What Pediatric Traumatic Brain Injury Can Teach Us About Autism

What Pediatric Traumatic Brain Injury Can Teach Us About Autism

Nearly three million Americans suffer a traumatic brain injury (TBI) each year, one quarter of them children. Most of these are mild, resulting in concussion, but 50,000 deaths result from TBI annually.

At the same time, one in 59 children is diagnosed with autism spectrum disorder each year. Three and a half million Americans live with autism spectrum disorder (ASD).

These two conditions share more than a surprisingly large impact on our children: they share many biologic mechanisms and symptoms. Researchers have begun inquiring into how diagnosis and treatment of ASD and TBI might inform each other and lead to breakthroughs in one or both.

Children with traumatic brain injuries exhibit many of the same challenges as children with autism. These include deficits in intelligence, memory, attention, learning and social judgment. Anatomical changes to the brain resulting from TBI can impair emotional decision-making, self-regulatory behavior, emotional perception and the ability to recognize non-verbal cues. These are also classic characteristics of autism.

Children with ASD often present with decreased diversity of microflora in their intestines, which can hinder brain development. For children suffering TBI, reduced metabolism can also lead to a lack of microflora diversity. Whether the nature of this reduced diversity is similar in the two groups will require more study, but administration of probiotics has had success in both.

Brain plasticity – the ability of one region of the brain to rewire itself to execute functions normally performed by a damaged region – offers a ray of hope to TBI patients and autistic individuals. With intense therapy, brain stimulation and intervention, children with these two conditions can learn new skills by “training” their brains to process information in new ways.

Applied behavior analysis (ABA) is considered the gold standard in autism treatment given the extensive research conducted on its efficacy. It is employed to redirect behavior from harmful and counterproductive to useful and beneficial, and to teach critical skills for independence. Begun early in a child’s life, the progressive learning process of ABA therapy has demonstrated success in addressing multiple deficits – e.g., verbal, attentional, and learning – associated with ASD. ABA is now being used to readapt pediatric TBI patients to their home environment. As with ASD, this therapy yields optimum results when begun early and maintained over time.

ABA requires children to verbalize (or express using assistive communication devices) the instructions they have been given in an iterative approach that builds beneficial habits. This progressive learning process is applied to multiple behaviors characteristic of ASD and TBI. Additional strategies such as Pivotal response treatment (PRT), based on the principles of ABA, targets “pivotal” areas of a child’s development instead of working on one specific behavior. By focusing on pivotal areas, PRT produces improvements across other domains of skill development.

Verbal behavior therapy is a comprehensive language program that focuses on understanding the purpose of words and how they are used to communicate specific ideas. Also built on an ABA foundation, verbal behavior positively reinforces correct use of verbal and non-verbal communication that connects the speaker and the listener.

Although ASD and TBI present similar symptoms, there is no evidence that ASD is caused by trauma or injury to the brain. Its causes appear to be multifaceted and complex, including genetics, fetal conditions and various maternal and paternal factors. Like TBI, skill development and expansion can be optimized with behavioral treatment that begins as soon as possible.


The brain is a complex and wondrous organ whose basic structure is a web of electrical impulses. The early journey of brain development is vital to its functioning for the rest of its owner’s life.

Brain development begins in utero and isn’t complete until roughly age 25. A baby is born with 85 billion neurons, or nerve cells, that transmit these signals to other neurons through synapses. A web of interconnected neurons is called a neural network and is crucial to the brain’s function.

The Role of Neural Pathways

Neuroscience research has determined that the most critical ages for brain development are zero to six, when the brain is building and reinforcing the neural connections that will last a lifetime. Each new encounter a baby has with their environment through the five senses creates new neural pathways, with repeated encounters strengthening those connections. Neural pathways that are not reinforced in this manner are literally culled by the brain in favor of others. Hence the phrase “neurons that fire together, wire together”.

Because babies’ brains are in the acquisition phase, this is the critical time for positive brain stimulation. Research shows that early brain stimulation leaves positive fingerprints on the brain throughout life.

The brain also favors encounters that bring pleasure. When babies’ needs are met and expectations fulfilled, their brains are stimulated to perform optimally. When babies endure persistent negative experiences, their emotional and social development suffer, as does the ability to learn and develop language. For these reasons, early childhood experts encourage new parents to talk, sing, smile at, read to their children as much as possible; to hold, hug and snuggle with them often; and to turn everyday moments into teaching moments.

The Autistic Brain is Different

Recent research suggests the brains of autistic children are different. Their brain cells are hyper-connected, with many more neural pathways than neuro-typical children have, particularly in the area of the brain that affects sight. The more severe the symptoms of autism, the more hyper-connected the brain. These excess connections appear to be the result of a deficiency in the culling process. The brain of a neuro-typical two-year-old begins weeding out roughly half the synaptic connections it has produced. The brain of an autistic two-year-old eliminates only about one-sixth of the synaptic connections, leaving what might be understood as clutter in the brain. These remaining pathways amount to a neural overload – akin to the sensation of attempting to drink water out of a fire hose.

“Our findings suggest that the imbalance of excitation and inhibition in the local brain circuits could engender cognitive and behavioral deficits observed in autism,” said Vinod Menon, Ph.D., a Stanford researcher who co-produced the research.

The Importance of Early Detection and Treatment

This breakthrough research finding may lay the groundwork for early detection of autism and improve diagnosis and treatment. Because the brain is so plastic – able to adapt, re-wire and create new neural pathways – earlier treatment can establish new and stronger neural connections, behaviors and skills. Evidence suggests that diagnosis and treatment starting by age three confers lifelong benefits on autistic children.

The optimal time for intervention is before the second major culling period in adolescence. For children with developmental and learning disabilities, reinforcing the pathways that lead to constructive behaviors and skills must be accomplished before those synaptic connections are erased for lack of use. Stimulating the brain with positive skills and behaviors before the culling period reinforces helpful synaptic connections and allows unhelpful ones to move to the head of the line for pruning.

In this way, it becomes evident that brain performance is neither all nature nor all nurture, but a combination of genetics and experiences working together. Engagement  and contemporary, early intervention can support autistic children in learning the skills critical to leading fulfilling lives as independently as possible.

Train Your Child’s Brain

One method of re-training your child’s brain: select one simple task and practice it 10 times daily. Observe whether your child is able to complete the task faster each time. Optimize your child’s brain development by engaging with them verbally and visually during regular daily activities like playing, diaper changing, feeding and bathing.

Examples of simple instructions include “drink from the cup,” “give me that book” or “show me the train ” Opportunities to practice these one-step tasks abound during the day. For autistic children, just as for neuro-typical children, perhaps even more, everyday moments can be teaching moments. Additionally, for children determined to be at risk for a developmental disorder, early intervention is critical to capitalize on the brains’ plasticity.

By Ronit Molko, Ph.D., BCBA-D