Wednesday, May 1, 1996
SAN JOSE MERCURY NEWS

Head Bumps Can Cause Big Problems

What mother can forget the first set of stitches? In our house, it happened when my first son, Ben, was 2 years old and so excited to show a family friend the big spider web hanging over the kitchen sink that he ran head-first into the cabinet corner. There was blood everywhere and, when we could calm him down long enough to look, a deep gash in the middle of his forehead. It took four stitches and five minutes in a straitjacket to repair the damage.

Naturally, my mind was replaying this scene during a recent conversation with Donna Jackson, director of Children’s Therapy Center in Gilroy, on the subject of mild head injuries and their possible long-term repercussions.

“We have children come to us in which there was no birth trauma, no drugs involved in pregnancy and no accident. When doing an assessment and trying to put together a picture, we find that there are too many things wrong for there not to have been a trauma,” says Jackson, an occupational therapist. “And when we ask the parents about their history, they remember a huge goose egg at 2 years old when the child had a big fall.”

Of course, all children fall and bump their heads. The vast majority suffer no lasting damage. You fall, you pick yourself up: Isn’t that what life is all about? And anyway, isn’t traumatic brain injury (TBI) a fairly obvious diagnosis?

Not a simple diagnosis

The answer is no, not always. A mild head injury can go undiagnosed for years, since many children who suffer one rarely lose consciousness. A constellation of symptoms (blurred or double vision, sleepiness, irritability, nausea, vomiting) should serve as a warning sign for immediate medical evaluation.

“Most minor head injuries resolve without major consequences,” says Catherine Popell, a Mountain View neuropsychologist specializing in brain and spinal cord injuries. Parents need to be alert, as they are when their child gets a minor cold. ’'Most colds never develop into anything serious, but if anything unusual develops a physician should be seen. If what appears to be a minor injury to the head results in lethargy, a change in pupil size or vomiting, the child should see a physician.’'

Classic effects of a mild to moderate brain injury may include problems with attention, concentration, memory, irritability, frustration, depression and subtle personality changes. So it’s not surprising that a TBI may be easily mistaken for attention deficit disorder (ADD), learning disabilities or even normal teen-age rebellion.

Over the past three months, Dr. Popell says she has seen three adolescents, all of whom exhibited a rebelliousness that their parents initially chalked up to normal teen-age behavior. “Except that it went on and on. Finally MRIs or CT scans were taken and they found brain damage in all three. One happened at age 8, when the child had a bicycle accident. He had stitches, but the doctors told his parents he was going to be fine. Another child had run into a pole and got black eyes; they went away and then they came back.”

A child who has had a mild brain injury may actually “grow into” his disability with time. Says Jackson: “When you’re 2, the parts of the brain that are expected to function when you’re 10 aren’t even working yet. So there might be damage but you won’t know it till you’re 10.”

“These children often have major motor planning problems. They cannot put words into a motor movement. So if you give a direction, ’I want you to go to your room, get your books, and meet me in the car’ they may be processing the words to the first part of the command and not get the rest of it.”

Compensatory skills

Most children (and adults) can be taught compensatory skills to help them cope. One young patient of Dr. Popell, who was left with a poor memory after a bump to the head, learned to write everything down in an agenda book that his father purchased for him. Every night after dinner, father and son would pour over their Daytimers, checking off what had been accomplished, and moving what had not into the next day’s page.

In the past few years, schools have been mandated to provide special services for children with traumatic brain injuries. These children may need speech therapy, occupational therapy, adaptive physical education, smaller class sizes, and a one-on-one approach to new concepts.

Yet too many schools, according to Richard Delmonico, a clinical neuropsychologist at Santa Clara Valley Medical Center, still treat the brain-injured child as “someone with a personality flaw.”

Dr. Delmonico referred to a 14-year-old patient whose academics are very good. “But behaviorally, he looks like someone who’s had a brain injury: difficulties with attention, impulsiveness, difficulties modulating his anger and frustration. This kid has been identified as a behavioral problem throughout his schooling, but it’s gotten worse over time. He’s in junior high school now, and he’s being sent to the principal’s office all the time.”

This particular boy suffered minor brain injuries after several big falls he took as a child.

Several?

“It’s not uncommon,” says Dr. Ben Mandac, a pediatric rehabilitation doctor at Valley Medical Center.

“One head injury begets another head injury and it becomes cumulative,” says Dr. Mandac. “You become more impulsive and you can put yourself in a position that you will hurt yourself again, and consequently have another head injury. There are certain children, because of their own personality, hyperactivity, ADD, or whatever there is, who are more at risk of having certain brain injury. Falls are the number one cause of head injury in children. Lots of children climb. Most don’t fall.“

Copyright 1996 San Jose Mercury News