Traumatic Brain Injury
or traumatic brain injury occurs to a person who is developing normally
and then suffers an assault.
100,000 children were hospitalized
last year for injuries to the head. the highest risk group - boys 15 and
Traumatic Brain Injury (TBI) or Acquired Brain Injury (ABI) occurs
to a person who is developing normally and then suffers an assault. It
may be the result of an injury - like an accident, a fall, drowning and
being resuscitated. Many of us were fascinated by the Christopher Reeves
story and his subsequent insistence on regaining normalcy in his life,
and his will power to continue to make contributions to others. Since
Christopher Reeves had his accident as an adult, he would not be given
the label TBI. TBI as a category must occur before reaching adulthood.
Concussion is a synonymous term for TBI
Direct blow to the head or shaken baby syndrome
|Internal injuries like stroke, brain tumor,
infection of the brain.
||These are injuries to the brain that are
sustained during the process of birth.
common causes of TBI in children over two are: falls, domestic accidents,
car and motor cycle accidents, pedestrian and bicycle accidents, assaults,
and sports accidents.
The most common cause of TBI
in children under two is child abuse.
ABI may also be the result of illness - a stroke, high temperature,
seizures, an illness that cuts off the oxygen to the brain, a tumor, brain
surgery. At present, ABI is not considered an eligible part of special
ed services, but since these youngsters are students, need support and
help and have many similar symptoms and needs as students who are classified
as TBI, they will be included in this reading.
Congenital injuries are present at birth or as a result of birth
trauma, and are not genetic in nature.
Though not always visible and sometimes seemingly minor, brain injury
is complex. It can have a very individualized effect, so understanding
one student with brain injuries may not help to understand symptoms and
needs of another student. It does help to have a general understanding
of the brain and know a little about how it works. There is a site on
the web that has a great map of the brain and a specific list of the effect
of injuries to different parts of the brain. Click
here to go to this site. You may want to print it out or book mark
it, as well, since it is an excellent guide to understanding the function
of different areas of the brain.
|Closed Head Injury
Slam into windshield
Slam into wall, tree, pavement
Hurt during sports activity
Hit with object
learning new things
trouble concentrating trips
or is clumsy acts
different from before the accident irritable
temper more often acts
gets mixed up about times, locations
needs more sleep and tires easily
difficult finding desired words
loss of speech
loss of memory
unable to breath unassisted
loss of language, ability to read or write
Open Head Injury
Blow to head
|Localized to area of insult, so varies
according to the function of the damage area or lobe.
(not an IDEA service category)
Wide range of injuries including all named above. Legislation
is currently pending to combine ABI and TBI as service classifications.
|Congenital (not an IDEA service category)
||Birth related or pre-birth events
||Many youngsters have multiple handicaps and may be
classified as profoundly affected or Very Low Incidence Disabilities.
TBI can show up in physical, cognitive, social, emotional, and educational
changes that affect a student for a short period of time or permanently.
The symptoms caused by a brain injury vary widely, depending on the extent
and location of the injury. The 1990 legal definition that Congress
used to make it an additional category is: 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 a child's educational performance. The term applies
to open or closed head injuries resulting in impairments in one or more
areas, such as cognition, language, memory. attention, reasoning, abstract
thinking, judgment, problem-solving, sensory, perceptual and motor abilities;
psychosocial behavior, physical functions, information processing and
speech. The term does not apply to brain injuries that are congenital
or degenerative, or brain injuries induced by birth trauma (34
CFR section 300.7).
Common results are seizures, loss of balance or coordination, difficulty
with speech, limited concentration, loss of the ability to read, to write,
to speak, memory loss, and loss of organizational and reasoning skills.
It is not unusual for a youngster to have to learn to walk or talk all
over again as a result of the trauma. As the youngster progresses through
therapy and healing it may seem like there is one step forward, two back,
nothing for a while, and then a series of gains. Sometimes the growth
and change will stop and it will feel like there is no more change possible.
This is often refereed to as a plateau. A "plateau" is not evidence that
functional improvement has ended. Like typical growth patterns,it often
goes in spurts. It is also likely that the disorganization that precedes
strong growth may feel panicky and cause anxiety and distress. It is normal
for "disequilibrium" to occur as part of the next growth spurt.
It is also true, and in some cases disheartening,g to realize that some
children will make a remarkable recovery while other youngsters cannot
recover or move back to a previous or a high level of functioning.
This is a TBI experience
described by an NAU Student, Katy Miller.
I had my TBI accident almost seven years ago on a Sunday morning
in February of 1996. I was with my then 16 year-old son when we
slid on ice and hit a telephone poll on the driver's side. I was
always thankful that I was driving that morning and not my son!
The last thing I remember before the accident was helping my then
9 year-old daughter with her science fair project on Saturday
afternoon. I basically have no rememberance of anything until
a week later.
