Evidence of residual cognitive deficits in young adults with a concussion history from adolescence

The present study investigated executive function and sustained attention of non-athlete, young adults (ages 18-23) with a history of concussion beyond ten months post incident. Cognitive functioning was examined in 24 non-athletic, college students with a concussion history (mean age 21 yrs.; mean time and range post-injury: 4 years, 10-90 months) and 24 non-athletic controls with no history (NH) of concussion. Computerized versions of two cognitive assessment techniques were utilized to examine executive functioning (Stroop) and sustained attention capacity (D2). Primary dependent variables were response time, error score, and sustained attention score. Relationships between dependent variables and concussion metrics were also analyzed. ANOVA's revealed a significantly higher error rate in concussion history (CH) participants when performing the Stroop task (p < 0.05), including a trend for greater errors in the incongruent task condition (p < 0.05). Group measures did not differ in the sustained attention test (all p > 0.05). Nevertheless, there was a significant relationship between D2 error rate and time since concussion (p < 0.01), showing that D2 error rate was greater for participants with more time since concussion sustainment. Our findings indicate the potential for prolonged cognitive dysfunction linked to decision-making, but not to processing speed, in young adult non-athletes with a CH averaging four years post-injury. These findings may provide evidence of residual cognitive deficits in young adults with a concussion history over time.

Outcomes after Complicated and Uncomplicated Mild Traumatic Brain Injury at Three-and Six-Months Post-Injury: Results from the CENTER-TBI Study

The objective of this study was to provide a comprehensive examination of the relation of complicated and uncomplicated mild traumatic brain injury (mTBI) with multidimensional outcomes at three- and six-months after TBI. We analyzed data from the Collaborative European NeuroTrauma Effectiveness Research (CENTER-TBI) research project. Patients after mTBI (Glasgow Coma scale (GCS) score of 13-15) enrolled in the study were differentiated into two groups based on computed tomography (CT) findings: complicated mTBI (presence of any traumatic intracranial injury on first CT) and uncomplicated mTBI (absence of any traumatic intracranial injury on first CT). Multidimensional outcomes were assessed using seven instruments measuring generic and disease-specific health-related quality of life (HRQoL) (SF-36 and QOLIBRI), functional outcome (GOSE), and psycho-social domains including symptoms of post-traumatic stress disorder (PTSD) (PCL-5), depression (PHQ-9), and anxiety (GAD-7). Data were analyzed using a multivariate repeated measures approach (MANOVA-RM), which inspected mTBI groups at three- and six-months post injury. Patients after complicated mTBI had significantly lower GOSE scores, reported lower physical and mental component summary scores based on the SF-36 version 2, and showed significantly lower HRQoL measured by QOLIBRI compared to those after uncomplicated mTBI. There was no difference between mTBI groups when looking at psychological outcomes, however, a slight improvement in PTSD symptoms and depression was observed for the entire sample from three to six months. Patients after complicated mTBI reported lower generic and disease specific HRQoL and worse functional outcome compared to individuals after uncomplicated mTBI at three and six months. Both groups showed a tendency to improve from three to six months after TBI. The complicated mTBI group included more patients with an impaired long-term outcome than the uncomplicated group. Nevertheless, patients, clinicians, researchers, and decisions-makers in health care should take account of the short and long-term impact on outcome for patients after both uncomplicated and complicated mTBI.

Mathematical outcomes and working memory in children with TBI and orthopedic injury

This study compared mathematical outcomes in children with predominantly moderate to severe traumatic brain injury (TBI; n550) or orthopedic injury (OI; n547) at 2 and 24 months post-injury. Working memory and its contribution to math outcomes at 24 months post-injury was also examined. Participants were administered an experimental cognitive addition task and standardized measures of calculation, math fluency, and applied problems; as well as experimental measures of verbal and visual-spatial working memory. Although children with TBI did not have deficits in foundational math fact retrieval, they performed more poorly than OIs on standardized measures of math. In the TBI group, performance on standardized measures was predicted by age at injury, socioeconomic status, and the duration of impaired consciousness. Children with TBI showed impairments on verbal, but not visual working memory relative to children with OI. Verbal working memory mediated group differences on math calculations and applied problems at 24 months post-injury. Children with TBI have difficulties in mathematics, but do not have deficits in math fact retrieval, a signature deficit of math disabilities. Results are discussed with reference to models of mathematical cognition and disability and the role of working memory in math learning and performance for children with TBI.

