Just a Few Knocks on the Head: The Concussion Conundrum

This is a tale of two teenage boys who lived in the same large city but came from very different backgrounds. Jason was the eldest of two sons and lived with his well- off, white, professional parents in a large house in one of the wealthiest suburbs of Auckland. He attended a private boys’ school and at 16 was already looking forward to university in two years. Howie, also 16, was the third eldest in a family of eight children and lived in a three-bedroom state house in one of the poorest suburbs of Auckland. His Maori mother worked as a cleaner and his white father was unemployed. Howie attended a large coeducational state school where most of the pupils came from poor families and where few of the pupils went on to university.

Yet these two boys had one very important thing in common. They were both mad about sports, and in particular rugby, New Zealand’s national game. What’s more, as a result of their passion they were both up-and-coming sports stars in their schools. In fact, as I later discovered, Jason and Howie had met each other on quite a few occasions on the rugby field and at parties after school matches. Their schools may have been miles apart in their educational standards and the discretionary funds they had to spend on extras for their pupils, but they were neck and neck when it came to rugby. One year the top team — the First Fifteen — in Jason’s school would win the annual secondary school rugby competition, and the next year the honor would go to the First Fifteen in Howie’s school. Of course some years neither school would win, but invariably both would be in the top six. At 16, Jason and Howie were young to be in their schools’ First Fifteen teams; most of the players were 17 or 18 and in their final school year. Perhaps it was their physiques — both boys were tall and strong for their age — that prompted their premature selection for the top team. Certainly their size was one of the factors that made them good “locks,” the rugby position they both held and that exposed them to more risk of head injuries than many other positions on the field.

Like every boy in every First Fifteen, Jason and Howie fantasized about a career as a professional rugby player. But in reality they knew that this was a long shot, and Jason had a backup plan, to obtain a master’s degree in sports psychology. Howie’s backup plan wasn’t quite so ambitious: he thought he’d try to get an apprenticeship as a mechanic at the local garage. Messing about with vehicles was his other passion.

Sadly, for these two boys the chance of being selected for the All Blacks — New Zealand’s famous rugby team — was stymied. Before they reached their 17th birthdays they were to discover they had one more thing in common — brain damage. Of course, nobody in their families thought of it as brain damage. For many months the boys and their parents, and even their teachers and sports coaches, looked upon the mild difficulties Jason and Howie were having as unfortunate but temporary consequences of “just a few knocks on the head.”

* * *

Jason’s mother, Becky, was a “mature” student in the large undergraduate “Introduction to Clinical Psychology” course I taught at the university. I knew her by sight, as she always sat in the front row of the lecture theater and often came up after the lecture to ask me a question. So when she knocked on my office door I assumed she was there to talk about her upcoming essay assignment. But after a brief exchange when she’d explained that she had returned to university part- time now that her two boys were in their teens and she had time on her hands, and that psychology was her favorite subject, she came to the real reason for her visit. She was worried about Jason and wondered if I could help. Over the last few months he seemed to have lost his zest for life, and she thought he might be depressed. Her husband, Andrew, even wondered if Jason was experimenting with drugs, although Becky was pretty sure he wouldn’t be so silly. Two weeks earlier, the situation had come to a head when Jason became very drunk at a party after the Saturday rugby game and had been delivered home at 3 a.m., semicomatose, by two of his friends. And last week the school headmaster had asked Becky and Andrew to come in for a chat, where he told them that Jason’s work standards had plummeted over the past few weeks and he had been missing some of his rugby practices. Becky and Andrew had tried talking to Jason, but with no success; he was sullen and rude and told them to get off his back before locking himself in his room for hours. Then Jason had been called in to see the school counselor, and that had caused more upset. Jason refused to go to school the following day, saying he was sick. By this point in her story, Becky was almost in tears, and I could see this would need more than a brief discussion with me.

“Do you think Jason’s behavior might just be a case of ‘teenage angst’?” I asked her.

