| Interventions
for pediatric TBI include psychotherapy, speech
therapy, cognitive therapy, play therapy, art therapy
and movement therapy. They include education of
the parents and siblings on how the TBI of one child
is likely to affect him and the entire family system,
and how to cope. Interventions also include forming
a partnership between the family of the brain injured
child and key personnel at his school, such as the
principal, the school psychologist, the special
education director and the child’s current
teacher. |
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 Brain
injury is the leading cause of death and disability in children
aged 1 through 14. Every year approximately 1,000,000 children
in the United States suffer brain injury from motor vehicle
accidents, bicycle accidents, sports injuries, falls, physical
abuse by adults or gunshot. Approximately 80-85% of pediatric
brain injuries are “mild,” and involve very little,
if any, observable loss of consciousness. The other 15-20% are
ranked as moderate or severe, and do involve varying periods
of loss of consciousness and post-traumatic amnesia. While the
severity and permanency of a child’s problems correspond
to the degree of brain injury he suffers, it remains true that
any brain injury, however mild, can have serious consequences,
especially to a very young child. |
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The potential consequences of a pediatric
brain injury include disturbances of alertness, orientation,
sensory processing, attention, auditory memory, visual
memory, immediate memory, delayed memory, comprehension
of speech and non-verbal communication, speech production
and pragmatic use of language for communication, concept
formation, abstract reasoning, problem solving, ability
to process complex information, cognitive processing speed,
executive functions such as self-monitoring and organization,
motor speed, motor coordination, mood, behavioral self-control
and psycho-social functioning including the ability to
make and keep friends or work successfully in a group
setting. Brain injury is likely to alter the way the child
communicates and acts within the family, and may lead
him to violate established roles, rules and traditions.
Education of parents and siblings about brain injury and
its effects will enable them to develop the understanding,
patience and tolerance they will need to adapt to the
changes in the brain injured child.
When a child falls his skull is less likely to fracture,
because it is more bendable. What typically happens is
that his skull bones comes apart, something called a diastatic
fracture. The brain of a child is smaller and occupies
less of the fluid filled intra-cranial space than the
adult brain, creating extra room for it to bounce back
and forth against the inside of the skull during an event
of head trauma. The neck of a child is less muscular and
more floppy than the neck of an adult, and less able to
restrain the head from moving after it is subjected to
an external force. These two conditions make children
more vulnerable than adults to sudden acceleration/deceleration
injury to the brain. They create the potential for lethal
TBI when an abusive adult shakes a baby or toddler by
the chest. This feature of children is what leads neurologists
to caution parents not let elementary school children
head the soccer ball. Although heading an air filled soccer
ball is not going to kill a 4th grader, repeated heading
of soccer balls can cause cumulative micro-trauma to his
brain from whiplash with neurocognitive deficits.
At birth the fetal brain weighs about one pound. The full
grown adult brain weighs three pounds, but begins losing
cells in appreciable numbers and shrinking in volume sometime
between age 35 and 40. The period of maximum brain growth
and maximum learning (the time when children acquire the
ability to stand, walk and use language to understand
and communicate with others) occurs between ages 0-3.
As the child ages, his brain myelinates from back to front.
Myelination refers to the process by which the axons (the
nerve fibers that connect brain cells to each other in
complex networks) become gradually sheathed in a coat
of fatty material that insulates the nerve fibers and
enables them to send neural messages at phenomenal speeds.
Full myelination of the frontal lobes does not occur until
the early 20s. The unpredictable, erratic quality of teenage
behavior vs. the more reliable, responsible behavior of
young adults in their 20s is not merely an effect of hormones,
but a direct manifestation of this neurobiologic process.
The greater the myelination of the brain, the more efficiently
it will use neuro-chemical signaling to process and synthesize
information. Autism is a disorder in which the process
of myelination is stunted at an early age, so the child
suffers from “under-connectivity” of brain
cells. Consequently autistic children can only process
one form of sensory input at a time, and have difficulty
synthesizing what they hear and see, or what they think
and feel. Although the causes of autism may vary, there
is solid evidence that some cases of autism result from
exposure to mercury that occurred before thimerosal was
banned. Thimerosal, a mercury containing substance, was
used as the preservative for many childhood vaccines until
the late 1990s.
Whereas the adult brain is a something of a completed
product, the child's brain is still growing in volume,
still developing neural networks in response to genetic
cues and environmental stimulation, and still myelinating
it axons. This is one reason that child are more likely
to develop epilepsy after head injury than adults. The
theory goes one source of seizures is abnormal wiring
in the brain. After TBI, the brain of a child (which is
still growing and flooded with substances called nerve
growth factors) is much more likely to develop new, abnormal
nerve circuits than the completed brain of an adult, which
engages in very little regeneration.
