TBI Leads to Cascading Problems for a Teenager

Before his brain injury, Andrew earned A’s and B’s in school, he loved to play soccer, he played with his friends, and he was a cooperative kid. At age 15 he was hit by a car in the school parking lot. He was not seriously injured. He broke his left arm and hit his head on the pavement. He lost consciousness for only a few minutes. He went to the emergency room where his arm was casted. He was still groggy, but he knew where he was and he knew the date. So the doctor said his head injury was not serious. The nurse told his family to watch him for the night. If he started vomiting, be sure to bring him back to the emergency department.

Andrew did not vomit, so his family thought he was okay. For the next few days, he was still not feeling well. He wasn’t thinking clearly and felt fatigued. He had headaches. The paper from the emergency department said that this was common after a concussion, but things would be better in a few days.

After two weeks, Andrew returned to school. Things did not seem to click like they previously did. Math was more difficult. He could not remember many of his Spanish words. He worked harder to catch up.

When he worked hard at studying, his headaches and fatigue worsened. So he quit working so hard. His parents were concerned. He needed to work harder to make up for lost time, to catch up. When his report card came, his grades had dropped to C’s and D’s. His parents were not happy.

His mother took him to his primary care doctor just to be sure that his head injury had healed. It was now two months after the injury. Andrew looked fine. He talked to the doctor and answered all the mental status questions appropriately. The doctor felt that Andrew had healed from the head injury.

Andrew had not returned to soccer and he was not doing well in school. His parents felt it was time to get tougher on him. He needed a push to do better. They grounded him from hanging with his friends and from video games until he improved his grades.

Andrew was devastated. His friends and video games helped him feel better. He was working harder than he ever had worked at school and could not improve his grades. Why couldn’t he make things work? He felt more and more depressed.

He became angry at his parents because they didn’t get it. They did not see how hard he was trying. They did not seem to care that his headaches worsened when he worked harder. They did not understand that he could not remember things. He stopped talking to them. He spent hours in his room alone.

One evening his parents went into his room to give him “the talk”. He needed to do his chores. He needed to get studying. Andrew blew up. He began screaming and swearing. He hit the wall, making a large hole. He threatened his sister who was watching. His father called the police. The police came and took Andrew to juvenile detention where he spent the night.

Over the next few months, Andrew did not improve. In fact, his family called the police three more times. He needed to go to court.

His parents took him to a psychiatrist who gave him a diagnosis of oppositional defiant disorder and put him on medication. This made him groggy, but did not improve his behavior.

We saw Andrew in the rehabilitation clinic 14 months after his injury, and it was clear that his struggles were related to his traumatic brain injury. He was not thinking clearly and it was frustrating. His cognitive difficulties had led to poor behaviors. He lashed out and ended up in the criminal justice system.

Fortunately, both Andrew and his family began to understand that his brain injury was the source of this downward spiral. They agreed to see a cognitive therapist. The cognitive therapist was highly experienced in working with teenagers after brain injury. He gave Andrew strategies for learning. He recommended cutting back on his class schedule.

The therapist told Andrew’s parents that their high expectations and behavioral approach were ideal for most kids. But they were not ideal after a brain injury. Andrew needed fewer expectations, at least for a while. He needed structure and support. He needed to hang with his friends and even to play video games as this was calming to him. His brain was not functioning in a normal way, even though he looked normal. His processing was slower. He was depressed and feeling worthless because he could not do what he previously could. He acted out when he felt frustrated and overwhelmed.

It will likely take a while for Andrew to make big changes. But he and his family have change course. Things are heading in a much better directions.

Here are some important points from Andrew’s story:

· After a concussion, you may recover quickly physically, but sometimes symptoms last longer.

· Brain injury can lead to difficulties with mental processing, attention, memory, planning, organizing, initiation, and impulse control.

· Thinking difficulties can lead to emotional struggles and outbursts.

· Headaches are common after brain injury.

· After a brain injury, people may be easily overstimulated and overwhelmed.

· A behavioral approach with punishment usually makes things worse.

· Understanding, structure and support usually make things better.

· The criminal justice system has limited understanding of brain injury.

· Cognitive therapy can help a lot.