“Over and over again, I was hearing the same stories,” says Gordon, associate director of Mount Sinai’s department of rehabilitation medicine. “People were being sent home from the emergency room and told that there was nothing wrong with them because they’d had a normal CAT scan. Emergency room doctors wouldn’t see memory problems and executive dysfunction. No one was giving these folks a list of things to look out for. Lives were being altered by this one event.”
With a clean bill of health from the ER and no education about the possible fallout from a jolt to the head, people often didn’t link the strange symptoms they were experiencing to the brain injury. A mom might find that she couldn’t multitask anymore; for example, she might be unable to talk on the phone while ironing or washing dishes. “She would find herself fuming at her kids for making too much noise; she couldn’t tolerate the radio blaring anymore because it was too much stimulation,” Gordon says. “But she never would make the connection with a brain injury.”
Often, Gordon could see the huge sense of relief many patients felt when they learned that the bizarre symptoms were real and could be traced back to a specific event. But, he says, it would have been much better if they’d been told on the day of the injury what to expect so they could have found a doctor to help. Even patients who recover in a relatively short time benefit from education about brain injuries. The doctor can explain what causes the strange symptoms and can provide a framework that helps a patient understand what to expect in the weeks to come. Beyond this, Gordon says, people can get help with immediate symptoms—medications for headaches and sleep problems, for example. And if the symptoms persist and there are cognitive deficits, then rehab is a possibility.
Most of the patients Gordon saw in his New York City office were adults, but he began to wonder what might be happening to kids in the same situation. He and his colleagues developed a questionnaire designed to ferret out undiagnosed TBIs and cognitive difficulties in children. The researchers took the questionnaire into the New York City schools to get an idea of how many kids were suffering with undiagnosed brain injuries. The results gave Gordon pause. In one city school, 10 percent of the children said they had sustained a significant head injury. When tested later, these children turned out to have cognitive impairments.
It was Gordon’s first hint that TBIs might be at the root of many cases of learning disability. With a grant from the U.S. Department of Education, he was able to explore the issue further. He and his colleagues surveyed children who’d been enrolled in special education classes. He was startled by the results: more than 50 percent of the learning-disabled children had experienced a sharp jolt to the head.
While the children had been identified as having some sort of learning disability, the typical curriculum in special education classes didn’t help with brain-injured kids’ deficits. Gordon realized that the best way to help these children was to educate the educators. He gathered up a team of Mount Sinai psychologists and, with federal dollars that had been set aside to fund TBI education, set up a project in 1995 to send them into the New York City schools.
One of those psychologists was Tamar Martin. She would meet with a school’s special education teachers and explain how the fallout from a brain injury could impact a kid’s class performance. Then she would show them ways to help brain-injured students do better in school. Each time she met with teachers from a new school, Martin would start by popping a video into the VCR. The video, titled All the King’s Horses and All the King’s Men, told the story of a family with a child who had sustained a TBI during a summer vacation. The child had always been a good student, but when school started up again in the fall, he was floundering. What’s more, his behavior had become increasingly odd. His brain injury—sustained when he fell off a bike and hit his head—was never reported, and nobody was able to make a connection between what had happened to the child and the impairments that appeared later. “Every time I would show that film,” Martin recalls, “there would be a few teachers in the audience who would say, ‘I have a kid just like that in my class.’ ”
These were often the kids that teachers saw as having transformed almost overnight from serious students to classroom problems. They would forget to do homework, forget to bring books back to school in the morning. They couldn’t seem to focus and would often drift off in class. They could be distracted by the most innocuous stimuli. Eventually, they would slink off to a seat in the back of the class, the one that was farthest from the watchful eyes of the teacher.
The children were soon labeled difficult. Their memory problems were misinterpreted by teachers as signs that the students didn’t care anymore, that they lacked ambition. Their exhaustion after one or two difficult classes in a row was mistaken for lack of initiative and motivation. When kids forgot to bring their homework to school, teachers would assume they hadn’t done it. When they did poorly on tests because of slowed processing, teachers would assume the kids hadn’t studied enough.
Martin remembers one little girl who languished for years, her schoolwork failing, her IQ scores declining. When “Julie” started first grade, teachers had noticed that she was a little off. She was highly verbal, but also seemed unfocused, immature, and accident-prone. As time passed, Julie got worse and worse. When she was seven and a half, she was evaluated again. This time she displayed problems with short-term memory and hand-eye coordination. She was also starting to show signs of a speech impairment. School administrators decided she should be moved to a class for the learning disabled. All the while, her parents were becoming increasingly distressed, pushing the school to figure out what was wrong with Julie. Two years passed and Julie seemed to be getting only worse in special education classes. Her parents asked administrators to put her back in a regular class. But that didn’t help, either. By the time Julie reached fifth grade, she had fallen even further behind and was exhibiting even more deficits: her language skills had declined; she had developed word-finding problems; she was restless, anxious, distractible, and depressed.
