Mild to Moderate Injury
Children who sustain minor TBI may demonstrate few, if any, consequences, or they may complain of subjective complaints such as headaches, mild memory impairment, and fatigue. This constellation of symptoms is consistent with postconcussive syndrome. Although children with a mild TBI may not require a prolonged hospital stay on the rehabilitation unit, they may still have difficulty returning to school. The challenges these children may encounter include difficulty with timed tasks, impaired attention, and impaired memory. Subtle language dysfunction and impaired prosody of speech may be notable, as well as behavioral and personality changes. For these children, neuropsychological testing to identify any deficits is imperative, lest they be allowed to fall behind in their academic progress as the effect of the injury on their cognitive function goes unnoticed (168). It is encouraging, however, to note that by 1 year after injury, children who sustained a minor TBI rarely have impairment that continues to challenge them academically (265). In 2004, Hawley and colleagues identified a group of 67 school-age children who sustained TBI (35 mild, 13 moderate, 19 severe) and gathered 14 control subjects as well. They reported that two-thirds of the children with TBI exhibited significant behavioral problems and 76% of the children with behavioral problems also had difficulties with schoolwork (266). Another study has noted that children with mild TBI also demonstrate difficulties compared to typically developing peers in some areas of metacognition—specifically in their ability to recognize semantic anomalies in spoken sentences (267). A recent review article noted that the symptoms seen after mild TBI in children are not unique to mild injury, typically resolve, and are more likely to persist if there is intracranial pathology present or preexisting cognitive impairment (268). These findings suggest that although it is encouraging that so many children do well academically after sustaining mild TBI, caution must be taken to not overlook behavioral concerns or higher executive functions that may affect academic performance.
Moderate to Severe Injury
Outcome studies regarding children who sustained significant TBI have demonstrated overall fair recovery. One such study evaluating 30 subjects noted that only 1 out of the 30 subjects failed to become ambulatory by two or more years postinjury, and 6 out of the 30 subjects ultimately attended college. The evaluators found that 13 out of 30 of those subjects returned to their previous level of functioning (269). Another study in 1980 by Brink and colleagues (66) noted 73% of pediatric survivors of severe TBI were able to demonstrate independence in ambulation and self-care within 1 year postinjury.
The literature regarding academic outcomes for children after severe TBI is less encouraging. These children demonstrate lower scores on standardized tests (201). Ewing-Cobbs (230) reported these children have lower reading recognition, spelling, and arithmetic scores compared with patients who sustained only a mild to moderate brain injury. Two years post-TBI, 39% of these patients had failed a grade and 73% of them needed special education assistance. Ewing-Cobbs (270) also reported that moderate to severe TBI sustained prior to the age of 6 had adverse persistent consequences for intellectual and academic development. These children were assessed 5 years after injury and were found to have continuing deficits with no further recovery of function, demonstrating a persistent performance gap with no "catch-up" phenomenon. They also found that children with focal nonprogressive brain injury demonstrated relatively good intellectual and academic outcomes. They concluded that there appeared to be significant limits on neurologic and cognitive plasticity. An interesting note was that the older children did fairly well on achievement testing but demonstrated poor functional academic recovery by failing a grade and needing ongoing support services. It seems that contributing components to success at school are the comorbid behavioral problems that almost two-thirds of children display after TBI and approximately three-quarters of those children demonstrate difficulties with school work (253).
Shaklai and colleagues (271) found predictors of better outcomes after severe pediatric TBI including GCS greater than 5, length of unconsciousness less than 11 days, FIM and IQ at discharge from rehabilitation, and length of acute hospitalization and rehabilitation (271).
Children with a profound brain injury and unconsciousness that lasted for greater than 90 days demonstrated a less favorable prognosis for recovery. In a series evaluating profoundly injured children by Kriel, only 1 of the 36 subjects had a normal motor outcome and no children demonstrated a normal cognitive outcome. Two-thirds of the patients recovered some language function, and one-quarter recovered independent ambulation with or without assistive devices (247).
Anoxic Brain Injury
Generally speaking, the children who sustain an anoxic brain injury tend to demonstrate a worse outcome than those with TBI. In a study that evaluated children who were unconscious for greater than 90 days secondary to an acquired brain injury, 75% of the subjects who had a TBI eventually regained consciousness. Only 25% with anoxic brain injury ultimately regained consciousness. One-quarter of children with TBI became ambulatory, and most of them regained some language function. Children with an anoxic brain injury who were unconscious for more than 60 days did not regain language skills or become ambulatory. A greater percentage of the children who had anoxic injuries died during the years of follow-up (272).