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Tarnow Articles

Brain Health: Children and Head Injuries by Sophia K. Havasy, Ph.D., Ron Swatzyna, Ph.D., LCSW, and Walker Peacock, Psy.D.

Good assessment leads to good treatment. One of the keys to a good assessment is an awareness of the scientific advances in research. A good example concerns the connection between strep infections and ADHD in children. We now know that strep infections can exacerbate ADHD. So we ask more questions about the child's history of strep as part of our assessments. New information provided by scientists and health care professionals with better windows into the brain is now telling us to pay more attention to head injuries and concussions, especially in children and adolescents.

Concussion, or Traumatic Brain Injury (TBI), refers to a range of head injuries that can occur either from a blow to the head, or from a violent jolt like a whiplash. Concussion may or may not involve loss of consciousness. This is an important point because there is a common misconception that a concussion only occurs if a head injury results in a loss of consciousness. A football player may deny ever having a concussion but will tell you, "I've had my bell rung a few times." In fact, injuries involving loss of consciousness account for only 8% to 19% of all sports related traumatic brain injuries.1,2

Concussions involve a complex process of kinetic energy shaking the brain abruptly, causing the brain to compress against the interior of the skull. The ensuing bruising, inflammation, axonal shearing, and biochemical processes interfere with blood flow to the brain, limiting access to the brain's primary power sources: oxygen and glucose. Immediate physical symptoms associated with concussions include nausea, vomiting, headache, visual disturbances, and light sensitivity. The victim of a head injury may be temporarily disoriented, unsteady, have trouble focusing, and become more emotionally reactive.

Additional difficulties associated with head trauma include impairments to cognitive functions such as attention, focus, reaction time, and memory. Injury to certain areas of the brain can also result in personality change, irritability, or impulsive behavior. Post-concussive syndrome is diagnosed when symptoms persist for greater than 6 months following injury. If untreated, these impairments can lead to later difficulties in school and in life. According to jail and prison studies, between 25% and 87% of inmates report a history of TBI.3,4 It should be noted that while such a high correlation might imply that brain injury leads to behavioral difficulties, it is also possible that preexisting behavioral difficulties make one more prone to participate in dangerous activities.5

Children who sustain a mild traumatic brain injury are at significant risk for later psychiatric disorders. 20% of children who suffer a mild TBI and 62% of children who suffer a severe TBI will develop a new psychiatric disorder within 2 years following the initial injury.6 Additionally, the anxiety and depression that often result when someone experiences a loss of functioning only make the post-concussive syndrome worse. Teasing out what is the head injury and what is the traumatic reaction to the head injury can be very difficult and requires a thorough physical and psychological evaluation.7

The Center for Disease Control (CDC) estimates that between 1.6 and 3.8 million sports-related concussions occur each year, and that nearly 135,000 children suffered a sports-related concussion between 2001 and 2005.8 Many of these children are cleared to return to play too quickly. A recent study in Ohio found that in 1308 incidences of concussions reported by athletic trainers, 38-55% of the injured athletes were returned to play too quickly.9 Given that concussions are often minimized by athletes or not recognized by coaches, a serious concern is the unknown number of athletes who continue to play without even receiving an evaluation.

In those cases that are serious enough to warrant a trip to the emergency room, physicians often order CAT scans or MRI's to assess for serious injury. Unfortunately, these scans only identify structural damage and are not reliable instruments to assess mild TBI.10 In fact, a series of studies from 1994 to 1999 found that fewer than 10% of CAT scans were effective in diagnosing TBI in children.11-14 Mild to moderately damaged brains have been functionally altered but often lack identifiable structural damage. Many times, patients with these mild to moderate TBI's are instructed to take it easy and avoid contact sports until they are symptom-free for a week or more. The resolution of symptoms, along with the amount of time someone needs to be symptom-free before being medically cleared, is difficult to establish. Traditional thinking has been that for 80% of people, the head injury resolves relatively quickly and the person returns to normal functioning within a few days or weeks. A 23-year follow up study has found, however, that 40% of pediatric survivors of TBI will continue to experience physical, emotional, and cognitive symptoms one to two years following the initial injury. The same study found that up to 23% of the pediatric subjects continued to experience deficits five years after the injury.15

