Mild Traumatic Brain Injury in Children



Traumatic brain injury occurs to the brain after a blow to the body or the head.  The trauma such as a fall, a sports injury, or car accident, causes the brain to move rapidly inside the skull.  The traumatic brain injury can damage brain cells, nerves, and blood vessels.  The injury is said to be "mild" if any of these occur:

• Loss of consciousness (black out), lasting less than 30 minutes.
• Change in mental state, such as being dazed, confused, or disoriented, lasting less than 24 hours even when there is no loss of consciousness.
• Loss of memory for events right before the trauma.
• Short lasting minor findings on neurological exam.

A mild TBI is the same thing as a concussion.  Health care providers often will use either term to refer to the same thing.  A person can have a mild TBI without losing consciousness.

 

Injury to the brain is sometimes too small to be seen on CT scan or MRI.  But even injury not seen on these types of tests can result in short and long term problems for your child.  After a mild traumatic brain injury (MBTI), your child may have physical, mental, social, and emotional symptoms.  For most children with an MTBI, symptoms tend to clear up within 3 months.  But, symptoms may last longer.  Sometimes they are mistaken for depression, lack of interest, or anxiety.  Research has shown that early diagnosis of the symptoms of MTBI, with proper follow up, can improve your child's recovery.

 

Doctors, who treat head injuries, agree that the single most important factor slowing recovery is the patient or parent not knowing what to expect and what to do about the symptoms.  Learning about MTBI can reduce the frustration and worry for the child and his family.  Learning to prevent further head injury is also important.

 

What Happens to the Brain after a Mild Traumatic Brain Injury?

 

For children and teens, activities that most often cause mild to moderate TBIs include:

• Team sports which are "high impact" such as football and soccer.  An MTBI can happen in any sport or activity.
• High-speed activities, such as in-line skating, skiing, biking, and skateboarding.  The Centers for Disease Control estimate that as many as 3.8 million TBIs result from sports and other activities in the U.S. each year.
• Risky behaviors or "stunts," like riding or jumping on top of a moving vehicle ("car surfing"), being pulled behind a motor vehicle while riding on a skateboard , etc.
• Motor-vehicle crashes
• Physical violence and abuse

A blow to the head may cause no lasting symptoms.  The brain is somewhat protected by the fluid that surrounds it as well as the skull.  But when the injury is more severe, the extent of the injury can affect the time it takes for the brain to recover.  The injuries include bruising, swelling, and damage to tissues, blood vessels, and other parts of the brain.

 

How Long Will the Symptoms Last?

 

All brain injuries are serious.  Mild traumatic brain injuries are no exception.  People who have MTBI should receive a complete medical exam as well as receive follow-up care.  Mild brain injury itself causes few hospital stays.  Those who are in the hospital do not stay for very long.  While most children who have a MTBI are back to normal well within 3 months, it is very important to prevent future head injuries.  Damage to an already injured brain can lead to lifelong, serious problems.

 

The best way to promote healing after a brain injury is to rest both the body and the brain.  That means avoiding exercise, sports, video games, computers, and reading (beyond what's required for school) in the weeks right after an injury.  Normal activities like bathing, dressing, and attending school are most often OK unless your child's doctor has advised against it.  Although not everyone recovers at the same rate, most doctors agree that your child will recover faster if he gets enough rest once he is home.  Your child should return to his normal routine slowly, not all at once. 

 

Recovery time varies after mild TBI.  It depends on such factors as a person's age, health history, and other injuries.  It will take longer for your child to recover if he has had a previous TBI, a history of migraines, an extended loss of memory for events around the time of the accident, or prolonged symptoms of feeling mentally "in a fog."  Some research shows that 60 percent of people who have had a MTBI often recover in two weeks and 80 percent recover in three weeks.  One in five people take longer than one month to recover from MTBI.

