TBI
(updated 9-18-03)
346 - Exceptional Child
I. Brain Injury in Children and Adolescents
Glasgow Coma Scale
The Glasgow is a commonly used rating scale for assessing cognitive status in a medical steeing.
Children with a variety of neurological diseases and disorders can experience problems in school and social adjustment, and would be covered under the “Other Health Impaired” provisions of IDEA.
Examples include childhood cancers, CNS infectious diseases, seizure disorders, and environmental toxins.
Childhood cancers are relatively rare but occur at all age groups. Brain tumors account for about 20% of these cases—approximately 1200 to 1500 new cases each year.
Treatment protocols often involve radiation therapy, chemotherapy, and/or surgical interventions. Outcomes vary from death to being cancer-free at 5-year follow-up.
With increased survival of childhood brain tumors, the “late effects” of treatments, especially irradiation, have received increasing attention. Declines in intelligence and memory, and poor academic progress have been reported. The clearest risk factors for poor outcome are earlier age for cancer (and treatment) onset, amount of radiation, extent of the tumor, and medical complications.
Acute lymphocytic leukemia (ALL) is the most common type of cancer in childhood, it accounts for 80% of the cases of leukemia in children.
95% of children with ALL survive their initial episode and 55% continue in remission 5 years after treatment. Age at diagnosis and initial white blood cell count (WBC) are strong predictors of remission and survival—children with high WBC and <2-years-old or >10-years-old have poorest prognosis. As risk factors/severity of illness increases—aggressiveness of treatment increases with associated “late effects of treatment” in survivors: learning and academic problems.
Meningitis—inflammation of the meninges (protective layers) of the CNS (brain and spinal cord). Bacterial meningitis is the most common form.
Sequelae depend on the age of onset, infectious agent, speed of diagnosis, severity of infection, and treatment used. Outcome varies from no identified residual effects to severe retardation, learning problems, and neurological handicap.
Encephalitis—generalized inflammation of the brain. Viruses are frequently the infectious agent. As with meningitis, the outcome varies from good to poor.
CNS involvement is estimated to be high in children who are HIV positive. Severe cases may be classified as AIDS Complex Dementia.
Epilepsy is often considered the most common neurological disorder of childhood, occurring in 1% to 2% of the population. Seizures can occur secondary to a number of etiological factors, or with no know cause. “Febrile” seizures (caused by a high temperature—above 102 degrees F) may occur once without any subsequent episodes. “Prodomal” [before the seizure] and “postictal” [after the seizure] effects may include irritability, lethargy, confusion, or behavior problems. Some, not all, individuals may experience an “aura” immediately prior to the seizure. Some, not all, individuals may show repetative behavior [“automatisms”] during the seizure—lip smaking, hand flapping, eye blinking, etc.
Parital seizures do not involve loss of consciousness, but may evolve into generalized seizures.
Simple partial seizures involve focal discharges/symptoms.
Complex partial seizures involve an impairment of consciousness.
Generalized seizures involve the entire brain and are associated with a loss or impairment of consciousness. 3 general patterns:
Febrile
Absence seizures (“petit mal”)
Tonic-clonic (“grand mal”)
Associated features of seizures disorders in youth
Because of the various types of seizure disorders and different etiologies, the population of children and adolescents with seizure disorders is very heterogeneous.
Lower tested intelligence, academic problems, learning problems, and behavior problems are statistically over represented in the population of individuals with seizures disorders. Very likely these comorbid problems are caused by the same underlying neurological abnormality or dysfunction which causes the seizures.
The most likely (modal) young person you know with a seizure disorder is just like you!
Fetal Alcohol Syndrome (FAS)
FAS refers to a pattern of growth deficiency, facial anomalies, & CNS dysfunction caused by prenatal exposure to alcohol. Children with FAS often show delayed development, overactivity, motor cluminess, attention deficits, learning problems, mental retardation, and seizure disorders. There may be comorbid diagnoses of MR, ADHD, LD, and other behavior problems.
An overall incidence of 1-3 per 1000 live births is cited but the actual prevalence varies greatly with community and local cultural norms.
Various thresholds for “safe use” have been discussed. Varying results may, in part, reflect individual differences in vulnerability of some fetiuses. Between 7 and 28 drinks (1 oz. of alcohol) per week the relationship between consumption and neurobehavioral sequalae become increasingly strong.
ADHD and intellectual limitations are often diagnosed in children with FAS. Problems with attention, adaptive behavior, academic achievement, and language skills are often reported. However, it is often difficulty to disentangle the effects of FAS from environmental effects: many children with FAS come from chaotic homes where alcohol and other drugs are used by the parents. Poor prenatal and neonatal care, neglect, abuse, inadequate nuitrition, inconsistent parenting
Exposure to even low levels of lead can cause cognitive and behavioral problems in children. Children with acute lead encephalopathy show severe medical symptoms—seizures, lethargy, ataxia, nerve palsy, and increased intercranial pressure. These can lead to death in severe cases; and in survivors: epilepsy, motor paralysis and spasticity, blindness, mental retardation, attention deficits and hyperactivity.
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