Learning Center
Plans & pricing Sign in
Sign Out

Traumatic Brain Injury

VIEWS: 32 PAGES: 100

									                     Traumatic Brain Injury
                      -The Silent Epidemic
                                   By Lynda C. Van Kuren
                      Published in CEC Today, Vol. 7, No. 7, March 2001

If you haven‘t already had a child with traumatic brain injury (TBI) in your classes, chances are
you will before you end your teaching career. Approximately 1 million children and adolescents
receive a head injury each year. Of these injuries, 16,000 - 20,000 will be serious enough to
cause lasting effects, and one in 500 will be severe enough to cause hospitalization. If the child‘s
injury requires hospitalization, it is likely that he or she will require special education services.
Children who have less severe head injuries may need only accommodations or services
provided by a Section 504 plan.

Because the effects of traumatic brain injury often resemble that of other disabilities such as a
learning disability, Attention Deficit Disorder, behavior disorder, or mild mental retardation,
children with traumatic brain disorder are often misdiagnosed. Or, they may not be diagnosed at
all. This, combined with the high but often unrecognized, number of children with traumatic
brain disorder, gives rise to the disability‘s alternate name — the ―silent epidemic.‖

Given the special needs of children with TBI, the silence around traumatic brain injury must be
broken if they are to progress academically and socially. Many of the learning strategies special
educators use with children with other disabilities are effective for these children as well. But,
children with brain trauma also require special assessment strategies, behavior interventions, and
understanding if they are to succeed.

Definition and Causes of TBI

TBI is defined in the Individuals with Disabilities Education Act as an ―injury to the brain caused
by an external 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 both open
and closed head injuries. The most common cause of TBI is car accidents. Other causes include
sports accidents, falls, and physical abuse.

Common Problems of Children with TBI

Children who have TBI vary tremendously in their needs, depending on the location and severity
of the injury. Most mild injuries, such as mild concussions, are usually not treated and occur
quite frequently. These types of injuries often have minor or short-term effects on a child‘s
performance in school. Other, more severe injuries can have long-lasting effects on a child‘s

Many children with TBI experience some type of difficulty after the injury. Problems can occur
in cognitive functioning, physical abilities, communication, and/or social interactions or
behavior. The most common area affected by TBI is memory, especially memory for new
information, says Janet Tyler, Director of the Neurologic Disabilities Support Project, Kansas
State Department of Education. In addition, children with TBI may be much more distractible
than other children.

The brain‘s executive function processes also are often affected. The executive function
processes include skills such as problem-solving, organization, recognizing priorities, planning,
acting to reach a goal, and recognition of attainment and evaluation. With executive function
brain disorder, the child may miss due dates and appointments, complete homework but
regularly forget to turn it in, have difficulty problem solving, processing old information in a
new way or drawing relationships between old and new information, learning new information,
and/or changing from one task to another.

Learning can be further impeded for children with TBI because the brain becomes overwhelmed.
The ―capacity of working memory becomes overloaded by the multiplicity of deficits (the
breakdown of multiple systems through injury) and the consequent need to relearn a number of
previously automatic or near automatic functions simultaneously,‖ says Dennis Williams in
Traumatic Brain Injury: When Children Return to School.

Behavior also is often impacted by TBI. This can result from various causes. First, these children
remember skills, ability, and knowledge they used to have. Dealing with their loss is frustrating,
and children with TBI can become agitated, aggressive, argumentative, withdrawn, and/or
depressed. In addition, TBI can cause the loss or impairment of impulse control. The child can
even lose the ability to discern appropriate behavior.

Educators should further be aware that children with TBI may experience fatigue, especially
when they first return to school, and many are subject to seizures and may be on medication.

How TBI Differs from Other Disabilities

The biggest distinction between children with TBI and children with other disabilities is that the
injury — and subsequent disability — occurs over night, says Carol Wong, education evaluation
specialist, Mulpnomah Education Service District. With other cognitive disabilities, the child and
his or her parents have had some time to deal with it emotionally and to learn how to manage the

―These kids were ‗normal,‘ and over night they have a changed brain, have altered ways of
acquiring information,‖ says Tyler. ―It is quite an adjustment to realize one‘s brain is not
functioning as it was and that one must do things differently.‖

Not only does this take a tremendous toll on the child and his or her family, it affects everyone
involved — including educators! It can be as difficult for teachers to change their expectations
for a child who has experienced brain trauma as it is for others, especially if the child looks fine
However, in some cases, particularly if the child suffered the injury at an early age, the
educational effects of TBI may not show up immediately. The child may not experience
problems in school until middle or high school. Then, as the child is asked to perform higher-
level thinking skills and more complex tasks, he or she may experience problems academically
and start to lag behind peers. The child may also start to experience difficulties socially, as he or
she has difficulty meeting increased demands on time and attention.

The problem is complicated by the fact that no one may link the child‘s learning problems to the
injury. The medical profession may have given the child a clean bill of health physically without
being aware of the ways the injury could affect the child educationally at a later date.

A third area that distinguishes children with TBI is that their knowledge can be scattered, leaving
the child with wide gaps in his or her learning. Some higher-level skills will remain intact but not
some lower-level skills, says Tyler.

A teacher can see the ―Swiss cheese effect,‖ adds Wong. ―A student can do algebra but can‘t
remember coin value.‖

Finally, children with TBI can make rapid advances in their academic skills and knowledge,
particularly in the first six months to a year after the injury. A school may have an IEP in place
when the child returns to school, and within three weeks or a month it will need major changes.
Children with TBI can also plateau for a time and then make major jumps in learning.


Often the traditional assessments performed for a child with a disability will be inadequate for
students recovering from TBI. First, many consider an evaluation by a neuropsychologist vital.
Neuropsychologists specialize in brain functioning and can give more comprehensive
information about how the injury will affect the child in the classroom than a school
psychologist, according to Tyler. For example, neuropsychologists will provide information on
the child‘s ability to problem-solve, to learn on repeated trials, how he or she will do if
distractions are present, and if the child can perform motor or processing tasks easily.

This information is combined with that of other rehabilitation professionals (occupational,
physical, and speech therapists), nurses, teachers, and social workers. Input from the child‘s
parents is also critical, as they know how the child performed before the accident and of any
difficulties the child is experiencing now.

Also, assessments must be done much more frequently for children with TBI. Some recommend
yearly testing. Children who have been recently injured may need to be tested even more
frequently. In just 3-6 months, a child with TBI may perform at a completely different level than
when they were tested at the hospital, says Tyler. To determine just how frequently to test,
educators must stay abreast of how rapidly the child is changing. The teacher is often the one to
monitor the child‘s progress.
In addition, educators must be aware that formal assessments for a child with TBI can provide
misleading information. For instance, the child may score well on a standardized assessment but
be unable to perform in the classroom.

Developing an Education Program for Children with TBI

Though many of the instructional strategies special educators already use will apply to their
students with TBI, they will need to take some additional steps for these students. For example,
because of the complexity of treatment for these children and the rapid changes they make
physically and educationally, it is essential that a case manager oversee the child‘s education
program. The case manager will need to ensure regular communication occurs between the
child‘s parents, medical personnel including the neurologist and rehabilitation personnel, any
outside therapists the child is seeing, social workers, and school staff. The case manager will also
monitor the child‘s academic and social progress and ensure the IEP team meets and updates the
IEP as needed.

As mentioned above, the educational needs of child with TBI will change quickly after the
injury. Therefore, the child‘s IEP goals and objectives must be developed initially for
achievement over short periods of time, 4-6 weeks, rather than six months to a year as is
traditionally done. Likewise, the child may need more frequent assessments than other children
with disabilities.

When working with children with TBI, the special education teachers‘ primary task is cognitive
rehabilitation. As with their other students, teachers will work to improve the child‘s deficits and
teach the child how to compensate for skills he or she may never regain. Thus, the teacher may
need to help the child re-learn how to do things that came naturally before the accident, such as
how to gather information from a passage or take a test. For skills the child will never recover,
such as memory, the teacher will need to teach the child coping mechanisms, such as using a
planner, a tape recorder, or other organizational aid.

When helping children with TBI regain social skills, teachers may need to adapt traditional
behavior modification techniques. Because the child may not have memory skills and/or lack the
ability to determine cause and effect, any behavior modification plan must be concrete and short-
term, recommends Tyler. For example, the child may have lost the knowledge that one is to be
quiet in a library. To teach that behavior, the teacher must rehearse the behavior with the child,
talk about it, and provide clear guidelines as to what is expected and the consequences of
incorrect behavior.

―The teacher will need to spend more time on antecedents verses consequences if the child does
not cooperate,‖ says Tyler. ―The child with TBI often will have impulse control problems. It
takes concentrated, intensive effort (for the child) to learn behavior.‖

Another factor educators must consider when working with students with TBI is their physical
protection. Whether because of loss of balance, impaired judgment, or an increase in impulsive
behavior, these children are prone to additional head injuries. Therefore, teachers will need to
closely supervise these children on the playground, may need to arrange for them to change
classes when the halls are less crowded, or, if conditions warrant, to wear a helmet at school.

Finally, collaborating with the parents of a child with TBI is vital. They know how the child
functioned before and after the accident, and they can provide valuable information on the
child‘s mental state.

How Do I Identify a Child with TBI?

If you think you know a student with TBI, you should check the student‘s history. If the
student‘s medical records don‘t mention a brain injury, ask his or her parents. They may
remember that the child took a hard fall as a toddler, which could be affecting the child‘s
learning progress now. The parents and teacher should see if the child‘s learning patterns
changed after the accident. Information about a child‘s head injury should be passed on from
year to year along with educational strategies that have proven successful.

For more information about the Council for Exceptional Children, which publishes CEC Today,
and much more information on special education, visit their web site at
       Introduction to Pediatric Traumatic
                  Brain Injury
                                 By Jeanne Dise-Lewis, Ph.D.
                                Edited by Jeannie Topkoff, B.S.

Every year, more than 1,000,000 children living in the United States have had a traumatic brain
injury (TBI) and in Colorado, it is estimated that about 6,000 children per year acquire a brain

Brain injury is the leading cause of both death and disability in childhood and adolescence.
Because of the tremendous growth in medical technology and knowledge, the emergency
medical response is now of such high caliber that the large majority of children survive their
brain injuries. At the same time, the length of stay in critical care and rehabilitation in the
hospital has decreased significantly over the past ten years, resulting in an influx of children who
have sustained serious brain injuries back to the care of their families, teachers, and primary care
pediatricians. The result of these changes is the following:

      Greater numbers of children survive TBI
      More children survive very serious TBIs
      Children arrive in the hospital rehabilitation service sicker and more impaired cognitively
      Children spend less time in hospital rehabilitation programs
      Children return home and to their public schools at an early stage of TBI recovery
      The responsibility for ongoing care, including rehabilitation, often falls primarily on the
       child‘s natural caregivers: family, pediatrician, and school personnel

While the largest cause of TBI is involvement in motor vehicle accidents, other sources include:
   Non-accidental trauma
   Falls
   Near-drowning
   Stroke
   Sport-related injuries

The severity of injury is related to several factors, predominately:
    Glasgow Coma Scale
    Length of amnesia for the events surrounding the accident
    Altered mental status

Although it is commonly believed that the sequelae of mild TBI do not persist, both the follow-
upand quality of data available on children with mild brain injuries are inadequate. In addition,
recent reports of the ―latent‖ effects of mild pediatric TBI have suggested that the assumption of
no lasting impact may be in error. In particular, deficits in ―executive functions‖ – processes
such as:
      Self-monitoring
      Attention
      Initiation
      Inhibition

have been documented. Other deficits have also been associated with mild TBI:

      Difficulty with mood regulation
      Slow rate of mental processing
      Verbal retrieval weakness
      Conceptual reasoning deficits

These deficits are thought to result from subtle disruption in the frontal lobes at sensitive periods
of growth, the effects of which are not apparent until later in life.

It is very important that parents‘ report of these subtle changes in mood , personality, or behavior
following a a head injury be taken seriously. Children suspected of having a mild TBI should be
followed closely and should have the benefit of evaluation and consultation.

It appears clear that brain injuries of a moderate or severe degree result in a host of physical,
cognitive, behavioral, social and emotional ramifications, which are likely to persist with some
degree of permanence.


The most commonly reported medical problems include:
    Sleep disturbances
    Fatigue
    Headaches

Typically, all three symptoms are noticed early in the recovery period, if they are going to occur
at all. Usually, sleep patterns become more regular and less disrupted as the weeks go by; failure
to re-establish a normal sleep-wake cycle spontaneously may indicate the need for assistance
with medication or psychological assessment and treatment for Post Traumatic Stress Disorder

Occasionally, headaches become an ingrained, long-lasting problem, with daily occurrences.
―Rebound‖ headaches, a continuous headache-cycle, can be caused by over-reliance on
acetaminophen or ibuprofen and may require management by a a neurologist. Mental and/or
physical fatigue is almost universally reported by individuals recovering from brain injury;
children typically sleep longer at nighttime and also require after school naps. Stamina for
recreational activities is often quite diminished.

TBI is associated with a variety of physical sensory, perceptual, and motor abnormalities. The
primary reported symptoms include:

      Loss of balance, coordination, motor planning abilities
      Difficulty accurately perceiving sensations from fingers
      Difficulty maintaining awareness of body positions
      Blurred or double vision
      Hyper-sensitivity to sounds, tastes, smells, or loss of smells
      Visual-perceptual distortions

Disturbances in the sensory and motor systems, besides requiring intervention in their own right,
also affect the child‘s energy and availability for ―higher order‖ cognitive activity.


The cognitive, emotional, and behavioral problems associated with TBI are often less obvious
than the physical symptoms, and they also are likely to be more individualized.