“I wish it were, but he’s so different than he’s ever been before that we think there must be something else going on. I think he’s depressed, and he has always been such an optimistic and balanced person. And he’s always been avidly against drugs because of his sport and keeping fit.” “It does sound as if it would be a good thing for him to see someone. Are you wondering whether he could come to the psychology clinic?”

“Yes, I think he might accept that. Having to go to the counselor at school was too embarrassing. And Andrew told him he had no option: He had to either tell us what was wrong with him or go to see someone who could help him.”

“And what was his reaction to that?”

“At first, he said he didn’t need to see anyone and went and shut himself in his room again. But in the middle of the night Andrew got up because he couldn’t sleep for worrying about him — neither of us could — and then he heard Jason crying in his room. He never cries, so it was very distressing. But thank goodness Andrew heard him. Anyway, he went in and after a while Jason did talk a bit, and said he was worried about himself. He thought he was going crazy. He said he’d never touched drugs and didn’t get drunk as much as most of his friends and didn’t know what was the matter with him. In the end he said he would go to see a psychologist as long as no one at the school had to know.”

The psychology clinic is a training clinic for our clinical psychology interns, but on the day of Jason’s first appointment, the intern who was scheduled to see him under my supervision went home sick just an hour before Jason was due to arrive. Jason was already on his way, so rather than postponing his initial session — at the risk of his deciding never to return — I decided to see him myself. Becky brought him in and introduced us and then, on my suggestion, went off to the library, saying she would be back to pick him up at the end of the session.

 Jason was a tall, good- looking young man, mature for his age; he could easily have passed for 18 or 19. He looked miserable, and answered my questions politely but with minimal effort. He told me in a monotone that he was in the top class at school but could no longer be bothered with it, and that he was in the First Fifteen, played cricket and tennis in the summer, and was a fairly good snowboarder. I asked him how he thought his best friend would describe him. He looked at me in surprise.

“How would I know? I suppose he thinks I’m all right. We get on OK most of the time.”

“How do you think he might describe your personality?”

“I don’t know.”

“Do you think you’re seen as an outgoing sort of person, or studious, or shy, or pushy?”

“I used to be outgoing, but not anymore. I can’t be bothered.”

“What does that feel like, not being able to be bothered?”

“Like shit.”

“And that’s different from how you used to feel most of the time?”

“Yeah.”

“Have you any theories about why you’ve started to feel like shit?”

“No.” Jason’s head was down and I could see he was struggling not to cry. Neither of us spoke. Then Jason’s fists clenched and he burst out: “There’s something wrong with my head. I think I’m going nuts.”

That was the breakthrough, and for the rest of that first session, another session three days later, and then a family meeting with Jason and his parents — Jason refused to have his younger brother involved — together we were able to build up a picture of Jason’s life over the past few years and the time sequence of the distressing changes he had been experiencing. Of course, as a neuropsychologist, I always had in mind the possibility of mild traumatic brain injury as a possible factor in any client who played rugby. However, as a clinical psychologist I was also alert to the many other possible causes for Jason’s problems, not least family stresses, drug and alcohol issues, depression or another psychological or even more serious psychiatric problem, a physical illness, or simply being a teenager.

Jason’s relevant “history” was unusually straightforward. His family life was happy; his parents were caring and had an excellent relationship with their sons; Jason was popular, extroverted, good with people of all ages —  including his grandparents and his small cousins — a keen sportsman, and academically high- achieving. He only occasionally got drunk, did not take drugs, had never smoked, and had been as “healthy as a horse” all his life. In short, Jason was — or had been until recently — a dream son. Over the past few months he had been feeling terribly tired, found it difficult to concentrate in class, struggled with his homework — especially where he had to learn facts — couldn’t stand being around his brother and his rowdy friends, and was irritable with his own friends, parents, and grandparents. Worst of all, his rugby game had deteriorated to the point where his coach had told him that if he didn’t improve his attitude on the field and off, he could say goodbye to the First Fifteen. This was a revelation to his parents, as Jason had not told them. So I was not surprised by Jason’s answer to my question, “Have you ever been knocked out, or even just dazed, during a rugby match or at any other time?” I might just as well have asked “How many times have you been knocked out,” but of course that would have been a leading question.