From the accident, I received a closed-head injury, broken rib,
punctured lung, and a fractured pelvis. I had to be cut from the
car and air-flighted to a hospital that was better equiped to
handle my care. I didn't realize how seriously I was injured until
I visited my family doctor 4 to 5 months later and he said that
I "looked pretty good for a corpse!" My stay in the hospital was
3 1/2 weeks. Initially, the doctors thought I would be in the
hospital for 6 to 8 weeks.
As I look back on my stay now, I realize I showed the almost
childlike feature many TBI patients experience. For me, this meant
I felt like everyone knew what was best for me and I must do everything
that the doctors, nurses, and therapists said. I remember one
instance when the hospital was planning a visit to the local mall.
The nurses wanted to know if I wanted to go. I really didn't want
to go because I didn't want to ride around in a wheel chair (pride,
I guess) but I was afraid to tell them "no" because
I didn't want the nurses to be "mad at me" for not going. It never
occured to me that they didn't care either way but more than that,
I didn't want to disappoint anyone. As time went on, I began returning
more and more to my "old self" and realized I went through this
interesting part of recovery. I saw this characteristic last year
with the TBI student I had in my class. When he first came back
to school after the accident (he wasn't a special education student
before the accident), he was very timid and wanted to do everything
I told him to do. He didn't want to disappoint me, a person with
authority. This was a change from his pre-accident behavior because
he was a discipline problem before the accident. As time went
on, and similar to my own experience, he began healing and regaining
more of his old personality. He became less and less cooperative.
Another aspect common with TBI's is trouble with memory. I still
struggle with this at times. I have learned to cope with this
problem by using frequent notes and reminders. I write many "to
do" lists! I also must keep many items in the same place so I
know where everything is. For instance, I always park in the same
space at malls I frequent so I know where I parked. This idea
of structure and order I use with all my students at school who
have trouble with memory and organization.
Possibly the greatest insight my TBI experience has given me
is the insight into my students' frustrations and impulsiveness.
I can remember being impulsive and not thinking an activity through.
My therapists would tell me to "stop, slow down, and think" when
doing a task. To me, I was doing it correctly and I was thinking
it through. Since I experienced this, I see many of my students
being impulsive and not thinking activities through. I have learned
to expect this from my challenged students, to understand this
as part of their disability, and to accept this as part of their
challenges and not them just decide they are being "careless".
Frustration is another aspect I experienced and see daily with
many of my students. I can remember having great frustration on
realizing I know the answers to the therapists' questions or should
know how to do a task but couldn't remember the information. At
times I couldn't remember my SSN, my home phone number, or even
my kids' middle names. The frustration included knowing I knew
these but couldn't recall. I see this daily with students becoming
frustarted because they know the material but can't recall it.
They have the frustration, for instance, of knowing they have
learned, in some cases for several years, some multiplication
tables but have no clue of the answer to 4 x 5! That is, probably,
the greatest understanding I bring to this job is the understanding
that lack of retention is a real problem and not just students
being "lazy" or "not paying attention" like some regular education
teachers may think.
Having a TBI has given me a unique viewpoint about my students'
learning difficulties. Having been there myself, it has given
me the patience with and understanding of kids' learning problems.
A traditional intelligence test is not an accurate assessment of cognitive
recovery after a brain injury since it may only test a small part of the
ability or inability to function. It may have little relationship to the
mental processes required for everyday thinking and working. For example,
students with brain injuries might perform well on brief, structured,
artificial tasks but have such significant deficits in learning, memory,
and executive functions that they are unable to perform well under the
stress of a real life situation. Sometimes the reverse is also true. Unable
to do well in the classroom or lab setting, some youngsters flourish in
real life, daily situations.
School accommodations for students with brain injuries might include
exam modifications, time extensions, taped lectures, instructions presented
in more than one way, alternative ways of completing assignments, note
takers, course substitutions, priority registration, study skills and
strategies training. It is vital to realize that the student is likely
to feel a profound sense of loss, and may need support in dealing with
feelings, learning to connect to peers, accepting the limitations and
Many of the youngsters who suffer a head injury are actually unaware
of the damage. Sometimes the injuries can be subtle. Sometimes the child
keeps the injury from a parent, and sometimes the problems are cumulative
- coming as a result of a number of injuries -- such as playing sports.
It may be helpful to make a note of typical symptoms of TBI.
