Introduction

Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality in youth worldwide. Though much remains to be learned, research focused on pediatric TBI has flourished in the last two decades. The current chapter will emphasize recent scientific literature relevant to understanding the consequences of moderate to severe TBI and the role of neuropsychological assessment in particular in characterizing and managing these difficulties. Epidemiological, pathophysiological, and intervention data will be highlighted as well. Outcomes and clinical care after uncomplicated mild TBI in children can be expected to differ from more severe injury; comprehensive reviews of this literature are available elsewhere [1, 2].

Epidemiology

In the USA, more than one million children and adolescents sustain TBI each year. Among children aged 0 to 14 years, TBI accounts for approximately 2700 annual deaths, 37,000 hospitalizations, and 435,000 emergency department visits [3]. Not surprisingly given such frequency, the associated financial costs are considerable. Annual hospitalization charges alone exceed $1 billion [4]. Rates and costs of all childhood TBI are undoubtedly much larger, as many milder injuries go unreported entirely or are treated in outpatient settings and remain unaccounted for in hospital-based estimates.

The incidence of TBI varies by severity, with mild TBI comprising 80 to 90% of all treated cases. Throughout childhood, boys are at considerably greater risk for TBI than girls.

Introduction

On what grounds does a hard-nosed number-crunching economist make such a claim? What does he mean? What are the implications for the elaboration of the knowledge base? For clinical practice?

A model is a tool for thinking, for organizing a body of data into a theoretically coherent construct whose validity can be tested. Thinking in both research and clinical arenas is based on a constant interaction between models and evidence. The challenge of empirical data (evidence) is that at any one point there may be much to make sense of. Data are not always internally consistent; and, until established by multiple replications across data sets, evidence is constantly subject to discussion, argument, and change. Models may not be subject to as rapid change as the evidence base. They cannot, nonetheless, be static: as evidence accumulates, models must be scrutinized and reformulated.

There are two major sources of change in science.

What is a good way to promote dialogue among researchers and practitioners from different perspectives in order to improve understanding of learning disorders, especially with respect to their brain bases? Work on learning disorders requires input from multiple disciplines, but despite this need, interdisciplinary cooperation on learning disorders and their brain bases has not been notably successful until relatively recently.

The children: the initial interview

The four boys are all 9 years old. They are right-handed. Jonathan has not experienced difficulty in learning to read. The other three boys have.

Jonathan

1. … … Well, I like to play sports… …. I like to play

2. [Jane Holmes Bernstein (JHB): You're a sportsman – OK]

3. lots of different sports, like… …. I play baseball … and soccer…. I want to play–LAUGHS–hockey and football but I can't–LAUGHS–

4. [JHB LAUGHS. Why can't you play hockey and football?]

5. 'cos I'll break too many teeth… … . disingenuous expression +

6. grin!

1. Facial Expression

2. Bright, animated, mischievous.

3. Intonation

4. Within normal limits: varies appropriately with content.

5. Posture

6. Arms on table, in “conversational space” with JHB.

7. Gaze Patterns

8. Gazes up when thinking/formulating remarks; focuses appropriately on JHB when making point.

9. Interviewer Comment

10. Comfortable with himself, enjoying the attention. Fluent use of conversational language: turn-taking is smooth with appropriate “cross-cutting” of his and JHB's remarks. Socially aware, even sophisticated: knows that his last remark will not be expected – waits for its effect on JHB!

William

1. … … I'm really good at geography… …. and … hummm!… I'm really good at

2. [Maryanne Wolf (MW): yeah]

3. singing… …. I'm pretty good at lots of things actually.

4. [MW: Yes, I know that … that's what I hear] [Yeah! That's great …]

1. Facial Expression

2. Bright, engaged.

3. Intonation

4. Appropriately varied; matched to content of remarks.

5. Posture

6. Arms on table; in conversational space with MW.

7. Gaze Patterns

8. Looks up and to the side when thinking/formulating; focuses on MW appropriately when offering specific information.

9. Interviewer Comment

10. Mildly anxious but very familiar with MW, whom he likes and who enjoys him. Elicits encouraging, soothing tone of voice from MW. Conversation moves smoothly between W and MW with appropriate cross-cutting of utterances.