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).

General Statistics

• In the United States, approximately half a million children ages 0–14 years (n = 473,947) are admitted to emergency rooms each year as a result of a TBI (Faul, Xu, Wald, & Coronado, 2010). The estimated annual number for TBI-related emergency room visits, hospitalizations, and deaths combined was 511,257 for this same age range (Faul et al., 2010).
• A review by Thurman (2016) reported a median estimated incidence of TBI of 691 per 100,000 children (0–24 years) annually based on U.S. emergency room visits.
• A review examining worldwide incidence rates of pediatric TBI revealed variations by country ranging from 47 to 280 per 100,000 children. Rates of hospital admission vary widely and are higher in the United States than in other countries (Dewan, Mummareddy, Wellons, & Bonfield, 2016).

Age

• In the United States, children ages 0–4 years had the highest estimated annual rates of TBI-related emergency room visits (1,256 per 100,000), followed by adolescents ages 15–19 years of age (757 per 100,000; Faul et al., 2010). These same trends were noted in a population-based study using combined data from emergency room visits, hospitalizations, and death (Koepsell et al., 2011).

Gender

• Across all age groups, the incidence rates of TBI are higher in boys than in girls (Faul et al., 2010; Keenan & Bratton, 2006; Langlois, Rutland-Brown, & Wald, 2006; Thurman, 2016). Based on combined data from emergency room visits, hospitalizations, and death, boys ages 0–4 years had the highest incidence rates of TBI (Faul et al., 2010).
• Thurman (2016) reported that boys (0–9 years) were 1.4 times more likely than girls to have a TBI. The male-to-female ratio increased to 2.2 for older children and young adults (10–20 years).
• Although the overall rates of TBI are generally higher in boys than in girls, the incidence of mTBI is on the rise for girls (Lincoln et al., 2011). In high school and collegiate athletics, girls have higher concussion rates than boys in sports played by both sexes (Covassin, Moran, & Elbin, 2016; Dick, 2009; Hootman, Dick, & Agel, 2007; Marar, McIlvain, Fields, & Comstock, 2012).

Severity

• Approximately 80% of TBI across the lifespan is categorized as mTBI (Bazarian et al., 2005; CDC, 2003; Wortzel & Granacher, 2015). These same trends are reported in children with mTBI occurring in 692 of 100,000 children aged 0–15 years (Guerrero, Thurman, & Sniezek, 2000) and in 296 of 100,000 children aged 0–17 years (Koepsell et al., 2011). Koepsell et al. (2011) reported lower incidence rates for moderate, severe, or fatal TBIs (0.8 per 100,000 children). Within this same group, the incidence rates were highest for children (aged 15–17 years). A study examining causes and trends of TBI-related hospitalizations in adolescents in the United States (n = 139,798) revealed that 46% of patients were categorized as mild, 38% as moderate, and 16% as severe (Asemota, George, Bowman, Haider, & Schneider, 2013).
• Each year, approximately 1 in 220 children are seen in emergency rooms as a result of a concussion (Meehan & Mannix, 2010).

Signs and symptoms vary depending on the severity of the TBI; Diagnostic and Statistical Manual of Mental Disorders [5th ed.; American Psychiatric Association, 2022]; CDC, 2015; Haarbauer-Krupa & Brink, 2020).

Although some children with TBI maintain typical developmental progression, others may have long-term cognitive difficulty.

Long-term effects happen because the pediatric brain is still developing (Agrawal et al., 2026). For example, sensory systems and the frontal lobes of the brain develop in childhood and continue to develop through late adolescence and into the second decade of life (S. J. Taylor et al., 2013).

Pediatric TBI often affects academic performance (Kingery et al., 2017). Monitoring children with TBI as academic demands increase is important (e.g., moving from elementary to middle school). As demands increase, deficits may become more apparent when they impact a child’s ability to achieve.

Functional difficulties include learning new information and negotiating complex social interactions (Anderson et al., 2012; Turkstra et al., 2015). These difficulties can affect multiple factors (Allonsius et al., 2024; Lundine et al., 2026; Shankar et al., 2018; Wehman et al., 2014). Such factors may include

• educational and vocational outcomes;
• friendships;
• home, school, and community participation; and
• overall quality of life and transition to adulthood (Catroppa & Anderson, 2009).

The full sequelae of pediatric TBI can emerge and/or persist well into adulthood, which is why pediatric TBI should be considered a chronic disease process rather than a one-time event (DePompei, 2010; Masel & DeWitt, 2010).

