Acquired brain injury (ABI) is the most common cause of injury in childhood and affects 18 in every 100,000 children in England (NHS England, 2013).

This includes both traumatic brain injury (e.g. road traffic accident) and non-traumatic brain injury (e.g. tumour, stroke, infection).

As the brain continues to develop until the late 20s, the impact of an ABI is considered to be a developing condition, rather than confined to the single physical injury.

The children and young people that are supported by the Brain Injury Community Service at The Children’s Trust, have often made a good physical recovery following their ABI and have returned to their previously attended school.

However, these children will likely experience something described as a ‘hidden disability.’ As discussed in Katy James’s NR Times article (Paediatric acquired brain injury and hidden disability, April 2019), ‘hidden disability’ refers to a range of difficulties that aren’t necessarily visible on the outside.

These may include underlying difficulties in areas such as attention and concentration, planning and organising, problem solving, understanding and using inferential language, memory, and emotional changes.

In terms of their language, these children may present with seemingly intact functional expressive and receptive language skills.

However, they commonly experience ‘higher-level’ language difficulties, which is an umbrella term under which there may be deficits in areas such as: word finding, sequencing, narrative skills, understanding figurative or ambiguous language and making inferences or predictions.

In addition to formal assessments, higher-level language skills can be picked up and assessed through observations across settings, the use of checklists as well as informal functional tasks.

For example, a community assessment in a supermarket can reveal much about a child’s ability to sequence, understand complex language and infer.

Ciccia et al. (2009) suggest that everyday tasks such as homework assignments, peer conversations and daily scheduling are likely to be more revealing of challenges faced than scores on standardised tests.

Higher-level cognitive and communication difficulties can have a devastating impact and are often ongoing and long-term (Anderson et al. 2004, Shakalai et al. 2014). As children and young people develop, they are expected to communicate in a range of increasingly complex academic, social and vocational contexts.

They are learning to regulate their own behaviour, negotiate and to use language to achieve complex goals (Ciccia et al, 2009).

Deficits in higher-level language abilities can therefore potentially have a significant impact on their participation in all areas of their lives, such as school/college, home, going out with friends, participating in clubs and leisure pursuits and planning for the future.

Language impairment, particularly in higher-level language skills, may misleadingly present as educational and social difficulties (Jordan & Ashton, 1996).

For example, the 10 year old who is being ‘disruptive’ in the classroom may actually be experiencing difficulties understanding the ambiguous or figurative language used by the teacher, which results in the behaviour seen.

Similarly, the 14 year old who is having difficulties making and maintaining friends, may be experiencing underlying difficulties inferring meaning from other’s intentions, resulting in the relationship breakdown.

Without the right level of support, children with ABI are at risk of increased mental health difficulties, reduced education and employment opportunities, antisocial behaviour and involvement in the criminal justice system (Hoofien et al. 2001, Williams et al. 2015).

It is therefore essential that those involved in supporting these children, have an awareness and understanding of hidden higher-level language needs.

Much of the support for the children and young people who access the Brain Injury Community Service will involve education, training and advocating for their hidden difficulties, including their higher-level language.

This involves working closely with home and school, as well as with speech and language therapy and occupational therapy colleagues in the community.

Co-written by Isobel Hatfield, speech and language therapist, Brain Injury Community Service, The Children’s Trust, and Dr Karen Cundy, speech and language therapist, The Children’s Trust.


Anderson VA, Morse SA, Catroppa C, Haritou F and Rosenfeld JV. Thirty month outcome from early childhood head injury: A prospective analysis of neurobehavioural recovery. Brain. 2004; 127: 2608-2620.

Ciccia AH, Meulenbroek P and Turkstra LS. Adolescent brain and cognitive developments: Implications for clinical assessment in traumatic brain injury. Topics in Language Disorders. 2009; 29(3): 249-265.

Hoofien D, Gilboa A, Vakil E and Donovick PJ. Traumatic brain injury (TBI) 10-20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning. Brain Injury. 2001; 15(3): 189-209.

Jordan FM. and Ashton R. Language performance of severely closed head injured children. Brain Injury.1996; 10: 91-97

NHS England. 2013/14 NHS Standard Contract for Paediatric Neurosciences: Neurorehabilitation, England. NHS England, 2013

Shakalai S, Peretz R, Spasser R, Simantov M and Groswasser Z. Long-term functional outcome after moderate-to-severe paediatric traumatic brain injury. Brain Injury. 2014; 28 (7): 915-921.

Williams WH, McAuliffe KA, Cohen MH, Parsonage M and Ramsbotham J. Traumatic brain injury and juvenile offending: Complex causal links offer multiple targets to reduce crime. The Journal of Head Trauma Rehabilitation. 2015; 30(2): 69-74.

The Children’s Trust Brain Injury Community Service provides specialist goal-orientated neurorehabilitation delivered in the child’s environment, at home, in school, or a combination of both.

With a member of its community service based in four of the UK’s major hospitals, and a dedicated multidisciplinary team based at their national specialist centre in Surrey, the service supports children from right across the UK.

To find out more about the service get in touch with the team by calling 01737 365 864 or visit

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