Traumatic brain injury (TBI) is a form of nondegenerative acquired brain injury resulting from a bump, blow, or jolt to the head (or body) or a penetrating head injury that disrupts normal brain function (Centers for Disease Control and Prevention [CDC], 2015).
TBI can cause brain damage that is focal (e.g., gunshot wound), diffuse (e.g., shaken baby syndrome), or both. Symptoms can vary depending on site of lesion, extent of damage to the brain, and the child's age or stage of development.
The functional impact of TBI in children can be different than in adults—deficits may not be immediately apparent because the pediatric brain is still developing. TBI in children is a chronic disease process rather than a one-time event, because symptoms may change and unfold over time (DePompei & Tyler, in press; Masel & DeWitt, 2010).
TBI can result from a primary injury or a secondary injury (see common classifications of TBI for more details). Severity of TBI may be categorized as mild, moderate, or severe, based on the extent and nature of injury, duration of loss of consciousness, posttraumatic amnesia (PTA; loss of memory for events immediately following injury), and severity of confusion at initial assessment during the acute phase of injury (Diagnostic and Statistical Manual of Mental Disorders, 5th ed. [DSM-5; American Psychiatric Association, 2013]; CDC, 2015).
Concussion, a form of mTBI, is an injury to the brain characterized by the physical and cognitive sequelae of TBI. Concussion typically occurs as a result of a blow, bump, or jolt to the head, face, neck, or body that may or may not involve loss of consciousness (McCrory et al., 2013). Concussion has received more attention in recent years, particularly with respect to sports injuries.
The roles of speech-language pathologists and audiologists in concussion prevention and management—including baseline testing and "return to learn" protocols—have become more prominent, especially in the school setting (Halstead et al., 2013; Hotz et al., 2014).
Incidence of pediatric TBI refers to the number of new cases identified in a specified time period. Prevalence of TBI refers to the number of children who are living with the condition in a given time period.
Incidence and prevalence rates of pediatric TBI vary across clinical and epidemiological studies. These variations are often due to differences in participant characteristics (e.g., ages included), diagnostic classification criteria within and across subtypes (e.g., mTBI vs. severe TBI), and sources of data (e.g., hospital admissions, emergency room visits, general practitioner visits). Moreover, current statistics do not take into account children and adolescents who do not seek medical care. Therefore, these estimates may significantly underestimate the incidence and prevalence of pediatric TBI.
Regardless of variations, TBI is the leading cause of disability and death in children ages 0–4 years and adolescents ages 15–19 years (CDC, 2015). Also, it is estimated that 145,000 children and adolescents (ages 0–19 years) are living with lasting cognitive, physical, or behavioral effects of TBI (Zaloshnja, Miller, Langlois, & Selassie, 2008).
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.
See ASHA's Practice Portal page on Voice Disorders.
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:
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.
Causes of pediatric TBI are varied and appear to differ by age. The Centers for Disease Control and Prevention (CDC) identified the following leading causes of TBI in children and adolescents ages 0 to 14:
Falls and assault (e.g., shaken baby syndrome or other physical abuse) are the most common mechanisms of TBI in infants, toddlers, and preschoolers. TBI secondary to velocity injury (e.g., motor vehicle or bicycle accidents, sports injuries) occurs more often in elementary school children and adolescents (Faul et al., 2010).
Speech-language pathologists (SLPs) do not diagnose TBI; however, they play a key role in the screening, assessment, and treatment of children and adolescents with TBI. The professional roles and activities in speech-language pathology include clinical services (assessment, planning, and treatment), prevention, and advocacy, as well as education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for SLPs include the following:
As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.
Audiologists play a central role in the assessment, diagnosis, and rehabilitation of hearing and vestibular deficits in children and adolescents with TBI. See ASHA's Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles for audiologists include the following:
As indicated in the Code of Ethics (ASHA, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so.
Collaboration and teaming are integral to speech-language pathology and audiology service delivery for children with TBI. Integration of knowledge and skills from a variety of disciplines is essential for identifying functional abilities; determining the levels of supports needed across clinical domains and service delivery settings; maximizing outcomes; and facilitating transition back to home, school, and community. Team members may include physicians, physical and occupational therapists, teachers, neuropsychologists, and school psychologists.
Team models vary (see ASHA's resource on collaboration and teaming). The model selected will depend on the needs of the child and his or her family. The role that each team member plays will evolve as the child or adolescent develops and as his or her needs change.