Having heard Martin’s presentation about brain injuries in children, one of Julie’s teachers began to wonder if a TBI might explain the girl’s sad spiral down. By the time Martin got involved, Julie’s school file contained so many tests and evaluations that it stacked a full two feet high. In an interview with Julie and her parents, Martin learned that there had been a car accident when the girl was two. Julie had been rushed to the hospital and kept there for over a week.
When Martin told Julie’s parents that their daughter’s problems most likely traced back to a brain injury suffered in the car accident years before, she was worried about how they would take the news. As it turned out, they were relieved. Someone had finally explained how their bright little girl could have developed so many problems. They asked if Julie’s declining IQ scores meant she was getting worse. Martin explained that in young kids you don’t always appreciate the extent of the brain damage immediately. It isn’t until classwork becomes harder and more complicated that certain deficits become obvious because the brain can’t deal with the new demands. Often that happens in fifth or sixth grade, when kids need more analytical skills and when deficits in executive function become apparent. This is when “word problems” are introduced in math class, and brain-injured kids often get stuck on these kinds of exercises.
Part of Martin’s mission in her yearlong course was to teach teachers to identify the signs of a TBI and show them strategies to help brain-injured children cope better with the demands of school. Teachers learned that brain-injured kids often had trouble maintaining focus. One way to help with that was for the teacher to keep walking around the classroom, periodically tapping students on the shoulder to snap them back to attention. Teachers were also told to seat students with a TBI far from windows and doors so the kids wouldn’t be distracted by outside activities or people walking past the classroom. Another strategy was to make lettering on handouts large and to limit the amount of information on a single
page so students wouldn’t be overwhelmed. Teachers were encouraged to provide brain-injured students with a peer note taker and a tape recorder so that the children would be able to focus all their attention on understanding what was being said.
School administrators learned that brain-injured children tended to become exhausted easily. The way to deal with that was to set up schedules that put breaks between tough classes like math and science, which would give the kids time to recharge. To accommodate damaged memories, Martin suggested that brain-injured students be encouraged to visit the resource room before and after school. That way teachers could make sure the student went home with the right assignments and had the right preparation to start each day. If books had been forgotten at home, spares could be loaned out. Teachers were encouraged to pay attention to the brain-injured children’s energy levels. If it looked like a kid was flagging, then it made sense to offer a break.
Martin explained to teachers that TBIs often led to slowed mental processing. This meant that kids would need more time for tests and that timed tasks should be avoided whenever possible. “We explained to them that it was better to emphasize the quality of the student’s work rather than the quantity,” Martin says. “Teachers needed to provide them with extra time and to reduce homework levels.”
As another concession to slowed processing, teachers were encouraged to give students more time to formulate answers to questions in class. “We taught them to avoid badgering students and to provide them with a preview of classwork for the day,” Martin says. “Then the students could be prepared.” Martin taught teachers about the value of day planners for brain-injured students and of color-coding materials by class; if the history text had a blue book cover, then it made sense that folders and notebooks for this class be blue as well.
Teachers were taught to break long-term projects into chunks that were more easily accomplished by brain-injured kids. Martin also had to convince teachers to be more open-minded so they would provide accommodations for students with TBIs. She encouraged the teachers to let brain-injured children use calculators in math class. Teachers, construing that as an unfair advantage, would often be pushing the kids to memorize multiplication tables. “You’d have to work with the teachers to get them to understand that this kid probably never would be able to do that,” Martin says.
Over the five years that the program was in effect, Martin and her colleagues worked with more than four hundred children. Funding petered out in 2001 and no one else stepped up to keep the TBI education program going. “I’m not aware of any program in existence now that is specifically geared to the needs of children with brain injuries,” Martin says. “I don’t know what happens to them now.”
The experience with “hidden” TBIs in the school system led Gordon to suspect that other people might be getting off track because of unrecognized brain damage. After a 2000 study showed that people with a head injury were at higher risk for depression as well as alcohol and drug abuse, Gordon and his colleagues decided to look at the prevalence of TBI in New York State substance abuse programs. The researchers interviewed more than eight hundred patients and found that 54 percent had a history of head injury. Forty percent of those with a history of head trauma had symptoms indicative of post-concussion syndrome. Further, those with head injuries turned out to have more mental illness and to be more prone to recidivism and treatment failure. “That suggests to me that these folks need a different treatment program,” Gordon says. “You can’t expect people with learning and memory problems to learn at the same pace as everyone else. If you see that a thirty-day program doesn’t work, that may mean that these people need sixty or ninety. Maybe they need structured environments to live in, too.”
The patients were all in their thirties when they were screened for TBI, and after extensive interviews, researchers learned that many had sustained multiple head injuries. Among those with multiple injuries, the average age when the first TBI occurred was fourteen. This, Gordon thought, might mean that early intervention could prevent damage down the line. “If they had been picked up and identified and treated as folks with a TBI upon that first injury,” he says, “they might have gotten the services they needed to prevent them from going down the path to substance abuse.”
In 2006, Gordon turned his eyes to the burgeoning homeless population. He linked up with Common Ground, a New York City nonprofit that builds houses for the homeless. Gordon and his colleagues tested one hundred homeless persons for signs of brain injury. Nearly 70 percent of the homeless people interviewed by the Mount Sinai researchers had deficits in memory, language, or attention—all indicative of a possible brain injury. Further, 82 percent reported a significant jolt to the head before they became homeless, often the result of abuse by a parent. Many of these people might be in a very different place in life had their brain injuries been recognized as serious, had they received treatment.
