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CLINICAL PRACTICE GUIDELINEFOR THE MANAGEMENT OFCOMMUNICATION AND SWALLOWINGDISORDERS FOLLOWING PAEDIATRICTRAUMATIC BRAIN INJURY

GUIDELINE

© Murdoch Childrens Research Institute and the National Health and Medical Research Council Centre of Research Excellence on Psychosocial Rehabilitation in Traumatic Brain Injury 2017

Publisher: Murdoch Childrens Research Institute

Publication date: February 2017

ISBN Print: 978-0-9876209-0-3

ISBN Online: 978-0-9876209-1-0

Suggested citation: Morgan A, Mei C, Anderson V, Waugh M-C, Cahill L, & the TBI Guideline Expert Working Committee. Clinical Practice Guideline for the Management of Communication and Swallowing Disorders following Paediatric Traumatic Brain Injury. Melbourne: Murdoch Childrens Research Institute; 2017.

Expert working committee:

Jeanette BakerKatie BanerjeeMandy BeatsonCandice BradyKate BrommeyerPetrea CahirCathy CatroppaCynthia Christianto

Suzi DrevensekDonna FallonJane FongRob ForsythMatthew FrithPatricia GrillinzoniFlora HaritouSophie Huntley

Tamara Kelly Kate OslandJessica PalmerClaire Radford Damien RobertsAdam ScheinbergJillian Steadall

Contact:

Murdoch Childrens Research Institute

Flemington Road, Parkville Victoria 3052 Australia

Phone: +61 (3) 8341 6200

Fax: +61 (3) 8341 6212

Email: [email protected]

Disclaimer:

This document is a general guide, to be followed subject to the clinician’s judgment and the patient’s preference in each individual case. The guideline is designed to provide information to assist decision-making and is based on the best evidence available at the time of development.

Acknowledgements

Sincere thanks to all members of the steering and expert working committees for their invaluable input into developing this guideline. We kindly thank the individuals and organisations that provided feedback on the draft versions of the guideline. This guideline was developed and published by researchers at the Murdoch Childrens Research Institute in collaboration with The Children’s Hospital at Westmead, Lady Cilento Children’s Hospital, The Royal Children’s Hospital (Melbourne), Sydney Children’s Hospital, Auckland District Health Board, Townsville Hospital, Women’s and Children’s Hospital (Adelaide), Newcastle University (UK), Hunter New England Health, Novita Children’s Services, and the Victorian Paediatric Rehabilitation Service.

Publication Approval

The guideline recommendations on pages 11–18 of this document were approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) on 13 November 2016 under section 14A of the National Health and Medical Research Council Act 1992. In approving the guideline recommendations, NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of five years.

NHMRC is satisfied that the guideline recommendations are systematically derived, based on the identification and synthesis of the best available scientific evidence, and developed for health professionals practising in an Australian health care setting.

This publication reflects the views of the authors and not necessarily the views of the Australian Government.

TABLE OF CONTENTS

Guideline Development Committee 9

Plain English Summary 10

Executive Summary 10

1. Introduction 191.1 Background 19

1.2 Purpose 19

1.3 Clinical need for this guideline 20

1.4 Organisation 20

1.5 Clinical questions 20

1.6 Scope and intended users of this guideline 21

1.7 Target population 21

1.8 Methods used to develop this guideline 21

1.8.1 Guideline Development Committee 21

1.8.2 Systematic review 21

1.8.3 Delphi survey 22

1.8.4 Developing evidence-based and consensus-based recommendations 22

1.9 Public consultation 22

1.10 Independent peer-review 22

1.11 Scheduled review of this guideline 22

1.12 Funding 22

2. Cultural considerations when managing communication and swallowing disorders 23

3. Clinical question 1: Predictors 243.1 Background 24

3.2 Recommendations 24

3.2.1 Language 24

3.2.2 Speech 25

3.2.3 Swallowing 25

3.3 Summary of evidence 25

3.3.1 Language 25

3.3.2 Speech 26

3.3.3 Swallowing 26

4. Clinical question 2: Health professionals 274.1 Background 27



5. Clinical question 3: Timing of assessment 285.1 Background 28



6. Clinical question 4: Areas to assess 306.1 Background 30


6.2.1 Language 30

6.2.2 Speech 31

6.2.3 Swallowing 31


6.3.1 Language 32

6.3.2 Speech 32

6.3.3 Swallowing 33

7. Clinical question 5: Assessment tools 347.1 Background 34



7.3.1 Language 34

7.3.2 Speech 35

7.3.3 Swallowing 36

8. Clinical question 6: Treatment 368.1 Background 36


8.2.1 Language 37

8.2.2 Speech 37

8.2.3 Swallowing 38


8.3.1 Language 38

8.3.2 Speech 39

8.3.3 Swallowing 39

9. Clinical question 7: Timing of treatment 409.1 Background 40



10. Clinical question 8: Information for parents 4010.1 Background 40



11. Future Research 42

12. References 43

TABLE OF CONTENTSCONTINUED

LIST OF TABLES

Supporting documents available online at www.mcri.edu.au/TBI-guideline

> Short Form Guideline> Administrative Report> Technical Report> Public Consultation Submissions Summary

TABLE 1 Definitions of recommendations 10

TABLE 2 NHMRC grades for recommendations 11

TABLE 3 Clinical questions 20

TABLE 4 Factors to consider when managing speech, language and swallowing disorders in culturally and linguistically diverse populations 23

TABLE 5 Summary of evidence: predictors of language disorders 25

TABLE 6 Summary of evidence: predictors of speech disorders 26

TABLE 7 Summary of evidence: predictors of swallowing disorders 27

TABLE 8 Summary of evidence: timing of assessment 29

TABLE 9 Summary of evidence: areas of language to assess 32

TABLE 10 Summary of evidence: areas of speech to assess 32

TABLE 11 Summary of evidence: areas of swallowing to assess 33

TABLE 12 Summary of evidence: language assessments 35

TABLE 13 Summary of evidence: treatment of speech disorders 39

TABLE 14 Summary of evidence: treatment of swallowing disorders 39

http://www.mcri.edu.au/TBI-guideline

Clinical Practice Guideline for the Management of Communication and Swallowing Disorders following Paediatric Traumatic Brain Injury

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Acquired brain injury

Any type of brain damage occurring after birth (e.g., traumatic brain injury, stroke, tumour)

Apraxia of speech A motor speech disorder that impairs the ability to voluntarily move and sequence speech movements (also known as dyspraxia)

Articulation Ability to produce speech sounds using the articulators (e.g., tongue, lips, jaw)

Augmentative and alternative communication

All forms of communication other than oral speech (e.g., gesture, symbols, communication books)

Bulbar Cranial nerves that arise from the brain

Cognitive therapy Defined here as therapy that targets the underlying cognitive processes that support language (e.g., memory, information processing)

Confrontation naming

Naming an object or action when provided with a stimulus (e.g., picture of the object/action)

Communication Ability to receive and send verbal and non-verbal messages, encompassing all aspects of speech and language

Community rehabilitation

Rehabilitation provided following discharge from hospital including therapy provided by the child’s local speech-language pathologist (e.g., private, educational or community health settings) and outpatient reviews

Delphi survey A series of surveys (typically three) completed by a group of experts in order to reach a consensus on a particular issue

Dysarthria A motor speech disorder due to an impairment (e.g., weakness) in the muscles used for speaking

Dysphagia Swallowing disorder

Dyspraxia See apraxia of speech

Errorless teaching A technique where the learner is prevented from reinforcing his or her own errors. The child is prompted to make a correct response, ensuring that it is achieved each time

Expressive language

Ability to use spoken language (words and sentences) to convey messages

Extubation Removal of the endotracheal tube for mechanical ventilation

Formal assessment

The use of standardised assessments that compare the child’s performance against their peers

Fiberoptic Endoscopic Evaluation of Swallowing

Swallowing structures are evaluated through the insertion of a flexible endoscope with a video camera into the nasal cavity

Fluency Fluency of speech (e.g., absence of sound, word or phrase repetitions)

Hypernasality See resonance

Informal assessment

An assessment that does not use formal or standardised assessments. Test items are usually less structured and performance may be judged against developmental norms.

Intelligibility How well an individual’s speech is understood by a listener

Language disorder Difficulty comprehending and/or using spoken language

Morphology Structure of words (e.g., grammar)

Mutism Complete absence of speech

Narrative skills Skills needed for storytelling (e.g., describing events in a logical order)

Oral motor The use and function of the facial muscles (lips, tongue, jaw, cheeks)

Oral phase Transferring the food/fluid to the back of the mouth

Oral preparatory phase

Preparing the food/fluid in the oral cavity for it to be swallowed

Oropharyngeal phases

Oral preparatory, oral and pharyngeal phases of swallowing

Pharyngeal phase The swallow is initiated and the food/fluid moves down the pharynx

Phonemic priming Word retrieval is facilitated by providing the first sound of the target word

GLOSSARY

GUIDELINE 7

Phonation The process of producing voice for speech

Phonology Sound system of a language and the rules that govern sound combinations

Post-traumatic amnesia

A period of time following a head injury in which a patient experiences memory loss

Pragmatics Social use of language

Prosody Rhythm or melody of speech

Receptive language

Ability to understand or comprehend spoken language

Resonance Airflow through the nose and mouth during speech. Too much airflow through the nose may result in hypernasality and too little airflow may result in hyponasality

Respiration Respiration during speech (e.g., coordinating speaking with breathing)

Scaffolding Support provided to an individual that facilitates learning

Semantics Meaning of words and sentences (e.g., word order)

Semantic feature analysis

A technique where an individual is prompted to produce words that are semantically similar to the target word (e.g., apple, orange, banana)

Semantic priming A response to a target (e.g., spoon) is facilitated when it is preceded by a semantically related word (e.g., fork)

Speech disorder Difficulty producing speech sounds correctly or fluently due to any of the following: articulation disorder, phonological disorder, dysarthria, apraxia of speech, or stuttering

Stuttering Disruption in the fluency of speech (e.g., repetition of sounds, words, phrases or prolongation of sounds)

Swallowing disorder

Difficulty eating or drinking during any of the core oral-pharyngeal phases of swallowing (i.e., oral preparatory, oral, and pharyngeal)

Syntax Structure of sentences

Tracheostomy Surgical opening into the trachea (windpipe) that allows for the insertion of a tube to assist with breathing

Traumatic brain injury

Injury to the brain caused by trauma to the head

Videofluoroscopy An x-ray that examines the ability to swallow

Visi-pitch Software that records the voice and provides visual and auditory feedback in real time

GLOSSSARY

CONTINUED


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AAC Augmentative and alternative communication

ABI Acquired brain injury

CBR Consensus-based recommendation

EBR Evidence-based recommendation

GCS Glasgow Coma Scale

TBI Traumatic brain injury

NHMRC National Health and Medical Research Council

PICU Paediatric intensive care unit

PTA Post-traumatic amnesia

SLP Speech-language pathologist

ABBREVIATIONS

GUIDELINE 9

Guideline Development CommitteeSteering Committee

A/Prof Angela Morgan (Chair) Speech Pathologist, Murdoch Childrens Research Institute, Victoria

Dr Louise Cahill Speech Pathologist, Lady Cilento Children’s Hospital, Children’s Health Queensland Hospital & Health Service, Queensland

Dr Mary-Clare Waugh Rehabilitation Consultant, Children’s Hospital at Westmead, New South Wales

Professor Vicki Anderson Neuropsychologist, Murdoch Childrens Research Institute, Victoria

Project Coordinator

Dr Cristina Mei Speech Pathologist, Murdoch Childrens Research Institute, Victoria

Expert Working Committee

Ms Jeanette Baker Consumer, New South Wales

Dr Katie Banerjee Rehabilitation Consultant, Children’s Hospital at Westmead, New South Wales

Ms Mandy Beatson Speech Pathologist, Auckland District Health Board, New Zealand

Ms Candice Brady Speech Pathologist, Children’s Hospital at Westmead, New South Wales

Ms Kate Brommeyer Speech Pathologist, Royal Children’s Hospital, Victoria

Ms Petrea Cahir Speech Pathologist, Royal Children’s Hospital, Victoria

A/Prof Cathy Catroppa Psychologist, Murdoch Childrens Research Institute, Victoria

Ms Cynthia Christianto Speech Pathologist, Sydney Children’s Hospital, New South Wales

Ms Suzi Drevensek Speech Pathologist, Children’s Hospital at Westmead, New South Wales

Ms Donna Fallon Physiotherapist, Townsville Hospital, Queensland

Ms Jane Fong Speech Pathologist, Women’s and Children’s Hospital, South Australia

Dr Rob Forsyth Neurologist, Newcastle University, England

Mr Matthew Frith Speech Pathologist, Hunter New England Health, New South Wales

Ms Patricia Grillinzoni Consumer, Victoria

Ms Flora Haritou Speech Pathologist, Royal Children’s Hospital, Victoria

Ms Sophie Huntley Dietitian, Royal Children’s Hospital, Victoria

Ms Tamara Kelly Speech Pathologist, Novita Children’s Services, South Australia

Ms Kate Osland Speech Pathologist, Children’s Hospital at Westmead, New South Wales

Ms Jessica Palmer Speech Pathologist, Townsville Hospital, Queensland

Ms Claire Radford Speech Pathologist, Lady Cilento Children’s Hospital, Queensland

Mr Damien Roberts Speech Pathologist, Royal Children’s Hospital, Victoria

A/Prof Adam Scheinberg Paediatric Rehabilitation Specialist, Statewide Medical Director, Victorian Paediatric Rehabilitation Service, Victoria

Ms Jillian Steadall Speech Pathologist, Royal Children’s Hospital, Victoria


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Plain English Summary

Traumatic brain injury (TBI) is a leading cause of disability, affecting approximately 7651 to 20082 per 100 000 Australian children each year. Its effects are vast and include speech, language and swallowing disorders. These disorders are more likely to affect children with moderate and severe TBI.

