Pediatric Traumatic Brain Injury And Autism

Introduction

Research into Pediatric Traumatic Brain Injury (TBI) and Autism Spectrum Disorder (ASD) has led scientists to the conclusion that TBIs may potentially result in ASD, as severe head injury can result in the neural rewiring of the brain. Even without a diagnosis of ASD, TBI and ASD, patients still exhibit many of the shared symptoms.¹

Pediatric TBI occurs when children have head trauma, resulting in internal injury. This can often lead to temporary/ or permanent disability and or even death in children. Disabilities from TBIs can be physical as well as but also intellectual disabilities.²

ASD is a developmental intellectual disability that manifests during early childhood. It often limits an individuals' social understanding and capabilities, with a host of positive and negative symptoms that can differ from patient to patient. There is no definitive cause, and many environmental and genetic factors are predicted to be responsible for the disorder.^3,7

In this article, I will discuss the connection between the two, how TBIs can lead to an increased risk of ASD, and what to do if you are concerned about your child. 

TBIs and ASD

TBI in children should be quickly identified and treated to minimise the risk of further injury and disability. Once the physical examination has occurred and the patient is deemed safe, a neurological exam is next to observe any changes in behaviour and function to determine if there is damage to neurological and cognitive function.⁴ Injuries of the brain can lead to dysfunction and negative symptoms dependent on location and severity, causing disability either physical, mental, emotional etc. This is due to the damage of neurons preventing correct signalling.¹

TBI at key developmental stages in a child's life can cause lasting effects that may be permanent, such as during birth or early childhood. Damage can lead to disability manifesting at a young age, and often requires behavioural and cognitive therapies to maintain normal behaviours.⁵ Children who have suffered a TBI have a more likely chance of being diagnosed with ASD and ADHD later in life, this chance increasing with increased TBIs either from accidents or abuse. This is one of the outcomes of long-term disability that may occur as a result of TBIs.^3,6 There are many other long-lasting outcomes possible depending on the injury. 

ASD manifests symptoms as early as 14 months old,⁷ but the changes in neural wiring occur as early as the 2^nd and 3^rd trimesters.^8,10 The differential wiring maintains itself throughout early development, persisting until adulthood.⁶

Symptoms of ASD include: 

• Communication and language deficits 
• Repetitive and irregular behaviour
• Limited interests

Other symptoms can include: 

• Increased anxiety 
• Issues with emotional regulation and recognition 
• Impaired executive function 

Each selection and severity of symptoms differ between individuals with ASD, resulting in a spectrum of results.^2,7

The cause of ASD has not been uncovered as of yet. There is much research into genetic causes, and certain genes have been identified, but it is presumed that it is the result of many different genes having small effects to lead to the large effect that is ASD. Environmental factors such as maternal smoking during pregnancy have also been observed to have an effect on development, but it is not stated to be the primary cause of ASD.⁹

Connection and causation

The primary feature of ASD at a cellular level is that the neurons in the brain are rewired differently from that of a neurotypical brain. Rewiring is the result of genetic risks mutations, and environmental stressors.^6,10 leading to incorrect signalling from cells and endogenous neuromodulators that occurs during prenatal and early development,¹¹ leading to both increased and decreased synapse formation depending on the area of the brain.^3,8,10 One key area found to be affected is the cerebellum, a key factor in the development of social capabilities after birth.³  

TBI results in neuronal damage, which results in the loss of synapses in the damaged area through microglia.¹² However, moderate or severe head injuries at key points of development - up to 3 years old - at targeted brain areas are associated with the over-activation of microglia and influencing the genetic factors and their expression leading to ASD-like symptoms.¹³ A primary area that when injured may result in ASD is the cerebellum.³

Changes to the cerebellum can lead to downstream changes in the structure of various areas associated with ASD, such as the hippocampus, amygdala, inferior temporal cortex & frontal neocortical areas.^3,8,10 The downstream effects in various areas are due to the long-distance loops it shares with many areas of the brain. Interruption of these loops can cause mismatched electrochemical firing of neurons and result in many different symptoms across brain structures. Issues with wiring from the cerebellum are present within ASD individuals and are thought to also be present in certain TBI patients.^3,8

Why does it have such a prolonged effect? 