Early attention impairment and recovery profiles after childhood traumatic brain injury

OBJECTIVES

To examine recovery of attention from 3 to 6 months postinjury; to identify effects of injury severity and time since injury on performance; to explore whether complex attention skills (eg, shifting, divided attention, attentional control) are more vulnerable to traumatic brain injury (TBI), and slower to recover than simple attention skills (eg, attentional capacity, selective attention, sustained attention).

DESIGN

Prospective longitudinal investigation.

PARTICIPANTS

A total of 205 school-aged children with TBI were divided into groups according to injury severity (mild = 63%, moderate = 27%, severe = 10%).

SETTING

Emergency departments of 3 metropolitan children's hospitals across Australia.

MAIN MEASURES

Standardized clinical measures of both simple and complex attention were administered at 3 months and 6 months postinjury.

RESULTS

Attention skills were vulnerable to the impact of TBI. More severe injury affected attention skills most negatively. Significant recovery was observed over time. There were few interaction effects, with severity groups exhibiting similar levels of recovery over the 6 months post-TBI. No differences in recovery trajectories were detected for simple and complex attention.

CONCLUSIONS

These findings have important clinical and educational implications, suggesting that children with TBI, and particularly those with more serious injuries, are most vulnerable to attention deficits in the acute stages postinjury. It is important that schools and families are aware of these limitations and structure expectations accordingly. For example, gradual return to school should be considered, and in the early stages of recovery, children should be provided with sufficient rest time, with reduced expectations for tasks such as homework.

The Starship Post-Traumatic Amnesia Scale: Does It Predict Outcome After Mild to Moderate Traumatic Brain Injury in Children Aged 3 to 7 Years?

This study assesses whether the Starship Post-Traumatic Amnesia scale, developed for children aged 3 to 7 years, can predict neuropsychological impairment and behavioural outcome following mild to moderate traumatic brain injury. Participants are 19 children aged from 3 to 7 years with a GCS score of >13, and a PTA of 0–3 days. Neuropsychological outcome is measured by the NEPSY, and behavioural outcome by the Child Behaviour Checklist (CBCL) two months after the TBI. The duration of PTA contributed to the prediction of scores on the NEPSY memory and learning domain. In all cases the longer the duration of PTA, the poorer the memory scores were. The duration of PTA did not contribute to the prediction of NEPSY visuospatial processing or attention and executive functions domain scores, or to any of the CBCL scores. This preliminary study suggests that the Starship PTA scale has good sensitivity for this very young age group, even when the TBI is mild.

The effects of pediatric traumatic brain injury on verbal and visual-spatial working memory

The purpose of this study was to investigate the effects of pediatric traumatic brain injury (TBI) on verbal and visual-spatial working memory (WM). WM tasks examined memory span through recall of the last item of a series of stimuli. Additionally, both verbal and visual-spatial tests had a dual-task condition assessing the effect of increasing demands on the central executive (CE). Inhibitory control processes in verbal WM were examined through intrusion errors. The TBI group (n = 73) performed more poorly on verbal and visual-spatial WM tasks than orthopedic-injured children (n = 30) and non-injured children (n = 40). All groups performed more poorly on the dual-task conditions, reflecting an effect of increasing CE load. This effect was not greater for the TBI group. There were no group differences in intrusion errors on the verbal WM task, suggesting that problems in WM experienced by children with TBI were not primarily due to difficulties in inhibitory control. Finally, injury-related characteristics, namely days to follow commands, accounted for significant variance in WM performance, after controlling for relevant demographic variables. Findings suggest that WM impairments in TBI are general rather than modality-specific and that severity indices measured over time are better predictors of WM performance than those taken at a single time point.

Neural correlates of interference control in adolescents with traumatic brain injury: functional magnetic resonance imaging study of the counting stroop task

Difficulty in inhibition or cognitive control is a common and significant sequela of pediatric traumatic brain injury (TBI). The present study used functional MRI to examine one specific inhibitory function, interference control, in 11 adolescents, aged 12-16 years, (mean age, 15.7 years) with TBI who were at least 1 year postinjury and 11 age-matched typically developing control participants (TC) (mean age, 15.2 years). Participants completed a Counting Stroop task with 2 main conditions: (1) a neutral condition requiring the counting of animal words and (2) an interference condition in which mismatched number words were counted. Both TBI and TC adolescents activated similar networks of brain regions relevant to interference control, but the TBI group showed higher levels of activation relative to the TC group in multiple brain areas within this network, including predominantly right frontal and parietal regions. Findings of greater activation of the relevant neural network in the TBI group are consistent with recent fMRI findings using other interference control paradigms with individuals with a history of TBI.