This guideline provides recommendations for the management of speech, language and swallowing disorders for children up to 18 years of age who are within the first year of recovery following moderate or severe TBI. The recommendations are primarily written for hospital and community-based healthcare professionals who work with children with TBI in the early or rehabilitative phases of recovery. The recommendations are summarised below:

• Children with a moderate or severe TBI should be assessed for speech, language and swallowing during the early phase of care (typically 0 to 2 weeks post injury). Regular monitoring should continue throughout inpatient hospital care and community rehabilitation.

• Speech pathologists and medical specialists and staff (e.g., doctors and nurses) are essential for the management of speech, language and swallowing disorders.

• When assessing a child, clinicians might take into consideration that TBI can affect multiple areas of speech, language and swallowing. A range of informal and formal measures may be used to assess each area.

• Speech, language and swallowing disorders should be managed using the most effective approach for the specific area of deficit.

• Treatment for speech, language and swallowing disorders should commence in the early (acute) stage of recovery once the patient is medically stable. In the early stages post-injury, priority may be given to swallowing and functional communication.

• Parents/caregivers and teachers should receive correct information about speech, language and swallowing that is specific to the child to support recovery.

• Information about factors that predict speech, language and swallowing disorders is limited. Factors that might be considered include extent, severity and site of injury, cranial nerve involvement, cognition, and ventilation period.

Executive Summary

This guideline provides evidence-based recommendations (EBRs) and consensus-based recommendations (CBRs) for the management of speech, language and swallowing disorders after paediatric TBI. The recommendations were developed by a multidisciplinary guideline development committee, represented by consumers and health experts in the field. The methods used to develop the guideline are detailed in section 1.8 of this document and in the Technical Report (available at www.mcri.edu.au/TBI-guideline). EBRs were developed based on a systematic review of the available evidence and CBRs were formulated based on the results of a Delphi survey completed by the guideline development committee. Recommendation types are defined in Table 1.

TABLE 1 Definitions of recommendations

Recommendation type Definition

Evidence-based recommendation

A recommendation developed following a systematic review of the evidence, with supporting references provided

Consensus-based recommendation

A recommendation developed in the absence of quality evidence or when the systematic review did not identify studies meeting the inclusion criteria for a clinical question. CBRs were formulated based on the results from a Delphi survey completed by the guideline development committee

GUIDELINE 11

Within this guideline, each EBR is supported by a list of references and an overall grade that reflects the strength of the evidence for the recommendation. The grades, ranging from A (highest) to D (lowest), were based on the National Health and Medical Research Council (NHMRC) grades for recommendations (Table 2).3

TABLE 2 NHMRC grades for recommendations

Grade Description

A Body of evidence can be trusted to guide practice

B Body of evidence can be trusted to guide practice in most situations

C Body of evidence provides some support for recommendation(s) but care should be taken in its application

D Body of evidence is weak and recommendation must be applied with caution

The developed recommendations are provided below for each clinical question addressed by this guideline. A summary is also available in the Short Form Guideline (available at www.mcri.edu.au/ TBI-guideline). The following is listed below for each recommendation: type of recommendation (CBR or EBR), NHMRC grade, and the section and page number of this document where more information about the recommendation can be found.

Clinical Question 1: What factors (e.g., injury or child related) predict the likelihood of developing a speech, language or swallowing disorder following a TBI compared to children with a TBI who do not develop these disorders or typically developing children?

Recommendation Type Grade Section Page

Prognostic data is limited to guide speech, language and swallowing disorders. The following variables may be considered by speech-language pathologists and medical specialists when determining prognosis:

• Extent and severity of brain damage (including size and site of lesion(s)) and other proxy measures e.g., Glasgow Coma Scale score, length of ventilation and intubation, loss of consciousness and length of post traumatic amnesia, brain surgery required post-injury, raised intracranial pressure

• Cause of TBI

• Cranial nerve involvement/palsy (speech and swallowing only)

• Presence of seizures or other co-morbid medical conditions (e.g., loss of hearing or smell)

• Extent of broader motor system involvement

• Additional physical/facial injuries (speech and swallowing only)

• Trajectory of recovery post-injury (i.e., rapid vs. slow recovery in early phases)

• Cognition (including visual and auditory system integrity, memory, attention, initiation, level of insight)

• Compliance to recommendations

• Age/developmental stage at injury and pre-morbid functioning

• Psychosocial support and pre-morbid family and social environment

CBR N/A 3 24

Language recommendations

Children with severe TBI show the poorest language outcomes (moderate to high risk of bias). We suggest that speech-language pathologists should screen and monitor children with severe TBI for language deficits (see clinical question 3 for timing of assessment).

EBR C 3 24

Variables specific to predicting language disorders include the extent of damage to key brain regions underpinning language function (e.g., left hemisphere, corpus callosum, arcuate fasciculus, inferior frontal and temporal regions) and the presence of mutism.

CBR N/A 3 24




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Speech recommendations

Variables specific to predicting speech disorders include the extent of damage to key brain regions underpinning speech/motor function (e.g., supplementary motor area, motor cortex, corticobulbar/corticospinal tract) and presence of mutism. Research shows left posterior limb of the internal capsule injury predicts poorer chronic speech outcome.

CBR N/A 3 24

Swallowing recommendations

The evidence suggests that the presence of dysphagia is associated with severe TBI and a longer ventilation period (>1.5 days) (low to moderate risk of bias). Evidence also suggests that children with dysphagia have a longer hospitalisation period and are more likely to have motor impairments than controls (low risk of bias). In addition, the resolution of dysphagia is correlated with the resolution of cognitive functioning and oral motor impairment (moderate risk of bias). We suggest that children with severe TBI and a ventilation period of greater than 1.5 days be screened by a speech-language pathologist for swallowing deficits (see clinical question 3 for timing of assessment).

EBR D 3 24

Variables specific to predicting swallowing disorders include the extent of damage to key brain regions underpinning swallowing function (e.g., brainstem, primary motor and sensory cortices). Research has shown that a Glasgow Coma Scale score of <8.5 and ventilation period of >1.5 days predicts the presence of dysphagia.

CBR N/A 3 24

Clinical Question 2: Which health professionals (medical and allied health) should be involved in assessment and treatment of speech, language and swallowing disorders, and at what time/stage during recovery should a referral be made to each professional group, compared to routine clinical care, to improve children’s outcomes?


Speech-language pathologists and medical specialists and staff (e.g., doctors and nurses) are essential for the management of speech, language and swallowing disorders, and should be referred during the acute stage. Children with a moderate or severe TBI should be referred by a medical or health professional to a speech-language pathologist during the acute phase (0 to 2 weeks) as per clinical question 3.

CBR N/A 4 27

Other health professionals that are important depending on the child’s presentation and referral include:

• Neuropsychologist or psychologist (referred by a medical or health specialist once patient is medically stable)

• Occupational therapist (referred by a medical or health specialist from acute only if indicated)

• Physiotherapist (referred by a medical or health specialist from acute only if indicated)

• Ear, nose and throat specialist (referred by a medical or health specialist only if indicated for swallowing or speech patients post-extubation)

• Dietitian (referred by a medical or health specialist only if indicated for swallowing patients or weight management)

• Radiologist (referred by a speech-language pathologist only if indicated for swallowing patients e.g., videofluoroscopy)

• Music therapist (referred by a medical or health specialist from acute only if indicated).

CBR N/A 4 27

GUIDELINE 13

Clinical Question 3: At what time and/or stage (e.g., intensive care, acute care vs pre- and post-discharge) during the first year of recovery should children at risk of speech, language and swallowing disorders be assessed for these impairments to improve children’s outcomes in speech, language and swallowing?


Children with a moderate or severe traumatic brain injury should be assessed by a speech-language pathologist for speech, language and swallowing during the acute phase of care (typically 0 to 2 weeks). Regular monitoring (i.e., on referral and transfer to rehabilitation, and prior to discharge) should continue throughout inpatient and community rehabilitation.

CBR N/A 5 28

For language, an informal assessment should occur by a speech-language pathologist (SLP) within the first 2 days of admission or once the child is alert and medically stable, to track recovery and assist in therapy planning. Children should then be monitored by a SLP at least weekly for informal language performance.

CBR N/A 5 28

For speech, children should be screened by a speech-language pathologist (SLP) within the first 2 days of admission or once the child is alert and medically stable, to track recovery and assist in therapy planning. Children should then be monitored by a SLP at key transition points (from paediatric intensive care unit to inpatient ward, from inpatient ward to day hospital/rehab, to outpatients).

CBR N/A 5 28

Speech-language pathologists (SLP) should not administer a standardised language assessment earlier than 6 to 8 weeks post emergence from post-traumatic amnesia. Speech and language assessment (where clinically indicated) should then occur at key transition points by a SLP (e.g., discharge from inpatient ward, hospital discharge back to the community). Speech and language review may be required at 3 to 6 months post-discharge, and then annually if deficits are ongoing. Formal language assessment is recommended prior to primary school, and then again before entry to high school, or when concerns are identified by the family or the rehabilitation team.

CBR N/A 5 28

For swallowing, an initial assessment by a speech-language pathologist (SLP) should occur within the first 2 days post-extubation and once the patient is alert and medically stable. If a swallowing disorder is present, the patient should then be monitored by a SLP at least weekly throughout the acute and inpatient rehabilitation phases and assessed on discharge. SLPs should then review the child as needed if there are persistent feeding difficulties on discharge (e.g., consider objective assessment on discharge and review again at 12 months depending on recovery).

CBR N/A 5 28

Clinical Question 4: What are the specific areas of speech, language and swallowing that should always be assessed in children with disorders in these areas during the first year following TBI (compared to children with TBI without these disorders) to enable an accurate diagnosis?


Language recommendations

When assessing a child, speech-language pathologists (SLPs) might take into consideration that TBI can affect multiple areas of language and cognitive abilities underpinning language. During the child’s initial assessment (0 to 2 weeks post-injury as per clinical question 3), we suggest that SLPs conduct a brief assessment into all areas of language in all children following moderate and severe TBI (i.e., semantics, syntax, morphology, phonology and pragmatics) including narrative and word finding skills.

EBR D 6 30


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Speech-language pathologists should assess the following areas of language via formal or informal assessment during the time frames specified under clinical question 3 or as applicable:

• Pre-verbal communication skills (depending on the patient’s age and level of functioning)

• Spoken and written expressive and receptive language including: − Discourse and narratives − Attention, memory, executive functioning − Impact on social skills and learning − Word finding ability

• Functional communication (e.g., conversational and social skills)

• Ability to use augmentative and alternative communication if necessary

• Patient’s insight into deficits where appropriate (after approximately 4 years of age)

CBR N/A 6 30

Speech recommendations

When assessing a child, speech-language pathologists (SLPs) might take into consideration that TBI can affect multiple areas of speech. During the child’s initial assessment (0 to 2 weeks post-injury as per clinical question 3), we suggest that SLPs conduct a brief assessment of all areas of speech in all children following moderate and severe TBI (i.e., articulation, oral motor function, respiration, resonance, prosody, phonation, fluency).

EBR D 6 30

Speech-language pathologists should assess the following areas of speech via formal or informal assessment during the time frames specified under clinical question 3 or as applicable:

• Speech sound development relative to peers (articulation and phonological ability)

• Voice disorder

• Motor speech (i.e., presence of dysarthria, apraxia of speech or stuttering, oral motor functioning)

• Overall intelligibility of speech

• Insight and self-monitoring where appropriate (after approximately 4 years of age)

CBR N/A 6 30

Swallowing recommendations

When assessing a child, speech-language pathologists (SLPs) might take into consideration that TBI can affect multiple areas of swallowing. During the child’s initial assessment (0 to 2 weeks post-injury as per clinical question 3), we suggest that SLPs assess core oral-pharyngeal phases of swallowing in all children following moderate and severe TBI (i.e., oral preparation, oral and pharyngeal).

