REPORT TO CONGRESS

Executive 

Summary

The Management of Traumatic 

Brain Injury in Children
REPORT TO CONGRESS

INTRODUCTION
 

Among all age groups, 

young children have one 

of the highest rates of 

Traumatic Brain Injury 

(TBI) related emergency 

department (ED) visits.1
 

TBI affects children differently than adults. An injury of 

any severity to the developing brain can disrupt a child’s 

developmental trajectory and may result in restrictions in school 

and participation in activities (e.g., sports). As a result of TBI, 

children can experience changes in their health, thinking, 

and behavior that affect learning, self-regulation, and social 

participation, all of which are important in becoming productive 

adults. Although most children recover well physically, they 

often experience changes in behavior and cognition that are 

not recognized immediately. Some of these post-TBI health 

problems emerge over time and are associated with significant 

financial and social challenges for adults having 

sustained a TBI as a child. Unlike other developmental health 

conditions in children that are diagnosed at birth, TBI is an 

acquired condition that can occur anytime during childhood 

with potential for a sudden alteration in development. The 

management of TBI in children is complex and depends 

upon multiple service delivery systems that frequently do 

not provide systematic or coordinated care to ensure an 

optimal recovery.2 However, due to the lack of robust scientific 

evidence identifying optimal pathways to recovery, current 

management is too often based on clinical practice experience 

rather than research. 

This report describes the public health burden of TBI in 

children and adolescents, including the range of outcomes 

that may be experienced following a TBI. In addition, the report 

lays out the current systems involved in the management of 

children with TBI, identifies gaps that exist, and outlines some 

practices that hold promise in addressing those gaps. Finally, 

opportunities for action are offered that suggest ways to 

improve TBI care in children, and how we might advance our 

understanding of TBI care in the future. 

2 
PUBLIC HEALTH BURDEN 

Traumatic brain injury in children represents a significant public health burden in the 

United States. A traumatic brain injury disrupts the normal function of the brain, and can 

be caused by a bump, blow, or jolt to the head, or a penetrating head injury.3

by or against an object, whereas for 

those 15-24 years of age, the leading causes were motor vehicle crashes and falls.1

Another common cause of TBI is sports and recreational activities which accounted for 

an estimated 325,000 TBI-related ED visits among children and teens in 2012.4

TBI severity is typically separated into categories of mild, moderate, and severe based 

on a patient’s initial clinical presentation. Mild TBI (mTBI) 

In 2013, there were approximately 640,000 TBI-related emergency department 

(ED) visits, 18,000 TBI-related 

hospitalizations, and 1,500 TBIrelated deaths among children 14 

years of age, and younger.1 The 

leading causes of TBI-related ED 

visits, hospitalizations, and deaths 

for those 0-14 years of age were 

unintentional falls and being struck 

640,000 

EMERGENCY 

DEPARTMENT VISITS 

18,000 

HOSPITAL 

STAYS 

accounts for most (70-90%) TBI-related ED visits.5,6 Although 

most TBIs are considered mild, TBI also accounts for a large 

portion of unintentional injuries that lead to severe disability 

and death in youth under age 19. Children with severe 

TBI are more likely to be hospitalized and have a lifelong 

disability compared to children who have a mild injury. 

Although most people think of TBI as an acute condition, 

the effects of TBI can be chronic and disabling. It is 

unclear how many children currently live with a TBI-related 

disability, largely because childhood disability is not defined 

61% 

More than 61% 

of children with 

moderate-to-severe 

TBI experience a 

disability. 

consistently. One study, which defined disability as the use of specialized medical and 

educational services, found that more than 62% of children with moderate-to-severe 

TBI experienced disability, compared to 14% of children with mTBI.7

EXECUTIVE SUMMARY 5 
REPORT TO CONGRESS

OUTCOMES OF TBI 

IN CHILDREN 

A TBI of any severity experienced by a child can result in 

changes that affect a child’s daily life.8-11 Symptoms of mTBI 

can include headaches and dizziness, as well as problems 

with thinking, memory, physical activities, emotions and 

moods, and sleep.12-20 Longitudinal studies suggest that most 

children with mTBI recover from the initial symptoms within 

6 weeks after injury, with approximately 60% having persistent 

symptoms at one month post-injury, 10% at three months 

post-injury, and less than 5% at one year post-injury.13,14,21-23

More severe brain injuries carry a range of medical, health, 

cognitive, motor, emotional, and behavioral issues. The 

significance of problems might not be realized until years 

after the injury when higher-level cognitive and behavioral 

functioning is required to meet typical developmental 

milestones, especially when the injury occurs at a very young 

age.24-28 Because of this, there is a critical need for follow-up 

care beyond the acute injury. 

