Pediatric Traumatic Brain Injury

Signs and symptoms of TBI vary, depending on the site and extent of injury to the brain, the age at which the injury occurred, premorbid abilities, and functional domains affected (e.g., physical, cognitive, language, sensory). The effects of TBI can be temporary or permanent, and no two children present with the same pattern.

Some young children with TBI may demonstrate relatively typical developmental progression after the initial stages of recovery. Others continue to have long-term difficulty learning new information and negotiating more complex social interactions due to impairments in cognitive functions (Anderson, Godfrey, Rosenfeld, & Catroppa, 2012; Turkstra, Politis, & Forsyth, 2015).

The functional impact of TBI in children can differ from that in adults because the pediatric brain is still developing. For example, sensory systems and the frontal lobes of the brain continue to develop past late adolescence (S. J. Taylor, Barker, Heavey, & McHale, 2013). Therefore, some children may not present with immediate effects of TBI, but will experience challenges later in their development, particularly as academic  demands increase (Gerrard-Morris et al., 2010; H. G. Taylor et al., 2008). These difficulties can affect educational and vocational outcomes; friendships; participation in home, school, and community; and overall quality of life (Catroppa & Anderson, 2009; Gamino, Chapman, & Cook, 2009).

The full sequelae of pediatric TBI can emerge and/or persist well into adulthood, lending to the perspective that TBI in children is a chronic disease process rather than a one-time event (DePompei, 2010; DePompei & Tyler, in press; Masel & DeWitt, 2010).

Signs and symptoms may co-occur with other existing developmental conditions such as attention-deficit/hyperactivity disorder, learning disabilities, autism spectrum disorder, intellectual disability, childhood apraxia of speech, childhood fluency disorders, late language emergence, spoken language disorders, written language disorders, and social communication disorders.

Signs and Symptoms Related to Traumatic Brain Injury

Physical

  • Changes in bowel and bladder function
  • Changes in level of consciousness, ranging from brief loss of consciousness to coma
  • Dizziness
  • Fatigue
  • Headaches
  • Impaired movement, balance, and/or coordination
  • Motor speed and programing deficits (dyspraxia/apraxia)
  • Nausea
  • Pain
  • Reduced muscle strength (paresis/paralysis)
  • Seizures
  • Vomiting

Sensory-Perceptual

Auditory and Vestibular
  • Auditory dysfunction from injury to the outer ear, middle ear, inner ear, and/or temporal lobe, resulting in
    • central auditory dysfunction;
    • difficulty hearing speech in noise;
    • dizziness, vertigo, and/or imbalance (see ASHA's Practice Portal page on Balance System Disorders);
    • hypersensitivity to sounds (hyperacusis);
    • loss of postural stability/control;
    • tinnitus (see ASHA's Practice Portal page on Tinnitus and Hyperacusis); and/or
    • transient or permanent hearing loss.
Visual
  • Changes in perception of color, shape, size, depth, and distance
  • Changes in visual acuity
  • Double vision (diplopia)
  • Problems with visual convergence and accommodation
  • Sensitivity to light
  • Visual field deficits/visual neglect
Other Sensory–Perceptual Sequelae
  • Gustatory—loss of taste
  • Olfactory—inability to recognize smells
  • Tactile—sensitivity or defensiveness to touch; changes in perception of pain, pressure, and/or temperature

Cognition

Attention
  • Deficits in shifting attention between tasks
  • Difficulty with selective attention
  • Impaired sustained attention for task completion or conversational engagement
  • Reduced attention span
Executive Functioning
  • Difficulty with the following:
    • decision making
    • flexibility
    • goal setting
    • initiation and self-monitoring
    • judgment
    • planning and organization
    • reasoning and problem solving
    • strategy selection
Information Processing
  • Increased response latencies
  • Reduced processing speed (e.g., of rapid speech and/or complex language), resulting in confusion
Memory and Learning
  • Deficits in short-term memory that negatively affect new learning
  • Deficits in working memory that negatively affect following directions
  • Difficulty retrieving information from memory
  • PTA—anterograde or retrograde
Metacognition
  • Lack of insight for monitoring one's strengths, weaknesses, functional abilities, problem situations, and so forth
  • Reduced awareness of deficits (anosagnosia)
Other Cognitive Deficits
  • Deficits in orientation to self, situation, location, and/or time
  • Impaired spatial cognition that can affect ability to navigate and ambulate