EBR D 6 30

Speech-language pathologists should assess the following areas of swallowing via formal or informal assessment during the time frames specified under clinical question 3 or as applicable:

• Cognitive-behavioural (including medical state, level of alertness/fatigue, behaviour, self-monitoring/insight and pace of eating)

• Posture/positioning and tone

• Respiratory function

• Bulbar and oral motor assessment (feeding and non-feeding)

• Oral phase (particularly for effectiveness of oral transit)

• Pharyngeal phase (particularly for swallow initiation and signs of aspiration)

• Need for non-oral feeding

CBR N/A 6 30

GUIDELINE 15

Clinical Question 5: What assessment tools are available to accurately diagnose speech, language and swallowing disorders in the first year following TBI when compared against a reference standard or in the absence of a reference standard?


Speech-language pathologists may use a range of informal and formal measures to assess speech, language and swallowing. Assessment of dysarthria should include perceptual and (where appropriate and available to the centre) instrumental methods.

CBR N/A 7 34

Instrumental assessments of voice or swallowing disorder (including Fiberoptic Endoscopic Evaluation of Swallowing or videofluoroscopy) should be used if clinically indicated (e.g., signs of aspiration). Voice may also be assessed on Visi-Pitch or other similar systems.

CBR N/A 7 34

Outcome measures (including Australian Therapy Outcome Measures (AusTOMS), Dysphagia Management Staging Scale, Oropharyngeal Swallow Efficiency, Goal Attainment Scales) should be used to document speech, language and swallowing outcomes pre- and post-therapy.

CBR N/A 7 34


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Clinical Question 6: What are the effective treatment strategies and techniques to treat speech, language and swallowing disorders in the first year following TBI, and the particular deficits within each of these areas, compared to no treatment, to improve children’s speech, language and swallowing outcomes?


A number of guiding principles are key across management of speech, language and swallowing including: use it or lose it, use it and improve it, specificity, repetition matters, intensity matters, time matters, salience matters, age matters, transference, and interference (Kleim & Jones, 2008).4

CBR N/A 8 36

Language disorders should be managed by speech-language pathologists (see clinical question 7 for timing) using the most efficacious evidence-based approach for the specific area of deficit, some strategies may include:

• Pre-verbal/early communication − Language stimulation − Vocabulary intervention

• Spoken and written expressive and receptive language − Scaffolding techniques (including binary choices, prompting, cues, priming

(semantic, phonemic), sentence completion, visual supports/information, chunking information, errorless teaching)

− Semantic, syntactic programs (including semantic feature analysis, concept mapping)

− Word finding intervention (including confrontation naming) − Literacy intervention (including reading and writing, narratives, parsing

whole paragraphs, reading comprehension, use of iPads/laptops) − High level language skills

• Functional communication − Social skills training (e.g., Stop-think-do, Topic Talk) − Gesturing − Picture boards − Functional tasks

• Augmentative and alternative communication (e.g., communication board) if required

• Other − Cognitive therapy (can be delivered by a speech-language pathologist. Where

possible, this should occur in consultation with a psychologist) − Communication partner education and training − Education to school staff, teacher aide support − Medications indicated by medical staff (e.g., stimulants) to assist attention

and concentration

CBR N/A 8 36

Speech disorders should be managed by speech-language pathologists (see clinical question 7 for timing) using the most efficacious evidence-based approach for the specific area of deficit, some strategies may include:

• Articulation or phonological therapy (i.e., speech sound disorder therapy) if indicated

• Dysarthria or dyspraxia therapy (i.e., motor speech therapy) e.g., Lee Silverman Voice Treatment, Nuffield and compensatory strategies such as slow rate, over articulate, stress syllables

• Augmentative and alternative communication

• Activity and participation

• Communication partner education and training

CBR N/A 8 36

GUIDELINE 17


Swallowing disorders should be managed by speech-language pathologists (see clinical question 7 for timing) using the most efficacious evidence-based approach for the specific area of deficit, some strategies may include:

• Postural/positioning modifications

• Environmental set-up/supports

• Cognitive (managed by a speech pathologist with referral to other health professionals where warranted)

− Management of behaviour, impulsivity, fatigue, awareness/cognition − Pacing and timing strategies

• Oral preparatory phase − Oral motor stimulation and exercises, systematic desensitization, jaw

support, visual feedback for chewing − Modification of utensils/specialised feeding − Texture/consistency/food/fluid modification

• Oral phase − Verbal prompts (e.g., take smaller mouthfuls, multiple swallows to clear

residue) − Texture/consistency/food/fluid modification

• Pharyngeal phase − Texture/consistency/food/fluid modification, nil by mouth − Swallow maneuvers/postures (including head turn, chin tuck, multiple

swallows, supraglottic swallow, effortful swallow, mendelsohn maneuver, strong swallowing)

− Supplemental/alternate feeding options (e.g., nasogastric tube, gastrostomy) if indicated by relevant multidisciplinary team (e.g., dietitian, nurse, medical officer)

• Other − Parent/caregiver and staff education/training (e.g., around feeding

modifications or strategies)

CBR N/A 8 36

Clinical Question 7: What time and/or stage (acute vs rehabilitation) should treatment for speech, language and swallowing occur for children with impairments in these areas in the first year following TBI to improve their outcomes?


Speech-language pathologists should commence treatment for speech, language and swallowing disorders in the acute stage once the patient is medically stable. In the early stages post-injury, priority may be given to swallowing and functional communication.

CBR N/A 9 40

For speech and language disorders, treatment (i.e., cueing and educating families about interventions) can occur whilst the child is in post-traumatic amnesia (where appropriate). Formal treatment directed towards the child’s impairment should commence after the patient has emerged from post-traumatic amnesia. The patient should receive regular therapy from local services post-rehab discharge (if available).

CBR N/A 9 40

For swallowing disorders, treatment should occur post-extubation, when the patient is alert and able to manage their own secretions, and is responding appropriately to automatic movements. Treatment may commence with a tracheostomy in situ (if a child is chronically unable to manage their own secretions) with treatment focusing on tracheostomy management and education.

CBR N/A 9 40


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Clinical Question 8: What information about the management and prognosis of speech, language and swallowing disorders would parents benefit from during the first year of recovery compared to routine or no information to improve children’s speech, language and swallowing outcomes?


Speech-language pathologists and medical specialists should provide parents/caregivers and educators with accurate information tailored to the child to support their recovery. This information should be provided following the child’s initial assessment with a speech-language pathologist or as appropriate. Parents/caregivers would benefit from the following forms of information about speech, language and swallowing disorders during the first year of recovery:

• Explanation of aetiology and possible impacts for speech, language and swallowing (e.g., injury severity, impact of cognitive deficits, physiology for swallowing in regard to motor abilities) so family or teachers can understand the 'why' of what they see

• Define speech, language and swallowing as relevant, and explain the patient’s specific diagnoses and specific likely difficulties and what to expect over the coming year, including:

− Managing social isolation − Managing fatigue for speech, language and swallowing − Rate of recovery

• Impact on social skills and importance of socialising, play dates, thinking games, conversational scaffolding and practice, and encouraging development

• When to intervene and factors that help predict outcomes into the longer term (where known) including patient engagement in treatment

• Impact of monitoring and supporting

• How to be a supportive communication partner and how to monitor, seek help, and support and advocate for their child

• How to integrate back to school

CBR N/A 10 40

GUIDELINE 19

1. Introduction

1.1 Background

Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality.5 In Australia, the incidence of head injury is estimated at 7651 to 20082 per 100 000 children each year. TBI is a significant public health burden, often resulting in long-term consequences6 that include physical, cognitive, speech, language and swallowing impairments. The financial burden of TBI in Australia is considerable, with the lifetime cost per case estimated at $2.5 million for moderate TBI cases and $4.8 million for severe cases.7

This guideline focuses on the management of speech, language and swallowing disorders following paediatric TBI. The incidence of speech and swallowing disorders in all children admitted for TBI is relatively low (1.2% for speech8 and 3.8%8 to 5.3%9 for swallowing). However, comparison of speech and swallowing outcomes across TBI severity groups reveals that these disorders commonly affect children with moderate and severe TBI. For severe TBI, the reported incidence of these disorders is 68% to 76% for swallowing and 20% for speech.8,9 Incidence rates for moderate TBI are lower but still considerable: 15% (for swallowing) and 20% (for speech).8,9 Children with mild TBI are less likely to be affected, with swallowing disorders occurring in 1% of these cases.9 A similar pattern is seen in relation to language, with more severe head injuries associated with poorer language outcomes.10,11 Given that the incidence of these disorders is highest in children with more severe head injuries, recommendations within this guideline are specifically focused on children with moderate and severe TBI.

The effects of TBI on speech, language and swallowing can vary across individuals, necessitating the need for speech-language pathologists (SLPs) to screen each area for all patients referred. Comorbidity of speech, language and swallowing disorders is common8 and not unexpected given the similarities between the neural correlates of speech, language and swallowing. In regard to the sub-types of these disorders, TBI is associated with acquired motor speech disorders such as dysarthria,12 apraxia of speech8,13 and stuttering.14 Language can be affected in the domains of comprehension, expressive language and social communication.15,16 All oropharyngeal stages of swallowing can be impacted after TBI including oral preparatory, oral and pharyngeal.17 Disorders within any of these areas can be transitory or persistent, and can potentially have far-reaching effects on areas such as participation in daily activities, forming relationships, education, and nutrition/growth.

Assessment of speech and language is usually performed using standardised assessments, although this is dependent on a number of factors such as the child’s age and their level of functioning. Commonly used paediatric speech and language assessments typically do not contain normative data for TBI, impacting on their applicability for this population. This can lead to SLPs relying on informal measures.8 A survey of speech pathologists found that no Australian paediatric tertiary hospital or centre was currently using formalised evidence-based guidelines or protocols for the management of speech or swallowing.18 The current lack of communication and swallowing guidelines has critical impacts on the care of children following TBI. A lack of guidelines or clear referral pathways can potentially lead to inequality of care and less optimized outcomes.19,20

This guideline aims to ensure a standard, best-evidence approach to the clinical care of children with communication and swallowing disorders, leading to optimized health and well-being for all children following TBI. The guideline covers the following aspects of speech, language and swallowing:

• Speech: articulation, phonology, dysarthria, apraxia of speech, fluency

• Language: receptive and expressive language, social communication

• Swallowing: oral preparatory, oral and pharyngeal phases

1.2 Purpose

The purpose of this guideline is to improve the care of children with TBI by providing health professionals with evidence-based and consensus-based recommendations to assist assessment and treatment of speech, language and swallowing after paediatric TBI.


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1.3 Clinical need for this guideline

Whilst TBI can have a considerable and often long-term impact on a child’s communication and swallowing, recent evidence suggests that formalised evidence-based guidelines or protocols to manage speech and swallowing disorders are not being utilised within key Australian head injury centres.18 The absence of evidence-based guidelines to inform referral, assessment and treatment for TBI patients is likely a reflection of the limited research in these areas. Considering that up to one third of children with TBI have unmet or unrecognised physical, cognitive or socioemotional needs during the first year after injury,21 it is critical that SLPs have access to evidence-based (or consensus-based) guidelines to ensure equality of care across patients and to maximize children’s outcomes. The present guideline aims to address the lack of guidelines within the field.

1.4 Organisation

This guideline was developed and published by researchers at the Murdoch Childrens Research Institute in collaboration with Lady Cilento Children’s Hospital, The Children’s Hospital at Westmead, The Royal Children’s Hospital (Melbourne), Sydney Children’s Hospital, Auckland District Health Board, Townsville Hospital, Women’s and Children’s Hospital (Adelaide), Newcastle University (UK), Hunter New England Health, Novita Children’s Services, and the Victorian Paediatric Rehabilitation Service. Information regarding the Guideline Development Committee is available in section 1.8.1.

1.5 Clinical questions

The clinical questions addressed by this guideline are detailed in Table 3.

TABLE 3 Clinical questions

Clinical question Research question typea

In children (0 to 18 years of age) with TBI who are within the first year of recovery:

1. What factors (e.g., injury or child related) predict the likelihood of developing a speech, language or swallowing disorder following a TBI compared to children with a TBI who do not develop these disorders or typically developing children?

Prognosis

2. Which health professionals (medical and allied health) should be involved in assessment and treatment of speech, language and swallowing disorders, and at what time/stage during recovery should a referral be made to each professional group, compared to routine clinical care, to improve children’s outcomesb?

Intervention

3. At what time and/or stage (e.g., intensive care, acute care vs pre- and post-discharge) during the first year of recovery should children at risk of speech, language and swallowing disorders be assessed for these impairments to improve children’s outcomesb in speech, language and swallowing?

