Traumatic Brain Injury

Definition

Traumatic brain injury (TBI) under federal law means an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects the student's educational performance. Traumatic brain injury applies to open or closed head injuries resulting in impairments in one or more of the following areas:

• cognition
• language
• memory
• attention
• reasoning
• abstract thinking
• judgment
• problem-solving
• sensory, perceptual, and motor abilities
• psychosocial behavior
• physical functions
• information processing
• speech

Traumatic brain injury does not apply to brain injuries that are congenital or degenerative, or induced by birth trauma.

Prevalence

The incidence of TBI peaks during three specific age periods: birth to 5 years of age, 15-24 years of age, and over 70 years of age. About 80,000 to 90,000 of the 475,000 children who have sustained TBIs are permanently disabled from their accidents or injuries. About 180 per 100,000 children under age 15 experience TBIs and of that number, 5% to 8% experience severe TBIs.

Characteristics

The Brain Injury Association (formerly the National Head Injury Foundation) calls TBI "the silent epidemic," because many children have no visible impairments after a head injury. Symptoms can vary greatly depending upon the extent and location of the brain injury. However, impairments in one or more areas (such as cognitive functioning, physical abilities, communication, or social/behavioral disruption) are common. These impairments may be either temporary or permanent in nature and may cause partial or total functional disability as well as psychosocial maladjustment.

Children who sustain TBI may experience a complex array of problems, including the following:

• Medical/Neurological Symptoms: speech, vision, hearing and other sensory impairment, decreased motor coordination, difficulty breathing, dizziness, headaches, impaired balance, loss of intellectual capacities, partial to full paralysis, reduced body strength, seizures, sleep disorders, and speech problems.
• Cognitive Symptoms: decreased attention, organizational skills, and problem solving ability; difficulty with abstract concepts; memory deficits; perceptual problems; poor concentration, poor judgment; slowed information processing, and poor memory.
• Behavioral/Emotional Symptoms: aggressive behavior, denial of deficits, depression, difficulty accepting and responding to change, loss of reduction of inhibitions, distractibility, feelings of worthlessness, lack of emotion, low frustration level, helplessness, impulsivity, inappropriate crying or laughing, and irritability.
• Social Skills Development: difficulties maintaining relationships, inability to restrict socially inappropriate behaviors, inappropriate responses to the environment, insensitivity to others' feelings, limited initiation of social interactions, and social isolation.

Any or all of the above impairments may occur to different degrees. The nature of the injury and its attendant problems can range from mild to severe, and the course of recovery is very difficult to predict for any given student. It is important to note that with early and ongoing therapeutic intervention the severity of these symptoms may decrease, but only in varying degrees.

Impact on Learning

Despite its high incidence, many medical and education professionals are unaware of the consequences of childhood head injury. Students with TBI are too often inappropriately classified as having learning disabilities, emotional disturbance, or mental retardation. As a result, the needed educational and related services may not be provided within the special education program. The designation of TBI as a separate category of disability signals that schools should provide children and youth with access to and funding for neuropsychological, speech/language, educational, and other evaluations necessary to provide the information needed for the development of an appropriate individualized educational program (IEP).

While the majority of children with TBI return to school, their educational and emotional needs are likely to be very different from what they were prior to the injury. Although children with TBI may seem to function much like children born with other handicapping conditions, it is important to recognize that the sudden onset of a severe disability resulting from trauma is very different. Children with brain injuries can often remember how they were before the trauma, which can result in a constellation of emotional and psychosocial problems not usually present in children with congenital disabilities. Further, the trauma impacts family, friends, and professionals who recall what the child was like prior to injury and who have difficulty in shifting and adjusting goals and expectations.

Teaching Strategies

Therefore, careful planning for school re-entry (including establishing linkages between the trauma center/rehabilitation hospital and the special education team at the school) is extremely important in meeting the needs of the child. It will be important to determine whether the child needs to relearn material previously known. Supervision may be needed (i.e. between the classroom and restroom) as the child may have difficulty with orientation. Teachers should also be aware that, because the child's short-term memory may be impaired, what appears to have been learned may be forgotten later in the day. To work constructively with students with TBI, educators may need to:

• Provide repetition and consistency
• Demonstrate new tasks, state instructions, and provide examples to illustrate ideas and concepts
• Avoid figurative language
• Reinforce lengthening periods of attention to appropriate tasks
• Probe skill acquisition frequently and provide repeated practice
• Teach compensatory strategies for increasing memory
• Be prepared for students' reduced stamina and increased fatigue and provide rest breaks as needed
• Keep the environment as distraction-free as possible

Initially, it may be important for teachers to gauge whether the child can follow one-step instructions well before challenging the child with a sequence of two or more directions. Often attention is focused on the child's disabilities after the injury, which reduces self-esteem; therefore, it is important to build opportunities for success and to maximize the child's strengths.