Understanding more about concussions make the Ohio study figures on return-to-play more alarming. Once a person has had a concussion, he or she is more vulnerable to having another. Second- impact syndrome is a serious condition that can occur when someone suffers a second concussion before fully recovering from a prior head injury. Such second impacts can potentially be fatal. David Hovda, director of the Brain Injury Research Center at UCLA, is quoted as saying, "[A] concussion produces an energy crisis in the brain. A second concussion will cause such an energy demand that it will overwhelm the survival capability of the brain."16

Although rarely fatal, repeated concussions can have negative consequences that last years, and even decades. A recent research finding looks at the long-term consequences for individuals who have suffered multiple sport concussions as young athletes. In an article published in January of 2009, a Canadian team of researchers looked at healthy former athletes (average age 60 years old) and compared those who had no history of concussion with those who had experienced their last sport-related concussion in their 20s. Their findings ". . . provide evidence for the chronicity of cognitive and motor system changes consecutive to sports concussion."17 These former athletes continue to deal with changes in their brains that resulted from head injuries experienced 30 years ago. The National Football League has only recently been investigating the increase in incidences of early dementia and depression in former players who suffered head injuries.

The American Academy of Neurology has guidelines regarding assessment, treatment, and return to play considerations following a potential concussion.18 These guidelines are 11 years old and have come under criticism for being too broad and lacking in specificity. The most prudent recommendation that has come out of the debate is for all student athletes to have neurocognitive testing in the preseason and again following any head injury. Preseason testing can provide a baseline of neurocognitive functioning and can help determine the extent of any trauma suffered.

The Tarnow Center offers such testing, and we administer a neurocognitive battery to all incoming children and adolescents. We tend to think in terms of vulnerable brains, especially with our child and adolescent clients. Younger brains are still developing, and are therefore more susceptible to brain injury. We also think in terms of flexible brains. Research has shown (and we have seen in our practice) that with the right exercise and repetition, damaged brains can return to baseline functioning, and healthy brains can improve from baseline. One such method we use is QEEG-guided neurotherapy (EEG biofeedback), which uses operant conditioning to teach patients how to normalize dysfunctional brainwave patterns. Quantitative EEG is an empirical, objective and non-intrusive statistical evaluation of the neuronal electrical activity that has been show to be highly accurate in identifying MTBI and Post-Concussive Syndrome.19

In order to establish that baseline, we use the CNS Vital Signs neurocognitive battery (CNS).20 The CNS is a brief (30 minute) assessment that examines the following domains: verbal and visual memory, cognitive processing speed, reaction time, complex attention, and cognitive flexibility. We primarily use the CNS to assess for difficulties with attention, focus, and processing speed, but specific tests included in the CNS are also sensitive to the effects of brain injury.21 Therefore, given our baseline scores, if a child suffers a head injury, subsequent testing will tell us which functions of the brain have been affected and will also help determine the best course of treatment.

Many sports programs in Texas have adopted the American Academy of Neurology's recommendation for preseason and post-injury neurocognitive testing. We encourage all schools to follow this recommendation, regardless of the student's age. The two age groups most at risk for TBI are children aged 0 to 4 years, and adolescents aged 15 to 19 years.22

If your program does not offer such testing, or if you would like to learn more about how an assessment program can be implemented at your school, please contact Dr. Ron Swatzyna at 713.621.9515.

