Your situation is all too common, and Pat appreciates your coming forward. Many parents (good parents included) have experienced the terror of a child's fall from a shopping cart; it only takes a couple of seconds. One of Pat's personal pet peeves is the lack of simple safety belts on shopping cart seats.

One way of determining whether your child may have sustained serious injury (warranting evaluation, at least) is to observe the child's behavior after the accident and compare with pre-injury behavior. Are there changes in cognitive, physical, or behavioral functioning? For example, are there differences between pre-injury and post-injury personality, stamina, sleep, habits, memory, learning, attention span, moods? If your child seems different or delayed, take him to a pediatric neuropsychologist, a professional skilled in evaluating and treating (or prescribing treatment for) behavioral and cognitive problems related to brain injury. The pediatric neuropsychologist may suggest a neurological evaluation to help accurately diagnose your child. Should brain injury-related problems be identified, the pediatric neuropsychologist can help you work with rehabilitation and educational professionals to address the child's limitations and accommodate them in the school setting.

Shaken Baby Syndrome or Shaken Infant Syndrome is one of the abuse-related causes of childhood brain injury. When someone violently shakes a baby, the infant's fragile neck cannot support its large head, so the head flops back and forth and the brain bumps against the skull. This can cause bleeding, bruising, and tearing of brain tissue. This is how child abuse leads to problems like learning impairments, seizures, delinquency, and worse.

You can search the medical literature at your nearest university library for information on Shaken Infant Syndrome and pediatric brain injury. Another source of articles on these topics is the Brain Injury Association, Inc. in Washington D.C. telephone: 202-296-6443. More information on pediatric brain injury is available from The Research and Training Center on Rehabilitation and Childhood Trauma, which is a joint program of the New England Medical Center and Tufts University School of Medicine. You can reach the RTC at 750 Washington Street, #75 K-R, Boston, MA 02111 telephone: 617-636-5031.

Lastly, you may try to contact your regional Kiwanis Club to see if they are participating in the Kiwanis International effort to educate the public about Shaken Infant Syndrome. Talk with a Kiwanis member in your community or contact Kiwanis International at 317-875-8755. The Kiwanis Club has established guidelines and materials for conducting a local educational campaign on Shaken Infant Syndrome.

Emphatically, YES. Children's brains are very vulnerable. The effects of a brain injury in a child may not show up until months or years after the actual injury. This is because pediatric brain trauma injures a developing brain. There is a wealth of information on pediatric brain injury and positive, effective behavior shaping techniques. You may want to start by contacting:

May Institute Center for Education and Neurorehabilitation
Ron Savage, Ed.D. (Specialist in pediatric neurorehabilitation)
35 Pacella Park Drive, Randolph, MA 02368
617) 963-3600

Research and Training Center on Rehabilitation and Childhood Trauma
New England Medical Center
750 Washington Street, #75K-R, Boston, MA 02111
(617) 636-5031

This student is fortunate to have you as an advocate. Your observations are very astute. Yes, it is possible for oxygen deprivation (anoxia/hypoxia) to result in serious brain damage. If you have not read the Frequently Asked Question on this site which refers to anoxia, please see the FAQ's, under brain injury causes.... Brain injury in children can result in impairments which become more and more apparent as the child matures. For example, cognitive impairments could manifest in language problems at age 2, social problems at age 5, reading problems at age 6, etc. A child with a brain injury may have difficulty managing his emotions, controlling his behavior, comprehending written material, following instructions, staying on task, interacting socially. Memory problems and distractibility are common problems for these children. If you have not done so, I would encourage you, along with the student's parents, to enlist the services of a pediatric neuropsychologist -- a good one. For a referral, contact your state Brain Injury Association. An experienced neuropsychologist can evaluate the relationship between the child's brain functioning and his behavioral functioning. This professional can make specific recommendations for the family and the school in assisting this child properly. A neuropsychological evaluation give you a better perspective on the effectiveness of Ritalin.

It would be helpful if you specified what the continuing frustrations are. Is your daughter sad most of the time? Is she having problems paying attention in class? Does she fight with siblings a lot? Does the family need more information on the side effects of her medicine? Is the family unsure how to act when she gets angry?