Aetiology

4. What are the specific areas of speech, language and swallowing that should always be assessed in children with disorders in these areas during the first year following TBI (compared to children with TBI without these disorders) to enable an accurate diagnosis?

Aetiology

5. What assessment tools are available to accurately diagnose speech, language and swallowing disorders in the first year following TBI when compared against a reference standard or in the absence of a reference standard?

Diagnosis

6. What are the effective treatment strategies and techniques to treat speech, language and swallowing disorders in the first year following TBI, and the particular deficits within each of these areas, compared to no treatment, to improve children’s speech, language and swallowing outcomesb?

Intervention

GUIDELINE 21

Clinical question Research question typea

7. What time and/or stage (acute vs rehabilitation) should treatment for speech, language and swallowing occur for children with impairments in these areas in the first year following TBI to improve their outcomesb?

Intervention

8. What information about the management and prognosis of speech, language and swallowing disorders would parents benefit from during the first year of recovery compared to routine or no information to improve children’s speech, language and swallowing outcomesb?

Intervention

a NHMRC evidence hierarchy3

b Speech intelligibility, expressive-receptive language, social communication, physiological swallowing function and the safe ingestion (i.e., without aspiration) of an age appropriate diet consistency.

1.6 Scope and intended users of this guideline

This guideline has been developed for the use of hospital and community-based healthcare professionals involved in the acute and rehabilitative management of speech, language and swallowing disorders in children after TBI. This specifically includes speech pathologists, doctors, nurses, and other relevant allied health specialists (e.g., physiotherapists, occupational therapists, psychologists, dietitians). The guideline is intended to be used by appropriately qualified health professionals to guide clinical management of communication and swallowing disorders.

1.7 Target population

The provided recommendations are intended to guide the assessment and treatment of children with moderate or severe TBI up to 18 years of age who are within the first year of recovery and who are either at risk for or are presenting with speech, language and/or swallowing disorders.

1.8 Methods used to develop this guideline

This guideline has been developed according to the processes outlined in the document Procedures and Requirements for Meeting the 2011 NHMRC Standard for Clinical Practice Guidelines.22 The methods used to develop this guideline are summarised below with further details available in the Technical Report.

1.8.1 Guideline Development Committee

A multidisciplinary guideline development committee was formed to develop the purpose, scope and content of the guideline. The committee consisted of health experts within the field and consumers (i.e., parents of a child who had sustained a TBI). Members of the guideline development committee are listed on page 9. Further information about the committee can be found in the Administrative Report (available at www.mcri.edu.au/TBI-guideline) including the role of the committee (section 1.3) and the processes used to select members (section 2.2).

1.8.2 Systematic review

A systematic review was conducted to identify studies relevant to the clinical questions to be addressed by the guideline. The methods used for the systematic review are described in the Technical Report (section 4). Studies were included in the review if they i) included children aged between 0 and 18 years with speech, language and/or swallowing disorders following TBI and who are within one year post-injury, ii) examined the assessment, diagnosis, treatment or prognosis of speech, language and swallowing disorders, and iii) were published after 1995.

The included studies were appraised for methodological quality and an NHMRC level of evidence3

was applied to each study (Technical Report, section 6). Where sufficient evidence was available, an evidence-based recommendation was formed by the steering committee. In the absence of sufficient evidence, expert opinion via a Delphi survey was used to inform the development of consensus-based recommendations.

Table 3 Clinical questions / continued



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1.8.3 Delphi survey

An online Delphi survey, consisting of three rounds, was used to obtain the expert views of members within the guideline development committee. The first round of the survey consisted of open-ended questions to identify the key areas of importance for each clinical question. Responses were used to develop statements. The second and third rounds of the survey involved the committee members rating the importance of each statement in order to reach a consensus regarding which statements would become a guideline recommendation. The methods of the Delphi survey are described in the Technical Report (section 5).

1.8.4 Developing evidence-based and consensus-based recommendations

Evidence-based recommendations were developed using the NHMRC evidence statement form (Technical Report, section 6). The form was used to assess the body of evidence for each clinical question. The body of evidence was evaluated according to the evidence base (e.g., number and quality of studies, level of evidence), consistency of results, clinical impact, generalizability and applicability. Where appropriate, an evidence-based recommendation was then made based on the available evidence. Recommendations were made final once all members of the steering committee reached a consensus.

Consensus-based recommendations were developed based on the results of the Delphi survey. Members were asked to rate the importance of each statement using the following scale: ‘absolutely essential’, ‘very important’, ‘moderately important’, ‘slightly important’, and ‘not at all important.’ A statement reached consensus and was included in the guideline as a recommendation if at least 80% of members rated it as ‘absolutely essential,’ ‘very important,’ or ‘moderately important.’

1.9 Public consultation

Public consultation for the draft guideline occurred between the 11th of May 2016 and the 9th of June 2016. The public consultation period was advertised in The Australian newspaper and via social media. Targeted submissions were also sought by sending email invitations to relevant professional and consumer organisations.

Six submissions were received. The steering committee reviewed all of the submissions and, where appropriate, revised the guideline accordingly. Further information regarding public consultation is available in the Administrative Report (section 3).

1.10 Independent peer-review

Methodological and clinical expert review of the final draft guideline was arranged by NHMRC.

1.11 Scheduled review of this guideline

This guideline will be reviewed no more than five years after the initial publication date.

1.12 Funding

The development, publication and dissemination of this guideline was fully funded by the National Health and Medical Research Council Centre of Research Excellence on Psychosocial Rehabilitation in Traumatic Brain Injury (#1023043). The funding body did not influence the content of the guideline.

GUIDELINE 23

2. Cultural considerations when managing communication and swallowing disorders

All culturally and linguistically diverse populations including Aboriginal and Torres Strait Islander cultures should have equitable access to appropriate information and services relating to speech, language and swallowing.23 A number of position papers have been developed to guide speech pathologists working with Aboriginal communities,23 culturally and linguistically diverse populations (within Australian,23 UK24 and US contexts25) and multilingual children with speech sound disorders.26 There are a number of factors that should be considered when managing communication and swallowing disorders in culturally and linguistically diverse populations including Aboriginal and Torres Strait Islander cultures. These are listed in Table 4.

TABLE 4 Factors to consider when managing speech, language and swallowing disorders in culturally and linguistically diverse populations

Case history

• Patterns of language used by the child and family

• Languages and dialects used at home, school and in the community

• Attitudes towards bilingualism and the use of English

• Age at which learning of each language began, and the context of learning

• Current and past literacy in all languages

Speech

• Phonemic or allophonic variations of the language spoken

• Knowledge of articulation disorder in the child’s language(s)

• Distinguish between an accent, dialect, phonological disorder and articulation disorder

• Understanding the typical norms within the cultural group

Language

• Characteristics of the child’s first language

• Patterns of development in the first language

• Typical patterns of bilingual language development

• The child’s proficiency in their first and second language

• Pre-morbid levels of proficiency in each language

• Typical language recovery following an acquired language disorder

• Standardised assessments may underestimate the communication abilities for speakers of Aboriginal English

• Communicative behaviours of Aboriginal children should be assessed in multiple contexts as the relationship between the child and communicative partner can impact on the child’s communicative behaviours

Swallowing

• Understanding of the specific cultural factors associated with eating, drinking and mealtimes

• Examples of culturally appropriate foods and fluids that the child can manage safely should be provided

• Culturally and linguistically appropriate verbal and written information should be provided to the family

• Use plain English information, translated materials and photos or pictures to support understanding

Adapted from Speech Pathology Australia23,27


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3. Clinical question 1: Predictors

3.1 Background

Understanding the predictors of a disorder is key to determining which cases are at most risk. As not all children who sustain a TBI will develop a speech, language or swallowing disorder, knowledge of the factors that predict these disorders is imperative to developing evidence-based referral protocols, which are currently lacking in the field.18 The below recommendations aim to support systematic referral of children presenting with a specific risk factor (e.g., severity of injury), to facilitate early diagnosis and reduce under-diagnosis of speech, language and swallowing disorders.

3.2 Recommendations

Recommendation Type

Prognostic data is limited to guide speech, language and swallowing disorders. The following variables may be considered by speech-language pathologists and medical specialists when determining prognosis:

• Extent and severity of brain damage (including size and site of lesion(s)) and other proxy measures e.g., Glasgow Coma Scale score, length of ventilation and intubation, loss of consciousness and length of post traumatic amnesia, brain surgery required post-injury, raised intracranial pressure

• Cause of TBI

• Cranial nerve involvement/palsy (speech and swallowing only)

• Presence of seizures or other co-morbid medical conditions (e.g., loss of hearing or smell)

• Extent of broader motor system involvement

• Additional physical/facial injuries (speech and swallowing only)

• Trajectory of recovery post-injury (i.e., rapid vs. slow recovery in early phases)

• Cognition (including visual and auditory system integrity, memory, attention, initiation, level of insight)

• Compliance to recommendations

• Age/developmental stage at injury and pre-morbid functioning

• Psychosocial support and pre-morbid family and social environment

CBR

In addition to the above consensus-based recommendation, variables specific to predicting each of language, speech and swallowing disorders are indicated below.

3.2.1 Language

Level I to IV evidence was identified to support an EBR for identifying predictors of language disorders following TBI.28-32 Due to the low quality of many of the studies, a CBR was also formulated.

Recommendation Type

Children with severe TBI show the poorest language outcomes (moderate to high risk of bias). We suggest that speech-language pathologists should screen and monitor children with severe TBI for language deficits (see clinical question 3 for timing of assessment).

EBR (Grade C)

Catroppa et al 200428

Chapman et al 200129

Kriel et al 199530

Ryan et al 201531

Vu et al 201132

Variables specific to predicting language disorders include the extent of damage to key brain regions underpinning language function (e.g., left hemisphere, corpus callosum, arcuate fasciculus, inferior frontal and temporal regions) and the presence of mutism.

CBR

GUIDELINE 25

3.2.2 Speech

There is currently insufficient published research to form an EBR on predictors of speech disorders following TBI. A CBR was formulated based on expert opinion.

Recommendation Type

Variables specific to predicting speech disorders include the extent of damage to key brain regions underpinning speech/motor function (e.g., supplementary motor area, motor cortex, corticobulbar/corticospinal tract) and presence of mutism. Research shows left posterior limb of the internal capsule injury predicts poorer chronic speech outcome.

CBR

3.2.3 Swallowing

Level II to IV evidence was identified to support an EBR for identifying predictors of swallowing disorders following TBI.8,9,33,34,35 Due to the quality of the studies, a CBR was also formulated.

Recommendation Type

The evidence suggests that the presence of dysphagia is associated with severe TBI and a longer ventilation period (>1.5 days) (low to moderate risk of bias). Evidence also suggests that children with dysphagia have a longer hospitalisation period and are more likely to have motor impairments than controls (low risk of bias). In addition, the resolution of dysphagia is correlated with the resolution of cognitive functioning and oral motor impairment (moderate risk of bias). We suggest that children with severe TBI and a ventilation period of greater than 1.5 days be screened by a speech-language pathologist for swallowing deficits (see clinical question 3 for timing of assessment).

EBR (Grade D)

Huang et al 201433

Morgan et al 20039

Morgan et al 2004b34

Morgan et al 20108

Rowe 199935

Variables specific to predicting swallowing disorders include the extent of damage to key brain regions underpinning swallowing function (e.g., brainstem, primary motor and sensory cortices). Research has shown that a Glasgow Coma Scale score of <8.5 and ventilation period of >1.5 days predicts the presence of dysphagia.

CBR

3.3 Summary of evidence

3.3.1 Language

Three prospective cohort studies,28,29,31 one cohort study,30 and one systematic review32 relevant to predictors of language disorders following TBI were identified (Table 5).

TABLE 5 Summary of evidence: predictors of language disorders

Evidence summary Level Reference

Prospective cohort study of 68 children consecutively admitted for mild to severe TBI. Examined factors associated with expressive language skills. During the acute stage, the poorest language outcomes were associated with severe TBI.

II Catroppa et al 200428

Prospective cohort study of 43 children consecutively admitted for mild to severe TBI. Examined factors associated with discourse skills. Poorer discourse ability was associated with severe TBI.

II Chapman et al 200129

Cohort study of 30 children unconscious for 90 days post-TBI (selected from consecutive admissions). Examined factors associated with the recovery of language. Children with a closed head injury were more likely to regain language skills and were the only group to regain higher-level language skills.

IV Kriel et al 199530


26


Prospective cohort study of 112 children consecutively admitted for mild to severe TBI. Examined factors associated with pragmatic language function at 6 months post-TBI. Children with mild, moderate and severe TBI demonstrated significantly poorer pragmatic skills compared to controls. Reduced pragmatic skills at 6 months post-TBI was significantly associated with corpus callosum lesions and frequent rule-breaking behaviour at 24 months post-TBI.

