Wall Street Journal
January 29, 2008; Page A1
Researchers studying brain injury believe they've found a common thread running through many cases of seemingly unrelated social problems: a long-forgotten blow to the head.
New research indicates hidden traumatic brain injuries can cause social or educational failure, such as alcoholism or homelessness. WSJ's Tom Burton talks with researchers at Mt. Sinai School of Medicine in New York for some insight.
They've found that providing therapy for an underlying brain injury often helps people with a variety of ills ranging from learning disabilities to chronic homelessness and alcoholism. If broadly verified, the findings could have a significant impact in dealing with such intractable difficulties.
That severe head injuries can lead to cognitive and behavioral problems is widely accepted. The U.S. Centers for Disease Control and Prevention estimates 5.3 million Americans suffer from mental or physical disability that is due to brain injury.
What's new is the contention of some researchers that there are many other cases where a severe past blow to the head, resulting in unconsciousness or confusion, is the unrecognized source of such problems. "Unidentified traumatic brain injury is an unrecognized major source of social and vocational failure," says Wayne A. Gordon, director of the Brain Injury Research Center at Mount Sinai School of Medicine in New York, where much of the research is being done.
Research by his team has consistently found high rates of "hidden" head trauma when screening various populations in New York schools, addiction programs and the general population. The CDC acknowledges its 5.3 million estimate is an undercount based on hospital admissions; it doesn't include people who sought no treatment for a severe blow to the head or who were sent home from a doctor's office or emergency room with little treatment.
• New Findings: Researchers say a blow to the head years earlier may be linked to problems later in life, such as learning disabilities, homelessness and alcoholism.
• Early Identification: Some schools are trying to identify children who may have had head injuries to provide special help in education.
• The Impact: The findings are offering new hope to adults coping with the onset of disorders such as losing the ability to read or concentrate.Causes of brain injury can include bike and car accidents, sports concussions such as those suffered by professional football players, and abuse and falls that can date back to childhood. Doctors say about 85% of common falls in infancy don't produce long-term deficits, but that some do.
To be sure, it's difficult to connect with any certainty a long-ago blow to the head to memory and cognition problems years later. Other researchers point out that many people do recover completely from severe head injury, and mental problems arise from other causes. Moreover, Mount Sinai's findings haven't all been published, nor have they been widely evaluated at other institutions.
Lost Ability to Read
Mount Sinai's research involves people like Kate Gleason, a business-college instructor who over the course of a year lost her ability to read, keep her home orderly and even maintain friendships.
In 1998, Ms. Gleason tried to open a window in her New York apartment building's hallway, but the heavy top window fell and bashed her on the head. She was treated by doctors at a local hospital, who she says let her walk home and told her she'd be fine. But on the way back, she was still so confused she had to hang onto lampposts and buildings to keep from losing her way.
A slim, auburn-haired woman then in her mid-40s, Ms. Gleason kept teaching, but found that the bright lights and hectic office were overwhelming. She says she confided in a boss about her troubles and soon lost her job. After that, she made ends meet by returning to proofreading work, but she slowly withdrew socially.
She didn't pay bills on time. Her house was a mess. "Years and years went by, and I had lots of problems," she says. "I didn't know it was from the head injury. I just thought I had a clutter problem." By 1999, Ms. Gleason, who has a master's from Columbia University, was "so bad on the level of functioning as a college grad that I wanted to die." She had no idea why.
Then about two years ago, she got a strange letter from Mount Sinai: It asked if she was having trouble thinking or solving problems or if she became easily overwhelmed. It turned out Mount Sinai doctors were reaching out to people whose medical records showed a blow to the head. Ms. Gleason responded, and when researchers interviewed her, she began to sob, saying, "Life is just so hard."
On what was to be the first day of an attention and memory program, Ms. Gleason got lost in the maze of hospital hallways and began crying again. Once she found the site, she discovered she wasn't the only patient who got lost a lot, or who cried.
For five days a week for six months, she worked through five hours of attention exercises, reading articles to explain the main idea, interpreting charts and graphs, taking classes on how to take apart a problem and reduce it to smaller steps, writing mock "advice columns" on how to handle life issues.
At first, she found the work so intense she needed a break every 15 minutes. By a week later, she could concentrate a little longer. She completed the program in August 2006, eight years after the window struck her. Now she's studying to be a church-based counselor. "That program gave me my life back," she says.
A group for whom the research on undiagnosed head injuries could be especially relevant is the homeless. Assessments by Mount Sinai researchers of about 100 homeless men in New York found that 82% had suffered brain injury in childhood, primarily as a result of parental abuse.
An epidemiological study in 2000 was larger. Researchers went door-to-door in New Haven, Conn., interviewing 5,000 people, 7.2% of whom recalled a past blow to the head that was followed by unconsciousness or a period of confusion. In follow-up testing, the researchers found that those who reported such injuries had more than twice the rate of depression and of alcohol and drug abuse as others.
They also had sharply elevated rates of panic disorder, obsessive-compulsive disorder and suicide attempts, say the researchers, led by Jonathan Silver of New York University.
