The effect of pediatric traumatic brain injury on behavioral outcomes: a systematic review

An average of 634,000 incidents of traumatic brain injury (TBI) occurs among children each year in the United States, with the highest TBI-related emergency room visits occurring in children under the age of 4 years and adolescents 15 years or older.1 Pediatric TBI in young children (<4y) is commonly caused by falls, which may account for approximately 40% of head injuries requiring hospitalization for children less than 4 years old.1 Inflicted injuries acquired secondary to child abuse (e.g. shaken baby syndrome) may account for 20 to 70% of hospitalizations in young children.2–4 In older children, motor-vehicle accidents are the more prevalent causes.1 Although focal brain lesions sustained during childhood generally show favorable recovery,5 the diffuse brain insult that frequently occurs in some combination with focal insults in TBI appears more threatening to the developing brain.6,7 Despite the prevalence and threat of childhood TBI, however, the impact of such damage on the brain remains poorly understood, especially within pediatric populations. Assessing sequelae from brain injury of varying etiologies on the developing brain remains a challenge for researchers. Even within the literature, the physical and cognitive consequences of pediatric TBI have historically received greater attention than behavioral and psychosocial problems. This is surprising as behavioral and psychosocial problems are often more concerning for parents and teachers, and may also more negatively influence patients’ lives than intellectual or physical problems.8,9 Early work by Rutter et al. showed that among children with severe head injury, rates of new psychiatric disorders were three times more common than in orthopedic injury comparisons.10,11 Left untreated, these adverse outcomes of childhood brain injury may persist into adulthood, predisposing individuals to violent crime12 or mental health disorders.13 It is commonly believed that children with behavioral problems are at greater risk for experiencing a TBI event, owing to their inability to predict the consequences of their actions and resulting tendency to be more accident prone.14 However, this belief is largely based on research using post-injury recall of pre-injury behavior.15 Prospective studies using pre-injury data collected before the TBI event, therefore avoiding potential recall bias, have demonstrated that pre-injury behavior does not actually serve as a significant predictor for a TBI event.14,16,17 It is thus critical that patients, families, and healthcare workers do not assume that post-injury behavioral deficits simply reflect an individual’s pre-injury characteristics or developmental trajectory.18 Rather, behavioral problems are a real and potential consequence of TBI that have detrimental effects on children’s long-term functioning and quality of life. In light of the growing recognition that childhood brain injury may contribute to the development of adverse, lifelong behavioral outcomes, it is critical to review systematically the recent empirical evidence and provide a comprehensive overview of the ongoing progress in this area. Despite the emerging research over the past two decades on the presentation, risk factors for and correlates of behavioral outcomes after pediatric brain injury, few have taken a systematic approach to evaluate the effects of TBI on behavioral outcomes. In the present review, therefore, we therefore examine the relationship between childhood TBI and behavioral problems, as well as possible contributing factors, to help inform healthcare professionals, patients, families, and future research efforts.