TBI aND YOUTH 101
What is A Traumatic Brain Injury and How Does It Impact Brain Development?
What is a TBI?
Traumatic brain injury (TBI) refers to a blow or jolt to the head, or a penetrating head injury which disrupts the function of the brain. TBI falls under the umbrella of acquired brain injury (ABI). Other types of ABI include non-traumatic brain injury caused by anoxia, a lack of oxygen to the brain that can occur from substance overdose (such as opioids), attempted strangulation or near drowning, stroke, or aneurysm.
A concussion is a type of mild TBI (mTBI) defined as a traumatically induced temporary disturbance of brain function. A concussion can, and often does, occur without a loss of consciousness.
Though classified as an mTBI, the effects are not always mild. Some individuals with concussion experience long-term changes in brain function. The effect of multiple concussions is cumulative and can cause serious long-term consequences in some individuals.
A person does not need to hit their head for a TBI of any severity to occur. Common causes of TBI include falls, motor vehicle collisions, assaults and domestic violence, gender based-violence, intimate partner violence, and sports injuries.
Those with a history of TBI, including concussion, are at a higher risk of sustaining another concussion. A history of multiple TBIs is associated with slower recovery and more complications. A TBI can result in cognitive and communication challenges that also impact behaviour and emotional regulation.
What is a youth / young person?
Youth: A period of transition from the dependence of childhood to the independence of adulthood, generally occurring between ages of 15 – 24.4
An Introduction to Brain Development in Children and Young people, and Why it Matters
A child’s brain is not the same
as an adult’s brain
Most people understand that a child’s brain is not the same as an adult brain. Despite this, children and youth are sometimes expected to act like adults. However, this simply isn’t possible—a child’s brain is fundamentally quite different from an adult brain.
From birth until our late twenties, the brain is undergoing rapid periods of development.
In particular, the brain’s frontal lobes are not fully developed until well into our twenties. This brain region is responsible for such things as:
- Organization and planning
- Behavioural self-regulation and impulse control
- Working memory
- Goal directed behaviour
Especially during the early years, children don’t have the ability to regulate or control their behaviour the way that adults do.
Children and young people may be able to engage in adult-level thought for short periods of time. However, this is not sustainable, particularly on complex topics. Therefore, a child or youth’s abilities and behaviour are different than an adult’s.
The impact of a responsive caregiver
Children and youth depend on a loving, attentive caregiver to soothe and comfort them. Close bonding and attachment with a responsive caregiver is critical for healthy brain development. In fact, studies show that a child’s relationship health history, meaning their positive (healthy) or negative (unhealthy) bonding and connections to a caregiver, parent, community, and culture, are more predictive of mental health than a history of adversity.
Children learn about the world from their caregiver, through positive stimulation such as:
- Time in nature
- Play with age-appropriate toys (that don’t need to be expensive or fancy!)
- Access to picture books and stories
- Exposure to language and conversation
- Good nutrition
- Adequate, restful sleep
What happens when children don’t have access to a responsive supportive caregiver and other key factors of growth?
Human brains are pre-wired for social connection. So, when infants and children’s basic needs for love, comfort, and care are not provided, this creates a pattern of chronic stress activation in their brains that tells them life and relationships are unpredictable and unreliable.
As a result, their brains don’t develop the skills needed to self-regulate. Infants and very young children do not have the ability to ‘self-soothe’ (i.e., comfort themselves). If they’re upset, hungry, or need to be changed, they need to know that someone loves them, is consistently responsive, and is trying to comfort them.
If they don’t, they quickly learn to try to gain attention through negative behaviours, or they withdraw. They often have difficulty with attention and self-regulation throughout their life. This can result in impulsive behaviour and poor judgement.
Language and Social development
As children age, language is also developing. Children and young people use language to organize their world, read and write to learn, and develop social relationships. As their brains mature and develop, children and youth become better able to:
- Use ‘self-talk’, to navigate the world, solve problems, self-soothe and self-regulate (e.g., telling yourself, “It’s okay, I’ve got this, I can do it, I’m okay, I can handle this”)
- Do some simple planning (around ages 7-9)
- Recognize that others can have a different point of view from their own (Theory of Mind)
Additionally, as language, communication and thinking (cognitive abilities) mature, children are better able:
- Form deep relationships
- Use language to navigate conflict
- ‘Read between the lines’
- Read their own and another person’s emotions
There is another increase in ‘Theory of Mind’ skills and knowledge of others’ mental states and attitudes between ages 10-13.