Considerations for Infants and Toddlers With TBI

Infants and toddlers may lack the communication or developmental skills to report signs and symptoms of TBI. Sometimes, there are no apparent external physical signs to indicate a TBI, and attention to behavioral symptoms is critical (Cox, 2016). Clinicians and caregivers 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

Per Dupont et al. (2024), postconcussive symptoms may include

• somatic (e.g., dizziness, headache),
• cognitive (e.g., confusion, poor concentration),
• affective (e.g., anxiety, sadness), or
• sleep related (e.g., fatigue, drowsiness) in nature.

For more information regarding the signs and symptoms of concussion in this population, please see Dupont et al. (2021) and Beauchamp et al. (2024).

Many cognitive skills are undeveloped in infants and toddlers, and TBI can affect the development of these skills. This population must be carefully monitored, as signs and symptoms may become apparent later in life as expected skills fail to develop or emerge more slowly (e.g., when a child is challenged academically; Anderson et al., 2005; McKinlay & Anderson, 2013).

The neurodevelopmental and physical characteristics of infants and toddlers can increase the risk of TBI as compared to adults (e.g., larger head-to-body ratio than adults or older children).

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

The 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 aged 0–14 years:

• falls
• struck by/against events
• motor vehicle accidents
• assault
• unknown/other

Falls and assault (e.g., abusive head trauma 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).

Roles and Responsibilities of the SLP

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, 2016).

Appropriate roles for SLPs include the following:

• Providing prevention information to individuals and groups known to be at risk for TBI as well as to individuals working with those at risk.
• Screening children with TBI for hearing, speech, language, cognitive-communication, and swallowing difficulties.
• Determining the need for further and ongoing assessment and/or referral for other services.
• Considering and being responsive to a person’s culture, linguistic background, and social determinants of health across the continuum of care.
• Gathering and reporting treatment outcomes, documenting progress, and determining appropriate discharge criteria.
• Facilitating the transition of services between medical, educational, community, and vocational settings.
• Counseling people with TBI and their caregivers on impairments and providing education to prevent further TBI complications.
• Providing training (e.g., in the use of augmentative and alternative communication [AAC] systems) to people with TBI and their caregivers and educators.
• Serving as an integral member of an interdisciplinary team working with individuals with TBI and their caregivers, including participating as a member of the school planning/individualized education program (IEP) team to determine eligibility, appropriate educational services, and transition planning.
• Consulting and collaborating with other professionals (e.g., teachers, neuropsychologists, occupational and physical therapists) to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate.
• Advocating for individuals with TBI and their families, particularly in school settings where cognitive-communication disorders may be mistaken for attitudinal or motivational problems.
• Educating other professionals, third-party payers, and legislators about the needs of children with TBI and the role of SLPs in diagnosing and managing speech, language, cognitive-communication, and swallowing disorders associated with TBI across settings.
• Remaining informed of TBI research and helping advance the knowledge base related to the nature and treatment of cognitive-communication and swallowing deficits associated with TBI.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Roles and Responsibilities of the Audiologist

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:

• Educating other professionals about the needs of children with hearing and vestibular/balance deficits post-TBI and the role of audiologists in diagnosing and managing them.
• Identifying hearing and vestibular/balance deficits post-TBI, including early detection and screening program development, management, quality assessment, and service coordination.
• Considering and being responsive to a person’s culture, linguistic background, and social determinants of health across the continuum of care.
• Referring the child with TBI to other professionals as needed to facilitate access to comprehensive services.
• Evaluating children with hearing and vestibular deficits post-TBI for candidacy for amplification and implantable devices, assistive technology, and vestibular rehabilitation.
• Fitting and maintaining amplification and implantable devices and assistive technology for optimal use.
• Developing and implementing an audiologic and/or vestibular rehabilitation management plan.
• Creating documentation, including interpreting data and summarizing findings and recommendations.
• Counseling the child with TBI and their family regarding the psychosocial aspects of hearing loss and other auditory processing dysfunction, modes of communication, and processes to enhance communication competence.
• Providing communication skills training for families and other professionals who interact with the child.
• Advocating for the communication needs of all individuals, including advocating for the rights to and funding of services for those with hearing loss, auditory disorders, and/or vestibular disorders.
• Remaining informed of TBI research and helping advance the knowledge base related to the nature, identification, and treatment of hearing and vestibular deficits post-TBI.
  As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists who serve this population should be specifically educated and appropriately trained to do so.

Collaboration and Teaming

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 support 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 their family. The role that each team member plays will evolve as the child or adolescent develops and as their needs change.

The roles of the SLP and the audiologist will be guided by each profession’s scope of practice, discipline-specific training, ethical considerations, and state licensure regulations. See ASHA's State-by-State for more information.

