A 15-year-old male came to clinic with a history of head injury from a soccer game 8 days previously. He had no loss of consciousness and sat out the rest of the practice. He continued to have a headache for about 48 hours which then resolved. He reported being more tired but this continued to improve over time. He had returned to school and did return to play after 4 days. He denied any problems with gross motor movements including having no balance issues or vertigo. He had no problems with lights or sounds. He said that he was doing his homework but that he seemed to be taking longer to do. He was having more problems learning information since the head injury. “I get most of it, but school used to be easy, and now I have to work. It took me a lot longer to learn my Spanish vocabulary this week and usually I’m right on top of my math. I study it and get it during class, but seem to forget it by the night and study it again. Then in the morning I can remember most but not all of it. I feel foggy,” he explained. When asking about how he had felt right after the accident, he stated, “I think it was the same, but I my head was hurting and I was so tired. I guess I thought about them more. I’m having some problems doing what my coach also just asks me to do in practice too.” His mother said that she had noticed that he seemed less organized and didn’t seem to remember various things he needed to do or schedules. She also said he seemed “a little fuzzy” to her as well. “I asked his friends and they thought he was fine. Also a friend of mine also is one of his teachers and she said he seemed to be doing okay at school, so I thought it was okay for him to go back to practice,” she offered. The past medical history showed no reported head trauma, learning problems or attentional problems.
The pertinent physical exam revealed a thin but muscular teen with normal vital signs. His examination was normal. His SCAT 3 head injury assessment was normal except for delayed recall of only 2 of 5 words, and he could do 4 digits forwards and 3 digits backward for concentration.
The diagnosis of head concussion with memory and concentration problems was made. The patient’s clinical course showed that cognitive rest for a week was recommended and at followup he and his father reported that he was acting normally and now was not having memory or concentration issues. His SCAT 3 assessment was entirely normal. He followed the return to play concussion plan and at his next appointment said that all had gone well. He continued to participate in high school and recreational league soccer.
Memory is an important part of what distinguishes higher order species from others. Memory also is part of one’s self-identity. Difficulties in short-term memory can make common, everyday tasks difficult for the person experiencing the problem particularly if it recently occurred and the person’s long-term memory is intact. Difficulties with long-term memory can also have problems when language, events or even one’s own identity are affected. For some people the memory loss is temporary but for others, memory impairments are permanent and must be accepted and accommodated as part of the overall person. Many people have relatively minor problems that they work with every day which are not disabling (always has a hard time finding a word, or planning details), but others have more severe problems which can be a disability for them.
Head injury can be a common, acquired cause of memory problems which maybe temporary or permanent. Amnesia of the event is quite common. Concussive symptoms often last longer in children and teens than in adults, and it is also not uncommon for new symptoms to occur after the initial time period. A review can be found here.
- Short-term memory (STM)
- Also called immediate memory or working memory
- STM “…hold[s] current perceived or retrieved information in an active and conscious format during the completion of a cognitive task.”
- STM “…integrate[s] current information with the immediate past and the immediate future and hence is a critical function for maintaining internal thoughts and activated cognitive representations synchronized with ongoing external events.”
- Examples: holding the successive results of a mental math calculation in one’s head to then use in the next step such as adding 4 numbers together, remembering a new word one has just heard before starting to repeat it orally or in one’s head, maintaining the picture of something that needs to be copied
- Impairment: immediate impairment of verbal sequences (such as digit recall) or visuospatial patterns (such as copying).
- Impairment causes: head injury, stroke, genetic syndromes such as Down, Kleinfelter, Turner, Velo-cardio-facial, Williams syndromes. It is also associated with other broader cognitive problems such as aphasia or dyslexia.
- Brain areas affected: inferior parietal lobe and/or interior front gyrus
- Treatment: treat underlying cause if possible, use “work arounds” such as computer/paper/pen to write down information, calculator, spell checker, etc.
- STM Subcategories
- Verbal – difficulty maintaining or using new words/language
- Order – difficulty maintaining order of events
- Visual – difficulty with mental imagery or new visual information
- Episodic long-term memory
- Episodic memory “allows the encoding, storage, and retrieval of information associated with the precise spatiotemporal context in which the information is experienced.”
- “[E]pisodic memory intimately related to autobiographical memory and the construction of one’s identity in an individual with a history of personal events.”
- It also helps us to think about future events such as planning tasks and completing to-do lists.
- Examples: remembering a vacation with family last year, telephone call 1 hour ago, first day of high school, etc.
- Retrieval: is longer because not only do the facts need to be retrieved but also the context of the memory.
- Impairment: in the encoding or placement into episodic memory (not correctly encoded), consolidation (high rates of forgetting), retrieval (information is correct if retrieved, but retrieval rate is low)
- People have difficulty with remembering tasks of activities or planning such activities
- Impairment causes: head injury, stroke, epilepsy, brain tumor, anoxia/ischemia, carbon monoxide poisoning, ADHD, genetic syndromes such as Down, Kleinfelter, Rett, Velo-cardio-facial or Williams syndrome.
- Brain areas affected: hippocampus
- Treatment: treat underlying cause if possible, repetition/practice, memory aids such as mnemonics, stories or other associations
- Semantic long-term memory
- Stores facts and general knowledge but does not also store the context.
- Examples: What is snow? Paraguay is located on what continent? Why is it hot on the equator?
- Retrieval is fast because context does not also have to be retrieved. The fact is “just known.”
- It can also be biographical but is not contextual. For example, relatives names, birthdate, nationality, etc.
- Impairment: poor factual knowledge, difficulty with categorizing (knowing cat and dog are both animals), vocabulary or other language problems
- Impairment causes: epilepsy, genetic syndromes such as Down syndrome, Fragile X or Williams syndrome
- Brain areas affected: medial and inferior temporal lobe
- Procedural long-term memory
- Procedural memory is a “relatively heterogeneous concept broadly regrouping complex sensorimotor knowledge and skills that are acquired implicitly or explicitly and, once fully automatized, are difficult to verbalize.”
- Examples: how to ride a bike, skilled reading or speaking, kitchen knife skills, keyboard typing, etc.
- Impairment: difficulty learning new sensorimotor skills especially language skills
- Impairment causes: temporal lobe epilepsy, Williams syndrome, or possible dyslexia or specific language impairment
- Brain areas affected: cerebellum
- Episodic long-term memory
Questions for Further Discussion
1. What are the recommendations for returning to school or activities after head injury or concussion?
2. How do memory issues affect children in school and what can be done to accommodate the problems?
3. How does sleep relate to memory?
- Symptom/Presentation: Mental Status Changes
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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Majerus S, Van Der Linden M. Memory disorders in children. Handb Clin Neurol. 2013;111:251-255. doi:10.1016/B978-0-444-52891-9.00027-0
Schneider W, Ornstein PA. Determinants of memory development in childhood and adolescence. Int J Psychol J Int Psychol. 2019;54(3):307-315. doi:10.1002/ijop.12503
Linden M, Hawley C, Blackwood B, Evans J, Anderson V, O’Rourke C. Technological aids for the rehabilitation of memory and executive functioning in children and adolescents with acquired brain injury. Cochrane Database Syst Rev. 2016;7:CD011020. doi:10.1002/14651858.CD011020.pub2
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa