I was recently consulting at a regional school for children with learning disorders, traumatic brain injury, autism, neurodevelopmental disorders, etc.  As we were reviewing patient records, the question was raised whether a young teenager had experienced early acquired brain injury.  One of the staff commented “No.  She had a scan and it was negative”.  I inquired as to what type of scan, the magnification available for the scan, and what was the medical history suggesting a scan.  The expectation was that if there had been a brain injury of any type, it would have been identified by the scan.    Myth #1                              

Another discussion evolved around the “physical” manifestations of acquired brain injury.  The expectation was expressed that there would be obvious physical signs of such an injury – hemi-paresis, physical anomalies (e.g., “drag a leg and drool”), severe developmental delays, disruption of motor movement, mental retardation.   The expectation was that such a patient is likely to be easily recognized.                    Myth #2                                                                                                      

In the course of review of children identified for consultation, one child, roughly age six or seven, was observed to be aggressively attacking a peer who had taken their book away.  He was hitting, kicking, and even biting.  It was obviously necessary to restrain the child physically, two aides having a difficult time, even given their size and strength.  “He is just “MEAN”!  He is one of the children with severe psychiatric problems!”  I asked to see the child’s chart, finding a history I had expected likely the case.  A review of the medical history reflected a particularly traumatic delivery, the boy “stuck” in the birth canal for an extended period of time, but other than some scratches “looked fine” post delivery.  Mom was reassured that he “was fine and would have no problems”.   Myth #3                                      

At the end of the consultation, walking out to the car, the director of the program thanked me for coming, and shared with me the experience her own daughter had experienced.  She was riding her bike in the neighborhood (without a helmet), when she lost control, into a utility pole, striking her head.  “She was crying but did not get knocked out.  She was just cried, got up, and walked her bicycle home!  Thank heavens she didn’t have a brain injury.  She didn’t lose consciousness.”                             Myth #4

Undoubtedly, more than any generation before us, we have more opportunity to experience brain injury.  Beginning with transportation, cars, planes, bicycles, followed by toys that create the opportunity, including Big Wheels, trampolines, skating, etc., we generate an amazing number of traumatic brain injuries.  As reported by the American Associations of Neurological Surgeons (AANS.com), at least 21% of traumatic brain injuries in children were a result of recreational or sports related activities.  There are statistics that surprised me!  Even with our technology of air bags, seat belts, helmets, injury to the brain still occurs, but the severity decreases, the brain injury less obvious. On one hand, as a clinical neuropsychologist it is job security, there is plenty of work to go around!  The depressing thought, in looking at the statistics for known brain injuries, with the exception of an Emergency Room visits, is how many brain injuries are not recognized as significant, and did not receive optimal support.  Another story, another time!

Probably the most basic function of the brain is that of being an impressive “regulator/organizer”, at least when it is working properly!  It regulates and organizes EVERYTHING we do.  Truly, the brain gets a lot of help from its “friends”, such as the heart, the lungs, stomach, and others, all of which have specific basic functions to perform. The brain is the “organizer” of ALL functional capacity.  Even when we are asleep, the brain is “on the job”.  When the brain is injured, there are functional changes that are common, predictable, and often obvious, if you know what you are looking for.  The symptoms are similar for children and adults, but given often adults hide “symptoms” better than kids. Adults have better control of their nervous systems by virtue of their age and physical maturity, and as such, symptoms are not usually as obvious.  A concern for children is that brain injury can disrupt developmental progression, children potentially not keeping up developmentally.

Aside from the most extreme pathology or injury (e.g., severe TBI, brain tumors, physical manifestations (e.g., appearance, motor, function), the most prominent symptoms are emotional/behavioral, often diagnosed as “psychiatric disorders”, not particularly extreme in their manifestation.  Parents may describe a “change in personality.  Any of the following can be seen in normal kids, but when the numbers of behavioral characteristics increase, the potential for neurologic injury increases.  Infants with early brain injury are often described as unable to negotiate the nipple, having a poor “suck”, not feeding well. Some exhibit extreme “colic” (but not really colic), becoming easily over-stimulated (e.g., noise, being held, bright lights, noisy environment). As kids develop, the demands increase.  Sometimes they are late in developing (e.g., walking, talking), sleep may become more disrupted.  Loud noises become disruptive, the child startling easily, and possibly to an extreme degree.  Self-calming behaviors become more prevalent (e.g., “rocking” themselves), or other repetitive movement. Language delays may be observed.  Slow developing motor function (e.g., not coordinated), multi-tasking, delays walking, poor coordination) are all potential contributors. 

As the children get older, problems become to show up in decreased social awareness, not reading social cues.  Inability to read social cues is often a problem; kids not making friends or not keeping friends.  Computational math is a frequent prominent weakness in academic progression, slow in developing.  Anger and related behavior problems become more pronounced, more reactive, more likely to seek a “physical’ solution (e.g., increased aggression, biting, kicking, hitting).  Emotional volatility, confrontation, volatile temper, and generally poor mood regulation can be observed to varying degrees in children.  This group of children often becomes lost, exhibiting poor visual/spatial skills.    They do not keep up developmentally with their age mates.

All said and done, no child has all of these, normal children will have some.  There is much be done to help the child and facilitate developmental progression.  Early intervention is always suggested.  The constellation of behavior is always somewhat unique. 

Questions are invited for discussion within the group.

Responses to Myths:

Myth #1 – Scans are a very valuable tool but not capable of identifying all brain injury, especially in the more mild range.  Some scans are not capable of picking up the subtley.

Myth #2 – Physical appearance, while perhaps obvious in some extreme forms of acquired brain injury, is never a particularly universal or reliable marker.

Myth #3 – Hypoxia is a potential consequence of some birth complications or trauma, injuring the brain, but not readily obvious in more mild to moderate injuries.

Myth #4 – Loss of consciousness (LOC) is not necessary nor is it always present for some brain injury, particularly for birth complications.