Attention processing abnormalities in children with traumatic brain injury and attention-deficit/hyperactivity disorder: differential impairment of component processes

Individuals with acquired and neurodevelopmental brain disorders often exhibit deficits in attention. Recent models of attention have conceptualized it as a multicomponent system. One influential model proposed by Mirsky et al. (1991) consists of factors that include focus, sustain, shift, and encode components. This model has been used to examine the structure of attention in a variety of clinical populations although few studies have contrasted performance of various clinical groups in order to determine whether these components are differentially affected. To address this issue, the current study investigated the differential sensitivity of these attention components in 90 children: 30 who had sustained traumatic brain injury (TBI), 30 who were diagnosed with attention-deficit/hyperactivity disorder (ADHD), and 30 normal controls. Results demonstrated that the TBI group had significantly lower focus factor scores, the ADHD group had significantly lower sustain scores, and that both clinical groups had lower encode factor scores than controls. Stepwise discriminant function analysis (DFA) retained the focus and encode factors in predicting clinical groups from controls with 75.6% accuracy. A second DFA retained the focus factor in differentiating the two clinical groups with 70.0% accuracy. These findings provide evidence of differential attention deficits resulting from TBI and ADHD.

Do lesion site and severity predict deficits in attentional control after preschool traumatic brain injury (TBI)?

PRIMARY OBJECTIVE

To determine the predictive value of structural neuroimaging in the clinical setting following TBI.

RESEARCH DESIGN

Prospective between-group design, comparing groups with regard to: (i) the presence or absence of cerebral pathology and (ii) the location of cerebral pathology. The predictive value of injury variables was investigated using hierarchical regressions.

METHODS AND PROCEDURES

Thirty-six children, between 6 and 14 years, who sustained a moderate to severe TBI 5 years previously participated in this study. Children's performances on five measures of attentional control were examined in relation to the presence, location and severity of their lesions, as coded by the Coffey classification system 1.

MAIN OUTCOMES AND RESULTS

Frontal lesion severity was not predictive of performance on any of the measures. However, generalized (frontal and extrafrontal) and extrafrontal lesion severity was predictive of poor performance.

CONCLUSIONS

These findings support the argument that functional organization in children may differ from that in adults, suggesting that multiple cerebral regions, or a diffuse cerebral network, may mediate children's executive functions (EF). Results are also consistent with the hypothesis that the amount of damaged brain tissue, rather than its location, may be more predictive of neurobehavioural outcome following early TBI.

Assessment of executive functioning in children after TBI with a naturalistic open-ended task: a pilot study

PURPOSE

Traumatic brain injury (TBI) often leads to executive functions (EF) deficits, resulting in severe longstanding disabilities in daily life activities. The sensitivity and ecological validity of neuropsychological tests have been questioned. The aim of this study was to pilot a novel open-ended naturalistic task and to compare it to other standardized assessments of EF in children post-TBI.

METHODS

Ten children aged 8-14, with moderate-to-severe TBI, and 18 matched controls participated in the study. The clinical group was assessed using cognitive tests and parent-based questionnaires of EF. An interactive ecological cooking task was designed.

RESULTS

Analyses indicated mild-to-moderate executive deficits in the cognitive tests in approximately half of the TBI group. For the experimental cooking task, all quantitative and qualitative variables were significantly impaired for the TBI group compared to the control group and failure in the cooking task was associated with lower scores in cognitive tests of EF. The task was able to discriminate the TBI children from the control group.

CONCLUSION

This pilot study highlights the role of naturalistic assessments, to complement standardized tests in assessing patients' dysexecutive impairments in complex activities of daily living post-childhood TBI.

Long-term neural processing of attention following early childhood traumatic brain injury: fMRI and neurobehavioral outcomes

Attentional deficits are common and significant sequelae of pediatric traumatic brain injury (TBI). However, little is known about how the underlying neural processes that support different components of attention are affected. The present study examined brain activation patterns using fMRI in a group of young children who sustained a TBI in early childhood (n = 5; mean age = 9.4), and a group of age-matched control children with orthopedic injuries (OI) (n = 8) during a continuous performance task (CPT). Four children in the TBI group had moderate injuries, and one had a severe injury. Performance on the CPT task did not differ between groups. Both TBI and OI children activated similar networks of brain regions relevant to sustained attention processing, but the TBI group demonstrated several areas of significantly greater activation relative to controls, including frontal and parietal regions. These findings of over-activation of the relevant attention network in the TBI group contrast with those obtained in imaging studies of Attention-Deficit/Hyperactivity Disorder where under-activation of the attention network has been documented. This study provides evidence that young children's brains function differently following a traumatic brain injury, and that these differences persist for years after the injury.