II Ryan et al 201531

Systematic review of Level II to IV studies examining the academic and language outcomes of children and adolescents with mild to severe TBI. Whilst the characteristics of participants in each of the included studies was not reported, authors found that children with severe TBI showed the greatest impairment in language compared to those with moderate and mild TBI.

I Vu et al 201132

The body of evidence supported that children with severe TBI show the poorest language outcomes. The full details of the evidence reviewed on the predictors of language disorders are provided in the Technical Report (Table 1B.1). Due to the low quality of many of the studies, the committee considered the body of evidence in conjunction with expert opinion when formulating recommendations.

3.3.2 Speech

One prospective cohort study36 and two retrospective cohort studies8,37 relevant to predictors of speech disorders following TBI were identified (Table 6).

TABLE 6 Summary of evidence: predictors of speech disorders


Prospective cohort study of 56 children with severe TBI. Examined predictors of consonant accuracy (Percentage of Consonants Correct – Revised, PCC-R). Only age at injury significantly correlated with PCC–R scores.

II Campbell et al 201336

Retrospective cohort study of 7 children with severe TBI and post-traumatic mutism. Predictors of post-traumatic mutism were: cranial nerve III paresis, signs of autonomic dysfunctions, and direct or indirect signs of mesencephalic lesions on brain imaging. The duration of mutism was associated with the duration of coma (i.e., a shorter coma duration was associated with a shorter phase of mutism).

III-3 Dayer et al 199837

Retrospective cohort study of 22 children with dysarthria consecutively admitted with TBI. Examined predictors of dysarthria during the acute phase. Compared to controls, more children with dysarthria sustained a motor vehicle accident, had abnormal brain imaging results, and had severe TBI. Dysarthria cases had significantly longer durations of hospitalization, ventilation and supplementary feeding, and were significantly more likely to have a motor impairment.

III-3 Morgan et al 20108

The body of evidence suggests that children with dysarthria have significantly longer durations of hospitalisation and ventilation, and that they are significantly more likely to have a motor impairment compared to controls. Further, age at injury (i.e., severe TBI at less than 60 months of age) was associated with reduced consonant accuracy. The steering committee agreed that there was insufficient available evidence to formulate an EBR. CBRs were formulated based on expert opinion. The full details of the evidence reviewed on the predictors of speech disorders are provided in the Technical Report (Table 1B.2).

3.3.3 Swallowing

One prospective cohort study,34 three retrospective cohort studies8,9,33 and one retrospective case series35 relevant to predictors of swallowing disorders following TBI were identified (Table 7).

TABLE 5 Summary of evidence: predictors of language disorders / continued

GUIDELINE 27

TABLE 7 Summary of evidence: predictors of swallowing disorders


A retrospective cohort study of 6290 children who underwent brain surgery during admission for TBI. Reported that 12.3% of children had severe dysphagia post-brain surgery. Severe dysphagia was associated with a younger mean age and a higher prevalence of ICU admission and length of stay. Severe dysphagia was not associated with gender or motor vehicle accidents.

III-3 Huang et al 201433

A retrospective cohort study of 1145 children consecutively admitted for TBI. Examined factors associated with the presence of dysphagia during the acute period. The strongest predictors were a GCS <8.5 and a ventilation period of >1.5 days.


A prospective cohort study of 13 children with moderate-severe TBI. Examined association between the resolution of dysphagia, cognition and oral motor functioning. High correlation between the resolution of cognitive functioning, oral motor functioning and swallowing impairment.

II Morgan et al 2004b34

A retrospective cohort study of 72 children with dysphagia consecutively admitted with TBI (mild-severe). Examined factors associated with the presence of dysphagia during the acute period. Compared to controls, more children with dysphagia sustained a motor vehicle accident and had abnormal CT/MRI results. Dysphagia cases had significantly longer durations of hospitalization, ventilation and supplementary feeding, and were significantly more likely to have severe TBI and motor impairment.


A retrospective case series of 5 children with mild to severe TBI. Reported factors associated with the presence and resolution of dysphagia. Factors associated with the presence of dysphagia: brainstem injury, diffuse axonal injury, subdural hemorrhages, and secondary mechanisms (e.g., oedema, seizures). Recovery of dysphagia reportedly poorer for children with subdural haemorrhages, cerebral oedemas and cranial nerve tear.

IV Rowe 199935

The body of evidence suggests that the presence of dysphagia is associated with severe TBI and a longer ventilation period (>1.5 days). In addition, children with dysphagia have a longer hospitalisation period and are more likely to have motor impairments than controls. The full details of the evidence reviewed on the predictors of swallowing disorders are provided in the Technical Report (Table 1B.3). Due to the low quality of many of the studies, the committee considered the body of evidence in conjunction with expert opinion when formulating recommendations.

4. Clinical question 2: Health professionals

4.1 Background

Speech pathologists frequently manage speech, language and swallowing disorders within a multidisciplinary team that includes doctors, nurses and allied health professionals. Depending on the child’s presentation, further health professionals (e.g., physiotherapist, occupational therapist, neuropsychologist, dietitian) may assist in the management of these disorders. For example, an occupational therapist may assist in positioning during mealtimes and a neuropsychologist may assist in cognitive processes that support language. As speech, language and swallowing disorders are often associated with other impairments (e.g., motor, cognitive) a multidisciplinary team is imperative to adequately address the child’s presenting needs.

4.2 Recommendations

There is currently insufficient published research to form an EBR on which health professionals should be involved in the management of speech, language and swallowing disorders following TBI. CBRs were


28

formulated based on expert opinion. The below recommendations intend to support multidisciplinary management of speech, language and swallowing following TBI.

Recommendation Type

Speech-language pathologists and medical specialists and staff (e.g., doctors and nurses) are essential for the management of speech, language and swallowing disorders, and should be referred during the acute stage. Children with a moderate or severe TBI should be referred by a medical or health professional to a speech-language pathologist during the acute phase (0 to 2 weeks) as per clinical question 3.

CBR

Other health professionals that are important depending on the child’s presentation and referral include:

• Neuropsychologist or psychologist (referred by a medical or health specialist once patient is medically stable)

• Occupational therapist (referred by a medical or health specialist from acute only if indicated)

• Physiotherapist (referred by a medical or health specialist from acute only if indicated)

• Ear, nose and throat specialist (referred by a medical or health specialist only if indicated for swallowing or speech patients post-extubation)

• Dietitian (referred by a medical or health specialist only if indicated for swallowing patients or weight management)

• Radiologist (referred by a speech-language pathologist only if indicated for swallowing patients e.g., videofluoroscopy)

• Music therapist (referred by a medical or health specialist from acute only if indicated).

CBR


No empirical evidence was found to guide which health professionals should be involved in the management of speech, language and swallowing disorders (see Technical Report, Table 2A). CBRs were formulated based on expert opinion.

5. Clinical question 3: Timing of assessment

5.1 Background

Speech-language pathologists (SLPs) typically assess patients with TBI following referral from medical or nursing staff. A referral is most often made when a disorder is suspected, rather than through routine referral protocols.18 A number of factors are taken into consideration by SLPs when determining the most appropriate timing of a speech, language and swallowing assessment. Factors include the child’s level of alertness and medical stability, the presence of post-traumatic amnesia, and the child’s ability to manage their own secretions. Care pathways are not commonly used by SLPs when managing children with ABI,18 which can potentially cause disparities in the timing of speech, language and swallowing assessments both within and across centres. This has the potential to result in inequality of care and sub-optimal outcomes for the child. The below recommendations aim to ensure that children are initially seen in a timely manner and that appropriate follow-up and monitoring is provided where required.

5.2 Recommendations

There is currently insufficient published research to form an evidence-based recommendation (EBR) on when children should be assessed following TBI. Consensus-based recommendations (CBR) were formulated based on expert opinion.

GUIDELINE 29

Recommendation Type

Children with a moderate or severe traumatic brain injury should be assessed by a speech-language pathologist for speech, language and swallowing during the acute phase of care (typically 0 to 2 weeks). Regular monitoring (i.e., on referral and transfer to rehabilitation, and prior to discharge) should continue throughout inpatient and community rehabilitation.

CBR

For language, an informal assessment should occur by a speech-language pathologist (SLP) within the first 2 days of admission or once the child is alert and medically stable, to track recovery and assist in therapy planning. Children should then be monitored by a SLP at least weekly for informal language performance.

CBR

For speech, children should be screened by a speech-language pathologist (SLP) within the first 2 days of admission or once the child is alert and medically stable, to track recovery and assist in therapy planning. Children should then be monitored by a SLP at key transition points (from paediatric intensive care unit to inpatient ward, from inpatient ward to day hospital/rehab, to outpatients).

CBR

Speech-language pathologists (SLP) should not administer a standardised language assessment earlier than 6 to 8 weeks post emergence from post-traumatic amnesia. Speech and language assessment (where clinically indicated) should then occur at key transition points by a SLP (e.g., discharge from inpatient ward, hospital discharge back to the community). Speech and language review may be required at 3 to 6 months post-discharge, and then annually if deficits are ongoing. Formal language assessment is recommended prior to primary school, and then again before entry to high school, or when concerns are identified by the family or the rehabilitation team.

CBR

For swallowing, an initial assessment by a speech-language pathologist (SLP) should occur within the first 2 days post-extubation and once the patient is alert and medically stable. If a swallowing disorder is present, the patient should then be monitored by a SLP at least weekly throughout the acute and inpatient rehabilitation phases and assessed on discharge. SLPs should then review the child as needed if there are persistent feeding difficulties on discharge (e.g., consider objective assessment on discharge and review again at 12 months depending on recovery).

CBR


One retrospective cohort study38 relevant to timing of speech and swallowing assessment following TBI was identified (Table 8).

TABLE 8 Summary of evidence: timing of assessment


Retrospective cohort study of 21,399 children with at least a serious TBI. Median time until the first speech therapy evaluation (for speech or swallowing) was 7 days (interquartile range: 4-13).

III-2 Bennett et al 201338

Other available evidence reviewed by the steering committee were:

• A prospective cohort study that found that dysphagia resolved by three months following moderate or severe TBI, suggesting the need to prioritise patients for early swallowing assessment followed by continual monitoring and intervention for at least three months post-injury.34

• A retrospective case series that provided anecdotal evidence that children with diffuse axonal injuries benefit from one or two extra days to improve level of alertness to ensure assessment results are valid and reliable.35

The full details of the evidence reviewed are provided in the Technical Report (Table 3B).

The steering committee agreed that there was insufficient available evidence to formulate an EBR on the time frames children with TBI should be assessed for speech, language and swallowing. CBRs were formulated based on expert opinion.


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6. Clinical question 4: Areas to assess

6.1 Background

Speech, language and swallowing are each comprised of various sub-components that require assessment in order for SLPs to accurately diagnose speech, language and swallowing disorders. This is essential for developing targeted intervention programs that address a child’s specific area(s) of need. TBI can affect a child’s speech, language and swallowing functioning on a number of different levels including:

• Speech: oral motor function, articulation, resonance, phonation, respiration, and prosody. Specific deficits including reduced tongue and lip function, imprecise consonants and vowels, hypernasality, and reduced speech rate.12,39,40

• Language: pragmatics, phonology, morphology, syntax, and semantics in the modes of spoken, auditory and written language. Specific deficits include reduced lexical diversity, word finding difficulties, and poor social communication.15,41

• Swallowing: oral preparatory, oral and pharyngeal phases with specific deficits including poor lip, tongue and jaw function, delayed oral transit time and aspiration.42

It is important that SLPs working with children with TBI are aware of the various areas of speech, language and swallowing that are likely to be impacted to facilitate assessment, diagnosis and treatment. The provided recommendations are to be used as a guide for areas to assess in order to inform accurate diagnosis and the implementation of targeted interventions.

6.2 Recommendations

6.2.1 Language

Level II to IV evidence was identified to support an EBR for areas of language to assess following TBI.31,43-46 Due to the low quality of many of the studies, CBRs were also formulated.

Recommendation Type

When assessing a child, speech-language pathologists (SLPs) might take into consideration that TBI can affect multiple areas of language and cognitive abilities underpinning language. During the child’s initial assessment (0 to 2 weeks post-injury as per clinical question 3), we suggest that SLPs conduct a brief assessment into all areas of language in all children following moderate and severe TBI (i.e., semantics, syntax, morphology, phonology and pragmatics) including narrative and word finding skills.

EBR (Grade D)

Morse et al 199943

Recla et al 201344

Ryan et al 201531

Trudeau et al 200045

Yeates et al 200446

Speech-language pathologists should assess the following areas of language via formal or informal assessment during the time frames specified under clinical question 3 or as applicable:

• Pre-verbal communication skills (depending on the patient’s age and level of functioning)

• Spoken and written expressive and receptive language including: − Discourse and narratives − Attention, memory, executive functioning − Impact on social skills and learning − Word finding ability

• Functional communication (e.g., conversational and social skills)

• Ability to use augmentative and alternative communication if necessary

• Patient’s insight into deficits where appropriate (after approximately 4 years of age)

CBR

GUIDELINE 31

6.2.2 Speech

Level II to IV evidence was identified to support an EBR for areas of speech to assess following TBI.36,37,39,40,47,48 Due to the low quality of many of the studies, CBRs were also formulated.

