Traumatic brain injury (TBI) in children can be difficult to diagnose, and it is even more difficult to predict an outcome. Traditionally, TBI is defined as mild, moderate, or severe by using certain indicators such as the Glasgow Coma Scale or loss of consciousness. Outcomes based on TBI severity can be unpredictable—mild TBI has been known to cause long-term deficits, and more severe TBI can sometimes result in a surprisingly good outcome.

A recent study found that force of impact was a more accurate predictor of outcome than TBI severity. Force of impact was defined as:

• Never sustained an impact with consequences worth considering
• Mild impact (e.g., knocking head against door frame)
• Moderate impact (e.g., knocked by a player’s elbow during sports)
• Strong impact (e.g., intentional punch to the head)
• Very strong impact (e.g., forceful collision with a hard surface, such as in a car
accident)

Children and parents may have a better memory for concrete examples of the injury, and may be too unfamiliar with clinical terms to accurately describe the event.

Halldorsson JG, Flekkoy KM, Arnkelsson GB, et al. The scope of early traumatic brain injury as a long-term health concern in two nationwide samples: Prevalence and prognostic factors. Brain Injury. (January 2012).

Full recovery after a sports-related concussion (i.e., mild traumatic brain injury) is critical in order to prevent cumulative damage from future concussion. Unfortunately, the pressure to return to play often outweighs the need to wait for full recovery, and athletes often return to play sooner than they should. There have been various tools proposed to measure recovery after a concussion, but these have shown inconsistent results. There is an urgent need for a more reliable measure of recovery after concussion.

Electroencephalography (EEG) measures brain activity and has been shown to be a sensitive tool for showing slight changes in brain functioning. In a recent study of high school football players, EEG was able to detect abnormalities of brain activity in those who had been concussed as compared to those who had not been injured. Using an emergency department-based algorithm, the researchers were able to show that abnormal brain activity occurred beyond the point in which traditional clinical tools had indicated full recovery.

The implication of this study is that traditional clinical tests of brain function after a concussion are not adequately measuring recovery, and players may be returning to the game too soon. EEG may be a more precise and reliable tool, and should be considered as a standard test in the future.

Barr WB, Prichep LS, Cahbot R, Powell MR, & McCrea M. Measuring brain electrical activity to track recovery from sport-related concussion. Brain Injury. (January 2012).

After discharge from the hospital or rehabilitation center, a person with traumatic brain injury (TBI) usually returns home. In most cases, one family member becomes solely responsible for the patient, creating a tremendous burden on that family member.

A recent study described the most common profile of the caregivers for TBI patients. Although the study focused on military families, the profile is likely to be similar for civilian families as well. The study found that:

• 79% of caregivers are women
• 62% are a parent of the patient
• 32% are a spouse of the patient
• 25% reported providing care for more than 40-hours per week
• 49% reported providing care for more than 80-hours per week
• 60% were the sole provider of care
• After four years, 22% of patients still needed intense care

The sole caregiver of a person with TBI is very likely doing so as an unpaid, full-time job. The financial and emotional burden of this responsibility is an often overlooked casualty of both military and civilian families.

Griffin JM, Friedmann-Sanchez G, Jensen AC, et al. The invisible side of war: Families caring for US service members with traumatic brain injuries and polytrauma. Journal of Head Trauma Rehabilitation. (February 2012).

Mild traumatic brain injury (mTBI) makes up approximately 80% of all TBI cases. It is associated with a range of physical, mood, and cognitive symptoms such as headaches, depression, and memory problems. While these symptoms usually dissipate within three months after injury, some patients experience long-term symptoms. In clinical and research settings, the long-term symptoms of mTBI is called post-concussion syndrome (PCS).

However, the syndrome can be difficult to diagnose. The International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders use different diagnostic criteria. The symptoms of PCS often overlap each other (eg, depression, insomnia, and headaches may all lead to fatigue or memory impairment). And, under the current guidelines, patients without a history of brain injury may be as likely to fit the criteria as patients with mTBI.

These difficulties in diagnosis call for the development of less ambiguous criteria that take the most recent mTBI research under consideration. The current definitions of PCS may otherwise lead to misdiagnosis and missed treatment opportunities.