Skull Fracture During Infancy: A Five-Year Follow-Up

A group of 19 children, who had received a skull fracture during infancy, were assessed at least 5 years following injury. The majority of the group (89%) had received a mild traumatic brain injury (TBI), with the remaining two (11%) having a moderate injury. The neuropsychological, academic, and psychosocial functioning of the TBI group was compared to that of 20 orthopedic subjects. The two groups were matched on the variables of gender, age, and socio-economic status. The TBI group was impaired on tests of visual attention and memory for faces. The two groups did not differ significantly on measures of language, sensorimotor functions, or visuospatial functioning. There were no statistically significant differences between the two groups on academic performance, or parent and teacher reports of psychosocial functioning. It is concluded that while there is an absence of deficits in the vast majority of functions, skull fracture in infancy can result in enduring impairment in specific cognitive skills related to the processing of complex nonverbal stimuli.

Brain activation during working memory after traumatic brain injury in children

Eight children with moderate to severe traumatic brain injury (TBI) and eight matched, uninjured control children underwent fMRI during an N-back task to test effects of TBI on working memory performance and brain activation. Two patterns in the TBI group were observed. Patients whose criterion performance was reached at lower memory loads than control children demonstrated less extensive frontal and extrafrontal brain activation than controls. Patients who performed the same, highest (3-back) memory load as controls demonstrated more frontal and extrafrontal activation than controls. Our findings of performance and brain activation changes in children after TBI await longitudinal investigation.

Susceptibility-Weighted Imaging and Proton Magnetic Resonance Spectroscopy in Assessment of Outcome After Pediatric Traumatic Brain Injury

OBJECTIVE

To assess the role of magnetic resonance imaging, specifically magnetic resonance spectroscopy (MRS) and susceptibility-weighted imaging (SWI), in the evaluation of children with traumatic brain injury (TBI).

DATA SOURCES

Literature review and data from our recently published clinical studies.

STUDY SELECTION

Children with pediatric TBI who underwent SWI. SWI is a 3-dimensional high-resolution magnetic resonance imaging technique that is more sensitive in detecting hemorrhagic lesions seen with diffuse axonal injury (DAI) than conventional imaging. MRS acquires metabolite information that reflects neuronal integrity and function from multiple brain regions and offers early prognostic information regarding outcome.

DATA EXTRACTION

Literature review.

DATA SYNTHESIS

Literature review and review of recently published data from our institution.

CONCLUSIONS

The data suggest that more sensitive imaging techniques that provide early evidence of injury and that are better predictors of outcome are needed to identify children at risk for such deficits. Specifically, the number and volume of hemorrhagic DAI lesions as well as changes in spectral metabolites such as reduced N-acetylaspartate or elevations in choline-related compounds correlate with neurologic disability and impairments of global intelligence, memory, and attention.

MR spectroscopy: Predicting long-term neuropsychological outcome following pediatric TBI

PURPOSE

To identify useful acute indicators of long-term neurocognitive outcome beyond clinical variables for children and adolescents treated for a traumatic brain injury (TBI).

MATERIALS AND METHODS

The efficacy of magnetic resonance spectroscopy (MRS) acquired 6+/-4 days after TBI in 20 children/adolescents in predicting intellectual and neuropsychological functioning one to four years post injury was assessed. Short echo-time single voxel MRS (SVS) from normal-appearing brain was compared to intermediate echo-time multivoxel MR spectroscopic imaging (MRSI) from normal-appearing and visibly-injured brain acquired through the level of the corpus callosum (CC).

RESULTS

N-acetyl aspartate (NAA) was moderate to strongly correlated with cognitive scores. Mean NAA/creatine (Cre) from MRSI alone explained over 40% of the variance in cognitive scores and 18% of the variance above and beyond demographic and clinical variables alone. Mild to moderate associations were noted between SVS metabolites (glutamate/glutamine [Glx] and myoinositol [mI]) and cognitive scores, with no such associations apparent for choline (Cho) or Cre. Exploratory analyses revealed trends for regional neuroimaging data and specific cognitive abilities.