The type and severity of problems depends both on the severity of injury and also on the child‘s
stage of development at the time of injury.

In general, previously learned behaviors and knowledge are recovered most quickly and robustly.
Therefore, other things being equal, early brain injuries (acquired during infancy or preschool
years) create more significant impact on both cognitive and behavioral functioning than do
injuries acquired at a later stage of development (adolescence, for example). However, the
emotional and social impact of TBI increases with age, adolescents‘ feeling it most acutely and
being prone to serious depression during recovery.

Brain injuries acquired during childhood or adolescence almost always result in:
    Unevenness among cognitive abilities
    Reduced rate of mental processing speed
    Diminished organizational abilities
    Mental inflexibility
    Difficulty self-monitoring and regulating emotional experiences

These neuropsychological problems, in turn, produce:
    Spotty acquisition of new information
    Mental fatigue
    Stress
    Poor frustration tolerance
    Confusion

Psychological, emotional and behavioral problems are often misinterpreted as being under the
child‘s control in some way, reflecting poor motivation, lack of effort, or lack of care. Often,
others will reassure the child‘s parents that these ―attitude‖ problems are normal, or that they will
outgrow them. This rarely happens, unless the underlying connections with the brain injury are
well understood and appropriate remedial accommodations are made.


In young children, the most commonly reported problems in this arena are behavioral and
     Temper tantrums
     Unpredictable swings of emotion and displays of emotion
     Non-compliance
     Resistance to change
     Impulsive, aggressive, and/or dangerous behavior

For the young child with a TBI, important interventions include:
    Increasing clarity and structure
    Emphasizing healthy routines regarding nutrition, sleep, and activities
    Providing supervision
    Creating multiple opportunities to learn appropriate behavior

Once parents and caregivers understand the essential problems their child is facing, it is often
quite possible to make significant change in these troubling symptoms.


Children whose TBI occurs in adolescence have a different task to face in recovery, and their
symptoms are usually more subtle. By adolescence, behavioral control should be well established
and the youngster has a solid foundation of academic, as well as personal and social,
competencies. The older child can draw on his/her fund of previously learned information in
school, and teachers may not recognize the impact of the head injury on the ability to learn new
material. Slow rate of mental processing and difficulty organizing and managing complex
information are two very common sequelae of TBI. These deficits make it very difficult for the
adolescent to function in the quick-paced and complex world of the middle or high school

For adolescents, the post-injury return to school and social activity can be very confusing,
agitating, and disappointing. Activities that once were routine now require thought, planning, and
assistance. The adolescent feels overwhelmed by the pace of material being presented in class
and feels discouraged by her inability to keep up with the demands to process multiple sources of
information simultaneously. She often worries that these symptoms mean that school will never
again be an arena of success.

The adolescent may be unable to resume such responsibilities as babysitting siblings and
monitoring and tracking his own schoolwork. He may lack judgment or be unable to think
quickly and efficiently on his feet. This loss of ability to function in the routine roles and
responsibilities of teenage life is very distressing to the teenager as well as to his/her parents and
Because typical adolescent social life is spontaneous, with few clear rules and little
predictability, the youngster with a TBI can become easily overwhelmed in the social arena;
afraid of making a mistake which would call attention to their problems, they often withdraw and
lose the support of their peer group.

Finally, adolescents often have some early notions regarding vocational interests, further
education, and maybe even a specific career. They have developed coping strategies, including
participation in sports and physical activities. Their injury may prevent or diminish their
involvement in such activities, further increasing the stress they feel and contributing to their loss
of social support.


When adults experience a TBI, there are many sources for cognitive rehabilitation, including
adult vocational rehabilitation, disability insurance, and general medical insurance. This
availability of funding sources has spawned a variety of treatment programs for adults and has
resulted in advances in knowledge regarding the mechanisms of TBI and the process of cognitive
recovery in adults.

For children, however, the cognitive ramifications of a TBI often are viewed as educational, and
public school teachers are expected to provide the cognitive rehabilitation for children through
the IEP process. Teachers assess the child‘s academic difficulties, behavioral problems, and
―motivational‖ deficits, and apply strategies which they have used with other populations of
children (e.g., mental retardation, Attention Deficit Disorder, or emotional disturbances).

However, while many symptoms may be the same, there are very fundamental and significant
differences in the root causes of school and behavior problems in the case of TBI, and traditional
interventions are rarely effective. It is important for parents and care providers of children with a
history of brain injury to know that their children are eligible for individualized educational
programming and support services in school, no matter what their I.Q. or achievement test scores

Support services and interventions, which are very important for children who have had a TBI
and their families, are offered at specialty care centers. These services and interventions include:
    Medical consultation and follow-up
    Multidisciplinary neuropsychological evaluation (including psychology, learning,
       speech/language, social work, OT and PT specialties)
    Consultation with families and school personnel
    Support groups for children and their parents
    Cognitive rehabilitation treatment groups
    Psychological treatment
 Traumatic Brain Injury in Children and
                                   Barbara C. Fisher, Ph.D.
                        Fully Licensed Psychologist, Neuropsychologist

Unlike the consequences of brain injury in adults, the first sign of the consequences of brain
injury in children is more often personality and behavioral changes. Too many times health care
providers assume that if there are no obvious cognitive impairments that there are no
consequences of pediatric brain injury. In pediatric brain injury the first sign or symptoms of the
consequences of traumatic brain injury can be behavioral and personality changes. All too often
the reality of pediatric brain injury is that the consequences of that injury are misdiagnosed as
symptoms related to hyperactivity and ADHD, Conduct Disorder or Oppositional Defiant
Disorder, when in fact the poor child is suffering from the consequences of traumatic brain
injury. The purpose of this paper is to help educators, insurance companies, lawyers, parents,
health care providers and others involved in the care of children and adolescents to understand
and appreciate that following a brain injury, the behavioral changes noted in the child may
actually be the consequence of that injury and not a separate psychological disorder.

The notion of personality change accompanying traumatic brain injury is not a new concept.
Much of the recent research points to the presence of emotional lability or instability; emotions
drastically increased in intensity that become out of control, following a traumatic brain injury.
Continual moodiness is an apt description. Dramatic and rapid shifts in behavior frequently
occur, more often unrelated or certainly not commensurate with the causal event. It is not
unusual for the child who has sustained a brain injury to become more irritable, whiney and
upset with the smallest issue. When the frontal lobes are directly involved it becomes a problem
of inhibition, the inability to stop a behavior from occurring or to curtail the behavior once it has
One young child I recently evaluated became upset and started to cry. The problem was that he
continued to cry without stopping, which quickly escalated to screaming and uncontrolled
sobbing, lasting for no less than one hour. He managed to somehow calm down for a few
minutes and I found myself looking at him as if watching the calm before the storm. It was not
long before he became upset about another issue and the process repeated itself. These children
have no idea of how to tolerate frustration. They become upset about numerous issues that
cannot be predicted. Once upset, these children have no idea of how to turn the faucet off, and
the parents remain just as perplexed. Even if the problem that originally upset the child is
resolved, they still continue to cry and scream. It is as if the brain did not compute that the
problem was fixed.

None of this type of behavior was seen prior to the traumatic brain injury. Other examples

      Post accident inability to get along with siblings.
      Post accident changes in play habits.
      Post accident changes in coloring and handwriting.
      Post accident changes in the understanding and following of parental direction and
      Post accident changes in former attainment of developmental milestones such as
       bedwetting following injury when pre-injury a child had been totally trained.
      In infants, significant changes occur in sleeping and eating habits.

These children have little or no ability to soothe themselves or to be soothed. Crying becomes
pathological in the extreme response to common everyday events: disappointment over
anticipated family plans such as a trip to the store, or a movie or outing; upset if corrected in
school or at home for mistakes and/or inappropriate behavior. The adolescent who has sustained
a brain injury responds with such intense emotion that the parent hesitates to reprimand them,
aware that a simple parental correction could become a daylong argument and/or initiate a
tantrum. The behavior of the TBI child or adolescent, lacking in inhibition, is that of an
immediate response, which is often emotionally reactive, out of control, sudden, and short lived.
The public, consisting of trained and untrained professionals, upon observing such behavior, all
too quickly arrive at the conclusion of a diagnosis that does not consider brain injury and only
describes the behavior they are witnessing at the time. The critical analysis of a child?s behavior
includes detailed information and observations of what the child was like prior to the injury.

The following case examples illustrate the critical role that neuropsychological assessment can
play in the proper diagnosis of the child?s difficulties for the educational/academic setting, as
well as for health care and litigation purposes.

The misdiagnosis of changes in personality post injury as ADD or Conduct Disorder:

A deaf child, who was a pedestrian in an MVA, sustained a fracture directly affecting the frontal
area of the brain, the area responsible for behavioral inhibition and emotional control. Following
the brain injury, teachers observed drastic personality changes and the child pre-injury who had
been the delight of the classroom, the hardest worker, the one who enjoyed school and who loved
learning new information, became a totally different student. She was described post injury as
one of the more aggressive children, defiant, and unmotivated in class. The teaching staff
uniformly described this child post injury as so oppositional and resistant to learning that they
believed she could no longer benefit from their teaching. At the time of the first
neuropsychological evaluation, the teaching staff was in process of searching for a residential
deaf school for her to attend to complete her schooling. By this time the teaching staff had
become convinced that her problem was her failure to accept her deafness.

When evaluated extensively by the author, the neuropsychological data identified cognitive
consequences matching the site of the brain injury, as opposed to seeing her learning problems as
the result of either her deafness or her out of control behavior. Following explanation of the
thorough neuropsychological evaluation, the school staff revisited their thoughts regarding the
issue of brain injury. For a period of time she received accommodations in the school, allowing
her to function better. However eventually her behavior became so problematic and so central to
her academic functioning that once again the focus turned to behavior problems as primary, and
the presence of cognitive deficits paled in comparison. Two years later, she no longer had any
friends, she could not ride the bus, and she was becoming more and more isolated in the
classroom. Her primary special education teacher asked for my help to explain to the teachers
why the presence of brain injury would produce such extreme behavior. The teachers at this
point were ignoring this child, giving her passing grades to move her out of their classroom. A
second evaluation and staff meeting was scheduled in her home area. The focus remained upon
her deafness and her out of control behavior. When teachers were questioned at a later date by
opposing counsel, they indicated that they did not think that she had suffered a brain injury at all.

The second neuropsychological evaluation echoed the findings of the first evaluation. Frontal
deficits of selective attention, integration, becoming distracted by the irrelevant, perseveration,
and inability to utilize feedback, predominated and pervasively affected all of her thinking
ability, including her ability to learn new information. Her skill set remained much the same, as
it was pre-injury, meaning that she had learned relatively minimal information in school, despite
the intervention of special education services. The PET scan requested by the author to resolve
the issue and provide further confirmation of the neuropsychological test results, indicated large
gaps in her functioning, profound bilateral frontal damage as well as damage to the temporal area
of the brain. Despite the presence of rather pervasive brain damage, the idea of brain impairment
had not been considered prior to the neuropsychological evaluations being completed. Teachers
who had carefully recorded in her school records the changes in her learning and academic skills
following the accident, five years later could only see the problem in her behavior. Despite their
own notations regarding the effects of this rather severe traumatic brain injury, this child had
never been re-certified within the school as TBI.

This case illustrates how difficult the challenge is for parents of a child with a traumatic brain
injury to secure the help within the school setting to address the consequences of that injury.
Despite the following events in this case, the school failed to recognize this child?s brain injury
and to provide proper educational assistance.

      Two consistent neuropsychological evaluations.
      A PET scan indicating pervasive damage, which confirmed the correctness of the
       neuropsychological evaluations.
      A defense ordered MRI revealed substantial findings.
      Three defense experts, all of whom confirmed the injury.
      A settlement recognizing that the child had sustained a substantial traumatic brain injury.
      Three school presentations by a neuropsychologist to explain the consequences of the
       brain injury and its impact upon school functioning.

In another respect, school systems are able to recognize a brain injury and will provide
accommodations for that injury including; home schooling, tutorial services, additional
equipment needs as well as classroom modifications. Another case example provides evidence of
success in securing TBI certification and the necessary accommodations to address the specific
consequences of this child?s electrical injury, following the second IEPC school meeting,
attended by a neuropsychologist and physician.

The unfortunate result of damage to the frontal processes usually tends to be the mistaken
emphasis upon the child?s behavior. The treatment path tends to target the reduction of unwanted
behavior, rather than addressing the impact to brain structures and the neurological sequelae as
well as the cognitive deficits, directly related to the brain injury. It has been shown that proper
attention to the cognitive problems would tend to decrease behavioral problems.

Points to consider from this particular case example:

    1. Behavior problems negated focus upon TBI and the school staff failed to certify this child
       as TBI, which would require school services to be available to her up to the age of 21
    2. The focus upon her behavior deterred any medical management from being undertaken.
       Behavioral interventions were repeatedly and continually implemented, despite their
       historical lack of success.
    3. The designated treatment approach by school personnel targeted her handicap of
       deafness. She was considered to be a deaf child, not a brain injured child.
    4. When evaluated by a recognized academic center for the deaf community, her language
       development was found to be impaired beyond what would typically occur with a deaf
       child who had no history of brain injury. The opposing counsel?s neuropsychologist
       concluded the finding of TBI.
    5. The neurologist hired by the opposing counsel performed an MRI and ruled in a
       condition resulting from such a high degree of cell death or necrosis. Not only did this
       child have a brain injury, her injury had become so pervasive that she had literally lost a
       good portion of her brain.