Recommendation Type

When assessing a child, speech-language pathologists (SLPs) might take into consideration that TBI can affect multiple areas of speech. During the child’s initial assessment (0 to 2 weeks post-injury as per clinical question 3), we suggest that SLPs conduct a brief assessment of all areas of speech in all children following moderate and severe TBI (i.e., articulation, oral motor function, respiration, resonance, prosody, phonation, fluency).

EBR (Grade D)

Cahill et al 200039

Campbell et al 199547

Campbell et al 201336

Dayer et al 199837

Theodoros et al 199840

Van Borsel et al 200148

Speech-language pathologists should assess the following areas of speech via formal or informal assessment during the time frames specified under clinical question 3 or as applicable:

• Speech sound development relative to peers (articulation and phonological ability)

• Voice disorder

• Motor speech (i.e., presence of dysarthria, apraxia of speech or stuttering, oral motor functioning)

• Overall intelligibility of speech

• Insight and self-monitoring where appropriate (after approximately 4 years of age)

CBR

6.2.3 Swallowing

Level II to IV evidence was identified to support an EBR for areas of swallowing to assess following TBI.17,34,35,42,49,50 Due to the low quality of many of the studies, CBRs were also formulated.

Recommendation Type

When assessing a child, speech-language pathologists (SLPs) might take into consideration that TBI can affect multiple areas of swallowing. During the child’s initial assessment (0 to 2 weeks post-injury as per clinical question 3), we suggest that SLPs assess core oral-pharyngeal phases of swallowing in all children following moderate and severe TBI (i.e., oral preparation, oral and pharyngeal).

EBR (Grade D)

Morgan et al 200149

Morgan et al 200250

Morgan et al 2004bc17,34

Morgan et al 200542

Rowe 199935

Speech-language pathologists should assess the following areas of swallowing via formal or informal assessment during the time frames specified under clinical question 3 or as applicable:

• Cognitive-behavioural (including medical state, level of alertness/fatigue, behaviour, self-monitoring/insight and pace of eating)

• Posture/positioning and tone

• Respiratory function

• Bulbar and oral motor assessment (feeding and non-feeding)

• Oral phase (particularly for effectiveness of oral transit)

• Pharyngeal phase (particularly for swallow initiation and signs of aspiration)

• Need for non-oral feeding

CBR


32


6.3.1 Language

Two prospective cohort studies,31,46 one case-control study45 and two cross-sectional studies43,44 relevant to areas of language affected by TBI were identified (Table 9).

TABLE 9 Summary of evidence: areas of language to assess


Cross-sectional study of 15 children with mild to severe TBI. Concluded linguistic analyses (particularly syntactic) were useful in understanding nature of language impairment after TBI and revealed differences in language performance across TBI severity ratings (mild, moderate and severe).

IV Morse et al 199943

Cross-sectional study of 118 children with severe TBI. Examined verbal and non-verbal IQ. Participants with severe language impairment typically also had moderately impaired cognitive functioning.

IV Recla et al 201344

Prospective cohort study of 112 children consecutively admitted for mild to severe TBI. Examined pragmatic language abilities at 6 and 24 months post-TBI. At 6 months post-TBI, subjects aged 5-9 and 12-15 years showed significantly poorer pragmatic skills than controls, while subjects aged 10-11 years showed comparable pragmatic abilities to controls.

II Ryan et al 201531

Single case-control study of a 17-month old child with severe TBI. Recovery of vocabulary was fast and complete by four months post-injury, although authors recommended that long-term follow-up post-TBI is still warranted.

IV Trudeau et al 200045

Prospective cohort study of 109 children with severe or moderate TBI. Data showed social outcomes were negatively impacted by TBI particularly in children with severe TBI.

II Yeates et al 200446

The body of evidence supported that multiple areas of language warrant assessment following TBI. The quality of the available evidence did not enable the formulation of a strong EBR. The full details of the evidence reviewed on areas of language to assess are provided in the Technical Report (Table 4B.1). Due to the low quality of a number of studies, the committee considered the body of evidence in conjunction with expert opinion when formulating recommendations.

6.3.2 Speech

Two prospective cohort studies,36,47 two case-control studies39,40 and two case series37,48 relevant to areas of speech affected by TBI were identified (Table 10).

TABLE 10 Summary of evidence: areas of speech to assess


Case-control study of 3 individuals (only 1 child with severe TBI met the inclusion criteria for this review). Reported sub-clinical deficits across oral motor, articulation, resonance, phonation, respiration and speaking rate.

III-3 Cahill et al 200039

Prospective cohort study of 9 children with severe TBI. Found children with TBI had significantly slowed speaking rates compared to controls.


Prospective cohort study of 56 children with severe TBI. Examined longitudinal changes in Percentage of Consonants Correct – Revised (PCC-R). PCC–R scores varied within and between children, with no significant linear trend over time.


Retrospective case series of 7 children with severe TBI and post-traumatic mutism. Reported recovery of speech following a period of mutism (5 to 94 days) was characterised by a hypophonic and monotonous voice (during the first few days) and moderate dysarthria, followed by rapidly improving rate and spontaneity of speech.

IV Dayer et al 199837

GUIDELINE 33


Case-control study of a child with severe TBI. Found dysarthria was characterised by deficits in oral motor, articulation, resonance, phonation, respiration and prosody.

III-3 Theodoros et al 199840

Case series of 2 individuals (one child with TBI and palilalia, a speech disorder involving repetition of words, phrases or sentences, met the inclusion criteria for this review). Noted that repetition of syllables was relatively common, occurring predominately at the beginning of words and on function words.

IV Van Borsel et al 200148

The body of evidence supported that multiple areas of speech warrant assessment following TBI. The quality of the available evidence did not enable the formulation of a strong EBR. The full details of the evidence reviewed on areas of speech to assess are provided in the Technical Report (Table 4B.2). Due to the low quality of many of the studies, the committee considered the body of evidence in conjunction with expert opinion when formulating recommendations.

6.3.3 Swallowing

Two prospective cohort studies,34,42 two cross-sectional studies17,50 and two case series35,49 relevant to areas of swallowing affected by TBI were identified (Table 11).

TABLE 11 Summary of evidence: areas of swallowing to assess


Case series of 3 children with severe TBI. All cases had impaired oral preparation, oral and pharyngeal phases.

IV Morgan et al 200149

Cross-sectional study of 18 children with moderate or severe TBI. Reported oral and pharyngeal phase impairments. Specific deficits included reduced lingual control, hesitancy of tongue movement, tongue pumping, presence of aspiration (including silent), delayed swallow reflex, reduced laryngeal elevation and closure, and reduced peristalsis.

IV Morgan et al 200250

Prospective cohort study of 13 children with moderate or severe TBI. In the first week post-TBI, moderate or mild–moderate oral motor impairments were noted as well as severe dysphagia in the majority. Resolution of oral motor and swallowing impairment and return to oral intake achieved in less than 11 weeks post-initial clinical bedside examination for all.

II Morgan et al 2004b34

Cross-sectional study of 14 children with moderate or severe TBI. Oral preparatory, oral and pharyngeal stage deficits reported. Deficits included impaired cognition, altered behavior related to feeding, severe tonal and postural deficits, oral motor, respiratory and laryngeal impairments, and oral sensitivity issues. Swallowing was characterised by reduced lip function (impaired lip seal), poor jaw stability, reduced tongue movement, labored/inefficient chewing, delayed oral transit time, coughing during/after swallowing, and reduced laryngeal elevation.

IV Morgan et al 2004c17

Prospective cohort study of 7 children with moderate to severe TBI. Impairments noted across the oral preparatory, oral and pharyngeal swallowing phases. Acute deficits include tongue extension-retraction, impaired bolus formation/chewing, anterior spillage, tongue pumping, impaired oral transit, premature spillage, oral residue, multiple swallows, delayed oral transit time and reflex swallow, hesitancy, impaired lingual-palate contact, vallecular and pyriform residue, laryngeal penetration, pharyngeal transit delay, reduced peristalsis and laryngeal elevation, aspiration, and pharyngeal lodging.

II Morgan et al 200542

Retrospective case series of 5 children following mild-moderate and severe TBI. Impairments noted across the oral preparatory, oral and pharyngeal phases of swallowing. Reported deficits include decreased oral movements, abnormal tone of the oral musculature, poor bolus control, delayed swallow initiation, decreased tongue-palate seal, nasal-pharyngeal reflux, premature entry into valleculae and pyriform sinuses, laryngeal penetration, aspiration, and pharyngeal residue.

IV Rowe 199935

TABLE 10 Summary of evidence: areas of speech to assess / continued


34

The body of evidence supported that multiple areas of swallowing warrant assessment following TBI. The quality of the available evidence did not enable the formulation of a strong EBR. The full details of the evidence reviewed on areas of swallowing to assess are provided in the Technical Report (Table 4B.3). Due to the low quality of many of the studies, the committee considered the body of evidence in conjunction with expert opinion when formulating recommendations.

7. Clinical question 5: Assessment tools

7.1 Background

The diagnosis of speech, language and swallowing disorders requires the use of assessment tools that are sensitive to detecting deficits associated with TBI. This can be problematic particularly for when detecting language or cognitive-communication disorders since commonly used assessments are not specifically designed for individuals with TBI.51,52 Non-standardised assessment approaches often provide an opportunity to detect deficits during informal activities that would otherwise be missed during a structured standardised language assessment.53 Informal measures are also commonly used to assess speech following brain injury, a reflection of the current lack of standardised assessments for children with acquired motor speech disorders.18 Similarly, swallowing function is also regularly assessed informally, with instrumental methods used where indicated.18,54 Systematic assessment of speech, language and swallowing functions within rehabilitation centres are lacking,18 potentially leading to under-diagnosis of these disorders. The below recommendations aim to guide the assessment of speech, language and swallowing to facilitate accurate diagnosis.

7.2 Recommendations

There is currently insufficient published research to form an EBR on which assessment tools should be used to assess speech, language and swallowing functions following TBI. CBRs were formulated based on expert opinion.

Recommendation Type

Speech-language pathologists may use a range of informal and formal measures to assess speech, language and swallowing. Assessment of dysarthria should include perceptual and (where appropriate and available to the centre) instrumental methods.

CBR

Instrumental assessments of voice or swallowing disorder (including Fiberoptic Endoscopic Evaluation of Swallowing or videofluoroscopy) should be used if clinically indicated (e.g., signs of aspiration). Voice may also be assessed on Visi-Pitch or other similar systems.

CBR

Outcome measures (including Australian Therapy Outcome Measures (AusTOMS), Dysphagia Management Staging Scale, Oropharyngeal Swallow Efficiency, Goal Attainment Scales) should be used to document speech, language and swallowing outcomes pre- and post-therapy.

CBR


7.3.1 Language

Three diagnostic case-control studies55,57,59 and two studies of diagnostic yield (no reference standard)56,58 relevant to language assessments for children following TBI were identified (Table 12).

GUIDELINE 35

TABLE 12 Summary of evidence: language assessments


Diagnostic case-control study involving 19 adolescents with severe TBI. Examined use of the La Trobe Communication Questionnaire (LCQ) following discharge from inpatient rehabilitation. Compared to controls, adolescents with TBI had a higher frequency of social communication difficulties. Concluded that the LCQ has potential to contribute to the assessment of social communication in adolescents with TBI.

III-3 Douglas 201055

Study of diagnostic yield (no reference standard) involving 8 children with severe ABI. Examined use of the Pragmatic Protocol. Participants had a relatively high number of inappropriate pragmatic behaviours. Concluded that the Pragmatic Protocol is useful for identifying aspects of communication competence in need of further detailed exploration.

IV Fyrberg et al 200756

Diagnostic case-control study involving 16 children with moderate or severe TBI. Examined the utility of the Awareness of Social Inference Test (TASIT) for assessing social cognition. Adolescents with TBI performed more poorly (compared to typically developing peers) on tasks requiring interpretation of sarcastic and sincere conversational exchanges with few cues. Concluded that the TASIT is a valid measure of pragmatic comprehension and social cognition for adolescents with TBI.

III-3 McDonald et al 201357

Study of diagnostic yield (no reference standard) involving 100 children consecutively admitted for TBI or ABI. Explored the psychometric properties of the Cognitive and Linguistic Scale (CALS), a measure of cognitive and linguistic functions. The CALS demonstrated adequate reliability and validity, and was sensitive to recovery in functioning during the inpatient rehabilitation period. Concluded that the CALS is a promising measure for tracking linguistic and cognitive recovery.