The roles of the SLP and audiologist will be guided by each profession's scope of practice, discipline-specific training, ethical considerations, and state licensure regulations. See ASHA's resource titled, Evaluating and Treating Communication and Cognitive Disorders: Approaches to Referral and Collaboration for Speech-Language Pathology and Clinical Neuropsychology and ASHA's State-by-State web page.
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.
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.
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.
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:
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:
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.
When selecting standardized assessments, consider the following:
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.
See ASHA's Practice Portal page on Childhood Hearing Screening.
See assessment section of ASHA's Practice Portal page on Speech Sound Disorders: Articulation and Phonology
See assessment section of ASHA's Practice Portal page on Voice Disorders.
See assessment section of ASHA's Practice Portal page on Written Language Disorders.
See assessment section of ASHA's Practice Portal page on Social Communication Disorder.
See ASHA's Practice Portal page on Augmentative and Alternative Communication.
See assessment section of ASHA's Practice Portal page on Pediatric Dysphagia.
The comprehensive assessment typically results in one or more of the following:
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.
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).
The following may have an impact on the assessment of feeding and swallowing:
See also the assessment section of ASHA's Practice Portal page on Pediatric Dysphagia.
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.
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
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).
Each child with TBI has a unique profile of strengths and needs. In developing a treatment plan, clinicians consider age, previous levels of function, and developmental status as well as functioning in related areas, such as sensory and motor skills.
Speech, language, and/or cognitive deficits that existed prior to the TBI—such as attention-deficit/hyperactivity disorder, autism spectrum disorder, childhood apraxia of speech, acquired apraxia of speech, learning disabilities, speech sound disorders, spoken language disorders and written language disorders—must also be considered.
Treatment of children with TBI addresses abilities to function effectively in everyday real-life environments, including home, school, work, and community. Treatment can focus on developing and generalizing new skills, remediating lost functions, and/or addressing unwanted behaviors (Blosser & DePompei, 2003).
Children and families bring different cultural backgrounds, medical and developmental histories, learning styles, and experiences to the treatment setting. Treatment of children with TBI is individualized, is provided in the language(s) used by the individual, and is done so with sensitivity to cultural values and norms. See ASHA's Practice Portal pages on Bilingual Service Delivery, Collaborating With Interpreters, and Cultural Competence.
Consistent with the ICF framework (WHO, 2001), intervention is designed to
Family-centered practice is the foundation of intervention for pediatric TBI. Treatment outcomes and reintegration to home, school, work, and community for children with TBI are best achieved when family members and caregivers play a central role (DePompei & Williams, 1994). These individuals not only are responsible for making decisions that affect the child's life and education but also provide long-term supports (Roscigno & Swanson, 2011).
Family members and caregivers can be frightened, stressed, and overwhelmed by the magnitude of the medical situation, changes in the child they once knew, and the process of learning to care for a child with TBI (Wade et al., 2006). Effective education, training, and counseling require sensitivity to these emotions.
Family-centered practice can provide a way to improve the family's ability to adapt to changes brought about by the TBI by helping family members communicate openly, identify priorities, and learn how to problem-solve together (Wade, 2006; Wade, Wolfe, Brown, & Pestian, 2005).
With proper educational and emotional support, families learn to work with their children and provide support to help them manage the cognitive, behavioral, communication, and other life changes associated with TBI (Gan, DePompei, & Lash, 2013).
Family-centered practice provides opportunities for family members and caregivers to
The roles of family members and caregivers will vary based on individual needs, severity of injury, family circumstances, cultural dimensions, and attitudes, beliefs, and expectations (Roscigno & Swanson, 2011). See also ASHA's resource on family-centered practice.
A variety of treatment approaches can be used in intervention for children with TBI. These approaches are listed separately below but are not mutually exclusive. Often, aspects of more than one approach are integrated in the delivery of speech and language services.
Restorative approaches involve direct therapy aimed at improving or restoring impaired function(s) through retraining. Treatment is often hierarchical, exercising target-specific processes in the impaired domain before introducing more demanding higher-level tasks in that domain and eventually generalizing skills to more functional activities and tasks (ASHA, 2003; Sohlberg & Mateer, 2001).
Habilitative approaches target skills that have not yet developed. Habilitative interventions help children learn, keep, or improve skills and functional abilities following their injury rather than restore skills that they had mastered prior to injury. These approaches often are used in treatment when the injury occurs before some developmental milestones have been met (e.g., cognitive, speech and language, or swallowing). Skills that are not yet fully developed at the time of TBI may be particularly vulnerable post injury.