A couple of factors which you mention make it imperative to identify specifically what the problems are. First: Attention Deficit Disorder (ADD) is not very well understood -- what exactly is the cause? what exactly are the symptoms? do children outgrow it? It's difficult to help your daughter when the diagnosis is this general; it describes the behavior but what about the etiology? Second: The long-term effects of brain injury in children are not predictable to any precise degree. Researchers have not identified a typical post-injury behavior pattern. However, uninhibited behavior, hyperactivity, and inattention are frequently reported problems. Perhaps your daughter's behavior is "normal" for someone experiencing the residual effects of brain injury (the effects of pediatric brain injury can show up years after the trauma, as your child grows and attempts to learn new skills).

The diagnosis of ADD may describe your daughter's behavior, and the medication may help, but do you fully understand why your daughter behaves the way she does? If you have more information, you can make better decisions about how to help her.

For specific information on your daughter's psychological assets and deficits, which will help your family and the school understand and support her, consider a pediatric neuropsychological evaluation. This will involve testing of her intellectual ability and behavioral tendencies, which will help guide you in creating a nurturing home-life and will help the teachers in creating a learning environment that works for her. For referral to a pediatric neuropsychologist, contact your state Brain Injury Association. If you need help doing this, contact the national Brain Injury Association at (703) 236-6000 

(Reference: Waaland, P. (1990). Pediatric Traumatic Brain Injury. Rehabilitation Research and Training Center, MCV: Richmond, Virginia.)

Shaken baby syndrome is a constellation of brain injuries that occur after the baby has been shaken violently. Infants with shaken baby syndrome typically have subdural hematoma, cerebral edema, and may show retinal hemorrhage. In other words, there is bruising and bleeding in the brain and often retinal damage due to violent shaking. Other injuries consistent with shaken baby syndrome can include neck injuries, skull fractures, or bruising or broken bones to the arms of chest (where the baby was grasped). The injuries result from the force generated by shaking the child violently back and forth. Studies have shown that the forces necessary to cause these injuries greatly exceed those sustained in routine play, infant swings or fall from low height. Certainly your child bumping his head on the car door or being accidentally kicked by a five-year-old would be insufficient for this type of injury. There is no other medical condition that mimics all the features of shaken baby syndrome.

Why are babies shaken? Most often it is the result of caregivers who are frustrated with crying. Shaking the baby often results in the child appearing dazed or drowsy – and the baby often stops crying (reinforcing the caregiver for the behavior). Unfortunately, the baby’s drowsiness and silence is usually the result of brain damage. Shaken baby syndrome can result in blindness, permanent disability, or death. I hope that your child is able to make a good recovery.

The problem of limited resources is serious in some places. It’s not clear why she is being placed in a residential facility. If she has no family available or is in the custody of the state, she could be placed in a foster care home. Some states have foster parents with medical training who can provide homes to medically challenged youth. However, if this isn’t an option, Pat suggests you locate a hospital that treats pediatric brain injury. They should have a social worker or services coordinator who could point you to services and professionals who deal with children with TBI. Your best bet may be to work with existing agencies to make modifications that will best help this young woman. Good luck!

Pat knows some doctors with "questionable" academic careers! But that’s not what you mean. Anyway, Emma should have a comprehensive neuropsychological evaluation. I can’t tell from your question how old Emma is or whether the "psychologist" was a neuropsychologist or not. I also can’t tell if the psychologist worked for the school or not. Let me explain the difference. Most clinical child psychologists conduct psychological evaluations that usually consist of an IQ test, and an assessment of behavior or emotional adjustment. Many psychologists also do an achievement test that can help to diagnose learning disabilities. A neuropsychological evaluation may include these types of assessments, but will also examine memory skills, motor skills, attention and concentration, and visual skills. Be sure that when you look for a neuropsychologist, you ask about their training. In many states, any licensed psychologist can claim expertise in neuropsychology, so ask about where they received training and supervision in neuropsychology. This type of evaluation should provide a comprehensive analysis of Emma’s strengths and weakness. In addition, the neuropsychologist should be able to provide specific recommendations to you and Emma’s teachers about how she learns best and what her limitations are likely to be.