School and post-school outcomes 

A child’s daily life centers on school, social participation, and 

extracurricular activities. A TBI of any severity can negatively 

affect a child’s future ability to learn and perform in school.29

Children with moderate-to-severe TBI earn worse grades, show 

higher rates of grade retention, and receive more special 

education services than their uninjured peers.30-33 Students 

with mild injury typically recover within a few weeks, and 

most of them return to their pre-injury classrooms. However, 

in a large study following children younger than 18 years 

of age, 14% of children who experienced an mTBI needed 

educational support services at school 12 months later.7

We know very little about the long-term adult outcomes of 

TBI in children. Most longitudinal studies of children with 

moderate-to-severe TBI have examined outcomes in children for 

intervals that are too short to understand how TBI impacts adult 

outcomes.19,29,34-36 A growing body of research indicates that for 

many students with moderate-to-severe TBI, post-high school 

career outcomes are poor.37-40 One study found that fewer than 

half of students with TBI who had been out of school a year 

or more had a paying job outside the home.41 Students with 

TBI also showed lower rates of enrollment in postsecondary 

education and independent living than those with most other 

disabilities.41 To date, there are no longer-term studies on 

children with milder injuries, or those who sustain multiple 

concussions across childhood. 

We have limited understanding of how childhood TBI 

impacts attainment of adult milestones (e.g., high 

school graduation, employment, or enrollment in postsecondary education). Studies of adults who sustained 

a childhood brain injury suggest common pathways 

to social difficulties, such as lower educational 

attainment and incarceration. 

FACTORS INFLUENCING 

OUTCOMES 

In addition to injury severity and the type of care a patient 

receives following injury, many factors can influence recovery 

from childhood TBI. Individual patient characteristics, such 

as age and pre-injury functioning, can play a big role in a 

child’s recovery. Co-occurring health and developmental 

conditions, such as a mental health diagnosis and AttentionDeficit/Hyperactivity Disorder (ADHD), can influence a child’s 

outcomes after TBI; however, there is limited evidence 

connecting medical conditions to achievement of longerterm milestones in children who have sustained a TBI.42

Socioeconomic status and family functioning also influence 

recovery.43-47 In any family environment, a TBI is an unexpected 

event that can create significant changes in family economic 

status and structure. Family-level factors are critical socialenvironmental influences on outcomes in children following a 

TBI.48 Economic and social disadvantage are associated with 

poor cognitive and academic outcomes following a severe 

TBI.45,49 Regardless of injury severity, many parents recognize 

differences in their child compared to their pre-injury status, 

which creates worry and concern for their future, especially as 

they approach adulthood.50 Parent/caregiver burden and family 

dysfunction are a particularly important consideration because 

they are a strong determinant of a child’s recovery, with 

children from well-functioning families demonstrating better 

psychosocial functioning.20,45,51 The adverse effects on families 

can persist for many years following injury.52,53

4
 

 

 

CURRENT SERVICE DELIVERY SYSTEMS
 

The management of TBI in children is complex and 

dependent upon multiple service delivery systems that 

often are neither systematic, nor coordinated to provide 

care across the child’s lifespan. In particular, there is 

large variation in what constitutes follow-up care and 

service delivery in critical areas, such as insurance 

coverage, utilization of pediatric trauma centers, service 

delivery in the schools, early intervention services, 

support for transition to adulthood, and family support. 

The goal of initial management for all types of brain 

injury is to determine injury severity, and to safely triage 

individuals to the most appropriate level of care. At this 

time, a wide range of treatments are prescribed postinjury. Management may include recommendations 

for graduated return to activities (school and physical 

activities), medication, and a range of therapies and 

other treatments. 

