Language Development in Children

This study examined narrative development in children, who suffered from a traumatic brain injury, between the ages of three and six years old, eighteen months post-injury. There were two group comparisons. The first group compared TBI vs. orthopedic injury. The second group compared severe TBI vs. moderate TBI. The researchers hypothesized that children with TBI would display deficits in narrative discourse task compared to children with orthopedic injury. They also examined whether age at assessment, injury severity, language pragmatics and verbal memory were predictors of narrative conversational skills. The TBI had to be from a blunt force trauma to the head, not related to child abuse, requiring overnight stay at the hospital and a Glasgow Coma Scale score of greater than thirteen. The children had to retell the story “The Crow and the Peacocks”. They were also asked a few questions about the story like, what lesson can be learned from this story and to rate ten statements from the story into important or unimportant. The Comprehensive Test of Spoken Language test was used to measure pragmatic judgments. The story recall subtest of the Woodcock-Johnson Scales of Achievement (3rd edition) was also used. Behavior was also accessed in regards to aggression, defiance, withdrawal and anxiety. The results showed that the TBI group was not as capable as the orthopedic injury group at answering questions about story content and identifying unimportant story information. The TBI group also responded with less information when asked to recall the story.

I enjoyed reading this research article and found it very easy to read and comprehend. However, one thing I was confused about was why the experimenters didn’t include children that suffered from abuse at home and resulted in a TBI. Then, I thought about it and maybe those children have other mental trauma other than a TBI that may affect their language development. I am not sure if these two components correlate, but that is another topic to be researched. I thought that measuring pragmatics skills and narrative retell, at ages three and six, may have impacted the results. Most typical developing five year olds are just learning these skills. How do the authors know that the low scores of these subtest were due to the TBI and not just that the child doesn’t have those skills yet? I learned that approximately one hundred and sixty per one hundred thousand children, under the age of five years old, suffer a traumatic brain injury (Walz. 2011, p. 143). I was surprised that so many children suffer from a TBI so young and that it is one of the most common causes of death among children.

The purpose of this study was to establish the attainability and the need to develop a clinical protocol of scheduled assessments, for children, after a moderate or severe TBI, with no signs of impairment upon discharge from the hospital. The children had to be diagnosed with a TBI before the age of two. Thirty-one children participated over the course of a three year follow-up with an Occupational Therapist, Audiologist, and Speech-Language Pathologist. The children’s expressive and receptive language skills were accessed, as well as their gross and fine motor skills. The results concluded that fifteen to twenty percent of children showed significant motor and/or language delays at the age of three years and six months. These children also showed difficulties with behavior and social skills. Majority of the children showed no delays/deficits in all the domains of language tested. All audiological measurements were found to be within normal limits. Clinicians reported little difficulty in scheduling or administrating the assessments supporting the attainability of this clinical protocol. However, the study did not significantly prove that a new follow-up protocol should be implemented.

When I first started reading this research article, I asked to myself, “why wouldn’t there be a follow-up protocol for children with a TBI, regardless if there were not signs of impairment when discharges from the hospital?”. I just assumed there was one because we know that a child who experiences a brain injury so young is susceptible to have delays academically and socially. If a child has no follow-up, how would clinicians know that a later developing deficit is or isn’t due to the TBI? Although the results didn’t come out the way the researchers wanted, I believe the results can be used to re-evaluate the current assessment protocol to optimize professionals time and effectiveness, but also the quality of care to the patient.

The overall aim of this study was to access the contribution of age at the time of injury to longitudinal outcome and recovery of pragmatic language. There were three groups categorized according to age at the time of injury: middle childhood (5-9 years old), late childhood (10-11 years old) and adolescence (12-15 years old). Pragmatic language was accessed at six months then again at twenty-four months after injury. The researchers predicted that children who experienced a TBI during middle childhood (ages 5-9) would have poorer pragmatic communication and increased behavior problems such as aggression and impulsiveness. The sample size was comprised of one hundred and twelve children with TBI and forty-three typically developing children as the control group.

The children were asked to interpret propositions, recognize and generate underlying social conversations and to make inferences based on a conversational script presented to them. The results concluded that the middle childhood TBI group showed significantly poorer pragmatic communication at six months and twenty-four months post injury when compared the the control group. Children in the late childhood TBI group showed comparable pragmatic language skills at six months and again at twenty-four months post injury when compared to typical developing children. The adolescent TBI group showed significantly poorer pragmatic communication at twenty-four months, but not at six months. This group was eventually ruled out because of a significant difference in age of the TBI participants compared to the age of control group participants. The results also showed that poorer pragmatic communication was associated with the presence of lesions to the corpus callosum. Behaviors such as aggressiveness, inclusiveness and rule-breaking was found to strengthen with time since injury.

I liked that this study was very specific and examined pragmatic communication outcomes and not just the overall language outcomes after a TBI. I expected children five to nine years old to have poorer pragmatic skills because it is most likely that these pragmatic skills are still rapidly developmenting at the time of injury. It surprised me that children ten to eleven years old did not show deficits with pragmatic language. This may be because these children have already mastered these pragmatic skills. I learned that age, at the time of injury, is an important factor when considering language deficits.

As I was looking for research articles about how a TBI impacts language development, I was finding it hard to come across such research. I think it is important that more research be conducted so, we as clinicians can know more about how a TBI affect language development, specifically in children. This is critical because a child’s brain is still developing during a their early years and language is just emerging. It’s hard to imagine that language would not be impacted. Often children with TBI have behavior problems later on (Pomerleau, G. 2012). My question is what would be the best therapy for these children who have behavior problems because of TBI, and is there an age where we can say that these problematic behaviors are not due to the TBI?

All three articles reported that TBI is the leading cause of disability and death among children. They also stated that children who suffer from a TBI show long term deficits in multiple domains including language, auditory function, cognitive abilities, motor performance and day to day activities. I learned that the side effects of a TBI can show up months and even years after the initial injury (Pomerleau, 2012). It is important to always follow up with patients who suffered with a TBI. In clinical practice when collecting case history, I will always ask the parents or guardians if their child has ever suffered from a TBI since we know symptoms can still emerge years after the initial injury.

The research conducted by Ryan, et al. (2015), studied pragmatic communication in five year olds. I think that maybe some of these task that the researcher asked the children to do were possibly to advanced and the children wouldn't have been able to do them and score within the norms without a TBI. We know that pragmatic skills development rapidly and enhance through adolescence. In the research by Waltz, Yeates, Taylor, Stancin & Wade (2011), the children were asked to process large about of oral language, compress information into important or unportantant, and state the overall meaning.

I think these skills are hard for five year old to do as well. These skills are just emerging during this time and will continue to to improve into adulthood, especially when the child enters kindergarten. These articles focus on children primarily elementary and middle school age. I wish I would’ve found an article about teenagers in highschool who suffered from a TBI when they were younger to find out what their language abilities look like now in high school?

Did they catch up to age equivalent norms? I learned that being a critical consumer of research will make me a better clinician and provide the best care to my clients. I also learned that is important to stay up to date on topics because discoveries are made everyday and things are always changing. I will use this information clinically to make sure the parents and guardians know their important roles when dealing with someone with a TBI - their education and involvement is critical for the recovery process.

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