The misunderstood cognitive deficits of frontal impairment, the executive reasoning,
supervisory system in the brain:

A child diagnosed with a skull fracture resulting from a fall down a flight of stairs at the age of
three years did not exhibit substantial cognitive deficits related to the site of the injury until the
age of 12 years. If the case had been settled previously, the extent of deficits from this frontal
injury would have remained unknown. The neuropsychological evaluation by this author,
revealed cognitive consequences of the traumatic brain injury, specifically related to the site of
the injury, and the child was referred to a local neurologist. The neurologist completed an EEG
evaluation, identifying seizure disorder and placed the child on medication. Up to this point
seizure disorder had not been confirmed on prior EEG assessment. The previous
neuropsychological evaluations obtained from the age of three years and onward had ruled in
essentially normal findings, although the test data did reveal the characteristic pattern of
cognitive consequences of frontal brain injury. At one point the child had been placed on
stimulant medication and mistakenly given the diagnosis of ADHD (Attention Deficit Disorder
with Hyperactivity). Symptoms of selective attention were misinterpreted as a developmental
attention disorder of genetic origin, rather than being seen as cognitive consequences of frontal
brain injury.

The presence of sequelae and the cognitive consequences of the traumatic brain injury,
specifically frontal impairment, were not diagnosed until the age of 12 years for several reasons:
      Prior examiners did not employ the use of sufficiently extensive testing to measure the
       impairment that was present.
      The child was bright enough to overcome deficits with compensatory strategies to
       produce overall average functioning.
      Finally, the injury affected an area of the brain whose deficits could not be fully
       observed, outwardly, until adolescence. Therefore, it was not until adolescence that the
       diminished functioning of this supervisory system would become observable in his
       behavior and thinking processes.

It was in adolescence that the following symptoms became obvious:

      The lack of inhibition, characteristic of this area of the brain, had resulted in the child?s
       calling out in class, exerts from his favorite movie, The Titanic, or television show, The
       Simpson?s, while the teacher was attempting to teach history to the class.
      Aberrant patterns of learning were highly apparent in his learning process as well as in
       his use of language. For example, he thought that the purpose of senators and
       congressmen was for them to ?live in nice houses and drive fancy cars?. He apparently
       learned this information while watching a television news program and observing their
       entrance into nice houses and fancy cars. He retained this idea despite obviously learning
       different information in social studies and government while in school. When evaluated
       at the age of eight, 10 and 12 years, respectively, he indicated the same statements noted
      He continually misspelled words to the degree that they could not be understood and he
       substituted words that had no relation to one another.
      While in conversation, he tended to stop mid-sentence, unable to think of the words to
       complete his sentence, ultimately forgetting what he had wanted to say.
      Emotionally he was becoming highly paranoid and suspicious of everyone. His behavior
       often made no sense. He was as compulsive as he was impulsive. He started fights on the
       playground, saying things to his peers that were clearly inappropriate and mean. He later
       expressed feeling hurt and abandoned when no one wanted to play with him. He had no
       understanding of why people were angry with him; he rarely recalled the exact sequential
       events of such incidents.
      It was not until the age of twelve years that his family and various professionals became
       painfully aware of his inability to control his emotions, to make appropriate decisions,
       and that his learning consisted of irrelevant information, which he believed to be correct.
       These thinking problems did not significantly emerge until this age, although present all
       along; directly related to the frontal skull fracture injury at the age of three years.

Problems of diagnosis specific to pediatric brain injury:

The neuropsychologist unfamiliar with the signs of frontal deficits would tend to diagnose the
child as a behavioral disorder and/or rule in the presence of ADHD. Measures available to
explicitly assess frontal processes are minimal, however the experienced neuropsychologist is
aware of how to assess such deficits and the necessity of examining the entire test results for
characteristic patterns revealing frontal deficits. Therefore what might appear to be minor injury
at the age of four years may in fact prove to be highly detrimental, five or even ten years later.
Children who are gifted and of higher levels of intelligence will be able to compensate on
general types of evaluation such as an intellectual assessments and therefore appear to be
developing normally. It is quite common for radiological tests, administered several years post-
injury to reveal abnormal findings not seen initially at the time of injury or immediately post-
injury. Mild brain injury can often be overlooked, misdiagnosed and confused with symptoms of
childhood developmental disorders such as A.D.D., Learning Disability, Tourette?s disorder, and

Any type of abbreviated battery for a child would therefore be totally inappropriate. The
neuropsychologist needs to be aware of the effects of commonly presented symptoms of
selective attention and concentration deficits, the manner in which such deficits affect the child?s
development and performance in the school setting, as well as their performance in sports
activities, their social adjustment and personality development. The neuropsychologist benefits
from following the child?s school development and from talking to teachers, looking for changes
in the child?s social behavior and motivation, comparing pre and post-injury behavior and
academic performance. The pediatric neuropsychologist who understands pediatric brain injury
is aware of the necessity of examining the way the child learns, not what they have learned. It is
critical that the neuropsychologist continue to evaluate the child on a regular basis, over a course
of years, prior to rendering a final opinion regarding the consequences of traumatic brain injury.

Pediatric brain injury has provided an even greater challenge to prove evidence of injury for
several reasons:

      Academic problems typically do not emerge until the child has been attending school on
       a formal basis for a sufficient amount of time.
      Report cards and progress reports generally do not begin to show problematic
       performance until the later grades of elementary school.
      Often, frontal injuries do not become completely understood or outwardly observable in
       the child?s thinking abilities until adolescent years.
      The brighter the child, the longer that it will take for deficits to become observable,
       signifying that the child is no longer able to compensate with strengths or asset areas, as
       school becomes more complex and demanding.

Unless the pediatric neuropsychologist spends a sufficient amount of time with the child, they
will tend to make assumptions that have a greater likelihood of being incorrect. It is only after
spending time with the child, watching their reactions and performance on various types of tasks,
in addition to employing a sufficient number of tests to determine impairment patterns, that the
evaluator will be able to arrive at valid, scientific assumptions regarding the degree and depth of
the child?s injury. Children suffering from pediatric brain injury suffer quietly, unaware of the
rather profound changes that have occurred in their thinking and behavior. Life is one continual
unending attempt to keep up the pace of their peers and to avoid getting into trouble with the
significant adults in their life. There are no time outs with pediatric brain injury.

These are the children who do not show improvement from behavior modification programs,
they only succeed in perplexing and more often, frustrating professionals, whose various
treatment or interventions continually prove unsuccessful. These are the children who in younger
years are asked to leave the preschool, they are labeled as bad troublemakers; parents of these
children are either ostracized or reprimanded for not exercising sufficient discipline to control
their child. No one understands- the parents left alone at the mercy of these children, who
vacillate between the extremes of being endearing and sensitive to cruel and mean, become tired.
They feel guilty, as if they have failed in their parenting, even when all of their other children are
well behaved. Too often the lack of understanding of the depth and impact of this problem upon
the family creates stress that is too overwhelming to keep the family unit from dissolving.

Pediatric brain injury does not just affect the child it impacts the entire family in the following

      The focus of the family is automatically on the child who has sustained a brain injury.
      The care, time and energy, necessitated by the child suffering from the consequences of a
       traumatic brain injury, results in the exclusion of the needs of the other children. Baseball
       practices are missed, school plays are not attended, and birthday parties are put off to
       another time.
      The care and time devoted by the parents to all of the children in the family results in the
       natural exclusion of their own needs as well as their marital relationship.
      Time becomes a commodity that no one has.
      The natural consequences of the above leads to parental guilt, feelings of failure, and
       overall unhappiness, as well as an overall diminished quality of life for the entire family

Brain injury may often be unseen to the naked eye. This does not mean that the injury is absent.
Brain injury may be subtle, albeit powerful, resulting in enormous, far-reaching consequences,
especially for children and adolescents. Its power should never be underestimated.

To summarize:

   1. The child misdiagnosed as a behavior problem never receives the help they need to cope
      with the cognitive consequences of the brain injury. The behavior is often so
      overwhelming and problematic that the cognitive consequences pale in comparison.
      Emotional outbursts, impulsivity, out of control behavior and aggressive behavior, as
      well as selective attention problems can be symptoms or consequences of a traumatic
      brain injury. Unfortunately, many of these children suffering from a brain injury are
      being mislabeled as a behavior problem and misdiagnosed as oppositional and the
      problematic behavior is not seen as directly related to the brain injury. A differential
      diagnosis of a behavior problem should include the exclusion of traumatic brain injury.
      There are countless examples of the missed opportunity to provide immediate treatment
      for the child suffering from the consequences of traumatic brain injury that resulted from
      the failure to recognize the important diagnostic criteria of behavioral changes observed
      post injury.
   2. Neuropsychological testing, when completed by a pediatric neuropsychologist, who
      understands and appreciates the complexity of pediatric brain injury, can discriminate a
      discipline problem versus the consequences of traumatic brain injury. Children suffering
      the consequences of traumatic brain injury often times do not have any control over their
     behavior and when accused of a specific incident, they cannot recall exactly what their
     behavior was or specifically what they did. The result is that they do not tend to admit
     responsibility or wrongdoing, leading to the false impression of a lack of remorse or
     caring and the diagnostic criteria of anti-social, oppositional and/or defiant personality
     features. The behavior problems for the above diagnoses are qualitatively different from
     the consequences of brain injury, which can be identified by comparing the pre and post-
     injury behavioral descriptions and observations of the child.
3.   It is not unusual for the brain injured child to be mislabeled with some type of pre-injury
     childhood developmental disorder, such as Attention Deficit Disorder given that these
     children typically show outward symptoms of poor sustained attention and concentration,
     as well as significant overactive behavior.
4.   Attention is not a simple, unitary concept that relates only to the child?s ability to focus
     and concentrate. The inattention of the A.D.D. child is substantially different from the
     inattention of the child who has sustained frontal lobe injury. Attention and concentration
     problems are commonly seen following brain injury. The concept of attention involves
     several elements: the ability to take in information from the environment, the ability to
     process that information and to send the information for use to the correct area of the
     brain. The element of distractibility can affect all of the above elements and the child who
     is continually distracted internally or externally will tend to miss information solely due
     to this particular element. All of these elements can and are, routinely impacted by a
     brain injury. In a synergistic manner, one element affects another element and so on, as
     all of these elements are necessary for the coordinated effort of sustained attention and
     focus to complete any given task in one?s everyday life. The far-reaching consequences
     of traumatic brain injury are immense with the potential to totally alter anyone?s life.
5.   Neuropsychological evaluation is a powerful tool. When employing competent and
     proper tests for the pediatric population, it provides an excellent method to identify the
     cognitive consequences of traumatic brain injury. When behavior becomes the primary
     focus, one of the goals of neuropsychological evaluation is to isolate the factors of brain
     injury from other diagnostic labels. Unfortunately the conscientious attempt of the family
     physician to secure help for the child results in the referral of the child to an adult
     neuropsychologist instead of a pediatric neuropsychologist.
6.   Despite the false notion that children have a better opportunity for recovery from brain
     injury than adults, the fact is that the theory of plasticity remains unsupported. Children
     can and do experience significant disabilities and cognitive problems, which may not
     become apparent until adolescence or several years following the injury. What appears to
     be only minor deficits at the age of five years may in fact have a major impact upon the
     educational, social, and emotional development of the child during adolescent or teen
     years as different parts of the brain become more challenged. Tasks in the educational
     setting naturally increase in complexity, taxing the system even further. Testing
     completed in later years following the injury, for this reason, tends to reflect deficiencies
     and problems not seen in earlier years.
7.   It is important to understand that the grades attained in school during the early years do
     not provide an accurate basis for determining whether the child has suffered from a
     traumatic brain injury because the academic work completed in these early grades do not
     challenge the entire brain. Parts of the brain that may be damaged are not called upon for
     use until later years. For example, output skills do not become critical until mid-
      elementary school grades. It not until the latter years of elementary school and beginning
      junior high that the child has to function more independently; to organize his or her own
      homework, to complete book reports and to write papers, as well as to respond to essay
      test questions.
   8. The finding of a normal CT Scan, normal MRI, or normal EEG does not rule out the
      presence of significant brain injury. The PET scan is emerging as the state of the art
      method to view the functional effects of traumatic brain injury. A child does not need to
      lose consciousness in order to suffer from a significant injury, whether it is sports related,
      occurs on a school playground, from a fall, or from a motor vehicle accident. A short
      period of time whereby the child is dazed following injury is sufficient to induce changes
      in the brain that can lead to significant consequences affecting the remainder of their life.

Based upon 17 years of work as a pediatric neuropsychologist, years of research and study,
having completed several thousand neuropsychological assessments (ranging in age from infancy
through adolescence) and having served as an expert witness in numerous cases around the
United States and Canada, it has become quite clear that a pediatric brain injury can be far more
problematic to the child than to the adult. The developing child is caught in the constant and
continual dilemma of attempting to re-learn the information they lost while trying to maintain the
pace of their peers and acquire new learning. The result for the developing child is that they are
continually caught in a world of confusion, ill equipped to learn in a manner similar to their age
mates, while having to re-learn and to continue to learn at the same time. The very equipment
that they need to depend upon to correct learning problems, malfunctions handicapping the child
who has sustained a brain injury, even further. Consider that the very skills we naturally take for
granted to function on a daily basis, results in the loss of five minutes per hour. Each day the
child is behind 35 minutes of a seven-hour school day and by the end of one week, they are
behind 175 minutes. There are no time outs in life for pediatric brain injury where unseen
deficits become profound problems later in life.
                          Critical Issues in
                        Pediatric Brain Injury
                                      Barbara C. Fisher, Ph.D.
                           Fully Licensed Psychologist, Neuropsychologist

Accuracy and Validity of the Evaluation

The accuracy of the evaluation is an historical subject of debate among the experts in the field of
neuropsychology. Does the test measure what it purports to measure? In other words, are the deficits
identified, positive findings and truly deficits that remain in existence, once the extraneous
variables/factors have been ruled out? Are these deficits significant to the degree that they can be
measured again with similar findings (provided that the situation remains commensurate and that
treatment intervention has not been implemented). Factors such as motivation, emotional overlay
(depression or anxiety) medication effects, pre-morbid factors and litigation concerns (malingering) are all
variables comprising the equation used to determine the reliability and validity of test results in a litigation

Motivation and emotional reactions are factors ruled in or ruled out by the examiner and the depth of the
examiner's clinical experience affects their ability to accurately judge and diagnosis these issues. Often
non-verbal cues or verbal interactions are mis-read or misinterpreted. The expression, "I can't do this" is
seen as an example of poor motivation and/or malingering. Anxiety can often be mis-read as hyperactivity
and/or oppositional defiant disorder. The presence of depression can impact psychomotor speed on
some tests but not on others, creating variations in the test data and erroneous conclusions by
neuropsychologists who ascertain that depression affected all of the speeded tests. One of the best
methods would obviously be the presence of lateralized findings on motor measures to rule out the global
effects of depression on timed/speeded evaluation.

