Youth Brain Injuries

Traumatic brain injury (TBI) is the primary cause of childhood injury and death in the United States, with children ages 0-4 and 15-19 at the greatest risk. As many as half a million emergency room visits for children under the age of fourteen are due to brain injury. In part, the high rate of youth brain injury is a result of the inherent risk in common childhood activities, like running around and playing sports. But the fundamental cause is anatomy. Children and teens, compared with adults, have large "bobbleheads" in relation to their neck size, allowing the nerve fibers in their brains to be torn apart more easily.

On a technical level, some of the most severe internal brain injuries are caused by a mechanism called "coup-countrecoup" - jarring the brain against the skull. Most of the time, brain fluid protects the brain from getting too shaken-up inside the skull, but in the event of a severe blow to the head, shaking of a child, or whiplash, brain fluid isn't enough. Coup-contrecoup can result in internal bleeding, bruising, or brain swelling, or tears in the internal lining, tissues, and blood vessels.

When presented with a possible brain injury, doctors will often conduct a combination of physical examinations and diagnostic tests, such as blood tests, x-rays, MRIs, CT or CAT scans, and EEGs, before making their diagnosis. Open head injuries, such as penetrating injuries or skull fractures, are easier to diagnose because their physical symptoms are more obvious. Although internal head injuries are more common, they are still difficult to diagnose due to their oftentimes subtle or overlapping symptoms. The different types of internal brain injury include:

• Concussion - The most common type of brain injury, concussions are caused by trauma from an impact, sudden momentum, or movement change. Although the brain's blood vessels might stretch or cranial nerves might be damaged, a concussion will not always show up on diagnostic imaging tests. Sometimes concussions result in a brief loss of consciousness, but more often a concussed person will remain conscious but feel dazed.

• Contusion - A bruise, or bleeding, in the brain, which can be caused by a direct impact to the head. Coup-countrecoup injuries result in contusions on either side of the brain, where it slammed into one side of the skull and rebounded against the other.

• Diffuse Axonal Injury - When the skull moves faster than the brain inside it, brain structures, such as nerve tissue, can tear and interrupt the brain's regular communication and chemical processes. This type of injury is caused by shaking or strong rotational forces, and can result in a number of different impairments depending on the location of the tears.

• Anoxic Brain Injury - Occurs when the brain does not receive oxygen. More specifically, Anoxic Anoxia results when oxygen supply to the brain is completely cut off, Anemic Anoxia results from blood that does not carry enough oxygen to the brain, and Toxic Anoxia results from toxins or metabolites prevent blood oxygen from being used in the brain. Similarly, Hypoxic Brain Injuries are caused when the brain does receive some oxygen, but not enough for its brain cells to function properly.

• Second Impact Syndrome - Also called "recurrent traumatic brain injury," occurs when a second brain injury is sustained before the symptoms from a prior brain injury have fully healed. The second injury is more likely to cause severe or more widespread damages, such as brain swelling.

Most conscientious observers can recognize the physical symptoms of traumatic brain injury: impairments in speech, vision, hearing, or motor coordination, nausea, headaches, muscle spasms, paralysis, seizure, or fatigue. But brain injuries can also cause cognitive or emotional impairments - particularly difficult to recognize in children, whose cognitive and emotional capacities change and grow so much as they age. TBI symptoms of lacking concentration, slow thinking, short attention span, or deficits in short-term memory, communication, planning, writing, reading, or judgement could be easily confused for any number of learning disabilities. Resulting emotional deficits such as mood swings, denial, self-centeredness, restlessness, lacking motivation, difficulty controlling emotions, anxiety and depression are often mistaken for unrelated mental illness.

With such understated and wide-ranging symptoms, traumatic brain injuries are difficult to recognize and properly diagnose in anyone; but noticing changes due to TBI is especially challenging in children, who are expected to change and grow as they age. In fact, when screening for youth TBI, physicians must compare a child's actions, thought processes, and emotions to the "norms" for his or her age group. A child's symptoms also have a vastly different functional impact than they would in an adult. Even if the TBI is diagnosed and treated early, its long-term effects will be different and likely more severe for a child.