“I’ve been dazed a few times, I suppose, but I’ve only actually had concussions two or three times when I’ve had to sit out the rest of the game and wasn’t allowed to play for three weeks.”

It took some careful detective work to discover that Jason had in fact been helped off the field three times over the past two years, twice in the current rugby season, which was by now nearly over. On each occasion he was unconscious for no more than a minute or two, was checked by his GP, and was not allowed to play on the next two Saturdays. Becky said that she had been worried after the last two knocks, as he had seemed confused and muddled for a few hours after each concussion. After a night’s sleep, Jason had no longer felt confused, but had a hellish headache. He said he had headaches quite often now, especially when he was trying to concentrate in class, and that was one of the reasons he couldn’t be bothered with school anymore.

By early evening he felt so tired he fell asleep over his homework. He used to be a sound sleeper, but he often woke two or three times in the night now, and struggled to get back to sleep. When I asked him if that’s when he got to worrying about everything, he admitted it was, and that he knew he was depressed. He couldn’t be bothered with parties, because the noise got to him and obviously he couldn’t hold his drink. He hated being drunk; he liked to be in control. His girlfriend had practically given up on him anyway, as he was such a morose bastard these days. On the positive side, his appetite hadn’t changed — he still ate like a horse — and he was adamant that he didn’t have any suicidal thoughts. I felt confident that he was not in danger of self- harm and probably didn’t require medication for his depressed mood — at least not until we had tried therapy. I suspected that just learning that there was a physical explanation for his changed feelings and behaviors would go a long way toward relieving Jason’s worries.

All Jason’s symptoms pointed toward a postconcussional syndrome (PCS). So as the next step, I scheduled a neuropsychologicalassessment to see if he displayed the patternof results typical of PCS. In the meantime I explained whata PCS was, and we discussed some simple strategies hecould use to help him manage his symptoms. First on thelist was the importance of taking a long break from rugbyand all other activities that might lead to another knock onthe head. He also agreed to avoid alcohol completely afterI explained that because of the PCS, he would becomedrunk much more rapidly. He should try to avoid situationswhere there was a lot of noise and sleep as much aspossible. Jason left the clinic armed with some informationbooklets on concussion and the PCS, as well as a bookwritten for the layperson covering all aspects of mildtraumatic brain injury (TBI) and its rehabilitation.

* * *

No universal standard exists for defining mild closed TBI — an injury to the brain caused by a blow to the head that doesn’t pierce the skull — but it is commonly defined as a loss of consciousness for less than 20 minutes with a posttraumatic amnesia (PTA) of less than 24 hours. PTA refers to the period of interrupted ability to form new memories following a concussion; for example, the concussed person may not remember that his parents visited him the previous day, even though he had a perfectly reasonable conversation with them at the time. Many people who sustain a mild TBI may lose consciousness for a few minutes only, or sometimes just feel dazed and confused, and have a PTA of only a few seconds. But even these people can occasionally develop a PCS.

Immediately following a mild TBI, the victim may suffer headaches and feel nauseated, extremely tired, and possibly confused and disoriented for hours to days after the accident. The best treatment at this stage is to sleep and rest. Most people feel fully recovered two weeks later, and many are able to return to work without difficulty, especially if the work is not too taxing mentally or physically. Twenty-five percent or more, however, suffer some symptoms that constitute the PCS for varying lengths of time and in varying degrees of severity. The most common of the cognitive symptoms are a decreased ability to focus on the task at hand, especially in a noisy or distracting environment; an impairment in processing complex information; and problems with recent memory. These deficits are usually assessed by performance on standard neuropsychological tests of attention, information processing, and new learning and recall. In day- to- day life, sufferers notice that they have to put much greater effort into learning and recalling names of new friends and facts in school; that they become irritable in noisy environments; and if they need to do tasks requiring concentration, memorizing information, or processing new information, that they tire very quickly, develop headaches, and soon find themselves falling behind in their work or schooling.

