Brain-Based Assessment and Treatment in Pediatric Brain Injury

One of the most pressing public health issues is acquired brain injury in children, youth, and young adults (up to 25 years of age). In fact, traumatic brain injury is the leading cause of death and disability in pediatric and young adult populations in the United States. Motor vehicle collisions, sports-related injuries, motor- pedestrian collisions, blast injuries from war, falls, and child abuse are the most common causes of traumatic brain damage. Acquired brain injury from nontraumatic causes such as stroke, brain tumors, seizures, encephalitis, anoxia, toxins, meningitis and substance abuse also can have a lasting impact on children at months and often years remote from the time of brain injury. Unfortunately, the standard of care ends long before the long-term impact of the injury is fully realized. The nation's cognitive-communication care ecosystems, whether medical, educational, social services, or home care, are not converting new evidence to practice fast enough for the children injured today to benefit from practices that could address and mitigate the unfolding danger of lasting deficits. This timely issue of Topics in Language Disorders (TLD) serves to inform practicing clinicians, whether speech-language pathologists, psychologists, counselors, teachers, or rehabilitation experts, about new developments in testing and treatment that will likely promote better long-term outcomes in this prevalent and often-debilitating childhood disorder.

In this issue, readers will learn some of the promising new approaches to stop the impending, later emerging, and worsening deficits after pediatric acquired brain injury. At present, new approaches are being discovered, tested, and developed throughout the United States to advance better long-term care for children with acquired brain injury. Several major themes and principles emerge and recur throughout the articles comprising this issue on "Brain-Based Assessment and Treatment in Pediatric Brain Injury." One theme is the consistent view that young life span monitoring (up to 25 years of age) is imperative for children who sustain moderate to severe brain injury, as well as perhaps several months of monitoring for those with milder forms of brain injury. A second theme is the recognition that few sensitive measurement tools and strategies were previously available, but some now are at or near clinical readiness. They likely will allow more sensitive and comprehensive characterization of the complexity of the cognitive, linguistic, social, and learning outcomes after pediatric acquired brain injury. Along this same line, a third theme is that measurements must include multiple domains take into account premorbid and other contextual factors related to the child's development. A fourth theme is the special window during adolescence concerning vulnerability (i.e., emergence of higher order cognitive deficits after early brain injury) and targeting the opportunity for repair (i.e., taking advantage of the extensive brain remodeling that is typically taking place). Finally, assessments are needed that provide direction to inform individualized training programs at different stages of recovery/development.

In the first article, Hotz, Helm-Estabrooks, Nelson, and Plante describe a newly developed test, namely, the Pediatric Test of Brain Injury, which assesses multiple cognitive and linguistic domains, appropriate after early brain injury and at later stages of recovery. The component domains are well documented as being impaired after acquired brain injury in childhood and include phonological, semantic, syntactic, and discourse knowledge as well as listening, speaking, reading, graphomotor, and gestural modalities of expression. The test assesses the key domains in a single measure that is efficient to administer and is predicted to be informative to monitor recovery at various stages of school reintegration. Hotz and colleagues present case illustrations to show how the quantitative and qualitative performance results inform the degree to which the child may be able or unable to handle learning in school and provide treatment guidelines.

Gamino, Chapman, and Cook provide new evidence that higher order cognitive measures of abstracting gist-based meanings from classroom-like texts are sensitive to the long-term sequelae of brain injury in adolescents. The paradoxical findings include normal recovery in the ability to remember the isolated facts after brain injury, but poor ability to combine the facts to form generalized meaning as measured by a recently developed tool, the Test of Strategic Learning. The ability to abstract meaning emerges during adolescence and is a more efficient strategy for new learning than simple fact-based learning. The authors propose that this higher order cognitive capacity may be stalled when the frontal networks are disrupted in pediatric brain injury prior to full maturation. The importance of young life span monitoring with measures sensitive to higher order cognitive development in adolescence is discussed as well as treatment implications with caution against a bottom-up approach of "learn as much as you can."

