The Conundrum of Resilience & Brain Plasticity in Children/Teens with Traumatic Brain Injury: Recommendations for Support

Article By: Dr. Erin Warriner, CPsych – Clinical Psychologist & Neuropsychologist

Previously, it was proposed that children were more resilient and their brains had the potential for greater neural plasticity and change than adults and thus it was assumed that they would recover more quickly and have limited lasting impact from a brain injury sustained in infancy or childhood. Often children appear “better” and bounce back into their daily routines once the physical symptoms of brain injury, such as headache, dizziness, and lethargy have resolved. Consequently, children often do not get referred for follow-up with specialists nor are any rehabilitation or education services put in place.  

While naturally some children do recover well, it is now better recognized that children are at least as vulnerable, if not more so, than adults in terms of experiencing long-term pervasive effects from brain injury.  Research supports that the brain has the potential for plasticity and new learning, but this process may be interrupted when the brain is injured. The child with a brain injury may require more structured explicit opportunities to learn and compensate in areas that were affected by the brain damage and in some areas may not improve or even seem to get worse over time.

Problems in cognitive, social, emotional and behavioural domains may not be obvious initially and in fact may become more pronounced or emerge later in life.  Children and teens often grow into their deficits as the demands, responsibilities and expectations at home and school change over time. Greater independence, organization/planning, self-regulation, logical reasoning, social perception/judgment, multi-tasking, and sound decision-making become emphasized as the child gets older; these are all key higher-level cognitive and behavioural processes frequently affected by brain injury. These struggles often lead to parent conflict, social isolation and academic failures, which can exacerbate frustration, anger, depression, anxiety, substance abuse, and conduct behaviours. The deficits from the brain injury and the associated reactions at this stage are often misattributed by parents and teachers as behavioural or emotional problems.

The misconception of resiliency and full recovery unfortunately contributes to false hopes for parents, leads to delays in obtaining necessary supports, and can perpetuate complications in later life. So, what can we do to support children and teens with brain injury?

Recognize the brain injury early. A neuropsychological consultation can help diagnose and identify the cognitive-behavioural changes post-injury. The assessment will be able to highlight the strengths of the child and the areas of need. It will also offer education and support to the children and their families around current and potential future challenges. The neuropsychological assessment can also provide the foundation to guide work by other health care professionals/therapists and highlight necessary supports that would be beneficial at home and at school.

Communicate regularly to offer a collaborative interdisciplinary approach. Involvement of a variety of health care professionals/therapists is needed to support the complex, ever-changing needs of children/teens with brain injury. This may include but is not limited to some of the following professions: occupational therapists, physiotherapists, speech and language pathologists, neuropsychologists, rehabilitation therapists, clinical psychologists, social workers or counsellors, physicians and nurses, behavioural therapists, etc. These various professionals can collaborate to offer joint and unique benefits for the child/teen and families in terms of their clinical expertise and interventions.

Involve specialists in pediatrics. Children do not just have miniature adult brains. It is pivotal that therapists working with children/teens with brain injury have an understanding of developmental processes and direct experience with this clinical population. Interventions need to be flexible and tailored to the individual and framed in the appropriate developmental context, which likely will involve different strategies/interventions than those used with adults.

Offer the family ongoing education/support. While maintaining hope and a positive outlook are important for coping and adjustment following an injury, I frequently share with families the concept of “realistic optimism.” This involves balancing between remaining open and invested in the potential for improvement but within the context of knowing more about what to expect and how to set and obtain supports to achieve realistic goals.  The various health professionals can work together with the child/teen and their families to provide education about the brain injury, potential challenges, and to set goals together depending on their needs, readiness and understanding at any given time.

Collaborate with the school system. Given that children spend a great deal of their time at school, open and regular communication between community therapists, school therapists and teaching staff will be needed to offer education about brain injury, develop coordinated interventions and reinforce consistency in implementation of any effective strategies across environments. Children will need appropriate educational services or individualized education plans which are set-up early and modified over time to remove or add supports as progress is made or new challenges arise over time.

Monitor progress and redevelop support plans. Children/teens with brain injuries need to be routinely followed over time (even when they are seemingly doing well) to ensure that both short-term and longer-term needs are met. For many children with brain injuries, assessments will likely need to be repeated at key developmental stages/transitions. Any plans and supports in place will need to be reviewed frequently and modified to coincide with changes from recovery and to promptly address developmental issues. Well-coordinated interdisciplinary specialized pediatric services offering tailored, adaptable supports can help children/teens with brain injuries achieve their fullest potential and a better quality of life.

Dr. Erin Warriner is a Clinical Psychologist and Neuropsychologist who specializes in the assessment and treatment of children, adolescents and young adults. She currently works at McMaster Children’s Hospital with children and teens who have neurological conditions and acquired brain injuires and also with adults and seniors in the Integrated Stroke Rehabilitation Program at the Hamilton General Hospital.  Through Rehab First’s MEDNet  program, Dr. Warriner performs assessments for all ages. Children and teens can be seen for neuropsychological, clinical psychological, psychoeducational and developmental assessments.  To arrange assessments with Dr. Warriner please contact Leigh Ann Van Doorselaer at 519-646-2949 or 1-888-REHAB90 (734-2290).