As cognitive, behavioral, academic, and social demands increase over time, children with TBI may demonstrate additional deficits not seen immediately following injury (Anderson et al., 2005; Gamino et al., 2009). Habilitative approaches may also be needed at this point to facilitate learning.
Compensatory approaches focus on adapting to deficits by learning new or different ways of doing things to minimize difficulties (National Institutes of Health [NIH], 1998). Compensatory approaches draw on the child's strengths to maximize his or her abilities, often through the use of external or internal aids (Blosser & DePompei, 2003; Shum, Fleming, Gill, Gullo, & Strong, 2011).
A compensatory approach to treatment may also include accommodations and/or modifications.
Accommodations are changes to the environment, task, or mode of response that allow an individual to access and participate in an activity without changing the activity itself. Academic accommodations are often needed for students with TBI so that they can demonstrate their knowledge without interference from their deficits (Bush & Burge, 2016; Childers & Hux, 2013).
Academic accommodations for students with TBI may include using note takers, listening to recorded lessons, receiving extra testing time, taking rest breaks, or reducing environmental noise and distractions in the classroom. An accommodation may be required as part of a Section 504 plan or an individual family service plan (IFSP) or IEP.
Modifications are changes to the nature of an activity to facilitate participation and promote success in home, community, academic, and work settings. Academic modifications can include changes in materials, curriculum content, or acceptable responses (New York State Education Department, 2002).
Modifications for students with TBI may include shortened class schedule or day, reduced number or type of assignment, or modified response type (e.g., multiple-choice questions instead of recall questions or short-answer questions).
Functional/contextualized approaches focus on personally meaningful goals, routines and activities with generalization of skills to relevant social, vocational, and educational activities. Contextualized interventions for children and adolescents with TBI are functional, personally relevant, nonhierarchical, and collaborative (Koole, Nelson, & Curtis, 2015). They involve teaming with educators, caregivers, and peers to facilitate carryover of skills to situations and activities of interest and importance to the child and family.
Functional goals take into account the child's and family's priorities and promote independence, generalization, and community competence across settings (Feeney & Ylvisaker, 2008; Sohlberg & Turkstra, 2011; Ylvisaker, Adelson et al., 2005).
Goal attainment scaling (GAS) is one collaborative approach for identifying and quantifying individualized, meaningful treatment outcomes using a point scale to objectively measure goal achievement (Kiresuk, Smith, & Cardillo, 2014). GAS is particularly applicable in TBI treatment that targets executive functions because it can help children identify their own goals, then plan and manage their related behaviors while engaging in everyday life activities (Grant & Ponsford, 2014).
The following are brief descriptions of both general and specific treatments for individuals with deficits and disorders associated with TBI. This alphabetized list is not exhaustive, and inclusion of any specific treatment does not imply endorsement by ASHA.
Augmentative and alternative communication (AAC) involves supplementing or replacing natural speech and/or writing with aided symbols (e.g., Picture Exchange Communication System [PECS], line drawings, Blissymbols, speech-generating devices, and tangible objects) and/or unaided symbols (e.g., manual signs, gestures, and finger spelling). AAC may be temporary—as when used by patients postoperatively in intensive care—or permanent—as when used by an individual with a disability who will need to use some form of AAC throughout his or her lifetime.
Factors that influence the selection and use of AAC systems following TBI include the child's communication abilities and needs as well as his or her cognitive, neurobehavioral, motor, sensory, and perceptual impairments (Fager & Spellman, 2010).
AAC intervention is an ongoing and dynamic process because the needs of the child following a TBI will vary over time, depending on the stage of recovery, presence of cognitive–behavioral changes, and communication needs in particular settings. The training of teachers, staff, and family members for the purpose of optimizing functional communication is also an essential part of AAC intervention (Fager & Spellman, 2010). See ASHA's Practice Portal page on Augmentative and Alternative Communication.
Behavioral interventions are used to teach desired behaviors and are based on behavioral/operant principles of learning (i.e., differential reinforcement, modeling, prompting, and fading). Injuries to the frontal lobe can result in behaviors such as agitation, aggression, impulsivity, and self-injury that interfere with a child's functioning in home, community, and school environments and his or her ability to communicate effectively. Behavioral interventions are often used to decrease these unwanted behaviors and teach functional alternative behaviors.
