by Stacy Suskauer, MD
A seminal paper published in 2010 argued for the conceptualization of traumatic brain injury (TBI) not as an isolated injury event, but as a disease process that unfolds heterogeneously over many years (Masel & DeWitt, 2010). The purpose of that paper was to summarize the evidence needed to encourage clinicians and, perhaps more importantly, the insurance industry, to recognize TBI as a condition that may require lifelong care. The World Health Organization defines a chronic disease as one that has one or more of the following characteristics: it is permanent, it requires specialized care, and/or it may require a long period of observation, supervision, or care (Pruitt & Epping-Jordan, 2002). The authors summarized scientific evidence that TBI is associated with an increased risk for a broad range of neurological and non-neurological health conditions, which together supported the notion that TBI may initiate and/or accelerate health decline across multiple body systems. Unlike an injury event (such as a broken bone) which has a finite recovery timeline, the sequelae of TBI appear to persist and evolve for years post-injury.
For all of these reasons, milder forms of TBI may not be recognized at the time of injury, and the effect may not be recognized until later in a child’s life. A prior injury and its effects may be recognized later in life as part of evaluation for later-appearing symptoms or deficits (for example, cognitive difficulties which become apparent after rmal entry into school) or may be identified through a screening process (standardized administration of questions querying past history of injury to the head and related symptoms).
Who might recognize that a child had a TBI?
Given that recognition of a TBI is not limited to the medical setting, along with the goal of identifying feasible ways to impact identification of TBI in children, the group undertook an effort to describe systems already invested in serving children. Information was supplied by workgroup members related to existing systems and related professional groups, funding sources, relevant regulations, and typical times of contact with children. TABLE 1 summarizes the identified systems, pediatric age groups served, and whether cute or historical TBIs would be most likely to be identified. These systems served to help inform stakeholder groups that could be engaged for activities to address gaps related to recognition of TBI in children.
Why is recognition of TBI important?
The workgroup produced an overarching message regarding why recognition of TBI in children is important. Several key themes to support were identified for the messaging.
1. It is important to recognize TBI because action should be taken at the time of the injury event. Information regarding even a possible TBI should be communicated at the time of the injury event to allow monitoring of symptoms (by the child, caregiver, school professionals, etc) and for the purpose of seeking medical care to facilitate diagnosis at a health care setting and related follow-up care.
2. Receipt of healthcare assessment at the time of the TBI event is important, because interventions exist and evidence demonstrates better outcomes from specific interventions (Lumba-Brown et al., 2018; Center for Disease Control and Prevention, 2018).
3. The ultimate goal is for children to be successful (and TBI can interfere with success). In total, the overall messaging is: Recognizing TBI and taking action are important because care is available to improve outcomes, and we want children to be healthy, have friends, be able to learn, and become productive members of society.
Organization by System of Care |
In order to drill down to specific, feasible ways to address this messaging related to recognition of TBI, the workgroup divided into subgroups based on the broad categories of systems of care discussed earlier. Three groups were formed, focusing on 1) medical systems, 2) school and community systems, and 3) the juvenile justice system. The discussion about issues and priorities proposed by each workgroup are described below based on the targeted system of care (medical, school/community, then juvenile justice). Some projects represent shared themes across more than one subgroup.
Recognition of children with, or at risk for, abusive head trauma was highlighted as a priority due to the possibility of intervention at the time of a milder injury to prevent severe TBI in young children. In particular, screening tools, such as the Pittsburgh Infant Brain Injury Score (Berger et al., 2016) and TEN-4 FACES rule (Pierce et al., 2010), have been created to help providers identify sentinel injuries in children presenting for care. The identification of a sentinel injury (such as frenulum injury or bruising on the torso) may prompt additional evaluation regarding the child’s current health status (e.g. ordering of a Head CT or MRI) and related to the safety of the home environment.
