Traumatic Brain Injury A Resource Guide For Parents, Students, and Teachers Background Information A traumatic brain injury (TBI) is an injury to the brain that results from a sudden blow to the head or from being violently shaken. The term TBI is not typically used for a person born with a brain injury. In addition to changing how a person acts, responds, and thinks, a TBI can also alter how a student learns and behaves in school. Traumatic Brain Injury commonly causes changes in the way an individual thinks and reasons, understands vocabulary, solves problems, talks, and behaves. TBI can also result in problems with memory, attention, problem solving, abstract thinking, physical activity, speech, and learning capability. It is estimated that approximately 1.5 million people sustain a brain injury each year and over a million of those affected are children. Over 30,000 of these children will face lifelong disabilities as a result of the injury. According to the Centers for Disease Control and Prevention, brain injury is a leading cause of disease and injury each year in the United States2. A CDC investigation has determined that each year in the US 50,000 people will die from a TBI and between 80,000 and 90,000 people will suffer long-term disability due to a TBI. TBI is prevalent among children and for those between 0 and 14 years of age TBI results in approximately 3,000 deaths, 29,000 hospitalizations, and 400,000 emergency room visits2. When compared with annual incidence of other leading injuries or diseases, it is clear that TBI is a serious problem in the US: *www.biausa.org Traumatic brain injury is caused by many factors but the leading causes for adults are automobile accidents, fire-arm incidents, and falls. For children, the leading causes of TBI include falls, abuse, recreational accidents (including sports injuries), and automobile accidents7. For Students and Parents: Coping with a traumatic brain injury can be a challenge. There are so many areas of everyday life that will need adjustment and continual modification. The best way to meet this challenge is to research and learn as much as possible. The information below is designed to help determine if a child is suffering from TBI, what to expect regarding academic ability and achievement, and what parents and families can do to assist and support the educational staff. Signs and Symptoms The symptoms of TBI are diverse and vary depending on the location and severity of the injury. Children with TBI may face many difficulties as their physical ability and thinking skills are impaired. In addition, it is common for children with TBI to exhibit social, emotional, and behavioral problems. Physical disabilities that may be apparent include difficulty speaking or processing vocabulary. Headaches and fatigue are common and motor skills may be diminished causing problems with writing or drawing. It may be difficult to control muscles and they may contract uncontrollably. In extreme cases, seizure and complete or partial paralysis occurs. Sensory motor difficulty may be prevalent and the child experiences difficulty seeing or hearing6. Problems with cognitive abilities are often the most disabling and the most difficult to diagnose. Decreased cognitive abilities might include difficulty paying attention, inability to remember things, and decreased levels of concentration. Thought processing is often at a slower rate and the child may suffer from the inability to sequence events and plan ahead4. After a TBI, the areas and networks in the brain that control our social-emotional lives often are damaged. This can result in major changes in personality and temperament. Affected children may have trouble relating to others and it is common for the child to exhibit inappropriate behaviors. There may be mood swings and the child may lose control over emotions. Other common behaviors might be lack of motivation, irritability, aggression, lethargy, and lack of inhibition6. This is the area that makes transition back to school and public life extremely difficult. Academic Ability and Achievement As with the signs and symptoms, the effect of TBI on ability to learn varies from case to case, however some generalizations can be made. After most injuries, previously obtained knowledge is usually retained therefore older children are in a better position than younger children. Young children do not have as large of an education foundation as older children. This can hinder them as they try to build on their knowledge base in later years3. Children rely on several different forms of memory to function and learn. TBI impairs ability to remember short-term and long-term information and frequently prevents the child from processing new information and communicating with others5. Memory impairment will definitely have a detrimental effect on learning capabilities. Lack of attention is one of the most common problems following TBI. Although ability to pay attention will usually improve over time, failure to focus will lead to decreased academic achievement. A child suffering from a brain injury often loses the ability to organize and sequence events. This coupled with decreased memory result in an inability to reason. The child will likely have difficulty when asked to compare and contrast objects and situations, draw conclusions given necessary information, and solve problems8. Below is a table highlighting areas of cognitive ability that have an effect on academic achievement