Clinical psychologist Célia Demarchi has been involved in helping shed light on brain injuries in children. Here, she talks about her recent research into how brain injuries affect this growing demographic, and why it’s important that research continues.
Outcomes following traumatic brain injury (TBI) are difficult to predict and NICE guidelines have emphasised the need for UK-based research into predictors of long-term conditions after brain injury.
Advances in medicine mean that more and more young people are surviving catastrophic injuries each year, but this does also mean that we now have a growing number of people with needs that aren’t always being met.
Childhood TBIs are often linked to persistent problems, and failure to recognise these problems limits a child’s access to appropriate healthcare and educational programmes, which in turn exacerbates the long-term effects of the injury. It is therefore really important that we are understanding the impact and intervening so that having a TBI does not have adverse life effects for a child.
This research was developed by a team of clinicians and academics at Great Ormond Street Hospital (GOSH) and Imperial College London (ICL), who had a keen interest in paediatric TBI. They felt that there were huge gaps in our understanding of what happens when children have a TBI and what the injury means for their future outcomes.
The team at GOSH have world class expertise in paediatric health and the team at ICL have world class expertise in TBI, so it was a good match and the start of a long and fruitful collaboration. I was fortunate enough to be brought onto the project in 2016 once it had been set-up, and immediately knew that we had lots of work ahead to do justice to the largest cause of death and disability in this age group.
We designed a cross-sectional study to investigate neuropsychological outcomes, and try to better understand how they relate to brain imaging in children and adolescents who had sustained a moderate-severe TBI.
We recruited over 40 young people with a TBI and their families to our study. Many families travelled from across the country, and even across the Irish sea, to take part. We have been so humbled by the support we received from families who wanted to contribute to a better understanding of outcomes following TBI.
We also recruited some control participants who were children in the same age range who had not sustained a TBI. This helped us to compare differences in both the neuroimaging and clinical neuropsychology of these two groups and try to disentangle the effect of the brain injury on development.
We are still in the midst of analysing our data, but so far we are finding that our TBI group and controls differed significantly on a range of cognitive measures. The largest effects were in domains of processing speed and executive functioning, with young people who had sustained a TBI experiencing more difficulties completing these tasks.
These cognitive skills are important for learning, and without the correct support at school, children will begin to fall behind as they may need a bit more time to get through the class work and also need support in organising their learning. Often, a child will recover well physically from a TBI and therefore teachers don’t always realise that the nature of these brain injuries means that it can lead to long-term hidden disabilities and needs.
Recognising these difficulties is really important. We don’t want children to fall behind and feel that they are doing poorly at school because of unrecognised needs following a TBI. It is our role as adults to ensure that a child grows up with the best education and that includes correct support, to not only support their learning but their developing self-esteem and sense of self. If we were to get things right at the child level, we would have happier and healthier adults.
Our research is novel as it combines detailed clinical neuropsychogical assessments with advanced neuroimaging. A key effect of TBI is to produce damage to the white matter connections of the brain, disrupting efficient communication between brain regions and networks. This type of damage has been difficult to diagnose in the past, but our advanced scans are now able to diagnose this damage.
Our cognitive functions depend on the efficiency of these connections and damage to these white matter tracts was found to relate to cognitive outcomes in our sample. We found that young people who had sustained a TBI had lower fractional anisotropy (FA) in some key white matter tracts and these reductions were associated with neuropsychological outcomes.
For example, damage to the splenium of the corpus callosum was associated with poorer processing speed. This effect was unique to our TBI group, not found in our healthy controls, thus suggesting a unique relationship between the effects of TBI on the brain and cognitive outcomes in children.
The exciting thing about this work is that the models can be applied at an individual level. My colleague Amy Jolly has developed a pipeline for processing single subject FA values against a group of healthy age-matched controls. This means we can look at one individual’s white matter tracts and make an assessment of the health of these tracts.
In our sample we found that FA values are better associated with neuropsychological outcomes than standard MRI scans. This is important for healthcare settings and clinicians need to be looking beyond standard structural imaging, which may not be telling us the whole picture when it comes to understanding the effects of the TBI on the brain.
If this advanced neuroimaging was offered routinely following a TBI, children at risk of developing cognitive difficulties could be identified and then referred to clinical neuropsychology in a timely manner.
Currently, services are vastly underfunded and therefore it is important to have a system for identifying children at-risk to ensure they are being adequately supported and we do not see them in our services only once they have started falling behind and problems have been flagged up by school and parents.
The All Party Parliamentary Group on Brain Injury recently reported that every primary school class has on average at least one child who has a brain injury so this is a sizeable problem and one that I think deserves our attention.
Owing to our successes with recruitment and building a network of interested parties across the whole country, Action Medical Research have funded us for two further years in which we hope to bring back the same young people. This will enable us to look more closely at brain development and neuropsychological development across childhood and adolescence and learn more about how TBI intersects with that.
This work is key in improving our understanding of why some children do well after a TBI and why some children go onto struggle, and this is key to ensuring that no child is left to struggle with unmet needs.
