Pediatric Traumatic Brain Injury

See the Traumatic Brain Injury section of the Pediatric Brain Injury Map Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspectives.

Children and adolescents with TBI are a heterogeneous group with varied and complex sequelae that can change over time. Assessment of children with TBI takes into account the child's behaviors, strengths, and needs over the course of development and rehabilitation, including school and community re-entry. For children in particular, it is helpful to focus assessment on areas critical to learning and school success. Assessment requires ongoing collaboration with the family and medical, surgical, rehabilitation, and educational professionals. Findings from the speech-language and audiologic assessments are analyzed in the context of findings from other professionals on the team. See ASHA's web page on Interprofessional Education/Interprofessional Practice (IPE/IPP).


Screening is conducted by speech-language pathologists and audiologists to identify possible deficit areas following a TBI. Screening is typically completed prior to conducting more comprehensive evaluations.

Screening does not provide a detailed description of the severity and characteristics of deficits resulting from TBI but, rather, identifies the need for further assessment. Screening may result in recommendations for rescreening, comprehensive assessments, or referral for other examinations or services.

Audiologic Screening

Hearing screening and otoscopic inspection occur prior to screening for other deficits. If the child wears hearing aids, the hearing aids are inspected by an audiologist to ensure that they are in working order, and aids should be worn by the child during screening. Hearing screening is within the SLP scope of practice. See ASHA's Practice Portal page on Childhood Hearing Screenings.

A referral for a full audiologic evaluation is necessary if the child fails the hearing screening or if hearing loss is suspected. Audiologists may also screen for auditory processing disorders, tinnitus, and vestibular deficits as indicated. See ASHA's Practice Portal pages on Permanent Childhood Hearing Loss, Hearing Loss: Beyond Early Childhood, Tinnitus and Hyperacusis, and Balance System Disorders.

Speech, Language, Cognitive-Communication, and Swallowing Screening

SLPs screen for speech, language, cognitive-communication, and swallowing deficits. Due to a lack of validated screening tools for this population, recommendations and referrals are often based on developmental expectations (Turkstra et al., 2015). Screening typically includes interviews with family members and/or teachers regarding concerns about the child's skills. Screening is conducted in the language(s) used by the child and family, with sensitivity to cultural and linguistic variables.

Comprehensive Assessment

The purpose of a comprehensive assessment for children with TBI is to determine speech, language, cognitive-communication, and swallowing abilities; identify strengths and deficits; and target interventions. The specific focus of a comprehensive assessment can vary depending on the child's current age and age at time of injury, the severity of the injury, the stage of recovery, and prior educational status. Ongoing assessment is necessary to evaluate performance and to track changes in functioning as the child recovers from TBI.

Factors that may influence assessment include the following:

  • Level of consciousness and arousal
  • Behavioral factors, such as agitation and combativeness
  • Emotional factors such as depression
  • Decreased physical endurance and ability to participate
  • Sensory deficits (e.g., visual neglect, hearing loss)
  • Presence of co-existing premorbid conditions such as attention-deficit/hyperactivity disorder, learning disabilities, and developmental disabilities

If a child wears prescription eyeglasses or hearing aids, and prescriptions are still appropriate post injury, the glasses or aids should be worn during assessment.

If the TBI resulted in additional hearing or visual deficits, sensory aids and/or accommodations that were used premorbidly may no longer be sufficient for the child, and physical or environmental modifications may be needed (e.g., large-print material, modified lighting, amplification devices).

If changes to premorbid hearing and/or vision are suspected, refer the individual for complete audiologic and/or vision assessments prior to any additional testing. (See ASHA's Practice Portal pages on Permanent Childhood Hearing Loss and Hearing Loss: Beyond Early Childhood.)

Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016b; WHO, 2001), ongoing comprehensive assessment of children with TBI is conducted to identify and describe the following:

  • Impairments in body structure and function, including underlying strengths and weaknesses in areas known to be affected by TBI.
  • Co-morbid deficits such as aphasia, motor speech disorders, dysphagia, hearing and vestibular problems.
  • The individual's limitations in activities and participation, including functional communication, interpersonal interactions, self-care, and resuming the role of student.
  • The impact of communication impairments on quality of life and functional limitations relative to premorbid social abilities and community access.
  • Contextual (environmental and personal) factors that serve as barriers to, or facilitators of, successful communication as well as school and life participation. These can include the following:
    • Facilitators—ability and willingness to use compensatory strategies for day-to-day communication and in the classroom; family/teacher/peer support; motivation to return to improve function.
    • Barriers—decreased confidence in one's ability to communicate and/or succeed academically; presence of cognitive deficits; visual and motor impairments; lack of awareness of disability.

Assessment Methods

A comprehensive assessment is conducted for children with TBI using both standardized and nonstandardized procedures to help identify areas of weakness, areas of strength, and/or effective educational supports. See ASHA's resources on assessment tools, techniques, and data sources and dynamic assessment.

