All about Acquired Brain Injuries in Children

Between 40,000 and 50,000 children and young people acquire a brain injury each year in the UK, so say the Child Brain Injury Trust. The effects of such brain trauma in childhood may not always be apparent for years, but they can be life-long and severe.

What is an acquired brain injury?

An acquired brain injury (often shortened to ABI) means that the injury to the brain has been ‘acquired’ or, rather, was not present at the child’s birth. It is the result of an illness or accident that has happened later.

There are two kinds of acquired brain injury:

• Traumatic brain injury (TBI)
  This is the result of an injury caused by an impact on the child’s head. This could have occurred in a fall or a car accident, for example.
• Non-traumatic brain injury
  This is often the result of an illness or medical condition such as a brain tumour or meningitis and the treatments used to treat such medical conditions and emergencies.

To clarify this further, traumatic acquired brain injuries are the result of external factors (something that’s happened outside of the body) whereas non-traumatic acquired brain injuries are the result of internal factors (something happening inside the body).

Regardless of the type of ABI, they often have similar effects and outcomes for children. Healthcare professionals may also refer to ABI in children as a paediatric acquired brain injury.

How is an acquired brain injury different in children to adults?

Children are often affected differently by acquired brain injuries than adults. This is often thought to be because the human brain does not normally develop fully until we’re in our 20s, with some believing it is still developing beyond this too.

Consequently, if a part of the brain is injured during an early stage of development, a child may not be able to progress in certain skill areas that they might have otherwise. The brain may remain at the developmental stage that it was at the time of the injury.

What is more, sometimes parts of the brain are not activated or ‘used’ until later in life. As a result, the full extent of the ABI may not be apparent until the child reaches the stage when this part of the brain would normally come into play. For example, if a four-year-old child suffers an injury to their frontal lobes (the parts of the brain at the front, behind our forehead), their decision-making, problem-solving and judgement skills may be affected. This may not be obvious until the child reaches the age of around 12 when these skills tend to be used more.

When an adult suffers from an acquired brain injury, the effects are nearly always obvious soon after the injury occurs. This is because their brains are fully developed and if parts of the brain now don’t function or don’t function as well, it is much more noticeable.

Some people believe that children’s brains are much more able to ‘bounce back’ as they’re younger and more ‘plastic’. Our common sense often tells us as such. Yet this is not generally the case.

Children often make rapid physical recoveries from trauma – they might be back sat up and playing seemingly normally within a few days of an injury. But the full effects of an acquired brain injury may take months or even years to surface. This happens as the difficulties and changes in a child’s brain are not always immediately obvious and can be considered more like a hidden disability.

The signs and symptoms of an acquired brain injury in children

Every child is different when it comes to the signs and symptoms of an acquired brain injury. A lot depends on the child’s age and where the ABI occurred within the brain. Equally, the way the child responds to an ABI is very varied, just like their response to other things in their lives is unique.

Given that the brain controls every part of our body, from our breathing and temperature regulation to our thought-processing, intelligence and behaviours, it’s difficult to give a definitive list of usual signs and symptoms of an acquired brain injury in children. The effects of an ABI may range from slight problems with the child’s memory to permanent learning disabilities and physical impairments.

Many parents report that their child has seemingly suffered from a personality change after an acquired brain injury. Often, this is quite distressing for the parents as they feel that they need to get to know their child all over again.

One way of aligning likely signs and symptoms of an acquired brain injury in children is related to the severity of the injury. Brain injuries tend to be classified as mild, moderate and severe, as discussed later.

Physical and Physiological Impairments

Many children experience physical and physiological impairments as a result of their acquired brain injury.

