By: David E. Nilsson Ph.D ABPP/CN
Editor’s Note: This article is directed at parents rather than professionals, however PediaStaff has chosen to feature it as a resources to share with the parents and guardians of your kiddos with brain injury.
A significant percentage of children who have been diagnosed with Autism or Asperger’s Syndrome have likely experienced some form of brain injury, often not recognized as having occurred. There is another percentage of that population where the etiology of the symptoms is unknown. But, in either event, the brain for such individuals is not functioning normally. Many children with a variety of emotional/behavioral disorders have some form of acquired brain injury, often not recognized or diagnosed.
It is not typical to think of children when one thinks of strokes, but an impressive number of children of infants born experience vascular events, the percentage reported in different studies has been estimated to be somewhere between 15% to 20%, conservatively. (Google “perinatal vascular event”) For a majority of those patients, there is no indication or evidence of outward manifestation of a stroke. Many of the strokes are a result of maternal clotting disorders (e.g., Factor 5 Lyden anomalies), a common occurrence. Most commonly, such events pass unnoticed, even to the most studied eye; the neurodevelopmental consequences become more evident as the child develops. The most disruptive influence of any form of brain injury is disruption to ongoing neurodevelopment. As the child develops and demands for speed and complexity increase, the consequences of vascular event become more apparent.
Our culture tends to think of someone having sustained “a brain injury” as being “retarded” or otherwise mentally compromised (e.g., intellectually, socially, or emotionally). The consequences of such an injury can be negligible, not obvious even to individuals who know the child very well. Sometimes brain injury “disrupts” to some degree ongoing neurodevelopment and behavior, even just to increase “neurogenic irritability”, the child becoming more irritable and reactive, exhibiting low stress/frustration intolerance, over-reacting to increased levels of stimulation. Contrary to popular belief, a child can sustain a brain injury and still become a “Rocket Scientist”, “Astronaut”, doctor, etc. However, for optimal benefit, the diagnosis should be made early, the symptoms recognized, and initiating treatment intervention, adaptation/accommodations, medication, and other interventions. There is considerable diversity of treatment intervention support available to facilitate successful developmental and neurodevelopmental progression of the individual child. Many children with acquired brain injury go on to excel. To facilitate success, treatment and developmental support increases the opportunity to develop optimally!
How do I know my child has sustained a brain injury? In most cases, the injury, or at least the potential for acquired brain injury, is dictated by the severity of the event. The more severe the event (e.g. motor vehicle accident, traumatic brain injury, infectious disease of the brain, extended loss of consciousness, stroke), the more likely severe compromise to the brain. Where a CT scan is performed, sometimes it helps to identify injury to the brain, but brain scans are not always particularly helpful. CT scans are usually used emergently, given their sensitivity to identifying blood outside of the vessels (e.g., stroke, hemorrhage). However, when the brain has healed, standard CT or MRI scans are not likely to pick up the consequences of the brain injury, unless it is a severe injury. There are more powerful MRI scans available to identify more subtle residuals of an acquired brain injury.
Perhaps a more sensitive clinical means of identifying acquired brain injury has occurred is by observing changes in behavior, personality, or functional capabilities. The most obvious consequence of a brain injury of significant severity is that of loss of consciousness, sometimes with emesis (e.g., throwing up). However, beyond loss of consciousness, other indications are less obvious. The most prominent behavioral symptoms of a traumatic brain injury are those of changes in behavior or changes in regulation of mood or emotion. The patient is identified as more irritable, reactive, exhibiting low stress or frustration tolerance, becoming easily over-stimulated. Such children tend to become easily over-aroused, the brain not regulating “over-stimulation” and arousal as previously. Obviously, this could be a problem where the patient has been injured in utero. Parents often describe a “change in personality”, often described as “acquired PMS”, given the reactive irritability, low stress and frustration tolerance commonly observed. Other changes include disruption of sleep patterns, actually becoming more somnolent (e.g., sleepy), fatigue with unusual facility, etc. Some headaches may be a result of an acquired brain injury, with resulting low stress tolerance, high levels of arousal, low frustration tolerance etc. Usually there are multiple symptoms identified.
Some groups of children having acquired brain injury experience disruption to ongoing development of cognitive skills and abilities. There may be a change in how they learn. A side effect for more severe brain injury is that of developing characteristics of “nonverbal learning disorder”, reflected in the child’s difficulty with conceptually integrating and organizing information. Socially they struggle to read social cues or to understand “cause-and-effect”. Computational math is commonly a problem. In other cases, it may be disruption to language, depending on the nature of the injury. A brain scan it is not very helpful in diagnosing previous injury. Commonly, neuropsychological evaluation is more helpful in understanding the overall pattern of memory, learning, and general function, providing information in considering treatment plans to optimize neurodevelopmental progression, and school support.
Historically, the possibility of “brain damage” or “brain injury” strikes fear into the heart of every parent, spouse, or grandparents. Where in some cases, severe brain injury is potentially devastating, in the majority of cases, while the consequences are present, there is a variety of support and compensatory strategies to be learned and implemented to facilitate the child, adolescent or adult’s learning and minimizing their disruption.
Intervention Considerations
While brain injury is scary and of concern to many parents, family members and others, the good news is that we now know a lot more about brain injury, causes, potential problems, and interventions of benefit. Future blogs will address the symptoms, intervention strategies of benefit and optimizing current development progression and developmental outcomes to minimize the consequences of brain injury. Watch for them!
Featured Author and Organization: David E. Nilsson Ph.D ABPP/CN and the NeuroDevelopment Resource Center
David E. Nilsson Ph.D. ABPP/CN is a clinical neuropsychologist having offices in Salt Lake City, UT and Boise, ID (long story). Although he sees children, adolescents, and adults, his practice is more predominantly pediatric, having begun his career as a pediatric neuropsychologist at Primary Children’s Medical Center in Salt Lake City. He has been committed not just to neuropsychological testing but to identifying and implementing aggressive early neurodevelopmental treatment and support, a critical contribution of pediatric neuropsychology in collaboration with other clinical disciplines.
The NeuroDevelopment Resource Center was organized as a means of sharing information, educating parents, educators, and clinicians, and “Understanding the Logic”, the title of his website/blog (http://www.neurodevcenter.com). The Center provides diagnostic and clinical support to patients and their families, identifying and implementing traditional and novel strategies (e.g., NeuroFeedback).