CONCLUSION

Acute MR spectroscopy of the pediatric brain injury patient improves prognostic ability and may provide valuable information for early treatment and intervention planning.

Comparing attentional skills in children with acquired and developmental central nervous system disorders

Attentional impairments in children occur in the context of both developmental and acquired disorders involving the central nervous system (CNS) and may have implications for ongoing development, potentially impeding cognitive, educational, and behavioral functions. Using a continuous performance paradigm (CPT), this study compared attentional profiles of children with developmental and acquired conditions impacting on the CNS: (i) attention deficit-hyperactivity disorder (ADHD: n=27); (ii) moderate traumatic brain injury (TBI: n=41); (iii) acute lymphoblastic leukemia (n=31); and (iv) insulin-dependent diabetes mellitus (n=39). A healthy control group (n=46) was also examined. Groups were compared on measures of sustained attention, selective attention, and response inhibition. In addition, measures of performance variability and deterioration and processing speed were examined. Results showed that children with ADHD exhibited global and severe attentional impairments in contrast to all other groups. Children with moderate TBI displayed mild attentional difficulties, restricted to selective and sustained attention domains. In conclusion, although CPT parameters differentiated the ADHD group from all others, a disorder-specific profile was not observed.

Long-term attention problems in children with traumatic brain injury

OBJECTIVE

To examine long-term attention problems and their cognitive correlates after childhood traumatic brain injury (TBI).

METHOD

Data were drawn from a prospective, longitudinal study conducted between 1992 and 2002. Participants included 41 children with severe TBI, 41 with moderate TBI, and 50 with orthopedic injury (OI), who were all between 6 and 12 years of age at the time of injury. Parent ratings of attention problems were obtained at a long-term follow-up on average 4 years post-injury and compared with ratings of premorbid attention problems obtained shortly after injury. At the long-term follow-up, children also completed several cognitive tests of attention and executive functions.

RESULTS

Hierarchical linear and logistic regression analyses indicated that the severe TBI group displayed significantly more attention problems than the OI group at 4 years post-injury, both behaviorally and cognitively, after controlling for race, socioeconomic status, and premorbid attention problems. At long-term follow-up, 46% of the severe TBI group displayed significant attention problems on the Child Behavior Checklist, as opposed to 26% of the OI group (odds ratio=3.38; 95% confidence interval, 1.15-9.94). On the Attention-Deficit/Hyperactivity Disorder Rating Scale, 20% of the severe TBI group displayed clinically significant attention problems compared with 4% in the OI group (odds ratio=9.59; 95% confidence interval, 1.24-73.99). However, group differences in behavioral symptoms were significantly larger for children with more premorbid symptoms than for children with fewer premorbid problems. Measures of executive functions were significantly related to behavioral attention problems, after controlling for group membership, race, and socioeconomic status.

CONCLUSIONS

Childhood TBI exacerbates premorbid attention problems. Long-term behavioral symptoms of attention problems are related to the cognitive deficits in attention and executive functions that often occur in association with childhood TBI.

Social competence in young children with inflicted traumatic brain injury

As infants develop skills that allow for increasing independence in social and cognitive domains, they acquire the ability to identify goals, sequence behaviors to carry out goals, and to flexibly use strategies for attaining goals in both social and independent play contexts. Little is known about how brain injury in young children may disrupt the precursors to such executive processes. In this study, we examined social and cognitive competence in 25 infants ages 3 to 23 months who sustained moderate to severe traumatic brain injury (TBI) secondary to physical abuse and in 22 healthy community comparison children. Children with TBI were evaluated an average of 1.6 months after the injury. A toy-centered activity with the examiner was used to capture joint attention and social behavior and an exploratory toy play situation was used to measure independent goal-directed play. The inflicted TBI group showed significant reduction in both social and cognitive domains relative to the comparison group. Canonical correlation analyses disclosed that inflicted TBI was associated with reduction in (a) initiation of social interactions, (b) responsiveness to interactions initiated by the examiner, (c) positive affect, and (d) compliance. The groups performed comparably on indexes of gestural and verbal communication and for the occurrence of negative affect. Joint attention was an area of vulnerability for the TBI group in both social initiation and response contexts. Although general cognitive and motor scores were lower in the inflicted TBI group, the complexity of independent toy play did not differ across groups. Early brain injury causes significant disruption in behaviors regulating initiation and responsiveness in social contexts. Longitudinal follow-up will characterize the long-term consequences of early disruption in joint attention and other behaviors on the development of social and cognitive precursors to executive processes.