IV Slomine et al 200858

Diagnostic case-control study involving 3 adolescents with severe TBI. Examined pragmatic function using four tasks developed by the authors. One child performed poorer than controls although this did not reach significance. The authors concluded that the test may capture aspects of pragmatics that are not reflected in standard academic and intellectual testing.

III-3 Turkstra et al 199659

The steering committee agreed that there was insufficient available evidence to formulate an EBR on which assessment tools should be used to assess language functioning following TBI. The full details of the evidence reviewed on assessments of language are provided in the Technical Report (Table 5B.1). CBRs were formulated based on expert opinion.

7.3.2 Speech

No Level I to IV evidence was found examining the accuracy of diagnostic speech assessments (see the Technical Report, Table 5A). Other available evidence reviewed by the steering committee were:

• Recommendations reported by a paediatric TBI outcomes workgroup on core speech outcome measures for TBI research.60

• A survey study of SLPs that reported commonly used standardised and informal motor speech assessments.18

• Two case-control studies that concluded a combination of perceptual and instrumental measures should be used to facilitate diagnosis and treatment of dysarthria after TBI.39,40

The full details of the evidence reviewed on assessments of speech to use following TBI are provided in the Technical Report (Table 5B.2). The steering committee agreed that there was insufficient available evidence to formulate an EBR on speech assessments to use following TBI. CBRs were formulated based on expert opinion.


36

7.3.3 Swallowing

No Level I to IV evidence was found examining the accuracy of diagnostic swallowing assessments (see the Technical Report, Table 5A). Other available evidence (describing the characteristics of dysphagia) reviewed by the steering committee were:

• A case series that concluded a modified barium swallow may prove valuable at 6 months post-TBI.49

• A cross-sectional study that concluded a need for instrumental assessment (videofluoroscopy swallowing study; VFSS) in some cases post-TBI due to the presence of silent aspiration.50

• A single case study that concluded the Verbal Motor Production Assessment for Children appeared more sensitive than the Frenchay Dysarthria Assessment to clinical changes in oral motor abilities.61

• A cross-sectional study that reported swallowing deficits could not be observed on VFSS alone, highlighting the importance of a clinical bedside examination.17

• A case series that reported at 6 months post-TBI children presented with clinically safe and functional swallowing outcomes despite VFSS revealing a number of residual physiological oropharyngeal swallowing impairments.42

The full details of the evidence reviewed on assessments of swallowing to use following TBI are provided in the Technical Report (Table 5B.3). The steering committee agreed that there was insufficient available evidence to formulate an EBR on swallowing assessments to use following TBI. CBRs were formulated based on expert opinion.

8. Clinical question 6: Treatment

8.1 Background

SLPs aim to provide patients with the most effective treatment strategies to improve speech, language and swallowing outcomes. Despite this, a number of systematic reviews have highlighted that there is insufficient high-quality evidence underpinning speech and swallowing interventions for children following brain injury.62-64 Thus, SLPs cannot be assured that they are providing patients with efficacious evidence-based interventions and patients are at risk of not receiving the most appropriate intervention to achieve optimal outcomes. Given the potential negative consequences associated with speech, language and swallowing disorders (e.g., poor academic performance, reduced social networks, inadequate nutrition) it is imperative that SLPs are aware of effective treatment approaches that are supported by high-quality evidence. The below recommendations suggest a range of potential treatment approaches and strategies to improve children’s speech, language and swallowing outcomes.

8.2 Recommendations

Recommendation Type

A number of guiding principles are key across management of speech, language and swallowing including: use it or lose it, use it and improve it, specificity, repetition matters, intensity matters, time matters, salience matters, age matters, transference, and interference (Kleim & Jones, 2008).4

CBR

GUIDELINE 37

8.2.1 Language

There is currently insufficient published research to form an EBR on effective treatment strategies and techniques to treat language disorders following TBI. CBRs were formulated based on expert opinion.

Recommendation Type

Language disorders should be managed by speech-language pathologists (see clinical question 7 for timing) using the most efficacious evidence-based approach for the specific area of deficit, some strategies may include:

• Pre-verbal/early communication − Language stimulation − Vocabulary intervention

• Spoken and written expressive and receptive language − Scaffolding techniques (including binary choices, prompting, cues, priming

(semantic, phonemic), sentence completion, visual supports/information, chunking information, errorless teaching)

− Semantic, syntactic programs (including semantic feature analysis, concept mapping)

− Word finding intervention (including confrontation naming) − Literacy intervention (including reading and writing, narratives, parsing

whole paragraphs, reading comprehension, use of iPads/laptops) − High level language skills

• Functional communication − Social skills training (e.g., Stop-think-do, Topic Talk) − Gesturing − Picture boards − Functional tasks

• Augmentative and alternative communication (e.g., communication board) if required

• Other − Cognitive therapy (can be delivered by a speech-language pathologist. Where

possible, this should occur in consultation with a psychologist) − Communication partner education and training − Education to school staff, teacher aide support − Medications indicated by medical staff (e.g., stimulants) to assist attention

and concentration

CBR

8.2.2 Speech

There is currently insufficient published research to form an EBR on effective treatment strategies and techniques to treat speech disorders following TBI. CBRs were formulated based on expert opinion.

Recommendation Type

Speech disorders should be managed by speech-language pathologists (see clinical question 7 for timing) using the most efficacious evidence-based approach for the specific area of deficit, some strategies may include:

• Articulation or phonological therapy (i.e., speech sound disorder therapy) if indicated

• Dysarthria or dyspraxia therapy (i.e., motor speech therapy) e.g., Lee Silverman Voice Treatment, Nuffield and compensatory strategies such as slow rate, over articulate, stress syllables

• Augmentative and alternative communication

• Activity and participation

• Communication partner education and training

CBR


38

8.2.3 Swallowing

There is currently insufficient published research to form an EBR on effective treatment strategies and techniques to treat swallowing disorders following TBI. CBRs were formulated based on expert opinion.

Recommendation Type

Swallowing disorders should be managed by speech-language pathologists (see clinical question 7 for timing) using the most efficacious evidence-based approach for the specific area of deficit, some strategies may include:

• Postural/positioning modifications

• Environmental set-up/supports

• Cognitive (managed by a speech pathologist with referral to other health professionals where warranted)

− Management of behaviour, impulsivity, fatigue, awareness/cognition − Pacing and timing strategies

• Oral preparatory phase − Oral motor stimulation and exercises, systematic desensitization, jaw

support, visual feedback for chewing − Modification of utensils/specialised feeding − Texture/consistency/food/fluid modification

• Oral phase − Verbal prompts (e.g., take smaller mouthfuls, multiple swallows to clear

residue) − Texture/consistency/food/fluid modification

• Pharyngeal phase − Texture/consistency/food/fluid modification, nil by mouth − Swallow maneuvers/postures (including head turn, chin tuck, multiple

swallows, supraglottic swallow, effortful swallow, mendelsohn maneuver, strong swallowing)

− Supplemental/alternate feeding options (e.g., nasogastric tube, gastrostomy) if indicated by relevant multidisciplinary team (e.g., dietitian, nurse, medical officer)

• Other − Parent/caregiver and staff education/training (e.g., around feeding

modifications or strategies)

CBR


8.3.1 Language

No Level I to IV evidence was found examining the efficacy of language interventions in children with TBI (see the Technical Report, Table 6A). Other available evidence reviewed by the steering committee were:

• A retrospective medical chart review reporting interventions documented in medical charts to manage cognitive-communication impairments. Interventions were: metacognitive training, functional activities, environmental modifications to support attention, memory aids, communication skills training, and caregiver training.65

• A non-systematic literature review that suggested the following school-based cognitive rehabilitation strategies: social integration therapy, expressive writing intervention, and strategies for planning and organization.66

The full details of the evidence reviewed on language interventions are provided in the Technical Report Table 6B.1. The steering committee agreed that there was insufficient available evidence to formulate an EBR on language interventions to use following TBI. CBRs were formulated based on expert opinion. The guideline development committee did not raise any specific concerns regarding the harms or benefits of language interventions.

GUIDELINE 39

8.3.2 Speech

One case series examining treatment of speech disorders was identified (Table 13).67

TABLE 13 Summary of evidence: treatment of speech disorders


Case series of 13 individuals (only 1 child with TBI met the inclusion criteria for this review) examining the use of growth hormone combined with rehabilitation. Concluded that growth hormone could be combined with rehabilitation for improving disabilities, regardless of whether the patient is growth hormone deficient. For the included case, dysarthria improved since tongue paralysis resolved and sialorrhea decreased. No control group was included.

IV Devesa et al 201367

Other available evidence reviewed by the steering committee were:

• A survey study of SLPs that reported commonly used intervention approaches for the treatment of motor speech disorders.18

The full details of the evidence reviewed on the treatment of speech disorders are provided in the Technical Report (Table 6B.2).

The steering committee agreed that there was insufficient available evidence to formulate an EBR on speech interventions to use following TBI. CBRs were formulated based on expert opinion. The guideline development committee did not raise any specific concerns regarding the harms or benefits of speech interventions.

8.3.3 Swallowing

Two case series examining treatment of swallowing disorders were identified (Table 14).68,69

TABLE 14 Summary of evidence: treatment of swallowing disorders


Case series examining the effects of food texture on food intake in 3 children with severe TBI. Concluded that food texture and the person feeding the child are important variables for intake.

IV DeMatteo et al 200268

Case series comparing the use of carbonated versus non-carbonated thin fluids delivered during a videofluoroscopic swallowing study in 24 children with neurological impairment (18 with TBI). Carbonated thin fluids significantly decreased pooling, penetration/aspiration and Penetration-Aspiration Scale scores. No significant difference in pharyngeal residue noted between the two fluid types. Concluded that carbonated thin fluids may provide an alternative to thickened fluids for children with neurogenic dysphagia.

IV Lundine et al 201569

The full details of the evidence reviewed on the treatment of swallowing disorders are provided in the Technical Report (Table 6B.3). The steering committee agreed that there was insufficient available evidence to formulate an EBR on swallowing interventions to use following TBI. CBRs were formulated based on expert opinion. Whilst the guideline development committee did not raise any specific concerns regarding the harms or benefits of the interventions, children with swallowing disorders may aspirate during mealtimes, which can potentially negatively impact on children’s respiratory status and health.


40

9. Clinical question 7: Timing of treatment

9.1 Background

In the early stages following TBI, SLPs often delay direct management towards the child until they are medically stable and show adequate levels of alertness. For swallowing, this is important for children to be able to safely manage food and fluids. Since children’s initial recovery can vary, the timing of treatment is often determined on a case-by-case basis. The recommendations outlined below aim to guide the appropriate timing of treatment.

9.2 Recommendations

There is currently insufficient published research to form an EBR on which time/stage during TBI recovery should treatment for speech, language and swallowing disorders occur. CBRs were formulated based on expert opinion.

Recommendation Type

Speech-language pathologists should commence treatment for speech, language and swallowing disorders in the acute stage once the patient is medically stable. In the early stages post-injury, priority may be given to swallowing and functional communication.

CBR

For speech and language disorders, treatment (i.e., cueing and educating families about interventions) can occur whilst the child is in post-traumatic amnesia (where appropriate). Formal treatment directed towards the child’s impairment should commence after the patient has emerged from post-traumatic amnesia. The patient should receive regular therapy from local services post-rehab discharge (if available).

CBR

For swallowing disorders, treatment should occur post-extubation, when the patient is alert and able to manage their own secretions, and is responding appropriately to automatic movements. Treatment may commence with a tracheostomy in situ (if a child is chronically unable to manage their own secretions) with treatment focusing on tracheostomy management and education.

CBR


No empirical evidence relevant to the timing of treatment was identified (see the Technical Report, Table 7A). CBRs were formulated based on expert opinion.

10. Clinical question 8: Information for parents

10.1 Background

The time following a child’s TBI is often a stressful and challenging period for parents.70 Parents often value detailed, frequent and understandable communication from health professionals during this stage to assist with decision-making and outcomes.71 However, for some parents, processing medical information at the time of their child’s injury can be difficult.72 Whilst parents of children with moderate TBI commonly have their early expectations met by receiving encouraging information and being involved in the acute care of their child, parents of children with severe TBI often report that early acute care information is not always user friendly and can be negatively framed.70 Some parents, however, may receive little or conflicting information regarding TBI, potentially adding to parents’ stressors.72 Whilst information provided to parents should be individualised, there are key areas that health professionals should address to ensure that parents are adequately informed, as recommended below.

GUIDELINE 41

10.2 Recommendations

There is currently insufficient published research to form an EBR on what information parents should be provided about speech, language and swallowing following TBI. CBRs were formulated based on expert opinion.