Also, if the psychologist is associated with the school, then I would encourage you to get an independent evaluation done. Most school psychologists are outstanding, but they also work for the school. Schools often have a vested interest in keeping their costs down and sometimes don’t like to provide a lot of "extra" services to children who need them. Some schools are better than others. However, public schools are legally required to provide needed accommodations to children with disabilities under the Americans with Disabilities Act (ADA). An independent psychologist or neuropsychologist will be able to help you assess whether the school is providing all the needed accommodations or not.

Finally, yes you should absolutely help Emma as much as possible and give her as much love and support as you can. Talk with all of her teachers regularly about her progress. Talk to Emma about how she is doing. Find out if there are tutors in your area that specialize in working with learning disabled children. Encourage Emma to participate in activities outside of school as well so she can develop other friends and interests. If Emma struggles in school, it will be important for her to have other activities and life experiences she can feel good about to boost self-confidence. It sounds like she has a good parent looking out for her best interests!

To the person looking for an opthomologist for occipital cortical blindness who is associated with a neurosurgery center:

You certainly know what you’re looking for. I don’t know anyone with the particular specialty. However, since I think you were mailing from Colorado, I would suggest you consult the Division of Neurosurgery at the University of Colorado. They might be able to better direct you. Their web address is:

https://medschool.cuanschutz.edu/neurosurgery

The basal ganglia are really several brain structures including the caudate nucleus and the putamen. These structures are involved in the control of both voluntary and autonomic movements. Damage to the basal ganglia most often result in movement disorders, although problems also can arise related to some aspects of attention, memory, learning, or speech production. The specific effects of injury to the basal ganglia will vary depending on the specific site of damage and the extent of damage. Cerebral Palsy (a term referring to a neurologic disorder affecting body movement and muscle coordination) can result from hypoxic or anoxic injury to the basal ganglia during the birth process. Cerebral Palsy is not progressive and must be distinguished from other progressive or genetic neurological conditions. It sounds like you are seeking good medical advice. Continue to be sure your son is followed closely by medical professionals so they can make an early determination if your son has CP or any other motor disorder.

Athetoid Movement - An impairment of the muscle tone (usually in large muscle groups), causing slow, involuntary contractions of the head, limbs, trunk, or neck. 

Chorea - A condition of uncontrolled, purposeless, rapid motions that interrupt normal movement. 

Pat always has suggestions! Some are even good ones! In your case, I can make a few.

First, it will be important for either the school or the parents to see a pediatric neuropsychologist for an evaluation. This would include evaluating a variety of the child’s skills including reasoning, attention, perceptual-motor skills, and basic academic skills. It will be hard for you as the teacher, or for the parents to have a good understanding of the child’s strengths and weaknesses without this type of evaluation. If you can understand the child’s strengths, you will be better able to use those strengths to help the child learn and to compensate for weaknesses. For example, if the child struggles to read, but can absorb information from hearing, that is very important in helping the child acquire academic knowledge. On the other hand, the child may learn better visually, which would be helpful to know as well. In the case you describe, it would be important to know if the child’s difficulty is limited to reading, or if symbolic processing is impaired in a way that will limit written language and math ability as well. So, start with a comprehensive neuropsychological evaluation… but that will take some time to schedule, conduct the evaluation, and receive feedback (this is all provided the parents are open to this course of action).

It will also be important to talk with the special education instructors or other learning disability experts in your school or area. In many cases the techniques to teach a child with an "acquired learning disability" will be similar or identical to teaching a child born with a learning disability. For example, "multisensory teaching" is often used to teach dyslexic children. Using this approach, students may be asked to not only look at the symbol and say the sound, but also to trace or write the letter to see how it "feels." In the meantime, it sounds like the child is lucky to have a caring, concerned and creative teacher. Keep trying new things with this child. For example, if he is very visual, some computer software for young learners might help him to practice basic reading skills. Continue to encourage the child and be sure to have frequent discussions with the parents about your concerns.