The conventional thinking about pediatric TBI used to
be that the child's brain was incredibly resilient to
trauma, because it was much more "plastic" than
the adult brain, and could grow new cells and circuits
that enabled to overcome the effects of TBI. This thinking
turned out to be based on very thin ice. The basis for
the belief in unlimited neuro-plasticity of the child’s
brain was a study published by neurologist Margaret Kennard
in 1936 in the American Journal of Physiology. She took
a group of chimpanzees and created lesions (focal damage)
in the motor cortex of their brains, the part of the brain
responsible for generating skilled voluntary movements.
After a period of brief observation, she found that younger
chimps were more likely to recover their ability to perform
a skilled action than the older ones. She attributed this
to the fact that the brains of the younger chimps were
still growing. She developed this into a universal principle
applicable to human children and adults. In retrospect,
this was hardly a solid basis for jumping to the generalization
that all human children were more likely to overcome the
cognitive, motor, emotional, psycho-social and behavioral
consequences of a TBI than human adults. It even turns
out that long term observation of Kennard’s chimps
showed that the younger chimps she described as full recovered,
developed problems with spasticity and motor control later
in their lives as their brains matured, and they were
required to perform more complex motor tasks.
Beginning in the mid 1990s researchers began accumulating
data that directly challenged the validity of the so called
Kennard principle. The data was acquired by such persons
as Marjaleena Koskiniemi, Jeanette White, Barbara Benz
and Cynthia Beaulieu, who followed the progress of human
pre-schoolers and elementary schoolers who suffered a
TBI of equivalent severity, and charted their neuro-cognitive
development over time. One of their studies showed that
kids younger than 4 did worse over time than kids who
suffered TBI older than 4, and that kids younger than
7 did worse over time than kids who suffered a TBI older
than 7. The research showed that the younger the child
at the time of the TBI, the more likely she would grow
up with severe, permanent deficits. This is because the
developing brain of the toddler is the very foundation
of the intellectual house that will be built through pre-school,
grades K-12 and college. Significant damage to that foundation
will cause big problems with the house erected upon it.
The tricky part is that the damage will not be immediately
apparent and will manifest itself sporadically at critical
junctures of later life. Time will reveal all wounds.
While TBI in an adult manifests itself immediately or
very soon after the injury occurs, in children we actually
expect delayed manifestation of consequences, because
their brains are still in the process of developing and
acquiring foundations of knowledge that will be utilized
only later in life. This point cannot be emphasized enough.
Children are not little adults. When planning the future
for a child with a TBI, it is necessary to take into account
that the child will or may experience developmental delays
in the future that are not in evidence now. This point
was well made by Lehr and Savage in 1990 in a book chapter
called “Community and School integration from a
Developmental Perspective” as follows: “Unique
to pediatric brain injury is the possibility of delayed
onset of deficits. Since an injury may affect parts of
the brain that are in the process of developing or not
expected to be fully functioning for a long period of
time after injury, it is possible for injury effects to
not be apparent for even many years after onset.”
The modern thinking on this issue is the reverse of the
Kennard principle that the earlier in life the brain injury
occurs, the less likely the victim will experience significant
problems in the future. The modern thinking is that childhood
TBI sets the stage for difficulties, and potentially for
failures, at later ages, as the cognitive, social and
physical demands upon the developing child become increasingly
complex and burdensome. When children are young, their
frontal lobes are immature. When their parents help them
remember, execute, monitor and correct mistakes in their
daily tasks, the parents are essentially acting as frontal
lobes for their children. As the children transition from
elementary to middle school, the world (in the guise of
school) is beginning to make real demands on their frontal
lobes, i.e. on their ability to plan activities, organize
their time, take responsibility for completing tasks and
learning to review and correct their work. A TBI that
impairs the ability of a young child with respect to attention,
memory, organization, self-monitoring or emotional self-regulation,
is likely to manifest itself more and more as the child
moves into higher grades.
A child who falls behind in his work, grows frustrated,
cries, throws things and says he hates school, is going
to stress out his parents in many ways. Over time, his
parents will be spending more of their time helping him
cope, to the point where are not meeting responsibilities
to each other, to the brain injured child's siblings or
to their jobs. Over time, his parents will begin to show
anxiety, depression and other signs of stress and they
will need psychological helps. Now that we know what the
future is likely to hold, and can predict problems like
this, we have the ability to smooth out the bumps by being
proactive. It is now accepted that when a child suffers
a TBI, there is a need for early testing and intervention,
with continued testing and intervention as needed throughout
childhood and adolescence.
The basis for all of a child’s learning and behavior
is the brain, but evaluation of the child who has suffered
a brain injury, must encompass more than analysis of intellectual
functioning of his brain. It must take account the context
of the brain injury and the child’s stage of development.
The context of the brain injury includes all environmental
variables that affect his cognitive, emotional and social
functioning, such as his family and school situations,
as well as the amount of time that has elapsed since the
injury and any treatment he has received. Development
means the child is constantly acquiring new knowledge,
new skills and new repertoires of behavior as he responds
and adapts to his changing environment. To maximize the
recovery of a child with a TBI through the rehabilitation
process, the persons who are assessing him need to pay
attention to how the injury has affected the structure
and function of his brain; what positive and/or negative
environmental influences are shaping his condition and
how his condition is inducing others to act towards him(context);
and how his child development is affecting and being affected
by the brain injury.