Defense neuropsychologists continually challenge the evaluation completed by the neuropsychologist
hired by the plaintiff's attorney. Some neuropsychologists have a reputation for their defense work and
they are predictable in their determination to rule out any evidence of brain damage no matter how severe
the injury. They dismiss the findings of the evaluation previously completed as invalid based upon factors
of depression, malingering and motivation, often attempting to explain rather clear symptoms of brain
damage as related to Attention Deficit Disorder, maintaining that such symptoms had been present prior
to the injury.

Problems of diagnosis specific to pediatric head injury
Pediatric brain injury provides a greater challenge to diagnose the effects of injury to the brain. All too
often the needs of the brain injured child are not served by the neuropsychologist who completes only a
basic evaluation and does not pursue problematic areas with further evaluation. The neuropsychologist
who is looking for the obvious effects of brain damage will tend to miss the subtle issues that while
appearing to be only mildly problematic at the age of five years, will prove to be rather devastating issues
when for this same child, ten years later. Academic problems often do not emerge until the child has been
in school for a sufficient period of time, especially if the child is bright and able to compensate for deficits.
It is only when school becomes sufficiently demanding and complex, that deficits resulting from injury to
the brain become observable to others. It is only at that point that the problems, which the child will face
in the future, begin to emerge. Symptoms seen in earlier years, which do not affect overall test scores,
which are seen qualitatively, as opposed to quantitatively, often do not become outwardly observable until
the latter years of elementary school or the beginning of junior high.
Children who have a higher level of intellectual potential can remain undiagnosed with brain injury
resulting from some type of accident, due to their ability to compensate for deficit areas. The presence of
brain injury is seen in the compromised functioning and in their outward appearance of average intellect
when in fact they actually have superior potential. Superior potential is utilized to compensate for deficits,
which tends to result in overall repressed functioning for the child. One school teacher described this
process in her description of a brain injured child as average and the fact that she had absolutely no idea
of the higher level of potential that had been repeatedly documented by evaluation. A child was evaluated
at the age of seven years and at that time although the overall scores were generally within the average
range, problems significant of future difficulties were qualitatively quite notable. When tested for memory
functioning at the age of seven years, this particular child confused items and demonstrated difficulty
recalling information correctly without adding items that were not part of the learned material. Testing two
years later revealed the same process that was now more prominent. The scores that were average on
the earlier evaluation had declined to low average and in some instances, below average. The exact
same pattern seen on the prior evaluation was seen when evaluated two years later whereby learned
memory items were confused and items were once again added that were not part of the learning
material. Rather confirming evidence is seen when re-evaluation provides the exact same pattern in the
test data as seen on earlier evaluation. There are two classically seen mistakes made by pediatric
neuropsychologists. One, the pediatric neuropsychologist makes the mistake of comparing scores rather
than the pattern of performance. Two, the child's performance is not the primary comparison. The
pediatric neuropsychologist can make grave errors in evaluation if comparing the child's performance to
normative data and age peers.

The best example of this problem was in evaluating an extremely bright child who was injured in a car
accident during the first year of life, and diagnosed with a hematoma, fracture and post traumatic
seizures. When first evaluated at the age of four years, her overall performance was within average to
above average limits. Although there were notable gaps in her testing pointing to deficits at the exact site
of injury documented by hospital records, it was erroneously ruled in that she was not suffering from brain
damage. When evaluated by myself one year later, those gaps in functioning remained, starkly different
from the other scores obtained in the evaluation. The presence of brain damage was rather obvious in her
performance from a qualitative and quantitative perspective although only in the specific area that was the
site of injury incurred from the accident.

However when later evaluated by another neuropsychologist, hired by the defense attorney, it was ruled
in that she did not have brain damage due to her overall test performance and the presence of average to
very superior functioning. The same pattern seen in previous evaluation was present although ignored by
the neuropsychologist who found the more important marker to be the presence of average to very
superior overall functioning. The child's functioning in school was proceeding well however by the time of
the second grade she was beginning to experience some reading difficulties and there were times in
class when she became noticeably confused. Stories that she would tell regarding events in her life
became fragmented as she lost words, forgot her thoughts and mid-way proceeded to talk about
something else. Up to this time she had been a rather even keeled child, not overly emotional, outwardly
happy and friendly. However, emotional changes began to become increasingly evident in her
moodiness, temper tantrums and periodic crying spells. The neuropsychologist hired by the defense
attorney ruled out these emotional issues as related to her parent's separation and the difficulty of living in
two houses. I evaluated the child one more time when she was eight years of age. By this time I had
formed a relationship with her due to traveling to her home area and spending many hours with her in
both conversation as well as evaluation. Changes in her emotional status were quite obvious to me as
she was more moody, easily frustrated, depressed, and highly distractible. In fact she appeared more
distracted than when I had initially tested her at much younger ages. In addition, she presented a
symptom that I had never seen before. She gave up easily. She became defeated and actually told me
that "she couldn't do it" in reference to completion of the task in front of her.

Now this was the same little girl who had stood out in my memory prior to this time. This was a child who
never gave up and who was determined to succeed, no matter what. In fact, she was the example that I
had used for many years in lecturing to describe a child who had learned to police herself, citing her
consistent self-statements of, "focus, focus" which she had used to keep her attention sustained to the
task at hand. The overall scores of this last evaluation that I completed on this child yielded the same
pattern of test results seen earlier; overall performance within average to very superior limits, however
there were some notable changes. Tasks she had been able to complete previously, she now became
confused on. More importantly, the same deficits were present in the same area seen on all of the
evaluations, which was the site of the original injury from the accident. PET scan and MRI analysis
completed subsequent to this last evaluation confirmed the findings that had been seen and documented
from the first neuropsychological evaluation onward. The PET scan revealed markedly diminished
functioning at the exact site of the injury and the MRI revealed that the brain was developing abnormally,
which can often be the result of pediatric brain injury.

The point is that all of the neuropsychological evaluations completed on this child were actually quite
consistent because the neuropsychological test data is so powerful in tracking damage to the brain. The
real issue was how the test data was interpreted, which tends to be based upon the clinical experience of
the pediatric neuropsychologist, and specifically with pediatric brain injury, the knowledge base of the
neuropsychologist. There are those neuropsychologists who tend to dismiss deficits seen in test data,
either because they are used to more severe brain injury and/or do they not perceive mild brain injury or
brain injury in a child of superior intellect as being particularly problematic.

Significant injuries to the brain in these circumstances tend to remain hidden and dismissed as
insignificant. The unique process of pediatric brain injury has been greatly understated leaving
neuropsychological evaluators rather naïve as to the effects of pediatric traumatic brain injury. The overall
assumption that children cannot suffer from frontal deficits, the misunderstanding that to measure frontal
deficits a specific measure must be administered, and the overall confusion surrounding the definition of
exactly what frontal deficits are. Frontal deficits or deficits in the executive reasoning, supervisory are of
the brain are difficult to truly understand and apply as a generalized concept to the child being assessed.
Although deficits to the executive reasoning area of the brain is typically discussed in any
neuropsychological evaluation textbook, the application is a more complicated endeavor. The
neuropsychologist who indicates that frontal deficits cannot be seen until that area of the brain matures at
the age of 12 to 13 years, or who maintains that specific test measures indicated as measuring this
particular brain area reveal intact functioning, does not truly understand frontal deficits or deficits of the
frontal processes.

The term frontal processes is often used due to the connectivity of this brain area, meaning that the
frontal area of the brain is so inter-connected with other brain areas that it becomes difficult to isolate
deficits as belonging solely to that particular brain area. Deficits in this supervisory system are more
accurately described as patterns occurring throughout the various tests administered by the pediatric
neuropsychologist that are consistent with the research and the tasks/functioning duties ascribed to the
supervisory area of brain functioning. The research is redundant in ascribing specific tasks that are
specific to frontal processes and the clinician who is astute can track such the presence of impaired
functioning in this area in children as young as five years of age.

Selective attention deficits and problems with integration can be seen in the elementary school child and
impact their ability to learn. The building block years can become rather disastrous for these children who
tend to pair unrelated items together as part of their learned repertoire and whose learning is filled with
intrusions and information which they think is related and which is actually not related at all. The child who
thinks that senators and congressmen are present to drive fancy cars and live in nice houses, the child
who describes migration as birds who hibernate, the child who steadfastly thinks that the sun sets in the
north and there are 129 days in the year, or the child who thinks that the plus sign means to subtract
numbers, provide examples of the type of aberrant learning that can occur subsequent to the presence of
diminished frontal processes. As would be expected the presence of deficits in the supervisory system
would become more apparent with the development of the child and would be seen with greater clarity by
the time of adolescence.
Injury does not remain static as once thought, the Theory of Plasticity is no longer accepted by
current research as a valid concept.

Pediatric head injury has been minimized by the historical belief of plasticity. The theory of plasticity
maintained that the brain can develop alternate pathways to either replace and/or take over for the
damaged neuronal pathway. The idea was that it was better to have a brain injury at a younger age due
to the resiliency of the pediatric population and their ability to recover from injury by forming alternative
pathways for nerve conduction. This theory was based on many split brain research studies whereby the
child learned to read despite the absence of the left or predominantly verbal hemisphere. The ability of
the right hemisphere to take over the function of reading demonstrated the resiliency of the brain to
recover from injury and to form an alternate means of neuronal functioning.

Recent research, however, consistently reports that pediatric brain injury, is actually more devastating.
Research has recently provided confirmation of changes, which occur in the brain on a cellular level,
resulting in altered pathway conduction, aberrant or abnormal signaling of neighboring neurons and a
cascade of events leading to permanently altered brain functioning, lowered immune system response,
the risk for further injury and the risk of future diagnosis of Alzheimer's disease. Research points to the
presence of over-activated biochemical functioning leading to the process of excitotoxicity and an altered
biochemical balance, which would have been present prior to the brain injury. Calcium toxicity, excessive
activation of specific brain neurotransmitters, the presence of free radical formation, mitochrondrial
dysfunction, can occur in brain injury similar to the cellular changes which comprise the ongoing process
of TIA's and the effect of stroke related ischemia.

Biochemical and reactive electrical changes following brain injury affects the functioning of the child for
his or her entire life, culminating in substantial vulnerability, which increases with the aging process. I
have had clinical experience whereby early brain injury literally impacted the forming of the brain and
even affected the development of the internal organs and muscular system.

I evaluated a child at the age of three years who had fallen down a flight of apartment stairs when the
railing gave way. At the time of the injury he was diagnosed with a transverse fracture spanning from one
hemisphere to the other. During the next eight years of almost yearly evaluation and re-evaluation he was
diagnosed with A.D.D. and significant learning disability, however none of the evaluations ruled in or ruled
out the presence of brain injury resulting from the accident at the age of three years. Unfortunately too
often those neuropsychologists in institutional types of settings become hesitant to rule in a brain injury
when they are aware that there is a litigation case. They will tend to assume that they are still helping the
child by ruling in some type of disorder and presence of a learning disability resulting in tutorial help for
the child. Unfortunately this only aids in delaying treatment for a child who may be in need of anti-seizure
medication and/or results in the child being treated with stimulant medication which over time enhances
seizure activity, if present. The normal EEG, seen as the standard to rule out evidence of seizure, is
clearly a misnomer that is not endorsed by the neurology community. However while it is clearly agreed
that the normal EEG does not rule out the presence of brain injury, the inherent assumption is still that the
normal EEG provides support for the lack of finding of brain injury, allowing the null hypothesis to be

This particular child injured at the age of three years did not have an abnormal EEG until, subsequent to
an evaluation by myself, at the age of 12 years. His last EEG evaluation at the age of 8 years was
interpreted as normal. Neurologists and radiologists may disagree as to the reading of a particular test
such as the EEG or MRI, ruling in or ruling out the presence of diffuse deficits that are not clearly
apparent. The common statement of slowing and/or the need for clinical correlation which some
neurologists and radiologists will view as confirming the presence of brain injury, may be negated or
rejected by other professionals in these fields.

The test data was relatively consistent across the various evaluations over the years although the
presence of brain injury was not ruled in. It was not until the child was yelling out themes from the movie
the Titanic or excepts from South Park that anyone thought of brain injury and requested the evaluation
that I completed at the age of 12 years. By that time, the child's language skills were clearly abnormal and
he could not even write a coherent sentence. His sentences were either grammatically grossly incorrect
or wandered off to another thought mid-sentence. When this boy decided to get a buzz cut, to be more
popular with his peers, that the fracture was seen as still clearly evident, spanning the entire transverse
section of the head, from ear to ear separating the frontal area from the rest of the brain. Today
medication to address the formerly undiagnosed seizure disorder has been of great help to this boy.
Although the learning deficits remain, he now has at least the opportunity to make his life better. While the
impact of pediatric brain injury is not removed with the introduction of medication, the control of seizure
via medication as seen clinically, allows the war to be over sufficiently for some learning to begin. It is
difficult for any child to learn new information. When feeling continually fatigued, suffering from
headaches, and faced with a process within the brain that places the brain in a state of constant flux,
learning becomes almost impossible for the brain injured child.