The physical and psychosocial symptoms of mild TBI have a neuropathological basis (lowered cortical arousal from frontal lobe dysfunction) but can be exacerbated if the TBI victim and others misunderstand the cognitive and behavioral changes typical of the PCS. Common symptoms include fatigue, nausea, changes in sleep and eating patterns, periods of dizziness, hypersensitivity to noise, lessened tolerance for alcohol, irritability, anxiety, and depression. If the PCS continues for many weeks or months, sufferers may gradually lose confidence in their ability to work and maintain relationships, resulting in frustration, irritability, and a lowering of self- esteem. Family disruption often occurs as family members struggle to cope with the problems of the head-injured person. Some sufferers may even come to believe they are going crazy or become so depressed that they feel suicidal, especially if they have not obtained information about PCS and do not relate their problems to the mild TBI they sustained weeks ago.

Because the symptoms of the PCS are common to many disorders, including depression with a psychological cause, the very existence of a PCS is controversial in some medical circles. Some doctors believe that the symptoms that make up the PCS are purely psychological and have no organic — physical — basis. Indeed, for many years the evidence from low- resolution computerized tomography (CT) brain scans corroborating the claims of a neuropathological cause for the symptoms of the PCS was rather slight, but this has changed with high- resolution magnetic resonance imaging (MRI) brain scans. Research studies using MRI have found that shortly after a concussion lasting less than 10 minutes a high proportion of people have small contusions and subcortical hemorrhages, usually located in the temporal lobes and the inferior anterior frontal cortex — the brain matter just above the eyes. Diffuse axonal injuries caused by stretching and tearing of nerve axons (the elongated projection attached to each neuron) are also a possible consequence of mild TBI, although these injuries are minimal compared with severe head injury. This type of damage can nevertheless result in a transient disruption of the reticular formation — a diffuse nerve network that connects the brain stem to the prefrontal lobes — causing lowered cortical arousal and the consequent common problems of fatigue, hypersensitivity to noise, and mood swings. Other research has shown that the effects of mild TBI can be cumulative, with patients who have sustained two or more mild concussions taking longer to recover than those sustaining a single mild concussion.

Another aspect of the PCS that fuels controversy over its very existence is that it is idiosyncratic in its choice of victims. Some people seem able to have multiple concussions without developing any of the symptoms of the PCS and others may have the smallest knock on the head and yet suffer a PCS. Why this might be is still unknown, but it is likely that interactions of many organic and psychological factors are responsible for the variable susceptibility of individuals to what appear to be relatively mild blows to the head. Multiple head injuries, a history of serious emotional or psychiatric problems, alcohol or solvent abuse, a demanding occupation, and the individual’s age — children, teenagers, and the elderly are more vulnerable — all increase the potential for a significant PCS. In some cases, malingering can be a factor in apparent PCS, especially where there is monetary compensation for problems related to the head injury. In many such cases, a PCS can be viewed as a psychological construct without an organic basis. In true cases of PCS, where there is an underlying organic cause, there is very often some psychological overlay, and it is as important to prevent these psychological symptoms from developing as it is to manage the rehabilitation of the organically mediated symptoms. Whereas some cases of extended PCS may be primarily the result of neurological damage — as supported by MRI findings of diffuse lesions following mild TBI — it is possible that many cases of PCS that continue for months or years have become almost purely psychological. These people should not, however, be viewed as malingerers but as suffering from a poorly managed PCS.

* * *

When Jason returned the following week for his neuropsychological assessment — scheduled on a school day at 9 a.m. to ensure that he was not tired before he even began — he seemed a little less down, and told me that after reading the information I had given him on the PCS, he figured that this might be what was wrong with him. On the whole it was a relief, he said, because at least it was something that he could do something about. But when I asked him how the past few days had gone, he looked at me glumly.

“Dad phoned my rugby coach and explained that I probably had these problems because of my concussions, so he banned me from games or even practices for the rest of the season.”

“That’s tough, but it is the only option if you want to get better. And the season is almost over, isn’t it?”

“Yeah, I suppose. But are you sure I’ll be cured in time for next season?”