Whilst this is always a very individual experience, physical impairments can include:

• Gross motor difficulties – Difficulties with walking, running and playing sports.
• Problems with coordination, balance and control – Tremulous movements, clumsiness and poor hand-eye coordination such as difficulties in writing or eating with appropriate utensils. This can sometimes lead to a misdiagnosis of dyspraxia.
• Problems with proprioception and spatial awareness – A child may appear ‘ungainly’ when they walk or appear awkward in their stance.
• Fatigue – This often occurs as a result of the brain having to ‘re-route’ its pathways, making processing take longer and therefore using more energy than would otherwise be required. This can be seen as children suffering from a decline in functioning as the day progresses or overwhelming tiredness after activity. The child may need to make an extra effort to focus or process information due to fatigue. Sometimes, children with ABI are perceived as unmotivated or ‘lazy’ due to their inability to keep up physically with their peers.
• Vision – Often impaired due to ABI including sight loss, partial sight loss, double vision, or difficulties with depth perception. The child may compensate automatically for some of these difficulties, so they may not always be obvious.
• Hearing – Difficulties with hearing may give rise to poor attention at school as the child may struggle to hear and therefore engage with learning. Sometimes the damage to the brain that affects hearing may also affect coordination and balance, so it is always worth investigating hearing problems if balance and coordination are already noted to be a problem.
• Smell and taste – The other senses are also sometimes affected by an ABI. This can result in a loss of appetite in children if they no longer enjoy eating.
• Bladder and bowel control – ABIs can sometimes cause a child to regress or not progress when it comes to being able to control their bladder and bowels. They may need the toilet more frequently or may have accidents when they didn’t before.
• Weight – Children can sometimes gain weight rapidly after a brain injury. This can sometimes be due to the injured area in the brain being related to appetite control and the child not feeling full or satisfied after eating. If this is combined with a loss of motor function, rapid weight gain can occur, often resulting in obesity.
• Sexual development and growth – Sometimes, ABI can affect the parts of the brain that are responsible for secreting hormones such as the pituitary gland and hypothalamus. This means that children may require hormone replacement therapy if they do not grow as expected.
  Sometimes, the damage can cause them to grow too quickly. Also, this could lead to the early onset of puberty and the early development of secondary sex characteristics. Very young boys may experience voice changes and grow pubic hair and very young girls may experience precocious menstruation and breast development. In contrast, other children with ABI may experience a delayed onset of puberty and adolescent boys may experience impotence which continues into their adult lives. Such issues may also lead to mental health problems, increased self-consciousness, poor self-esteem and a lack of confidence. Some children with ABI are also increasingly vulnerable as they may develop sexually disinhibited behaviour.
• Epilepsy – Is often an issue after an acquired brain injury, particularly a traumatic brain injury, even if the child did not have epilepsy before. These children are often treated with anti-convulsant medication which also has significant side effects including unusual behaviour and drowsiness.

Cognitive and Intellectual Impairments

Aside from the physiological and physical difficulties and impairments that a child with an acquired brain injury may suffer, many children suffer from cognitive and executive functioning impairments.

Again, each child is different, but such impairments may include:

• Speed processing difficulties such as difficulties with speech, slower reactions to stimuli, slower speed of writing, asking for instructions to be repeated and slower movements when changing activities or tasks.
• Concentration and attention difficulties, both of which are important prerequisites for learning at school.
• Memory and learning difficulties including forgetting instructions, forgetting past learning and losing equipment or personal belongings due to difficulties retaining information are common experiences in acquired brain injuries in children.
• Speech and communication difficulties particularly when it comes to higher-level language. This greatly depends on the age of the child when they suffered from their acquired brain injury. An injury occurring in the toddler years may mean that the child struggles with more complex grammatical structures in language as they grow older as such skills are not typically developed until the early primary years. Children who are older when their injury occurred may be able to manage language but may struggle with reasoning skills and abstract thinking as these skills are not usually developed until after age 10. Some children with ABI may struggle to keep track of conversations in group situations but do not have as many difficulties with one-to-one discussions.
• Emotional difficulties including intense and rapid mood changes, irritability, frustration, moodiness and over-the-top reactions to situations are all common in children with acquired brain injuries. Anxiety and fear can also develop in children who did not suffer from this previously. This is not always a direct result of the injury but can be due to post-traumatic stress or worry that an illness may recur.
  Similarly, children can also go on to suffer from clinical levels of depression with the associated symptoms of apathy and a loss of interest in activities that they previously enjoyed. They may also feel a sense of loss over their identity if their difficulties have caused significant changes to their abilities, emotions and/or physical appearance and condition.
• Behavioural and personality changes have already been mentioned. Some children may just seem ‘different’ after their ABI and this is thought to be due to multiple factors. Children who were once hardworking and independent may become needier or impulsive. In the same vein, children who were once outgoing and active may now find themselves withdrawn and subdued. They may suffer from a marked shift in their behaviour including outbursts and meltdowns. Challenging behaviour is common and can be as a direct result of damage to the hypothalamus in the brain or indirectly as a result of anger, frustration and sadness at the difficulties the child now faces.
  Some of these behaviours are often similar to those experienced by children with autistic spectrum conditions or ADHD. Indeed, it has been posed that some children who are diagnosed with these conditions could have suffered an unknown or unidentified ABI earlier in their life. However, diagnoses of neurodivergence in children with ABI can mask the child’s story and experience of the acquired brain injury as well as hinder any forward planning in their treatment and the long-term implications that the ABI may have.
• Changes in relationships – Children with acquired brain injuries often have difficulties reintegrating within their peer groups after their injuries. This can be a result of spending a lot of time in hospital or out of school or could be a direct consequence of changes in their behaviours or personality as a result of the brain injury. Sometimes children make new friendships after their ABI and it is not uncommon for these to be with older people including adults or with much younger children.
  Siblings of children with ABIs may also find it difficult to adjust as their lives can be affected in many ways. They may take on some responsibilities in the home, be a young carer, or they may be/feel side-lined due to their parents/caregivers needing to spend so much time with their sibling in hospital, at appointments, or at home afterwards. The child’s parents will also go through a significant period of adjustment after the injury and they may also need support both practically and psychologically.