coupled with specific behaviors a TBI student may exhibit if facing a challenge in that area: Ability Area Specific Behavior Memory forgets personal belongings forgets assignments has difficulty learning new concepts pre-injury memory is intact but cannot remember new information struggles to follow a daily schedule repeats a story or experience out of order tries to complete a task by starting in the middle cannot recognize inferences and double meanings speech rambles and is off-topic sentences and stories are not cohesive uses vague fillers such as “Um,” “and,” “you know” cannot recall the desired term and corrects with vague phrases such as “that thing” uses incorrect terms cannot think abstractly cannot identify important features of a problem cannot sequence events to come to the correct solution has slow response time to verbal cues unable to follow lengthy instruction unable to process rapid verbal instruction has difficult time staying on task loses place when reading cannot maintain attention and focus overloads quickly given too much stimulus has difficulty with goal setting process exhibits lack of initiative has reduced interest in activities lacks anticipation and excitement for coming events has limited conversational scope has limited responses fails to read listener cues Sequencing Language comprehension Language Organization Vocabulary Recall Problem Solving Information Processing Concentration Executive Functioning Pragmatics * Modified from Wisconsin Dept. of Public Instruction To Help With Transitions and Improve Academic Achievement Because it is impossible to predict how an individual will recover from TBI, it is critical to seek professional attention immediately. To promote rapid improvement, locate resources that will help address emotional, cognitive, physical, and behavioral challenges. Excellent sources might include occupational therapy, counseling, and special education. Often, children suffering from TBI are in the hospital or are homebound subsequent to the injury. As the condition of the individual improves new challenges will surface. The transitions from the hospital treatment regimen, to a hospital/homebound school program, and eventually back to a regular school schedule can be filled with frustration and uncertainty. For a TBI student the recovery process is concurrent with brain development. Over time, long-term effects of the injury may become apparent as learning increases in complexity and academic requirements become more challenging1. Each child and each injury is unique therefore there is no single teaching strategy or program that will successfully apply to all TBI students. Adaptation of instruction and modification of the learning environment provide greater opportunities for a TBI student to find success in the classroom and the community. Learning how to best help a child is a difficult process in which parents have a special role and perspective. Because no one knows their child better, it is critical for the parent to actively participate in the transition process and continuously monitor the progress of the child. Parents are the link between teachers, classes, and the school. They not only have the ability to compare their child before and after the injury but they have seen their child progress through the various stages of medical care and rehabilitation. By participating in the educational planning process, a parent can use their experience and knowledge to assist educators as they design effective strategies for the classroom. Often strategies and techniques used by the teacher can be practiced at home providing consistency and continuity for the student. As parents help students with homework and support the efforts of the teacher, the student receives maximum benefit and the result will be improvement in academic and social skills. Only if parents and educators work together will there be an effective educational plan that will truly benefit the student. It is very important to carefully plan for the child’s return to school. Parents should research the special education services provided by the school well in advance so that the transition is smooth. This information is usually available from the school administration, special education teacher, or guidance counselor. When the child returns, the school should thoroughly evaluate the abilities of the child. This will provide information regarding the specific educational needs of the child. From the information gathered, the school and parents will develop an Individualized Education Program (IEP) to address the specific needs of the child. The following are useful suggestions and tips that will help begin the planning process: Request a meeting with the educational team, which should include parents, teachers, those involved with special education services, and anyone who will play a role in the education and rehabilitation of the child. Review medical and rehabilitation information regarding the injury, medication requirements, and ongoing therapy to better understand how the brain was injured and the consequences for learning and behavior. Review the progress of the student prior to the accident and review any special needs that were addressed before the injury occurred. This might include work samples, effective instructional strategies, and techniques for behavior management that were useful in the past. Review any special services or supports were provided in the past to gain a clear understanding