Those neuropsychologists who are willing to devote the time and patience to carefully study, to document
and to observe the functioning of these brain injured children can provide a wealth of data to help rule in
or rule out the long term effects of brain injury. Consider that 90% of the brain development occurs within
the first two years after birth, and that approximately 80% of brain growth occurs within the first year, and
then consider the impact of brain injury with the altered neuronal connections and cellular changes. The
full impact of early brain injury can be enormous when we consider the vast changes that actually occur
within the brain in response to the acceleration, deceleration, shearing of white matter, and contusions as
the brain moves inside its bony exterior. When injury occurs prior to the age of two years (and this
situation is exacerbated the closer to birth the injury occurs) there is a greater likelihood that the brain will
develop abnormally.

I evaluated a child who was involved in a car accident at the age of six months. Before the car accident
this child had been developing normally, gaining weight, eating properly and moving through the familiar
developmental milestones. A short time after the car accident he stopped eating and was hospitalized for
dehydration, labeled as failure to thrive. What did not become apparent was that he had developed
hypotonia, a condition of floppy muscle or diminished muscle tone affecting his ability to swallow and
digest food. Eating became so problematic that a feeding tube was surgically inserted into his stomach,
which he had until five years of age. This poor child was tested for practically every imaginable genetic
illness and put through the most gruesome and painful medical procedures without any of the treating
physicians ever thoroughly giving any credence or consideration to the impact of brain injury as resulting
from this rather serious car accident.

Generally speaking, professionals tend to refrain from attributing problems to brain injury due to a fear of
court involvement unless they are hired as experts to oppose or defend the case. It is quite
understandable that parents of a brain injured child would simply want to forget that an accident ever
occurred in order to emotionally divorce themselves from what would have been a rather traumatic time in
their lives. The attorney hired to litigate the case is not about to automatically request evaluation of a child
who is not exhibiting significant problems that would warrant such a request. Teachers are not trained to
watch for brain injury signs nor to specifically observe one child out of a total of 20 or 30 children.
Teachers who have attained specialized training and/or have had some type of personal experience with
brain injury will recognize signs and symptoms and report them to the parents. Often teachers will
indicate that a child blanks out, staring straight ahead or staring at nothing and it tends to be the astute
teacher who would see these types of symptoms as characteristic of brain injury as opposed to being due
to a disorder such as ADHD. Who then is going to observe and watch for signs of brain injury in the child'
It is not surprising that many symptoms are glossed over and inadvertently forgotten. Thus, it is usually
when the symptoms become so blatant that they cannot be ignored, that parents will finally make the call
for evaluation to determine if there are any repercussion from a questionable brain injury.

As a result, this child who appears outwardly the same as pre-injury, is actually very far from being the
same. Abnormal cell growth can occur, neuronal connections made by neighboring neurons are not the
same, the neurotransmitter biochemistry becomes permanently altered, and there are numerous changes
at the site of the original damage as well as changes to the nearby tissue. These cellular changes can
create deficits in specific areas of brain functioning, in addition to altering the overall development of the
brain. Neurologists have referenced the diagnosis of seizure disorder as a clinical diagnosis, recognizing
the difficulty of diagnosing such a phenomenon with the use of radiological measures such as the EEG.
Various forms of the EEG such as video recordings, digitrace, 24 or 48 hours or even a week of telemetry
can fail to diagnose the presence of seizure disorder which may reveal itself at a later date on any one of
the above measures. Neurologists in recognition of the problems of such situations consider specific
signs behavioral signs to be evidence of seizure disorder such as short periods of time with a clear
beginning and ending whereby ictal or interictal signs are evidenced. Ictal signs can be anything from
repeated behaviors such as sheet fumbling, sudden mood swings, bizarre behavior to the staring
discussed above. Movements at night, night terrors and various other phenomenon can be seen as
evidence of the clinical signs of seizure disorder. Clinically The introduction of medical management
usually will bring relief from such symptoms. Key issues according to various neurologist are that the
signs are brief in duration and not long lasting yet represent a clear period of time. The epilepsy society
defines such symptoms as:

The effects of frontal deficits, diminished frontal functioning
The presence of frontal deficits means that the largest area of the brain, the director, the president, the
supervisory system and overseer of the brain is not functioning properly. The presence of diminished
functioning in this brain area can create a variety of selective attention deficits, integration problems,
rigidity and a lack of flexibility in the thinking processes.

    1. The relative absence of an error correction system minimizes the ability to learn from one's
    2. Those with frontal deficits tend to perseverate, becoming stuck in a particular thought or idea or
        routinized method of doing some type of task.
    3. The presence of selective attention deficits creates a vulnerability to distractibility that is beyond
        what would normally be seen with a disorder such as A.D.D. It is in the presence of frontal or
        selective attention deficits that one thought actually replaces another thought, which then literally
        ceases to exist. For example when distractibility is present we can move from one uncompleted
        task to another, temporarily forgetting the task that we were working on, although at a later time
        or date we will all of a sudden recall what task we did not complete. When distractibility occurs as
        a result of selective attention deficits, the task is permanently forgotten. Selective attention
        problems seen with frontal deficits means that the brain cannot gate out some stimuli and
        selectively attend to the chosen stimuli. The brain tends to select all of the information, it is like
        pulling down the entire computer menu and then becoming overwhelmed by the vast influx of
        data. When a child has selective attention deficits it is as if everything is novel and interesting.
        They become mesmerized by each new thing that they see, they walk into a mall, their face lights
        up and they proceed to wander from one new sight to another being just as delighted and excited
        with each new stimuli. They cannot sustain attention for any period of time as the brain selects
        another stimuli to attend to, it is as if the channel clicker has gone wild, clicking one continuous
        channel after another in an endless array of stimuli. In testing one six year old boy, he was in the
        midst of a task, when he looked out the window and said, "Wow". When I looked out the same
        window to see what had intrigued him, there was nothing there and it dawned on me that he saw
        everything while I saw nothing. In selecting all of the stimuli to attend to, these brain injured
        children see everything, however if you ask them what they see, they will say nothing, because
        attending to everything is to become so overwhelmed with information that they cannot
        differentiate what they have seen.

In becoming distracted on a continuous basis, it is not surprising that new learning would become
infiltrated with intrusions, information that is unrelated and does not belong. The brain injured child thinks
something and maintains that someone else said it. The brain injured child who is learning a fact in
history, in studying a similar time period in English begins to confuse the concepts presented in each
class. These children have absolutely no idea that their learning is incorrect and those teaching them
would never be able to conceptualize what it is that they may have paired together to arrive at the
conclusions that can appear so bizarre, making little sense and highly idiosyncratic. The tendency of
diminished frontal processes to result in perseveration presents the opportunity for erroneous and
incorrect learning to become forever inundated in the child's repertoire of information. When one
considers that such erroneous information becomes the learning to determine acceptance or rejection of
further learning, the enormous impact of pediatric brain injury becomes evident.

Learning is often aberrant and idiosyncratic to the situation and internal thought process

In working with the brain injured population for twenty years, I continually see this type of incorrect or
aberrant learning. The child who suffers an injury either prior to or during the building block grades is
continually placed in the position of having to continually learn new information, while attempting to
maintain the pace of his or her non-injured peers. The child is in the position of continually attempting to
make up lost learning, while attempting to learn new information that is presented in a fairly rapid manner,
during these building block grades. The learning acquired by the child in the classroom becomes the
necessary information to be used for learning the next day and so on. The brain injured child can become
highly frustrated, laboring under this barrage of information, experiencing the realization that they are
unable to learn in the same manner, pace and degree, as they could, pre-injury. These children begin to
develop symptoms of depression and dangerously low self-esteem as they feel increasingly different from
their age peers.

One young man who had suffered extensive injuries throughout his life, and was then the victim of
substantial electrical injury, was so devastated by his lack of skills that his only method of attaining some
degree of self-esteem was to continue to perform various jumps with his skate board or specially
designed bicycle. Fashioning himself as an evil knieval, he was devoted to a variety of sports involving
jumping and hurdling over some type of object. He found that he could only maintain his position with his
peers by remaining on the cutting edge of sports, developing the reputation of the only one with the
courage to attempt the impossible. Although concerned about further brain injury, he admitted that he
truly did not care, his life had become so intolerable that it did not matter if one of these days he did not
survive the jump with his board or bike.

Those children who are gifted or superior in intellectual potential tend to have the most difficult time
adapting to such changes. They will tend to reference themselves as stupid, continually making self-
derogatory comments regarding their inability to perform a given task. The brain injury child rather than
recovering from the injury, becomes increasingly fragile and vulnerable emotionally over time.

Example: Abnormal language development
A child who was injured at the age of 3 years is evaluated periodically up until the age of 13 years. Over
the ten year span the effects of this aberrant learning, the pairing of various items of information that were
in fact unrelated, become increasingly more apparent.

       In response to being questioned as to the definition of the word, boast this child at the age of
        eight years, responded, sword and the stone.
       He repeated this definition when assessed at the age of ten years and again when assessed at
        twelve years.
       When assessed by myself at the age of twelve years, I asked him why he thought this and he
        replied that he had been watching the movie, The Sword and the Stone, and the young man had
        been called boastful when he pulled the sword out of the stone.

The above type of learning that is clearly erroneous, often seen with diminished executive reasoning,
supervisory system, frontal functioning.

Emotional changes: lability, continual mood shift and overall increased vulnerability and fragility

The presence of diminished frontal processes can often result in the child becoming increasingly
emotional and unable to control their emotional state resulting in their being mis-labeled as oppositional
and impulsive. These children can become overly aggressive and at times literally change in their
disposition from one moment to the next without rhyme or reason. While maintaining this hard core shell
the pediatric head injured population can become highly vulnerable and fragile internally, unable to
differentiate reality from their own internal irrational thoughts and appearing quite suspicious and paranoid
as a result. They are highly emotional, reactive to everyone and everything in their environment. The
people around them become rather wary and apprehensive waiting for that surprise moment when the
child becomes irrational, nasty and aggressive. As the sun goes down, Sundowner's Syndrome, things
become worse. I literally watched one child turn from this well mannered, suit-jacketed person to the
shining as nightfall occurred.

There are periods of time filled with a lack of orientation and clearly inappropriate behavior that the child
never quite recalls totally, which can be seen as a form of seizure activity. Peer relationships become
highly detrimental and often the child is either ostracized, avoided or ignored, due to their periodic bizarre
behavior. The isolation of their peers only promotes further isolation and increased loss of reality for the
head injured child who is progressively becoming worse than they were immediately following the injury.
Deficits that were not present at the age of 2 to 3 years become clearly apparent at the age of 10 to 12
years. The testing battery that is not extensive or the inexperienced clinician that does not fully
understand the above principles will tend to rule out the presence of injury and perform a grave disservice
to the head injured child.

Testing the child in their home town provides a wealth of information to the pediatric
neuropsychologist, reducing the stress and trauma to the brain injured child

This vulnerable, emotionally fragile child, is the child that experts ask to travel, at times, rather long
distances for their evaluation. The continual traveling of this highly vulnerable child eventually produces
either initial signs of post traumatic stress disorder and/or exacerbates the trauma already present from
the head injury. Further, in the testing situation, these children, who at times have traveled half way
across the country, are often very quiet. They have to be prompted to gain full credit for verbal response
test items. While they complete all of the tasks asked of them, assuming that there has been a valid
evaluation, the pediatric neuropsychologist still remains unaware of the full impact of deficits from the
injury upon their life.

Recently, I have found such a tremendous difference in the evaluation that I complete when a child
travels to my office versus when I go to their home town, that I remain convinced as to the efficacy of
such an approach. By the time that the evaluation process, which takes approximately three days to
complete, is over, I feel as if I truly know and understand the child. How often do parents spend two days,
24 hours, of uninterrupted time with their child in a setting where the child is their primary focus? The
richness of such an experience, in terms of truly understanding how the child thinks, and who they are, as
well as the full impact of the injury upon their everyday life, renders this process invaluable.

A wealth of information is obtained in meeting the teachers directly, in talking with the parents face to
face, and observing the child in their natural environment. In the testing situation, I have found
significantly reduced anxiety and depression when seeing the child in their hone area versus my office

Those involved with pediatric head injury and litigation are becoming increasingly aware of the trauma
induced when parents travel with their child all over the country to participate in the various assessments
as litigation proceeds. The court case is pursued, however too often, to the demise of the child.

Lack of available test measures created solely for the pediatric population
The absence of measures specifically designed for children or the use of measures that are not designed
to measure brain impairment further complicates the picture. Many of the measures employed to evaluate
pediatric head injury are educational measures or measures designed to assess learning disability,
intelligence level, and not necessarily injury to the brain. While such measures can be employed to
assess deficits, they need to be carefully explained from a qualitative standpoint as well as a quantitative
perspective. This means that simply providing the score of such a measure does not address the issue of
injury to the brain.

The need for several measures to assess the same function
Language deficits require specific assessment using several input (receptive) and output expressive
vocabulary measures. The necessity of several different testing instruments, measuring the same type of
function, such as language, becomes critical given the inherent differences between test measures. A
measure of expressive vocabulary can be highly discrepant from another measure of expressive
vocabulary. Some children perform better on measures assessing a more formal type of language, such
as that learned within the academic setting, versus words typically used in the family environment. A child
may perform better on one measure versus another, depending upon the type of language being
assessed. Language deficits in the pediatric head injured population are qualitatively specific reflecting
the aberrant learning patterns.

