traumatic brain injury ( tbi ) sustained at a very young age is associated with high rates of long - term morbidity and mortality .
the aetiology and pathophysiology of head injuries in children younger than 4 years of age differ from those in older children .
although the causes of tbi in children under 4 include falls , as well as traffic accidents as passengers [ 1 , 2 ] , whose prevalence increases from infancy ( 23% of all tbis ) to adolescence ( 82% ) , the proportion of nonaccidental head injuries ( nahi ) is very high , between 20% and 75% [ 47 ] .
the first postnatal years are characterized by an extremely fast rate of brain growth , which involves numerous processes such as dendritogenesis , axogenesis , synaptogenesis and synaptic stabilisation , gliogenesis , and myelination [ 914 ] .
tbi in very young children is associated with greater severity of impairments in language , attention , fine motor speed , tactile recognition , and visuospatial functions , compared to older children [ 1519 ] .
the influence of age at injury on the long - term cognitive outcomes of tbi interacts with a number of others factors , including time since injury , vulnerability of specific functions , and site and extent of brain damage .
differences in outcomes according to which cerebral lobe is involved , and more specifically the impact of frontal lobe damage , have been investigated in several series of school - aged children .
several studies assessed the influence of frontal lobe involvement on cognitive functions , including intellectual and executive functions , emotional aspects of narratives , and verbal memory .
greater impairment of these functions was associated with younger age at injury and with involvement of one or both frontal lobes . in one study , however , frontal lobe involvement was not associated with behavioural outcomes or adaptive functioning . moreover ,
frontal lesion size was not associated with measures of executive function in a study of children aged 7 to 15 years .
differential effects of right versus left frontal lobe injury at 5 to 15 years of age were looked for in a longitudinal study .  
the results showed an interaction between age and tbi severity : thus , word fluency recovery was slower after severe tbi in younger children than after severe tbi in older children or mild tbi in younger children .
in addition , involvement of the left frontal lobe was associated with worse word - fluency performance in older children , compared to younger children and to involvement of the right frontal lobe
. this result may be ascribable to a greater functional commitment of the left frontal lobe to expressive language and word fluency in older than in younger children and/or to the combined influence of expressive language deficiency and executive function impairment .
little is known about the impact of frontal lobe involvement on outcomes after tbi in very young children . a single case - series of children with frontal lobe injury included patients younger than 6 years at injury .
general intelligence was assessed using the wisc , and four tests of executive functions were performed .
the results showed that frontal lobe injury impaired the development of both executive skills and general intelligence .
a number of case - reports have supplied information on adulthood outcomes after frontal lobe injury sustained in early childhood [ 2730 ] .
overall , these reports indicate that early prefrontal injury can lead to impairments not only in executive functions ( e.g. , planning or decision - making ) , but also in social behaviour . two young adults with a history of prefrontal injury before 16 months of age had impaired decision making , behavioural dyscontrol , social defects , and abnormal emotion   contrasting with normal performance on tests for intellect , memory , language , and perception . in a patient who sustained extensive damage to the right dorsolateral prefrontal cortex at age 7 , evaluations 4 and 8 years later showed significant improvements in many cognitive areas including working memory and several attentional and executive tasks ( such as design fluency and planning ) , with no evidence of social impairment , abnormal personality , or moral disturbances .
however , attentional difficulties and impulsive responding were noted . we are not aware of other patients in whom longitudinal data were collected after early tbi .
because most of the patients were evaluated only in adulthood , it is unclear whether the cognitive or behavioural deficits were direct consequences of the frontal lobe damage .
repeated testing over time is required to study the developmental impact of early frontal - lobe injury and to look for interactions with other factors . here
, we report on a patient who sustained bilateral frontal lobe damage at 19 months of age during a domestic accident and who was subsequently evaluated six times between the ages of 3 years 9 months and 9 years 10 months .
the development of psychomotor , language , and executive functions in this patient is described below .
the patient was a boy born to moroccan parents living in the french - speaking part of belgium .
both french and arabic were spoken at home , and his language development was normal . at 19 months of age , he fell from a height of six meters .
he was taken immediately to the emergency room , where the physical examination showed a deep wound in the forehead , bilateral epistaxis , periorbital hematoma , and palpebral oedema .
his deep tendon reflexes and plantar reflexes were normal but he had mild paresis of the left lower limb .
computed tomography ( ct ) of the brain showed multiple fractures of the frontal bone with displaced fragments ; fractures of the ethmoidal bone , right supraorbital area , and right nasal bone ; and brain oedema .
the postoperative course was favourable , with gradual improvement of the paresis of the left lower limb .
two weeks later , magnetic resonance imaging ( mri ) disclosed bilateral high signal from the base of the frontal cortex , as well as a right anterior insular lesion .
two years later , a control mri   showed stability in white matter lesions , but atrophy of bifrontal cortex was more severe ( figures 1 and 2 ) .  
finally , late posttraumatic epilepsy characterized by partial seizures developed 2 years after the injury .
he received motor and speech rehabilitation therapy outside our unit and was enrolled in a special - education program at 7 years of age .
he was first evaluated at our clinical unit when he was 3 years 9 months old .
subsequently , we re - evaluated him once a year , for a total of six evaluations ; thus , at the last evaluation , he was 9 years 10 months old .
his cognitive development was assessed using measures of motor function , language , and neuropsychological status .
immediately after the injury , they detected no behavioural or emotional changes , except regarding language .  
however , 2 months later , his parents described him as  hyperactive  at home , moving around continuously and unable to remain still or to play the same game for more than a few minutes .
he started to attend nursery school 18 months after the injury , when he demonstrated difficulties relating to his peers .
psychomotor disturbances emerged at that time : thus , although he was then 3 years old he was unable to distinguish a circle from a square , to pedal on a tricycle , or to put his finger on his mouth or nose .
about 6 months later ( when he was 3 years 6 months , 2 years after the injury ) , he had attentional deficits , delayed language development with a combination of vocabulary deficiency and receptive language impairment , and delayed motor development .
french was chosen as his main language , as bilingualism was felt to be too complicated for him .
three years after the injury ( when he was 4 years 10 months old ) , he was less hyperactive but exhibited major attention deficiency , particularly in his class group , where he was easily distractible and seemed not to hear others .
one year later ( when he was 5 years 9 months old , 4 years after the injury ) , he was described as very impulsive , with deficits in expressive language and in psychomotor skills .
when he was 7 years old , his persistent difficulties with attention and language led to his enrolment in a special - education program . during the last two evaluations at our clinical unit
, he seemed excessively obedient and polite : for example , he did not ask for food when he was hungry . on the other hand , he occasionally exhibited symptoms of hyperactivity , running and jumping during games that did not require physical activity . at school ,
he was described as the perfect student , being interested in everything , very polite , and reserved .
the last evaluation was performed when the parents asked that he be returned to the mainstream school system , as they felt he no longer required special education .
cognitive development was assessed using measures of ( a ) general intellectual abilities , ( b ) attentional and executive functions , ( c ) working memory , ( d ) language , and ( e ) psychomotor skills .  
we chose among the following scales based on age at evaluation : wechsler intelligence scale for pre - school children  revised , wechsler intelligence scale for children  third edition , and wechsler intelligence scale for children  fourth edition .
an increasing number of tests were performed from one evaluation to the next , as the patient advanced in age .  