• Find out as much as you can about the child's injury and his or her present needs. Find out more about TBI. See the list of resources and organizations at the end of this publication.
• Give the student more time to finish schoolwork and tests
• Give directions one step at a time. For tasks with many steps, it helps to give the student written directions
• Show the student how to perform new tasks. Give examples to go with new ideas and concepts
• Have consistent routines. This helps the student know what to expect. If the routine is going to change, let the student know ahead of time
• Check to make sure that the student has actually learned the new skill. Give the student lots of opportunities to practice the new skill
• Show the student how to use an assignment book and a daily schedule. This helps the student get organized
• Realize that the student may tire quickly. Let the student rest as needed
• Reduce distractions
• Keep in touch with the student's parents. Share information about how the student is doing at home and at school
• Be flexible about expectations. Be patient. Maximize the student's chances for success

Assistive Technology:

Due to the various levels of traumatic brain injury, multiple types of assistive technology may be used. As with any student with disability, the assistive technology would need to address student accessibility to the educational curriculum. For students with TBI, assistive technology falls into three categories:

Devices for Memory and Organization: These assistive technology devices focus on helping the student with memory and organization difficulties. This includes a wide range of devices:

• calendar boards
• schedule organizers
• voice organizers
• medication reminders
• Smartphones
• specialized watches
• PDA devices (www.biausa.org/Pages/AT/general.php)

Devices to Access Information: These assistive technology devices focus on aiding the student to access the educational material. These devices include:

• speech recognition software
• screen reading software
• tinted overlays for reading (this may help with visual processing)
• academic software packages for students with disabilities

Devices for Positioning and Mobility: These assistive technology devices focus on helping the student participate in educational activities. These devices include:

• canes
• crutches
• wheelchairs
• specialized beds
• specialized chairs, desks, and tables

Organizations

Brain Injury Association (formerly the National Head Injury Foundation)

The Brain Injury Association of America (BIAA) is the leading national organization serving and representing individuals, families and professionals who are touched by a life-altering, often devastating, traumatic brain injury (TBI). Their mission is to create a better future through brain injury prevention, research, education and advocacy.

8201 Greensboro Drive, Suite 611
McLean, VA 22102

Email: FamilyHelpline@biausa.org
Web site: www.biausa.org

Center for Disability and Development

Dept. of Educational Psychology
4225 Texas A&M University
College Station, TX 77843-4225

Email: cdd@tamu.edu
Web: cdd.tamu.edu

Emergency Medical Services for Children — National Resource Center

The EMSC Program is dedicated to collaborating with federal partners to support EMSC research infrastructure and improve the quality and quantity of EMSC research.

111 Michigan Avenue N.W.
Washington, DC 20010

Email: information@emscnrc.com
Web: www.ems-c.org

Family Caregiver Alliance

FCA is a public voice for caregivers, illuminating the daily challenges they face, offering them the assistance they so desperately need and deserve, and championing their cause through education, services, research and advocacy.

180 Montgomery St., Suite 1100
San Francisco, CA 94104

Email: info@caregiver.org
Web site: www.caregiver.org

Family Voices

Family Voices, a national grassroots network of families and friends, advocates for health care services that are family-centered, community-based, comprehensive, coordinated and culturally competent for all children and youth with special health care needs; promotes the inclusion of all families as decision makers at all levels of health care; and supports essential partnerships between families and professionals.

2340 Alamo SE, Suite 102
Albuquerque, NM 87106

Email: kidshealth@familyvoices.org
Web site: www.familyvoices.org

Head Injury Hotline

This hotline is composed of a multidisciplinary team trained in traumatic brain injury. Consultants include individuals with TBI, family members, learning specialists, nurses, paraprofessionals, lawyers, neuropsychologists, and physicians specializing in emergency medicine, and neurology. The TBI Consulting Team offers consultations, research assistance, case management services, legal services, and in-service training. They serve individuals with brain injuries and their families, government officials, agency heads, educators, medical and legal professionals, and social workers.

212 Pioneer Building
Seattle, WA 98104-2221

Email: brain@headinjury.com
Web site: www.headinjury.com

National Resource Center for Traumatic Brain Injury (NRC TBI)

The National Resource Center for Traumatic Brain Injury is supported by NIDRR to provide research and technical assistance to professionals who work with individuals with traumatic brain injuries. They provide articles, trainings, and conferences.

Department of Physical Medicine and Rehabilitation
P.O. Box 980542
Richmond, VA 23298-0542

E-mail: mbking@hsc.vcu.edu
Web site: www.neuro.pmr.vcu.edu

References

Gargiulo, R.M. (2006). Special education in contemporary society: An introduction to exceptionality. Belmont, CA: Thomson Wadsworth.

Turnbull, A., Turnbull, R. & Wehmeyer, M. L. (2007). Exceptional lives: Special education in today's schools. Upper Saddle River, NJ: Pearson Merrill Prentice Hall.

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