The CDC is working to develop the first-ever 

evidence-based clinical guideline on the diagnosis 

and management of mild TBI among children 

and adolescents. This Guideline will be based on 

recommendations from a federal advisory committee, 

informed by a Pediatric Mild Traumatic Brain Injury 

Guideline Workgroup composed of leading experts in the 

field. Although the Pediatric Mild Traumatic Brain Injury 

Guideline workgroup acknowledged research gaps in 

both diagnosis and treatment of pediatric mild TBI, the 

Guideline — based on the current best available evidence 

and informed by expert opinion — will represent an 

important step forward in providing consistent care for 

children with mild TBI. There is also a need for stronger 

evidence to inform standards of care for the treatment 

of moderate and severe TBI. In the absence of evidence, 

individualized symptom management is the most common 

recommendation. There is evidence to suggest that care 

from pediatric specialists results in better outcomes for 

pediatric TBI patients. For example, children who receive 

inpatient rehabilitation at pediatric hospitals typically 

have more efficient functional improvement than children 

receiving inpatient rehabilitation at other hospitals.54

This is especially relevant to rural areas where access to 

pediatric specialized physicians and facilities55-5 as well as 

specialized TBI services58 are more limited. 

When children are ready to return to preschool or school, 

a range of supports and services are available, including 

early intervention services, special education under the 

Individuals with Disabilities Education Act,59 supports 

and accommodations through a Section 504 plan,60

and informal supports provided by a classroom teacher. 

Younger children (0 to 3 years) can be referred to early 

intervention services via Child Find, which requires school 

systems to identify, locate, and evaluate children from 

birth to 21 years of age with disabilities or suspected 

disabilities. School nurses and comprehensive healthcare 

clinics at schools provide an important system of health 

and mental health services for children with TBI. However, 

it is unclear to what extent nursing or special education 

services are utilized for TBI across the country, especially 

in private or charter schools. 

Families of children with a TBI can take advantage 

of resources available to parents of all children with 

disabilities (e.g., PACER Family-to-Family Health 

Information Centers, Parent Training and Information 

Centers). Some states offer support groups specifically 

for parents and families (www.biausa.org, www.usbia.

org). Furthermore, some state services provide case 

management for families to assist navigation between 

medical and school services. 

Each state and U.S. territory has a lead agency and 

coordinator for TBI services. States also rely on the 

Federal TBI grant program in the Administration 

for Community Living, Department of Health and 

Human Services, to meet the needs of underserved 

populations, including children and youth with a TBI. 

Twenty-three states have TBI trust funds designated 

by legislation to support services for individuals of 

all ages with a TBI. 

EXECUTIVE SUMMARY 5
REPORT TO CONGRESS

 

 

IDENTIFYING GAPS AND IMPROVING THE MANAGEMENT 

OF TBI IN CHILDREN 

There is frequently an incomplete understanding about 

the effects of TBI beyond the initial injury among parents, 

healthcare professionals, and educators.2,61-63 This often 

creates barriers to optimizing outcomes for children 

across their lifespan, including achievement of high school 

graduation, employment, and engagement in a healthy 

lifestyle. It is widely recognized that children with brain injury 

are under-identified for health and educational services and 

under-served by existing supports, placing them at risk for 

poor health and educational outcomes.61,64,65 Understanding 

the gaps in care and developing approaches for optimal 

assessment, access to services, and service delivery is 

critical to ensuring that children with TBI have the best 

possible treatment and outcomes. 