Recommendation Type

Speech-language pathologists and medical specialists should provide parents/caregivers and educators with accurate information tailored to the child to support their recovery. This information should be provided following the child’s initial assessment with a speech-language pathologist or as appropriate. Parents/caregivers would benefit from the following forms of information about speech, language and swallowing disorders during the first year of recovery:

• Explanation of aetiology and possible impacts for speech, language and swallowing (e.g., injury severity, impact of cognitive deficits, physiology for swallowing in regard to motor abilities) so family or teachers can understand the 'why' of what they see

• Define speech, language and swallowing as relevant, and explain the patient’s specific diagnoses and specific likely difficulties and what to expect over the coming year, including:

− Managing social isolation − Managing fatigue for speech, language and swallowing − Rate of recovery

• Impact on social skills and importance of socialising, play dates, thinking games, conversational scaffolding and practice, and encouraging development

• When to intervene and factors that help predict outcomes into the longer term (where known) including patient engagement in treatment

• Impact of monitoring and supporting

• How to be a supportive communication partner and how to monitor, seek help and support and advocate for their child

• How to integrate back to school

CBR


No empirical evidence relevant to what information about speech, language and swallowing parents should receive after their child’s injury was identified (see the Technical Report, Table 8A). CBRs were formulated based on expert opinion.


42

11. Future Research

The development of this guideline has identified a need for high-quality research examining the speech, language and swallowing of children following TBI. Evidence-based recommendations for a number of clinical questions were unable to be developed due to the paucity of research in the field and the quality of the available evidence. Many of the available studies were of lower levels of evidence, highlighting the need for future studies to employ robust study designs and rigorous methodologies.

The guideline has highlighted a number of key areas concerning assessment, intervention and prognosis that require future research in order to strengthen the evidence-base. With regard to assessment, there is a need for the development of language and motor speech assessments that are specifically designed for children with brain injuries. Currently available evidence precludes the ability to recommend a list of “gold standard” measures within this guideline to use for clinical and research purposes. Where possible however, researchers should strive to include common measures or assess the key areas of speech, language and swallowing suggested in the recommendations of this guideline.

Research is also needed to identify effective speech, language and swallowing interventions for this population (e.g., interventions for dysarthria, social communication). Studies should include pre- and post-treatment outcome measures, short and long term follow-up, and a control group. Intervention studies should also consider whether subgroups of children are most likely to benefit from specific types of treatment. To improve referral of patients to SLPs and subsequent service planning, further research is required to determine prognostic indictors for the presence, resolution and persistence of speech, language and swallowing disorders following paediatric TBI.

Whilst this guideline focused on management during the first year post-TBI, it should be emphasised that of course children with moderate to severe TBI typically show persistent deficits well beyond this early period post-injury, and the impacts of a TBI are often life long. Further longitudinal research is required to examine the evolution of disorders following TBI in order to assist in the development of evidence-based management guidelines for children after their first year of recovery.

GUIDELINE 43

12. References

References marked with an asterisk were included in the systematic review

1. Mitra, B., Cameron, P., & Butt, W. (2007). Population-based study of paediatric head injury. Journal of Paediatrics & Child Health, 43(3), 154-159.

2. Crowe, L., Babl, F., Anderson, V., & Catroppa, C. (2009). The epidemiology of paediatric head injuries: data from a referral centre in Victoria, Australia. Journal of Paediatrics & Child Health, 45(6), 346-350.

3. National Health and Medical Research Council (2009). Levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC.

4. Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. Journal of Speech, Language, & Hearing Research, 51(1), 225-239.

5. Keenan, H. T., & Bratton, S. L. (2006). Epidemiology and outcomes of pediatric traumatic brain injury. Developmental Neuroscience, 28, 256-263.

6. Thurman, D. J. (2016). The epidemiology of traumatic brain injury in children and youths: a review of research since 1990. Journal of Child Neurology, 31(1), 20-27.

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9. *Morgan, A., Ward, E., Murdoch, B., Kennedy, B., & Murison, R. (2003). Incidence, characteristics, and predictive factors for dysphagia after pediatric traumatic brain injury. Journal of Head Trauma Rehabilitation, 18(3), 239-251.

10. Brookshire, B. L., Chapman, S. B., Song, J., & Levin, H. S. (2000). Cognitive and linguistic correlates of children’s discourse after closed head injury: a three-year follow-up. Journal of the International Neuropsychological Society, 6(7), 741-751.

11. Crowe, L. M., Anderson, V., Barton, S., Babl, F. E., & Catroppa, C. (2014). Verbal ability and language outcome following traumatic brain injury in early childhood. Journal of Head Trauma Rehabilitation, 29(3), 217-223.

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16. Turkstra, L. S., McDonald, S., & DePompei, R. (2001). Social information processing in adolescents: data from normally developing adolescents and preliminary data from their peers with traumatic brain injury. Journal of Head Trauma Rehabilitation, 16(5), 469-483.

17. *Morgan, A., Ward, E., & Murdoch, B. (2004c). Clinical characteristics of acute dysphagia in pediatric patients following traumatic brain injury. Journal of Head Trauma Rehabilitation, 19(3), 226-240.

18. Morgan, A. T., & Skeat, J. (2011). Evaluating service delivery for speech and swallowing problems following paediatric brain injury: an international survey. Journal of Evaluation in Clinical Practice, 17(2), 275-281.

19. Hainsworth, D. S., Lockwood-Cook, E., Pond, M., & Lagoe, R. J. (1997). Development and implementation of clinical pathways for stroke on a multihospital basis. Journal of Neuroscience Nursing, 29(3), 156-162.

20. McIlvoy, L., Spain, D. A., Raque, G., Vitaz, T., Boaz, P., & Meyer, K. (2001). Successful incorporation of the severe head injury guidelines into a phased-outcome clinical pathway. Journal of Neuroscience Nursing, 33(2), 72-82

21. Slomine, B. S., McCarthy, M. L., Ding, R., MacKenzie, E. J., Jaffe, K. M., Aitken, M. E., ... & Paidas, C. N. (2006). Health care utilization and needs after pediatric traumatic brain injury. Pediatrics, 117(4), e663-e674.

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27. Speech Pathology Australia (2008). Working with Aboriginal people in rural and remote Northern Territory. A resource guide for speech pathologists. Melbourne: Speech Pathology Australia.

28. *Catroppa, C., & Anderson, V. (2004). Recovery and predictors of language skills two years following pediatric traumatic brain injury. Brain & Language, 88(1), 68-78.

29. *Chapman, S. B., McKinnon, L., Levin, H. S., Song, J., Meier, M. C., & Chiu, S. (2001). Longitudinal outcome of verbal discourse in children with traumatic brain injury: three-year follow-up. Journal of Head Trauma Rehabilitation, 16(5), 441-455.

30. *Kriel, R. L., Krach, L. E., Luxenberg, M. G., & Chun, C. (1995). Recovery of language skills in children after prolonged unconsciousness. Neurorehabilitation & Neural Repair, 9(3), 145-150.

31. *Ryan, N. P., Catroppa, C., Beare, R., Coleman, L., Ditchfield, M., Crossley, L., ... & Anderson, V. A. (2015). Predictors of longitudinal outcome and recovery of pragmatic language and its relation to externalizing behaviour after pediatric traumatic brain injury. Brain & Language, 142, 86-95.


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32. *Vu, J. A., Babikian, T., & Asarnow, R. F. (2011). Academic and language outcomes in children after traumatic brain injury: a meta-analysis. Exceptional Children, 77(3), 263-281.

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34. *Morgan, A., Ward, E., & Murdoch, B. (2004b). Clinical progression and outcome of dysphagia following paediatric traumatic brain injury: a prospective study. Brain Injury, 18(4), 359-376.

35. *Rowe, L. A. (1999). Case studies in dysphagia after pediatric brain injury. Journal of Head Trauma Rehabilitation, 14(5), 497-504.

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39. *Cahill L. M., Murdoch, B. E., & Theodoros, D. G. (2000). Variability in speech outcome following severe childhood traumatic brain injury: a report of three cases. Journal of Medical Speech-Language Pathology, 8(4), 347-352.

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42. *Morgan, A., Ward, E., Murdoch, B., & Bilbie, K. (2005). Six-month outcome for dysphagia following traumatic brain injury: radiological assessment. Journal of Medical Speech-Language Pathology, 13(2), 109-126.

43. *Morse, S., Haritou, F., Ong, K., Anderson, V., Catroppa, C., & Rosenfeld, J. (1999). Early effects of traumatic brain injury on young children’s language performance: a preliminary linguistic analysis. Developmental Neurorehabilitation, 3(4), 139-148.

44. *Recla, M., Bardoni, A., Galbiati, S., Pastore, V., Dominici, C., Tavano, A., ... & Strazzer, S. (2013). Cognitive and adaptive functioning after severe TBI in school-aged children. Brain Injury, 27(7-8), 862-871.

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49. *Morgan, A. T., Ward, E. C., Murdoch, B. E., Gilmore, G., & Bilbie, K. (2001). A study of the resolution of paediatric dysphagia following traumatic brain injury: Practical implications for clinicians. Asia Pacific Journal of Speech, Language & Hearing, 6(1), 9-19.

50. *Morgan, A., Ward, E., Murdoch, B., & Bilbie, K. (2002). Acute characteristics of pediatric dysphagia subsequent to traumatic brain injury: videofluoroscopic assessment. Journal of Head Trauma Rehabilitation, 17(3), 220-241.

51. Turkstra, L. S. (1999). Language testing in adolescents with brain injury: a consideration of the CELF-3. Language, Speech, & Hearing Services in Schools, 30(2), 132-140.

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53. Coelho, C., Ylvisaker, M., & Turkstra, L. S. (2005). Nonstandardized assessment approaches for individuals with traumatic brain injuries. Seminars in Speech & Language, 26(4), 223-241.

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58. *Slomine, B., Eikenberg, J., Salorio, C., Suskauer, S., Trovato, M., & Christensen, J. (2008). Preliminary evaluation of the Cognitive and Linguistic Scale: a measure to assess recovery in inpatient rehabilitation following pediatric brain injury. Journal of Head Trauma Rehabilitation, 23(5), 286-293.

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GUIDELINE 45

61. Morgan, A., Ward, E., & Murdoch, B. (2004a). A case study of the resolution of paediatric dysphagia following brainstem injury: clinical and instrumental assessment. Journal of Clinical Neuroscience, 11(2), 182-190.

62. Morgan, A. T, & Vogel, A. P. Intervention for dysarthria associated with acquired brain injury in children and adolescents. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006279. DOI: 10.1002/14651858.CD006279.pub2.

63. Morgan, A. T., Dodrill, P., & Ward, E. C. Interventions for oropharyngeal dysphagia in children with neurological impairment. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD009456. DOI: 10.1002/14651858.CD009456.pub2.

64. Pennington, L., Miller, N., & Robson, S. Speech therapy for children with dysarthria acquired before three years of age. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD006937. DOI: 10.1002/14651858.CD006937.pub2.

65. Ennis, S. K., Rivara, F. P., Mangione-Smith, R., Konodi, M. A., MacKenzie, E. J., & Jaffe, K. M. (2013). Variations in the quality of inpatient rehabilitation care to facilitate school re-entry and cognitive and communication function for children with TBI. Brain Injury, 27(2), 179-188.

66. Shaw, D. R. (2014). Pediatric cognitive rehabilitation: effective treatments in a school-based environment. NeuroRehabilitation, 34(1), 23-28.

67. *Devesa, J., Reimunde, P., Devesa, P., Barberá, M., & Arce, V. (2013). Growth hormone (GH) and brain trauma. Hormones & Behavior, 63(2), 331-344.

68. *Dematteo, C., Law, M., & Goldsmith, C. (2002). The effect of food textures on intake by mouth and the recovery of oral motor function in the child with a severe brain injury. Physical & Occupational Therapy in Pediatrics, 22(3-4), 51-71.

69. *Lundine, J. P., Bates, D. G., & Yin, H. (2015). Analysis of carbonated thin liquids in pediatric neurogenic dysphagia. Pediatric Radiology, 45(9), 1323-1332.

70. Roscigno, C. I., & Swanson, K. M. (2011). Parents’ experiences following children’s moderate to severe traumatic brain injury: a clash of cultures. Qualitative Health Research, 21(10), 1413-1426.

71. Moore, M., Robinson, G., Mink, R., Hudson, K., Dotolo, D., Gooding, T., ... & Vavilala, M. S. (2015). Developing a family-centered care model for critical care after pediatric traumatic brain injury. Pediatric Critical Care Medicine, 16(8), 758-765.

72. Clark, A., Stedmon, J., & Margison, S. (2008). An exploration of the experience of mothers whose children sustain traumatic brain injury (TBI) and their families. Clinical Child Psychology & Psychiatry, 13(4), 565-583.

CLINICAL PRACTICE GUIDELINEFOR THE MANAGEMENT OFCOMMUNICATION AND SWALLOWINGDISORDERS FOLLOWING PAEDIATRICTRAUMATIC BRAIN INJURY

GUIDELINE

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