visual selective attentionthe following tests were used.crossing tasks from the nepsy : the child is instructed to select only the items ( part 1 : cats ; part 2 : faces ) that match the target stimuli on pages containing both targets and distractors .
the number of correctly identified targets ( maximum 20 cats and faces ) and the completion time ( maximum 180 seconds ) are scored.the visual selective attention task on the tap ( test battery for attentional performance ): crosses appear in a random configuration on a 44 matrix , and the child is asked to press a key when four of the crosses form a square .
the following tests were used.crossing tasks from the nepsy : the child is instructed to select only the items ( part 1 : cats ; part 2 : faces ) that match the target stimuli on pages containing both targets and distractors .
the number of correctly identified targets ( maximum 20 cats and faces ) and the completion time ( maximum 180 seconds ) are scored.the visual selective attention task on the tap ( test battery for attentional performance ): crosses appear in a random configuration on a 44 matrix , and the child is asked to press a key when four of the crosses form a square .
reaction times , missed responses , and unwarranted responses are recorded . crossing tasks from the nepsy : the child is instructed to select only the items ( part 1 : cats ; part 2 : faces ) that match the target stimuli on pages containing both targets and distractors .
the number of correctly identified targets ( maximum 20 cats and faces ) and the completion time ( maximum 180 seconds ) are scored .
the visual selective attention task on the tap ( test battery for attentional performance ): crosses appear in a random configuration on a 44 matrix , and the child is asked to press a key when four of the crosses form a square .
the visual attention task was the same as above . 
  a dual task from the tap   was used .
the child is asked to cross out as fast as possible two kinds of target signs on sheets that also contain distractor signs , for 10 minutes .
the child is asked to cross out as fast as possible two kinds of target signs on sheets that also contain distractor signs , for 10 minutes .
statue test from the nepsy : the child is asked to remain standing , pretending to hold a flag , with the eyes closed and no vocalizations , for 75 seconds.knock-and-tap test from the nepsy : the child is asked to knock on the table with the knuckles when the examiner taps the table with the palm and vice versa .
a total of 15 trials are performed in pseudorandom order.go/no-go task from the tap   and kitap : the child must press a key as fast as possible when a target ( a cross in the tap or a bat in the kitap ) appears on the screen but not when other images resembling the target are displayed . the interference fruit task , based on the stroop word test and adapted from the fruit task developed by archibald and kerns .
this task includes three conditions that can be performed by young children who have not yet learned to read .
contrary to the fruit task developed by archibald and kerns , unlimited time is allowed for naming the colours of the rectangles .
furthermore , we included only three common fruits ( banana , pear , and strawberry ) , whose colours ( yellow , green , and red ) are well known by young children . in the first condition ,
the child is asked to name colours of 45 rectangles as quickly as possible , to provide a measure of processing speed . in the interference condition
, the child must say the correct colours of 45 incorrectly coloured pictures of fruits , ( e.g. ,  yellow  when shown a picture of a green banana ) .
total completion time and errors are scored for both conditions . incompatibility ( tap ) . in this task
, arrows pointing to the left or right are shown on the left or right side of a fixed point .
the child must press a key on the left or right , depending on the direction of the arrow , irrespective of the location of the arrow relative to the point .
when the side and direction of the arrow are the same ( i.e. , leftward - pointing arrow to the left of the point ) , the condition is classified as compatible ; otherwise , the condition is classified as incompatible .
statue test from the nepsy : the child is asked to remain standing , pretending to hold a flag , with the eyes closed and no vocalizations , for 75 seconds.knock-and-tap test from the nepsy : the child is asked to knock on the table with the knuckles when the examiner taps the table with the palm and vice versa .
a total of 15 trials are performed in pseudorandom order.go/no-go task from the tap   and kitap : the child must press a key as fast as possible when a target ( a cross in the tap or a bat in the kitap ) appears on the screen but not when other images resembling the target are displayed .