Access to comprehensive care 

at the time of injury 

Access to specialized care in a pediatric trauma center 

at the time of the injury is especially important for 

children because early injury care can influence long-term 

outcomes.66 There is substantial variation in care among the 

sites where children are seen for acute injury care. Not only 

are there inconsistences in TBI assessment, but also in the 

comprehensiveness of discharge recommendations for all 

severity levels of TBI.2,67

Long-term management 

Currently, there are no formal systems to monitor the health 

of children with a TBI over time. Most children with a TBI are 

discharged home following initial injury care at the ED.68

For children who are hospitalized, whether a child receives 

long-term medical rehabilitation services often hinges on 

health insurance status; only 1.5% of uninsured children 

move directly from the hospital to inpatient rehabilitation, 

compared to 4% of children with private insurance.68

Frequently, children who need pediatric rehabilitation 

services do not receive them. In the first year after injury, a 

substantial portion of children with moderate-to-severe TBI 

have unmet or unrecognized healthcare needs.69

Family support and training 

The suddenness of a TBI forces parents into multiple 

roles, including advocacy for their child in the healthcare 

and school settings.70-72 Few parents understand the 

potential for a TBI of any severity level to become a chronic 

medical condition, nor are they aware of the pathways 

to care beyond initial medical services. When children 

return to school, parents often encounter a lack of 

understanding about the effects of the injury and find that 

school services are not suitable for a student who has 

experienced a TBI in the midst of their development.73

In the long-term, parents and caregivers may experience 

impairment to their own functioning due to the stress 

experienced when caring for their child. 

Return to school 

Many students who sustain a TBI will need post-injury support 

at school, ranging from informal academic support specific 

to their symptoms67,74,75 to longer-term formalized support 

(e.g., early intervention services, special education services, 

support and accommodations through a Section 504 

plan). However, children and their families often experience 

difficulties accessing these services. 

The causes of an inability to access 

available educational services include: 

•	 A lack of communication between healthcare and 

educational institutions about a child’s injury2,76,77, 

•	 The potential under-identification of students with TBI 

for special education services61 and 

•	 A lack of awareness of educators about the effects of 

TBI on learning.73,78,79

Further study is needed to understand the type and 

availability of school-based services and qualified staff to 

serve students with TBI in rural areas. 

6
Return to activity 

Although return-to-play guidelines for sports have been 

devised for mTBI, similar consensus guidelines have 

not been developed for return to other recreational and 

physical activities outside of organized sports. 

Following TBI, children are 

at risk for increased social 

isolation and reduced 

participation in activities 

outside of the school setting, 

and this can have harmful 

effects on their well-being. 

Transition to adulthood for children 

with TBI 

As children reach adulthood, the transition from pediatric 

to adult medical care providers is a particular area of 

clinical concern.81 Research has demonstrated that access 

to (and use of) healthcare services declines significantly 

as adolescents transition to adult care, resulting in worse 

health outcomes in adolescents with identified health 

conditions.81-84 In the public school system, only children 

enrolled in special education when they enter high school 

EXECUTIVE SUMMARY 7

While there may be awareness of these risks among those 

who care for children, there is a lack of guidance as to how 

to minimize these risks. Additionally, neither consensus 

nor evidence-based guidelines for return to activities after 

moderate and severe TBI exist. 
REPORT TO CONGRESS

 

receive transition planning for post high school graduation as 

part of their educational program under IDEA. Private schools 

that do not accept federal funds are not required to provide 

specialized educational services for transition plans for 

students with a TBI. 

Professional training 

Effective medical and educational management practices 

implemented by trained professionals can contribute 

to successful outcomes for children with TBI. However, 

many medical, educational, and other professionals who 

provide care and support for children after TBI received 

limited training specific to TBI recognition or management. 

Further, there is a significant lack of healthcare providers 

with pediatric-specific TBI training.85 Lack of adequately 

trained healthcare providers leads to inconsistent and 

variable clinical assessments, inconsistent diagnoses, 

variable guidance about expected recovery course, and 

variability in management decisions early and later after 

injury. In the school setting, teachers lack training in their 

academic programs86 and continue to have some basic 

misconceptions and knowledge gaps about TBI and the 

effects of brain injury on students in their classrooms.78 In 

general, educators need better training in methods that are 

effective with students with TBI.61,87-89

Research 

We currently know very little about long-term outcomes 

for children with TBI. At present, most management of TBI 

is based on consensus guidelines and expert opinion.90-94

Only a few rigorous, systematic clinical trials have been 

performed.93 For mTBI, the most recent guidelines 

recommend pacing, or gradual return to cognitive 

and physical activities, as tolerated by symptoms.95-97

Implementation of those pacing recommendations, as 

the cornerstone of management in this population, is 

variable. High-quality studies are necessary to determine 

the ideal duration and intensity of rest, and the ideal time 

to introduce both cognitive and physical activity. There is 

wide variation in the use of medications after mTBI, with 

no high-level evidence for the use of any medication.98

Managing more prolonged symptoms has not been the 

focus of prior consensus statements or guidelines and 

is primarily based on consensus opinion.99 A wide range 

of medical, behavioral, physical, and other therapies are 

used in the management of mTBI, but definitive, high-level 

evidence-based guidelines do not currently exist. CDC is 

currently developing the first evidence-based guideline for 

the management of mTBI in children, based on a systematic 

review of the available evidence conducted by a panel of 

pediatric mTBI experts. This guideline will include clinical 

recommendations based on the systematic review and is 

expected to be released in 2018. 

