Behavioral sequelae are also common after TBI in children. These can include impulsivity, personality changes, depression, anxiety, becoming easily frustrated, aggression, and sleep problems (147). These problems persist long term and are reported in 10% to 50% of children with TBI (148,149). Some authors report an increase of emotional and behavioral symptoms over time (149). Also, a number of authors note that those who sustain TBI are more likely to have a preinjury history of behavioral or psychiatric concerns (148,150). Behavioral problems can be significantly disabling even in the absence of significant mobility or ADL impairment (148). Behavioral problems appear to be more significant and more common in those injured at a younger age (150). Approaches to address behavioral concerns include providing structured environments and daily routines but allowing the individual to make choices when possible, as well as assisting in breaking down tasks to their component parts, providing cues or aids for organization, creating situations in which the individual will be successful, and helping the individual to communicate the need to escape a task or situation. Positive reinforcement of desired behaviors has also been used. Involvement of family members in the process is important (150,151). Various medication interventions have been tried in the past, but none has been shown to be ultimately superior to others in addressing this variety of behavioral symptoms. It is imperative that those working with the individual understand that the behavioral problems are neurologically based. Behavioral symptoms are strong predictors of family burden over time (149).


A variety of communication impairments can be seen after TBI in children. If there is focal injury in areas of the brain that control language, aphasia can be seen. Also, motoric impairment can contribute to dysarthria. In general, the communication impairments that are seen more commonly are due to other cognitive deficits, such as memory impairment and executive function concerns (150). Difficulties with response speed can contribute to a reduced rate of speech and, conversely, impulse control difficulties can result in a rapid rate of speech (152). Word finding and verbal learning deficits are common, potentially relating to memory impairment (150,153). Discourse, abstract language, and social interaction with language are all commonly impaired (150,154). Also, verbal working memory, which is commonly impaired, is important in acquiring language, reading, and arithmetic in children (155). Authors report that the ability to use language functionally is typically more impaired than one would expect from reported results of standardized intelligence testing (156).


The area of executive function is one that is commonly affected, even in children who have experienced a mild TBI. It also is one in which the full effect of the injury may not be manifest until the child has matured to the point when one would expect him or her to demonstrate these particular skills. Executive function is defined as the ability to manage and direct more modular cognitive abilities in order to set, manage, and attain goals (6). This includes problem solving, organization, self-monitoring and self-regulation, self-appraisal, and self-management. It has been suggested that children are particularly susceptible to impairment in executive function if injured, as they are experiencing rapid development in this area (6). Impairments of executive function are noted to be more severe in children injured at a young age (157).

Working memory is one of the first executive function areas to develop, emerging between 7 and 12 months of age. It involves being able to temporarily store some information while concurrently processing and retrieving other data (158). It has been shown to be impaired after TBI, and the degree of impairment relates to the severity of injury (6,155,158). Other areas commonly affected by TBI include the ability to inhibit, shifting set, planning, self-monitoring and control, decision making, social cognition, and behavioral self-regulation. The Behavior Rating Inventory of Executive Function (BRIEF) is a tool that uses parent and teacher ratings to evaluate the impact of executive dysfunction on everyday life (6). Interventions for executive dysfunction have not been rigorously studied. Some have suggested using an approach that breaks tasks into problem-solving steps. Also, the provision of a structured environment and expectations is important. Incentives for progress toward a goal can be helpful. It is imperative that parents develop an effective working relationship with their child's school program providers to have open communication around the issues of executive dysfunction and its impact on school programming (6,157,159).


It is not possible to totally separate social functioning from executive function; however, a separate comment on this important area will be undertaken here. A child's ability to effectively function within his or her social milieu is often significantly affected by TBI. Emotional lability is common (160). Often, children have difficulty interpreting social cues from others or recognizing the emotions being expressed (161,162). Janusz and colleagues (160) reported on social problem-solving skills in children with TBI. They found that although the children were able to articulate the social dilemmas, they chose less developmentally mature strategies as the best means to solve them and also used low-level reasoning to evaluate whether the strategies were effective. Social participation is also reported to be decreased in children with TBI compared to their typically developing peers. Bedell and Dumas (163) reported that 30% to 73% of the children with acquired brain injuries that they studied were restricted in at least one of the participation domains they evaluated. Family-reported institutional, social, and attitudinal barriers were more often contributing to this restriction than physical environmental barriers (163). One recent study reported that two-thirds of children and adolescents with TBI continued to experience difficulty in a variety of social settings at 2 years after injury. These challenges were associated with their behavioral symptoms (164).

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