“Until we get the results of your neuropsychology tests we won’t know for sure if you have a PCS. But if you do, then we’ll need to work out a rehabilitation plan. All going well, I would think you’d be back to normal within a few months, but recovery from PCS is very variable and it could take longer. I’m afraid that it’s going to take a lot of patience.” I didn’t add that returning to rugby at all might prove to be a very bad idea; at this point Jason needed to hang onto hope rather than be battered with what would probably seem to him to be the worst possible scenario.

“Right. Let’s get on with these tests then,” Jason said, sounding a little less glum.

Jason was easy to assess; he picked up the instructions for each test quickly and refused to stop for breaks. In fact, at the halfway point I insisted we stop for a 15-minute rest and sent him outside with a cup of coffee to sit in the sun. I could see he was tired but determined to stick at it, and I wanted to see how well he did on the tests when he wasn’t exhausted. We completed the assessment in two-and-a-half hours, and at the end Jason admitted he was “stuffed” and was happy to agree to my suggestion that he take the rest of the day off from school and go home to sleep. He returned with his parents two days later to discuss the results — he had asked if I could score the tests quickly, as he didn’t want to wait for ages before he “knew the worst.”

I was able to tell them that Jason’s pattern of results strongly supported my preliminary diagnosis: Jason was suffering from a PCS as a consequence of his multiple mild head injuries and concussions. His performance on the general knowledge, vocabulary, verbal comprehension, and verbal abstraction tests placed him in the “superior” range for verbal abilities, which was congruent with his schooling history. But on a test where he was given mathematical problems and asked to work them out in his head, he scored in the average range. This was clearly an impairment for him, as math had been one of his best subjects. His difficulty was being unable to hold long problems in memory while he worked them out, and his performance improved when I gave him the written problem and an unlimited time in which to solve it using pen and paper. He also lost points for slowness when asked to perform speeded tests of visuospatial ability, such as copying a pattern by putting blocks together. But he was able to perform the tasks to a high level if given sufficient time.

On a test of “information processing capacity” specifically designed for TBI victims, Jason’s performance was below average. This test, which involves listening to a long string of numbers and adding each number to the previous one while not forgetting the number you just heard, places demands on sustained attention and concentration, working memory, and performing multiple mental tasks under time pressure. The trials of the test are given at increasingly faster speeds. Performance correlates highly with the symptoms of PCS, and repeated assessments with the test over time can provide a good indication of rate of recovery from the concussion. When performance nears normal levels, the individual is usually ready to return in a graduated way to work or school. Jason found this test very frustrating, and almost gave up on it. At the fastest two speeds he was unable to do it at all.

His scores on tests of new learning and memory fell in the average range; he found these tests very tiring as well. Although he drew an excellent copy of a complex figure, his recall of it from memory 45 minutes later was just average. All these average scores marked a considerable drop for Jason, given his position near the top of the academic ranking in his school. On the positive side, on tests of verbal abstraction and other frontal lobe abilities such as organization, planning ahead, and insight into his performance, Jason performed very well.

After a discussion of his results, Jason and his parents agreed that I should talk with Jason’s school headmaster and explain the situation. Jason had his end-of-year exams coming up in just over two months, and he was concerned that he would fail them, given his difficulty in concentrating in class and staying awake in the evenings long enough to do his homework. I thought the strategy most likely to assist his rehabilitation was for him to reduce his school hours to mornings only and perhaps drop some of the more taxing subjects completely. Jason looked relieved when I suggested this and said he could drop math and physics, because they were the subjects he now struggled with the most. His father expressed concern that it would put him back a year if he didn’t take all his exams, but Becky was quick to disagree, pointing out that even if he had to repeat the year — and this would surely be the worst scenario — that was vastly preferable to having him fail and on top of that not get better.