What causes an acquired brain injury in children?

Acquired brain injuries in children, as explained above, have either a traumatic or a non-traumatic cause.

There are many causes for each type of acquired brain injury as shown in the table below.

Traumatic Acquired Brain Injury Causes

• Closed head injury
  This type of head injury is the most common in children. The fact that the injury is referred to as ‘closed’ simply means that the brain has not been exposed during the injury and the skull isn’t broken.
  These types of injuries are caused by things such as a car accident where a sudden jolt causes the head to move rapidly, with the brain experiencing forces from the movement inside the skull. Bony ridges within the skull can cause increased damage to the brain. With this type of injury, many parts of the brain can be affected. This is often called a diffuse acquired brain injury.
• Penetrating or open head injury
  This is a less common injury. As you may have deduced, this type of injury involves the skull breaking and the brain being exposed. This could happen during an impact or collision or could be the result of a bullet wound or explosion. Sometimes both a penetrating or open head injury and a closed head injury happen simultaneously.
• Crush injuries
  This type of injury is the least common form of traumatic acquired brain injury. This injury happens when a person’s head is between two hard objects and is met with force from both sides.

Non-Traumatic Acquired Brain Injury Causes

• Brain tumours
  Both malignant and benign brain tumours can cause a non-traumatic brain injury. Malignant tumours tend to grow more quickly and can spread. Brain tumours cause damage to the brain tissue which results in symptoms and pain by growing and increasing pressure within the skull. This can damage the brain tissue causing an acquired brain injury.
• Meningitis
  Meningitis is an infection and inflammation of the membranes that surround the spinal cord and brain. The inflammation can cause an acquired brain injury in serious cases.
• Encephalitis
  Encephalitis is where the tissue in the brain becomes inflamed. This can be due to infection or due to an autoimmune condition.
• Hypoxic/anoxic brain injury
  If the brain does not receive enough oxygen for some reason, a brain injury can result. Hypoxic means that the brain doesn’t get enough oxygen; anoxic is where there is no oxygen in a part of the brain. These injuries occur when a person’s breathing is affected or compromised such as in an asthma attack, through inhaling carbon monoxide or in a near-drowning.
• Stroke
  Strokes in children are rarer than in adults but they still happen. Those who often have a stroke often have another condition that predisposes them to strokes such as sickle cell disease or heart problems. A stroke happens when the brain’s blood supply is cut off and cells begin to die.
• Arteriovenous malformation (AVM)
  AVM is when the blood vessels have not developed properly within the brain. Children are often believed to be born with AVM and most people do not know that they have AVM until a haemorrhage occurs.
• Aneurysm
  An aneurysm occurs when a blood vessel bulges out because the walls of the blood vessel are weak. The pressure of the blood causes the bulge to grow and burst, with blood leaking into the brain tissue. This bleed can cause damage to the brain and the lack of ongoing blood supply after the aneurysm can cause additional damage.
• Brain haemorrhage
  A brain haemorrhage is when there is bleeding around or within the brain. This can be caused by a traumatic brain injury or because of a ruptured aneurysm or AVM. There are different kinds of brain haemorrhage depending on where they occur.
• Other causes
  Aside from those mentioned, there are sometimes other causes of non-traumatic brain injuries including suffocation/asphyxiation, the result of surgery such as brain tumour removal, prolonged epilepticus where a seizure lasts for over an hour, and as a complication of diabetes.

