Restoring Jack's Broken Crown

Jack and Jill went up the hill

To fetch a pail of water.

Jack fell down and broke his crown,

And Jill came tumbling after.

As a kid I remember being puzzled about why Jack was wearing a crown. Was he a prince? I was considering a future career in crown restoration that would let me model lots of crowns, when some adult let me in on the secret that Jack had hit his head. My budding career was dashed.  

My Experiences with Traumatic Brain Injury (TBI)

When my brother was three, he rode his tricycle down our steep driveway, and crashed into the bricks at the corner of the garage. He had a gaping gash in his forehead which bled profusely. Since this was well before the invention of cell phones, I watched my panicked mother frantically dialing our rotary kitchen wall phone to track my father down with one hand. At the same time she held a towel over my crying brother's head with the other, while a pool of blood was accumulating on the floor. Eventually, dad came home in our only car and transported all of us to the emergency room where my brother’s broken crown was stitched up; I watched in fascinated horror as the doctor demonstrated this type of crown restoration.

Fast forward to adult me with a 19 year old daughter who was working at an after-school program. My kid is outside minding ten year olds playing soccer. One child is a future Pelé, and kicks the ball at warp speed into her head only a few feet away from her. Her brain sloshes from one side of her head, into the other, and back, banging against the inside of her skull twice, and she momentarily blacks out. Suddenly, ‘breaking your crown’ takes on a whole new meaning when your child suffers a traumatic brain injury (TBI).

My daughter suffered a concussion with amnesia and short-term memory disruption. A week later she went into a grocery store with her little brother and when he disappeared to fetch the cereal they missed, she realized she had no idea why she was there, and did not know how to get out. Panicking, she started calling his name. He arrived back to find her badly shaken, tearful, and scared. “I’m taking you home right now” he said, hurrying them both to the check-out stand. “Promise you won’t leave me in here again?” she asked.


Brain Injury Classification

In my work as a Stanford-trained Trauma Therapist and a Certified Rehabilitation Counselor, I have a disproportionate number of clients with brain injuries, from mild to severe. What I have learned is no two head injuries are alike.

Brain injuries are initially categorized broadly:

• Closed (Blunt) v. Open (Penetrating)
• Traumatic v. Acquired (Non-traumatic)

My daughter’s injury was closed, while my brother’s was open with a skull fracture. Both were traumatic. Acquired (non-traumatic) brain injuries include those in which the brain is deprived of oxygen or blood flow, most commonly during a stroke or heart attack.


Posttraumatic Stress (PTS) v. Posttraumatic Stress Disorder (PTSD)

I specialize in posttraumatic stress treatment (PTS) and acquired disabilities. Posttraumatic stress was formerly called posttraumatic stress disorder (PTSD); there has been a growing movement away from referring to it as a “disorder” in an effort to destigmatize it for our returning troops. When a person is in a situation in which they must be hyper vigilant day after day, and many ongoing traumatic events occur, posttraumatic stress is a normal reaction to an abnormal situation.

Unfortunately, many children grow up in households in which they regularly experience violence. Posttraumatic stress is estimated to occur in as many as 25% of children.  The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) estimates a lifetime prevalence occurs in approximately 8% of adults. Many of my clients have PTS (PTSD) as a result of the event that caused the head injury. Stanford Cue-Centered Treatment is a short-term cutting-edge new trauma therapy that can quickly resolve posttraumatic symptoms.  


PTSD symptoms v. Mild Traumatic Brain Injury (mTBI)

Interestingly enough, the symptoms of a mild TBI and PTS (PTSD) are exactly the same. Anxiety, stress and depression also have similar symptoms. I recently attended a Brain Injury Conference in Maryland. Fellow presenters Mark Huslage and Jill Penaloza of Sinai Hospital presented the following table which demonstrates how difficult it can be to tease out symptoms of a mild TBI from PTS (PTSD).

Symptom Comparison Across Psychological Diagnoses
By Mark Huslage & Jill Penaloza

Concussion & PTSD*: headaches, drowsiness, irritability, depression, poor memory, attention/concentration, fatigue, poor sleep, nausea, worry, dizziness/loss of balance, impaired hearing

Stress & Anxiety: all of the above except impaired hearing

Depression: all of the above except impaired hearing, nausea and dizziness/loss of balance
  
* PTSD =  posttraumatic stress disorder

Causes/Recovery from TBI

According to the Brain Injury Association of America, the most common causes of head injury are falls (35% - how Jack got injured!), motor vehicle accidents (17%), a strike by or against the head (16%) and assault (10%). In our deployed troops, the number one cause is blast injuries.

Most people recover from a mild TBI within 3 months. However, a certain percentage of people go on to develop postconcussive syndrome which often includes significant depression and anxiety, along with irritability, aggression, impulsivity and sleep disturbances. The most common reason for developing ongoing postconcussive syndrome is not resting enough when the injury first occurs. The amount of fatigue and rest needed due to even a mild brain injury is much greater than one might imagine. In the first few days, a person might need complete rest. As the brain continues its healing in the first months after the injury, breaks/rests (20-30 min.) every 90-120 minutes are common. One of my clients was understandably dismayed when three months after the injury, she continued to have significant fatigue.

TBI in Children and Older Adults

Concussions are much more dangerous in children than adults, and every precaution should be taken to insure another does not occur while healing from the first. This is because their brains are still developing and much more vulnerable. After the mid 40s recovery is slower and may not be complete, and after age 55 there generally is no full recovery according to Dr. Jeffrey Barth, keynote speaker at the conference I attended. Dr. Barth is head of Neurocognitive Studies in the Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine. He has an excellent video series on brain injury found here.

It can be very difficult for adults to admit that they have impairment as a result of a brain injury. No one wants others, particularly at a job, to know that they are not able to think well, have poor memory, or difficulty organizing tasks, or become overly fatigued when concentrative effort is required. As we learn more about brain injuries, hopefully, postconcussive symptoms will become less stigmatizing.

Crown Restoration

I am happy to report my brother grew up to become a scientist. My daughter is in school and doing well, although she still has some postconcussive symptoms seven years later.