The school headmaster was receptive to my concerns and said he would discuss with Jason’s teachers the best way they could help him reduce his schoolwork without entirely sacrificing the year’s work so far. The following week Becky and Jason returned to the psychology clinic and showed me his new schedule. Jason would continue to attend English, biology, and chemistry classes, but he would only be expected to do the homework he felt he could manage. At most he was to do no more than one hour’s homework each day. When his classes were in the afternoon or he had a free period between classes, he could go and rest in the “sick bay.” Jason’s teachers had assured him that if he passed the three subjects he was continuing with, the following year he would be able to advance with his peer group to the next class for everything but math and physics. He could either repeat those subjects this year, or if he was completely back to normal, he could take some extra, catch- up classes to get him up to speed. When the time came to take his exams, he could take them in a separate quiet room and would be given additional time to complete each exam.

This was an excellent start to his rehabilitation program, and Jason seemed reasonably happy with it except for one aspect: He was concerned that he would lose all his fitness, as it had been decided that he should give up all competitive sports for the time being. So together we looked for ways to work some pleasure into his life. This is what we came up with. To keep up some fitness, Jason was permitted to swim in the school pool for 30 minutes each day if he felt like it. He would also begin walking rather than cycling to and from school — a 30-minute walk — with the proviso that if he felt tired after school he would phone his mother to come and pick him up in the car. Cycling and driving within the busy city were off limits for a while because of his slowed reaction times, and to avoid any possibility of another knock on the head!

He should try to get to bed as early as possible each night, and to encourage good sleeping patterns — he had been having trouble getting to sleep even though he felt exhausted — he would complete his homework before the evening meal, and after dinner would do something relaxing, like listening to music or reading a novel, followed by a bath and a hot drink. Once in bed he would put the light out rather than reading or doing anything else. The idea here was to establish his bedroom and bed as a place he associated with sleep rather than, for example, messing around on his computer. In fact his computer was to be moved to the family room, which would allow Becky to keep an eye on Jason’s tendency to sit in front of it for hours on end. If he felt like it he could go out with his friends in the weekend to watch sports or go to a movie, with the proviso that he would not drink any alcohol and the suggestion that he avoid noisy situations or parties where he would be bombarded by too much information — situations very stressful for PCS victims, who have an impaired ability to filter out background noise. Jason was amenable to these suggestions, as he had no interest in being anywhere noisy; he couldn’t even cope with the TV anymore.

* * *

Within a week of first seeing Jason, I received a referral to assess another 16- year- old schoolboy with suspected PCS. The referral came from the New Zealand Government Accident Compensation Corporation — the ACC — which provided national insurance for accident victims, including funding medical treatments, counseling, assessments, rehabilitation, retraining, and financial compensation. Howie was brought into my office by his ACC caseworker, who explained that he had been referred to the ACC by his GP after his school rugby coach had expressed concerns about his slow recovery from a concussion during a match.

Howie was a fine-looking and very solid young man who at 16 towered above me. He had a lovely smile and quickly put me at ease. After his caseworker left, we spent the next half- hour talking about Howie’s background and the problems he’d been having before beginning the neuropsychological assessment. Like Jason, he had sustained multiple mild head injuries over the preceding two years: three during rugby games and one as a result of falling off his motorcycle 12 months before I met him. Although he was in the same school year as Jason, Howie’s school, in an area of low socioeconomic status, had less ambitious educational aims. Howie usually managed to achieve grades in the average range in English and math, although this was often a struggle, but he did better in his favorite subjects of art, Maori language, and practical mechanics. After his most recent concussion eight weeks ago, when he was unconscious for almost fi ve minutes and spent a night in the local hospital before being discharged home, he had suffered from most of the typical symptoms of the PCS. Now, he said, his worst problems were tiredness, difficulty in concentrating, losing his temper with his brothers and sisters, and awful headaches.

His home environment was much less conducive to rehabilitation than Jason’s. Howie shared a small bedroom with three of his brothers, and the noise levels in the small state house where he lived with his parents, his grandmother, and his seven siblings, ranging from three to 18 years, were extreme and continuous. Howie’s mother worked two jobs, the fi rst cleaning hotel rooms from 9 a.m. to 1 p.m., and the second cleaning offices from 7 p.m. to midnight. When I asked what his father did, Howie grimaced and replied that he had been unemployed for years and spent his time either at home watching sports on the TV or in the local bar getting drunk. His grandmother got the kids off to school and looked after the two preschoolers, and the older kids — Howie was the third oldest — were kept pretty busy doing odd jobs to earn a bit of extra cash and making kai (food) for the family in the evening.

