Epidemiology

Traumatic brain injury (TBI) is the most common cause of interruption to the normal development of any child. It is believed in the United States, 500 in 100,000 children will experience a TBI in any one year and out of 30 newborns 1 will sustain a TBI before they turn 6 (Anderson et al. 2012). TBI accounts for 9.6% of pediatric deaths (0-19) in Canada and 40% in the US (White et al. 2001). They are considered the leading cause of death in those under the age of 19 (Guice et al. 2007; Kan et al. 2006; Kraus et al. 1990; Schunk & Schutzman 2012; Young et al. 2004). Children under the age of 6 are at a greater risk of mortality following a TBI compared to older children (Lichte et al. 2015).

The main cause of TBI in children is due to motor vehicle accidents in North America (Asemota et al. 2013), Saudi Arabia (Alhabdan et al. 2013), Italy (Gazzellini et al. 2012), the Netherlands (De Kloet et al. 2012), Australia (Amaranath et al. 2014) and South Africa (Okyere-Dede et al. 2013; Schrieff et al. 2013). Other causes of TBI include falls, auto and pedestrian incidents, bike related injuries, sport related injuries and acts of violence (Schunk & Schutzman 2012). Boys are twice as likely to experience a TBI as girls. Boys are more likely to experience an intentional injury (i.e., physical assault), adopt risk-taking behaviour that may lead to injury, and fall from great heights, whereas girls are more likely to experience a TBI in the home due to small falls (Collins et al. 2013). Non-accidental trauma represents <10% of pediatric TBI with the highest rates being reported in Nigeria (10%) and Malaysia (9%), and only 1-8% in the United States (Dewan et al. 2016).

The early years of childhood are a time of much growth and change. The body and brain are growing and developing daily; therefore, a brain injury interrupts this complex pattern of growth and development. Sustained injury may lead to increased variability in baseline skills, the need for age/stage appropriate testing and rehabilitation programming, as well as longitudinal follow-up to address the increasing gap between the skills of the child and age appropriate peers. Many children that sustain a TBI have behavioral problems, learning difficulties, and lack restraint (Anderson et al. 2013). Mental health problems that are common are aggression, internalizing disorders, post-traumatic stress disorder, attention deficit hyperactivity disorder, and personality changes are also common (Schachar et al. 2015).

The residual effects are different between children and adolescents, perhaps due to the difference in developmental stages. Older children more often have headaches, cognitive impairments and behavioural disorders post-TBI compared to younger children (Choe 2016). The majority (90%) of children who sustain a TBI have mild injuries (Araki et al. 2017); however, those with more severe injuries have the potential for significant deterioration immediately post-injury and further complications in rehabilitation (Schunk & Schutzman 2012).

Due to the still developing nervous system, treating a child with a TBI is distinctly unique from treating an adult. Rehabilitation for those who sustain head injuries can have a positive and significant impact on the road to recovery (Greenspan & MacKenzie 2000). Furthermore, it is believed that rehabilitation following brain injury does not simply expedite recovery, but helps to improve functional outcomes beyond what is expected from spontaneous recovery (Cope 1995).