What is the appropriate management for a child who repeatedly hits their head on the wall, potentially indicating underlying medical or psychological conditions?

Management of Head-Banging Behavior in Children

A child who repeatedly hits their head on the wall requires immediate assessment to distinguish between benign self-stimulatory behavior versus concerning trauma or underlying pathology, with the critical first step being evaluation for signs of abusive head trauma, neurological injury, or developmental/behavioral disorders.

Immediate Assessment Framework

Rule Out Acute Trauma and Abuse First

• Any child presenting with head-banging behavior must be evaluated for abusive head trauma (AHT), which remains the major cause of serious head injury in infants and young children 1, 2
• Look for specific red flags including altered mental status, vomiting, seizures, lethargy, irritability, or any focal neurological deficits 3, 1
• Examine for additional injuries inconsistent with the reported history, including bruising in unusual locations, retinal hemorrhages, or multiple injuries at different stages of healing 3, 4
• If ANY suspicion exists for non-accidental trauma, do not apply standard PECARN criteria—instead obtain either non-contrast CT or MRI regardless of clinical presentation 5, 3

Neurological Examination Priorities

• Assess Glasgow Coma Scale (GCS) score—any score ≤14 requires immediate non-contrast head CT 5, 3
• Examine for signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF otorrhea/rhinorrhea)—these indicate 4.3% risk of clinically important traumatic brain injury and mandate immediate CT 5, 3
• Palpate the entire skull for fractures, particularly in children <2 years old 5, 6
• Check for scalp hematomas—nonfrontal hematomas in children <2 years carry higher risk than frontal ones 5, 6

Risk Stratification for Imaging

High-Risk Features Requiring Immediate CT (Without IV Contrast)

• GCS ≤14 or any altered mental status (4.3-4.4% risk of clinically important injury) 5, 3
• Palpable skull fracture 5, 6
• Signs of basilar skull fracture 5, 3
• Post-traumatic seizures 5
• Any suspicion of abusive head trauma 5, 3

Intermediate-Risk Features (Consider CT vs. Observation)

For children ≥2 years with GCS 15 and normal mental status but with:

• History of loss of consciousness 5
• Severe or persistent headache 5
• Repeated vomiting 5
• Severe mechanism of injury 5
• Risk of clinically important injury approximately 0.8% 5

For children <2 years with GCS 15 and normal mental status but with:

• Loss of consciousness >5 seconds 5
• Severe mechanism of injury 5
• Not acting normally per parent 5, 7
• Risk approximately 0.9% 5

Very Low-Risk (Can Safely Forgo Imaging)

Children ≥2 years meeting ALL criteria:

• GCS = 15 with normal mental status 5
• No basilar skull fracture signs 5
• No loss of consciousness 5
• No vomiting 5
• No severe mechanism 5
• No severe headache 5

Children <2 years meeting ALL criteria:

• GCS = 15 with normal mental status 5
• No palpable skull fracture 5
• No nonfrontal scalp hematoma 5
• Loss of consciousness ≤5 seconds 5
• No severe mechanism 5
• Acting normally per parents 5
• Risk <0.02% with 100% sensitivity and negative predictive value 5

Behavioral and Developmental Assessment

Distinguish Self-Injurious Behavior from Trauma

Once acute trauma is ruled out, consider:

• Benign rhythmic head-banging typically occurs in neurologically normal toddlers (ages 6 months to 3 years) as self-soothing behavior, usually during sleep transitions or when upset
• Pathological head-banging may indicate autism spectrum disorder, developmental delay, sensory processing disorder, or other neurodevelopmental conditions
• Assess developmental milestones, social interaction patterns, communication abilities, and presence of repetitive behaviors
• Evaluate for signs of neglect or environmental stressors that may trigger self-injurious behavior

When to Refer for Specialized Evaluation

• Persistent head-banging beyond age 3-4 years warrants developmental-behavioral pediatrics referral
• Any head-banging causing visible injury or occurring with high frequency/intensity requires immediate intervention
• Associated developmental delays, regression, or autism spectrum concerns need comprehensive neurodevelopmental assessment

Imaging Technical Specifications

CT Protocol (When Indicated)

• Perform non-contrast CT only—IV contrast may obscure subtle hemorrhages 5, 3
• Use dedicated pediatric protocols tailored to patient size following ALARA principles 5, 3
• Obtain multiplanar and 3D reconstructions to increase sensitivity for fractures and small hemorrhages 5, 3

What NOT to Do

• Never obtain skull radiographs—they miss up to 50% of intracranial injuries and provide no brain parenchyma information 5, 6
• Do not use MRI in acute trauma setting due to longer examination times and potential sedation requirements 5, 3
• Do not delay CT when high-risk features are present 5

Post-Assessment Management

If Trauma Identified

• Complete physical and cognitive rest for first 24-48 hours 7
• Avoid strict prolonged rest beyond 48 hours as this may be detrimental 7
• Use acetaminophen cautiously for headache; avoid NSAIDs/aspirin in immediate post-injury period due to theoretical bleeding risk 7
• Monitor for red flags: worsening headache, repeated vomiting, altered mental status, seizures, visual changes 7

If Behavioral Etiology Confirmed

• Implement environmental modifications to reduce triggers
• Consider protective measures (padded surfaces, helmets in severe cases)
• Behavioral intervention strategies including positive reinforcement for alternative behaviors
• Address underlying developmental or psychological needs through appropriate referrals

Critical Pitfalls to Avoid

• Never dismiss repetitive head-banging without thorough evaluation for abuse—AHT can present with vague symptoms and correct diagnosis is frequently missed 4, 1
• Do not assume benign self-soothing behavior without ruling out trauma, especially in pre-verbal children who cannot report symptoms 7, 4
• Maintain extremely high index of suspicion in children <2 years due to ongoing brain development and higher vulnerability 7, 5
• Do not obtain routine "pan-scan" whole-body CT—use selective region-specific scanning based on clinical findings 5
• Every additional hour of observation decreases unnecessary CT utilization without delaying diagnosis of significant injury in appropriate cases 5