For further reading, please see Haarbauer-Krupa et al. (2017) and Alessi et al. (2026).

Children and adolescents with TBI have varied and complex sequelae that can change over time. Assessment considers the child’s behaviors, strengths, and needs over the course of development and rehabilitation, including school and community reentry. It is helpful to focus childhood assessment on areas that are 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 webpage on Interprofessional Education/Interprofessional Practice (IPE/IPP).

Note that mental health concerns are common after pediatric TBI (Max et al., 2022), and clinicians should look for potential indicators (e.g., premorbid history of psychiatric disorder) and refer to appropriate health care providers (e.g., psychiatrists and psychologists) as necessary.

Screening

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

Screening identifies the need for further assessment but does not provide a detailed description of severity or symptoms. Screening may result in recommendations for rescreening, comprehensive assessments, or referral for other examinations or services.

Audiologic Screening

Hearing screening and otoscopic inspection ideally occur prior to screening for other deficits. If the child has a history of hearing loss, they would not be appropriate for hearing screening. In this case, follow-up audiologic assessment would be appropriate to determine if the TBI added to the existing hearing loss.

Hearing screening is within the SLP scope of practice. See ASHA’s Practice Portal page on Childhood Hearing Screening.

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 assess auditory processing, tinnitus, and vestibular function as indicated. See ASHA’s Practice Portal pages on Hearing Loss in Children, Hearing Loss in Adults, 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 that involves such interviews can also occur in the school setting prior to SLP involvement. In this case, screening may identify previously unrecognized TBIs and/or indicate SLP involvement in assessment and treatment (Perrier et al., 2026). Screening is conducted in the language(s) used by the child and family, with consideration of 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 determine appropriate interventions. The specific focus of a comprehensive assessment can vary depending on the child’s current age and the child’s age at the time of injury, the injury’s severity, 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)
• awareness of deficits
• presence of coexisting premorbid conditions, such as attention-deficit/hyperactivity disorder, learning disabilities, and developmental disabilities
• social determinants of health (e.g., insurance status, location, access to transportation; see ASHA’s page on Social Determinants of Health for further information)

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 Hearing Loss in Children and Hearing Loss in Adults.)

Assessment Methods

Comprehensive assessment uses 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. Functional assessment that includes information from multiple sources (e.g., caregivers, teachers) should be considered to give a better idea of the child’s specific areas of need and how they function in situations that are relevant to their lives (Riccardi et al., 2022).

Ongoing monitoring of cognitive function is necessary due to potential developmental impacts, latent presentation of deficits, and changing environmental expectations (Haarbauer-Krupa et al., 2017).

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 et al., 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 subtle difficulties in children with mTBI (Lundine, Ciccia, & Brown, 2019).
• 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 the level of functioning in everyday situations (Blosser & DePompei, 2003; Coelho et al., 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 can supplement data from standardized tests. Due to the limitations in standardized assessments, nonstandardized assessment is a critical component of any comprehensive evaluation for youth with TBI.

Nonstandardized measures that focus on process rather than content knowledge may provide valuable information for targeting interventions and identifying effective treatment strategies (Turkstra et al., 2015). These procedures may provide information about the ability of children with TBI to function in real-world contexts (Hall et al., 2021).

Nonstandardized assessments can add insight into a school-age child’s functioning in natural environments (Lundine & Hall, 2020) and may answer questions such as the following:

• 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

• Guided credible history interviews—a nonvalidated informal set of interview questions that can help a school-based team identify children with TBI who have not been formally diagnosed. Per McCart et al. (2023), these interviews help verify
  • that a TBI occurred and
  • if the student’s behavior and/or learning has been impaired as a result of the injury.
• 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 the individual and on their family/caregivers.
• Social determinants of health (SDOH)—nonmedical variables that form our big picture of health.
• Goals and priorities of the individual and their family/caregivers.
• Linguistic exposure and background, including which dialect(s)/language(s) they use and in what contexts they use them.

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 the lips, tongue, jaw, and velum.
• Symmetry of structures of the face, oral cavity, head, and neck at rest and during speech.
• Sensation of the 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.

Speech Sound Assessment

See the Assessment section of ASHA’s Practice Portal page on Speech Sound Disorders: Articulation and Phonology.

Motor Speech Assessment

See the Assessment sections of ASHA’s Practice Portal pages on Childhood Apraxia of Speech and Acquired Apraxia of Speech.

Voice Assessment

See the Assessment section of ASHA’s Practice Portal page on Voice Disorders.

Spoken Language Assessment

See the Assessment sections of ASHA’s Practice Portal pages on Spoken Language Disorders and Late Language Emergence.

