Acquired brain injury Acquired brain injury

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Dr Adrienne Epps
Brain Injury Rehabilitation Program
Rehabilitation Department
Sydney Children’s Hospital
Randwick, NSW Australia

Full article Download full article (.pdf 175kB)

DET websites

Resources

  • Dawson H. Sexuality and Acquired Brain Injury in Children and Adolescents. A Guide for Health Professionals and for the Family. The Children’s Hospital at Westmead, Westmead NSW, 1999.

  • DePompei R, Epps A, Savage, Blosser J, Castelli E. Educational needs of children and adolescents after brain injury: a global perspective. Neurorehabilitation 1998;11:85-100.

  • Savage RC, Wolcott GF (Eds). Educational Dimensions of Acquired Brain Injury. Austin, Texas: Pro-Ed, 1994.

  • TAFE ABI brochure

For further publications For further publications, see full article (.pdf 175kB).

What is acquired brain injury?

Acquired brain injury (ABI) refers to any damage to the brain that occurs after birth. That damage can have various causes, of either traumatic or non-traumatic origin.

Approximately 75% of ABI presenting to hospital rehabilitation services is caused by trauma. Twice as many boys than girls experience traumatic brain injuries.

These can be brain injuries from:

  • falls

  • motor vehicle accidents

  • bicycle accidents

  • sports injuries

  • assault

  • shaking and abusive head trauma.

These can be brain injuries from:

  • strokes and other cerebrovascular accidents from blockage to the blood supply or internal bleeding from vascular malformations

  • infectious diseases (eg encephalitis, meningitis)

  • diseases of the brain (eg Huntington’s disease)

  • anoxic injuries (eg hanging, drowning, choking, severe blood loss)

  • brain tumours and their associated neurological deficits

  • metabolic disorders (eg hypoglycaemia, liver and kidney disease)

  • toxic products taken into the body through inhalation or ingestion (eg alcohol or drug abuse).

Immediately following the injury there may be a variable degree of impairment of consciousness and neurological dysfunction. The severity of the injury is assessed by:

  • the Glasgow Coma Scale (GCS) to determine level of consciousness – the lowest possible score is 3 (deep coma) and the highest score is 15 (fully awake and aware)

  • imaging of the brain using CT or MRI to determine if there is bleeding, swelling, bruising, localised or diffuse injury to the brain.

As the level of consciousness improves, the child’s orientation and memory can be assessed using a post-traumatic amnesia (PTA) scale.

Traumatic brain injuries are classified as follows:

  • Headaches, dizziness, vomiting and lethargy are common acute symptoms.

  • Memory and attentional difficulties, irritability, fatigue, anxiety, sleep disturbance and deterioration in schoolwork can persist for some time after the acute injury.

  • Post-concussive symptoms generally resolve completely within a few weeks.

  • Where symptoms persist beyond several weeks, further assessment is recommended.

  • Information about symptoms and reassurance about the likelihood of a good outcome, are important to facilitate recovery and avoid long-term secondary complications.

Persistent cognitive and behavioural deficits are more likely but generally a good recovery is expected.

  • Permanent sequelae are much more likely.

  • Memory, attention and behaviour difficulties, slow information processing, difficulties with new learning, planning and organisation as well as communication and language disorders may occur.

  • Post-traumatic amnesia (PTA) of longer than three weeks is invariably associated with serious neurobehavioural sequelae.

  • The longer the duration of PTA, the worse the outcome.

ABI results in varying degrees of functional disability or impairment that can affect physical functions, sensory and perceptual abilities, cognition, speech-language communication and psychosocial behaviour. These impairments may adversely affect educational performance.

Headaches are common after a traumatic brain injury, and may be related to fatigue, development of intracranial complications such as subdural effusion or hydrocephalus, migraine, or possibly from an associated musculoskeletal cause such as a whiplash injury. Persisting headaches should always be referred for medical assessment.

Post-traumatic amnesia is characterised by disorientation, confusion and memory impairment for laying down new memories from one day to the next. Assessing the length of time in PTA assists with determining the severity of the brain injury and likelihood of longer-term cognitive and behavioural consequences as well as guiding the rehabilitation team in provision of rehabilitation interventions as the child improves.

Post-traumatic epilepsy occurs in approximately 9% of children who have had a severe traumatic brain injury. Seizures occurring immediately after the acute injury are quite common, but seldom recur. Recurring seizures which can develop anytime after the first week usually require treatment with anticonvulsant medication.

  • Sleep disturbances, fatigue, increased appetite or difficulty regulating food intake and resulting weight management issues.

  • Vestibular disturbance may occur causing dizziness and disturbance of balance.

  • Swallowing difficulties can cause safety concerns with eating and drinking. Sometimes alternatives such as PEG or gastrostomy feeds are required for nutritional support.

  • Endocrine disorders are uncommon, but hormonal deficiency causing complications with fluid imbalance or growth impairment may occur and require treatment.

  • Early onset of puberty or precocious puberty is not uncommon and may require medical management.

  • Hydrocephalus occurs in less than 1% of severe head injuries. A shunt may be required to drain fluid away, thereby reducing the pressure on the brain.

  • It is always important to recognise the impact and contribution of premorbid conditions on the child’s level of function after ABI, particularly pre-existing learning and behavioural difficulties.

  • Mental health issues, particularly mood disturbance, adjustment disorders and emotional regulation disturbances are quite common after ABI.

  • Attention difficulties not unlike those seen in ADHD are sometimes helped by stimulant medication.

  • Where medication is required during school time, information about administration and storage procedures can be accessed from the student health section of the NSW Department of Education and Training website.

Motor and sensory concerns

The most common motor impairments include weakness, spasticity or disorders of tone manifesting as stiffness or resistance to movement, ataxia or movement disorder on one or both sides of the body.