References:

  1. Schultz, M.R., Marshall, S.W., Mueller, F.O., Yang, J., Weaver, N.L., Kalsbeek, W.D. et al. (2004). Incidence and risk factors for concussion in high school athletes, North Carolina, 1996-1999. American Journal of Epidemiology, 160(10), 937-944.
  2. Collins, M.W., Iverson, G.L., Lovell, M.R., McKeag, D.G., Norwig, J., & Maroon, J. (2003). On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clinical Jounral of Sport Medicine, 13(4), 222-229.
  3. Morrell, R.F., Merbitz, C.T., Jain, S., & Jain, S. (1998). Traumatic brain injury in prisoners. Journal of Offender Rehabilitation, 27(3-4), 1-8.
  4. Slaughter, B., Fann, J., & Ehde, D. (2003). Traumatic brain injury in a county jail population: Prevalence, neuropsychological functioning and psychiatric disorders. Brain Injury, 17(9), 731-741.
  5. Brown, G., Chadwick, O., Shaffer, D., Rutter, M., & Traub, M. (1981). A prospective study of children with head injuries: III. Psychiatric sequelae. Psychological Medicine, 11, 63-78.
  6. Shaffer, D. (1995). Behavioral sequelae of serious head injury in children and adolescents: The British studies. In S.H. Broman & M.E. Michel (Eds.), Traumatic Head Injury in Children (pp. 55-69). New York: Oxford University Press.
  7. Bryant, R.A. Disentangling mild traumatic brain injury and stress reactions. (2008). The New England Journal of Medicine, 358, 525-527.
  8. Concussion in Sports Factsheet
  9. Gregory, S. Hard Knocks. How to keep high school kids with concussions on the bench. (2.2.2009). Time. 63-64.
  10. McAllister, T.W., Spoarling, M.B., Flashman, L.A., & Saykin, A.J. (2001). Neuroimaging findings in mild traumatic brain injury. Journal of Clinical and Experimental Neuropsychology, 23(6), 775-791.
  11. Davis, R.L., Mullen, N., Makela, M., et al. (1994). Cranial computed tomography scans in children after minimal head injury with loss of consciousness. Annals of Emergency Medicine, 24, 640-645.
  12. Homer, C.J. (1999). American Academy of Pediatrics technical report: Blunt head injury in children. Pediatrics, 104, 1-7.
  13. Schunk, J.E., Rodgerson, J.D., & Woodward, G.A. (1996). The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Pediatric Emergency Care, 2, 160-165.
  14. Quayle, K.S., Jaffe, D.M., Kuppermann, N., et al. (1997). Diagnostic testing for acute head injury in children: When are head computed tomography and skull radiographs indicated? Pediatrics, 99, 1-8.
  15. Klonoff, H., Clark, C., & Klonoff, P.S. (1993). Long-term outcome of head injuries: A 23-year follow up study of children with head injuries. Journal of Neurology, Neurosurgery, and Psychiatry, 56, 410-415.
  16. Gregory, S. Hard Knocks. How to keep high school kids with concussions on the bench. (2.2.2009). Time. p. 64.
  17. De Beaumont, L., Theoret, H., et. al., Brain function decline in healthy retired athletes who sustained their last sports concussion in early adulthood. (2009). Brain Advance Access, 1-14, p. 1.
  18. Gregory, S. Hard Knocks. How to keep high school kids with concussions on the
    bench. (2.2.2009). Time. 63-64.
  19. Thatcher, R.W., Walker, R.A., Gerson, I. & Geisler, F.H. (1989). EEG Discriminant analyses of mild head trauma. Electroencephalography and Clinical Neurophysiology 73, 94-106.
  20. Gualtieri, C.T. & Johnson, L.G. (2006). Reliability and validity of a computerized neurocognitive test battery, CNS Vital Signs. Archives of Clinical Neuropsychology, 21, 623-641.
  21. Gualtieri, C.T., & Johnson, L.G. (2008). A computerized test battery sensitive to mild and severe brain injury. Medscape Journal of Medicine, 10(4), 1-18.
  22. Langlois, J.A., Rutland-Brown, W., & Thomas, K.E. (2006). Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Diesease Control and Prevention, National Center for Injury Prevention and Control.