Written Language Assessment

See the Assessment section of ASHA’s Practice Portal page on Written Language Disorders.

Social Communication Assessment

See the 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 they attempt 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 (AAC).

Feeding and Swallowing Assessment

See the Assessment section of ASHA’s Practice Portal page on Pediatric Feeding and Swallowing.

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, such as
  • 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 the Assessment sections of ASHA’s Practice Portal pages on Hearing Loss in Children and Hearing Loss in Adults.

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 potentials (VEMPs), and the subjective visual vertical (SVV) test.
• Videonystagmography (VNG; Wintrow, 2013).

See the Assessment sections of ASHA’s Practice Portal pages on Balance System Disorders and Tinnitus and Hyperacusis.

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 reentry 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 and from school age to the workplace).

Assessment Considerations

Cultural and Linguistic Factors

Assessments are informed by a person’s cultural and linguistic background and are completed in the language(s) used by the individual with TBI (see ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Cultural Responsiveness; and Collaborating With Interpreters, Transliterators, and Translators). TBI may affect each language used by the child in different ways. Therefore, information about all languages 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.

Conversational and nonverbal norms vary widely across cultures. Clinical judgment should not be based solely on the clinician’s experience of what is appropriate or should be expected. Instead, clinicians consider each child’s cultural and linguistic norms when assessing factors that require subjective judgments (e.g., initiation and response time, turn-taking in conversations, topic maintenance).

Cognition and Language

TBI often causes deficits in cognition and language. It is important to recognize the overlap and distinctions between these two domains. Language impairment 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.

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 the age of the child)
• extent and severity of trauma
• location of damage (e.g., frontal lobe and occipital lobe)
• physical damage to the oral, pharyngeal, and/or laryngeal structures
• respiratory status, including the presence of tracheostomy and/or use of mechanical ventilation (Morgan, 2010; Morgan et al., 2003, 2010)

See also the Assessment section of ASHA’s Practice Portal page on Pediatric Feeding and Swallowing.

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 Balance System Disorders.

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 (Haarbauer-Krupa & Brink, 2020). Cognitive-communication skills are still developing during this period, making symptoms difficult to evaluate, particularly in preverbal children. Ongoing assessment at various points post-injury is critical to monitor for emerging deficits, particularly as cognitive-communication demands increase. It is also essential that caregivers understand the necessity of informing schools about the child’s TBI as they transition to formal schooling (i.e., kindergarten). Structured interviews with parents or caregivers of preschool-age children may help provide information about symptoms (Lundine, Ciccia, & Brown, 2019).

There are few standardized tests for young children with TBI (Haarbauer-Krupa & Brink, 2020); 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,
• the developmental stage at the time of injury, and
• the developmental stage at the time of assessment (McKinlay & Anderson, 2013).

Assessment of School-Age Children and Transitioning Youth

Social skills and academic performance are considered during assessment (Riccardi et al., 2025). Academic success is connected to each child’s social, behavior regulation, and cognitive abilities. Demands on cognitive and social skills increase as children graduate from each grade level. For this reason, deficits that went unnoticed at an early age might become apparent as the child gets older (Crook et al., 2023).

Ideally, cognitive-communicative development is monitored through high school and during the transition to postsecondary educational or vocational settings to help identify any previously missed deficits. Strategies to maximize functional outcomes and life participation can be implemented as deficits are discovered.

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.

Preexisting cognitive-communication deficits, including, but not limited to, attention-deficit/hyperactivity disorder and autism spectrum disorder, should also be considered.

Treatment is ideally functional and individualized. It addresses the ability to effectively function in everyday environments (e.g., home, school, work, and community). Treatment can focus on developing and generalizing new skills, remediating lost functions, and/or addressing unwanted behaviors (Crook et al., 2023).

Every child and family has a unique set of circumstances (e.g., cultural background, medical and developmental history, learning styles, social determinants of health) that can affect treatment. Treatment is individualized; provided in the language(s) used by the individual; and done with consideration of their values, needs, and preferences. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness.

Family-Centered Practice

Family-centered practice is the foundation of intervention for pediatric TBI. Treatment outcomes and reintegration into home, school, work, and community environments for children with TBI are best achieved when family members and caregivers play a central role (Lundine, Utz, et al., 2019). These individuals are responsible for making decisions that affect the child’s life and education and 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 their child, 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.

Per Lundine et al. (2026), caregivers may have the following concerns:

• TBI leads to lasting changes in the child.
• The health care environment is overwhelming.
• TBI forces a shift in caregiver responsibilities.
• School challenges persist over time.

Family-centered practice targets the family’s ability to adapt to changes brought about by TBI. Clinicians can assist by helping family members communicate openly, identify priorities, and learn how to solve problems together.