the interference fruit task , based on the stroop word test and adapted from the fruit task developed by archibald and kerns .
this task includes three conditions that can be performed by young children who have not yet learned to read .
contrary to the fruit task developed by archibald and kerns , unlimited time is allowed for naming the colours of the rectangles .
furthermore , we included only three common fruits ( banana , pear , and strawberry ) , whose colours ( yellow , green , and red ) are well known by young children . in the first condition ,
the child is asked to name colours of 45 rectangles as quickly as possible , to provide a measure of processing speed . in the interference condition
, the child must say the correct colours of 45 incorrectly coloured pictures of fruits , ( e.g. ,  yellow  when shown a picture of a green banana ) .
total completion time and errors are scored for both conditions . incompatibility ( tap ) . in this task ,
arrows pointing to the left or right are shown on the left or right side of a fixed point .
the child must press a key on the left or right , depending on the direction of the arrow , irrespective of the location of the arrow relative to the point .
when the side and direction of the arrow are the same ( i.e. , leftward - pointing arrow to the left of the point ) , the condition is classified as compatible ; otherwise , the condition is classified as incompatible .
statue test from the nepsy : the child is asked to remain standing , pretending to hold a flag , with the eyes closed and no vocalizations , for 75 seconds .
knock - and - tap test from the nepsy : the child is asked to knock on the table with the knuckles when the examiner taps the table with the palm and vice versa .
go / no - go task from the tap   and kitap : the child must press a key as fast as possible when a target ( a cross in the tap or a bat in the kitap ) appears on the screen but not when other images resembling the target are displayed .  
the interference fruit task , based on the stroop word test and adapted from the fruit task developed by archibald and kerns .
this task includes three conditions that can be performed by young children who have not yet learned to read .
contrary to the fruit task developed by archibald and kerns , unlimited time is allowed for naming the colours of the rectangles .
furthermore , we included only three common fruits ( banana , pear , and strawberry ) , whose colours ( yellow , green , and red ) are well known by young children . in the first condition ,
the child is asked to name colours of 45 rectangles as quickly as possible , to provide a measure of processing speed . in the interference condition
, the child must say the correct colours of 45 incorrectly coloured pictures of fruits , ( e.g. ,  yellow  when shown a picture of a green banana ) .
arrows pointing to the left or right are shown on the left or right side of a fixed point .
the child must press a key on the left or right , depending on the direction of the arrow , irrespective of the location of the arrow relative to the point .
when the side and direction of the arrow are the same ( i.e. , leftward - pointing arrow to the left of the point ) , the condition is classified as compatible ; otherwise , the condition is classified as incompatible .
cognitive flexibilityspontaneous and reactive flexibility   were assessed . to assess spontaneous flexibility , we used 1-minute fluency tasks .
verbal fluency was measured based on the names of animals , beverages , and foods , using normative data from the nepsy .
visuospatial fluency was evaluated using the design fluency task from the nepsy . for all fluency tasks ,
the total number of correct responses was determined . to evaluate reactive flexibility , we chose the flexibility task from the tap , in which a letter and a number are displayed side by side on the screen .
the child is asked to react alternatively to the letter and to the number by pressing the corresponding key .
spontaneous and reactive flexibility   were assessed . to assess spontaneous flexibility , we used 1-minute fluency tasks .
verbal fluency was measured based on the names of animals , beverages , and foods , using normative data from the nepsy .
visuospatial fluency was evaluated using the design fluency task from the nepsy . for all fluency tasks ,
the total number of correct responses was determined . to evaluate reactive flexibility , we chose the flexibility task from the tap , in which a letter and a number are displayed side by side on the screen .
the child is asked to react alternatively to the letter and to the number by pressing the corresponding key .
number of models built successfully at the first attempt , total number of trials needed to build the 12 models , planning times , and execution times were recorded . 
 