of the specific strengths, difficulties, and needs of the student before the injury. Establish a plan for regular communication between the school, teachers, and parents. This will help diffuse any potential problems before they fully develop. Determine resources both within and outside of the school that might provide training, education, and consultation on TBI. Remember that the educational plan is a tool that should change in response to the changing needs of the student. Recovery is an ongoing process and student outcome objectives should be continually reviewed and revised to reflect the changing needs of the student. Be ready for transitions. Change is uncertain and can be frightening to a TBI student. Prepare well in advance for necessary changes and provide as much consistency and structure as possible so that the student is comfortable. This will provide the greatest possible chance for success. Continuously look to the future. Time passes quickly and students must be prepared to leave high school and face adulthood. Transition planning for life after school should begin early. Whenever possible, include the student in the planning process. This will help increase his or her understanding of goals and objectives. This will also help reduce anxiety the student may have regarding the return to school. The Individuals with Disabilities Education Act includes transition planning services as a special education requirement. The process should begin as soon as possible and usually the process occurs when special needs students are 14 to 16 years old. The goal of transition planning is to help the young-adult develop the academic, vocational, and life skills needed to move from high-school to adulthood7. After considering the abilities and interests of the student, different options should be explored including any additional educational or vocational training that will be required after high school in order to meet the established goals. It is important for TBI students to make early decisions about job training, career choices, college options, and independent living. Involvement of the entire education team in the process is required to prepare the student and establish links with adult services. Tips and Additional Information Learn about TBI – the more you know, the more you can help yourself and your child. Work with the medical team to understand your child’s injury and treatment plan. Ask questions, make suggestions and tell them what you know, think, and feel. Monitor your child’s treatment. Develop a strategy to organize and maintain treatment history. Throughout the recovery process, keep a written record of what the medical experts say. Copy and retain any paperwork you are given in a logical manner. You will not be able to remember everything and your “paper trail” will be invaluable to you and your child. If you are asked to provide paperwork to anyone, always submit a copy and never the original! Create a support network for yourself. Talk to others who have children or other family members with TBI. Remember that you are not alone! If your child was in school before the injury, notify them of the injury and communicate. Have the medical team share information with the school and plan for your child’s return. Keep in touch with your child’s teacher. Communicate regarding progress at home and monitor how your child is doing at school. As you child reaches young-adulthood, research federal and state programs for adults that your child might be eligible for in the future. There are agencies that will provide written information and that have special educational programs for families. Most states have a Brain Injury Association. Contact the organization and request any information that is relevant to your situation. There is also a national organization in Washington D.C. that could assist you as needed. Many local Social Security Offices provide written information highlighting programs for children and adults with disabilities. The Federation for Children with Special Needs has a national network of Parent Training and Information Center. Contact the Federation and ask for the name, address, and telephone number of a center nearby. References and Resources 1. Brain Injury Association of America. June 2004. www.biausa.org. 2. Centers for Disease Control and Prevention. “Traumatic Brain Injury: Incidence and Distribution.” Publication 2003. June 2004. www.cdc.gov.node.do/id/0900f3ec8000dbdc/aspectId/A0400020. 3. Hibbard, Mary, et al. “Students with Traumatic Brain Injury: Identification, Assessment and Classroom Accommodations.” Research and Training Center on community Integration of Individuals with Traumatic Brain Injury. November 2001. 4. Mount Sinai School of Medicine. “RTCTBI FAQ’s About TBI.” June 2004. www.mssm.edu/tbinet/alt/faq.html. 5. National Center for the Dissemination of Disability Research. “Focus: Technical Brief Number 3, Underachieving Students.” June 2004. www.ncddr.org/du/products/focus/focus3/. 6. National Dissemination Center for Children With Disabilities. “Traumatic Brain Injury: Fact Sheet 18.” June 2004. www.nichcy.org/pubs/factshe/fs18txt.htm. 7. National Resource Center for Traumatic Brain Injury. June 2004. www.neuro.pmr.vcu.edu/faq/FAQ.htm. 8. Wisconsin Department of Public Instruction. “Wisconsin DPI Traumatic Brain Injury Training Presentation.” June 2004. www.dpi.state.wi.us/dpi/dlsea/een/tibhomepg.html.
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