 

Intervention and Management

 

After a mild traumatic brain injury, the health care staff will likely give you certain limits to help protect your child's healing brain and to avoid further brain injury.  Your child may not take part in these activities which carry a risk for further injury.  These would include bike riding, climbing, skateboarding, etc.  Once your child is allowed to return to such activities, protective helmets should be worn.  Drinking alcohol is not a good idea during recovery from a MTBI.  It is very important to prevent another brain injury.  After one brain injury, people are at increased risk for having another.

 

The most common symptoms after a mild head injury are sometimes called the post-concussion syndrome (PCS).  Eight out of 10 patients with a mild brain injury show some of the signs of the syndrome during the first three months after the accident.  These symptoms are part of a normal recovery.  They are not signs of medical problems.  The symptoms tend to begin during the first four weeks.  They most often go away without any special treatment within a few days to a few weeks.  In some cases, symptoms of PCS last longer than a few weeks.  When patients and parents know what to expect, recovery is faster and the child feels better.  Children with PCS sometimes display more extreme behaviors.  For example, a child who was defiant or impulsive before his injury may be more impulsive or resistant to authority after the injury.

At first, some children may find that PCS makes it hard to do schoolwork, get along with others, relax, or focus their energy.  The best way to deal with these changes is to resume the normal routine slowly, a little at a time.  The amount of time the child spends at school, work, and social activities can be based on the child's comfort level.  The child should pace himself and be sure to rest.  If the child's symptoms get worse, or if he notices new symptoms, this is a sign to slow down and rest.  Ignoring symptoms and trying to "tough it out" can make the symptoms worse.  PCS can be viewed as the brain's way of telling your child to rest.  Most children with PCS have more energy in the morning than later in the day.  Your child may benefit from rest breaks or daytime naps.  Studies have shown that one week of relaxing at home followed by a week of slow increase in activity is best for most patients.  Most of the patients who took this advice were back to normal in less time than patients who weren't told what to do.  The patients who weren't told what to do also had more PCS symptoms. 

 

Headache, memory, attention, and concentration problems are among the most common complaints noted after a mild traumatic brain injury. 

 

The Most Common Symptoms Present after a Mild TBI

• Headache
• Dizziness or trouble with balance
• Weakness, tingling, or numbness
• Nausea and vomiting
• Double vision or blurred vision
• Appetite changes
• Problems smelling and tasting
• Problems hearing including ringing in the ears
• Extreme sensitivity to sound, light, noise, over-stimulation, or other visual problems
• Limited energy
• Feeling foggy, slowed down, dazed, or stunned

 

Headaches.  Headaches can be part of the normal recovery process, but that doesn't make them any less of a bother.  Headaches after MTBI are often accompanied by the other common symptoms listed above.  Studies show that paying attention to these symptoms can make them seem worse.  Distraction may help your child not think so much about these symptoms.  Stress or tension is often the cause when the headaches start for the first time after the injury.  Tension headaches might mean that your child is trying to do too much.   Headaches should improve if your child takes a break or shortens his daily routine for a time.  If your child has tension headaches or is stressed, learning to relax muscles can help.  Your child's doctor or a counselor can help you and your child learn more about muscle relaxation.

 

Memory problems.  Many people who have a MTBI do not remember events around the accident (events just before, during or right after).  But, people who have a MTBI sometimes also have problems remembering new information about events since the accident.  They may feel confused about recent events.

Concentration problems are a normal part of recovering from a head injury.  Memory problems are a normal side effect of this.  Writing things down or using a pocket tape recorder are very good ways of coping with these problems.  These techniques will not slow recovery after a MTBI.  Concentration problems can be a sign that your child is pushing herself too hard or that she is over-tired. 

 

Distraction, poor concentration, difficulty doing two things at once.  Your child may find it hard to return to where he left off, if interrupted.  One example is going back to his homework after being called away by a phone call.  Creating a structured and quiet setting can help your child if these symptoms are present.