number of models built successfully at the first attempt , total number of trials needed to build the 12 models , planning times , and execution times were recorded .
working - memory tests included the hand movements and spatial memory tasks from the kabc scale . 

expressive language 
 speech praxisit was evaluated using the praxis tests from the bepl   until the patient was 5 years old and the henin praxis test   thereafter .
the child was asked to imitate movements made by the examiner , such as pulling out the tongue , puffing out the cheeks , or giving a kiss . 

semantic fluencywe used the msca subtest , in which the child is asked to name as many foods , animals , clothing items , and methods of transportation as possible , in 20 seconds for each category . 

phonetic fluencywe used a test from the l2ma , in which the child must say as many words as possible that start with the phonemes /p/ and /f/ , in 1 minute for each category . 

phonologywe used the bepl phonology subtests ( pho1 & pho2 ) until the patient was 6 years old and two subtests from the neel ( monosyllabic and polysyllabic words ) thereafter . in these subtests ,
errors in pronunciation are recorded , and the ratio of correctly named pictures over the total number of pictures is determined . 

subtest from the neel   and the  vocabulary  ( denomination ) subtest of the l2ma , in which the child is asked to name pictures .
repetitionwe first used the bepl , in which the child repeats syllables and sentences ( subtests art . &
after the patient reached 6 years of age , we tested the repetition of syllables and sentences using the neel ( monosyllabic and polysyllabic words , syntax , and number of words ) and the eel ( subtests rep , ph1 & ph2 ) .
morphosyntaxtwo tests were used : the tcg , in which the patient is asked to complete a sentence started by the examiner ; and tvap definitions [ 51 , 52 ] , in which the patient must define words said by the examiner . 

 

speech praxisit was evaluated using the praxis tests from the bepl   until the patient was 5 years old and the henin praxis test   thereafter .
the child was asked to imitate movements made by the examiner , such as pulling out the tongue , puffing out the cheeks , or giving a kiss . 

semantic fluencywe used the msca subtest , in which the child is asked to name as many foods , animals , clothing items , and methods of transportation as possible , in 20 seconds for each category . 

phonetic fluencywe used a test from the l2ma , in which the child must say as many words as possible that start with the phonemes /p/ and /f/ , in 1 minute for each category . 

phonologywe used the bepl phonology subtests ( pho1 & pho2 ) until the patient was 6 years old and two subtests from the neel ( monosyllabic and polysyllabic words ) thereafter . in these subtests ,
errors in pronunciation are recorded , and the ratio of correctly named pictures over the total number of pictures is determined . 

subtest from the neel   and the  vocabulary  ( denomination ) subtest of the l2ma , in which the child is asked to name pictures .
repetitionwe first used the bepl , in which the child repeats syllables and sentences ( subtests art . & rph . ) .
after the patient reached 6 years of age , we tested the repetition of syllables and sentences using the neel ( monosyllabic and polysyllabic words , syntax , and number of words ) and the eel ( subtests rep , ph1 & ph2 ) . repetition of nonwords was evaluated using the belec . 

morphosyntaxtwo tests were used : the tcg , in which the patient is asked to complete a sentence started by the examiner ; and tvap definitions [ 51 , 52 ] , in which the patient must define words said by the examiner . 
 
