Subtle brain injuries in children
Depressed skull fractures result from a significant force. It is estimated that 30% of depressed skull fractures in children have associated intracranial injuries. In addition to intracranial haemorrhage, complications such as compression of underlying brain parenchyma, intraparenchymal bone fragments and cosmetic deformity are also seen.
A child’s skull is more elastic than that of an adult’s and so often more force is required to cause a fracture. In my case study of Jamie Pinkerton the child was 15 years old and the initial CT Scan of the brain didn’t reveal at A/E damage to the brain but there were fascial fracture to the basal area and the around the eye socket. The neurosurgeon Mr Fred Nath, who I instructed attended before the High Court Judge and his evidence was accepted by HHJ Freeman that the forces that could cause such fractures on the balance of probability would cause damage to the underlying areas of the brain. This evidence was coupled with the typical bulls eye damage to the defendant’s windscreen and the fact that Jamie had a seizure at the hospital even though there was no evidence picked up either on the CT scan at the time of his admittance at the A/E or on the more sensitive and detailed MR Scan he underwent in 2012 some 6 years after the accident when he was in his 20’s.
In my experience of Child brain injury cases unless there is profound brain damage which is obvious to everyone including all the medical experts and Doctors who treat the individual even when there has been a fracture and some intracranial bleed the child will make a very good and superficial recovery from the physical injury. Usually as in Jamie’s case the head injury is just part of the picture and often the child will present with other more obvious injuries . In Jamie’s case he suffered a quite nasty fractured right leg which had to be treated at the hospital and from which he left the hospital on crutches and in plaster.
Those treating Jamie and those looking after him on his release such as his Mother , Uncle and friends and relatives even the local GP and the fracture clinic focused quite rightly on his obvious and immediate injury to his leg.
The head injury was forgotten in his case the family were not aware of the extent of the facial fractures. They knew he had a seizure and were aware he had suffered an serious injury and blow to the head but not what that may mean to him in the future. What ensued was a full recovery from the leg fracture coupled with a number of weeks off his school in the run up to his O’ Levels. This in itself was blamed for the fact that his results were poorer than expected. Interestingly as in most brain injury cases Jamie’s intellect was not effected by the damage which he suffered to his brain but he began to show more subtle signs of the effects of his head injury.
In his case these were not initially associated with his accident or any head injury. He was a teenager after all his change in mood and behaviour was put down to hormones and adolescence as was his violent tempers and anger. He battled with his mother like he had never before. He was forgetful, he lacked the ability to initiate and plan anything that before he had been interested in such as looking to his future, his interprets in engines and cars and anything mechanical. Whereas before the accident he was full of dreams of being a chef in the Navy and joining his pals on a submarine or working in a garage with cars and engines he became disinterested and disinhibited. His behaviour was such that he was thrown off his college course that he started after O’ level. The new college knew nothing of the pre-accident Jamie and put this down to his going through adolescence. His Mother couldn’t cope he lacked and motivation to do even simple things like tidy his room or keep up with personal hygiene. He was thrown out of home and even did little to help his Gran he moved in with who he had loved so much before and was in need of simple help with errands and medication which he couldn’t be bothered to assist with. All in keeping with the subtle effects of the traumatic brain injury.
The interesting feature of this case is the fact that unless the family, mother , father ,school ,teachers or other individuals are aware of the subtle features and presentation of a child with acquired traumatic brain injury this can be lost and attributed to other issues which are unrelated and blamed on a child’s upbringing, his family setting, his behaviour in general and as such the child will not have the benefit of more appropriate help, assistance and treatment maybe therapy or rehabilitation which is focused and provided by a suitably trained and qualified child psychologist. In my experience the school and teachers have to be educated about the features associated with such changes in the child and this will need to go on through the child’s education from Primary school with each year and change in teachers and year teachers on to Secondary school and maybe College. Otherwise he/she will be potentially misdiagnosed as a problem child maybe someone with ADHD or autism ironically the blame that is attached to upbringing and the family history perhaps of siblings with behaviour issues or learning difficulties may actually be present which just add to the problems for the child where he or she may have the problems of the brain injury superimposed on the environmental and family dynamics which adds to the difficulties and presentation.
The Perpetual teenager
In my case of AC ,which is , in the case study section , I set out the real issues which ensued on that case.
A was 8 years old when she was knocked over by a car crossing a road and she suffered a fractured skull some intracranial bleeding and a fractured leg. The leg injury was nasty and lead to serious scarring which was disfiguring and added to the trauma for this girl as she grew up. The family had their own issues as her natural Father was imprisoned and the family moved around from Lancaster ,where the accident occurred , to Bolton where ,when she was 18 ,after some encouragement from her sister, she decided to pursue a claim for compensation.
What was unearthed in my investigations was a child who went through school and adolescence but who was seen as a problem child, she had brushes with the police and she couldn’t relate to people, she was argumentative and had violent tempers. The authorities and school looked at her back ground saw a Mother who had her own psychological issues and broken home with a jail bird Father and just attributed this to her problems not knowing some years earlier at the age of 8 she suffered a brain injury which was the genesis to her problems.
As with Jamie in reality the brain injury left her a perpetual teenager where her reactions to life were trapped at that point, where she could not plan or initiate without help and assistance , she would suffer apathy and bordem and had relationship issues. The case allowed me to explore these issues with experts in psychology, neurology and Neuropsychiatry and once we had managed to resolve liability we could get some initial funding to her and her family to start to help put together the sort of help she needed.
These cases often take many years to finally be resolved. The liability issues are normally sorted out swiftly certainly within a year and there is no reason why this should not be the case the only delay is the obtaining of independent evidence from outside agencies such as the police and the Health and Safety Executive. Once that has been resolved the assessment of the effect of the brain injury on a young person whose brain has not fully developed can be profound and the the assessment of what that persons life may have been but for the accident compared with the way their life may now proceed can often only really be assessed when they reach the age of 18 and have left the education system.
Using that time to the utmost
Although the legal case may take a long time to get to a point where the assessment I have mentioned above can be made and an accurate calculation of that persons losses and the valuation of their life long claim can be made , the case will provide the family with the best chance of as a good an outcome for their child than anything. Provided funds can be obtained form the insurer on an interim basis which i have described in this website either by agreement or through a court order, a package of support, therapy, treatment and rehabilitation can be put in place which will have a profound impact on the child’s life. Such a package will be put in place by a Case Manager with skills in this area and should be headed up by a Neuropsychologist and structured like a pyramid with the Neuropsycholgist at the top filtering down to the rst of the team the knowdlege and direction for the brain injured child.
Please see the paper