 

The main cause of poor concentration is fatigue.  When it becomes hard for your child to concentrate, he should take a break and relax for 15 to 30 minutes.  If he keeps having problems, briefly shorten the work day, class schedule, and daily routine.  Reducing distractions can help improve poor concentration.  Encourage your child to work where it's quiet.  Discourage him from trying to do too many things at once.

 

Problems dealing with stress.  After a mild TBI, it's easy to see that your child might have more stress from being in the hospital, getting back to school or work, and dealing with PCS.  Homework can pile up, time is lost, and there may be injuries to other parts of the body.  Another cause of stress after a brain injury is the child's worry about the symptoms he has.  If your child is anxious, you can help him feel better by calming his worries.

 

One of the most frequent causes of irritability is fatigue.  People lose their tempers more easily when they are tired or overworked.  After MTBI, your child may be more emotional, fail to reason as well as before the injury, become more easily frustrated, and have more conflicts with others.  If your child finds herself getting into arguments that cause trouble at home or at school, try to help her change the way she thinks about things.  Problems can often be solved more easily if your child can stay calm.  Your child may become sad or even depressed when unpleasant things happen to her.  An effective way to manage the depression or sadness related to PCS is to make sure that good things happen and frustrating events are avoided, as much as possible.

 

Bear in mind that some children have more problems controlling tears after an MTBI.  Being more tearful may reflect increased sadness, but it may mean only that your child is having more problems keeping her emotions in check.  A psychologist can help you figure out whether your child is depressed or not.

Difficulty reasoning.  Thinking problems can take the form of being unable to analyze one's own behavior, problems seeing the other person's point of view, or being unable to figure out the results of her actions. These problems have to do with foresight, planning, and organization.  Your child's thought processes may also be slower after MTBI.  Your child may need more time to understand and respond in his thinking.  The child may repeat questions and answer them more slowly than usual.  Many of the symptoms of PCS can make it hard to think clearly.  Like these other symptoms, trouble thinking is a sign that your child may be doing too much too soon.

 

Poor skills starting activities and showing less interest in favorite activities.  The child who shows less initiative may appear aimless, lazy, resistive, unmotivated, or irresponsible.  It is important to understand that this symptom may reflect changes in the child's brain.  Providing structure (e.g. a schedule) and helping the child get started doing activities may be a way to help your child if he lacks initiative after a MTBI. 

 

Problems with word finding.  Sometimes after a mild TBI, children have greater problems calling to mind familiar words such as names of people or objects.  This is like "the tip of the tongue" event we all have from time to time.  Be patient.  Provide support and reassurance to help the child cope with these symptoms. 

 

Repeating thoughts and behaviors.  Your child may repeat himself or have problems changing from one activity to another.  Helping your child look ahead may be one way to avoid this problem.  Being unable to change focus or behavior should not be confused with recurring thoughts about a traumatic event.

 

Changes in school performance.  After a mild TBI, children and teens who return to school might have any of the symptoms that interfere with school performance and friendships.  It's very important to tell teachers and other school staff (school nurses, counselors, psychologists, and social workers) about the child's MTBI.  Staff can help the student manage schoolwork, learn coping skills, and avoid feelings of frustration and failure.  Some of these adjustments can help when your child returns to school.

• Teacher or other staff person may need to check school performance.
• Student may need a change in the length and complexity of assignments.
• Student may need help with organization.
• Student may need to postpone major tests.
• Student may need changes to timed tests.
• Student may need rest times.
• Student may need to shorten the school day.
• Student may need to change those activities which require physical skills or pose a risk for a fall or injury.
• Student may need to have his assignments checked.
• Parents need to keep in touch with teachers and staff about overall performance.

Parents should contact their child's primary care provider or other medical staff if the school suggestions above don't help or if symptoms last for more than 60-90 days.