it was evaluated using the praxis tests from the bepl   until the patient was 5 years old and the henin praxis test   thereafter .
the child was asked to imitate movements made by the examiner , such as pulling out the tongue , puffing out the cheeks , or giving a kiss .
we used the msca subtest , in which the child is asked to name as many foods , animals , clothing items , and methods of transportation as possible , in 20 seconds for each category .
we used a test from the l2ma , in which the child must say as many words as possible that start with the phonemes /p/ and /f/ , in 1 minute for each category .
we used the bepl phonology subtests ( pho1 & pho2 ) until the patient was 6 years old and two subtests from the neel ( monosyllabic and polysyllabic words ) thereafter . in these subtests ,
errors in pronunciation are recorded , and the ratio of correctly named pictures over the total number of pictures is determined .
subtest from the neel   and the  vocabulary  ( denomination ) subtest of the l2ma , in which the child is asked to name pictures .
we first used the bepl , in which the child repeats syllables and sentences ( subtests art . & rph . ) .
after the patient reached 6 years of age , we tested the repetition of syllables and sentences using the neel ( monosyllabic and polysyllabic words , syntax , and number of words ) and the eel ( subtests rep , ph1 & ph2 ) . repetition of nonwords was evaluated using the belec .
two tests were used : the tcg , in which the patient is asked to complete a sentence started by the examiner ; and tvap definitions [ 51 , 52 ] , in which the patient must define words said by the examiner . 

receptive language 
 auditory discriminationwe used the gno subtest from the bepl   until the patient was 6 years old .
subsequently , we used the edp 48-year test , which requires the child to point to a picture corresponding to a word said by the examiner ( e.g. ,  show me the hat  ) . 

word comprehensionthe tvap 35 and 58-year test [ 51 , 52 ] , as well as the evip ( peabody ) , were used . in these tests ,
sentence comprehensionit was evaluated only after 6 years of age , using the o-52   and ecosse   tests .
the child must point to pictures corresponding to sentences said by the examiner ( e.g. ,  show me the picture where the cat is behind the tree  ) . 

the reynell developmental language scales they were used until the patient was 6 years of age .
these scales assess both receptive and expressive language in children between 1 and 6 years of age . 

metaphonologywhen the patient was 8 years old , we used three subtests from the belec   to evaluate the abilities required for written language : syllabic reversal ( e.g. , if the examiner said  pato  , the child had to say  topa  ) , phonemic reversal ( e.g. , if the examiner said  il  , the child had to say  li  ) , and consonant subtraction ( e.g. , if the examiner said the nonword  fepa  , the child had to say  epa  ) . 

 

auditory discriminationwe used the gno subtest from the bepl   until the patient was 6 years old .
subsequently , we used the edp 48-year test , which requires the child to point to a picture corresponding to a word said by the examiner ( e.g. ,  show me the hat  ) . 

word comprehensionthe tvap 35 and 58-year test [ 51 , 52 ] , as well as the evip ( peabody ) , were used . in these tests , the child points to pictures corresponding to words said by the examiner . 

sentence comprehensionit was evaluated only after 6 years of age , using the o-52   and ecosse   tests .
the child must point to pictures corresponding to sentences said by the examiner ( e.g. ,  show me the picture where the cat is behind the tree  ) . 

the reynell developmental language scales they were used until the patient was 6 years of age .
these scales assess both receptive and expressive language in children between 1 and 6 years of age . 