More research is needed
 

to understand children’s
 

long-term outcomes and
 

effective management
 

approaches that support
 

children achieving adult
 

milestones, such as high
 

school graduation and
 

employment.
 

Further, we need to better understand how management 

and intervention across a child’s lifespan relate to everyday 

improvements for children and their families. Overall, there 

is a critical need to reduce variability and inconsistency in 

care delivered at the time of injury, and over the long-term 

after mild and more severe pediatric TBIs. Standardization of 

care is critically needed; however, a better evidence base is 

required to inform management practices. 

8
OPPORTUNITIES FOR ACTION 

Opportunities for Action: Enhancing Healthcare Services to Improve 

the Management of TBI in Children 

At the time of the injury visit 

•	 Healthcare providers assessing TBI can consistently inquire about the child’s medical history and family 

circumstances, and consider these factors in treatment planning. Providers can advise parents to 

maintain a record of their child’s TBI history to complement data in a child’s medical record. 

•	 Healthcare providers can offer guidance and written information to caregivers about the types 

of healthcare, state, and school services that are available for their children after a TBI. 

Healthcare providers should encourage caregivers of children with a TBI to remain with a “medical 

home,” or consistent primary care provider, across the child’s lifespan to facilitate care that is 

more comprehensive. 

Opportunities for post-injury services 

• Systematic examination of healthcare-to-school transition programs and practices is necessary by 

educators and healthcare providers to inform the field about best practices. 

•	 Hospital systems and healthcare providers can work to optimize and streamline delivery of postacute care, rehabilitation, and community services for children with a TBI, and their families. 

Adoption of quality care standards (e.g., The Commission on Accreditation of Rehabilitation Facilities, 

an independent nonprofit accreditor of health and human services) can facilitate improvement of 

service delivery. Existing networks, such as Child Find, a state-based reporting system for locating 

and assessing children suspected of needing specialized school services, can be utilized to address 

potential needs across the continuum of care. 

Systems opportunities for clinical decision-making tools 

• Clinical decision support tools are promising, but need wider use and evaluation to demonstrate their 

utility and effectiveness. 

EXECUTIVE SUMMARY 9
Opportunities for Action: Improving Children’s Return to School, 

Activity, and Independence After a TBI 

Models of care 

•	 Policies that expand support for school-based health clinics and telemedicine can be considered as 

a means to improve follow-up care after a TBI, especially in rural communities. 

•	 Guidelines for return to sports after mTBI can continue to be refined and informed based on new 

evidence. Processes devised for return to sports can be amended to cover return to all children’s 

recreational activities, and also serve as a point of reference for return to sports and recreational 

activities after a more severe TBI. 

Monitoring and service delivery 

•	 Educators and medical professionals within states can ensure that all children who return to school 

following a TBI are monitored and that needed services or accommodations are received. 

•	 Educators and medical professionals should support the coordination of care across settings and 

providers that is centered on the comprehensive needs of children and their families. 

•	 School personnel can prominently note identified TBI history in school records, and monitor children 

during critical transition periods, such as the move from elementary to middle and high school. 

School transitions 

•	 Schools and state agencies can more frequently work with healthcare professionals to develop and 

evaluate healthcare-to-school transition processes for preschool children that better utilize statelevel services to help with the identification and management of TBI when these children begin 

elementary school. 

•	 Schools can monitor students as they transition from elementary to middle and then high school. 

•	 Schools can consistently work with families to identify the optimal pathway to learning (and subsequent 

high school graduation) to enhance adult outcomes for children who have sustained a TBI. 

Opportunities for Action: Improving the Transition to Adulthood for 

Children with TBI 

•	 Models of care for children with a history of a TBI who transition from pediatric to adult healthcare 

systems need to be developed and supported within the healthcare system. 

