Pediatric Traumatic Brain Injury

Traumatic brain injury (TBI) is a form of nondegenerative acquired brain injury resulting from a bump, blow, or jolt to the head (or body) or a penetrating head injury that disrupts normal brain function (Centers for Disease Control and Prevention [CDC], 2015).

TBI can cause brain damage that is focal (e.g., gunshot wound), diffuse (e.g., shaken baby syndrome), or both. Symptoms can vary depending on the site of the lesion, the extent of damage to the brain, and the child’s age or stage of development.

The functional impact of TBI in children can be different than in adults—deficits may not be immediately apparent because the pediatric brain is still developing. TBI in children is a chronic disease process rather than a one-time event, because symptoms may change and unfold over time (DePompei & Tyler, in press; Masel & DeWitt, 2010).

TBI can result from a primary injury or a secondary injury. The severity of TBI may be categorized as mild, moderate, or severe, based on the extent and nature of the injury, duration of loss of consciousness, posttraumatic amnesia (PTA; loss of memory for events immediately following injury), and severity of confusion at initial assessment during the acute phase of injury (Diagnostic and Statistical Manual of Mental Disorders, 5th ed. [DSM-5; American Psychiatric Association, 2013]; CDC, 2015).

  • Mild TBI (mTBI) — loss of consciousness for less than 30 minutes, an initial Glasgow Coma Scale (GCS) or Pediatric GCS of 13–15 after 30 minutes of injury onset, and PTA for not greater than 24 hours (CDC, 2015; McCrory et al., 2013; Ontario Neurotrauma Foundation, 2013).
  • Uncomplicated — mTBI where there are no overt neuroimaging findings.
  • Complicated — mTBI where there are intracranial abnormalities (e.g., bruising or a collection of blood in the brain) seen on CT scan or MRI.
  • Moderate TBI — loss of consciousness and/or PTA for 1–24 hours and a GCS of 9–12 (CDC, 2015).
  • Severe TBI — loss of consciousness for more than 24 hours and PTA for more than 7 days with a GCS of 3–8 (CDC, 2015).

Concussion, a form of mTBI, is an injury to the brain characterized by the physical and cognitive sequelae of TBI. Concussion typically occurs as a result of a blow, bump, or jolt to the head, face, neck, or body that may or may not involve loss of consciousness (McCrory et al., 2013). Concussion has received more attention in recent years, particularly with respect to sports injuries.

The roles of speech-language pathologists and audiologists in concussion prevention and management—including baseline testing and “return to learn” protocols—have become more prominent, especially in the school setting (Halstead et al., 2013; Hotz et al., 2014).

Incidence of pediatric TBI refers to the number of new cases identified in a specified time period. Prevalence of TBI refers to the number of children who are living with the condition in a given time period.

Incidence and prevalence rates of pediatric TBI vary across clinical and epidemiological studies. These variations are often due to differences in participant characteristics (e.g., ages included), diagnostic classification criteria within and across subtypes (e.g., mTBI vs. severe TBI), and sources of data (e.g., hospital admissions, emergency room visits, general practitioner visits). Moreover, current statistics do not take into account children and adolescents who do not seek medical care. Therefore, these estimates may significantly underestimate the incidence and prevalence of pediatric TBI.

Regardless of variations, TBI is the leading cause of disability and death in children ages 0–4 years and adolescents ages 15–19 years (CDC, 2015). Also, it is estimated that 145,000 children and adolescents (ages 0–19 years) are living with lasting cognitive, physical, or behavioral effects of TBI (Zaloshnja, Miller, Langlois, & Selassie, 2008).

General Statistics

  • In the United States, approximately half a million children ages 0–14 years (n = 473,947) are admitted to emergency rooms each year as a result of a TBI (Faul, Xu, Wald, & Coronado, 2010). The estimated annual number for TBI-related emergency room visits, hospitalizations, and deaths combined was 511,257 for this same age range (Faul et al., 2010).
  • A review by Thurman (2016) reported a median estimated incidence of TBI of 691 per 100,000 children (0–24 years) annually based on U.S. emergency room visits.
  • A review examining worldwide incidence rates of pediatric TBI revealed variations by country ranging from 47 to 280 per 100,000 children. Rates of hospital admission vary widely and are higher in the United States than in other countries (Dewan, Mummareddy, Wellons, & Bonfield, 2016).


  • In the United States, children ages 0–4 years had the highest estimated annual rates of TBI-related emergency room visits (1,256 per 100,000), followed by adolescents ages 15–19 years of age (757 per 100,000; Faul et al., 2010). These same trends were noted in a population-based study using combined data from emergency room visits, hospitalizations, and death (Koepsell et al., 2011).


  • Across all age groups, the incidence rates of TBI are higher in boys than in girls (Faul et al., 2010; Keenan & Bratton, 2006; Langlois, Rutland-Brown, & Wald, 2006; Thurman, 2016). Based on combined data from emergency room visits, hospitalizations, and death, boys ages 0–4 years had the highest incidence rates of TBI (Faul et al., 2010).
  • Thurman (2016) reported that boys (0–9 years) were 1.4 times more likely than girls to have a TBI. The male-to-female ratio increased to 2.2 for older children and young adults (10–20 years).
  • Although the overall rates of TBI are generally higher in boys than in girls, the incidence of mTBI is on the rise for girls (Lincoln et al., 2011). In high school and collegiate athletics, girls have higher concussion rates than boys in sports played by both sexes (Covassin, Moran, & Elbin, 2016; Dick, 2009; Hootman, Dick, & Agel, 2007; Marar, McIlvain, Fields, & Comstock, 2012).


  • Approximately 80% of TBI across the lifespan is categorized as mTBI (Bazarian et al., 2005; CDC, 2003; Wortzel & Granacher, 2015). These same trends are reported in children with mTBI occurring in 692 of 100,000 children aged 0–15 years (Guerrero, Thurman, & Sniezek, 2000) and in 296 of 100,000 children aged 0–17 years (Koepsell et al., 2011). Koepsell et al. (2011) reported lower incidence rates for moderate, severe, or fatal TBIs (0.8 per 100,000 children). Within this same group, the incidence rates were highest for children (aged 15–17 years). A study examining causes and trends of TBI-related hospitalizations in adolescents in the United States (n = 139,798) revealed that 46% of patients were categorized as mild, 38% as moderate, and 16% as severe (Asemota, George, Bowman, Haider, & Schneider, 2013).
  • Each year, approximately 1 in 220 children are seen in emergency rooms as a result of a concussion (Meehan & Mannix, 2010).

Signs and symptoms of TBI vary, depending on the site and extent of injury to the brain, the age at which the injury occurred, premorbid abilities, and functional domains affected (e.g., physical, cognitive, language, sensory). The effects of TBI can be temporary or permanent, and no two children present with the same pattern.

Some young children with TBI may demonstrate relatively typical developmental progression after the initial stages of recovery. Others continue to have long-term difficulty learning new information and negotiating more complex social interactions due to impairments in cognitive functions (Anderson, Godfrey, Rosenfeld, & Catroppa, 2012; Turkstra, Politis, & Forsyth, 2015).

The functional impact of TBI in children can differ from that in adults because the pediatric brain is still developing. For example, sensory systems and the frontal lobes of the brain continue to develop past late adolescence (S. J. Taylor, Barker, Heavey, & McHale, 2013). Therefore, some children may not present with immediate effects of TBI, but will experience challenges later in their development, particularly as academic demands increase (Gerrard-Morris et al., 2010; H. G. Taylor et al., 2008). These difficulties can affect educational and vocational outcomes; friendships; participation in home, school, and community; and overall quality of life (Catroppa & Anderson, 2009; Gamino, Chapman, & Cook, 2009).

The full sequelae of pediatric TBI can emerge and/or persist well into adulthood, lending to the perspective that TBI in children is a chronic disease process rather than a one-time event (DePompei, 2010; DePompei & Tyler, in press; Masel & DeWitt, 2010).

Signs and symptoms may co-occur with other existing developmental conditions such as attention-deficit/hyperactivity disorder, learning disabilities, autism spectrum disorder, intellectual disability, childhood apraxia of speech, childhood fluency disorders, late language emergence, spoken language disorders, written language disorders, and social communication disorders.