metaphonologywhen the patient was 8 years old , we used three subtests from the belec   to evaluate the abilities required for written language : syllabic reversal ( e.g. , if the examiner said  pato  , the child had to say  topa  ) , phonemic reversal ( e.g. , if the examiner said  il  , the child had to say  li  ) , and consonant subtraction ( e.g. , if the examiner said the nonword  fepa 
we used the gno subtest from the bepl   until the patient was 6 years old .
subsequently , we used the edp 48-year test , which requires the child to point to a picture corresponding to a word said by the examiner ( e.g. ,  show me the hat  ) .
the tvap 35 and 58-year test [ 51 , 52 ] , as well as the evip ( peabody ) , were used . in these tests ,
it was evaluated only after 6 years of age , using the o-52   and ecosse   tests .
the child must point to pictures corresponding to sentences said by the examiner ( e.g. ,  show me the picture where the cat is behind the tree  ) .
these scales assess both receptive and expressive language in children between 1 and 6 years of age .
when the patient was 8 years old , we used three subtests from the belec   to evaluate the abilities required for written language : syllabic reversal ( e.g. , if the examiner said  pato  , the child had to say  topa  ) , phonemic reversal ( e.g. , if the examiner said  il  , the child had to say  li  ) , and consonant subtraction ( e.g. , if the examiner said the nonword  fepa  , the child had to say  epa  ) .
the average motor quotient in the general population is 100 and the standard deviation is 15 .
general intellect was first evaluated when the patient was 4 years 10 months old , using the wppsi - r .
the second evaluation at 5 years 9 months of age showed only a small improvement .
the third evaluation was done using the wisc - iii at 6 years 7 months of age and yielded results similar to those of the first evaluation using the wppsi - r .
wisc - iii results at 8 years 3 months indicated improvements in verbal skills , suggesting a beneficial effect of the special - education program started at 7 years of age . in contrast , nonverbal performances did not improve , and the score on the picture arrangement subtest deteriorated . the last evaluation was done using the wisc - iv at 9 years 8 months and showed results similar to those of the previous wisc - iii .
overall , these data indicate steady progress with persistence over time of the same degree of developmental delay .
the first two evaluations performed at 3 years 9 months and 4 years 10 months were somewhat crude given the young age of the patient .
the results indicated a deficiency in visual selective attention during nepsy tasks ( bunnies and cats crossing task ) .
they were performed at 6 years 7 months , 8 years 3 months , and 9 years 8 months of age ( see table 2 ) .
the results showed a persistent deficiency in visual selective attention despite a possible learning effect due to the repeated administration of the same tests .
deficiencies in divided attention and sustained attention were noted at 8 years at age but not at the following evaluation 1 year later .
the first evaluations consisted only in the nepsy statue test , given the young age of the patient ( 3 years 9 months , 4 years 10 months , and 5 years 9 months ) .
although the parents reported hyperactivity , the results of the first two evaluations was within the normal range .
the third evaluation supported the parents ' report of restlessness , as the raw score remained unchanged , at 11 .
however , a more sophisticated evaluation 1 year later ( at 6 years 7 months of age ) was within the normal range , with no restlessness , despite reports of inattention at home and at school .
difficulty with inhibition was noted at the last two evaluations performed when the patient was 8 years 3 months and 9 years 8 months of age ( see table 3 ) .
flexibility was impaired at the first of these two evaluations but was within the normal range the following year .
for example , during the direct - order digit - span test , the sequence 
3417  became  3457  and during the reverse - order test  7296  became  6789  .
similarly , on the code subtest of the wisc - iv , the symbol  became the number 7 .
planning and organization were within the normal range at 8 years 3 months of age . the last evaluation   ( 9 years 8 months ) showed excessively long planning and execution times on the tower of london test , although the quality of the response was very good , suggesting that the patient took care to comply with the instruction to make as few mistakes as possible .
the serial evaluations showed no progress in working memory for those tests where there is no learning effect ( digit span , block tapping test ) .
tests from the k.abc were impaired at the first evaluation and became normal subsequently ( see table 4 and figure 4 ) . at the last evaluation ( 9 years 8 months ) , storage during the phonological loop and visuospatial sketch pad tasks was insufficient overall .
motor quotients were consistent with the total iqs from the general intellectual evaluations ( see figure 5 ) .
at the first evaluation at 3 years 9 months of age , the motor quotient was 73 . despite regular motor rehabilitation therapy ( two sessions per week throughout follow - up ) , his performance remained stable , with motor quotients of 74 at 4 years 10 months and 76 at 5 years 9 months of age ( see table 5 ) .
performance was poorest on balance , speed , simultaneous movements , perceptive graphic organization , and constructive praxis . at the last two evaluations , the motor quotient was still in the borderline range ( 71 at 8 years 3 months and 70 at 9 years 8 months ) and he had persistent difficulties with balance , speed , simultaneous movements , handwriting , and constructive praxis .
at the first evaluation , praxis performance and auditory processing were within the normal range ; whereas deficiencies were noted in phonology , morphosyntax , and lexical processing ( during both expression and comprehension ) .
the evaluations of expressive language showed weaknesses or deficiencies in phonology until 8 years of age ( see tables 6 and 7 ) .