Ruling out test variables that may compromise test findings:

Pre-morbid A.D.D.
Testing variables of motivation and pre-morbid causal factors of A.D.D. are promoted by defense experts
to dispel findings of either their own and/or previous assessment.

There is a pattern that I have seen over the last 15 years which clearly identifies the presence of pre-
morbid A.D.D. and which is separate and distinct from the pattern of brain injury. The older the child the
easier it becomes to separate these issues. Children who are brain injured tend to appear with attentional
deficits given the impact to selective attention, frontal processes.

Motivational Issues
Low frustration tolerance minimizes performance as children give up easily when they could have
attained a better performance had they remained with the task just for a short time longer. Head injury
can be confused with symptoms of developmental disorders such as ADD attention deficit disorder,
learning disability or Tourette's Disorder. Childhood depression can be manifested as anger and defiance
and easily misread as such. Impulsivity can be assumed to be behavioral, rather than reactive to a task
the child has already anticipated they will fail at. The tendency too often is to see the child as defiant and
oppositional, rather than reactive to specific types of tasks, which tend to elucidate their deficits.

Mis-assumptions based upon a lack of knowledge of the child's method of compensation and test
response patterns

Unless the pediatric neuropsychologist spends a sufficient amount of time with the child, to learn their
response patterns and methods of compensation, observed over a variety of test measures, they will tend
to make assumptions that have a greater likelihood of being incorrect. It is only after spending time with
the child, watching their reactions to various tasks and by providing a sufficient amount of assessment to
determine impairment patterns, can the evaluator arrive at valid, scientific assumptions regarding the
degree and depth of the child's injury.

Case in point: One evaluator saw a child as anxious, worried about her performance, becoming
perfectionist and compulsive at various times. Defiant behavior or silliness was seen as a method of
compensation, diversion and a way to escape from the depression that naturally results when she feels
that failure is imminent. Another evaluator in assessing the same child saw the silliness and defiance as
that of an overpowered child whom the family had catered to and chastised those professionals involved
with the child as contributing to her misinformed belief of the presence of deficits and head injury.

How is it that two members of the same field can view a child so differently and how does one determine
who is correct?
The need and demand for scientific methodology, ruling in and ruling out various hypotheses
based upon decision tree type of analysis

The courts are employing the requirement of more scientific methodology for evaluation to attempt to
resolve this issue. However even implementing such requirements may still leave the jury questioning
which expert is more believable.

Getting to know the brain injured child-the pediatric neuropsychologist who talks to teachers,
parents, extended family members, family friends and significant individuals significantly
increases their understanding of the effects of the brain injury upon the child's functioning in their
home and school environment, while dispelling the accusation of being a hired gun.

Too often, forensic neuropsychologists, as the attorney retained experts in a litigation case are accused
of being hired guns. They are seen as not caring about the child, only about earning a living and proving
themselves correct. When an expert takes the time to fly to the home town of the child, to spend several
days with that child, getting to know the child, completing all of the testing themselves without the use of a
technician, that expert will be better equipped to dispel such an allegation. The pediatric
neuropsychologist who completes their own testing becomes more familiar with the child, has a greater
understanding of the child's patterns and overall functioning. It is common knowledge that first hand
observation is significantly more revealing than reading the notes of a technician.

The pediatric neuropsychologist is in the unique position of having information about the brain injured
child that no other professional will have. This information can become very powerful in helping the child
when shared with other professionals who are involved in the child's care or education. The pediatric
neuropsychologist can interface with various treaters of the child, and in a team approach work with the
school, physician and family to arrive at conclusions regarding the child's needs. Face to face contact
cannot be replaced by a telephone interview and I am continually amazed by the results that can be
gained when traveling to the child's home area and meeting with all of these professionals and significant
individuals. Imagine everyone who interface with the child on a daily basis, all being in agreement as to a
particular plan of action and method to address everyday issues.

The last evaluation I completed I was able to host a school meeting attended by the child's teaching staff
as well as the special education staff. The agenda was to discuss the child's deficits and for the
professionals to jointly concur with various interventions which were then written into a formalized IEPC
agreement. This means that the teaching staff as well as the staff providing special services such as
speech and language training, have an operating set of rules and procedures to cope with the behavioral
outbursts, the periods of refusal to cooperate and methods to learn, which uniquely fit the child's assets
as well as deficit areas.

During this same evaluation, I had the opportunity to resolve some conflictual issues between the two
divorced parents and to arrange mutually agreed upon visitation that would bring relief to one parent and
more involvement to the non-custodial parent. The pediatric neuropsychologist has a unique set of
characteristics and trained abilities to provide intervention as well as evaluation.

Similarly, the pediatric neuropsychologist talks to the parents about what they can do in the home
environment, summarizing the deficit areas of the child and what the parents may be able to
hypothetically expect as a result of such deficit areas in the future. In this respect, as an expert, the
neuropsychologist is able to present their information in such a manner that they are discussing the
needs of the child rather than attempting to convince the jury in one direction or another.

Is the expert operating in the best interests of the child?

The expert who goes against overwhelming evidence of brain damage subsequent to the brain injury,
including post-trauma documented seizure and radiological findings, leaves themselves at risk to appear
as only concerned about litigation rather than the brain injured child. The expert who spends their time
disputing the results of other experts rather than presenting their own findings may not be acting in the
best interests of the child.

Many neuropsychologists maintain that the role of the neuropsychologist is to communicate their findings
to the parents and the child's teachers, discussing significant findings from a more general perspective
designed to educate these individuals about the needs of the brain injured child. Personally, when it is
possible, I have found wonderful results that emerge from taking the time to talk with parents and
teachers. When parents and teachers understand and comprehend the specific problems of the brain
injured child, they are able to teach coping mechanisms and to provide helpful interventions. At times, just
understanding why their child acts a certain way is helpful to cope with the various problems that emerge.
Often these children have voices that are overly loud, they talk constantly and interrupt any of the
conversations which occur. They demand continual attention and can become rather embarrassing
behaviorally when out in public. In view of the high degree of emotionality that exists with head injury,
parents tend to feel that they are fighting a war they do not fully understand, resulting in feelings of
hopelessness and helplessness.

Biased testimony

If the expert has spent sufficient time with the child to understand their patterns, their deficit areas, their
strengths and weaknesses, how this affects them in school, in the family system, with their friends and
home environment, then they can speak easily as to the effects of the head injury. The expert should be
able to assess the child's strengths and weaknesses as if they were on either side of the playing field, the
defendant or the plaintiff. Ideally the expert would represent the needs of the child, irregardless of any
type of ongoing litigation.

The expert who works hard to rule out the various emotional variables of low frustration tolerance,
depression and anxiety, to spend the time addressing other possible diagnoses, ruling in and ruling out
for various reasons, would tend to present a more accurate assessment. When experts remain
entrenched in their belief systems, which is a by-product of their experiences and prior learning, there is
the tendency to bias testing based upon their idiosyncratic conclusions. Spending a considerable amount
of time with the child, deliberately taking the time to rule in and rule out various diagnostic hypotheses
provides a method to address this bias. Extra steps such as repeating various measures over a
substantial period of time, utilizing a testing of the limits approach, provide some methods to address
discrepancies in the child's performance. Testing of the limits is an approach that can be completed once
the measure has been administered properly and often offers valuable information to rule out concerns
regarding extraneous variables and to ensure that the assessment is truly the best that the child has to
offer. The experience of this expert is that by providing a warm and caring environment, remaining alert to
changes in the child's testing behavior, the examiner can intervene and/or address various issues related
to extraneous testing variables such as hypoglycemia, fatigue, anxiety, depression and lack of motivation.

Testing can provide a positive experience for the child.

This examiner devotes considerable effort to provide a testing experience which is positive for the brain
injured child. In traveling to the child]s home town, the examiner is affording the opportunity to gain a
tremendous amount of information about the child. In spending elongated time together the examiner and
child often develop a connection that can be quite beneficial to the child, possible increasing low self-
esteem. Testing tends to denote negative connotations and this point was confirmed during a recent
conversation with a private school principal, who was quite surprised by the child's excitement regarding
their upcoming testing situation. Testing does not always have to be negative, nor does it have to appear
as work.

One of the benefits of having the expert come to the home town of the child and spend a number of days
with the child is the attention the child receives as a result of this experience. How many children have the
total undivided attention of an adult for a lengthy period of time? Rather than being traumatic, the
evaluation process has the potential to provide the child with an experience that they will never forget, a
time when they were of the utmost importance. During the evaluation, these children feel recognized, they
feel special, which is expressed via the sadness, that is present when the testing is completed, and the
expert has to leave.

Example: I became more aware of this on my most recent evaluation when the last day of testing as the
child became aware of my packed bags, he became increasingly sad and forlorn. When I indicated that I
would be in contact with him, he responded, probably not, "nothing good remains for me". He indicated
that he had enjoyed the time spent with the examiner, he had not seen the time spent as testing, although
we had been quite busy completing a large number of measures.

Testing in the office setting vs. testing in the child's home area.

There are times that a tremendous difference occurs when the child is seen outside of the clinic or office
setting which became apparent in the continuing evaluation of one particular child who I first tested when
she was four years of age. The first time that I evaluated her was in the office setting and when I saw her
two years later in her home town, there was a distinct difference in her ability to relate to me. Not
withstanding developmental changes, the time spent with her established a relationship, which has
continued to exist since that time. I was perceived as less of a stranger and consequently able to ask
questions about school, her feelings regarding her friends and family, and subsequently to learn more
about her perceptions of life. She was quite revealing in her spontaneous comments about noise and her
difficulty in the classroom when the other students become overly talkative. Overall, the process of
evaluating her in her home town provided the opportunity to learn more about her and to talk with her in
depth about the day to day effects of the brain injury. While maintaining the scientific quality of the
assessment process, ensuring the quietness of the room and minimal external distractions, this process
was enhanced with the gathering of additional data, that would only have been attained by traveling to her
home town.

The benefits of qualitatively assessing the child's test performance.

Observing the performance of several hundred children on any particular test measure, allows the
experienced clinician to formulate hypothetical conclusions regarding the child's deficit areas as well as
what the test actually measures. It is well known in the neuropsychological field that what a test is
supposed to assess and what that test measure actually assesses clinically can often be two different
entities. Tests that are supposed to be assessments of memory may actually provide better assessments
of frontal processes. There is an ongoing debate over various tests that are proposed as specific
measures of frontal functioning which when assessed clinically actually measure other brain areas.
Frontal processes in particular are best assessed across a variety of measures to determine the presence
or absence of specific patterns suggestive of deficits in the functioning of this all important supervisory
system. It is the experience of this examiner that average scoring does not mean the absence of brain
impairment and that qualitative assessment will reveal patterns of deficits that become more pronounced
with time, eventually resulting in impaired scoring. It is not uncommon for children who are bright to be
seen as not suffering from brain impairment. Scoring that is within above average or superior limits is
assumed to represent the absence of brain impairment when qualitative analysis will provide evidence of
patterns of impairment that do not emerge until years later as tasks become more complex and

The benefits of repeated evaluation on a yearly basis

The opportunity for the expert to conduct repeated testing over a period of years provides information that
becomes highly significant in tracking specific deficit patterns and in understanding the nature of pediatric
head injury. It was interesting to watch this one particular child whom I had examined several times prior
commencing at the age of four years. On each of the successive evaluations she remarked about the
tasks she was able to complete which had presented difficulty for her in years past. In this manner she
was able to track her own progress. She was provided with the concept of evaluation as a measure of her
growth while indicating those areas that still needed to grow, rather than viewing the testing as a measure
of whether she was smart or incompetent.