Signs and Symptoms Related to Traumatic Brain Injury


  • Changes in bowel and bladder function
  • Changes in level of consciousness, ranging from brief loss of consciousness to coma
  • Dizziness
  • Fatigue
  • Headaches
  • Impaired movement, balance, and/or coordination
  • Motor speed and programming deficits (dyspraxia/apraxia)
  • Nausea
  • Pain
  • Reduced muscle strength (paresis/paralysis)
  • Seizures
  • Vomiting


Auditory and Vestibular
  • Auditory dysfunction from injury to the outer ear, middle ear, inner ear, and/or temporal lobe, resulting in
    • Central auditory dysfunction;
    • difficulty hearing speech in noise;
    • dizziness, vertigo, and/or imbalance
    • hypersensitivity to sounds (hyperacusis);
    • loss of postural stability/control;
    • tinnitus
    • transient or permanent hearing loss.
  • Changes in perception of color, shape, size, depth, and distance
  • Changes in visual acuity
  • Double vision (diplopia)
  • Problems with visual convergence and accommodation
  • Sensitivity to light
  • Visual field deficits/visual neglect
Other Sensory–Perceptual Sequelae
  • Gustatory—loss of taste
  • Olfactory—inability to recognize smells
  • Tactile—sensitivity or defensiveness to touch; changes in perception of pain, pressure, and/or temperature


  • Deficits in shifting attention between tasks
  • Difficulty with selective attention
  • Impaired sustained attention for task completion or conversational engagement
  • Reduced attention span
Executive Functioning
  • Difficulty with the following:
    • decision making
    • flexibility
    • goal setting
    • initiation and self-monitoring
    • judgment
    • planning and organization
    • reasoning and problem solving
    • strategy selection
Information Processing
  • Increased response latencies
  • Reduced processing speed (e.g., of rapid speech and/or complex language), resulting in confusion
Memory and Learning
  • Deficits in short-term memory that negatively affect new learning
  • Deficits in working memory that negatively affect following directions
  • Difficulty retrieving information from memory
  • PTA—anterograde or retrograde
  • Lack of insight for monitoring one’s strengths, weaknesses, functional abilities, problem situations, and so forth
  • Reduced awareness of deficits (anosagnosia)
Other Cognitive Deficits
  • Deficits in orientation to self, situation, location, and/or time
  • Impaired spatial cognition can affect the ability to navigate and ambulate


Pragmatic/Social Communication
  • Conversational turns marked by verbosity
  • Difficulty initiating conversation and maintaining topic
  • Difficulty taking turns in conversation
  • Impaired ability to use nonverbal communication effectively (e.g., tone of voice, facial expression, body language)
  • Inability to interpret nonverbal communication of others
  • Tendency to be tangential
Spoken Language
  • Anomia or word retrieval deficits
  • Decreased ability to formulate organized discourse or conversation
  • Difficulty following directions
  • Difficulty formulating fluent speech
  • Difficulty making inferences
  • Difficulty understanding abstract language/concepts
  • Tendency to perseverate in verbal responses
  • Tendency to use tangential speech
  • Use of incoherent or confabulatory speech
Written Language
  • Difficulty comprehending written text, particularly with respect to complex syntax and figurative language
  • Difficulty planning, organizing, writing, and editing written products


  • Apraxia of speech (motor programming)
  • Aprosodia/dysphonia, marked by deficits in intonation, pitch, stress, and rate
  • Dysarthria characterized by articulatory imprecision and/or vowel distortions
  • Hypernasality secondary to paresis or paralysis of velopharyngeal muscles involved in speech


  • Aphonia/dysphonia resulting from intubation, tracheostomy, or use of a mechanical ventilator
  • Laryngeal hyper/hypofunction marked by abnormal pitch; poor control of vocal intensity; or changes in vocal quality (e.g., hoarseness, strained–strangled voice, glottal fry)
  • Neurogenic phonatory abnormalities resulting from injury to sensory or motor innervations to the vocal folds
  • Psychogenic phonatory abnormalities (e.g., related to post-traumatic stress disorder)

Feeding and Swallowing

  • Oral and/or pharyngeal dysphagia
  • Risk of aspiration related to the impact of cognitive impairment (e.g., poor memory, reduced insight, limited attention, impulsivity, and agitation) while eating

Behavioral and Emotional

  • Agitation, aggression, and/or combativeness
  • Anxiety
  • Apathy and/or lack of motivation
  • Changes in effect—overemotional, overreactive, emotionless (flat affect)
  • Changes in sleep patterns (e.g., insomnia or hypersomnia)
  • Depression
  • Difficulty identifying emotions of self and others (alexithymia)
  • Disinhibition and poor self-regulation
  • Emotional lability
  • Excessive drowsiness
  • A feeling of disorientation or “fogginess”
  • Heightened sensory sensitivity with exaggerated reactions to perceived threats (hypervigilance)
  • Impulsivity
  • Irritability
  • Mood changes or mood swings
  • Reduced frustration tolerance

Considerations for Infants and Toddlers With TBI

Infants and toddlers may lack the communication or developmental skills to overtly report the signs and symptoms of TBI noted above. Clinicians and families need to be aware of the following signs that may be initially observed after TBI for this age group:

  • Changes in the ability to pay attention
  • Changes in eating or nursing habits
  • Changes in play (e.g., loss of interest in favorite toys/activities)
  • Changes in sleeping habits
  • Irritability, persistent crying, and inability to be consoled
  • Lethargy
  • Loss of acquired language
  • Loss of new skills, such as toilet training
  • Sensitivity to light and/or noise
  • Unsteady walking, loss of balance

In cases of abusive head trauma such as shaken baby syndrome, sometimes there are no apparent external physical signs to indicate a TBI. Attention to behavioral symptoms such as those listed above is critical (Cox, 2016).

For infants and toddlers, acute deficits following TBI tend to be in skill areas that are developing at the time of injury. Lack of overt deficits in these very young children just after TBI does not mean that they will not require services later. For skills that are not fully developed at the time of injury, later-onset symptoms can arise, including memory and attention deficits, language delay or deficits, and behavioral problems. These younger children are also more likely to have difficulties academically compared with children who were injured at later ages (Anderson, Catroppa, Morse, Haritou, & Rosenfeld, 2005). The full extent of deficits may become evident only as the child’s brain matures and expected skills fail to develop or emerge more slowly (McKinlay & Anderson, 2013).

Causes of pediatric TBI are varied and appear to differ by age. The Centers for Disease Control and Prevention (CDC) identified the following leading causes of TBI in children and adolescents ages 0 to 14:

  • Falls (50.2%)
  • Struck by/against events (24.8%)
  • Motor vehicle accidents (6.8%)
  • Assault (2.9%)
  • Unknown/other (15.3%)

Falls and assault (e.g., shaken baby syndrome or other physical abuse) are the most common mechanisms of TBI in infants, toddlers, and preschoolers. TBI secondary to velocity injury (e.g., motor vehicle or bicycle accidents, sports injuries) occurs more often in elementary school children and adolescents (Faul et al., 2010).

Roles and Responsibilities of the SLP

Speech-language pathologists (SLPs) do not diagnose TBI; however, they play a key role in the screening, assessment, and treatment of children and adolescents with TBI. The professional roles and activities in speech-language pathology include clinical services (assessment, planning, and treatment), prevention, and advocacy, as well as education, administration, and research.