Are acquired brain injuries in children serious?

Brain injuries in children (and in adults) tend to fall in the categories of mild, moderate and severe. However, it’s important to note that doctors will not always have the full picture of the child’s injury from the outset.

The idea of explaining the injury in this way is to give parents an idea of how the injury may affect the child. Nevertheless, a lot of the time this is just guesswork as it’s difficult to tell what the final outcome may be.

Mild ABI

A mild acquired brain injury often has, but often not all, some of the following symptoms:

• Headache.
• No loss of consciousness, but perhaps a confused, disoriented and dazed state, or a loss of consciousness that lasts for a few seconds to a few minutes only.
• Nausea/vomiting.
• Drowsiness and fatigue.
• Dizziness and/or loss of balance.
• Sleeping difficulties.
• Speech problems.
• Ringing in the ears, blurred vision, changes in smell and/or taste.
• Concentration or memory problems.
• Feelings of anxiety and depression.

Moderate to Severe ABI

Moderate acquired brain injuries can include some of the following symptoms:

• Loss of consciousness that lasts from a few minutes to hours.
• Worsening or persistent headache.
• Continued nausea and vomiting.
• Seizures.
• Dilated pupil(s).
• Clear fluids running from the ears or nose.
• Difficulty in waking from sleep.
• Numbness or weakness in toes and fingers.
• Profound confusion.
• Loss of coordination.
• Unusual behaviour such as combativeness and agitation.
• Slurred speech.

When a severe acquired brain injury occurs, the prognosis is not often favourable. Often, those with moderate to severe victims of ABI will have a long, difficult battle ahead.

Children with severe ABI will typically be affected by the injury for the rest of their lives. It is often a very uncertain time, especially in the first few days, weeks and even months after the injury occurs.

Treatments for acquired brain injuries

There are many ways of treating acquired brain injuries in children. The treatment options will depend on where in the brain the injury has occurred as well as the severity of the injury.

Surgery

Surgical options may include repairing any skull fractures or removing clotted blood from the brain after a haemorrhage or aneurysm.

Medication

Some medications may be used to help reduce symptoms or prevent any further damage to the brain.

They may include:

• Anti-seizure medicines if seizures are suspected or occur as a result of the injury.
• Drugs to induce a coma to relieve pressure in the brain.
• Diuretics to reduce the fluid in the brain tissues thus relieving pressure.
• Anti-depressants to treat symptoms of mood instability and depression.
• Anti-anxiety medications to reduce feelings of fear and anxiety.
• Stimulant medications to improve attention and alertness.

Rehabilitation

The majority of treatments after a brain injury will be largely rehab-based. These treatments may need to continue for the rest of the child’s life.

They may include:

• Physiotherapy – To help with movements, balance and walking.
• Occupational therapy – To help the child learn or learn activities of daily living or improve their skills in this area, including age-appropriate self-care.
• Vocational therapy – This may help a child get back into the classroom after an absence or when symptoms continue to occur.
• Speech and language therapy – This may help the child regain any lost speech as well as help with their cognitive functioning.

Final thoughts on ‘Acquired Brain Injuries in Children’

Acquired brain injuries in children can range in severity from mild to severe and can have a traumatic or non-traumatic cause.

If you or someone you know needs support for a child’s acquired brain injury, the following organisations may help:

• Headway.
• Child Brain Injury Trust.
• The Children’s Trust.