More often, however, these children feel quite hopeless about themselves and their future. It becomes
difficult for the children to see themselves performing better on one task only to experience difficulty on
another test areas that is new to them. There seems to be a pattern whereby the children gradually
resolve specific areas of difficulty with repeated evaluation however with the onset of a new test measure
the problems quickly reappear. It seems as if they are climbing up the mountain to reach the top only to
slide back down again requiring them to begin again. Successes are quickly replaced by failures. It was
particularly upsetting to this child when she was unable to perform a task, which she had excelled at the
year prior. Recognizing the difficulties of these children and working with those significant to the child to
provide information, which only a thorough neuropsychological evaluation may yield, is in the opinion of
this examiner, one of the most valuable assets a pediatric neuropsychologist has to offer.
Primary Issues of the Brain Injured
   Child Seen Clinically and in
                                 Barbara C. Fisher, Ph.D.
                      Fully Licensed Psychologist, Neuropsychologist

1. The child becomes highly aware of what they can and cannot do. They predict and anticipate
     success or failure based upon their awareness of their specific deficit areas. Often they are
     misdiagnosed as oppositional in their refusal to participate in a task they have assumed will result
     in failure.
2.   Brain injured children via the mechanisms involving the repercussions of brain injury may have
     emotional deficits as well as cognitive impairment. Often these children are emotionally
     vulnerable and sensitive, craving praise adulation while reacting in a rather extreme manner to
     any type of failure resulting in rather poor frustration tolerance. Poor frustration tolerance can
     prevent these children from putting forth the necessary time and effort to improve their functioning
     in deficit areas. Brain injured children, depending upon the impact of impairment and area of
     deficit, can become highly emotional which tends to undermine their ability to resolve conflicts
     particularly those involving their own issues. They personalize any failure, seeing failure as a
     measure of their stupidity and incompetence.
3.   Often brain injured children experience depression and heightened anxiety, becoming
     increasingly gloomy and negative regarding their future and/or ability to cope with the present.
     They become internally wounded and disappointed in themselves when deficit areas emerging
     from the brain injury prevent their ability to accomplish the goals they expect of themselves. They
     become angry and unhappy, depression fills the room as their quiet struggle continues.
4.   Brain injured children may take on the role of entertainer. They may identify themselves as
     incompetent to function autonomously and instead they become heavily reliant upon others for
     their care. Thus, they entertain to please others, becoming preoccupied with their ability to please
     others in the hopes that they will not be abandoned, lacking in their own resources.
5.   Sequelae associated with brain injury often leads to an increased emotional fragility and/or
     reactivity. The emotional functioning of the brain injured child can lead to additional psychiatric
     disorders, the most commonly seen tending to be anxiety, depression and post traumatic stress
6.   Continual sleep deprivation, if present, can become misinterpreted and often the brain injured
     child does not receive sufficient sleep resulting in constant complaints of fatigue and/or
     headaches, an increased emotional response, the tendency to appear overly dramatic, to seek
     the necessary approval from those significant, demonstrating hysteria and over-reactivity if
7.   Brain injured children who are pre-morbidly gifted are often described by teachers as intellectually
     average. The child mobilizes all of their potential to attempt to compensate for areas of brain
     impairment resulting in an overall repression of functioning or regression towards the mean.
8.   The building block grades are nightmarish in the demands that information learned today will be
     used tomorrow and the reliance upon prior learning for new learning to occur. The brain injured
     child is continually caught in the vise like grip of trying to catch up what they have missed while
     missing new information that is given which is necessary to understand additional information and
     subsequent learning.
9. It is not uncommon for bizarre events to occur due to the misunderstanding or misperception of
      the brain injured child. Example: A brain injured 8 year old girl is participating in a class
      discussion. She raises her hand, however either forgets the question or the answer during the
      short period of time it takes for the teacher to respond to her raised hand. No understanding the
      directions of a particular homework task, she records two answers hoping that one will be right
      however unable to differentiate the correct answer.
10.   The siblings of the brain injured child tend to feel ignored and that their needs are inconsequential
      in comparison to their brain injured sister or brother. The brain injured child often feels
      responsible for changing the lifestyle of the family.
11.   Brain injured children can have memory problems as well as frontal deficits which prevent or
      seriously hamper the learning and application of any new learning. When frontal deficits are
      present there are problems with sequential learning such as riding a bike or tying a shoe.
      Learning that requires pure memorization can become quite difficult such as the memorizing of
      multiplication tables. Concepts of addition, subtraction, division can become confusing to the
      brain injured child who cannot see similarities between basic math principles. If the child has
      difficulty integrating information, the application and generalizability of learning becomes quite
      problematic for them.
12.   Frontal deficits of selective attention if present can create tremendous learning difficulties and the
      tendency to confuse information that is learned. Concepts are paired that do not belong together
      and idiosyncratic learning remains undetected while impeding new learning.
13.   The tendency to perseverate leaves the brain injured child hopelessly entwined in concepts that
      are incorrect and often do not make sense. The brain injured child can become rigidly attached to
      perceptions that are unfounded and often misguided leading to rather disastrous social
14.   Word finding deficits characteristic of diminished frontal processes, prevent the brain injured child
      from adequately expressing themselves. At times they think they actually expressed the thought
      that they subsequently lost while attempting the necessary word search to adequately verbalize
      what they were thinking. It is quite common for the entire thought to be forgotten while in process
      searching for the words for adequate verbal expression. Communication becomes a rather
      confusing endeavor for these children who are often ostracized from their peer group.
         Neuropsychological Issues for
               Children at Risk
                                    Barbara C. Fisher, Ph.D.
                         Fully Licensed Psychologist, Neuropsychologist

How do we know after a documented brain injury, nutritional deprivation, and any process
affecting the brain, that the child is actually fine and there are no long lasting effects?

      Pediatric brain injury can be deceptive.
      The child appears outwardly fine however there are subtle changes occurring that will have far
       reaching consequences in that child's life.
      When brain injury is not outwardly apparent, there may be subtle signs of impact to the brain that
       will substantially affect the child in later developmental years.
      The old theory that the younger the child, the more benign the impact of brain injury, and the
       greater the ability of the child to recover, is no longer being substantiated in the research.
      The use of Neuropsychological evaluation to identify various issues in the brain to isolate and/or
       target particular areas for the physician to explore.
      Seizure activity is often the overlooked phenomena occurring in pediatric injury and the process
       by which the brain continues to erode over time.

Seizure Activity: Associated Symptoms

      Panic attacks
      Blank staring
      Lack of memory
      Event and disorientation
      Described as periods of black or darkness
      Lost of moments of time
      Sleepwalking
      Thrashing in one's sleep
      Waking up tired as if sleep did not occur
      Drooling
      Drop attacks

Minor brain injury, which can typically result in the presence of post concussive symptoms (PCS)
occurs in approximately 50% of this population.

Post Concussive Syndrome/ mis-diagnosed as Conduct Disorder, Anxiety, ADHD, Oppositional
Defiant Disorder (ODD) can present the following common symptoms:

      easily fatigued
      balance-coordination difficulties
      noise sensitive
      heat sensitive
      touch sensitive
      whines a lot
      little noises
      once upset cannot get them back
      blank emotionless stare
      emotional lability
      emotional reaction over-reaction to situation
      easily upset
      stress increases all of the above
      sleep walking
      incontinence
      periodic movements at night during sleep
      tired when wake up in morning
      aggression out of nowhere (swearing, inappropriate behavior)
      panic out of nowhere (does not fit situation)
      continual headaches
      dizziness, nausea
      short term memory
      irritability
      distractibility
      OCD symptoms
      automatisms, repetitive movements
      slow thinking speed
      appetite decreases

PCS can occur years after the brain injury has occurred. PCS tends to be seen as the syndrome
resulting from the changes occurring within the brain following the brain injury and can
accompany the presence of seizure disorder.

Trauma associated with either the accident or the type of injury, as well as events occurring
subsequent to the injury, can create symptoms of Post Traumatic Stress Disorder (PTSD).

Post Traumatic Stress Disorder (PTSD) Symptoms

      symptoms of distractibility are increased
      flat, bland affect, little or no display of emotion
      hyper-alertness or hyper-vigilance
      sleeping difficulties: insomnia, nightmares, flashbacks, recall of the upsetting event
                          The Forgotten Child
                                     Barbara C. Fisher, Ph.D.
                          Fully Licensed Psychologist, Neuropsychologist

The Child of the Brain Injured Parent

In the world of brain injury, we tend to focus upon the injured party, whether that is the parent and/or the
child. We focus on the needs of the family member who has suffered the head injury and we expect the
remaining family members to understand why their needs are no longer being addressed and to
understand why they have been forgotten. We expect the family to be sympathetic and understanding, to
be accepting of the tremendous changes occurring in their lives and in their relationship with the family
member who has been injured. There is little or no time to grieve the loss of the injured family member or
to miss how they were before the accident. The almost immediate help/care-taking that becomes
necessary post-injury does not afford the other family members, a period of time, to grieve. We expect the
family to put forth the utmost in effort towards the care of the injured member and to remain content in
receiving little of the effort they have extended in return. The relationship that was once reciprocal has
been drastically altered and the inherent expectation is to simply move on, adjust, and adapt.

The struggle of the caregiver is being addressed to a greater degree in the brain injury research and
literature. Depression and stress are common symptoms measured and observed in the family members,
seen as significant of the struggle with the drastic changes the brain injury of either the spouse or child
has created. The research has focused primarily upon the effects upon the spouse of the brain injured.

Although there is also trauma when the sibling is the brain injured child, this article will focus on the
children of the brain-injured parent who tend to remain forgotten and where the greatest psychological
impact can occur. Suffice it to say that when a sibling is injured the child will tend to feel unimportant and
forgotten, raised with a "sick child" taking a backseat to the brain injured child's needs. Issues generally
arise relating to feelings of being insignificant which can result in the child becoming more demanding in
their relationships outside of the family unit or more giving, remaining in a subsidiary role in their peer

We do not tend to consider the impact of the parent's brain injury upon the child. The injury of a parent
alters their life forever and often can create far reaching consequences, affecting their emotional and
cognitive thinking/learning ability. The focus herein will be upon the child whose parent suffers a brain

Several factors emerge as prominent in determining the impact upon those children whose parent has
suffered a brain injury, based upon the stages depicted in child development as well as principles of

       The developmental stage the child was at when the brain injury occurred.
       The impact of brain injury of a parent versus a sibling
       The impact of brain injury to the child's identification figure and/or maternal object versus their
        non-identification figure.
       The child's response to the injury of the parent they were closest to, versus the parent with which
        they had less attachment prior to injury.
       The degree to which their life has been impacted by the brain injury.
The developmental age of the child determines the level of coping mechanisms and the quality of
cognitive thought processes, which they have available to process the change and ultimately the loss of
the parent they had known prior to the injury. Often, depression is present as the result of the "perceived
loss". "Perceived loss" is referenced as the loss the child feels although the parent or sibling actually
remains alive. It is the loss of what that individual was before the injury versus how they are after the
injury that becomes so painful for these children.

The far-reaching consequences for the infant or toddler who in the midst of attachment, suffers the
perceived loss of a parent, can create enormous difficulty in developing later attachments. The infant or
toddler who has lost the parent they knew during this all important stage of trust development creates a
long lasting sense of mis-trust for all future attachments. The infant or toddler who is surprised by the
sudden change, thus perceived loss of their parent, tends to predict and anticipate future losses that are
similar. The surprise of this event contributes to its impact and such children find solace in avoiding close
relationships as opposed to opening themselves for another major disappointment and/or loss. When the
parental loss is the primary caregiver, the impact is that much greater. It is during these early years of
development that when the parent is gone from the home for a period of time, due to either
hospitalization, rehabilitation or the continual doctor appointments, that the child assumes that they are
not returning and they automatically begin a process of mourning.

The elementary school child may have difficulty processing the changes that occurred in their parent
following the injury, often feeling overly responsible for the injury. Developmental issues common for this
particular age range; magical thinking (the belief in things happening for no other reason than that of
magic) interacts with egocentrism (the concept that everything revolves around the child-they see
themselves as the center of their universe) to result in the child feeling guilty and to blame in some way
for the brain injury of their parent. If the child fought with the parent earlier that day, if the child was
reprimanded or disappointed the parent in some way (especially if within close time proximity to the injury)
the elementary school child tends to attribute blame to themselves and their behavior becomes the
reason for the brain injury. Consequently feelings of depression following the injury are the result of these
issues in addition to the perceived loss of the parent. The child either becomes overly pleasing towards
the parent, often at the expense of their own needs, growing up far more quickly as they become the little
adult, taking over the household duties. The child who becomes pleasing tends to feel guilty (generally
due to perceived blame) and/or they are in fear of losing the parent. Instead of becoming overly pleasing,
the child can present with the opposite reaction, becoming overly oppositional and defiant. Both of these
reactions can stem from the guilt felt by the child and/or assumptions that they somehow had a causal
role in the parent's injury.

The child who is in the midst of adolescence will tend to feel pulled between their own needs, the needs
of their peers and the need to assume the role of adult/parent, to take care of the injured parent. Often
adolescents become conflicted and torn between the needs of their parent/or family versus their own
more selfish wants or desires. Adolescence, is usually the time for self expression, whereby the child
breaks free from the restraint of parental beliefs, to establish his or her needs as well as a more
independent lifestyle and/or connection with their peer group, that supersedes the family connection.
When allowed to progress through this highly emotional reactive state, the rebellious adolescent who
during this time period may appear as if they have totally abandoned the parental values taught from
childhood years, eventually returns to the family unit and adopts those very values they rebelled against
in years past. The adolescent acquires a new maturity having experienced new situations, they remain
content to reconnect and if attached, usually re-establish themselves very close to the value system
espoused by their parents.

However if prevented from this time period of self-wonder, self-indulgence and self-actualization in terms
of trialing new experiences, they forever feel robbed of this precious opportunity and blame the family or
injured parent for their additional loss of freedom. If the adolescent does not process such feelings, they
can remain repressed emotionally into adulthood. Unresolved issues in adolescence do not tend to
become resolved in adulthood. Repressed feelings and emotions can remain with the individual as a life
long reaction affecting their ability to connect, to relate to others empathetically, and to form emotional

The child's age level and developmental process can determine their perception of the parent's injury. For
instance if the child is in the stage of cognitive thinking that is concrete, they will tend to see the parent's
injury as irreversible and permanent, thus prompting a process of loss. If the child has not developed the
concept of object permanence, they will see lengthy hospitalizations as evidence that the parent is
permanently lost to them and not apt to return. When the parent does finally return to the home, the child
reacts as if they have seen a ghost and they have difficulty recovering from this experience. However the
child who is in the stage of object permanence realizes that the parent is returning and they are able to
process the fact that although different, their parent actually has returned.

The presence of the brain injury in a parent may arrest the child's resolution of typical emotional
conflictual issues:

       The development of trust for significant people versus mis-trust, which can result in
        suspiciousness in their interpersonal relationships.
       The development of a sense of autonomy, a sense of separateness and individuality versus
        feeling shameful and doubting one's ability or capability.
       The ability to initiate a course of action, to set goals and to have specific plans versus feeling
        incompetent and guilty, highly dependent and unable to separate from the family system.
       The ability to positively interact with individuals outside of the family system, in the neighborhood
        and school setting to develop attachments and positive relationships.
       The development of an individual identity, versus identify confusion and the lack of specific
        direction in one's life.
       The establishment of intimacy versus isolation and a lack of closeness in one's interpersonal
        relationships that persists throughout adulthood and into the aging process.