Appropriate roles for SLPs include the following:

  • Providing prevention information to individuals and groups known to be at risk for TBI as well as to individuals working with those at risk
  • Screening children with TBI for hearing, speech, language, cognitive communication, and swallowing difficulties
  • Determining the need for further and ongoing assessment and/or referral for other services
  • Conducting a comprehensive assessment and diagnosing speech, language, cognitive-communication, and swallowing disorders associated with TBI, with sensitivity to individual differences, including cultural and linguistic variations
  • Developing and implementing treatment plans involving direct and indirect intervention methods for maintaining functional speech, language, cognitive communication, and swallowing abilities at the highest level of independence, with sensitivity to individual, cultural, and linguistic variations
  • Gathering and reporting treatment outcomes, documenting progress, and determining appropriate discharge criteria
  • Facilitating the transition of services between medical, educational, community, and vocational settings
  • Counseling persons with TBI and their families regarding impairments across the SLP scope of practice and providing education aimed at preventing further complications relating to TBI
  • Providing training (e.g., in the use of augmentative and alternative communication [AAC] systems) to persons with TBI and their families, caregivers, and educators
  • Serving as an integral member of an interdisciplinary team working with individuals with TBI and their families/caregivers, including participating as a member of the school planning/individualized education program (IEP) team to determine eligibility, appropriate educational services, and transition planning
  • Consulting and collaborating with other professionals (e.g., teachers, neuropsychologists, occupational and physical therapists) to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate
  • Advocating for individuals with TBI and their families, particularly in school settings where cognitive-communication disorders may be mistaken for attitudinal or motivational problems
  • Educating other professionals, third-party payers, and legislators about the needs of children with TBI and the role of SLPs in diagnosing and managing speech, language, cognitive communication, and swallowing disorders associated with TBI across settings
  • Remaining informed of research in the area of TBI and helping advance the knowledge base related to the nature and treatment of cognitive communication and swallowing deficits associated with TBI

Roles and Responsibilities of the Audiologist

Audiologists play a central role in the assessment, diagnosis, and rehabilitation of hearing and vestibular deficits in children and adolescents with TBI.

Appropriate roles for audiologists include the following:

  • Educating other professionals about the needs of children with hearing and vestibular/balance deficits post-TBI and the role of audiologists in diagnosing and managing them
  • Identifying hearing and vestibular/balance deficits post-TBI, including early detection and screening program development, management, quality assessment, and service coordination
  • Conducting a comprehensive and culturally and linguistically sensitive assessment, using behavioral, electroacoustic, and/or electrophysiological methods to assess hearing, auditory function, vestibular and balance function, and related systems
  • Referring the child with TBI to other professionals as needed to facilitate access to comprehensive services
  • Evaluating children with hearing and vestibular deficits post-TBI for candidacy for amplification and other sensory devices, assistive technology, and vestibular rehabilitation
  • Fitting and maintaining amplification and other sensory devices and assistive technology for optimal use
  • Developing and implementing an audiologic and/or vestibular rehabilitation management plan
  • Creating documentation, including interpreting data and summarizing findings and recommendations
  • Counseling the child with TBI and his or her family regarding the psychosocial aspects of hearing loss and other auditory processing dysfunction, modes of communication, and processes to enhance communication competence
  • Providing communication skills training for families and other professionals who interact with the child
  • Advocating for the communication needs of all individuals, including advocating for the rights to and funding of services for those with hearing loss, auditory disorders, and/or vestibular disorders
  • Remaining informed of research in the area of TBI and helping advance the knowledge base related to the nature, identification, and treatment of hearing and vestibular deficits post-TBI

Collaboration and Teaming

Collaboration and teaming are integral to speech-language pathology and audiology service delivery for children with TBI. Integration of knowledge and skills from a variety of disciplines is essential for identifying functional abilities; determining the levels of support needed across clinical domains and service delivery settings; maximizing outcomes; and facilitating transition back to home, school, and community. Team members may include physicians, physical and occupational therapists, teachers, neuropsychologists, and school psychologists.

Team models vary model selected will depend on the needs of the child and his or her family. The role that each team member plays will evolve as the child or adolescent develops and as his or her needs change.

The roles of the SLP and audiologist will be guided by each profession’s scope of practice, discipline-specific training, ethical considerations, and state licensure regulations.


Children and adolescents with TBI are heterogeneous groups with varied and complex sequelae that can change over time. Assessment of children with TBI takes into account the child’s behaviors, strengths, and needs over the course of development and rehabilitation, including school and community re-entry. For children, in particular, it is helpful to focus assessment on areas critical to learning and school success. Assessment requires ongoing collaboration with the family and medical, surgical, rehabilitation, and educational professionals. Findings from the speech-language and audiology assessments are analyzed in the context of findings from other professionals on the team.


Screening is conducted by speech-language pathologists and audiologists to identify possible deficit areas following a TBI. Screening is typically completed prior to conducting more comprehensive evaluations.

Screening does not provide a detailed description of the severity and characteristics of deficits resulting from TBI but, rather, identifies the need for further assessment. Screening may result in recommendations for rescreening, comprehensive assessments, or referral for other examinations or services.

Audiologic Screening

Hearing screening and otoscopic inspection occur prior to screening for other deficits. If the child wears hearing aids, the hearing aids are inspected by an audiologist to ensure that they are in working order, and aids should be worn by the child during screening. Hearing screening is within the SLP’s scope of practice.

A referral for a full audiological evaluation is necessary if the child fails the hearing screening or if hearing loss is suspected. Audiologists may also screen for auditory processing disorders, tinnitus, and vestibular deficits as indicated.

Speech, Language, Cognitive-Communication, and Swallowing Screening

SLPs screen for speech, language, cognitive communication, and swallowing deficits. Due to a lack of validated screening tools for this population, recommendations and referrals are often based on developmental expectations (Turkstra et al., 2015). Screening typically includes interviews with family members and/or teachers regarding concerns about the child’s skills. Screening is conducted in the language(s) used by the child and family, with sensitivity to cultural and linguistic variables.

Comprehensive Assessment

The purpose of a comprehensive assessment for children with TBI is to determine speech, language, cognitive-communication, and swallowing abilities; identify strengths and deficits; and target interventions. The specific focus of a comprehensive assessment can vary depending on the child’s current age and age at the time of injury, the severity of the injury, the stage of recovery, and prior educational status. Ongoing assessment is necessary to evaluate performance and to track changes in functioning as the child recovers from TBI.

Factors that may influence assessment include the following:

  • Level of consciousness and arousal
  • Behavioral factors, such as agitation and combativeness
  • Emotional factors such as depression
  • Decreased physical endurance and ability to participate
  • Sensory deficits (e.g., visual neglect, hearing loss)
  • Presence of co-existing premorbid conditions such as attention-deficit/hyperactivity disorder, learning disabilities, and developmental disabilities

If a child wears prescription eyeglasses or hearing aids, and prescriptions are still appropriate post-injury, the glasses or aids should be worn during the assessment.

If the TBI resulted in additional hearing or visual deficits, sensory aids and/or accommodations that were used premorbid may no longer be sufficient for the child, and physical or environmental modifications may be needed (e.g., large-print material, modified lighting, amplification devices).

If changes to premorbid hearing and/or vision are suspected, refer the individual for complete audiology and/or vision assessments prior to any additional testing.

Consistent with the World Health Organization’s (WHO) International Classification of Functioning, Disability, and Health (ICF) framework (ASHA, 2016b; WHO, 2001), ongoing comprehensive assessment of children with TBI is conducted to identify and describe the following:

  • Impairments in body structure and function, including underlying strengths and weaknesses in areas known to be affected by TBI.
  • Co-morbid deficits such as aphasia, motor speech disorders, dysphagia, and hearing and vestibular problems.
  • The individual’s limitations in activities and participation include functional communication, interpersonal interactions, self-care, and resuming the role of student.
  • The impact of communication impairments on quality of life and functional limitations relative to premorbid social abilities and community access.
  • Contextual (environmental and personal) factors that serve as barriers to, or facilitators of, successful communication as well as school and life participation. These can include the following:
    • Facilitators—ability and willingness to use compensatory strategies for day-to-day communication and in the classroom; family/teacher/peer support; motivation to return to improve function.
    • Barriers—decreased confidence in one’s ability to communicate and/or succeed academically; the presence of cognitive deficits; visual and motor impairments; lack of awareness of disability.

Assessment Methods

A comprehensive assessment is conducted for children with TBI using both standardized and nonstandardized procedures to help identify areas of weakness, areas of strength, and/or effective educational supports.