Dean PJA, O’Neill D, & Sterr A. Post-concussion syndrome: Prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Injury. (January 2012).

Progesterone is a hormone that has been shown to have a rapid, neuroprotective effect after TBI. This effect has been strong during pre-clinical, phase I, and phase II trials, and is now in the process of both a national and an international phase III clinical trial, bringing it closer to FDA approval for clinical use. Other clinical trials have begun for the use of progesterone after pediatric brain injury, stroke, and other neurodegenerative diseases.

Some of the potential benefits of progesterone are that it can:
1. Cross the blood brain barrier
2. Be administered as long as 24 hours after the injury and still be effective
3. Reduce swelling and edema
4. Decrease inflammation
5. Protect neurons that might otherwise die
6. Enhance remyelination, the white matter of the brain
7. Reduce potential cognitive, sensory, and spatial deficits

Progesterone is a strong candidate for the acute treatment of TBI, at a time when little else is available. It is not expensive or difficult to administer, and is considered safe for most people.

Stein DG. Is progesterone a worthy candidate as a novel therapy for traumatic brain injury? Dialogues in Clinical Neuroscience. (December 2011).

In the highly supportive environment of early childhood, children with traumatic brain injury do not show evidence of significant friendship problems. However, as children age, relationships become more complex, and children with TBI become more vulnerable to social isolation and poor peer interactions.

Children with traumatic brain injury often show cognitive deficits related to emotional recognition and social problem solving. This can have negative impact on social functioning. A recent study on children ages 7-14 found that, while 75% of the control group reported 4 or more friends, only 39% with mild, 20% with moderate, and 14% of children with severe TBI had the same number. Researchers also found that children with severe TBI had difficulty managing conflict and less intimacy in their friendships.

Children with TBI have more severe problems with hyperactivity, attention deficit disorders, and emotional problems, which impact their ability to communicate and participate socially. Children with TBI may also be likely to experience loneliness and poor quality of life as a result of their injuries.

Ross, KA, McMillan, T, Kelly, T, Sumpter, R, and Dorris, L. Friendship, loneliness, and psychosocial functioning in children with traumatic brain injury. Brain Injury. (November 2011).

Executive functioning is a mental skill that requires a higher level of thinking, such as planning and problem solving. Impaired executive functioning is common after a traumatic brain injury because it is associated with the prefrontal cortex, an area of the brain that is highly vulnerable to injury.

When a traumatic brain injury occurs in childhood, impaired executive functioning can be difficult to assess. Children often won’t develop comprehensive executive functioning until they are in high school. Even then, problems can be difficult to assess unless they have some relationship to real-life situations.

The Party Planning Task is an assessment tool for executive functioning. It requires the participant to organize a party while meeting several constraints. The task requires a high level of problem-solving and reasoning. A recent study found that the Party Planning Task accurately assessed impaired executive functioning in two adolescents who sustained a brain injury when they were younger. The Party Planning Task may therefore be a useful tool for clinicians who need an accurate, real-life simulation of executive functioning.

Shanahan L, McAllister L, & Curtin M. The Party Planning Task: A useful tool in the functional assessment of planning skills in adolescents with TBI. Brain Injury. (October 2011).

On Friday September 9, 2011, the House Appropriations Subcommittee on Labor/HHS will consider a draft version of a Fiscal Year 2012 Health and Human Services, Education, and Related Agencies (Labor/HHS) bill. Contained in the bill will be provisions important to people with brain injury including programs authorized through the TBI Act as well as the TBI Model Systems of Care program. Although subcommittee consideration will likely be top line figures only, it is important that Members of Congress remember brain injury as a vital issue requiring broad attention.

It is essential that these underfunded programs gain the resources necessary to improve access to quality care for people with brain injury. Call your Congressmen now!

Take Action!

