Children are at significant risk for TBI. Did you know that 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 cross-fire gunshot wounds. 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.
What kinds of problems should the parent of a brain injured child be watching out for? 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 forgiveness 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 conditions make children more vulnerable than adults to sudden acceleration/deceleration injury to the brain.
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 5th 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 age 25. 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 neurobiological process.
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 its axons. This is one reason that children are more likely to develop epilepsy after head injury than adults. The theory goes that 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 it 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. Dr. Kennard 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 fully recovered, developed problems with spasticity and motor control later in their lives as their brains matured and when 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 preschoolers 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 while 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 can hold and we 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. That is why a lawyer handling a pediatric TBI case should not be in a rush to settle it, but should leave time for potential developmental delays to manifest themselves, and leave time to assess what interventions will cost and how effective (or not) they are for the child.
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 of 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 in a healthy child means the child is constantly acquiring new knowledge, new skills and new repertoires of behavior as he responds and adapts to his changing environment. A child with a TBI will manifest a pattern of disturbed development with difficulty acquiring and mastering new knowledge, skills, and behaviors.
The appropriate testing of a child who has suffered a significant TBI should include neurologic evaluation by a pediatric neurologist, psycho-social and 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).
What happens if the defendant’s insurance company wants to settle your child’s case? How does your lawyer ascertain the money value of the case and help ensure that the money is held in a safe way for the child as he or she ages? In a pediatric brain injury case the experts on damages 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 your lawyer should hire 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.
If you have suffered a serious head injury call (866)-668-9476 or contact us at firstname.lastname@example.org to find a Head Injury Lawyer to fight for the compensation you deserve.