"While the brain undergoes spontaneous recovery in the immediate days, weeks and months following a brain injury," according to Dr. Lori Cook, pediatric brain injury specialist, "cognitive deficits may continue to evolve months to years after the initial brain insult when the brain is called upon to perform higher-order reasoning and critical thinking tasks." Though the "plasticity" of a younger brain may aid children's spontaneous recovery, long-term damages to a child's impressionable and developing brain are typically more devastating than to an adult's. Some of the most common effects of TBI, including trouble processing information or impaired judgement, blend in with the cognitive expectations for a young child. If a toddler wasn't able to solve algebraic equations before his accident, his cognitive symptoms, such as an inability to think through sophisticated problems, won't be noticeable for years after his initial injury.

As such, children "grow into their TBI." When an injured child ages, encountering increasingly abstract thinking or complex problem solving as they get older, the damaged parts of his brain may not be able to keep up with age-appropriate expectations. In the years following TBI, the child may reach a "neurocognitive stall," in which the social or cognitive skills expected of him surpass the ability of his impaired brain. His newly-visible disability can be treated with therapy or accommodated with an individual education plan, but the emotional consequences can be enduring. The child and his peers will likely remember how things were different before the accident, which can cause many social and emotional changes. A child who was injured years ago, when he was an infant or a toddler, may not even remember his injury, making his sudden symptoms all the more frustrating and confusing.

Treatments depend on a variety of factors, including the type of brain injury, its severity, and the child's age. Common treatments for minor to moderate TBI include ice, rest, antibiotics and bandages, observation, and possibly stitches. More severe cases may require breathing assistance, diagnostic tests, or surgery. Since many symptoms of TBI affect a child's ability to perform in school, both socially and academically, parents will often make accommodations for their child through the school's special education department. Even in the most minor cases, an injured child is likely to suffer temporary academic setbacks due to fatigue or an inability to concentrate.

The common modes of brain injury vary depending on the age of the child. For the youngest children, under age four, falls are particularly prevalent, whereas older children are more likely to suffer brain damage from car accidents (either riding as a passenger or hit as a pedestrian). For all children, blunt trauma, including sports accidents, is the most frequent cause of brain injury. In total, for both adults and children, 41% of reported brain injuries are caused by falls, 15% by blows to the head, 14% by car crashes, 11% by assaults, and 19% by unknown causes. But these statistics are likely biased, because many brain injuries go unreported. Cultures of resilience, secrecy, and shame, surrounding athletics and domestic abuse in particular, often prevent brain injury victims from seeking treatment.

While serious brain injuries that occur on the athletic field are easy to diagnose, subtler injuries often fly under the radar. If a soccer goalie loses consciousness after getting hit with the ball, the coach knows he should call for an ambulance. But what if the goalie doesn't lose consciousness, she just looks a little disoriented? What if she's the team's MVP, and she says she feels good enough to keep playing? Combined, these factors contribute to an epidemic of under-reported and untreated brain injuries. Coaches, parents, even athletic trainers want to see their teams win. This group of adults, responsible for evaluating athletes for signs and symptoms of brain injury, is biased toward allowing a possibly concussed athlete to return to play.

Between the incentives of competition or scholarships, and the cultural belief that athletes should be tough, many of the student-athletes who sustain brain injuries will not be given adequate time to recover, if they are taken off the field at all. For an athlete who has suffered a concussion in the past, the risk of future brain injury doubles down. If that concussed soccer goalie goes back to playing before all of her symptoms have cleared up, not only is she more likely to sustain another concussion, the health consequences of her re-injury are much more severe. Repeated concussions put young athletes at risk for devastating conditions, such as second-impact syndrome, early onset dementia, Parkinson's disease, and other neurological disorders requiring neurosurgery.

The topic of traumatic brain injuries in youth sports has garnered a lot of attention in the public media and in state legislatures. Much of this coverage stems from a single tragic event: in 2006, 13-year-old Zachary Lystedt from Washington State suffered a traumatic brain re-injury after his premature return to football with an undiagnosed concussion. The Washington legislature reacted with the 2009 passage of the Lysted Law addressing youth sports TBI, the first of its kind in any of the fifty states. Over the next three years, forty-four other states (including Washington D.C.) passed similar laws, attempting to increase TBI identification and reduce the risk of re-injury. The Lystedt framework features several secondary-level intervention methods, but no preventative measures. In addition to required coaches' training in TBI management and concussion information sheets for parents, Lystedt laws typically mandate a 24-hour minimum removal from play and evaluation by a healthcare professional for athletes suspected of suffering a TBI. Although the laws have certainly put TBI on parents' and coaches' radars, their measures cannot fully prevent re-injury.