While the solution seems simple in theory—get patients diagnosed quickly and then give them whatever rehab is necessary—it doesn’t translate into reality so easily. Most of us continue to think that if we can walk away from a collision, we’re fine. Still, if there was one place where you might expect brain injuries to be spotted, it would be on the battlefield—certainly military personnel would be on the lookout for injured brains. But, as it turns out, soldiers fighting in Iraq and Afghanistan were far more likely to receive a diagnosis of post-traumatic stress disorder than traumatic brain injury even if they’d been involved in explosions.
• • •
For the longest time Major Michael Zacchea assumed his persistent headaches and nausea were brought on by the pressures of his job. He’d been sent to the Middle East to train a battalion of Iraqi soldiers for the war and then to lead them into battle. From the moment the thirty-six-year-old marine stepped off a plane in Baghdad, he was on constant high alert. Westerners were being targeted for kidnapping and torture. Attacks by Iraqi insurgents could spring up out of nowhere. And once he had arrived at the Iraqi army base where he’d been assigned to retrain soldiers, there were regular death threats to him and his men.
But when Zacchea thinks back now, he realizes that those symptoms, along with others that developed later, could be traced to the two times he hurt his head. The first incident was back in September 2004 while he was out on a reconnaissance mission near the Taji Military Complex, the Iraqi army base where he was stationed. He had gone out to assess the severity of an insurgent attack, and as he drove along the perimeter of the base, a hail of bullets from an insurgent’s machine gun suddenly engulfed his vehicle. He careened off the road into a ditch and slammed his head hard on the steering wheel. Dazed and seeing stars, he pulled himself out of the truck and ran to take cover in one of the rickety wood guard towers just behind the chain-link fence that surrounded the base. He paused for a few minutes trying to shake the fuzzy feeling from his brain, then radioed back to the base to order up air support to push the insurgents back and to request help for the wounded soldiers he’d passed while driving along the perimeter. Zacchea stayed in the tower for another six hours, fighting alongside his Iraqi soldiers until the attack subsided.
In the days that followed, he began to have migraines and often felt nauseous. Because he never linked those symptoms to his bang on the head, he never went to a doctor. He just kept on doing his job and assumed that the migraines and sick stomach were symptoms of the unremitting tension he was experiencing. Since the stress wasn’t about to let up anytime soon, he figured the migraines and nausea would be there for the duration.
Two months later, Zacchea and his troops were ordered to join a force of marines and soldiers storming Fallujah, which several months earlier had been ceded to the insurgents. Once they battled their way into the city, Zacchea and three other marines began a house-to-house search for insurgents. As they made their way down one street, the marines suddenly became the target of machine gun fire from the upper story of a nearby house. Taking cover against one of the s
tone walls lining the street, they crouched down and began to leapfrog their way closer to where the shots were originating from. When they were close enough, Zacchea and two of the others stepped out into the street to shower the house with bullets, providing cover while the fourth marine ran over and tossed a grenade up through the second-story window. As the marine turned around to face Zacchea and his comrades, he suddenly froze, his eyes wide open.
Zacchea turned to see what had so startled the marine. Then he saw them: just down the street were two insurgents positioning a rocket-propelled grenade launcher and sighting it on the marines. Without an instant’s pause, Zacchea swung his rifle into position, located the insurgents in his sight, and let off a shot. As he pulled the trigger, he heard the RPG go off and then a whine and roar as the grenade streaked toward him. Everything from that moment seemed to pass in slow motion. He could see the round flying toward him. He thought, “I have time for another shot.”
Then he had the sense that he was floating. The next thing he knew, he was lying on his back on the street. He couldn’t move or speak. He looked up at the sky and noticed it was a brilliant blue. He thought, “OK. This is how I’m going to die. I can do this.” Zacchea closed his eyes and waited for death to come. Then, through a hail of sniper fire, the two marines who had taken cover against one of the walls rushed out, grabbed him, and dragged him down the street and around the corner. As he made it to his feet and leaned up against the wall, Zacchea wondered whether he’d been hit. One of the marines noticed blood on his shirt and asked, “Whose blood is this? Who’s been hit?” Zacchea, soaked from water that had spewed from his canteens and camel pack when they were shredded by shrapnel from the grenade, wasn’t sure. Then he noticed the bloody body print he’d left on the wall and thought, “Oh boy, I’m in big trouble.” He looked up at the other marines and said, “I think I was hit.” They pulled off his clothes and examined him. There were shrapnel wounds on his shoulder, but the main damage appeared to be a fracture to the joint. They wanted to medevac him back to the Combat Army Support Hospital just outside of Fallujah, but Zacchea refused. He was afraid that if he left, his Iraqi battalion might desert en masse. So he stayed on in Fallujah fighting alongside his troops for another six weeks, never stopping to get his shoulder set.
The Concussion Crisis Page 14