  • Inability or difficulty with walking

  • Difficulty with activities of daily living (such as dressing, bathing and toileting)

  • Clumsiness with feeding and handwriting

  • Difficulty participating in sporting activities.

Improvement in physical performance can occur for several years after the injury.

  • Hearing loss may occur if there is damage to the auditory nerve or trauma to other parts of the hearing apparatus such as the small bones (ossicles) which transmit sound through the middle ear.

  • Occasionally the sense of smell is damaged impacting on day-to-day quality of life and occasionally causing safety concerns.

  • Vision Impairment can result from damage directly to the eye, or to the nerves which control eye movements, causing a squint and double vision, or damage to the optic nerve and optic pathways which transmit visual information through the brain to the visual processing centres at the back of the brain.

    • Homonymous hemianopia occurs when the visual pathways on one side of the brain are damaged.

    • Damage to the occipital lobes at the back of the brain may result in cortical vision impairment or permanent inability to recognise objects (agnosia).

    • Prosopagnosia is a very rare condition which occurs following damage to specific parts of the brain involved in recognising faces.

Speech, language and cognitive concerns

Brain injury may result in impairments to oral motor function, language processing, pragmatic skills and the generation of written and verbal language.

Speech and language abilities may be affected by injury to parts of the brain involved with cognition and communication.


For more information Download: Communication disorders in students with an acquired brain injury (.pdf 81kB) to learn more.

In the early recovery period following injury, cognitive and behavioural function is characterised by confusion, inability to lay down new memories, features of post-traumatic amnesia (PTA) and agitated and inappropriate behaviour.

For more information Download: Cognition and learning of students with an acquired brain injury (.pdf 68kB) to learn more.

The presence of brain damage is associated with a marked increase in psychiatric disorder, which tends to increase with time. This may result in:

  • a change in personality

  • socially uninhibited behaviour in the severely brain-injured group

  • difficulties with self-control

  • apathy, lack of initiation and motivation.

Children with ABI are at high risk of becoming socially isolated due to the many overt and hidden disabilities that impact on their ability to make and keep friends.

The long-term outcome of an ABI depends on:

  • the age at which the child is injured

  • the developmental maturation of the brain at the time of injury

  • the family and environmental context in which the child continues to grow and develop.

The younger the child at the time of injury, the more significant the effect on global intellectual function over time and the more severe the likely impact on future brain development and skill acquisition.

The aim of rehabilitation is to achieve:

  • a lifestyle which provides success and satisfaction as close as possible to that enjoyed before the injury

  • adaptive adjustment to the changes that have occurred

  • support for ongoing development of skills and social connectedness and achievement of optimal potential in school, social and community life.

Often, early rehabilitation starts in the intensive care unit focusing on physical care to prevent the development of contractures in all limbs and to prevent pressure sores.

This is a long period for many families of becoming educated about ABI and the collaborative role they will have along with the interdisciplinary team in:

  • supporting recovery

  • preventing development of secondary conditions

  • working hard on restoration of function

  • use of adaptive strategies to compensate for areas that are not recovering or recovering slowly.

After emergence from coma, children are typically confused and disoriented. This phase, called post-traumatic amnesia, is best managed with:

  • a quiet, calm environment

  • family present to assist with orientation to where they are, what has happened and what needs to happen for medical and nursing care

  • a daily schedule to structure the day

  • favourite toys and familiar objects from home.

Early management of severe brain injury is usually undertaken in intensive care to protect the brain from further injury. Surgery may be required, eg drainage of haematomas and management of cerebral swelling and increased intracranial pressure.

The following issues are the major concerns of ongoing rehabilitation:

  • motor dysfunction, eg walking

  • feeding difficulties

  • communication

  • cognitive/behavioural deficits.

Eventual discharge from hospital requires careful planning:

  • Home modifications.

  • Support, counselling, education about ABI and referral to community services are provided for families.

  • The child’s school environment will need to be assessed for modifications.

  • School staff and peers need to be prepared for the child’s return to school with appropriate supports in place.

  • Where there is minimal physical impairment, return home is usually achieved in a shorter time frame.

  • The family and school staff need information about the likely cognitive and behavioural effects of the injury and what to expect when the child returns to his or her home and community environment.

  • Limitations may need to be placed on return to sport and other physical activities for safety reasons.

Specialised equipment may be needed for assisted mobility (eg orthoses, walking frame, crutches, manual or motorised wheelchair). Various adaptive devices may be recommended by the occupational therapist to assist with functional activities such as feeding, dressing, handwriting or operating a specialised keyboard.

Assessment of hearing, language and speech is essential during the recovery phase to address communication difficulties, as well as analysis of the nature of any language deficit.

For more informationDownload: Communication disorders of students with an acquired brain injury (.pdf 81kB) to learn more.

  • A consistent and structured environment is most beneficial.

  • Behaviour management techniques should be used as appropriate from the earliest possible time following the occurrence of the ABI.

  • Medication may be beneficial in children with attention deficit and frontal lobe dysfunction.

  • Support and counselling for the family are critical.

  • Counselling and support for the student’s peers, particularly in upper primary school and high school, are also important.

Remediation of cognitive deficits begins early in the rehabilitation program, using strategies to improve the child’s attention to tasks.

For more information Download: Cognition and learning of students with an acquired brain injury (.pdf 68kB) to learn more.

Collaborative involvement of the student, his or her family, health care team and school staff in the ongoing rehabilitation process is critical for the achievement of the best possible long-term outcome. This ongoing liaison over many years is really important to monitor and reassess the student’s changing needs as he or she grows and develops and to ensure that the right supports are in place.

Motor vehicle driving

Students with ABI may go on to be capable drivers but should have a formal Occupational Therapy Driving Assessment before going ‘on road’.