Standardized Assessments

When selecting standardized assessments, consider the following:

  • There are a limited number of standardized cognitive-communication assessments specifically for children and adolescents with TBI (Chevignard, Soo, Galvin, Catroppa, & Eren, 2012; Turkstra et al., 2015).
  • Standardized assessments that are too difficult for children with severe TBI may not yield useful information for treatment.
  • Tests typically used for children with moderate or severe TBI may not identify the subtler difficulties in children with mTBI.
  • Standardized tests are usually administered in quiet settings that control for distractions, tend to be highly structured, and often focus on skills that the child can still access. Therefore, performance may not accurately reflect or predict level of functioning in everyday situations (Blosser & DePompei, 2003; Coelho, Ylvisaker, & Turkstra, 2005; Turkstra, 1999; Turkstra et al., 2015).
Nonstandardized Assessments

Functional or situational assessments (e.g., language sampling, analog tasks, and naturalistic observation) and anecdotal reports are particularly useful for supplementing data from standardized tests when assessing individuals with TBI.

Nonstandardized measures that focus on process rather than content knowledge may provide valuable information for targeting interventions and identifying effective strategies (Turkstra et al., 2015). For example, with school-age children, these procedures may help answer some of the following questions about a child's functioning in natural environments.

  • Does time pressure affect performance in the classroom?
  • Can the student prioritize tasks or manage more than one task at a time?
  • Do classroom accommodations or task modifications help maximize the student's academic performance?
  • What natural supports in the classroom (e.g., priority seating, partnering with peers) can facilitate academic success for the student?
  • What social skills should be developed to support successful communication?

Comprehensive Speech-Language Assessment for Pediatric TBI: Typical Components

Case History

  • Medical status prior to injury (e.g., surgeries, prior TBI)
  • Psychiatric and psychosocial history prior to injury
  • Nature and onset of TBI and related hospitalizations
  • Current medical status, including medications
  • Developmental milestones
  • History of hearing or vision problems
  • Speech and language status prior to injury, including history of speech and language services
  • Concerns regarding current communication status and context of concern (e.g., daily routines, school activities, social interactions)
  • Impact of current condition on individual and their family/caregivers
  • Goals and priorities of the individual and their family/ caregivers

Hearing Screening

  • Hearing screening (if not previously completed)

See ASHA's Practice Portal page on Childhood Hearing Screening.

Oral–Peripheral Exam and Integrity of Speech Subsystems

  • Strength, speed, and range of motion of lips, tongue, jaw, and velum
  • Symmetry of structures of the face, oral cavity, head, and neck at rest and during speech
  • Sensation of face, oral cavity, taste, and smell
  • Respiration and breath support for speech

Cognitive-Communication Assessment

  • Impact of cognitive factors on functional communication in various activities and settings; examples include
    • attending to, perceiving, and processing verbal and nonverbal information;
    • remembering verbal and nonverbal information; and
    • having the metacognitive and executive functioning skills necessary for interacting in home, school, and community settings.

See ASHA's cognitive-communication resources page and ASHA's Practice Portal page on Traumatic Brain Injury in Adults.

Speech Sound Assessment

See assessment section of ASHA's Practice Portal page on  Speech Sound Disorders: Articulation and Phonology

Motor Speech Assessment

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

Voice Assessment

See assessment section of ASHA's Practice Portal page on  Voice Disorders.

Spoken Language Assessment

See assessment sections of ASHA's Practice Portal pages on Spoken Language Disorders and Late Language Emergence.

Written Language Assessment

See assessment section of ASHA's Practice Portal page on Written Language Disorders.

Social Communication Assessment

See assessment section of ASHA's Practice Portal page on Social Communication Disorder.

Curriculum-Based Assessment

  • Analyze the language demands of curricular activities
  • Observe the student as he or she attempts curricular activities without assistance
  • Identify gaps between the demands of the task and the abilities of the student

Augmentative and Alternative Communication (AAC) Assessment

See ASHA's Practice Portal page on Augmentative and Alternative Communication.

Feeding and Swallowing Assessment

See assessment section of ASHA's Practice Portal page on  Pediatric Dysphagia.

Comprehensive Audiologic Assessment for Pediatric TBI: Typical Components

Case History

  • Review case history information (including medical information and results from any previous assessments)
  • Gather additional details related to hearing, balance, and auditory processing difficulties

Behavioral Hearing Testing

  • Pure tone and speech audiometry, including modifications as needed
    • simplifying directions,
    • using pulsed tones,
    • slowing presentation of speech stimuli,
    • providing reminders to respond, and
    • responding with "yes" instead of raising a finger or pressing a button.
  • Otoacoustic Emissions or Auditory Brainstem Response testing—if accurate test results cannot be obtained using traditional behavioral testing methods

See assessment sections of ASHA's Practice Portal pages on Permanent Childhood Hearing Loss and Hearing Loss: Beyond Early Childhood.