Increased public awareness of sports-related TBI is a step in the right direction, but Lystedt Laws alone are not enough. The symptoms and long-term effects of TBI are broad, ranging from headaches to memory loss or other significant neurologic deficits. If TBIs are difficult for health professionals to diagnose, than a coach with cursory pre-season training cannot be expected to accurately diagnose and report every TBI on his field. Even if he could, there is no standard diagnostic metric for TBI, and no nationalized reporting protocol. Additionally, if an athlete is properly diagnosed with any form of TBI, a 24-hour break from sports is not enough recovery time. The only treatment for a concussion is rest - no reading, no TV, no school, no sports - until all symptoms clear up. Even then the student-athlete can't simply jump back into her old routine. She must ease back in slowly, potentially sacrificing her performance this season for a chance to play at all next year.

Another tragically unrecognized cause of TBI, child abuse is estimated to cause 1,400 traumatic brain injuries in the United States each year. But any domestic violence statistic is likely to be under-representatively low. Youth brain injuries are difficult to diagnose in general, but abusive traumatic brain injury combines the challenges of recognizing TBI with the challenges of recognizing child abuse. Domestic violence is underreported and underdiagnosed for a number of predictable reasons: fear of reporting, belief that the aggressor will change, etc. Only 15 percent of abuse victims have visible injuries, so their police reports are often minimized to account for what can be seen. Likewise, emergency rooms inexplicably typically fail to screen abuse victims for brain injury. With abusive TBI in particular, symptoms such as memory loss or mood changes are often misunderstood and can lead to misdiagnosis.

Common consequences of brain injury are easily confused with mental health issues or substance abuse. If a patients is understood to be a victim of abuse, he may suffer misdiagnosis as a result of assumptions about his lifestyle or medical history, even within the medical community. Anxiety, depression, lowered self-esteem, mood swings, and lack of motivation are symptoms both of mental health issues and brain injury. Another common TBI symptom, memory loss, often takes away from the victim's credibility, preventing him from getting out of harm's way. Victims often can't remember an exact sequence of events, and can't explain the event in clear terms. With law enforcement or in a courtroom where the burden of proof resides with the plaintiff, TBI victims can sound like liars when, in fact, poor recall is actually evidence of their abuse.

Early diagnosis of TBI is especially important when the injury is a result of child abuse. The chances of re-injury, and thus second-impact syndrome, are high in a violent environment, where abuses are often repetitive. If violence has occurred once it is likely to happen again, and escalate with each occurrence. Brain-damaging abuses, such as strangulation, are often the last step a perpetrator will take before a homicide. A variety of converging factors, such as youth, victimization, and the oftentimes subtle symptoms of brain injury, make abusive TBI difficult to diagnose in children. But children, with their bobble-heads and undeveloped brains, are also at a greater risk for permanent injury than adults. If a child is returned to an abusive home he is likely to suffer lifelong damages, many of which may not be noticeable until he grows into the full cognitive function of his brain. With such a delay between the injury and the appearance of recognizable symptoms, domestic violence intervention is often too late to prevent a child's permanent disability.

The most common causes of brain injury, car accidents, falls, and blunt force trauma, are also the easiest to prevent. Common-sense practices such as wearing a seat belt or buckling children into an appropriate booster seat for their height, weight, and age, are especially helpful for preventing car accident brain injuries. Concerned parents should fall-proof their homes, making sure to install window guards and safety gates, secure rugs and use rubber mats in bathtubs, and keep stairs clear of clutter that could be tripped over. Children, especially toddlers learning to walk, should play on shock-absorbing surfaces such as mulch or sand. Helmets and other protective equipment should be fitted properly, maintained regularly, and worn consistently when children play sports.

In all TBI scenarios, supervision is key. Kids are going to fall down, they're going to ride in cars or on bicycles, and many play sports. It is impossible to buffer children from every possible cause of TBI, but keeping a watchful eye can go a long way. There are some causes of youth TBI, child abuse in particular, that are impossible to prevent without vigilance. If an initial brain injury cannot be prevented, it is even more important to maintain supervision in order to prevent a devastating re-injury.