I have been working clinically with children with head injury now for over 12 years and this has allowed me to see the longitudinal effects of childhood head injury for myself. What I have noticed is that some children with what appeared to initially be mild head injury (i.e. no prolonged loss of consciousness) continued to have problems over time. I have looked at these cases in some detail and their developmental problem can’t be explained by pre morbid functioning (i.e. any difficulties before the head injury). This experience is not what the textbooks say is supposed to happen. Mild head injury is thought to be associated with better prognosis and is very rarely followed up by medical services. However, three new studies this year suggest that Mild Head Injury may result in more problems than previously though.

A new study reported in the Journal of Head Trauma and Rehabilitation looked over time at preschool children (before the age of 5) who suffered a minor head injury. They reaseessed these children at age 14 to 16 years and found that the group who had been hospitalised with MHI were significantly more likely to show symptoms of ADHD, conduct/oppositional disorder, substance abuse and mood disorder than a control group or a non hospitalized group.

This research group also reported in a separate journal with similar findings and the results are summarised in the excellent child psychology research blog. As Nestor Lopez-Duran the blog’s author reports ‘ the data strongly links TBI history to the presence of ADHD and conduct disorder symptoms years after the injury, and regardless of the underlying mechanism”

These studies are also on the back of another study by Keith Yeates and his research group published in Pediatrics . They found persistent problems more than 12 months after mild head injury.

So what are the implications of this. Firstly I think we need to look at categorisation of head injury in children. At present the main categorization tool is the Glasgow Coma Scale (GCS). This basically looks at levels of consciousness. Another important measure is Post Traumatic Amnesia -PTA (which looks at length of time where the person is confused or amnesic following the HI), however PTA in my experience is rarely assessed clinically. I think that both categorization tools are very blunt instrument. I have seen many children, for example with skull fractures who have not lost consciousness but seem to have poor outcome. The New Zealand studies above found that hospitalization was an important indicator. The Yeates study found that children with ‘mild traumatic brain injuries whose acute clinical presentation reflected more severe injury’ had a worst outcome. Therefore it seems clear that GCS is not sufficient in predicting neuropsychological outcome. All clinicians and researchers should be looking in more detail at the wider clinical picture.

The other implication is that many of these children are discharged from hospital back to their families and schools with no follow up and no information that there may be ongoing problems. About 1 in 30 children suffer a traumatic brain injury so the problem is potentially very big and will affect all schools. It may that teachers could be the best people to identify these children providing that they have the knowledge to do so. There is a great need to educate teachers and other educational professionals about this. Most children with problems after a head injury will show a deterioration in behaviour and academic functioning in school often over time. For the teachers out there if you notice a child struggling or notice a deterioration in behaviour and performance it is worth enquiring whether the child has suffered a head injury. If this is the case it would be important to alert child health services. Also for mental health professionals it is important to always check for a history of head injury including mild head injury especially for children with ADHD or behaviour problems. I am certain that there are many children and adults out there who are not being indentified and suffering as a result.