Standardized Assessments

When selecting standardized assessments, consider the following:

  • There are a limited number of standardized cognitive-communication assessments specifically for children and adolescents with TBI (Chevignard, Soo, Galvin, Catroppa, & Eren, 2012; Turkstra et al., 2015).
  • Standardized assessments that are too difficult for children with severe TBI may not yield useful information for treatment.
  • Tests typically used for children with moderate or severe TBI may not identify the subtler difficulties in children with mTBI.
  • Standardized tests are usually administered in quiet settings that control for distractions, tend to be highly structured, and often focus on skills that the child can still access. Therefore, performance may not accurately reflect or predict level of functioning in everyday situations (Blosser & DePompei, 2003; Coelho, Ylvisaker, & Turkstra, 2005; Turkstra, 1999; Turkstra et al., 2015).
Nonstandardized Assessments

Functional or situational assessments (e.g., language sampling, analog tasks, and naturalistic observation) and anecdotal reports are particularly useful for supplementing data from standardized tests when assessing individuals with TBI.

Nonstandardized measures that focus on process rather than content knowledge may provide valuable information for targeting interventions and identifying effective strategies (Turkstra et al., 2015). For example, with school-age children, these procedures may help answer some of the following questions about a child’s functioning in natural environments.

  • Does time pressure affect performance in the classroom?
  • Can the student prioritize tasks or manage more than one task at a time?
  • Do classroom accommodations or task modifications help maximize the student’s academic performance?
  • What natural supports in the classroom (e.g., priority seating, partnering with peers) can facilitate academic success for the student?
  • What social skills should be developed to support successful communication?

Comprehensive Speech-Language Assessment for Pediatric TBI: Typical Components

Case History

  • Medical status prior to injury (e.g., surgeries, prior TBI)
  • Psychiatric and psychosocial history prior to injury
  • Nature and onset of TBI and related hospitalizations
  • Current medical status, including medications
  • Developmental milestones
  • History of hearing or vision problems
  • Speech and language status prior to the injury, including the history of speech and language services
  • Concerns regarding current communication status and context of concern (e.g., daily routines, school activities, social interactions)
  • Impact of current condition on individuals and their family/caregivers
  • Goals and priorities of the individual and their family/ caregivers

Hearing Screening

  • Hearing screening (if not previously completed)

Oral–Peripheral Exam and Integrity of Speech Subsystems

  • Strength, speed, and range of motion of lips, tongue, jaw, and velum
  • The symmetry of structures of the face, oral cavity, head, and neck at rest and during a speech
  • The sensation of the face, oral cavity, taste, and smell
  • Respiration and breath support for speech

Cognitive-Communication Assessment

  • Impact of cognitive factors on functional communication in various activities and settings; examples include
    • attending to, perceiving, and processing verbal and nonverbal information;
    • remembering verbal and nonverbal information; and
    • having the metacognitive and executive functioning skills necessary for interacting in home, school, and community settings.

Speech Sound Assessment

Motor Speech Assessment

Voice Assessment

Spoken Language Assessment

Written Language Assessment

Social Communication Assessment

Curriculum-Based Assessment

  • Analyze the language demands of curricular activities
  • Observe the student as he or she attempts curricular activities without assistance
  • Identify gaps between the demands of the task and the abilities of the student

Augmentative and Alternative Communication (AAC) Assessment

Feeding and Swallowing Assessment

Comprehensive Audiologic Assessment for Pediatric TBI: Typical Components

Case History

  • Review case history information (including medical information and results from any previous assessments)
  • Gather additional details related to hearing, balance, and auditory processing difficulties

Behavioral Hearing Testing

  • Pure tone and speech audiometry, including modifications as needed
    • simplifying directions,
    • using pulsed tones,
    • slowing presentation of speech stimuli,
    • providing reminders to respond, and
    • responding with “yes” instead of raising a finger or pressing a button.
  • Otoacoustic Emissions or Auditory Brainstem Response testing—if accurate test results cannot be obtained using traditional behavioral testing methods

Auditory Processing

  • Speech in noise
  • Temporal processing
  • Binaural processing

Vestibular Testing

  • Dix-Hallpike and roll tests
  • Semicircular canal function tests, such as caloric, rotational, and video head impulse testing
  • Otolith testing, such as ocular and cervical vestibular-evoked myogenic potential (VEMPs), and the subjective visual vertical (SVV) test
  • Videonystamography (VNG; Wintrow, 2013)

The comprehensive assessment typically results in one or more of the following:

  • Diagnosis of a speech, language, voice, cognitive-communication, and/or swallowing disorder
  • Diagnosis of an auditory and/or vestibular disorder
  • Clinical description of the characteristics and severity of the disorder(s) and their impact on life activities
  • Identification of strengths and facilitators in addition to any barriers to everyday activities
  • Prognosis for change
  • Programming and intervention decisions, including placements, functional and personally relevant goals, and school and community re-entry plans
  • Determination of the effectiveness of interventions and supports (e.g., accommodations and modifications; technologies)
  • Identification of facilities or agencies involved at the time of the evaluation and referrals to relevant follow-up services for appropriate intervention and support for youth with TBI and their families (e.g., social services and counseling support)
  • Recommendations for effective strategies and support for parents, caregivers, and teachers
  • Recommendations for support for transitions (e.g., early intervention into school age; school age into the workplace

Assessment Considerations

Cultural and Linguistic Factors

Assessments are sensitive to cultural and linguistic diversity and are completed in the language(s) used by the individual with TBI (see ASHA’s Practice Portal pages on Bilingual Service Delivery, Cultural Responsiveness, and Collaborating With Interpreters ). TBI may affect each language used by the child in different ways. Therefore, information about all language(s) should be collected. Any accommodations and modifications related to the native language or culture must be documented. Standard scores should not be reported if a standardized test is modified or translated, as norms will not apply.

Cognition and Language

TBI often causes deficits in cognition and language. It is important to recognize that these two domains are intrinsically and reciprocally related in development and function. Impairment of language can disrupt cognitive processes (e.g., attention, memory, and executive functions). Impairment of cognitive processes can also disrupt aspects of language (e.g., syntax, semantics, and pragmatics). The assessment identifies strengths and deficits in these related domains. Difficulty with any aspect of communication that is affected by disruption of cognition is diagnosed as a cognitive-communication disorder.

Feeding and Swallowing

The following may have an impact on the assessment of feeding and swallowing:

  • Level of alertness
  • Ability to follow directions (as appropriate for age of the child)
  • Extent and severity of trauma
  • Physical damage to the oral, pharyngeal, and/or laryngeal structures
  • Respiratory status, including the presence of tracheostomy and/or use of mechanical ventilation (Morgan, 2010; Morgan, Mageandran, & Mei, 2010; Morgan, Ward, Murdoch, Kennedy, & Murison, 2003)

Hearing and Balance

Children with superior canal dehiscence or enlarged vestibular aqueduct are more susceptible to hearing and balance problems after TBI. Audiologists need to be aware of the potential impact of these conditions during the assessment. Promoting hearing wellness and monitoring the acoustic environment are also key roles for the audiologist in assessment.

Assessment of Young Children (Infants, Toddlers, and Preschoolers)

One of the main challenges in assessing infants, toddlers, and preschoolers is a lack of objective information regarding pre-injury function on which to base an evaluation of deficits (McKinlay & Anderson, 2013). Cognitive and communication skills are still developing during this period, making symptoms difficult to evaluate, particularly in pre-verbal children. Ongoing assessment at various points post-injury may be necessary to identify emerging deficits, particularly as cognitive-communication demands increase.

There are few standardized tests for young children with TBI; therefore, observation and parent reports are key components in determining changes in baseline function or differences from developmental norms. When interpreting assessment results for children ages 0–5 years, it is important to consider

  • age at injury;
  • time since injury;
  • the developmental stage at the time of injury; and
  • the developmental stage at the time of assessment (McKinlay & Anderson, 2013).

Assessment of School-Age Children and Transitioning Youth

For school-age children, the assessment focuses on the child’s ability to perform academically and interact with peers (Turkstra et al., 2005). The assessment describes strengths and needs for supporting new learning and/or re-learning and helps identify areas for remediation.

The development of cognitive-communication skills continues to be monitored through high school and during the transition to postsecondary educational or vocational settings. The impact of new demands and challenges is assessed so that strategies to maximize functional outcomes and life participation can be implemented (Blosser & DePompei, 2003; New Zealand Guidelines Group, 2006).