Post-TBI behavioral interventions include the following:
Cognitive-communication interventions in pediatric TBI can address discrete components of the child's cognitive-communication domains or focus more globally on functional communication. The complex relationship between cognitive and communication domains needs to be considered when selecting interventions. For example, poor insight into deficits may affect treatment buy-in, strategy use, or adherence to recommendations.
Cognitive-communication treatment methods can include direct remediation (e.g., breaking the target into discrete steps and sequentially completing a task) or strategy-based training and accommodations (e.g., training the individual to develop internal strategies to perform complex tasks; making changes in the classroom). Some treatment options fall into overlapping categories, and clinicians use the approach or approaches that best meet the needs of the child (Ylvisaker, Adelson et al., 2005; Turkstra et al., 2015).
Computer-assisted treatment refers to the use of specially designed software programs to improve cognitive-communication functions through repeated, structured practice of tasks related to attention, memory, problem solving, executive function, language, and speech. These programs are available for use on computers, smartphones, and tablets. Computer-assisted treatment can be used and monitored by a clinician in person or remotely, providing consistent feedback to the individual (e.g., Politis & Norman, 2016; Teasell et al., 2013).
This type of intervention does not refer to the use of computers or electronic devices (e.g., electronic memory aids or web-based organizational assistants) as external aids.
See considerations for selecting technology or related treatment products.
Direct attention training (DAT) provides structured opportunities for repeated practice to improve various aspects of attention, including sustained attention over time (vigilance), selective attention, divided attention, and the ability to shift attention (Sohlberg, 2002; Sohlberg et al., 2003). Repetitive drills provide opportunities for practice on tasks that impose increasingly more complex attentional demands (Sohlberg & Mateer, 2001; Sohlberg et al., 2003).
Metacognitive skills training is an integral part of DAT when used to treat cognitive-communication deficits in children with TBI (e.g., Lee, Harn, Sohlberg, & Wade, 2012; Sohlberg, Harn, MacPherson, & Wade, 2014).
Drill and practice is the repetition of a specific therapy activity or target. Repetitive drills practice assumes that neural networks underlying performance are strengthened by repeated activation (Sohlberg et al., 2014). Spaced or distributed practice is a drill-and-practice technique in which practice is broken up into a number of short sessions over a longer period of time. Recall and carryover of information is better when practice trials are spaced or distributed rather than massed (Sohlberg, Ehlhardt, & Kennedy, 2005; Sohlberg & Turkstra, 2011).
Dual task training focuses on improving task complexity by targeting the ability to carry out two competing tasks simultaneously. Dual task training aims to restore executive functions that are often affected by TBI; it is sometimes used to train tasks across both physical and cognitive-communicative domains (Valovich McLeod & Guskiewicz, 2012).
Errorless learning is a treatment method in which the clinician tries to minimize errors as the individual learns a targeted skill by
Errorless learning is most beneficial for individuals with relatively unimpaired procedural memory and severely impaired declarative memory (Sohlberg et al., 2005). Spaced retrieval (Sohlberg et al., 2005; Sohlberg & Turkstra, 2011) and method of vanishing cues (Sohlberg et al., 2005) are based on principles of errorless learning.
External aids are used to facilitate improved attention, time management, organization, and recall of events and information (Burns, 2004; Teasell et al., 2013). Headphones, computers, and handheld devices, including smartphones and voice recorders, may serve as functional external aids for children; low-tech options include calendars, timers, checklists, maps, color-coded binders, and small notebooks (Burns, 2004; DePompei et al., 2008). Training children with TBI to apply these strategies independently requires structured, sequenced, and repetitive practice and needs to take into consideration the child's level of deficit awareness (Sohlberg et al., 2007; Ylvisaker, 1998). Clinicians consider the most appropriate option for each individual when selecting and training use of external aids to facilitate cognitive-communication function in everyday activities (Wild, 2013, 2014).
Internal aids are mental strategies used to enhance memory and executive function. Examples include mnemonics, visual imagery, association, elaborative encoding, and chunking. For example, mnemonics and visual images can help improve recall for names (Kashel et al., 2002; OʼNeil-Pirozzi, Kennedy, & Sohlberg, 2015). With elaborative encoding, individuals learn to associate new information with related features or information already in memory (Oberg & Turkstra, 1998). Grouping or chunking information into logical categories can be used when large amounts of information need to be remembered (Kennedy, 2006).
