One of my closest friends has a daughter with Down syndrome. She was my cutie pie; always showing me her latest dance moves while wearing a smile that could light up a room. Much to my concern, in her younger years, she would run away from her home dashing out of the house and into the street without taking proper precautions. Although her mother was aware of the problem and took care to lock the house, her daughter would always figure a way out. After one such escapade, I still remember a frantic call from my friend as she was trying to organize a search party. They lived near a river and a heavily trafficked road. All sorts of tragic scenarios were crossing her mind and mine. Fortunately, my cutie pie grew up avoiding what could have been a terrible accident.
Individuals with developmental disabilities, whether Down syndrome or autism, are prone to accidents and their attendant injuries. Especially when young, some of these children may be guided by impulse and inattentiveness. Cognitive and physical disabilities may also compromise their capacity to handle potentially hazardous situations. In addition, the presence of comorbidities such as seizures, may propitiate some of these accidents. It is therefore unsurprising that the risk for unintentional injury in children with developmental disabilities is double that of the general population. The odds for injury increases for children with multiple disabilities.
For children with a serious disability, most injuries happen at home; however, rates are still higher anywhere else they may attend or participate. Although conscious of this problem, administrators have found it challenging to create safe and accessible pubic facilities that could diminish the risk of injury in this vulnerable population. When one considers that one in every 10 children worldwide has one or more serious disabilities, the potential for injury is an unfortunate everyday occurrence.
It does not appear to be a coincidence that the Office of Special Education (OSEP) started collecting data for traumatic brain injury (TBI) the same year it began collecting information for autism spectrum disorder (ASD). This agency is dedicated to improving educational results for infants, toddlers, children and youth with disabilities ages birth through 21. Longitudinal studies by OSEP indicate that both TBI and ASD have shared a similar increase in prevalence. This is of serious concern as TBI may lead to substantial neurological impairment and deficits in intelligence, memory, attention, learning and social judgement.
TBI is the leading cause of death and disability in children less than 1 year of age. It accounts for 640,000 visits to the emergency room and 18,000 hospital admissions annually. The etiology of TBI depends on age; from 0-4 year it is primarily due to falls, while from 15-24 years it is usually attributed to falls, assault, and motor vehicle accidents. When trauma leads to an altered mental state we have a type of TBI named concussion. Within the United States, concussions have a prevalence of 692 per 100,000 children less than 15 years and an estimated incidence of 1.1-1.9 million per year in patients less than 18 years of age. Concussions are very common in high school sports with highest levels in tackle football followed by soccer and then lacrosse.
As physicians and parents, we usually employ negative thinking and tend to worry about possible worse outcomes after a child suffers from a head injury. We know from movies about the possibilities for space occupying lesions such as bleeds and cerebral edema. Less known is the possibility for diffuse axonal injury (DAI). In the latter case, the long connecting fibers (axons) that crisscross the white matter are sheared as the brain rapidly shifts position after trauma causes it to undergo rotational acceleration. Pediatric patients are at increased risk for DAI due to the incomplete myelination of their brains and ongoing maturational changes.
At a doctor’s office, a TBI patient will be evaluated and followed-up with a variety of screening tools. Some of these screening tools, e.g. Acute Concussion Evaluation form (ACE), Sport Concussion Assessment Tool (SCATS), provide for evaluation, recommendations and home care advice. They can be obtained for free from the internet:
Management and follow-up for TBI has changed widely during the last few years. An outdated recommendation is for complete rest until symptoms resolve. Taking such a remedial step actually leads to slower resolution. New guidelines from medical agencies (AAP, AAN) promote the early introduction of activity, as tolerated, with gradual progression of both physical activity and learning. At present there are no medication to facilitate resolution, but there are some that can promote symptomatic relief. Melatonin can be recommended for sleep. Topamax/amitriptyline is usually prescribed for headache prevention, and selective serotonin reuptake inhibitors (SSRI) or amantadine for emotional effects.