Each child with TBI has a unique profile of strengths and needs. In developing a treatment plan, clinicians consider age, previous levels of function, and developmental status as well as functioning in related areas, such as sensory and motor skills.

Speech, language, and/or cognitive deficits that existed prior to the TBI—such as attention-deficit/hyperactivity disorder, autism spectrum disorder, childhood apraxia of speech, acquired apraxia of speech, learning disabilities, speech sound disorders, spoken language disorders, and written language disorders—must also be considered.

Treatment of children with TBI addresses abilities to function effectively in everyday real-life environments, including home, school, work, and community. Treatment can focus on developing and generalizing new skills, remediating lost functions, and/or addressing unwanted behaviors (Blosser & DePompei, 2003).

Children and families bring different cultural backgrounds, medical and developmental histories, learning styles, and experiences to the treatment setting. Treatment of children with TBI is individualized, is provided in the language(s) used by the individual, and is done so with sensitivity to cultural values and norms.

Consistent with the ICF framework (WHO, 2001), intervention is designed to

  • capitalize on strengths and address impairments related to the child’s structures and functions that affect speech, language, cognition, communication, and swallowing;
  • facilitate activities and participation by helping the child acquire new skills and strategies; and
  • modify contextual factors that are barriers and enhance facilitators of successful communication and participation, including identification and use of appropriate accommodations.

Family-Centered Practice

Family-centered practice is the foundation of intervention for pediatric TBI. Treatment outcomes and reintegration to home, school, work, and community for children with TBI are best achieved when family members and caregivers play a central role (DePompei & Williams, 1994). These individuals not only are responsible for making decisions that affect the child’s life and education but also provide long-term support (Roscigno & Swanson, 2011).

Family members and caregivers can be frightened, stressed, and overwhelmed by the magnitude of the medical situation, changes in the child they once knew, and the process of learning to care for a child with TBI (Wade et al., 2006). Effective education, training, and counseling require sensitivity to these emotions.

Family-centered practice can provide a way to improve the family’s ability to adapt to changes brought about by the TBI by helping family members communicate openly, identify priorities, and learn how to problem-solve together (Wade, 2006; Wade, Wolfe, Brown, & Pestian, 2005).

With proper educational and emotional support, families learn to work with their children and provide support to help them manage the cognitive, behavioral, communication, and other life changes associated with TBI (Gan, DePompei, & Lash, 2013).

The family-centered practice provides opportunities for family members and caregivers to

  • identify treatment goals and implement techniques and strategies to facilitate the generalization of therapy gains to everyday life and improved function in the home and community;
  • exchange information with professionals to learn from one another and make informed decisions that will maximize treatment outcomes; and
  • advocate for their child by providing important information about performance in home and school as the child progresses through transitions.

The roles of family members and caregivers will vary based on individual needs, the severity of injury, family circumstances, cultural dimensions, and attitudes, beliefs, and expectations (Roscigno & Swanson, 2011).

Treatment Approaches

A variety of treatment approaches can be used in intervention for children with TBI. These approaches are listed separately below but are not mutually exclusive. Often, aspects of more than one approach are integrated in the delivery of speech and language services.

Restorative Approaches

Restorative approaches involve direct therapy aimed at improving or restoring impaired function(s) through retraining. Treatment is often hierarchical, exercising target-specific processes in the impaired domain before introducing more demanding higher-level tasks in that domain and eventually generalizing skills to more functional activities and tasks (ASHA, 2003; Sohlberg & Mateer, 2001).

Habilitative Approaches

Habilitative approaches target skills that have not yet developed. Habilitative interventions help children learn, keep, or improve skills and functional abilities following their injury rather than restore skills that they had mastered prior to injury. These approaches often are used in treatment when the injury occurs before some developmental milestones have been met (e.g., cognitive, speech and language, or swallowing). Skills that are not yet fully developed at the time of TBI may be particularly vulnerable post injury.

As cognitive, behavioral, academic, and social demands increase over time, children with TBI may demonstrate additional deficits not seen immediately following injury (Anderson et al., 2005; Gamino et al., 2009). Habilitative approaches may also be needed at this point to facilitate learning.

Compensatory Approaches

Compensatory approaches focus on adapting to deficits by learning new or different ways of doing things to minimize difficulties (National Institutes of Health [NIH], 1998). Compensatory approaches draw on the child’s strengths to maximize his or her abilities, often through the use of external or internal aids (Blosser & DePompei, 2003; Shum, Fleming, Gill, Gullo, & Strong, 2011).

A compensatory approach to treatment may also include accommodations and/or modifications.

Accommodations are changes to the environment, task, or mode of response that allow an individual to access and participate in an activity without changing the activity itself. Academic accommodations are often needed for students with TBI so that they can demonstrate their knowledge without interference from their deficits (Bush & Burge, 2016; Childers & Hux, 2013).

Academic accommodations for students with TBI may include using note-takers, listening to recorded lessons, receiving extra testing time, taking rest breaks, or reducing environmental noise and distractions in the classroom. Accommodation may be required as part of a Section 504 plan or an individual family service plan (IFSP) or IEP.

Modifications are changes to the nature of the activity to facilitate participation and promote success in home, community, academic, and work settings. Academic modifications can include changes in materials, curriculum content, or acceptable responses (New York State Education Department, 2002).

Modifications for students with TBI may include shortened class schedule or day, reduced number or type of assignment, or modified response type (e.g., multiple-choice questions instead of recall questions or short-answer questions).

Functional/Contextualized Approaches

Functional/contextualized approaches focus on personally meaningful goals, routines, and activities with the generalization of skills to relevant social, vocational, and educational activities. Contextualized interventions for children and adolescents with TBI are functional, personally relevant, nonhierarchical, and collaborative (Koole, Nelson, & Curtis, 2015). They involve teaming with educators, caregivers, and peers to facilitate the carryover of skills to situations and activities of interest and importance to the child and family.

Functional goals take into account the child’s and family’s priorities and promote independence, generalization, and community competence across settings (Feeney & Ylvisaker, 2008; Sohlberg & Turkstra, 2011; Ylvisaker, Adelson et al., 2005).

Goal attainment scaling (GAS) is one collaborative approach for identifying and quantifying individualized, meaningful treatment outcomes using a point scale to objectively measure goal achievement (Kiresuk, Smith, & Cardillo, 2014). GAS is particularly applicable in TBI treatment that targets executive functions because it can help children identify their own goals, then plan and manage their related behaviors while engaging in everyday life activities (Grant & Ponsford, 2014).

Treatment Options

The following are brief descriptions of both general and specific treatments for individuals with deficits and disorders associated with TBI. This alphabetized list is not exhaustive, and the inclusion of any specific treatment does not imply endorsement by ASHA.

Alternative and Augmentative Communication (AAC)

Augmentative and alternative communication (AAC) involves supplementing or replacing natural speech and/or writing with aided symbols (e.g., Picture Exchange Communication System [PECS], line drawings, Blissymbols, speech-generating devices, and tangible objects) and/or unaided symbols (e.g., manual signs, gestures, and finger spelling). AAC may be temporary—as when used by patients postoperatively in intensive care—or permanent—as when used by an individual with a disability who will need to use some form of AAC throughout his or her lifetime.

Factors that influence the selection and use of AAC systems following TBI include the child’s communication abilities and needs as well as his or her cognitive, neurobehavioral, motor, sensory, and perceptual impairments (Fager & Spellman, 2010).

AAC intervention is an ongoing and dynamic process because the needs of the child following a TBI will vary over time, depending on the stage of recovery, the presence of cognitive–behavioral changes, and communication needs in particular settings. The training of teachers, staff, and family members for the purpose of optimizing functional communication is also an essential part of AAC intervention (Fager & Spellman, 2010).

Behavioral Intervention

Behavioral interventions are used to teach desired behaviors and are based on behavioral/operant principles of learning (i.e., differential reinforcement, modeling, prompting, and fading). Injuries to the frontal lobe can result in behaviors such as agitation, aggression, impulsivity, and self-injury that interfere with a child’s functioning in home, community, and school environments and his or her ability to communicate effectively. Behavioral interventions are often used to decrease these unwanted behaviors and teach functional alternative behaviors.

