Executive Function in Children After Mild to Severe Brain Injury
For many years, the CDC has advised us that approximately half a million kids in the US visit the Emergency Room every year for concussion-related injuries. A study published in the medical journal Pediatrics revised that estimate to between 1 and 2 million youth concussions per year during sports and recreation, and between 500,000 and 1.2 million concussions are not even reported to any health care providers annually. While there is what the CDC calls “a substantial gap in how the US estimates pediatric concussions,” there is no dispute that concussions, a form of a traumatic brain injury, are extremely common in children, and managing pediatric brain injury is a major public health concern that impacts treatment and educational support for children surviving traumatic brain injury (TBI).
Pediatric TBI can impact executive functions, affecting school performance and social development. Executive functions are a set of cognitive processes necessary for cognitive control of behavior. Examples include self-regulation skills impacting attention, cognitive inhibition and control, working memory and cognitive flexibility. Higher-order executive functions include planning, reasoning and problem solving. In children, these processes are critical for academic and social success.
While executive functions are adversely impacted by TBI, little has been known about executive function recovery patterns in children. A recent study published in the March, 2021 JAMA tracked the executive functioning of a cohort of 559 children, ages 2 to 15 years-old, in the 3 years after the various types of TBI (mild, moderate and severe). Treatment took place at the Primary Children’s Hospital in Salt Lake City, Utah, and Children’s Memorial Hospital in Houston. Researchers monitored executive function by using the rating tool, Behavior Rating Inventory of Executive Function (BRIEF), and neurocognitive testing. 155 of the cohort had mild TBI, 162 had complicated mild or moderate TBI, 90 had severe TBI, and 152 had an orthopedic injury with no TBI (control group).
Children with good executive function development are more likely to succeed in school, at home and social settings than those with executive function difficulties. The trajectories of children in the study with TBIs ranging from mild to severe diverged from the orthopedic injury-only participants, indicating that even children with mild TBI did not return to their pre-injury baseline within 3 years. Among children with severe TBI, trajectories were the most pronounced, indicating increased problems from the time of injury to up to 12 months for Emotional Control, Inhibition, and Working Memory subscales. Their trajectories plateaued with a secondary acceleration before 36 months for Emotional Control and Working Memory subscales. Children with mild TBI had worse 36-month scores on all subscales except Inhibition, compared to the children with only orthopedic injuries.
The longitudinal cohort study concluded that children need longitudinal reassessment beyond 1 year after TBI, as some children indeed worsen after reaching a recovery plateau. The study also concluded that having healthy family relationships and using a family-centered approach after TBI promotes a child’s long-term success.
In short, it is critical that a child’s executive function is tested over time after a TBI in order to tailor treatment, social and educational interventions. Across the TBI severity spectrum, some executive functions may worsen again after a plateau, and a targeted assessment can identify the need for educational, cognitive or socioemotional support to the child.
If you would like to learn more about pediatric TBI, neurocognitive testing and treatment options, please contact us.
 Sports and Recreation-Related Concussions in US Youth, Mersine A. Bryan, MD, Ali Rowhani-Rahbar, MD, MPH, PhD, R. Dawn Comstock, PhD, Frederick Rivara, MD, MPH, on behalf of the Seattle Sports Concussion Research Collaborative. (doi: 10.1542/peds.2015-4635).
 Trajectory of Children’s Executive Function After Traumatic Brain Injury, Heather T. Keenan, MDCM, PhD; Amy E. Clark, MS; Richard Holubkov, PhD; Charles S. Cox Jr, MD; Linda Ewing-Cobbs, PhD. Published: March 19, 2021. doi:10.1001/jamanetworkopen.2021.2624
 “mild” TBI was characterized by a Glasgow Coma Scale (GCS) of 13 or higher with a GCS of 15 within 24 hours or upon discharge; “moderate” TBI was characterized by a GCS of 9 to 12; “severe” TBI was characterized by a GCS score of 3-8.