The appropriate testing of a child who has suffered a
significant TBI should include neurologic evaluation by
a pediatric neurologist, cognitive evaluation by a pediatric
neuropsychologist, communication evaluation by a speech
and language pathologist, personality evaluation by a
clinical psychologist and learning evaluation by an educational
specialist. Evaluation should establish the child’s
pre-injury baseline of global functioning, compare the
child’s present level of functioning to his baseline
and to age related norms, identify strengths and weaknesses,
develop therapies to rehabilitate the child and develop
“compensatory” strategies for utilizing strengths
and overcoming or circumventing weaknesses during the
rehabilitation process. Testing should be redone periodically
to establish how the child is developing and progressing
with respect to cognitive, motor, emotional, social and
behavioral milestones. For this purpose, periodic evaluations
by a developmental pediatrician would be a good idea.
The medical professionals who care for brain injured children
tend to be compassionate and empathic people who can be
a source of knowledge and emotional support for the family
of the injured child. Their help will be needed to interface
with the child’s school, and with the child’s
employer(s) as he matures and enters the workforce. If
a legal claim or lawsuit for injuries was filed to obtain
compensation for the child’s brain injury, then
these same professionals will be needed to explain to
a judge or jury the nature of the injury and its effects,
as well as the child’s present and future needs
for care, therapy and assistance as he ages. Although
it may be hard to understand or accept, some medical professionals
are only willing to treat the child but refuse to participate
in any way in his lawsuit for damages, while others are
willing to do forensic evaluations and testify as experts,
but decline to treat the child. The number of medical
professionals willing to act in both capacities is relatively
small.
Aside from medical professionals, the family will need
assistance from lawyers and educational specialists to
work with the school. The lawyers who work with the school
to set up special education programs are expert on the
IDEA (the federal Individuals with Disabilities in Education
Act). Our office can refer the family to IDEA specialists,
but our specialty is not the IDEA but obtaining monetary
compensation from the defendant who injured our client
(if self-insured) or from his liability insurance company.
Our office handles damage claims against the negligent
party that injured the child, which could be the driver
of a car, van, bus or truck; a school district; a day
care center; or other. We undertakes the job of proving
the defendant was negligent in causing the child’s
brain injury and is legally liable for the child’s
pain, suffering and economic losses associated with medical
care, therapy, educational assistance and reduced earning
capacity as an adult. We also undertake the job of proving
who the child was, how he was likely to function in later
life absent the brain injury along with the present and
likely future consequences of the brain injury on his
functioning within and enjoyment of his life within the
realms of family, school, community, work, leisure and
recreation.
To do our job requires us to work directly with the family
of the injured child and his medical providers, and to
obtain the child’s birth records, family photos
and videos, grade transcripts, IQ tests, standard achievement
tests, medical records and therapy records. We must also
hire experts. Liability experts in fields such as human
factors and accident reconstruction, are necessary when
the defendant disputes liability for the injury. Damages
experts are always necessary, even when liability is admitted.
In a pediatric brain injury case, these experts typically
include a neurosurgeon, a neurologist, a neuropsychologist,
a pediatrician, an educational specialist, a vocational
rehabilitation counselor, a life care planner and an economist.
When it appears that a fair settlement can be made, our
office hires an expert in structured settlements and life
insurance annuities to make proposals for how to invest
the settlement proceeds into a tax free annuity that will
make guaranteed future payments for the child’s
welfare. In order to resolve a pediatric TBI case through
settlement, it is necessary to obtain the informed consent
of the parents and the approval of a Superior Court Judge
having jurisdiction over the civil claims of minors.
Children’s cases are complicated because a child’s
life is just beginning. When predicting how a brain injury
will adversely affect a child throughout his lifetime,
we must first predict what his life would have been like
absent the brain injury. This is not an easy task. A child
does not have the same kind of “track record”
of school accomplishments, work history, marriage, parenthood
or long term development of hobbies and avocations that
adults have. In predicting how a child would have developed,
absent his brain injury, one important source of information
is the capabilities, accomplishments, earnings and life
style of his parents. However, this is not conclusive,
because all individuals are different, and children have
the potential to exceed or depart from the kinds of lives
their parents put together for themselves. Although children’s
cases are challenging, they are also incredibly rewarding.
Children have an innocence adults do not have. While adult
clients are very articulate about their complaints, regrets
and frustrations, children tend to smile even when their
lives are difficult. Children represent human potential
and hope for the future. Helping a child get back onto
the right track with the right medical and educational
support team funded in a stable, secure manner by a fair
settlement or jury verdict, and knowing that our work
has helped give the child a fighting chance of having
the best possible life consistent with the limitations
of his brain injury, is our greatest reward. |
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