Proper education and emotional support can help bolster families’ innate ability to work with and assist their children. This assistance can help them manage the cognitive, behavioral, communication, and other life changes associated with TBI (Gan et al., 2013).

Family-centered practice provides opportunities for family members and caregivers to

• identify treatment goals and implement techniques and strategies to facilitate generalization of therapy gains to everyday life and improved function in the home and community,
• exchange information with professionals to learn from one another and make informed decisions that will maximize treatment outcomes, and
• advocate for their child by providing important information about performance in the home and school as the child progresses through transitions (e.g., from fifth to sixth grade).

The roles of family members and caregivers vary based on individual needs; the severity of injury; family circumstances; cultural dimensions; and attitudes, beliefs, and expectations (Roscigno & Swanson, 2011). See also ASHA’s resource on focusing care on individuals and their care partners.

For further information, please see Jenkin et al. (2022, 2025) and Laatsch et al. (2020).

Treatment Approaches

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.

For further information related to treatment for pediatric TBI, see Laatsch et al. (2020) and Crook et al. (2023).

Restorative Approaches

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

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

Compensatory approaches focus on adapting to deficits by learning new or different ways of doing things to minimize difficulties (National Institutes of Health, 1998). Compensatory approaches use a child’s strengths to maximize their abilities, often through the use of external or internal aids (Blosser & DePompei, 2003; Shum et al., 2011).

A compensatory approach to treatment may also include accommodations and/or modifications.

For further information, please see Ylvisaker and Feeney (1998).

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 can help students with TBI demonstrate their knowledge and skills by reducing the impact of injury-related challenges, allowing them to engage with learning in ways that reflect their true capabilities (Childers & Hux, 2013).

Academic accommodations for students with TBI may include

• using notetakers,
• listening to recorded lessons,
• receiving extra testing time,
• taking breaks to rest, or
• reducing environmental noise and distractions in the classroom.

An accommodation may be required as part of a Section 504 plan or as part of an individualized family service plan (IFSP) or individualized education program (IEP).

Modifications are changes to the nature of an activity to facilitate participation and promote success in home, community, school, 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).

External Aids

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 use 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 the use of external aids to facilitate cognitive-communication function in everyday activities (Wild, 2013, 2014).

Internal Aids

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 (Kaschel et al., 2002; OʼNeil-Pirozzi et al., 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).

Functional/Contextualized Approaches

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 et al., 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 consider the child’s and caregivers’ 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 by using a point scale to objectively measure goal achievement (Kiresuk et al., 2014). GAS targets executive functions by helping children identify their own goals and plan and manage their related behaviors while engaging in everyday life activities (Grant & Ponsford, 2014).

Treatment Options

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 the inclusion of any specific treatment does not imply endorsement by ASHA.

Augmentative and Alternative Communication (AAC)

AAC involves supplementing or replacing oral 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).

Factors that influence the selection and use of AAC systems following TBI include the child’s communication abilities and needs as well as their cognitive, neurobehavioral, motor, sensory, and perceptual impairments (Fager & Spellman, 2010).

AAC intervention is an ongoing and dynamic process because the needs can vary over time, depending on the stage of recovery, the 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 (AAC).

Behavioral Intervention

Behavioral intervention is used to teach desired behaviors and is 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 with their ability to communicate effectively. Behavioral interventions are often used to decrease unwanted behaviors and teach functional alternative behaviors.

Post-TBI behavioral interventions include the following:

• Proactive positive behavior interventions and supports (PBIS; e.g., structuring the environment, adjusting tasks to ensure success, and providing well-understood daily routines) that focus on preventing and controlling antecedents in the environment rather than reacting to problem behaviors (Ylvisaker, Turkstra, et al., 2007).
• Contingency management procedures that focus on the consequences of behaviors (i.e., differential reinforcement of positive behaviors and extinction procedures through planned ignoring of negative behaviors; Ylvisaker, Turkstra, et al., 2007).
• Metacognitive skills training focuses on improving awareness, self-monitoring, and self-regulation of behaviors (Kennedy & Coelho, 2005).

Cognitive-Communication Intervention

Cognitive-communication intervention can address discrete components of the child’s cognitive-communication domains (e.g., memory, attention) or focus more globally on functional communication. Clinicians select interventions and use tools that are appropriate for the child’s current age and current level of development.

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). Treatment approaches may overlap. Clinicians use the approach or approaches that best meet the child’s needs (Turkstra et al., 2015; Ylvisaker, Adelson, et al., 2005).

Cognitive deficits can impact a child’s ability to participate in therapy. For example, poor insight into deficits may affect treatment buy-in, strategy use, or adherence to recommendations.