Metacognitive skills training—also called metacognitive strategy instruction—focuses on improving awareness, self-monitoring, self-regulation, and use of goal-setting strategies to facilitate learning and behavioral success. Strategies such as mental imagery, self-talk, self-reflection, and keeping an agenda are used to work through problem situations, provide feedback, and track progress toward goals. Metacognitive skills training can be integrated with direct attention training (Kennedy et al., 2008; Sohlberg et al., 2005, 2014; Sohlberg & Turkstra, 2011).
Project-based intervention is used to help improve cognitive-communicative function and social engagement. Intervention facilitates participation in meaningful activities by involving individuals in a long-term, collaborative project that results in a tangible product. Projects often target competence in planning, organizing, social interaction, and self-regulation (Ylvisaker, Feeney, & Capo, 2007).
Sensory stimulation—also referred to as coma stimulation—is the systematic exposure of an individual with severe TBI to a variety of visual, auditory, tactile, olfactory, and kinesthetic stimuli to improve arousal/level of consciousness and prevent sensory deprivation. Intensity and frequency of stimulation can be tailored to a child's threshold in order to elicit a meaningful behavioral response following TBI and to monitor changes in responsiveness during recovery (Hotz et al., 2006).
Strategic learning intervention is the ability to organize, combine, and synthesize details from texts, lectures, or conversations in order to abstract the most important concepts. This skill typically develops in early adolescence; it is often deficient in youth with TBI, resulting in academic challenges. Strategic learning interventions for older children and adolescents focus on improving the ability to abstract gist-based meaning. Training is hierarchical and strategy based rather than content based, often incorporating text-based materials from the child's schoolwork. The Strategic Memory and Reasoning Training (SMART) program is one example of a strategic learning intervention that teaches the student how to eliminate unimportant information; summarizing information in one's own words; and consider multiple interpretations (Cook, DePompei, & Chapman, 2011).
In task analysis, a target skill is analyzed or broken down into a sequence of smaller steps that can be taught one step at a time and then chained together. In this way, tasks that seem complex and difficult to learn become more manageable as smaller units (Sohlberg et al., 2005). This process can be applied to skills in any of the cognitive-communication domains.
Language intervention for children with TBI takes into account the interconnection between cognition and communication (Blosser & DePompei, 2003). For example, impairments in processing speed, working memory, and executive function may contribute to deficits in language (Ewing-Cobbs & Barnes, 2002).
Language intervention varies, depending on the child's developmental level at the time of injury and the pattern of deficits that require intervention. For younger children, intervention tends to emphasize following directions, phonological awareness, vocabulary development, and word fluency for early literacy skills. For older children and adolescents, the emphasis is often on inferencing, higher-level comprehension, narrative and discourse processes, and academic or vocational literacy (e.g., summarizing text, taking notes). Regardless of age at injury, treatment goals for children with TBI might also address the appropriate use of social language in different contexts and under varying demands (Blosser & DePompei, 2003; Ewing-Cobbs & Barnes, 2002; Turkstra et al., 2015).
Although some traditional language stimulation techniques and treatments can be used with this population, not all are applicable for children with acquired language disorders. See ASHA's Practice Portal pages on Late Language Emergence, Spoken Language Disorders, Written Language Disorders, and Aphasia.
Social communication intervention for children and adolescents with TBI frequently focuses on training the child's communication partners (Togher, 2014; Togher, McDonald, Tate, Power, & Rietdijk, 2013; Togher, Power, McDonald, Tate, & Rietdijk, 2010; Ylvisaker, Turkstra, & Coelho, 2005; Ylvisaker & Feeney, 2007) and helping school personnel provide the necessary supports, structure, and instruction to help students learn (or relearn) appropriate behaviors and social skills in real-world communications (MacDonald & Wiseman-Hakes, 2010; New York State Education Department, 2002; New Zealand Guidelines Group, 2006).
Social communication intervention helps children develop conversation skills, learn appropriate pragmatic language norms (e.g., taking turns, remaining on topic, inhibiting confabulations), and practice impulse control necessary for improved social interactions (Burns, 2004; McDonald, Togher, & Code, 2014).
Intervention in the context of natural environments may incorporate supports such as structured feedback, use of videotaped interactions, modeling and role play, rehearsal and coaching, and training in self-regulation and self-monitoring strategies (MacDonald & Wiseman-Hakes, 2010; Sohlberg & Turkstra, 2011; Ylvisaker, Turkstra, & Coelho, 2005).
See ASHA's Practice Portal page on Social Communication Disorder, for additional information.