More information on dyslexia can be found at:

http://www.interdys.org

I wish every child could have educators who were as dedicated and passionate! Unfortunately, it will be very difficult – if not impossible – to get this child the help he needs if the parents are uncooperative. It sounds like this child needs to have a comprehensive neuropsychological examination to assess his strengths and weaknesses. It is difficult to develop an appropriate and realistic educational plan without knowing a child’s capabilities. If he is in 2nd grade and only knows "some letter sounds" and is yet to form words – he’s clearly very delayed. Without knowing the extent of brain damage or his level of skill, it’s impossible to know what approach will work best or even if he will be capable of learning in a "mainstream" academic environment. In the meantime, you may want to consult with the special educational coordinator at your school (if you haven’t already). You may want to try to adapt multi-modal learning strategies and other techniques used to teach learning disabled students. However, even with that, two 30 minute sessions a week aren’t very much for a child with such significant learning delays.

I certainly understand the parents’ desire not to have their child "labeled." Emotionally, parents often have difficulty adjusting to the fact that a previously "normal" child now has impairments of disabilities as the result of an injury. It is certainly important for school personnel to be understanding and sympathetic to the parents. However, I wonder if the parents are aware of the child’s deficits in the classroom. I don’t know what kind of relationship the parents have with the school at this point, but it might be helpful to invite the parents to observe the class. If this child is noticeably far behind the other children, seeing it with their own eyes may help them decide something must be done.

Talking with the parents about all the options should be considered. For example, if they are concerned about "labeling" the child as "learning disabled" because they believe he will eventually recover – perhaps they could be provided with a label such as "Other Health Impaired." It may also help to explain the children who receive services are periodically re-evaluated and if he no longer shows learning problems at a future date, services could be stopped and he would no longer have a "special education" classification. Finally, the parents could be encouraged to seek an independent neuropsychological evaluation (it may be paid for by their insurance). This would provide them with confidential feedback about their child and his needs. Although the school could not receive a copy of the report without the parents’ consent – at least they could hear from a neutral expert how their child is doing and what his educational needs are. Maybe after hearing the facts, they would change their minds about placement options.

On the other hand, if the parents continue to resist services, tension between the parents and school may increase. Although there are options the school can pursue at that point to force the issue, it’s beneficial for everyone involved (especially the child) for this to be resolved cooperatively.

I’m afraid I don’t have any information about fetuses sustaining brain injuries (A difficult subject to research). Unfortunately, even if you can find documentation of fetuses sustaining brain injuries, it will be very difficult to figure out if your son’s problems have resulted from the accident, genetic factors, or factors associated with the prenatal or postnatal environment.

Pat always has some information! Whether it’s the information you want, I don’t know…

Here are the basics – Ritalin (Methylphenidate) is an Central Nervous System stimulant and is a widely used treatment for Attention Deficit/Hyperactivity Disorder (ADHD) in children and adults. Using a stimulant to treat inattention may seem like a strange idea. Treatment effects are believed to occur because the drug stimulates the release of neurotransmitters needed to focus attention.

Regarding Ritalin’s use as a treatment for brain injury, research has shown it can be effective in treating symptoms such as inattention, impulsivity, or hyperactivity. In addition to these uses, research indicates that stimulants can be helpful for treating other symptoms common after brain injury including fatigue, apathy, and hypersomnia (sleeping too much).

Side effects can include increased anxiety or nervousness, loss of appetite, disrupted sleep, nausea, dizziness or an increase in blood pressure. In rare situations, it may trigger cardiac arrhythmias. If you or someone you care about is taking Ritalin, it is important to be alert for possible side effects. In addition, always inform your physician about all your medications due to the potential for adverse drug interactions. Although Ritalin has been used extensively in treating children and adolescents with ADHD and brain injury, effectiveness and safety in children under 6 is not well established.

There are rehabilitation programs specifically for children with brain injury. Programs and support groups may be available through a local children's hospital. Call and find out if they offer any outpatient programs for children with brain injury or if they can refer you to someone who does. You can also contact the Brain Injury Association and ask for help locating resources.

If you've read Pat's column before, you know that existing programs for "special needs" children (e.g. learning disability) can sometimes be modified in a way to assist a child with brain injury. Talk to people involved with these groups in your community and find out if they can be modified to assist a child with brain injury.

The Brain Injury Association
105 North Alfred Street
Alexandria, VA 22314
Phone: 703-236-6000 Fax: 703-236-6001

http://www.biausa.org