•	 Evidence-based approaches supporting the transition to post-secondary education and employment 

for students with TBI need to be developed to ensure optimal adult outcomes, and the effectiveness 

of these approaches in promoting healthy lifestyles for young adults needs to be evaluated. 

10 REPORT TO CONGRESS 
Opportunities for Action: Improving Professional Training for Those 

Involved in the Management of TBI in Children 

• Healthcare professionals who care for children after a TBI would benefit from more formalized 

training related to TBI diagnosis and management, both as part of their medical and nursing school 

programs and through continuing education. 

•	 Enhanced training of educators in TBI management is needed within education curricula, as well as 

through the expanded use of in-service training models. 

Opportunities for Action: Filling Knowledge Gaps 

More research is needed in the following areas in order to improve the care of TBI in children: 

Foundational science is needed 

•	 Produce comprehensive estimates on the incidence and underlying causes of pediatric TBI, as 

well as on the use of healthcare and rehabilitation services following a TBI. CDC’s pilot National 

Concussion Surveillance System can provide initial data, but long-term surveillance is needed to 

track trends to inform prevention efforts. 

•	 Investigate the effects of a TBI experienced during particular periods of brain development on 

subsequent physical, cognitive, behavioral, and social growth and development. 

•	 Disentangle how non-TBI-related issues, such as the child’s family environment and co-occurring 

health conditions, impact recovery. Identify modifiable risk and protective factors associated with 

short- and long-term outcomes of a TBI. 

•	 Determine the feasibility of developing a pediatric version of the TBI Model Systems database as a 

means to better understand long-term outcomes after pediatric TBI. 

•	 Collect natural history data that will describe differential recovery trajectories across both age and 

severity that could be used for the development of and presentation of personalized medical treatment. 

Science is needed to advance acute and long-term management of 

pediatric TBI 

•	 Evaluate existing healthcare-to-school transition models (i.e., return-to-learn processes). 

•	 Evaluate the efficacy of guidelines and management protocols across domains of care, including 

CDC’s forthcoming pediatric mTBI guideline. 

•	 Support clinical trials, rigorous quasi-experimental, and evaluation studies that examine 

effectiveness of healthcare, rehabilitation, and technology-assisted interventions across multiple 

settings, including, inpatient, outpatient, and at school. 

EXECUTIVE SUMMARY 11
REPORT TO CONGRESS

 

CONCLUSION 

In 1985, the first textbook on pediatric TBI management 

by Mark Ylvisaker, Head Injury Rehabilitation: Children 

and Adolescents,100 was published. This work was the first 

comprehensive documentation of the impact of a TBI on a 

developing child, and the need for improved management 

of TBI in children. Many of the opportunities for action in this 

report were noted in the original text, and continue as unmet 

needs after all this time. Over the past 30 years, we have seen 

a proliferation of research that better describes children’s 

brain development, outcomes from a TBI, and service needs. 

Unfortunately, services to support TBI management in 

children after initial injury care have declined in availability, 

length of time, and consistency within the United States. 

The information provided in this report represents a call-toaction to improve the care children receive after a TBI so 

they can maximize their potential for recovery. 

Moving forward, this effort will require increased 

coordination and collaboration among the many 

stakeholders focused on the burden of TBI in children. A 

quote from the Mark Ylvisaker book still resonates: “Longterm care extends beyond the four walls of our rehabilitation 

facility and touches all aspects of a child’s life.”100 All 

involved with the care of children can use this report and the 

opportunities for action within as a guide to improve care for 

children who sustain a TBI. 

12
SUBMITTED BY 

Centers for Disease Control and Prevention 

National Center for Injury Prevention and Control 

Division of Unintentional Injury Prevention 

ANNE SCHUCHAT, MD 

Rear Admiral, U.S. Public Health Service 

Acting Director, Centers for Disease Control and Prevention 

DEBRA HOURY, MD, MPH 

Director, National Center for Injury Prevention and Control 

GRANT BALDWIN, PHD, MPH 

Director, Division of Unintentional Injury Prevention 

EXECUTIVE SUMMARY 13 
U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Center for Injury Prevention and Control 

Division of Unintentional Injury Prevention 

go.usa.gov/xnvbq