Speech problems resulting from TBI can include dysarthria, apraxia, phonation, resonance, respiration, articulation, and/or fluency disorders. Traditional approaches to remediation of theses clinical disorders can be used in children with TBI. See ASHA's Practice Portal pages on Childhood Apraxia of Speech, Acquired Apraxia of Speech, Speech Sound Disorders: Articulation and Phonology, Cleft Lip and Palate, Voice Disorders, and Childhood Fluency.
Intervention for speech problems may focus on the individual speech subsystems of respiration, phonation, articulation, and velopharyngeal function or, more globally, on overall speech intelligibility, using behavioral and instrumental treatments, prosthetics, compensatory strategies, AAC, and/or environmental modifications (McDonald et al., 2014; Morgan et al., 2010; Morgan & Vogel, 2008).
Children who are unable to use natural intelligible speech for communication (e.g., due to severe dysarthria or a voice disorder) may need long-term AAC (Doyle & Fager, 2011).
Some children with TBI may initially be unable to speak because they have had a tracheotomy. In these cases, a speaking valve may be used to facilitate voicing.
Underlying speech subsystems may still be developing at the time of injury in pediatric populations, or the child may have pre-existing speech deficits. Therefore, clinicians need to consider previous levels of function and developmental status when planning treatment. Cognitive status post injury is also considered, because a child may appear to have apraxia when the impairment is really one of higher-level executive functioning, initiation, and/or planning (Blosser & DePompei, 2003).
The primary goals of dysphagia treatment are to support safe and efficient oral intake and to ensure adequate nutrition and hydration. Age and developmental skill level at the time of injury are important considerations when designing feeding and swallowing treatment protocols and providing intervention, especially in infants and young children who can change so quickly (Mendell & Arvedson, 2016). See ASHA's Practice Portal page on Pediatric Dysphagia.
Clinicians also consider the child's cognitive-communication skills, oral–motor function, physical and sensory–perceptual limitations, behavioral deficits, and environmental supports in targeting dysphagia (Morgan, 2010; Morgan, Ward, & Murdoch, 2004; Morgan, Ward, Murdoch, & Bilbie, 2002). Decreased cognitive abilities (e.g., decreased insight for deficits, poor self-initiation, and difficulty implementing strategies) and behavioral challenges (e.g., impulsivity or agitation) may have a negative impact on the success of dysphagia treatment.
Changes in hearing and balance post injury have the potential to exacerbate other TBI effects, especially cognitive-linguistic and social communication deficits.
Treatment for hearing loss may include selection and fitting of amplification devices and training in the use of assistive technologies (e.g., frequency modulation [FM] systems in classrooms). Hearing aids, cognitive behavioral interventions, and/or sound masking may be used to manage tinnitus associated with TBI (Myers, Henry, Zaugg, & Kendall, 2009).
Vestibular rehabilitation programs aim to improve symptoms of vertigo and other balance-related problems following TBI (Teasell et al., 2013). Intervention may differ when balance and dizziness symptoms are due to post-concussion syndrome versus peripheral vestibular dysfunction; differential diagnosis is key to management and recovery (Doettl, 2015).
Treatment for auditory-related symptoms may also incorporate counseling regarding the use of coping and compensatory skills to minimize the effects of hearing and balance disorders and reduce safety risks.
Different dimensions of culture may influence the family's belief system in seeking care and external support (see ASHA's resource on examples of cultural dimensions ). For example, some cultures may have a sense of shame or feel it is necessary to hide a disability, which may influence how an individual and caregivers approach habilitation/rehabilitation.
Treatment is also sensitive to linguistic diversity and is 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).
Unlike school-age children, infants, toddlers, and preschoolers do have not have a single point of entry into a system for treatment after the acute phases of their injuries. Some eligible families will receive treatment through their state or local early intervention agencies; others will go to inpatient or outpatient programs. Early intervention typically occurs in the family's natural environment, taking into consideration the needs of the child with TBI as well as those of caregivers and siblings (McKinlay & Anderson, 2013).
Treatment with this population focuses on development of school readiness skills (H. G. Taylor et al., 2008). Differentiating between acquired and developmental disorders is an important consideration when identifying treatment goals and methods. Interventions for children with premorbid deficits in knowledge and skills will differ from interventions for children who have not yet developed certain knowledge or skillsets (Turkstra et al., 2015).