Post-TBI behavioral interventions include the following:

  • Proactive positive behavior interventions and supports (PBIS; e.g., structuring the environment, adjusting tasks to ensure success, and providing well-understood daily routines) that focus on preventing and controlling antecedents in the environment rather than reacting to problem behaviors (Ylvisaker et al., 2007).
  • Contingency management procedures that focus on the consequences of behaviors (e.g., differential reinforcement of positive behaviors and extinction procedures through planned ignoring of negative behaviors; Ylvisaker et al., 2007).
  • Metacognitive skills training that focuses on improving awareness, self-monitoring, and self-regulation of behaviors (Kennedy & Coelho, 2005).

Cognitive-Communication Interventions

Cognitive-communication interventions in pediatric TBI can address discrete components of the child’s cognitive-communication domains or focus more globally on functional communication. The complex relationship between cognitive and communication domains needs to be considered when selecting interventions. For example, poor insight into deficits may affect treatment buy-in, strategy use, or adherence to recommendations.

Cognitive-communication treatment methods can include direct remediation (e.g., breaking the target into discrete steps and sequentially completing a task) or strategy-based training and accommodations (e.g., training the individual to develop internal strategies to perform complex tasks; making changes in the classroom). Some treatment options fall into overlapping categories, and clinicians use the approach or approaches that best meet the needs of the child (Ylvisaker, Adelson et al., 2005; Turkstra et al., 2015).

Computer-Assisted Treatment

Computer-assisted treatment refers to the use of specially designed software programs to improve cognitive communication functions through repeated, structured practice of tasks related to attention, memory, problem-solving, executive function, language, and speech. These programs are available for use on computers, smartphones, and tablets. Computer-assisted treatment can be used and monitored by a clinician in person or remotely, providing consistent feedback to the individual (e.g., Politis & Norman, 2016; Teasell et al., 2013).

This type of intervention does not refer to the use of computers or electronic devices (e.g., electronic memory aids or web-based organizational assistants) as external aids.

Direct Attention Training (DAT)

Direct attention training (DAT) provides structured opportunities for repeated practice to improve various aspects of attention, including sustained attention over time (vigilance), selective attention, divided attention, and the ability to shift attention (Sohlberg, 2002; Sohlberg et al., 2003). Repetitive drills provide opportunities for practice on tasks that impose increasingly more complex attentional demands (Sohlberg & Mateer, 2001; Sohlberg et al., 2003).

Metacognitive skills training is an integral part of DAT when used to treat cognitive-communication deficits in children with TBI (e.g., Lee, Harn, Sohlberg, & Wade, 2012; Sohlberg, Harn, MacPherson, & Wade, 2014).

Drill and Practice

Drill and practice is the repetition of a specific therapeutic activity or target. Repetitive drills practice assumes that neural networks underlying performance are strengthened by repeated activation (Sohlberg et al., 2014). Spaced or distributed practice is a drill-and-practice technique in which practice is broken up into a number of short sessions over a longer period of time. Recall and carryover of information is better when practice trials are spaced or distributed rather than massed (Sohlberg, Ehlhardt, & Kennedy, 2005; Sohlberg & Turkstra, 2011).

Dual Task Training

Dual-task training focuses on improving task complexity by targeting the ability to carry out two competing tasks simultaneously. Dual-task training aims to restore executive functions that are often affected by TBI; it is sometimes used to train tasks across both physical and cognitive-communicative domains (Valovich McLeod & Guskiewicz, 2012).

Errorless Learning

Errorless learning is a treatment method in which the clinician tries to minimize errors as the individual learns a targeted skill by

  1. breaking the targeted task down into small, discrete steps;
  2. modeling target behavior before the person attempts each step;
  3. discouraging guessing;
  4. immediately correcting errors, modeling the correct step, and asking the person to do it again; and
  5. carefully fading supports and prompts (Sohlberg et al., 2005; Sohlberg & Turkstra, 2011).

Errorless learning is most beneficial for individuals with relatively unimpaired procedural memory and severely impaired declarative memory (Sohlberg et al., 2005). Spaced retrieval (Sohlberg et al., 2005; Sohlberg & Turkstra, 2011) and the method of vanishing cues (Sohlberg et al., 2005) are based on principles of errorless learning.

External Aids

External aids are used to facilitate improved attention, time management, organization, and recall of events and information (Burns, 2004; Teasell et al., 2013). Headphones, computers, and handheld devices, including smartphones and voice recorders, may serve as functional external aids for children; low-tech options include calendars, timers, checklists, maps, color-coded binders, and small notebooks (Burns, 2004; DePompei et al., 2008). Training children with TBI to apply these strategies independently requires structured, sequenced, and repetitive practice and needs to take into consideration the child’s level of deficit awareness (Sohlberg et al., 2007; Ylvisaker, 1998). Clinicians consider the most appropriate option for each individual when selecting and training the use of external aids to facilitate cognitive communication function in everyday activities (Wild, 2013, 2014).

Internal Aids

Internal aids are mental strategies used to enhance memory and executive function. Examples include mnemonics, visual imagery, association, elaborative encoding, and chunking. For example, mnemonics and visual images can help improve the recall of names (Kashel et al., 2002; OʼNeil-Pirozzi, Kennedy, & Sohlberg, 2015). With elaborative encoding, individuals learn to associate new information with related features or information already in memory (Oberg & Turkstra, 1998). Grouping or chunking information into logical categories can be used when large amounts of information need to be remembered (Kennedy, 2006).

Metacognitive Skills Training

Metacognitive skills training—also called metacognitive strategy instruction—focuses on improving awareness, self-monitoring, self-regulation, and the use of goal-setting strategies to facilitate learning and behavioral success. Strategies such as mental imagery, self-talk, self-reflection, and keeping an agenda are used to work through problem situations, provide feedback, and track progress toward goals. Metacognitive skills training can be integrated with direct attention training (Kennedy et al., 2008; Sohlberg et al., 2005, 2014; Sohlberg & Turkstra, 2011).

Project-Based Intervention

Project-based intervention is used to help improve cognitive-communicative function and social engagement. Intervention facilitates participation in meaningful activities by involving individuals in a long-term, collaborative project that results in a tangible product. Projects often target competence in planning, organizing, social interaction, and self-regulation (Ylvisaker, Feeney, & Capo, 2007).

Sensory Stimulation

Sensory stimulation—also referred to as coma stimulation—is the systematic exposure of an individual with severe TBI to a variety of visual, auditory, tactile, olfactory, and kinesthetic stimuli to improve arousal/level of consciousness and prevent sensory deprivation. The intensity and frequency of stimulation can be tailored to a child’s threshold in order to elicit a meaningful behavioral response following TBI and to monitor changes in responsiveness during recovery (Hotz et al., 2006).

Strategic Learning Intervention

Strategic learning intervention is the ability to organize, combine, and synthesize details from texts, lectures, or conversations in order to abstract the most important concepts. This skill typically develops in early adolescence; it is often deficient in youth with TBI, resulting in academic challenges. Strategic learning interventions for older children and adolescents focus on improving the ability to abstract gist-based meaning. Training is hierarchical and strategy based rather than content-based, often incorporating text-based materials from the child’s schoolwork. The Strategic Memory and Reasoning Training (SMART) program is one example of a strategic learning intervention that teaches the student how to eliminate unimportant information; summarize information in one’s own words; and consider multiple interpretations (Cook, DePompei, & Chapman, 2011).

Task Analysis

In task analysis, a target skill is analyzed or broken down into a sequence of smaller steps that can be taught one step at a time and then chained together. In this way, tasks that seem complex and difficult to learn become more manageable as smaller units (Sohlberg et al., 2005). This process can be applied to skills in any of the cognitive-communication domains.

Language Intervention

Language intervention for children with TBI takes into account the interconnection between cognition and communication (Blosser & DePompei, 2003). For example, impairments in processing speed, working memory, and executive function may contribute to deficits in the language (Ewing-Cobbs & Barnes, 2002).

