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Traumatic Brain Injury: Getting the Whole Picture

The numbers are startling: each year, for more than one million children who take part in common activities such as skateboarding, diving into a pool, or just crossing the street, life will never be the same. They suffer a traumatic brain injury (TBI), a condition health experts are now calling "a silent epidemic."

At Mt. Washington Pediatric Hospital, experts in TBI say it's crucial to get a complete picture of the child's history, so that they can plan a successful recovery. These experts from Mt. Washington Pediatric Hospital spoke at the annual conference of the Brain Injury Association of Maryland, which was held at the Maritime Institute in Linthicum.

"It's important to get enough information so that we get the whole picture," says Dr. Antolin M. Llorente, Director of Neuropsychology at MWPH. He added, "This relationship with the school should commence from the moment the child enters the hospital."

Getting the "whole picture" is integral to Mt. Washington's mission of treating the whole child.

Mt. Washington Child Life Therapist Lindie McDonough, a school liaison specializing in children with brain injuries, helps patients cope while hospitalized, and transition from the hospital back into the community.

"For second grade, for instance, we may take them back to class and they'll talk about the fun things they did at the hospital," she says, "or we'll tell the class, 'Johnny' was in the hospital, but he is ready to come back now."

Helping Brain Injury Patients Go From Hospital to Home

A discussion with the two leaders of MWPH's Cognitive Community Group. more >

"We ask parents to really take a look at critical variables such as: Can your child make safe decisions? How do they handle frustration? Would it be appropriate for a school environment? Do they need a rest period...a calculator? Can they be independent at recess?"

McDonough adds that since the returning child may not behave quite the same as before, it's vitally important to educate classmates and others in school about disability awareness, encompassing the entire spectrum from physical thought to emotional challenges to other types of disabilities. As part of that process, teachers also may assign a buddy to the returning child, to assist them, and make sure they don't feel alone.

Boy holding skateboard above his head

Referring to the transition from hospital to school, "This is a process - it's not an endpoint," Dr. Llorente says, adding, "Many times we do not see the full impact of a TBI" until a protracted period of time has elapsed. Because of that delay, as well as other reasons, Dr. Llorente says he works with the school before re-entry to formulate an Individualized Education Plan (IEP) -- essentially an educational roadmap - which enables a child to receive special services such as speech, occupational or physical therapy and special adaptive equipment. That way, if more problems surface later, Dr. Llorente says, he's "already ahead of the game."

"Children cannot advocate for themselves," he says, "therefore, the role of the professional and parent is to get the maximum amount of assistance, counseling and services available when children sustain a TBI so they get the best resources possible." In some instances, Dr. Llorente noted that "you must become a squeaky wheel."

Diagnosing and Treating Psychiatric Issues in Children with TBI

"Half of patients who come in have pre-existing psychological symptoms or diagnoses," says Dr. Harriette Wimms, a pediatric psychology fellow. She and Dr. Andrew Burns, Director of Inpatient Pediatric Psychology Services at Mt. Washington Pediatric Hospital, spoke at the annual conference of the Brain Injury Association of Maryland about understanding and treating existing psychiatric issues in children and adolescents with TBI.

Referring to the issue of delineating between the new injury and a pre-existing condition, Dr. Wimms said, "Many times, aggression, depression and mood swings are frequently associated with brain injury. We have to tease these issues apart," she says.

According to Drs. Burns and Wimms, in a two year period ending in 2009, more than half of those children admitted to Mt. Washington with a TBI (who were older than four), were found to have had a remarkable psychiatric history prior to the injury. Previous diagnoses included Attention Deficit Hyperactivity Disorder (ADHD), Mood/Bipolar Disorder, Oppositional Defiant Disorder, Depressive Disorder, and Anxiety and Eating Disorders.

For instance, the doctors cite issues such as poor impulse control and a lack of attention to the environment as contributing factors to traumatic brain injuries in pre-teen boys, referring to examples like a skateboarding accident, biking without a helmet, or diving into shallow water.

Another important factor to consider is the possibility of Post Traumatic Stress Disorder or Acute Stress Disorder stemming from the injury. Dr. Burns says children may show signs of intense fear, helplessness or horror, avoidance, and/or nightmares or daytime reliving of the trauma.

"They could be having flashbacks," says Dr. Burns. "When there's a struggle to get back to the community, when you go back to school, that's where the clinical aspects come about."

Psychological treatment at Mt. Washington includes individual, group and family therapy, procedural support, assistance with reintegration into the community and other ongoing support as needed. "We help them understand, yes, 'this does stink,' and we know it's hard," Dr. Wimms says.

In order to help patients and their families cope, and ultimately recover, members of the Mt. Washington Pediatric Psychology team say it's important to determine the appropriate "baseline" for behavioral, emotional and cognitive functioning in the TBI patient, to understand the environmental stressors that may impact recovery, and to develop appropriate goals for recovery.

"Let's not forget that family members of children with traumatic brain injuries need help too," Drs. Wimms and Burns noted. "They have to deal with the fact that milestones and events like the prom, may have to be a little different from what they expected," she says, adding how important it is to educate them about support groups in the community, and get them closely involved in follow-up treatment.

In striving to obtain the whole picture of what happens before and after a traumatic brain injury occurs, Mt. Washington's team of experts are able to better help patients and their families address pre-existing behavioral and emotional difficulties, and give them the tools they need to make appropriate, healthy choices in the future.

If you would like to make an appointment or talk to someone about our services, please call 410-578-8600 (Inpatient Programs) or 410-367-2222 (Outpatient Programs).