vocabulary was deficient until 6 years of age and improved thereafter , being weak at 8 years and normal at the last evaluation 1 year later .
the lexical stock was limited but accessible , with no missing words and good semantic fluency .
the bilingual environment in which the patient lived should be borne in mind when interpreting the test results .
however , results on the definitions test were within the normal range at the last evaluation .
passive vocabulary was deficient at the first evaluation and slightly improved but nevertheless weak at the second evaluation ; it developed favourably starting at 5 years of age and was within the normal range at the last evaluation .
syntactic comprehension was tested after the patient reached 6 years of age ; the results were within the normal range until 8 years of age and weak at the last evaluation 1 year later .
metaphonological skills , necessary for learning written language , were investigated only at the last two evaluations ( see table 7 ) .
phonemic division and consonant subtraction were weak at 8 years of age and within the normal range at 9 years of age .
overall , whereas most language test results were weak or deficient at the first evaluation , all language skills except morphosyntax were within the normal range at the last evaluation .
thus , the patient 's oral - language performance was good at last followup , except regarding morphosyntax . moreover , he experienced major difficulties with written language : thus , at 8 years of age he was able to recognize only about 20 letters and to read consonant - vowel syllables made up of those letters .
his writing skills were weak . at last followup , his academic skills were at the level of the second grade of primary school .
this paper reports on the prospective 8-year followup , including repeated motor and cognitive testing , of a patient who sustained a bifrontal brain injury at 19 months of age . to our knowledge , this is the first such case report .
although clinical and ecological observations showed steady improvement , severe impairments persisted in important areas such as the iq , psychomotor skills , and executive functions .
previous reports described either adulthood outcomes after bifrontal injury in childhood or childhood outcomes after unilateral frontal injury .
reported outcomes in 2 patients who sustained bifrontal injuries in childhood and who were evaluated at 28 and 24 years of age , respectively .
both patients displayed severe behavioural disorders , and their social and moral development was arrested at an immature stage .
performance was satisfactory in the areas of language , memory , and visuospatial skills used during daily activities .
proof was not obtained that the brain damage in these 2 patients was strictly confined to the prefrontal areas . in 1947 ,
ackerly and benton described the case of a 35-year - old man who sustained a bifrontal brain injury at about 3 years of age .
however , he had behavioural abnormalities with immaturity , inability to learn from experience , lack of drive and curiosity , and irritability when restricted .
he failed to benefit from the treatments used and 15 years later he continued to display impulsiveness and inappropriate sexual behaviour .
another patient was evaluated 26 years after she sustained a focal injury to her left frontal lobe at 7 years of age . although mri showed a lesion strictly confined to the left prefrontal cortex and underlying white matter , a xenon cerebral blood flow study showed low flow in both frontal regions .
her performance was within the average range for global intelligence , language , memory , and visual perception .
however , she exhibited impairments in sustained attention and executive functions . because all these patients were examined as adults , the relation between the early frontal damage and the cognitive or behavioural deficits remained unclear .
a few prospective case studies were reported more recently . in 1992 , marlowe described how a small injury to the right frontal lobe sustained at 3 years of age disrupted the acquisition of executive and emotional control over the next 3 years , interfering with the development of adaptive behaviours , executive control , emotional regulation , and personality .
the patient performed very well on familiar tasks , displaying age - appropriate planning and self - maintenance . on unfamiliar tasks , however , he tended to loose the plan and failed to inhibit maladaptive behaviour . over the 3-year follow - up
, his intelligence scores remained normal on the wppsi and subsequently on the wisc tests , but he was slow in processing verbal information , exhibited difficulties with visuospatial organisation and productions , and had problems maintaining a mental set .
described the pattern of recovery in a 15-year - old boy who sustained extensive damage to the right dorsolateral prefrontal cortex at age 7 related to rupture and surgical treatment of a deep arteriovenous malformation .
follow - up evaluations 4 and 8 years after surgery showed resolution of left hemispatial neglect and other visuospatial impairments in working memory , design fluency , and planning and organisation .
after 8 years , however , he had an acquired form of attention - deficit disorder with impulsivity [ 32 , 60 ] .
we recently reported alarming data about the intellectual development of children after severe brain injury in early life : a retrospective review of 50 children showed intellectual deficiencies in 52% of cases and deterioration of intellectual abilities over time . in patients with congenital hemiplegia ,
intellectual development was nearly normal until 6 to 8 years of age and abnormally slow thereafter .
this time - course is at variance with the widespread belief that cortical plasticity in younger patients consistently leads to functionally beneficial reorganization within the brain cortex .
the vulnerability of the very young brain may be related to a combination of factors [ 20 , 63 , 64 ] including vulnerability of rapidly emerging skills , vulnerability of established skills , and alterations in recovery or acquisition of skills .
our results are consistent with the hypothesis that brain injury sustained at a very young age is associated with disruptions of cognitive development , especially in the event of bifrontal damage .
