Not every bump on the head is a brain injury, but children injure their heads often – when they learn to walk, on the playground, in sports and in traffic. A traumatic brain injury (TBI) in childhood differs from one in adults in an important way: the brain is still developing. Some consequences therefore become visible only years later, when a child is expected to master new skills. Parents, teachers and doctors need to know the signs and the support children are entitled to.
Causes: What Leads to Brain Injury at Different Ages
TBI is an acquired brain injury – it happens after birth and is not inherited. The causes change with age:
- Babies and toddlers: Falls are the most common cause – from changing tables, beds, stairs, shopping carts or windows.
- School-age children: falls on the playground, bicycle and scooter accidents, being hit by a car as a pedestrian.
- Teenagers: sports and recreation such as football, soccer, ice hockey and cheerleading, and motor vehicle crashes – teen drivers have the highest crash rates of any age group.
Abusive head trauma
Abusive head trauma, also known as shaken baby syndrome, is according to the CDC a leading cause of physical child abuse deaths in children under five. Most victims are younger than one year. Violent shaking makes the baby’s relatively heavy head swing back and forth; veins on the surface of the brain tear, bleeding and swelling follow. The trigger is often inconsolable crying. Parents who are at their limit should put the baby safely in the crib, leave the room for a few minutes and call someone for help. The National Child Abuse Hotline (1-800-422-4453) offers support around the clock.
Signs of Brain Injury in Children
Babies and toddlers
Young children cannot describe a headache or blurred vision. Warning signs are changes in behavior:
- Crying that cannot be calmed
- Repeated vomiting
- Refusing to nurse or eat
- Unusual sleepiness, difficult to wake
- Irritability or listlessness
- A bulging soft spot (fontanelle)
- Loss of skills already learned
Older children and teenagers
- Headache, dizziness, nausea
- Confusion, memory gaps, slowed thinking
- Balance problems, blurred vision, sensitivity to light and noise
- Mood changes, irritability, sadness
- Sleeping more or less than usual
- Declining performance at school
Bleeding inside the skull can build up pressure over hours. After a fall, a blow to the head or a car crash, a child must be watched closely. Seizures, repeated vomiting, unequal pupils, increasing drowsiness or inability to wake the child are reasons to call 911 immediately. More details are in the article on traumatic brain injury symptoms.
Assessment in the hospital
To assess consciousness, doctors use the Pediatric Glasgow Coma Scale, an adapted version of the adult scale for children who cannot yet speak. It scores eye opening, verbal response – in babies, for example, cooing, crying or no sound – and movement. To avoid unnecessary radiation, emergency departments decide with tested rules such as the PECARN criteria whether a CT scan is needed after a minor head injury.
Why Problems Can Appear Years Later
The human brain continues to mature until the mid-20s. The frontal lobes, which control attention, planning, self-control and social behavior, develop last. An injury in early childhood can damage abilities that the child does not yet need. The problem shows only when these abilities are expected – in the first grade with reading and writing, in middle school with organization and independent work, in adolescence with self-control.
Specialists call this “growing into the injury.” A child who seemed to recover fully after an accident may have learning or behavior problems years later. Parents should tell teachers and pediatricians about earlier head injuries, even if they seem long past.
Possible long-term effects
- Problems with attention, memory and processing speed
- Difficulty planning, organizing and starting tasks
- Impulsivity, irritability, emotional outbursts
- Problems with friendships and social situations
- Speech and language difficulties
- Fatigue and headaches
Children with moderate and severe TBI benefit from rehabilitation with physical, occupational and speech therapy and from neuropsychological testing, which shows strengths and weaknesses and helps plan support.
Support at School
IDEA and the IEP
The Individuals with Disabilities Education Act (IDEA) guarantees children with disabilities a free appropriate public education. It goes back to Public Law 94-142, the Education for All Handicapped Children Act of 1975. In 1990 the law was renamed IDEA, and traumatic brain injury became its own eligibility category.
Children who qualify receive an Individualized Education Program (IEP). It sets specific learning goals and services, such as special education, speech therapy, occupational therapy or extra help in the classroom. Parents can request an evaluation from the school in writing; the school then has to decide within a set time.
Section 504 plan
Students who do not need special education but are limited by their injury can receive accommodations under Section 504 of the Rehabilitation Act of 1973 – for example extra time on tests, rest breaks, a quiet place to work, reduced homework or written copies of notes.
Return to learn after a concussion
After a concussion, a step-by-step return to school is recommended. Many students start with shorter days or reduced workload and increase as long as the symptoms allow. School nurses, teachers and doctors should work together on the plan. Return to sports follows only after full return to learning and medical clearance.
Concussion Laws for Youth Sports
All 50 states have laws on concussions in youth sports. The first was the Zackery Lystedt Law in Washington State in 2009, named after a 13-year-old football player who suffered a severe brain injury after returning to the game following a hit. Most laws follow the same three rules:
- Coaches, players and parents are educated about concussion.
- A young athlete with a suspected concussion is removed from play immediately.
- Return to play requires written clearance from a licensed health care provider.
Prevention
- Use the right car seat or booster seat for the child’s age and size; children under 13 ride in the back seat.
- Helmets for cycling, skating, scooters, skiing and contact sports.
- Window guards and safety gates at stairs.
- Never leave babies alone on changing tables or beds.
- Playgrounds with soft surfaces such as wood chips or rubber mulch.
- Rules for fair play and safe tackling technique in sports.
Frequently Asked Questions
What are the most common causes of brain injury in children?
Falls in young children; sports, recreation and motor vehicle crashes in older children and teenagers. Abusive head trauma is a major cause of severe injury and death in babies.
Can problems appear years after the injury?
Yes. Because the frontal lobes mature until the mid-20s, difficulties with attention, planning or behavior can show up only when a child reaches the age at which these skills are needed.
How can school help a child with a brain injury?
Through an IEP under IDEA if the child needs special education, or through a Section 504 plan with accommodations. After a concussion, a return-to-learn plan eases the student back into class.
When should a child see a doctor after a head injury?
After any loss of consciousness, vomiting, unusual sleepiness, confusion or behavior changes. Seizures, unequal pupils or inability to wake the child require a 911 call.