Hanten, Li, Newsome, Swank, Chapman, Dennis, Barnes, Ewing-Cobbs, and Levin comprehensively describe the recovery of reading skills and expressive language in children with mild, moderate, or severe traumatic brain injury, using both prospective follow-up testing and a retrospective cohort. Their results reveal that measures of higher order reading skills are more sensitive to the impact of brain injury than early maturing reading skills. Adding to the growing literature, Hanten and team also find that younger age at injury has a more deleterious impact on higher level cognitive skills than older age at injury, despite a more rapid rate of recovery initially for the younger children with injury. Their findings underscore the pressing mandate to conduct regular follow-up assessments to ensure that children maintain the trajectory of cognitive growth at various stages of development postinjury. Perhaps not too surprisingly, yet an often-ignored contextual factor, is the significant role of socioeconomic status in predicting outcome.

Ciccia, Meulenbroek, and Turkstra provide an informative "must-read" research overview for clinicians working with any adolescent population. The fact that the adolescent brain is undergoing more change than any other time of life outside the first few months of life has important implications for understanding later emerging cognitive vulnerabilities associated with brain injury as well as recognizing the potential of this vital window for immense brain plasticity, given proper training/intervention. The authors present a clear case regarding the complex interactions that occur among age at injury, site of brain injury and disrupted functional networks, and the likelihood of later emerging cognitive and behavioral deficits. The knowledge of the link between adolescent brain and cognitive development is foundational to recognizing how an earlier injury could produce later emerging or worsening deficits and to defining effective assessment and treatment protocols to prevent this impending and heretofore untreated setback.

The final article in this issue is the contribution of Gioia, Isquith, Schneider, and Vaughan. This team makes a powerful case for the urgency in understanding and evaluating the multifaceted vulnerabilities in cognition, behavior, motor performance, and learning that may occur after a child sustains a cerebral concussion. None too soon, the authors fill a major void in describing a newly developed, sensitive protocol, the Pediatric Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), to assess and monitor pediatric mild brain injury due to cerebral concussion to ensure that symptoms are treated and alleviated before further damage is done. The incidence and prevalence of concussion in children account for by far the largest percentage of brain injury, with an estimated annual incidence in the millions. As related to mild brain injury, Gioia and colleagues comprehensively address the recurring TLD issue themes including the vital need for longer monitoring, development/ employment of more sensitive measures, adopting a broad-based approach to assessment, consideration of premorbid and other contextual factors, and the need for individualized treatment adaptations.

This issue of TLD provides timely contributions from brain injury experts to improve assessment and treatment practices for cognitive- communication skills in pediatric brain injury populations. Extant evidence indicates that an injury to a young person's brain can detrimentally impact the later developmental trajectory of cognition, behavioral, social, and motor functions. Thus, professionals in medical facilities, school systems, and private practice are challenged to adopt new methods to provide more appropriate assessments, sensitive monitoring protocols, and timely intervention strategies to both detect and stave off later emerging deficits. Because of the added incidence of new injuries year after year, the prevalence of pediatric brain injury grows exponentially with each year. This is because the impact of a significant brain injury tends not to be mitigated 1 year out and many children existing in the population continue to demonstrate special needs while new cases are added. Medical professionals evaluate and monitor children with most acquired diseases such as cancer, heart disease, asthma, and cystic fibroses, to mention a few, throughout their lives. Such practice needs to become the standard protocol for children and young persons with acquired brain injury as well. After physical injuries heal, it may be more difficult to associate ongoing cognitive-behavioral issues with earlier trauma. By incorporating some of the measures and principles set forth in this issue, clinicians and researchers can respond more effectively\vadjust to the challenge presented by pediatric acquired brain injury with goals to improve long-term cognitive outcomes.

-Gillian Hotz, PhD, Issue Editor

Director, Neurotrauma Outcome Research, Codirector Pediatric Brain & SCI Program, Associate Research Professor, Department of Neurosurgery, University of Miami Miller School of, Medicine, Florida

-Sandra Bond Chapman, PhD, Issue Editor

Chief Director, Center for BrainHealth, Dee Wyly Distinguished Professor, School of Behavioral and Brain Sciences, The University of Texas at Dallas