If a young person has language, communication, and/or cognitive difficulties, this impacts all aspects of their life. They may have difficulty:
- Expressing themselves
- Following conversations
- Navigating relationships
School and learning are likely to be challenging. They may resort to physical ways of addressing conflict. They may have low self-esteem and become the victim of bullying. They may become vulnerable to exploitation and abuse.
Despite the fact that we now know that a child’s brain is not fully developed (especially the frontal lobes) until the mid-to-late twenties, we still expect them to behave like adults.
Many of the world’s religions identify the transition to adulthood as age 13 and the onset of adolescence. In the developed world, children and youth are considered adults at age 18 and no longer have access to developmentally appropriate pediatric services. But this age group is particularly vulnerable as, in many cases, they no longer have the external supports they did as children.
If young people have not had access to the care and support as well as the academic and social learning opportunities that we know to be important, this will be reflected in their brains and in their behaviour.
Therefore, a young person’s behaviour is the product of an interplay between genetics, biology, the environment, and experience. Experience and environment play a bigger role than conventionally thought, which presents greater opportunity to support positive development as well as provide interventions and supports. The onus is on society to recognize that young people do not act in a vacuum, and that adults have an even greater responsibility to structure their environment and experiences in the most beneficial way possible.
Jehava, V., Kadish, J., Kakonge, L. & Wiseman-Hakes, C. (2022) Early attachment and the development of social communication: A neuropsychological approach. Frontiers in Psychiatry, 13. https://www.frontiersin.org/articles/10.3389/fpsyt.2022.944889/full
Korkmaz, B. (2011) Theory of mind and neurodevelopmental disorders of childhood. Pediatric Research, 69, 101-108. https://www.nature.com/articles/pr92011100
Perry, B. & Winfrey, O. (2021) What Happened To You? Conversations On Trauma, Resilience, and Healing. Flatiron Books.
Wiseman-Hakes, C., Kakonge, L., Summerby-Murray, S. (2018) Language, Cognitive-Communication and Social-Communication. In G. Locascio & B. Slomine (Eds.), Cognitive Rehabilitation for Pediatric Neurological Disorders. Cambridge University Press.
cognitive & behavioural challenges after TBI
How does Traumatic Brain Injury Affect Cognition?
The cognitive abilities of children and young people develop as their brains develop, shaped by their life experiences, including:
- Social relationships
- Learning (in school and in the community)
- Exposure to life events
As cognition and communication abilities grow, behavioural and emotional control increases as well.
Sustaining a TBI in childhood can disrupt the development of cognition, behavioural control, communication, and social relationships.
TBI can result in a range of impairments across various cognitive domains, including:
- Poor attentional control
- Reduced working memory
- Reduced inhibition
- Poor cognitive flexibility
- Difficulty with abstract thinking
- Difficulty with planning and organizing
- Impaired reasoning
- Decrease in goal-directed behaviour
As a result, children with TBI often have learning problems and difficulty in school. Early dropout is frequent.
Importantly, intellectual function is rarely impacted long-term following mTBI in childhood. Even children and young people with moderate to severe injuries usually maintain IQ levels in the average range. Therefore, the cognitive challenges can have profound functional implications but not necessarily intellectual.
Special education supports tailored to those with brain injury, as well as cognitive rehabilitation, are critical to maximize academic success.
How does Traumatic Brain Injury Affect Behaviour?
As a result of executive function challenges such as poor impulse control, children and young people with TBI also have difficulties with emotion regulation and behaviour.
They may be more aggressive or lack the verbal abilities to initiate social activities or manage conflict. Childhood TBI often leads to persistent emotional, behavioural, and social problems that can have a big impact on their lives.
Unless properly addressed through specialized rehabilitation and support for the child and families, these challenges can become risk factors for exploitation, abuse and criminal involvement.