Such research began in the late 1980s with Mount Sinai's Dr. Gordon and Mary Hibbard, both Ph.D. psychologists specializing in rehabilitation and neuropsychology. In questioning patients referred to them, they were struck by how often they turned up a history of a brain injury that wasn't in the patients' medical records.
Using a questionnaire they devised, they tried to determine how many children in the city school system had head injuries that were followed by cognitive difficulties. At one school, 10% of students told of having once had a significant head injury. Later testing of these children frequently "was suggestive of impairments," Dr. Hibbard says.
Next, with a grant from the U.S. Department of Education, they set out to determine how many pupils enrolled in programs for children with learning disabilities had ever suffered a hard blow to the head. The results were startling: About 50% had.
"The accident can be three months ago, but by the time the symptoms happen, the accident is forgotten. Nobody puts it together," says Tamar Martin, a psychologist in the program. The team worked with about 400 children, finding that many children who'd had brain injuries were lost in regular learning-disabilities classrooms.
They have trouble with their memory from day to day, and teachers can assume they're not trying hard, Dr. Martin says. They need more breaks between topics. But their performance varies greatly from day to day, and a teacher can also erroneously perceive this fluctuation as lack of initiative.
Just giving such children more time often helps, she says, as do special prompts from teachers. For instance, Dr. Martin says, a teacher may say, "In a couple of minutes, I am going to ask you about problem No. 10," and give the child time to prepare before officially asking.
One 14-year-old girl had a high intellect, but after she was hit by a car, she suddenly couldn't do outlines or organize her time, her mother says in an interview. "Her processing was slower," adds Michelle Kornbleuth, another psychologist in the Mount Sinai program. "She was frustrated, and her scores came out in the average range."
With Dr. Kornbleuth's help, the girl was allowed to take exams privately in an office and could concentrate better. With such accommodations, she completed high school and went on to graduate from prestigious Smith College.
Kansas systematically tries to identify brain injuries among the "learning disabled." School social workers and teachers with special training across the state show other teachers how to recognize and work with the brain-injured, says Janet Tyler, director of a neurologic-disabilities project in the state education department.
"When you look at children with learning disabilities or behavior problems, there's often an underlying high percentage of children with traumatic brain injury. We're looking at about 20%," she says.
In Mulvane, Kan., Sandy Baca's son Timothy, who was hit by a car at age 2, struggled in school for years. Ms. Baca says that once teachers understood the difference between brain injury and other disability, "they found ways for him to be successful. If he couldn't do the work one day, they would lower expectations for the day." Ultimately, he finished high school.
The Mount Sinai team evaluates people via a battery of "neuropsych" tests lasting up to nine hours. They are shown pictures of objects, then asked minutes later what they saw. They see a complex geometric design with triangles, lines and circles and are asked to draw it from memory. They're shown a series of multiple random letters and asked to cross out, say, the "c" and "e" every time they see one.
On a recent morning, a 44-year-old manager at a New York investment firm was working on attention training with a postdoctoral fellow. He had sustained several sports concussions as a younger man and then in recent years twice banged his head hard. Lately, he had been feeling confused. Commuting between New York City and Long Island, he boarded the wrong train three days in a row.
In the first of several exercises, the patient was asked to read a page of text while crossing out all words ending in "ing," and then to answer questions about what he'd read. The first time through, he caught only seven of 12 "ing" words. A second test asked him to choose a word that didn't belong in a group of five, while listening to other words and pressing a buzzer when he heard words with four letters.
About five years ago, the Mount Sinai team began looking at residents of New York centers for alcoholism and drug abuse. They evaluated 845 patients and determined that 54% had once suffered a hard blow to the head. Of course, some had injuries after they began drinking, so there is a certain chicken-and-egg problem with that number.
Link to Addiction
Steven Kipnis, medical director of a New York state agency for alcoholism and addiction, says his work with counselors convinces him that many of the patients became alcoholic or addicted in part because of a head injury, and knowing about it helps in treatment.
"Someone can get hit in the head with a softball and still be working. They tend to be in denial. They get mood swings, they yell at a spouse. It's a slow downward spiral, and that's when alcohol and drugs" become an option, he says.
The agency has a program specifically for the brain-injured at the R.E. Blaisdell Addiction Treatment Center in Orangeburg, N.Y. A counselor there, Steve Oswald, tells of one patient who dropped out of a general alcoholism program three times before the program for the brain-injured began, and then successfully completed the program.
In 2006, Mount Sinai's Dr. Gordon began to work with Common Ground, a New York nonprofit that builds housing for the homeless. About 70% of 100 homeless people they tested came out in the 10th percentile or lower for memory, language or attention, says the group's director of psychiatric services, Jennifer Highley. Questioning uncovered that 82% had a significant blow to the head prior to becoming homeless, usually from severe parental abuse during childhood.
"People get abused as kids, making them inattentive in school and sometimes unable to learn," says Ms. Highley. She says head injury and the emotional fallout from abuse can lead to alcoholism and addiction, and "that combination creates the inability to function and often leads to homelessness."