Computer-Assisted Treatment

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 cognitive domains (e.g., attention, memory), 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 et al., 2003; Sohlberg & Mateer, 2001).

Metacognitive skills training is an integral part of DAT when used to treat cognitive-communication deficits in children with TBI (e.g., Lee et al., 2012; Sohlberg et al., 2014).

Drill and Practice

Drill and practice is the repetition of a specific therapy activity or target. Repetitive-drills Using a repetitive drill-and-practice technique 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 several 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 et al., 2005; Sohlberg & Turkstra, 2011).

Drill and practice can be part of the learning process of a new skill. However, clinicians work to transfer these developing skills as soon as possible from drill into an ecologically valid environment (i.e., the classroom) to assist with generalization and learning.

Dual-Task Training

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-communication domains (Valovich, McLeod, & Guskiewicz, 2012).

Errorless Learning

Errorless learning is a treatment method in which the clinician tries to minimize errors as the individual learns a targeted skill by

1. breaking the targeted task down into small, discrete steps;
2. modeling target behavior before the person attempts each step;
3. discouraging guessing;
4. immediately correcting errors, modeling the correct step, and asking the person to do it again; and
5. carefully fading supports and prompts (Sohlberg et al., 2005; Sohlberg & Turkstra, 2011).

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 the method of vanishing cues (Sohlberg et al., 2005) are based on principles of errorless learning.

Metacognitive Skills Training

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 DAT (Sohlberg et al., 2005, 2014; Sohlberg & Turkstra, 2011).

Project-Based Intervention

Clinicians use project-based intervention to help improve cognitive-communication 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).

Disorders-of-Consciousness Treatment

Treatment for disorders of consciousness—previously 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 and level of consciousness and to prevent sensory deprivation. Intensity and frequency of stimulation can be tailored to a child’s threshold to elicit a meaningful behavioral response and to monitor changes in responsiveness during recovery (Hotz et al., 2006).

For further information, please see Slomine and Suskauer (2024) and Giacino et al. (2018).

Strategic Learning Intervention

Strategic learning intervention targets the ability to synthesize disparate information (e.g., from text, lectures) into core concepts. This ability typically develops in early adolescence; it is often deficient in youth with TBI and may result in academic challenges.

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, summarize information in one’s own words, and consider multiple interpretations (Cook et al., 2011).

For further information about collaborative intervention related to goals that are relevant to the child and their caregivers, please see Ylvisaker and Feeney (1998).

Task Analysis

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

Language deficits can exist in isolation or in conjunction with cognitive-communication deficits. For example, deficits in working memory may impact a child’s ability to fluently engage in conversation (Ewing-Cobbs & Barnes, 2002).

Language intervention varies depending on the child’s developmental level at the time of injury and their specific deficits.

For younger children, language intervention tends to emphasize

• following directions,
• phonological awareness,
• vocabulary development, and
• reading fluency for early literacy skills.

For older children and adolescents, the emphasis of language intervention 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).

For further information, see ASHA’s Practice Portal pages on Late Language Emergence, Spoken Language Disorders, Written Language Disorders, and Aphasia.

Social Communication Intervention

Social communication intervention for children and adolescents with TBI frequently focuses on training the child’s communication partners (Togher, 2014; Togher et al., 2010, 2013; Ylvisaker & Feeney, 2007; Ylvisaker, Turkstra, & Coelho, 2005). It also focuses on 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 pragmatic language norms (e.g., taking turns, remaining on topic, inhibiting confabulations), and practice impulse control necessary for improved social interactions (Burns, 2004; McDonald et al., 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 Intervention

Speech intervention addresses problems that result from TBI, such as dysarthria, apraxia, phonation, resonance, respiration, articulation, and/or fluency disorders. Traditional approaches to remediation of these 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 Stuttering, Cluttering, and 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 effectively communicate with speech or sign (e.g., due to severe dysarthria, a voice disorder, or motor issues) may need 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 preexisting 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).

Feeding and Swallowing Intervention

Feeding and swallowing intervention aims 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 Feeding and Swallowing.

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 et al., 2002, 2004).

For further information, please see Glisson et al. (2026).

Hearing and Balance Intervention

Hearing and balance intervention addresses changes in hearing and balance post-injury. Such changes can potentially exacerbate other TBI effects, especially cognitive–linguistic and social communication deficits.

Treatment for hearing loss may include selection and fitting of amplification or implantable 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.

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.

See ASHA’s Practice Portal pages on Balance System Disorders, Tinnitus and Hyperacusis, Classroom Acoustics, Hearing Loss in Children, and Hearing Loss in Adults.

