Kids, a feature of Brainline.org, provides information about children ages birth through 22 years who are affected by Traumatic Brain Injury.

Abusive Head Trauma / Shaken Baby Syndrome (Nemours)
Signs, symptoms, outcomes, and prevention of abusive head trauma/shaken baby syndrome; KidsHealth.

Traumatic Brain Injury (CDC)
Educational initiatives and campaigns for clinicians, parents, educators, coaches, and individuals including children with TBI. Free, downloadable materials and fact sheets; Centers for Disease Control and Prevention.

Types of Memory (PDF Document 59 KB)
A five-page handout developed by Dr. Glen Johnson, Clinical Neuropsychologist, that describes the types of memory, things that affect memory, and tips for improving memory.

Fatigue (PDF Document 41 KB)
Courtesy of Dr. Glen Johnson, Clinical Neuropsychologist, this handout describes fatigue and ways to adjust to the fatigue factor.

The Road to Rehabilitation Series (BIAUSA) (PDF Document 758 KB)
Eight articles (total 80 pages) for TBI patients and families about dealing with pain, headaches, cognition and memory, behavior changes, speech and language, drug therapy, spasticity, and concussion/mild brain injury; Brain Injury Association of America.

National Resource Center for Traumatic Brain Injury
Practical information for professionals, persons with brain injury, and family members.

Pediatric Neuropsychology: A Guide for Parents (PDF Document 456 KB)
Describes pediatric neuropsychology, how it differs from a school psychological assessment, reasons for referral, what is assessed, what it will tell you about your child, and how to prepare for the test.

Easter Seals
Nonprofit organization offering services for individuals with disabilities and their families. Primary services include medical rehabilitation, early intervention, physical and occupational therapy, speech and hearing therapy, child care, recreation, and transition.

Family Functioning Following Pediatric Traumatic Brain Injury (Word Document 80 KB)
Information about family adaption after TBI and characteristics of healthy families, re-entry into community and school, role of the pediatrician, and family functioning research; Brain Injury Association of Washington.

When your Child is in the Hospital
Information about TBI specific to the Boston area. Good tools/resources for families in any state; Brain Injury Center at Children’s Hospital, Boston.

Pressure Ulcer Resource Guide (PressureUlcer.net)
Information for families and caregivers about pressure ulcer types, causes, treatments, preventions, and remedies.

Traumatic Brain Injury: Hope Through Research (NINDS)
Research and clinical trials that are funded by the National Institute of Neurological Disorders and Stroke.

National Resource Center for TBI (Virginia Commonwealth University)
Answers basic questions for parents and teachers, provides lists of links that address a multitude of topics such as medication, education, family support, legal issues, rehab resources and more.

National & Local Support

Brain Injury Association of America
Links to resources, publications, and information about policy/legislation and state chapters.

Services for Patients & Families in Nevada

Select services for a different state: ID, MT, NM, RI, UT

Audiology

See all Audiology services providers (5) in our database.

Educational Advocacy

See all Educational Advocacy services providers (1) in our database.

Neuropsychiatry/Neuropsychology

See all Neuropsychiatry/Neuropsychology services providers (1) in our database.

Occupational Therapy, Pediatric

See all Occupational Therapy, Pediatric services providers (8) in our database.

Pediatric Gastroenterology

See all Pediatric Gastroenterology services providers (5) in our database.

Pediatric Neurology

See all Pediatric Neurology services providers (7) in our database.

Pediatric Neurosurgery

See all Pediatric Neurosurgery services providers (4) in our database.

Pediatric Ophthalmology

See all Pediatric Ophthalmology services providers (5) in our database.

Pediatric Orthopedics

See all Pediatric Orthopedics services providers (4) in our database.

Pediatric Otolaryngology

See all Pediatric Otolaryngology services providers (2) in our database.

Pediatric Physical Medicine & Rehabilitation

We currently have no Pediatric Physical Medicine & Rehabilitation service providers listed; search our Services database for related services.

Pediatric Sleep Medicine

We currently have no Pediatric Sleep Medicine service providers listed; search our Services database for related services.

Physical Therapy

See all Physical Therapy services providers (17) in our database.

Psychiatrist, Child-18 (MD)

See all Psychiatrist, Child-18 (MD) services providers (14) in our database.

Speech - Language Pathologists

See all Speech - Language Pathologists services providers (13) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors & Reviewers

Initial Publication: September 2017; Last Update: October 2018
Current Authors and Reviewers (click on name for bio):
Author: Teresa Such-Neibar, DO
Contributing Authors: Wendy Walker, RN, BSN, CRRN
Jenny Wood, RN, BSN, CRRN

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