Language

Pragmatic/Social Communication
  • Conversational turns marked by verbosity
  • Difficulty initiating conversation and maintaining topic
  • Difficulty taking turns in conversation
  • Impaired ability to use nonverbal communication effectively (e.g., tone of voice, facial expression, body language)
  • Inability to interpret nonverbal communication of others
  • Tendency to be tangential
Spoken Language
  • Anomia or word retrieval deficits
  • Decreased ability to formulate organized discourse or conversation
  • Difficulty following directions
  • Difficulty formulating fluent speech
  • Difficulty making inferences
  • Difficulty understanding abstract language/concepts
  • Tendency to perseverate in verbal responses
  • Tendency to use tangential speech
  • Use of incoherent or confabulatory speech
Written Language
  • Difficulty comprehending written text, particularly with respect to complex syntax and figurative language
  • Difficulty planning, organizing, writing, and editing written products

See ASHA's Practice Portal pages on Aphasia, Spoken Language Disorders, Written Language Disorders, and Social Communication Disorders in School-Age Children.

Speech

  • Apraxia of speech (motor programming)
  • Aprosodia/dysposodia, marked by deficits in intonation, pitch, stress, and rate
  • Dysarthria characterized by articulatory imprecision and/or vowel distortions
  • Hypernasality secondary to paresis or paralysis of velopharyngeal muscles involved in speech

See ASHA's Practice Portal pages on Acquired Apraxia of Speech and Childhood Apraxia of Speech.

Voice

  • Aphonia/dysphonia resulting from intubation, tracheostomy, or use of mechanical ventilator
  • Laryngeal hyper/hypofunction marked by abnormal pitch; poor control of vocal intensity; or changes in vocal quality (e.g., hoarseness, strained–strangled voice, glottal fry)
  • Neurogenic phonatory abnormalities resulting from injury to sensory or motor innervations to the vocal folds
  • Psychogenic phonatory abnormalities (e.g., related to post-traumatic stress disorder)

See ASHA's Practice Portal page on Voice Disorders.

Feeding and Swallowing

  • Oral and/or pharyngeal dysphagia
  • Risk of aspiration related to impact of cognitive impairment (e.g., poor memory, reduced insight, limited attention, impulsivity, and agitation) while eating

See ASHA's Practice Portal pages on Pediatric Dysphagia and Adult Dysphagia.

Behavioral and Emotional

  • Agitation, aggression, and/or combativeness
  • Anxiety
  • Apathy and/or lack of motivation
  • Changes in affect—overemotional, over reactive, emotionless (flat affect)
  • Changes in sleep patterns (e.g., insomnia or hypersomnia)
  • Depression
  • Difficulty identifying emotions of self and others (alexithymia)
  • Disinhibition and poor self-regulation
  • Emotional lability
  • Excessive drowsiness
  • Feeling of disorientation or "fogginess"
  • Heightened sensory sensitivity with exaggerated reactions to perceived threats (hypervigilance)
  • Impulsivity
  • Irritability
  • Mood changes or mood swings
  • Reduced frustration tolerance

Considerations for Infants and Toddlers With TBI

Infants and toddlers may lack the communication or developmental skills to overtly report the signs and symptoms of TBI noted above. Clinicians and families need to be aware of the following signs that may be initially observed after TBI for this age group:

  • Changes in the ability to pay attention
  • Changes in eating or nursing habits
  • Changes in play (e.g., loss of interest in favorite toys/activities)
  • Changes in sleeping habits
  • Irritability, persistent crying, and inability to be consoled
  • Lethargy
  • Loss of acquired language
  • Loss of new skills, such as toilet training
  • Sensitivity to light and/or noise
  • Unsteady walking, loss of balance

In cases of abusive head trauma such as shaken baby syndrome, sometimes there are no apparent external physical signs to indicate a TBI. Attention to behavioral symptoms such as those listed above is critical (Cox, 2016).

For infants and toddlers, acute deficits following TBI tend to be in skill areas that are developing at the time of injury. Lack of overt deficits in these very young children just after TBI does not mean that they will not require services later. For skills that are not fully developed at the time of injury, later-onset symptoms can arise, including memory and attention deficits, language delay or deficits, and behavioral problems. These younger children are also more likely to have difficulties academically compared with children who were injured at later ages (Anderson, Catroppa, Morse, Haritou, & Rosenfeld, 2005). The full extent of deficits may become evident only as the child's brain matures and expected skills fail to develop or emerge more slowly (McKinlay & Anderson, 2013).

See the Assessment and Treatment sections for more information about young children with TBI.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.