This is an area that we have specialized in at United Psychological Services for more than 20 years.
The truths about pediatric brain injury from a clinical perspective seen consistently through time:
- The first sign of a brain injury in children is their behavior; which appears hyperactive and impulsive, oppositional and defiant.
- Children are at risk to not outgrow a brain injury and instead the effects can worsen over time.
- Deficits are not always seen immediately and instead may appear several months’ post injury.
- Brain injury in children can have devastating consequences over time, the earlier the injury the worse things can become.
- The risk increases as those injured in childhood move into the aging process.
- Early diagnosis of a process occurring in the brain such as seizures can make a huge difference if treated with medication and cognitive rehabilitation/training.
- Symptoms of seizure can range from a staring attack, to bicycling or thrashing in bed, to a few moments of altered consciousness. Seizures can manifest as an emotional or physical outburst whereby the child becomes unusually aggressive. Rarely does any type of intervention work at that time if the problem is brain driven.
- Seizures can be misdiagnosed as Bipolar Disorder.
- Pediatric brain injury affects the entire family for years after the injury has occurred.
- Things become worse in adolescence as children “grow into their deficits”.
When there is damage to the frontal and temporal areas of the brain and their vast connections, the following deficits can interfere with learning, especially the acquisition of concepts taught during the building block grades. Deficits interfere with learning due to both behavioral and thinking (cognitive) difficulties in the classroom setting.
Behavioral difficulties tend to create the following:
- Difficulty understanding the social nuances of conversation and the impact of their actions and words upon those around them.
- Tendency to perceive the thoughts or emotions of others as similar to their own.
- Tendency to do as they think, act as they want, and operate with total abandon in a hedonistic manner going after the thrills of life with little or no regard for the appropriateness of their behavior.
- Problems understanding the use of empathy and placing themselves in “shoes of someone close to them”.
- Over or under-emotionality, feeling too many emotions, dramatic and hysterical or having no emotions.
- Emotions are more often not predictable, surprising in their occurrence and based upon an emotional reaction that is idiosyncratic or specific to the child.
- Tendency to blame others and not take responsibility for their own behavior, truly believing that they are blameless.
- Highly reactive to the moment, there is difficulty developing a “sense of self” with goals, values, direction in life, political ideations and family values.
- Lack of inhibition, poor impulse control and ability to regulate their own behavior.
- Lack of understanding, insight and prediction of consequences of their behavior.
- Problem of abstract reasoning, ability to see “the whole picture” to anticipate and avoid problems.
Cognitive (thinking) difficulties tend to be seen in the:
- Difficulty recalling newly learned information
- The learning of new information is subject to confusion and incorrect learning
- Poor memory efficiency which limits the ability to learn a lot of new information at one time and store it correctly for later recall
- Selective attention, tendency to select everything to attend to in their environment
- Integration, the ability to apply what they have learned to different settings, situations, problems, and so on, to generalize learning into concepts
- Perseveration, tendency to become stuck on certain issues, thoughts, ideas, results in incorrect learning that persists through time
- Limited problem solving, becoming rigid and unable to generate new solutions when problem solving is unsuccessful
- Tendency to take things very literally and concrete in life
- Word retrieval, difficulty expressing thoughts and feelings
- Problem of verbal and written output to express thoughts and communicate
- Problems understanding concepts that are more abstract especially if based upon previously learned concepts that the child may have missed or not learned correctly.
Patterns seen in pediatric brain injury:
- What might appear to be a minor deficit or difficulty under the age of five years may in fact prove to be highly problematic at the age of ten or fifteen years, or even young adulthood.
- Gifted children or children who have higher levels of cognitive ability compensate for deficits revealing overall average functioning even though they are working as hard as they can.
- Achievement and intellectual assessments are not designed to measure brain injury.
- It is not uncommon for seizures to be diagnosed long after the injury has occurred.
- Mild brain injury is easily overlooked, misdiagnosed, and confused with symptoms of childhood developmental disorders such as attention deficit disorder (ADD/ADHD), learning disability, conduct disorder, autism, bipolar disorder or depression.
- Pediatric brain injury has proved to be more challenging than adult injury especially when it occurred in the first few years of life.
- We are only born with 10 to 20 percent of our brain, 70 to 80 percent of our brain is developed within the first year of life.
- Report cards and progress reports do not begin to show academic problems until concepts the child was expected to learn is necessary for further concept acquisition in the latter grades of elementary school.
- Injuries to the executive reasoning area of the brain and its connections, typical of traumatic brain injury do not become completely understood or seen in the child’s thinking abilities until adolescent years.
TAKE HOME POINTS:
- Children misdiagnosed as a behavior problem never receive the help they need to cope with the cognitive and behavior consequences when there is an injury to the brain.
- Focusing on the child’s behavior can result in missing an ongoing progressive process in the brain.
- Emotional outbursts, attention problems, impulsivity, out of control behavior, as well as aggressive behavior can be symptoms of a brain injury.
- Neuropsychological testing is one of the first methods to document injury to the brain. Testing should be completed by a pediatric neuropsychologist who understands and appreciates the complexity of pediatric brain injury.
- Children with a brain injury can have an acquired attention problem that is not the genetic disorder of ADHD/ADD.
- The finding of a normal CT scan, normal magnetic resonance imaging (MRI), or normal EEG does not rule out the presence of significant brain injury.
The developing child is caught in the continuing spiral of attempting to relearn and/or learn the information that was lost (following the brain injury) while trying to maintain the pace of their peers and still acquire new learning. The result is that they are caught in a world of confusion; ill equipped to learn in a manner similar to their peers.
Consider the idea that due to brain related deficits the child falls behind in learning at least 5 minutes per hour. This means that at the end of a seven-hour school day the child is now behind 35 minutes. By the end of one week the child is behind 175 minutes.
There are no time-outs in life for pediatric brain injury where unseen and undiagnosed deficits become profound problems later in life. Too often the first, last and only diagnosis of a brain injury is ADD which limits the ability to treat and understand the unique problems of this population. Can we truly afford to miss injury to the brain, knowing that things get worse over time if left untreated?