When the child reaches school age, it is important to alert staff at each new school about the child's medical history and the possible impact of TBI, so that necessary supports are put into place and behavioral or learning difficulties are not mistakenly attributed to some other cause (e.g., attention-deficit disorder or learning disability; Chapman, 2006; Gamino et al., 2009; Haarbauer-Krupa, 2012b; Turkstra et al., 2015).
Most children with TBI are, or will be, in school. Therefore, many speech and language interventions will target the cognitive-communication, behavioral, and social demands of the school environment.
The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) defines TBI as
. . . an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance. Traumatic brain injury applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; and speech [§300.8(c)(12)].
According to IDEA (2004), TBI "does not apply to brain injuries that are congenital or degenerative, or to brain injuries induced by birth trauma" [§300.8(c)(12)]. However, individual states may define TBI more broadly and may include children with nontraumatic acquired brain injury (e.g., stroke, brain tumor, anoxia) when determining eligibility for services.
Children with TBI can qualify for special education services with IFSPs, IEPs under IDEA, or Section 504 Plans under the Americans with Disabilities Act (see ASHA's resource on eligibility and dismissal in schools). Yet, more than half of these children do not receive school-based services or do not receive appropriate services due to
Health care and school-based SLPs can play a critical role in the identification of students with TBI who qualify for services by facilitating communication among medical professionals, educational professionals, and parents so that appropriate transition plans can be developed (Allison, Byom, & Turkstra, 2017; Allison & Turkstra, 2012; Denslow, Doster, King, & Rayman, 2012; Glang et al., 2008; Haarbauer-Krupa, 2012a, 2012b). Students with TBI may require specialized instruction and support, accommodations, and assistive technology to access the educational curriculum and demonstrate knowledge based on their cognitive-communication and academic needs.
Organizing a systematic return to school is central to the student's academic and social success (Sharp, Bye, Llewellyn, & Cusick, 2006). Some states follow well-established school re-entry protocols or have dedicated concussion/TBI transition teams. These teams include health care-based SLPs and school-based SLPs who attend IEP meetings and help plan for the child's return to school (Denslow et al., 2012; Glang, Tyler, Pearson, Todis, & Morvant, 2004; Newlin & Hooper, 2015; University of Oregon, n.d.; Ylvisaker, 1998; Ylviskaer et al., 1995, 2001).
School-based SLPs provide services to children and adolescents with a range of deficits post-TBI—from those with subtle but significant deficits to those that require full-time special education placement. In addition to providing direct intervention to facilitate "return to learn" from an academic and social perspective, the role of the school SLP in school entry/re-entry includes but is not limited to the following:
(Blosser & DePompei, 2003; Bush & Burge, 2016; Deidrick & Farmer, 2005; Dettmer, Ettel, Glang, & McAvoy, 2014; Duff, 2009; Duff & Stuck, 2012; Haarbauer-Krupa, 2012a, 2012b; New York State Education Department, 2002; Salvatore & Fjordback, 2011; Sohlberg & Ledbetter, 2016; Ylvisaker, 1998)
Youth with persisting cognitive and communication deficits post-TBI may continue to have problems as they transition to postsecondary education and to vocational and independent living settings (Todis, Glang, Bullis, Ettel, & Hood, 2011). The potential impact of persisting speech, language, cognitive, and social difficulties highlights the need for continued support to facilitate a successful transition to young adulthood. SLPs in all settings need to work closely with youth, family, school-based professionals, employers, and community members to plan and facilitate transitional supports. See ASHA's resource on transitioning youth.
Attention, memory, learning, executive function, and social–emotional impairments—coupled with self-regulation challenges—place students with TBI at greater risk for postsecondary failure (Kennedy, Krause, & Turkstra, 2008). For college students with TBI, learning to overcome cognitive-communication deficits can have a positive impact on personal and professional success later in life (Kennedy, O'Brien, & Krause, 2012).
Students with TBI whose injuries occur prior to vocational school or college have lower graduation rates than their nondisabled peers; those with transition plans that link them with disability services and support agencies are more likely to complete postsecondary programs (Todis & Glang, 2008). Disability support services staff may collaborate with SLPs to select courses, modify schedules, and implement accommodations (under Section 504 or similar plans, if applicable) that might include note takers, extended time for tests and assignments, and assistive technology (e.g., to help with reading and writing tasks).
The SLP can also support students with TBI transitioning to postsecondary education through individualized transition plans, interactive coaching, and environmental assessments that identify systems and services to facilitate studying, learning, organization, time management, social relationships, self-regulation, self-advocacy, and use of compensatory strategies (Kennedy & Krause, 2011; Turkstra, Gamazon-Waddell, & Evans, 2004; Volkers, 2015).
