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ESE504 : The Class : Advanced CD : TBI

Traumatic Brain Injury

Acquired, 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 older

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.


The most 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.

Common symptoms
Closed Head Injury

Whip lash

Slam into windshield

Slam into wall, tree, pavement


Hurt during sports activity

Hit with object

Mild restlessness memory problems difficulty learning new things trouble concentrating trips or is clumsy acts different from before the accident irritable forgetful may lose temper more often acts without thinking inattentive gets mixed up about times, locations needs more sleep and tires easily difficult finding desired words

Severe paralysis loss of body function loss of speech loss of memory unable to breath unassisted seizures mental retardation loss of language, ability to read or write

Open Head Injury

Gun shot

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.


Sites to explore Brain Function

One * * Two * * Three * * Four * * Five


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.

Personal notes

Links and chat rooms for ABI/TBI

Personal story of Acquired or Traumatic Brain Injury

Practical and personal web ring for TBI

Doctornet set of links and sites

Model system for TBI

Spinal cord injury links and sites

Brain Injury Association

Center for Neuroskills (CNS)

Assessment scales for evaluating TBI

Training program to help parents



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 changes.

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
Thought processes
Physical symptoms






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 lost thoughts

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, hearing, vision

Loses equilibrium

Confused movements

Agitated or tremor-like movements

Visual problems or blurred vision

Auditory deficit


Skull fracture

Sleep disorder


Headaches - including a new site for headaches

Blacking out or losing consciousness


Tips and Strategies

Cognitive Retraining
Personal Notes

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 unmotivated.

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.



I need to feel





Who I have become is still enough!
I have many things I can do well!

Basic Needs

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 and support.

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.


Student action


Creative solution
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.

Book List

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, and epilepsy.

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 impairment.

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 and frustration.

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 organizers.

3. Pace the activities for success and stimulation - and allow for individualization.

4. Provide more time for processing information.

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 overload.

10. Plan fun and creative ways to get through drill or highly repetitious activities.

11. Encourage open discussion of frustration, needs, problems.

12. Encourage the parents to come to school often and to share concerns as they arise.


Activity List

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 points].

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 work.

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Course developed by J'Anne Ellsworth


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