While pediatric specialty centers (emergency departments, trauma centers) may be vigilant for signs of possible child abuse, this is less likely to be the case in general medical settings where children represent a small fraction of patients, and where abuse may be seen rarely. The need to raise awareness in settings where abuse is a low-frequency concern presents a challenge, as messaging close in time to when a provider sees an at-risk child is most useful. For this reason, incorporating automatic messaging into electronic medical records, would allow delivery of information at the time that a young child presents for care. Such automatic messaging has already been built for individual pediatric healthcare sites using Epic and Cerner, and sharing these through resources such as the Epic library could allow relatively rapid dissemination. As an alternative, there may be low fidelity options which are easier to institute at individual sites (but harder to standardize across systems). In order to highlight the importance of related work at individual sites, longer term strategies may include requiring training/messaging related to sentinel images as part of pediatric trauma center certification or broader pediatric hospital accreditations. Some states already require continuing medical education credits related to safety or child abuse specifically for license renewal; this could be expanded across states. Further, efforts related to identification of sentinel injuries should extend beyond medical systems. In particular, programs evaluating and caring for young children, such as Early Intervention, Child Protective Services, and early Head Start may be important targets for education and staff in these settings are typically mandatory reporters of suspected abuse or neglect. Development of educational resources to share via conferences and on-line continuing education opportunities could be used to disseminate this information. With regard to identification and initial management of TBI within medical systems, mild TBI was highlighted as having the greatest need (given that severe TBI is typically more evident). In particular, children with mild TBI and minimal related symptoms may be at risk for being misdiagnosed, and, as described earlier, mild TBI may be overlooked in the presence of co-occurring injuries. Dissemination of the CDC Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children and related materials (Lumba-Brown et al., 2018; https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html) was recommended as a feasible means of sharing information regarding evidence-based strategies for evaluation and initial management. In addition to exposing providers to this information, optimizing discharge instructions so that they are in line with the current Guideline (and updated to reflect future iterations of such documents) is a priority for facilitating appropriate care and related education for children and their families. The use of the electronic medical record (EMR) can help with standardization/roll out across sites. Current free resources exist for this, though there is no system in place for ensuring that instructions are updated as new evidence becomes available, and there is no information regarding dissemination and implementation efforts underway. Partnering with vendors of discharge instructions was one suggestion for creating a process that ensures regular updating of such information. Across the Recognize workgroup, the potential for medical providers to routinely screen for history of mTBI as part of well child checks was discussed as an option with regard to establishing periodic screening evaluations and having that information be part of the medical record. Age-based curricula already exist for screening and anticipatory guidance as part of well child visits and could be an ideal way to incorporate TBI screening and education. However, there is significant competition/vetting for inclusion in such curricula, and it’s not clear that evidence exists to support the importance of adding screening for TBI. It was also not felt to be reasonable to expect that the pediatrician, given short visit times and competing needs, will consistently consider and evaluate for history of TBI in children presenting with cognitive or behavioral concerns remote to any known trauma. In contrast, it was felt that mental health providers, who often conduct more extensive interviews, can be encouraged to screen for TBI as part of their evaluations and refer to a brain injury specialist when indicated and available.
School and Community
Similarly, while routine screening for history of TBI as part of a child’s educational history would be ideal, the group felt that consistent implementation would be a challenge in light of diverse local governance structures of schools. Screening for history of TBI may be more feasible in the subset of children for whom concerns are identified, such as part of the Multidisciplinary Team educational evaluation process in schools, though evaluating for and delivering services to meet the child’s needs would be more important than etiologic considerations. Ultimately, the workgroup felt that focusing initial efforts of improving recognition of acute mild TBIs would be most feasible.The goal of improving recognition of mild TBI was broadly applicable when considering school and community settings and was inclusive of identification by children, family members, school professionals, coaches, and behavioral health providers. One message “Be a PEST” (see sidebar) was developed as an example of how information would be disseminated regarding symptoms of mild TBI as well as the importance of recognition and reporting of injury.