Behaviors or Emotions
At loose ends
Overly emotional or panicky
Unaware of changes
Unwilling to accept changes
Not like self
Trouble finding words, names
Lack of attention to detail
Sudden change in ability to organize or arrange
Slower to recognize directions or follow through on requests
Thoughts seem to get "stuck" or perseverate
Difficulty with higher forms of thinking - synthesis, application,
evaluation of situations
Decreased ability to stay focused
Quick changes of subject
Forget thoughts in mid sentence or long pauses in speech with
Lack of self discipline
May begin to stutter or have trouble finding words while talking
Describes odd smells
Asynchronous senses - unusual report or lessening of smell, taste,
Agitated or tremor-like movements
Visual problems or blurred vision
Headaches - including a new site for headaches
Blacking out or losing consciousness
Tips and Strategies
1. Test scores can be misleading, so use a wide range of observation,
task analysis and discussion with the family to ascertain the
full extent of student ability.
2. Take for granted that the student will not be fully aware
of the full extent of cognitive deficits.
3. Work in concert to determine what will work and what the family
and student visualize as a solution and hope for the future.
4. Show the student what a task involves rather than telling
them what to do.
5. Keep good records of attempts and progress on tasks - hopefully
in concert with the student.
6. Move the skills toward interpersonal and life functioning
so the social and emotional growth also occurs.
7. Provide the student with practice and repetition that is stimulating
or rewarding and focus on minimizing boredom.
8. Recognize that volition is often affected, so the student
may be unable to initiate practice r tasks rather than just being
9. The full extent of involvement of emotion and affect is not
clear, so expect a change in the emotional responses of youngsters
and help them and family members come to appreciate who the student
has come to be and what the student can do -- realizing that this
may involve a process of grief and loss.
10. Help all involved look for new strengths, the positive factors
that emerge and the good that is emerging.
Who I have become is
I have many things
I can do well!
This can be very disorienting for
children and for their families. It is a natural part of life
to see children grow and develop. When something sets the clock
back and there are losses in functioning, it is hard on the
esteem, and hopes and dreams. Many families have additional
stress because of the time spent helping the child recover --
which may include getting day services for the youngster who
is no longer able to be alone or unattended, time getting children
to therapy, finding ways to pay for medical services, changing
the whole function and focus of a family.
Parents may need a great deal of understanding
The child may need help rethinking
about who he or she is, making a different set of friends -
and in some cases, may lose a peer group as friends go on to
another grade while recovery occurs.
|Stuttering or long pauses.
Student - to be soothed - Safety
Teacher - to teach and have peace - Safety, self actualize
Class - to learn, concentrate - Safety, need to know
|Increase the level of comfort and safety for the student
who is having difficulty speaking fluently; help class to
increase tolerance by helping them understand the actions in a positive
frame - student is trying hard. Teacher - observe time of
day and subject and check to see if this is a pattern and if so
what sets it off. While student is expressing self, monitor actions
that might signal impatience
|Student becomes agitated at transition points
Student - to be soothed, to get help finding out what triggers
the emotions and feelings of panic, to know what is acceptable
and have help regaining control
Teacher - to let the youngster know the change is coming, model
a peaceful demeanor and help the student recognize triggers and
find better ways of maintaining composure
Class - to model changes with the least distraction and most
support for the peer
|Set up a system that communicates by picture, gesture
or words, that a transition or change is coming so the student can
adjust. If helpful, help the student learn to prepare self and area
before the bell rings, and do this consistently through the day.
Students may assist with this - perhaps even one for each bell or
change in activity through the day.
Fill in other examples and solutions. Give yourself
25 points for each completed line and scenario.
Bauby, Jean-Dominique. (1997). The diving bell and
the butterfly. New York: Alfred A. Knopf. Bauby suffered a stroke
that left him nearly completely paralyzed. He composed this book by
using eye blinks to signal the letters one by one and is a testimony
to the powerful drive of communication.
Fishman, Steve. (1988). A bomb in the brain: A heroic
tale of science, surgery and survival. New York: Scribner. The author
recounts his personal battle with a brain hemorrhage, neurosurgery,
Gardner, Howard. (1974). The shattered mind. New
York: Alfred A. Knopf. Gardner describes his purpose in writing this
book: "to demonstrate that a host of critical issues in psychology can
be illuminated by a thoughtful study of the behavior and testimony of
brain damaged individuals." H addresses aphasia, alexia, and memory
Klawans, Harold L. (1989). Toscanini's tumble and other
tales of clinical neurology. New York: Bantam Books. A neurologist
discusses what he learned from patients about neurological disorders
any how people contend with them.
Klawans, Harold L. (1990). Newton's madness. New
York: Harper and Row. Continuing beyond his book, Toscanini's tumble,
Klawans describes patients with a variety of neurological disorders.
Laplante, Eve. (1993) Seized. New York: Harper
Collins. The author shares insights into temporal lobe epilepsy as a
medical, historical, and artistic phenomenon. The three people with
this disorder include a corporate executive, a small-town attorney,
and a prison inmate and mental patient.