Arciniegas, D. B., Held, K., & Wagner, P. (2002). Cognitive impairment following traumatic brain injury. Current treatment options in neurology, 4, 43-57. https://doi.org/10.1007/s11940-002-0004-6
Babikian, T., Merkley, T., Savage, R. C., Giza, C. C., & Levin, H. (2015). Chronic aspects of pediatric traumatic brain injury: review of the literature. Journal of neurotrauma, 32(23), 1849-1860. https://doi.org/10.1089/neu.2015.3971
Beauchamp, M. H., & Anderson, V. (2013). Cognitive and psychopathological sequelae of pediatric traumatic brain injury. Handbook of clinical neurology, 112, 913-920. https://doi.org/10.1016/B978-0-444-52910-7.00013-1
Beauchamp, M. H., & Anderson, V. (2010). SOCIAL: an integrative framework for the development of social skills. Psychological bulletin, 136(1), 39–64. https://doi.org/10.1037/a0017768
Brain Injury Canada. (2022) Individuals with brain injury. Brain Injury Canada.
Carriere, G., Garner, R. & Sanmartin, C. (2022 January 19) Significant factors associated with problematic use of opioid pain relief medications among the household population, Canada, 2018. Statistics Canada. https://www.doi.org/10.25318/82-003-x202101200002-eng
Centers for Disease Control & Prevention (n.d.) Traumatic Brain Injury & Concussion. https://www.cdc.gov/traumaticbraininjury/index.html
Cristofori, I., & Levin, H. S. (2015). Traumatic brain injury and cognition. Handbook of clinical neurology, 128, 579-611. https://doi.org/10.1016/B978-0-444-63521-1.00037-6
Dikmen, S. S., Corrigan, J. D., Levin, H. S., Machamer, J., Stiers, W., & Weisskopf, M. G. (2009). Cognitive outcome following traumatic brain injury. The Journal of head trauma rehabilitation, 24(6), 430-438. https://doi.org/10.1097/htr.0b013e3181c133e9
Levin, H.S., Hanten G., (2005). Executive Functions After Traumatic Brain Injury in Children, Pediatric Neurology, 33(2) 79-93. https://doi.org/10.1016/j.pediatrneurol.2005.02.002
Ryan, N. P., Catroppa, C., Godfrey, C., Noble-Haeusslein, L. J., Shultz, S. R., O’Brien, T. J., Anderson, V., & Semple, B. D. (2016). Social dysfunction after pediatric traumatic brain injury: A translational perspective. Neuroscience and biobehavioral reviews, 64, 196–214. https://doi.org/10.1016/j.neubiorev.2016.02.020
Semple, B. D., Canchola, S. A., & Noble-Haeusslein, L. J. (2012). Deficits in social behavior emerge during development after pediatric traumatic brain injury in mice. Journal of Neurotrauma, 29(17), 2672–2683. https://doi.org/10.1089/neu.2012.2595
Schretlen, D. J., & Shapiro, A. M. (2003). A quantitative review of the effects of traumatic brain injury on cognitive functioning. International review of psychiatry, 15(4), 341-349. https://doi.org/10.1080/09540260310001606728
Stålnacke, B. M., Saveman, B. I., & Stenberg, M. (2019). Long-term follow-up of disability, cognitive, and emotional impairments after severe traumatic brain injury. Behavioural Neurology. https://doi.org/10.1155/2019/9216931
Wiseman-Hakes, C., Kakonge, L., Doherty, M., & Beauchamp, M. (2020). A Conceptual Framework of Social Communication: Clinical Applications to Pediatric Traumatic Brain Injury. Seminars in speech and language, 41(2), 143–160. https://doi.org/10.1055/s-0040-1701683
Wiseman-Hakes, C., Kakonge, L., Summerby-Murray, S. Language, cognitive-communication and social-communication interventions. (2018) In Locascio G., & Slomine B. [Eds.] Cognitive Rehabilitation for Pediatric Neurological Disorders. Cambridge University Press.
United Nations. (n.d.) Definition of Youth. https://www.un.org/esa/socdev/documents/youth/fact-sheets/youth-definition.pdf