 

Intense emotional reaction.  Strong feelings of sadness, fear or worry, or helplessness might not be a result of brain injury, but the result of post traumatic stress reaction.  Post traumatic stress reaction can include recurring thoughts or dreams about the trauma, acting or feeling as if the trauma were happening at that moment; intense emotions when  exposed to things which remind the person of the event; deliberate efforts to avoid things which remind the person of the trauma; sleep problems; and concentration problems.  Post traumatic stress reaction is not a part of post concussive syndrome but is a psychological reaction to what your child has been through.  If your child shows these symptoms consult your child's doctor or a mental health professional.

 

It can be hard to recognize symptoms of MTBI in infants and toddlers.  Young children may not be able to tell you how they feel and many of the behaviors that go with MTBI, do not apply to infant and toddler age children.

Repeat Injuries

 

A child who has a second TBI before the first has healed can develop life-threatening complications.  This is called, "second-impact syndrome".  That's why your child's health care team imposes activity limits while the brain is healing.  People who have more than one TBI, even months or years apart, can have more serious problems than just the accumulation of two distinct "minor" injuries.  For example, a child who has one mild TBI might have attention or concentration problems for a short time after the injury.  But if that child has another mild TBI years later, attention or concentration problems or other symptoms can be much more serious and long-lasting.  This is because after the first injury, brain damage no matter how "mild" can create much more significant problems.  It's very important to follow the recommendations and safety guidelines that your child's health care team has given you and practice prevention and safe behavior to protect your child from future brain injuries.

 

After Three Months

 

If three months have passed since the child's MTBI and symptoms do not improve as expected, it is a good idea to have your child evaluated.  Neuropsychological testing is an important tool for diagnosing these ongoing problems relating to the child's mental and physical abilities.

 

If neuropsychological testing confirms problems related to MTBI, referrals for therapy and re-training may be made.  Public schools are legally required to provide services such as special tutoring, individual programs, a reduced course load, or learning resource specialists to meet the needs of a brain injured child.  If the child qualifies, parents and teachers, together, can work to develop an Individualized Educational Plan (IEP) to meet the student's need for structure, support, and special help.  Speak with your child's doctor or other members of your child's rehabilitation team if you would like further information about your child's educational rights and needs.

 

Returning to Activity

 

To avoid serious complications, it's important that your child heal fully before returning to sports and other activities.  Before becoming active again, patients must be symptom-free.  Patients also must be able to think and learn as they did before the injury.  Staff in the Pediatric Trauma Clinic can help assess your child's readiness to return to sports.  Patients who have skull fractures or brain hemorrhages most often can't return to the activity for at least six to eight weeks, no matter what symptoms they have.

 

AFCH's "Pediatric Trauma Clinic" under the direction of Lynne Sears, PNP, is designed to provide follow-up care for children and teens who have had mild TBIs.  In that clinic, children are evaluated for post-injury changes of any sort.  When needed, clinic staff also perform physical exams and order tests.  Clinic staff also help patients and families make decisions related to school and returning to sports and other activities.

 

Summary

 

• The most common symptoms after a head injury are known as the post-concussion syndrome.  These symptoms are part of the normal recovery process and are not signs of medical complications.
• Few patients will have all of the symptoms of PCS; the symptoms may not develop until days or even weeks after the accident.  Most patients will be back to normal in three months without any special treatment.
• Most doctors who treat brain injuries agree that recovery is faster when the patient gets enough rest and resumes a normal routine slowly.  If your child's symptoms get worse for a short time or if you notice new PCS symptoms when your child is tired or stressed, this could be a sign that your child needs to rest and relax.
• Slowly adjust your child's work day, class schedule, or daily routine based on the way your child is coping and adjusting.

Keep in mind, if you have concerns about your child's recovery, speak with your child's doctor or members of the team who helped care for your child while she or he was in the hospital.

 

The Spanish version of this Health Facts for You is #6941.

The information provided should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Any duplication or distribution of the information contained herein is strictly prohibited.

Last Updated: 10/25/2010

Copyright © 05/12/2010 University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing. UWH #6328

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