Language intervention varies, depending on the child’s developmental level at the time of injury and the pattern of deficits that require intervention. For younger children, intervention tends to emphasize following directions, phonological awareness, vocabulary development, and word fluency for early literacy skills. For older children and adolescents, the emphasis is often on inferencing, higher-level comprehension, narrative and discourse processes, and academic or vocational literacy (e.g., summarizing text, and taking notes). Regardless of age at injury, treatment goals for children with TBI might also address the appropriate use of social language in different contexts and under varying demands (Blosser & DePompei, 2003; Ewing-Cobbs & Barnes, 2002; Turkstra et al., 2015).

Although some traditional language stimulation techniques and treatments can be used with this population, not all are applicable to children with acquired language disorders.

Social Communication Intervention

Social communication intervention for children and adolescents with TBI frequently focuses on training the child’s communication partners (Togher, 2014; Togher, McDonald, Tate, Power, & Rietdijk, 2013; Togher, Power, McDonald, Tate, & Rietdijk, 2010; Ylvisaker, Turkstra, & Coelho, 2005; Ylvisaker & Feeney, 2007) and helping school personnel provide the necessary supports, structure, and instruction to help students learn (or relearn) appropriate behaviors and social skills in real-world communications (MacDonald & Wiseman-Hakes, 2010; New York State Education Department, 2002; New Zealand Guidelines Group, 2006).

Social communication intervention helps children develop conversation skills, learn appropriate pragmatic language norms (e.g., taking turns, remaining on topic, inhibiting confabulations), and practice impulse control necessary for improved social interactions (Burns, 2004; McDonald, Togher, & Code, 2014).

Intervention in the context of natural environments may incorporate supports such as structured feedback, use of videotaped interactions, modeling and role play, rehearsal and coaching, and training in self-regulation and self-monitoring strategies (MacDonald & Wiseman-Hakes, 2010; Sohlberg & Turkstra, 2011; Ylvisaker, Turkstra, & Coelho, 2005).

Speech Intervention

Speech problems resulting from TBI can include dysarthria, apraxia, phonation, resonance, respiration, articulation, and/or fluency disorders. Traditional approaches to the remediation of these clinical disorders can be used in children with TBI.

Intervention for speech problems may focus on the individual speech subsystems of respiration, phonation, articulation, and velopharyngeal function or, more globally, on overall speech intelligibility, using behavioral and instrumental treatments, prosthetics, compensatory strategies, AAC, and/or environmental modifications (McDonald et al., 2014; Morgan et al., 2010; Morgan & Vogel, 2008).

Children who are unable to use natural intelligible speech for communication (e.g., due to severe dysarthria or a voice disorder) may need long-term AAC (Doyle & Fager, 2011).

Some children with TBI may initially be unable to speak because they have had a tracheotomy. In these cases, a speaking valve may be used to facilitate voicing.

Underlying speech subsystems may still be developing at the time of injury in pediatric populations, or the child may have pre-existing speech deficits. Therefore, clinicians need to consider previous levels of function and developmental status when planning treatment. Cognitive status post-injury is also considered, because a child may appear to have apraxia when the impairment is really one of higher-level executive functioning, initiation, and/or planning (Blosser & DePompei, 2003).

Feeding and Swallowing Intervention

The primary goals of dysphagia treatment are to support safe and efficient oral intake and to ensure adequate nutrition and hydration. Age and developmental skill level at the time of injury are important considerations when designing feeding and swallowing treatment protocols and providing intervention, especially in infants and young children who can change so quickly (Mendell & Arvedson, 2016).

Clinicians also consider the child’s cognitive-communication skills, oral–motor function, physical and sensory-perceptual limitations, behavioral deficits, and environmental supports in targeting dysphagia (Morgan, 2010; Morgan, Ward, & Murdoch, 2004; Morgan, Ward, Murdoch, & Bilbie, 2002). Decreased cognitive abilities (e.g., decreased insight for deficits, poor self-initiation, and difficulty implementing strategies) and behavioral challenges (e.g., impulsivity or agitation) may have a negative impact on the success of dysphagia treatment.

Hearing and Balance Intervention

Changes in hearing and balance post-injury have the potential to exacerbate other TBI effects, especially cognitive-linguistic and social communication deficits.

Treatment for hearing loss may include the selection and fitting of amplification devices and training in the use of assistive technologies (e.g., frequency modulation [FM] systems in classrooms). Hearing aids, cognitive behavioral interventions, and/or sound masking may be used to manage tinnitus associated with TBI (Myers, Henry, Zaugg, & Kendall, 2009).

Vestibular rehabilitation programs aim to improve symptoms of vertigo and other balance-related problems following TBI (Teasell et al., 2013). Intervention may differ when balance and dizziness symptoms are due to post-concussion syndrome versus peripheral vestibular dysfunction; differential diagnosis is key to management and recovery (Doettl, 2015).

Treatment for auditory-related symptoms may also incorporate counseling regarding the use of coping and compensatory skills to minimize the effects of hearing and balance disorders and reduce safety risks.

Treatment Considerations

Cultural and Linguistic Factors

Different dimensions of culture may influence the family’s belief system in seeking care and external support (see ASHA’s resource on examples of cultural dimensions ). For example, some cultures may have a sense of shame or feel it is necessary to hide a disability, which may influence how an individual and caregivers approach habilitation/rehabilitation.

Treatment is also sensitive to linguistic diversity and is completed in the language(s) used by the individual with TBI

Treatment of Young Children (Infants, Toddlers, and Preschoolers)

Unlike school-age children, infants, toddlers, and preschoolers do not have a single point of entry into a system for treatment after the acute phases of their injuries. Some eligible families will receive treatment through their state or local early intervention agencies; others will go to inpatient or outpatient programs. Early intervention typically occurs in the family’s natural environment, taking into consideration the needs of the child with TBI as well as those of caregivers and siblings (McKinlay & Anderson, 2013).

Treatment with this population focuses on the development of school readiness skills (H. G. Taylor et al., 2008). Differentiating between acquired and developmental disorders is an important consideration when identifying treatment goals and methods. Interventions for children with premorbid deficits in knowledge and skills will differ from interventions for children who have not yet developed certain knowledge or skillsets (Turkstra et al., 2015).

When the child reaches school age, it is important to alert staff at each new school about the child’s medical history and the possible impact of TBI, so that necessary supports are put into place and behavioral or learning difficulties are not mistakenly attributed to some other cause (e.g., attention-deficit disorder or learning disability; Chapman, 2006; Gamino et al., 2009; Haarbauer-Krupa, 2012b; Turkstra et al., 2015).

Treatment in the School Setting

School Entry/Re-Entry

Most children with TBI are or will be, in school. Therefore, many speech and language interventions will target the cognitive-communication, behavioral, and social demands of the school environment.

The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) defines TBI as

. . . an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child’s educational performance. Traumatic brain injury applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; and speech [§300.8(c)(12)].

According to IDEA (2004), TBI “does not apply to brain injuries that are congenital or degenerative, or to brain injuries induced by birth trauma” [§300.8(c)(12)]. However, individual states may define TBI more broadly and may include children with nontraumatic acquired brain injury (e.g., stroke, brain tumor, anoxia) when determining eligibility for services.

Children with TBI can qualify for special education services with IFSPs, IEPs under IDEA, or Section 504 Plans under the Americans with Disabilities Act

  • inadequate transition plans from home or hospital;
  • delayed onset effects of pediatric TBI;
  • lack of long-term monitoring; or
  • being misidentified with another disorder (Duff & Stuck, 2012; Haarbauer-Krupa, 2012b; Russell, 1993; Todis, 2007).

Healthcare and school-based SLPs can play a critical role in the identification of students with TBI who qualify for services by facilitating communication among medical professionals, educational professionals, and parents so that appropriate transition plans can be developed (Allison, Byom, & Turkstra, 2017; Allison & Turkstra, 2012; Denslow, Doster, King, & Rayman, 2012; Glang et al., 2008; Haarbauer-Krupa, 2012a, 2012b). Students with TBI may require specialized instruction and support, accommodations, and assistive technology to access the educational curriculum and demonstrate knowledge based on their cognitive communication and academic needs.