Howie said getting any homework done was pretty impossible in their house, and since his last concussion even the simplest school work was a mission. He’d planned to leave school and get a job as a mechanic at the end of that year, but was thinking he might as well leave right now. I suggested we complete his assessment and see if we could come up with a more feasible rehabilitation plan first and then look at his options, and he said he’d go along with that, as he didn’t think he could handle a mechanic’s job anyway in his current state.

I was aware that Howie might be disadvantaged by being given the standard battery of tests, developed for white people, and that because of his close connections with his mother’s extended Maori whanau (family), Howie strongly identified himself as Maori rather than as pakeha (white New Zealander) like his father. However, because he had been in the Western, “white” school system all his life and his first language was English, on balance I decided to give him the same tests I had given Jason, although I did use the Maori- friendly test instructions and more culturally appropriate “Maori” examples where I had these available. Howie’s overall results showed quite a similar pattern to those of Jason, although, on the basis of his school performance over the past four years, the scores that I considered “unimpaired” for Howie fell in the low average to average range, and his “impaired” scores fell in the range lower than this. He was unimpaired on general knowledge, vocabulary, and verbal comprehension. But he had a lot of difficulty with the mental arithmetic test, although he improved marginally when given more time to solve the problems using pen and paper. Like Jason, he lost points for slowness when asked to perform speeded tests of visuospatial ability, such as making patterns with blocks and drawing a complex figure, but given unlimited time he actually scored in the high average range, which was congruent with his performance in art at school.

Howie was completely stumped by the difficult test of information processing capacity, and early in the very first, slowest trial lost track of the string of numbers he had to hold in his head while adding up others. He flatly refused to attempt any of the faster trials. I didn’t contradict him when he excused his poor performance by saying he’d always been hopeless at sums, but I suspected that he would have performed a good deal better, at least on the slower trials, if he didn’t have a PCS. On the tests of new learning and memory his scores fell in the low average range or lower, and his recall of the complex figure 45 minutes after his good copy of it was also below average. Like Jason, he was unimpaired on tests of executive abilities such as verbal abstraction, organization, planning ahead, and insight into his performance.

It proved difficult to find a time when Howie and his mother, Rosie, could come in to talk about Howie’s results and the best way to set up a rehabilitation program, but we finally managed to schedule a meeting. Rosie looked tired and harassed, but said she was grateful that Howie was being looked after, as she had been worried about him. It soon became clear that Howie’s father was not interested in participating in his son’s rehabilitation, and that Howie’s tiredness after school and reduced ability to help out increased the burden on Rosie and his grandmother. In spite of this, we did manage to establish some goals that Rosie and Howie thought might be attainable. I would discuss with the school headmaster how to reduce Howie’s school program and see if he could rest at school during the day. Rosie would ask her eldest son if he would give up his trailer in the garden where he slept to Howie for a few months until he was back to normal. Howie shared a bedroom with his other three brothers, and he said it was impossible to sleep or do any schoolwork there, and he was constantly getting into fights with his brothers because he was so bad- tempered these days. The other children would be asked to help Howie by taking on some of the household tasks he usually did. Rosie said that her kids all loved Howie, and she thought they would help out once they understood he was not well.

Over the next six weeks, Howie’s ACC caseworker visited Howie regularly, and every week he came in to see me or we had a phone conversation. His brother did vacate his trailer for Howie, and this according to Howie was a “lifesaver”; he was able to get away from the noise and disruption of the house, although he still had trouble sleeping through the night. Like Jason, he was able to reduce his schoolwork considerably, and he reluctantly gave up rugby and his motorcycle for the remainder of the year. But when, six weeks after I first saw him, I assessed him again on a small number of the tests he had been impaired on, he showed little improvement. I was also concerned about his low mood. Howie talked for a while about the problems he was still experiencing — fatigue, headaches, and depression — and how his problems didn’t seem very important in their family when compared with his father’s drunkenness, his mother’s constant exhaustion, and the ongoing problems his mother and grandmother had looking after his younger brother who had attention deficit disorder. He rarely saw his mates anymore now that he couldn’t play rugby or ride his motorcycle, and he admitted that the only way he could cope was to smoke a joint of marijuana every night. He told me in a glum tone that if he was never going to be able to play rugby again he couldn’t see the point of staying at school, and added that that was the only reason he was there anyway, as he was pretty dumb. Perhaps, he said, he should leave school and try to get some sort of a job to help his mother out.