The development of a trial making test in young children: the TRAILS-P

Preschool children have a more limited verbal repertoire, less proficient manual skills, and more variable attention spans relative to those of school age, with comparatively few neuropsychological tasks available for use in this age range. A prototypic neuropsychological test, the Trail Making Test, was adapted for use with young children, the TRAILS-P, using a developmentally salient storybook format with colorful stimuli in differing conditions with varying executive demands. The TRAILS-P was administered to 103 normally developing preschoolers between 2 and 6 years of age; 30 of these children were retested within one month to determine test reliability. Correlations among latencies to complete each condition and condition errors generally were moderate to high, suggesting coherence in test content. There also was evidence for good test-retest reliability. Latency to complete the TRAILS-P conditions differed as a function of the interaction of condition type and age group. Although the youngest children generally took more time to complete all TRAILS-P conditions, 3-year-old children were disproportionately slow to complete the condition that required shifting between stamping stimuli of two classes, with distraction by the additional presence of irrelevant stimuli. In contrast, the number of errors differed only in the 5-year-olds relative to younger children. These findings suggest that executive abilities can be assessed adequately in young children when tasks are designed to take advantage of the developmentally unique features of the preschool period.

Child clinical/pediatric neuropsychology: some recent advances

The neuropsychological assets and deficits of several types of pediatric neurological disease, disorder, and dysfunction are described. These are examined from the perspective of the syndrome of nonverbal learning disabilities (NLD) and the "white matter model" designed to explain its complex manifestations. It is concluded that children with some of these diseases exhibit the NLD phenotype, whereas others do not. For the most part, the diseases in which the NLD phenotype is particularly evident are those wherein it has been demonstrated that perturbations of white matter (long myelinated fibers) are particularly prominent.

Metacognition following pediatric traumatic brain injury: a preliminary study

Metacognition is one of the cognitive processes included under the general term executive functions. The executive functions are widely held to be under the control of the prefrontal cortex, an area often damaged after severe traumatic brain injury (TBI). We examined the metacognitive processing of a group of 9 children with TBI, and a group of 9 healthy, age-matched control children. Children with TBI showed significant impairments in their accuracy of prediction of the ease with which an item would be learned and their ability to predict recall of an item after a 2-hr delay. No significant differences in recall performance between the TBI and control groups were exhibited. The results are interpreted as suggesting an impairment in metacognitive processing resulting from frontal lobe damage after TBI in children. Additional research is necessary to confirm the relation of frontal lobe pathology and severity of injury to metacognitive impairments.

Porteus Maze performance following traumatic brain injury in children

To investigate planning in traumatically brain injured children, the authors gave the Porteus Maze Test (PMT; S. D. Porteus, 1959) to 276 pediatric patients who had sustained a traumatic brain injury (TBI) at least 3 years previously. Sensitivity of the PMT to TBI severity, age at test, and volume of focal brain lesions detected by magnetic resonance imaging was also studied. The Peabody Picture Vocabulary Test-Revised (L. M. Dunn & L. M. Dunn, 1981) was also administered as a control measure. Results indicated that the PMT was highly sensitive to TBI severity and to volume of circumscribed prefrontal lesions. In contrast to the PMT data, receptive vocabulary was related to injury severity but not to discrete prefrontal lesions. Implications for mechanisms of cognitive deficit after TBI in children are discussed.

Neurobehavioral recovery after pediatric head trauma: injury, pre-injury, and post-injury issues

This article reviews the most significant demographic, neurological, and psychosocial factors affecting the occurrence of and recovery from traumatic head injury (THI) in children and adolescents. Review of the available literature suggests that, as with adults, there is no compelling evidence for persistent neurobehavioral deficits after mild THI in children. In contrast, neurobehavioral deficits are common in children who have sustained moderate to severe THI. This article emphasizes that a long-term developmental perspective that considers in concert injury, pre-injury, and post-injury variables is needed for a proper appreciation of possible sequelae of pediatric THI. Specific pitfalls in forensic assessments of these children are reviewed. Empirical findings are presented to support the position that neuropsychological evaluations of children with THI that do not consider pre-injury status are likely to lead to misattribution errors. Clinical implications are illustrated with a case example.