Treatment Considerations

Cultural and Linguistic Factors

Culture and language influence how a child communicates, learns, and interacts, and cultural and linguistic norms vary greatly from family to family. Effective treatment plans take these variables into account to help the child function best in their environment. Family beliefs, preferences, and access to resources help determine priorities in treatment, support authentic participation, and strengthen collaboration with caregivers.

Treatment is completed in the language(s) used by the individual with TBI and their caregivers, including counseling, education, and any written materials shared. See ASHA’s page on Social Determinants of Health and Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Cultural Responsiveness; and Collaborating With Interpreters, Transliterators, and Translators).

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

Preschoolers do not have a consistent point of entry into educational support systems following the acute stages of TBI. Children may receive services through early intervention programs, outpatient rehabilitation, or other community-based services depending on eligibility and local resources. Early intervention services are ideally provided in natural environments and emphasize family-centered care that addresses the needs of the child and their siblings and caregivers.

Intervention for young children focuses on maintaining development and building skills needed for participation in home, community, and future educational settings. The effects of TBI may not become apparent until developmental demands increase. Therefore, ongoing monitoring of communication, cognition, behavior, and social participation is critical throughout early childhood (Ciccia et al., 2019).

Clinicians consider the child’s developmental stage, pre-injury functioning, and family priorities when establishing treatment goals. The impact of TBI on a developing brain may differ from that of developmental disorders and may affect the rate at which new skills are acquired (Agrawal et al., 2026).

Families and professionals should communicate the child’s history of TBI to educational teams as children approach school entry and progress through new educational environments. Ongoing collaboration among health care providers, families, early childhood programs, and schools can help identify emerging difficulties and ensure timely supports as academic, social, and behavioral expectations increase (Dichiaro et al., 2023; Haarbauer-Krupa et al., 2023).

Treatment in the School Setting

School Entry/Reentry

Most children with TBI attend school or will attend school. As a result, treatment by a SLP often focuses on the educational environment. Children with TBI may demonstrate needs in areas such as language, cognitive-communication, pragmatics, executive functioning, social competence, behavior, and participation. School-based supports may need to be individualized based on the student’s profile and social and environmental contexts (Crook et al., 2023; Riccardi et al., 2022).

Children with TBI may qualify for special education and related services through

• individualized family service plans;
• individualized education programs under the Individuals with Disabilities Education Act of 2004, Part 300 (Part B) § 300.8(c)12 (U.S. Department of Education, n.d.); or
• Section 504 plans under the Rehabilitation Act of 1973, 29 U.S.C. § 794, Sec. §504.

School teams consider the student’s educational performance; functional communication; cognitive-communication needs; participation in academic and social routines; and need for accommodations, modifications, assistive technology, or specialized instruction.

Students with TBI may not be identified or supported immediately because symptoms can change over time. Additional needs may emerge as academic and social demands increase. “Hospital-to-school transition services, educational supports and services, and long-term follow-up must be individualized for students with acquired brain injury (ABI)” (Riccardi et al., 2021).

SLPs help facilitate communication among caregivers, medical providers, rehabilitation professionals, educators, and school teams. This collaboration can help identify students with TBI, contribute to the development of appropriate school reentry plans, and provide for ongoing monitoring of skills (Perrier et al., 2026). SLPs also educate caregivers, teachers, and other school personnel about

• TBI in general;
• the possible effects of TBI on learning, communication, behavior, and social participation; and
• the possibility that needs may emerge or change over time.

Collaboration among specialized instructional support personnel (e.g., physical therapists, SLPs) and the child, their caregivers, school staff, and other relevant partners will help manage difficulties and provide accommodations.

Organizing a systematic return to school is central to supporting the student’s academic and social participation. Return-to-school programs may be housed in health care settings, schools, or state agencies. Program structures differ in access, models of care, and how students are monitored over time. Children with TBI benefit from health care assessment and follow-up that includes parental involvement when returning to school (Haarbauer-Krupa et al., 2023).

Postsecondary Transition Planning

Youth with persistent deficits following TBI may continue to experience difficulties as they transition to other settings (e.g., postsecondary education, employment, independent living). Because the effects of childhood TBI can evolve as developmental and environmental demands increase, ongoing monitoring and individualized supports may be needed throughout adolescence and young adulthood. School- and community-based supports are ideally tailored to the individual’s strengths, needs, and future goals (Riccardi et al., 2021).

SLPs collaborate with multiple partners, including the individual, their families, educational teams, vocational personnel, and others to facilitate successful transitions to adulthood.

See ASHA’s resource on postsecondary transition planning and Riccardi et al. (2021).