he experienced only two brief partial seizures ( less than 1 minute ) and received carbamazepine for 3 years .
late posttraumatic epilepsy and carbamazepine therapy may have contributed moderately to the poor neurodevelopmental outcome . during the 8-year followup after the injury , our patient received one - on - one motor and speech rehabilitation therapy .
however , improvements in motor function were slow , and impairments in visuospatial functions and graphic skills persisted . over time , his intellectual and motor quotients remained within the same range .
most areas were impaired at the first evaluation , including phonology , morphosyntax , and lexical processing , for both expressive and receptive language . at the last evaluation ,
the morphosyntax deficiency may be ascribable to a working memory deficit , as morphosyntax tests involve the manipulation of verbal information .
he continued to experience major difficulties with written language : at 8 years of age , he could recognize only 20 letters and read only consonant - vowel syllables made up of those letters ; in addition , he confused letters of similar shape .
these last difficulties may be ascribable to the deficiency in visual selective attention , corresponding to a more basic deficit .
ewing - cobbs and barnes reported that diffuse head injury in young children adversely affected language development , most notably in the lexical and discourse areas .
tests for attention showed a persistent deficit in visual selective attention , which was not addressed by remedial therapy .
in contrast , symptoms indicating deficient inhibition ( e.g. , distractibility and restlessness ) were reported from the beginning , and some of them resolved over the years .
flexibility was impaired at the next - to - last evaluation but normal at the last evaluation , although clinical observation continued to show perseverative behaviours .
the emergence of executive difficulties during the evaluations was consistently delayed compared to the behavioural observations : thus , the test abnormalities did not coincide with the difficulties reported in everyday life . in addition , some abnormalities resolved from one evaluation to the next yet remained present upon clinical observation .
these data raise questions about test sensitivity , their ecological relevance , and the possible impact of learning effects .
impairments in planning and organisation were detected only at the last evaluation , whereas several wisc - iii subtests ( e.g. ,   picture arrangement , described as sensitive to frontal damage and disordered executive function by van der linden et al . ) were already impaired during previous evaluations .
secondary attention - deficit - hyperactivity - disorder was described in a study of children who were 5 to 15 years of age at brain injury .
executive functions in children who sustained moderate to severe tbi before 6 years of age scored significantly lower than controls on working memory and inhibitory control .
we consider that clinical attentional or executive deficits result from early damage of anatomo - functional frontal system , but language , psycho - motor , and visuospatial skills may result from interaction with executive functioning or directly from more diffuse lesions . repeated evaluations of working memory showed no progress in storage capacities for tests that are not susceptible to learning effects ( digit span and block tapping test ) . at the last evaluation ,
remedial treatment for the attentional and executive impairments was not given , for practical reasons .
regarding behaviour , our patient is the first to be described as exhibiting hyperactivity and difficulties with social integration . over the years , his hyperactivity decreased , and at last follow - up he was almost too quiet and polite .
he experienced persistent difficulties in relationships with his peers , as a result of his interests being appropriate for a younger age group and of his reserved behaviour .
enrolment in a special - education program became necessary when he was 7 years of age .
the school evaluations showed evidence of learning , albeit at a slower pace compared to other children .
thus , at last followup , he was 2 grades behind in french and arithmetic , although he had none of the typical signs of dyslexia or dyscalculia .
our data from a patient with early bifrontal brain damage highlight the importance of long - term followup , as the difficulties change from year to year , in keeping with results described by eslinger et al .
[ 32 , 60 ] . some impairments resolved over the years , whereas new impairments emerged . despite the limitations of the test methods ( limited sensitivity , failure to assess ecological factors , and possible impact of learning effects ) , and despite the limitations of frontal tests ( tests are executive only during the first test ) ,
thus , daily functioning was globally normal in our patient , with an environment adapted to his needs ( remedial therapy and special education ) .
this may change over time , because behavioural difficulties may emerge in response to increasing environmental demands , as described by marlowe   and in studies of adults [ 2729 ] .
to better understand the cognitive outcomes of early bifrontal early injuries , prolonged in - depth followup is essential .
 we describe six psychomotor , language , and neuropsychological sequential developmental evaluations in a boy who sustained a severe bifrontal traumatic brain injury ( tbi ) at 19 months of age . 
 visuospatial , drawing , and writing skills failed to develop normally . 
 gradually increasing difficulties were noted in language leading to reading and spontaneous speech difficulties . 
 the last two evaluations showed executive deficits in inhibition , flexibility , and working memory . 
 those executive abnormalities seemed to be involved in the other impairments . in conclusion , 
 early frontal brain injury disorganizes the development of cognitive functions , and interactions exist between executive function and other cognitive functions during development . 
1. Introduction
2. Method
3. Results
4. Discussion