Because academic and vocational literacy demands increase during postsecondary transitions, SLPs can have a meaningful impact on outcomes in these areas as well (Krause, Byom, Meulenbroek, Richards, & O'Brien, 2015).
The nature of deficits associated with TBI creates unique challenges for youth in post-secondary community and/or work environments. Fatigue and sensory issues as well as deficits in oral communication, pragmatic language, literacy, attention, and memory are among the factors that may negatively affect independent living and performance in social and professional settings.
The SLP identifies current cognitive-communication deficits, determines how these may affect life skills and job performance, and then trains intervention strategies to minimize the impact of the deficits in functional settings (Bonelli, Ritter, & Kinsler, 2007). The SLP collaborates with a vocational rehabilitation therapist as appropriate, assessing and treating functional work and community-based skills in context and implementing necessary accommodations for maximum outcomes.
Each member of the collaborative, interdisciplinary team is responsible for components of integrated goal setting and strategy implementation designed to achieve the best functional outcome possible for children and youth with activity/participation limitations following TBI. In addition to determining the type of speech, language, cognitive, and swallowing treatment that is optimal for children and youth with TBI, SLPs consider other service delivery variables that may affect treatment outcomes, including format, provider, dosage, and setting. Service delivery decisions are made based on the child's communication and/or swallowing needs relative to his or her family, community, school, social, or work setting.
Format refers to the structure of the treatment session (e.g., group and/or individual; direct and/or pullout; integrated and/or consultative). The appropriateness of the treatment format often depends on service delivery setting, stage of recovery, severity of injury, and the primary goal at a particular point in the intervention process.
Formats in acute-care or rehabilitation hospitals will look much different from those that are school or community based. For example, initial treatment may involve one-on-one strategy training and/or practice in using AAC with family members only. However, once the child has made progress on these goals, group treatment may be considered to provide opportunities for generalization and practice.
Group therapy can also target cognitive domains and provide opportunities to initiate social interactions and engage in project-based learning in structured and natural environments with feedback from the clinician and peers (Hickey & Saunders, 2010; Teasell et al., 2013).
Telepractice may be another appropriate avenue of service delivery. Telepractice can focus on improving the child's functional abilities while offering support and training to caregivers, teachers, and employers in functional, everyday environments. Telepractice eliminates the need to travel and can facilitate practice, carryover, and generalization of skills in naturalistic contexts (Houston, 2013; Rietdijk, Togher, & Power, 2012; Turkstra, Quinn-Padron, Johnson, Workinger, & Antoniotti, 2012). See ASHA's Practice Portal page on Telepractice.
Provider refers to the person providing treatment (e.g., SLP, trained volunteer, caregiver, or teacher). Recommended practices follow a collaborative process that involves an interdisciplinary team including the child, family, caregivers, and professionals. Family, teachers, and significant others play a critical role in supporting and augmenting the treatment plan. When rehabilitation incorporates accommodations, modifications, and supports in everyday settings, SLPs often provide (a) information to help communication partners understand the child's needs and (b) training in how to use strategies to facilitate communication. Other professionals (e.g., physical therapists or occupational therapists) may also be involved in co-treatment of deficits. See ASHA's resources on family-centered practice, and collaboration and teaming.
Dosage refers to the frequency, intensity, and duration of service. Dosage depends on individual factors, including the child's arousal level and ability to tolerate therapy sessions, prognosis, stage in recovery, and frequency of other therapeutic activity (CDC, 2015).
Setting refers to the location of treatment and varies across the continuum of care (e.g., acute-care or rehabilitation hospital, home, school- or community-based).
Following time in acute-care hospital and rehabilitation settings, young children with TBI return home to receive services through early intervention, preschool, or community-based programs. Older children return to school, where long-term rehabilitation services are provided (Haarbauer-Krupa, 2012a, 2012b). The role of the SLP in the transition from hospital setting to school setting is key in identifying students who qualify for services and helping them access these services and any other necessary educational supports (Allison, Byom, & Turkstra, 2017; Allison & Turkstra, 2012; Denslow et al., 2012; Glang et al., 2008; Haarbauer-Krupa, 2012b; Savage, Pearson, McDonald, Potoczny-Gray, & Marchese, 2001).
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Pediatric Traumatic Brain Injury page.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Pediatric Traumatic Brain Injury (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Pediatric-Traumatic-Brain-Injury/.