To contact your Member of Congress to urge them to tell the Subcommittee to support sustained and increased funding for TBI programs, call the Capitol Switchboard at (202) 224-3121 or 800-965-4701 and ask for your Member’s office. If you do not know who your Member of Congress is, visit www.house.gov and insert your zip code in the top right corner of the home page. Feel free to use the following script when speaking with Congressional staff:

Hello, my name is _______________ and I’m calling from ______________, which is in your district. Please register my support for TBI programs contained in the Labor/HHS/Education appropriations bill and urge Representative ____________ to support sustained and increased funding for the TBI Act and TBI Model Systems of Care found in the bill.

Please tell Rep. ____________ to voice his/her support for these programs to the Labor/HHS Appropriations Subcommittee which are vitally beneficial to people with brain injury and their families who reside in your district. It is critical that the Subcommittee consider this important issue while allocating funding during consideration of this legislation on Friday, September 9^th. Thank you for your continued support of people with brain injury.

On August 2, 2011, the President signed a bill into law with authorizes a $900 billion increase in the debt limit that would allow the government to cover its liabilities through 2011. The bill would also cap total discretionary spending over the next ten years. If appropriations in the next ten years are equal to the caps in discretionary spending and the maximum amount of funding is provided for the program integrity initiatives, the Congressional Budget Office estimates the caps would decrease budget deficits by $917 billion between 2012 and 2021. In Fiscal Years 2012 and 2013, specifically, the Act would impose caps of $1.043 trillion and $1.047 trillion, about $7 billion and $3 billion, respectively, below current levels. For 2012 and 2013, separate caps for security and non-security budgetary authority would be in effect; from 2014 on, only one cap would apply to total discretionary funding.

The second stage would involve a joint congressional committee, made up equally of Republicans and Democrats, which would recommend changes in law to reduce the deficit by $1.5 trillion (through entitlement reform and/or tax revenues). If that bipartisan committee agrees to a proposal worth $1.5 trillion, and Congress approves it, then the plan would raise the debt ceiling by $1.5 trillion. If Congress passes a bill that enacts savings between $1.2 and $1.5 trillion, the debt ceiling would match the final number. If Congress fails to enact a bill, the debt limit would be raised by $1.2 trillion.

If the committee fails to reach a compromise that would decrease the federal deficit by at least $1.2 trillion by January 15, 2012, or Congress fails to enact it, the Act includes a budget enforcement mechanism (known as “sequestration”) that will implement automatic spending cuts to both discretionary and direct spending over 2013 through 2021. Half of those cuts would come from defense spending and the other half from nondefense programs. The amount cut would be based on the difference between the savings reached by the joint committee and $1.2 trillion in the debt limit increase. The reductions in direct spending would be cut by a uniform percentage, with the exception of Medicare; cuts to Medicare would be limited to 2% of the program’s cost and would come from payments to providers and insurance plans, not benefits or beneficiary cost sharing. Social Security, Medicaid and other specified entitlements would be exempt from sequester.

The Act also includes increases in discretionary spending for two program integrity initiatives that could ultimately reduce overpayments for Disability Insurance and Supplemental Security Income programs, as well as Medicare, Medicaid and the Children’s Health Insurance Program. In addition, the Act would require both the House and Senate to vote on a balanced budget constitutional amendment before the end of the year.

BIAA will continue to monitor the situation closely and alert grassroots advocates if funding for any important programs that serve people with brain injury are threatened.

A recent case study has been published about a young man who was treated with therapeutic barbiturate coma after a traumatic brain injury. Coma was induced after the patient showed signs of intracranial pressure that did not subside. He remained in the barbiturate coma for three days, with no abnormal lab findings.

When he was brought out of the coma, however, his labs showed a steep rise in potassium and sodium, then a subsequent drop in sodium that is indicative of cerebral salt wasting syndrome. Saline was administered, and he improved within a week.

Cerebral salt wasting syndrome can sometimes occur after traumatic brain injury. But in this case study, the reaction was related to the increased excretion of sodium after termination of barbiturate therapy. Clinicians should therefore be aware of this possibility, especially in traumatic brain injury patients for whom the syndrome is especially critical.

Kontogiorgi M, Opsimoulis P, Diamanti-Kandarakis E, & Karabinis A. Cerebral salt wasting syndrome in traumatic brain injury following therapeutic barbiturate coma. Acta Neurochirurgica. (August 2011).