Considerations for Transitioning to Postsecondary Education

Students with TBI may experience persistent deficits that can affect success in postsecondary education, vocational training, employment, and independent living. Ongoing assessment that considers communication, participation, and contextual factors can help identify supports needed to promote successful transition outcomes.

Transition planning may include connecting students and families with supports (e.g., community resources, disability support services) before graduation from high school. Students with acquired brain injury may require individualized educational supports and long-term follow-up because needs can change over time as academic, vocational, and social demands increase (Riccardi et al., 2021).

School and community professionals collaborate to identify accommodations and supports that facilitate participation and learning. Depending on the student’s needs and setting, accommodations may include extended time for testing and assignments; modified course schedules; and assistive technologies that support reading, writing, organization, and communication (Riccardi et al., 2021).

SLPs may support students transitioning to postsecondary education through

• individualized transition planning and goal setting;
• coaching and instruction related to executive functioning and self-management skills;
• support for studying, learning, organization, and time management;
• development of self-advocacy skills and understanding of available accommodations and supports;
• support for social communication, relationship building, and participation in academic and community settings;
• identification and implementation of compensatory strategies and assistive technologies; and
• collaboration with educational, vocational, health care, and community partners to coordinate services across settings.

Considerations for Transitioning to Community and Work

Youth with TBI experience unique challenges in postsecondary 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 teaches the individual strategies that can help minimize the impact of the deficits in functional settings (Bonelli et al., 2007). The SLP collaborates with a vocational rehabilitation therapist as appropriate, assessing and treating functional work and community-based skills in context and implementing the necessary accommodations for maximum outcomes.

Service Delivery

Format

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 the service delivery setting, stage of recovery, severity of injury, and 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 et al., 2012; Turkstra et al., 2012). It may also reduce barriers related to geography or the limited number of service providers in a family’s area with professional experience related to pediatric TBI. See ASHA’s Practice Portal page on Telepractice.

Provider

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 focusing care on individuals and their care partners and collaboration and teaming.

Dosage

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

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).

• For children with mild TBI/concussion, treatment typically is centered in school- or community-based settings.
• Following moderate–severe TBI, families and professionals initially collaborate in medical settings, where the focus is on survival, recovery, and rehabilitation. The Commission on Accreditation of Rehabilitation Facilities (CARF) has instituted detailed standards for service delivery in hospital-based pediatric TBI specialty programs to which SLPs must adhere. These programs are consistent with the World Health Organization’s International Classification of Functioning, Disability and Health framework (Commission on Accreditation of Rehabilitation Facilities, 2015; World Health Organization, 2001).

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 settings to school settings is key in identifying students who qualify for services and helping them access these services and any other necessary educational supports (Allison et al., 2017; Allison & Turkstra, 2012; Denslow et al., 2012; Glang et al., 2008; Haarbauer-Krupa, 2012b; Savage et al., 2001).

ASHA Resources

• Common Classifications of TBI
• New mTBI Guidelines for Young Children: What Do They Mean?
• Patient Information Handouts: Audiology Information Series
• Traumatic Brain Injury: A Primer for Professionals
• Traumatic Brain Injury [Consumer Information]

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• Brain Injury Association of America (BIAA)
• BrainLine.org
• Brain Trauma Foundation
• Frontiers: Understanding Traumatic Injury to the Human Brain
• HEADS UP (CDC)
• International Paediatric Brain Injury Society Toolbox
• Living Guideline for Pediatric Concussion
• Brain Links
• RCSLT: New Long COVID Guidance and Patient Handbook
• Return To School: Tools
• The Center on Brain Injury Research and Training
• The National Pediatric Acquired Brain Injury Plan

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Acknowledgments

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.

• Jean L. Blosser, EdD, MA, CCC-SLP
• Angela Hein Ciccia, PhD, CCC-SLP
• Roberta DePompei, PhD, CCC-SLP/A
• Kathryn Y. Hardin, MA, CCC-SLP
• Gillian A. Hotz, PhD, CCC-SLP
• Jennifer Lundine, PhD, CCC-SLP
• Peter J. Marincovich, PhD, CCC-A
• Devin L. McCaslin, PhD, CCC-A
• Kathleen A. Munroe, MS, CCC-SLP
• Adam Politis, MS, CCC-SLP
• Colleen Sheahan, AuD, CCC-A
• Taryn E. Townsend, SLPD, CCC-SLP
• Lyn S. Turkstra, PhD, CCC-SLP
• Mary Ann Williams-Butler, MA, CCC-SLP

ASHA seeks input from subject-matter experts representing differing perspectives and backgrounds. At times, a subject-matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

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/