The importance of shared information between medical and educational systems (Haarbauer-Krupa et al., 2017) was highlighted by the workgroup as a goal for intervention. Similar to case management systems in place in some states, identification of a liaison to facilitate communication between the systems was suggested. Key features of this role would be identification of personnel that was less likely to turnover and a goal of triggering of referrals to the medical system to facilitate proper medical care for child.
The subgroup addressing recognition of TBI among children served through the juvenile justice system identified a sub-message to the larger message described above. This sub-message was for personnel working within the juvenile justice system to make the connection between the child’s history of TBI and the offending behavior in order to help put the youth on a path to being a productive citizen and reducing recidivism as well as to change attitudes toward such youth. A number of professionals could be targeted through related messaging, covering intake to the system, the period of detention, and transition out of the system. This includes judges, magistrates, attorneys, law enforcement officers, case/social workers, detention center staff, resource facilitators, probation officers, vocational rehabilitation professions, and others involved with the child care and case.
A public service announcement may be an ideal way to share information regarding how a TBI can change behavior and how recognition of the TBI may present unfavorable outcomes. In addition, visuals that may reflect this information in juvenile justice settings may help with delivering the right message at the right time. The number of potential partners in distributing such messaging were identified, including the National Partnership of Juvenile Services which has developed a position statement regarding access to TBI resources.
Even after focused work to narrow proposed projects to those that are feasible for shorter-term interventions, it is clear that there remains much work to be done with regard to the recognition of TBI in children which in turn can lead to and subsequent monitoring and care. Proposed next steps include engaging a variety of potential stakeholders, including those from healthcare and educational settings, in helping to promote the next annual Brain Injury Awareness month in March 2020. In addition, dissemination of information and resources (e.g. fact sheets, EMR strategies) within meetings/groups that workgroup members also attend/interact with provides a feasible means of beginning to address the large scale needs described above. The workgroups will spend the next 9 months working on the projects described above and will disseminate results after the May 2020 Galveston meeting.
Recognize workgroup members who contributed to this article: Daphne Babrow, Margaret Brown, Cindy Brunken, Amy Colbert, Christopher Falco, Juliet Haarbauer-Krupa, Cindy Ivanhoe, Ronda Johnson, Daniel Lindberg, Kerri Lowery, Christina Master, Drew Nagele, Christian Niedzwecki, Stacy Suskauer, Cameron Trout, and John Whyte.
Berger R. Fromkin J. Herman B., et al. Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma. Pediatrics. 138(1): e20153756, 2016
Blackwood B. Bean J. Sadecki-Lund C., et al. Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly. Journal of Pediatric Surgery. 51(4): 654-658, 2016
Donaldson K. Li X. Sartorelli K., et al. Management of Isolated Skull Fractures in Pediatric Patients: A Systematic Review. Pediatric Emergency Care. 35(4): 301-308, 2019.
Lumba-Brown A. Yeates K. Sarmiento K., et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatrics. 172(11): e182853, 2018.
Pierce M. Kaczor K. Aldridge S., et al. Bruising characteristics discriminating physical child abuse from accidental trauma.” Pediatrics. 125(1): 67-74, 2010
Center for Disease Control and Prevention Report to Congress: The Management of Traumatic Brain Injury in Children. Atlanta, GA, National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention, 2018.
Stacy Suskauer, MD, earned undergraduate and medical degrees from Duke University. She completed residencies in Pediatrics and Physical Medicine & Rehabilitation at Cincinnati Children’s Hospital Medical Center and the University of Cincinnati. Dr. Suskauer completed a Pediatric Rehabilitation Brain Injury Research fellowship at Kennedy Krieger Institute and Johns Hopkins School of Medicine and is currently an Associate Professor at those institutions. Dr. Suskauer oversees clinical services and provides direct care to children with acquired brain injury of all severities and is the principal investigator on a number of studies related to understanding and improving outcomes after childhood brain injury.