TBI at early ages can cause changes in the stress hormone, cell signalling factors and genetic expression.^5,12,14 These changes can result in different neuron attachments and changes in DNA expression, causing a change in wiring that is maintained. The change in neuronal wiring can cause symptoms like communication and social issues similar to that of ASD. The chemical and structural changes are also similar to ASD.⁵

Symptoms and diagnosis

If a child has a severe head collision, medical diagnosis should be sought out immediately to prevent any further internal or external injury. If the injury is internal, there is a higher chance of prolonged effects, some of which may be disabilities.^1,4

After a TBI, children should be closely monitored for any abnormal changes in behaviour.^1,5 Diagnosis of ASD and ADHD is external to the TBI treatment and should be sought out if deemed necessary, as the symptoms of such will not appear for some time after the injury.⁶

ASD-like symptoms that arise as a result of TBIs show similar developmental issues as that of ASD and are frequently diagnosed as such, regardless of history.¹³

ASD diagnosis is an extended process that involves monitoring the patient for key behaviours, such as reduced eye contact, peculiar and repetitive behaviour, and reduced social interactions.² ASD children often miss key stages of development and social milestones, such as knowing the appropriate situational facial expressions and not sharing or showing interests with others.¹⁵

Does TBI cause ASD?

This question comes down to the semantics of what is considered ASD or not. ASD developmental issues occur before birth and the changes are enacted throughout development post-birth. TBIs are environmental factors that cause changes during or after birth that result in ASD-like symptoms, hence developmental changes. TBIs can be deemed an environmental factor associated with ASD or a separate entity itself due to the lateness of the changes seen.

Regardless of what is considered, children with ASD symptoms - genetic or environmental - will develop differently from neurotypical children. Despite the differences in causality, they have similar symptoms,^3,5 can be diagnosed the same,¹³ will face similar challenges and require similar care.⁵ Perhaps they are different, but it does not help to differentiate between the two when it comes to the patients themselves.

Care

Care for ASD has been difficult due to the various areas that are affected, the lack of understanding of the disorder itself, and no real way to prevent the development of the disorder. To deal with severe symptoms that affect day-to-day life medications can be described depending on the symptom being managed, such as attention problems, or depression.^2,5

Current therapies focus on cognitive behavioural therapy (CBT) to help manage the behavioural symptoms of ASD. By taking part in CBT, ASD individuals can learn to manage negative symptoms more carefully to prevent large outbursts, meltdowns, and aggressive behaviour toward others and themselves, and improve communication and social capabilities.²

A large factor in ASD is understanding of the disorder. There are things which maybe can be learned, but often ASD individuals struggle with or cannot help many of their behaviours. This makes it difficult to communicate ways to understand or assist with what is happening or intentions that can help with interactions and socializing. With ASD diagnosis becoming normalised within society accommodations can be put in place to assist with anything they may struggle with. Symptoms can be shared but each ASD individual is different and often requires unique care, which should be discussed with either the individual or carers of individuals.²

TBI care immediately after is either short-term or long-term. They may suffer from memory issues and issues with balance and motor functions temporarily and may require assistance with basic tasks until symptoms pass. This assistance can be found through rehabilitation therapies to help achieve daily functions, such as strengthening, speech practice, and psychological and cognitive therapy.^1,4

Care for disabilities that occur as a result of TBIs is dependent on the nature of the disability, and advice should be sought out from a medical professional. In terms of intellectual disabilities, diagnosis and appropriate care for ASD and ADHD as detailed above is the ideal route for providing a child with the best care.

Summary

TBIs in children can result in temporary issues with many aspects of life, moderate and severe injuries leading to possible life-long disabilities. Young children, up to 3 years old, with TBIs have an increased chance of being diagnosed with ASD and ADHD, a developmental disorder affecting social capability and brain functions.

Differences between TBI-causing ASD-like symptoms and ASD without TBIs are non-significant and require similar care, understanding individual needs at the centre of proper care.

FAQs

Can you gain ASD from a TBI in later life?

No, due to the nature of the disability, it cannot be gained once the brain has developed past a certain point. Damage to neurons in later life will destroy those neurons/synapses, and regrowth will occur when necessary. It does not change the development of an adult as it can in children, as those structures are already in place.

What are the benefits of ASD diagnosis?

Benefits are unique to the individual. Sometimes diagnosis can help confirm suspicions and give closure to the patient and their carers. It can help put in place accommodations to help their day-to-day life and receive help in personal and professional environments. Individuals may not necessarily benefit from a diagnosis and don’t deem it necessary to determine if they are. A diagnosis should happen to help the ASD individual live a comfortable life in a society that isn’t tailored to them.

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Kay Taylor

Bachelors in Neuroscience - University of Dundee

Masters in Science and Health Communication – University of Dundee, Ongoing

Autism Practitioner – Scottish Autism

They have a great interest in any form of medical communications from Medical Writing to Festival Work. They are quickly obtaining experience in communications through several avenues to improve their skill foundations in writing, presenting, public engagement, and various different tools and programs.

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