Auditory Processing

  • Speech in noise
  • Temporal processing
  • Binaural processing

Vestibular Testing

  • Dix-Hallpike and roll tests
  • Semicircular canal function tests, such as caloric, rotational, and video head impulse testing
  • Otolith testing, such as ocular and cervical vestibular-evoked myogenic potential (VEMPs), and the subjective visual vertical (SVV) test
  • Videonystamography (VNG; Wintrow, 2013)

See the assessment section of ASHA's Practice Portal pages on Balance System Disorders and Tinnitus and Hyperacusis.

The comprehensive assessment typically results in one or more of the following:

  • Diagnosis of a speech, language, voice, cognitive-communication, and/or swallowing disorder
  • Diagnosis of an auditory and/or vestibular disorder
  • Clinical description of the characteristics and severity of the disorder(s) and their impact on life activities
  • Identification of strengths and facilitators in addition to any barriers to everyday activities
  • Prognosis for change
  • Programming and intervention decisions, including placements, functional and personally relevant goals, and school and community re-entry plans
  • Determination of the effectiveness of interventions and supports (e.g., accommodations and modifications; technologies)
  • Identification of facilities or agencies involved at the time of the evaluation and referrals to relevant follow-up services for appropriate intervention and support for youth with TBI and their families (e.g., social services and counseling support)
  • Recommendations for effective strategies and supports for parents, caregivers, and teachers
  • Recommendations for support for transitions (e.g., early intervention into school age; school age into workplace

Assessment Considerations

Cultural and Linguistic Factors

Assessments are sensitive to cultural and linguistic diversity and are completed in the language(s) used by the individual with TBI (see ASHA's Practice Portal pages on Bilingual Service Delivery, Cultural Competence, and Collaborating With Interpreters ). TBI may affect each language used by the child in different ways. Therefore, information about all language(s) should be collected. Any accommodations and modifications related to native language or culture must be documented. Standard scores should not be reported if a standardized test is modified or translated, as norms will not apply.

Cognition and Language

TBI often causes deficits in cognition and language. It is important to recognize that these two domains are intrinsically and reciprocally related in development and function. An impairment of language can disrupt cognitive processes (e.g., attention, memory, and executive functions). An impairment of cognitive processes can also disrupt aspects of language (e.g., syntax, semantics, and pragmatics). Assessment identifies strengths and deficits in these related domains. Difficulty with any aspect of communication that is affected by disruption of cognition is diagnosed as a cognitive-communication disorder (see ASHA, 1997; and Turkstra et al., 2015).

Feeding and Swallowing

The following may have an impact on the assessment of feeding and swallowing:

  • Level of alertness
  • Ability to follow directions (as appropriate for age of child)
  • Extent and severity of trauma
  • Physical damage to the oral, pharyngeal, and/or laryngeal structures
  • Respiratory status, including presence of tracheostomy and/or use of mechanical ventilation (Morgan, 2010; Morgan, Mageandran, & Mei, 2010; Morgan, Ward, Murdoch, Kennedy, & Murison, 2003)

See also the assessment section of ASHA's Practice Portal page on Pediatric Dysphagia.

Hearing and Balance

Children with superior canal dehiscence or enlarged vestibular aqueduct are more susceptible to hearing and balance problems after TBI. Audiologists need to be aware of the potential impact of these conditions during assessment. Promoting hearing wellness and monitoring the acoustic environment are also key roles for the audiologist in assessment. See ASHA's Practice Portal page on Superior Canal Dehiscence.

Assessment of Young Children (Infants, Toddlers, and Preschoolers)

One of the main challenges in assessing infants, toddlers, and preschoolers is a lack of objective information regarding pre-injury function on which to base an evaluation of deficits (McKinlay & Anderson, 2013). Cognitive and communication skills are still developing during this period, making symptoms difficult to evaluate, particularly in pre-verbal children. Ongoing assessment at various points post injury may be necessary to identify emerging deficits, particularly as cognitive-communication demands increase.

There are few standardized tests for young children with TBI; therefore, observation and parent report are key components in determining changes in baseline function or differences from developmental norms. When interpreting assessment results for children ages 0–5 years, it is important to consider

  • age at injury;
  • time since injury;
  • developmental stage at time of injury; and
  • developmental stage at time of assessment (McKinlay & Anderson, 2013).
Assessment of School-Age Children and Transitioning Youth

For school age children, assessment focuses on the child's ability to perform academically and interact with peers (Turkstra et al., 2005). Assessment describes strengths and needs for supporting new learning and/or re-learning and helps identify areas for remediation.

The development of cognitive-communication skills continues to be monitored through high school and during the transition to postsecondary educational or vocational settings. The impact of new demands and challenges is assessed so that strategies to maximize functional outcomes and life participation can be implemented (Blosser & DePompei, 2003; New Zealand Guidelines Group, 2006).

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.