After this session, through his ACC case manager, I referred him to a male Maori clinical psychologist whose practice was close to Howie’s school and who had enjoyed considerable success with young people like Howie. It seemed particularly important to expand Howie’s support networks and explore ways he could reconnect with his friends. I managed to convince him to go to a head- injury support group for teenagers who met once a week to share their experiences and to join in recreational activities such as pool and card games. There, quite by chance, he met up with Jason, whose rehabilitation program was now overseen by the ACC. The two boys recognized each other from their past meetings on the rugby field and quickly discovered they had a lot in common despite their very different backgrounds.

One day, out of the blue, Jason and Howie showed up at my office. I had heard from each of them earlier that they had met at the head- injury support group but didn’t know they had become close friends, going — as spectators — to sports events and to the gymnasium four nights a week. They had come to tell me that Jason’s family was going away to their beach house for the long summer break and Howie was joining them. Both boys were going to have a complete break from schoolwork and spend their time fishing, swimming, snorkeling — the beach house was close to a marine park—and eating lots of seafood. Howie grinned and added that they had made a pact to keep their alcohol consumption to two beers on Saturdays and that he had given up marijuana to please Jason, who was totally against all drugs. When they returned in time for the next school year, Jason was planning to go on to his fi nal year at school while taking catch-up classes in math and physics, and Howie, encouraged by Jason, was also keen to spend another year at his school.

I was delighted. They had come up with the perfect rehabilitation program for a PCS: rest from tasks that tax the damaged systems of the brain, giving those systems time to recover; a quiet environment with no pressure to “perform” and plenty of time to sleep; minimal alcohol intake; enjoyable and varied activities; and regular, manageable exercise that would not put them at risk of further head injuries. But best of all, their “program” was sure to work because they would be doing it together. Mild TBI has been dubbed “the unseen injury,” as to outsiders the PCS seems almost unbelievable. Jason and Howie’s relationship had begun because of their common understanding and experience of the debilitating effects that can occur after mild TBI, but had grown into a true and enduring friendship that would far outlast their PCS symptoms.

They had promised me they would drop by when they returned to Auckland, and true to their word, they did. They had had a wonderful summer and both boys were now keen amateur marine biologists. They had spent most of the summer snorkeling, and Jason had been told by his doctor that if his neuropsychological assessment demonstrated that he was “cured,” he would be able to take up diving with a tank. Howie figured that the same rule should apply to him!

I reassessed both boys, and as I suspected simply from their happy faces and renewed energy levels, both were now back to normal. Even Howie managed to perform at an unimpaired level on the challenging information processing task. They had decided they would not persevere with their rugby dreams but stick to noncontact sports, although Howie said he could not give up his motorcycle.

Jason did go on to university and became a secondary school teacher of biology and physical education, in his spare time coaching schoolchildren in rugby — but not playing it. Howie also remained at school another year and then scored a job as a technician in the marine biology department of the university, where he was able to indulge his love and knowledge of engines — now in boats — as well as diving, regularly accompanying students on their marine biology field trips. In the summer months, Jason and Howie went diving together most weekends, afterward sharing a beer or two over a barbecue with their partners, and later their children. When I last talked with them they said that they had managed to avoid any further knocks on the head, and Howie added that the very thought of having to do that bloody number- crunching test again was enough to make sure they kept it that way!

Further Reading

Ogden, J. A. 2005. The unseen injury: Mild traumatic brain injury. In: Fractured Minds: A Case- Study Approach to Clinical Neuropsychology, 2nd Ed. (pp. 193–203). New York: Oxford University Press.