Martin, Russell. (1986). Matters gray and white: A
neurologist, his patients and the mysteries of the brain. New York:
Henry Holt and Co. The author uses clinical experiences to tell about
the practice of neurology, how neurological disorders affect people,
and what these disorders reveal about the brain.
Noonan, David. (1989). Neuro- (Life on the front lines
of brain surgery and neurological medicine). New York: Simon and Schuster.
A neurologist is followed as he diagnoses and treats disorders. Noonan
shares the doctor and patients' perspectives with personal insights
and graphic information on diagnosis and treatment.
Rabin, Roni. (1985). Six parts love: One family's battle
with Lou Gehrig's disease. New York: Scribner. This biography of
the author's father gives a person account of the trials of amyotrophic
lateral sclerosis (ALS).
Sacks, Oliver. (1970). The man who mistook his wife
for a hat and other clinical tales. New York: Summit Books. Sacks
describes his experiences with a variety of patient with wonderment
and affection. The cases include individuals with sensory agnosia, aphasia,
autistic savant syndromes, Tourette's syndrome, etc..
Sacks, Oliver. (1990). Awakenings. New York: Harper
Perennial. Sacks describes the results of L-Dopa medication given to
people afflicted with parkinsonism resulting from a kind of sleeping
sickness that often results in catatonic states. L-Dopa first seemed
like a miracle, but for many, the miracle dissolved into disappointment
Sacks, Oliver. (1995). An anthropologist on Mars.
New York: Vintage Books. Sacks examines the lives of a colorblind painter,
a man with frontal lobe syndrome, a surgeon with Tourette's syndrome,
a man with visual agnosia, an autistic savant, and a woman who has overcome
many consequences of autism.
Sylvester, Edward J. (1993). The healing blade: A tale
of neurosurgery. New York: Simon and Schuster. This journalistic
account, is mostly about a neurological institute in Phoenix, a neurosurgeon
named Dr. Robert Spetzler, and. descriptions of surgical procedures
and the surgeons who perform them.
Tips and Strategies
Here are some great
ideas for helping a youngster feel more comfortable in coming
back into the school, including natural ways to regain a peer
group and social status
1. Organize a small group of peers to
support the student in learning and social situations.
2. Provide oral, written and pictorial
3. Pace the activities for success and
stimulation - and allow for individualization.
4. Provide more time for processing
5. Provide advance notice of questions
that will be asked and allow the student to write out and then
read an answer until speech facility improves.
6. Permit and when possible, provide
any and all useful Assistive devices - keyboards, calculators,
manipulatives, tape recorders, etc.
7. Work with the student to organize
self and maintain a successful set of rituals
8. Modify assignments to meet the student's
strengths, at least initially, and move into more challenging
areas in a way that maximizes potential for success.
9. Provide adequate structure in the
classroom that the student may concentrate, especially if noise
or activity is extremely distracting or disquieting - including
the use of a carol, ear phones and music as ways of minimizing
10. Plan fun and creative ways to get
through drill or highly repetitious activities.
11. Encourage open discussion of frustration,
12. Encourage the parents to come to
school often and to share concerns as they arise.
1. Read a book written by a family member, telling about
their personal insights and challenges. Make a list of the ways a teacher
might support the parent experiences. Make a second list of things parents
might tell an educator about a child. [50 points].
2. Locate a parent who will allow you to visit the child
at the school or in the home and spend a minimum of 4 hours observing
the youngster. As part of the observation experience, identify at least
three student strengths. Look for the youngster's interests and determine
some of the ways contact points that could be used to engage the student.
For example, one youngster with TBI continues tirelessly to find a way
to regain the ability to walk. Another youngster became immersed in finding
a way to understand his condition and is preparing for a medical degree..
[25 points per hour for observing; 50 points for the adaptation summary].
3. Watch Awakenings, the movie for 50 points and
send a review of the characterization of a youngster with TBI/ABI for
another 25 points. Another movie is _______________. You may watch
and report on this movie, too.
4. Learn about assistive technology. Try to find an opportunity
to watch someone use this with a child. After looking at the pros and
cons, develop a paragraph describing some of the more and less sophisticated
techniques that can help a youngster succeed in communicating, becoming
more mobile, feeling more a part of the classroom learning community [25
5. Identify areas of the brain and the different types of
symptoms or dysfunctions that occur when specific areas are involved in
injury. Describe some of your findings and the way scientists have developed
this understanding.[50 points]
6. Locate and review one of the diagnostic instruments used
to evaluate youngsters who may have TBI . In general, do you expect students
to score in a wide range of intellectual abilities, or will more students
score at or below average intelligence? [25 points].
7. Remember to feel free to develop your own personal response
to the material. Allot yourself approximately 25 points per hour for your
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Ellsworth at Janne.Ellsworth@nau.edu
Course developed by J'Anne
Copyright © 1999
Northern Arizona University
ALL RIGHTS RESERVED