Organizing a systematic return to school is central to the student’s academic and social success (Sharp, Bye, Llewellyn, & Cusick, 2006). Some states follow well-established school re-entry protocols or have dedicated concussion/TBI transition teams. These teams include healthcare-based SLPs and school-based SLPs who attend IEP meetings and help plan for the child’s return to school (Denslow et al., 2012; Glang, Tyler, Pearson, Todis, & Morvant, 2004; Newlin & Hooper, 2015; the University of Oregon, n.d.; Ylvisaker, 1998; Ylviskaer et al., 1995, 2001).

School-based SLPs provide services to children and adolescents with a range of deficits post-TBI—from those with subtle but significant deficits to those that require full-time special education placement. In addition to providing direct intervention to facilitate “return to learn” from an academic and social perspective, the role of the school SLP in school entry/re-entry includes but is not limited to the following:

  • Educating teachers, families, and other school personnel about TBI, how changes can affect learning and communication, and the possibility of delayed onset of symptoms following injury.
  • Assessing the educational environment to identify potential barriers to academic and social success and factors that may facilitate academic and social success.
  • Supporting students and staff by helping to identify and integrate modifications, accommodations, or strategies in classroom and social settings.
  • Developing protocols for ongoing assessment and long-term monitoring of children with TBI—particularly at various stages of development and transition—to identify changing needs (e.g., back to school, a new classroom, a new teacher, a new home).
  • Identifying students that may have a previously undiagnosed TBI.
  • Creating and participating in TBI prevention and advocacy programs.
  • Forming and collaborating with TBI/concussion teams to collect baseline and post-concussion cognitive data and make “return to learn/play” recommendations.

(Blosser & DePompei, 2003; Bush & Burge, 2016; Deidrick & Farmer, 2005; Dettmer, Ettel, Glang, & McAvoy, 2014; Duff, 2009; Duff & Stuck, 2012; Haarbauer-Krupa, 2012a, 2012b; New York State Education Department, 2002; Salvatore & Fjordback, 2011; Sohlberg & Ledbetter, 2016; Ylvisaker, 1998)

Transitioning Youth and Postsecondary Students

Youth with persisting cognitive and communication deficits post-TBI may continue to have problems as they transition to postsecondary education and to vocational and independent living settings (Todis, Glang, Bullis, Ettel, & Hood, 2011). The potential impact of persisting speech, language, cognitive, and social difficulties highlights the need for continued support to facilitate a successful transition to young adulthood. SLPs in all settings need to work closely with youth, families, school-based professionals, employers, and community members to plan and facilitate transitional support.

Considerations for Transitioning to Postsecondary Education

Attention, memory, learning, executive function, and social–emotional impairments—coupled with self-regulation challenges—place students with TBI at greater risk for postsecondary failure (Kennedy, Krause, & Turkstra, 2008). For college students with TBI, learning to overcome cognitive-communication deficits can have a positive impact on personal and professional success later in life (Kennedy, O’Brien, & Krause, 2012).

Students with TBI whose injuries occurred prior to vocational school or college have lower graduation rates than their nondisabled peers; those with transition plans that link them with disability services and support agencies are more likely to complete postsecondary programs (Todis & Glang, 2008). Disability support services staff may collaborate with SLPs to select courses, modify schedules, and implement accommodations (under Section 504 or similar plans, if applicable) that might include note-takers, extended time for tests and assignments, and assistive technology (e.g., to help with reading and writing tasks).

The SLP can also support students with TBI transitioning to postsecondary education through individualized transition plans, interactive coaching, and environmental assessments that identify systems and services to facilitate studying, learning, organization, time management, social relationships, self-regulation, self-advocacy, and use of compensatory strategies (Kennedy & Krause, 2011; Turkstra, Gamazon-Waddell, & Evans, 2004; Volkers, 2015).

Because academic and vocational literacy demands increase during postsecondary transitions, SLPs can have a meaningful impact on outcomes in these areas as well (Krause, Byom, Meulenbroek, Richards, & O’Brien, 2015).

Considerations for Transitioning to Community and Work

The nature of deficits associated with TBI creates unique challenges for youth in post-secondary communities and/or work environments. Fatigue and sensory issues as well as deficits in oral communication, pragmatic language, literacy, attention, and memory are among the factors that may negatively affect independent living and performance in social and professional settings.

The SLP identifies current cognitive-communication deficits, determines how these may affect life skills and job performance, and then trains intervention strategies to minimize the impact of the deficits in functional settings (Bonelli, Ritter, & Kinsler, 2007). The SLP collaborates with a vocational rehabilitation therapist as appropriate, assessing and treating functional work and community-based skills in context and implementing necessary accommodations for maximum outcomes.

Service Delivery

Each member of the collaborative, interdisciplinary team is responsible for components of integrated goal setting and strategy implementation designed to achieve the best functional outcome possible for children and youth with activity/participation limitations following TBI. In addition to determining the type of speech, language, cognitive, and swallowing treatment that is optimal for children and youth with TBI, SLPs consider other service delivery variables that may affect treatment outcomes, including format, provider, dosage, and setting. Service delivery decisions are made based on the child’s communication and/or swallowing needs relative to his or her family, community, school, social, or work setting.


Format refers to the structure of the treatment session (e.g., group and/or individual; direct and/or pullout; integrated and/or consultative). The appropriateness of the treatment format often depends on the service delivery setting, stage of recovery, the severity of the injury, and the primary goal at a particular point in the intervention process.

Formats in acute-care or rehabilitation hospitals will look much different from those that are school or community-based. For example, initial treatment may involve one-on-one strategy training and/or practice in using AAC with family members only. However, once the child has made progress on these goals, group treatment may be considered to provide opportunities for generalization and practice.

Group therapy can also target cognitive domains and provide opportunities to initiate social interactions and engage in project-based learning in structured and natural environments with feedback from the clinician and peers (Hickey & Saunders, 2010; Teasell et al., 2013).

Telepractice may be another appropriate avenue of service delivery. Telepractice can focus on improving the child’s functional abilities while offering support and training to caregivers, teachers, and employers in functional, everyday environments. Telepractice eliminates the need to travel and can facilitate practice, carryover, and generalization of skills in naturalistic contexts (Houston, 2013; Rietdijk, Togher, & Power, 2012; Turkstra, Quinn-Padron, Johnson, Workinger, & Antoniotti, 2012).


Provider refers to the person providing treatment (e.g., SLP, trained volunteer, caregiver, or teacher). Recommended practices follow a collaborative process that involves an interdisciplinary team including the child, family, caregivers, and professionals. Family, teachers, and significant others play a critical role in supporting and augmenting the treatment plan. When rehabilitation incorporates accommodations, modifications, and supports in everyday settings, SLPs often provide (a) information to help communication partners understand the child’s needs and (b) training in how to use strategies to facilitate communication. Other professionals (e.g., physical therapists or occupational therapists) may also be involved in the co-treatment of deficits.


Dosage refers to the frequency, intensity, and duration of service. The dosage depends on individual factors, including the child’s arousal level and ability to tolerate therapy sessions, prognosis, stage in recovery, and frequency of other therapeutic activity (CDC, 2015).


Setting refers to the location of treatment and varies across the continuum of care (e.g., acute-care or rehabilitation hospital, home, school- or community-based).

  • For children with mTBI/concussion, treatment typically is centered in school- or community-based settings.
  • Following moderate-severe TBI, families and professionals initially collaborate in medical settings, where the focus is on survival, recovery, and rehabilitation. The Commission on Accreditation of Rehabilitation Facilities (CARF) has instituted detailed standards for service delivery in hospital-based pediatric TBI specialty programs to which SLPs must adhere. These programs are consistent with the WHO’s ICF framework (CARF, 2015; WHO, 2001).

Following time in acute-care hospitals and rehabilitation settings, young children with TBI return home to receive services through early intervention, preschool, or community-based programs. Older children return to school, where long-term rehabilitation services are provided (Haarbauer-Krupa, 2012a, 2012b). The role of the SLP in the transition from a hospital setting to a school setting is key in identifying students who qualify for services and helping them access these services and any other necessary educational supports (Allison, Byom, & Turkstra, 2017; Allison & Turkstra, 2012; Denslow et al., 2012; Glang et al., 2008; Haarbauer-Krupa, 2012b; Savage, Pearson, McDonald, Potoczny-Gray, & Marchese, 2001).


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