The parent who returns to the home post-injury can often be very different from the parent the child knew
before the injury. The greater the change in the parent's thinking and emotional, behavioral responses,
the more prone the child will be to view that parent as being substantially different post-injury. The child
tends to feel as if a death has actually occurred, becoming acutely aware of all of the changes that are
present in their parent. Despite their best efforts, they will tend to make continual comparisons of their
parent pre and post-injury. Sometimes this situation is actually worse than if the parent has actually died,
which would allow the child to mourn. If the parent is very different and so different that they can no
longer connect with the child, the child is left without a parent, and yet unable to mourn the loss of the
parent they no longer have.

The more developed cognitively and intellectually the child is at the time of injury, the greater wherewithal
that they have available to them to process this traumatic event. Generally speaking, it is obvious that the
brain injury of a parent is going to have more of an impact than that of a sibling. The dynamics involved in
the brain injury of a parent would tend to trigger more issues of stress, as well as symptoms of anxiety
and depression due to the perceived and/or real loss of the caretaker in their life, whom they counted
upon in the past for safety and the maintenance of their needs. The injury to a sibling while changing the
family system and taking more time from the caretaker would not have the same effects as injury to the
parental figure. It is well known that children are far more resilient than we could ever imagine and they
can survive all kinds of things, however safety is a primary factor and when their parental figure is
threatened their life takes on an unsafe quality.

Thus, it is not surprising to find symptoms of post traumatic stress disorder (PTSD) in the children of the
brain injured parent. The definition of PTSD is the occurrence of an event that was not expected nor
foreseen which has an enormous effect upon the child's life and which they are powerless to change.
Factor in the injury occurring to the parent whom the child is closest to and/or whom the child looks to
emulate and protect him or her, i.e., the identification figure, and this would logically represent the more
difficult situation for the child to adjust to and eventually recover from. It has been clearly established that
even mild brain injury drastically reduces the individual's ability to communicate and socially interact with
those around them, to make the necessary adequate decisions in their everyday lives and in essence to
function in a manner commensurate with their ability pre-injury.

Consequently when the primary caretaker, the parent the child looks to for safety in their life, and/or the
parent whom the child counts upon get their needs met, suffers a brain injury, this is definitely going to
provoke some type of reaction in the child. It can be predicted that the closer the child is to the parent, the
greater their difficulty in adjusting and the more the effect that the parent's brain injury will have upon
them. Similarly, the move severe the injury, the more impaired the parent's functioning becomes, also
increases the likelihood of greater changes which the child will have to encounter and ultimately cope

Symptoms of PTSD emanate from the impact upon the HPA (hypothalamic pituitary adrenal axis) are
related to changes within the adrenaline system and the influx of adrenaline as in the flight fight response,
and the impact upon the catecholamine system (dopamine, serotonin and norepinephrine) and are as

       Recurring dreams and flashbacks
       Prominent sleep disturbances, insomnia and nightmares
       A general lack of emotional responsiveness
       Increased arousal characterized by hyperviliglance
       Irritability
       Hypoglycemia
       Increased anxiety
       Physiological vulnerability and lowered immune system response
       Increase in allergies or asthma
       Hyper-reactivity
       Exaggerated startle response
       Flattened emotionality
       Increased fatigue and report of feeling tired
       Decreased attention and concentration.
       Diminished expressive vocabulary output, talking less
              o Events that you would anticipate that would be problematic are easily taken in stride.
              o oDissociative symptoms, intrusive memories, feelings of depersonalization, fear and
                   helplessness often emerge.
              o oAnger, depression, and aggressiveness, are misunderstood and often attributed to
              o other factors and/or diagnoses.

There are many facets to identifying trauma or depression in these forgotten children and there are a
series of psychological and neuropsychological tests, which address and measure symptoms of Post
Traumatic Stress Disorder, as well as symptoms of anxiety and depression. Checks and balances, the
utilization of a number of measures which are standardized and methodological considerations for test
selection based upon current research will fulfill the conditions for court acceptance under Daubert. There
is definitely a gap in the care of the children who have siblings or parents suffering from a brain injury.
These children have been forgotten. They remain wounded, undiagnosed and misunderstood.
Subsequent school difficulties and changes in social and peer relationships remain unidentified and
unconnected to parental brain injury. These children remain undetected, undiagnosed and uncared for.
Although their lives could have been permanently altered by the brain injury to a member of their family,
no one is aware of this and as a result, these children do not receive the help they need to resolve such
losses, thus remaining the forgotten children.
          First Guidelines for Treatment of
          Pediatric Traumatic Brain Injury
June 19, 2003 — The same group that created guidelines for treating adults with traumatic brain
injury (TBI) have created the first guidelines for the treatment of pediatric TBI. In most areas,
the panel found insufficient evidence to establish standards of care. But wherever possible, the
panel provided guidelines and/or options for care providers to consider.

The "Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants,
Children, and Adolescents" were published on June 6 as special supplements to Pediatric
Critical Care Medicine, Critical Care Medicine and the Journal of Trauma, ensuring a
multidisciplinary audience of more than 30,000 specialty providers.

"There's an enormous amount of information out there about what works and what doesn't in
treating pediatric brain injury," principal investigator Randy Chesnut, MD, an associate professor
of neurological surgery at Oregon Health & Science University (OSHU), says in a news release.
"We not only want to publish guidelines that bring together all the best practices, we want to
remove obstacles to putting those guidelines to work saving lives."

In 1997, Dr. Chesnut led another multidisciplinary team that published the first comprehensive
guidelines for treating adult brain injury. In Poland, Hungary, the Czech Republic, and other
countries with socialized healthcare systems, implementing the guidelines halved adult mortality
from TBI.

"It was natural for us to look next at developing pediatric guidelines," says Dr. Chesnut. "But it's
not as easy as just applying the adult guidelines to children. Children are still growing and there
are some important developmental issues to which you have to pay attention in treating brain

According to the Brain Injury Association of America, more than 1 million children in the U.S.
sustain brain injuries each year, of whom 250,000 are admitted to hospitals, 7,000 die, and
30,000 are permanently disabled.

The pediatric guidelines panel was made up of experts in neurosurgery, emergency medicine,
and pediatrics from the Evidence-Based Practice Center at OHSU, the University of Pittsburgh,
the University of Michigan, and Emory University. Beginning in March 2000, they authored the
guidelines after reviewing more than 700 peer-reviewed journal articles and thousands of

Their objective was to create uniform guidelines for optimal treatment of brain injuries in
children, so that treatment would not vary based on the country where the injury occurred; means
of transport to the hospital; facilities, equipment and staff of the treating hospital; or other
variables that could affect outcome.
"For parents sitting in ED waiting rooms, this means that if that hospital is following the new
guidelines, the physicians will be using the best evidence to treat their child as opposed to
looking at the adult guidelines and trying to translate that to treat a child or relying only on their
own clinical experience," says investigator Nancy Carney, PhD, also from OSHU.

Although the adult guidelines cover 14 topic areas, the pediatric guidelines cover 18 topics.
Three phases of treatment identified as priorities for guidelines development in pediatric TBI
were acute medical management, rehabilitation, and re-entry to school, family, and community.

Data are thought to be insufficient regarding seizure prophylaxis, so anticonvulsant therapy is not
recommended to prevent late posttraumatic seizures in children. The panel acknowledged that
children with severe TBI were more likely to survive if treated in pediatric trauma centers or in
adult centers specially equipped to handle pediatric patients, but they felt that the evidence was
insufficient for specific guidelines regarding trauma centers.

Other topics covered in the guidelines include airway management during transport to the
hospital, intracranial pressure monitoring, surgical options, and nutrition.

A spinoff of this evidence-based review was defining research priorities in treatment of pediatric
TBI. Based on findings from ongoing and future research in these areas, the panel may be able to
improve the guidelines as additional treatment options are proven to be effective.

Professional societies that endorse these guidelines include the American Association for the
Surgery of Trauma, International Society for Pediatric Neurosurgery, World Federation of
Pediatric Intensive and Critical Care Societies, Society of Critical Care Medicine, Child
Neurology Society, and International Trauma Anesthesia and Critical Care Society.

"All this speaks to the widespread recognition of the importance of this work," Dr. Carney says.
"People are willing to cross boundaries in order to accomplish the widest possible dissemination
of these guidelines."

Continued efforts by the panel will be to monitor implementation and outcomes of the guidelines
in the U.S. and abroad, with updates as needed. The U.S. team will collaborate with Cuba's
Ministry of Public Health and the Argentine Society for Intensive Therapy to observe outcomes
in different healthcare systems.

In Cuba, a healthcare system that is both socialized and relatively sophisticated will allow
outcomes research before and after national adoption of the guidelines. "It's a great opportunity
to conduct a well-controlled, population-based implementation study that could not be carried
out in the U.S.," Dr. Carney says.

Because Argentina has limited hospital technology and posthospital rehabilitation, the focus will
be on how to best implement the guidelines in a less developed healthcare system.

"In Argentina, critical care physicians are willing to help implement the guidelines nationwide,"
Dr. Chesnut says. "But many hospitals there don't have equipment called for in the guidelines,
such as intracranial pressure monitors or CT scanners." Planned modifications of the guidelines
will therefore be based on locally available technology and expertise and greater involvement of
family members in rehabilitation.

"Here in the U.S., the biggest obstacle to implementation isn't technology, it's that our healthcare
delivery system is so scattered," Dr. Chestnut concludes.

Synthes Corporation, the International Brain Injury Association, and two members of the
National Institutes of Health helped support this project.

A related systematic review reported in the June 11 issue of The Journal of the American
Medical Association finds that hypothermia may be beneficial for adults with traumatic brain
injury. However, despite this, the researchers conclude that there is still insufficient evidence to
recommend therapeutic hypothermia in traumatic brain injury.

Crit Care Med. 2003;31:suppl

Clinical Context

According to a review article published in the December 1999 issue of Pediatrics by a
committee from the American Association of Pediatrics and the American Academy of Family
Physicians, head trauma is a common accident in childhood. Such accidents account for 600,000
emergency room visits per year in the U.S. Most cases of pediatric head trauma do not require
intervention or result in negative sequelae. However, in developed countries, according to a
report in the March 1988 issue of the Journal of Neurosurgery, brain injury remains one of the
most common causes of death and disability in childhood.

Despite the high prevalence of traumatic brain injury in the pediatric population, there are no
evidence-based guidelines for the care of victims of this particular trauma. This is in part due to
the fact that some treatments, such as mannitol for lowering intracranial pressure, were being
used extensively prior to rigorous scientific inquiry. Thus, such measures are commonly
accepted as being valid and beneficial, but they are difficult to recommend as evidence-based.
Another issue complicating the development of guidelines for pediatric traumatic brain injury are
the varying methods and outcomes of research in this area. The authors of these guidelines
overcame these shortcomings by reviewing more than 700 peer-reviewed articles to arrive at
their conclusions.

Study Highlights

      Pediatric patients with traumatic brain injury should be treated in a pediatric trauma
       center or, failing that, a level I or II adult trauma center with pediatric trauma services.
       Transfers should be made as efficiently as possible -- a previous treatment protocol for
       adult head traumas resulted in increased transfer times in one state.
      Hypoxia must be treated appropriately; however, there is no evidence to support
       endotracheal intubation vs. bag-mask ventilation during transfer to the hospital.
      Prophylactic treatment with mannitol or mild hyperventilation is usually unnecessary but
       should be used in patients with evidence of cerebral herniation or worsening neurologic
      Intracranial pressure monitoring is indicated for children with a Glasgow coma score of
       less than 8, but it may also be employed for children in whom serial neurologic
       examination is not feasible.
      Treatment for increased intracranial pressure should be initiated when the pressure rises
       more than 20-25 mm Hg.
      The sensitivity of ventricular catheters, external gauge transducers, or catheter tip
       pressure transducers in monitoring intracranial pressure appears equal. Subarachnoid,
       subdural, epidural, and externally placed monitors are less accurate.
      Cerebral perfusion pressure should be maintained at more than 40 mm Hg. Further
       research is needed to determine an optimal cerebral perfusion pressure range.
      The routine use of sedation and neuromuscular blockade in severe pediatric traumatic
       brain injury is not supported by any scientific evidence.
      Cerebrospinal fluid drainage via ventriculostomy is a first-line option for refractory
       elevated intracranial pressure; lumbar drainage may be added in patients with open
       cisterns on imaging and without major mass lesions or midline shift.
      Mannitol or hypertonic saline are both acceptable agents for lowering intracranial
      Hyperventilation should only be used as a second-line method to reduce refractory
       intracranial pressure. In this setting, the PaCO2 should be kept at <30 mm Hg.
      High-dose barbiturates may also be employed in the treatment of refractory increased
       intracranial pressure. Patients receiving this therapy require extremely close monitoring
       for hypotension.
      Hyperthermia has been postulated to increase secondary mechanisms of brain injury in
       adults. Therefore, hyperthermia should be avoided in younger patients. Hypothermia, on
       the other hand, may be beneficial, and when intracranial hypertension is refractory, the
       authors recommend that it be considered, despite a lack of evidence.
      Decompressive craniectomy also may be considered to improve refractory intracranial
       pressure. Surgical interventions may be more successful in patients with reversible brain
      There is no evidence to recommend steroid therapy in children with traumatic brain
      Although research has not directly addressed outcomes in pediatric patients with
       traumatic brain injury, nutritional support should be strongly considered with a goal of
       replacing 130%-160% of resting metabolism expenditure.
      Prophylactic antiseizure medications are not recommended.

Pearls for Practice

      Prompt recognition and transfer of pediatric victims of traumatic brain injury is
       paramount to good outcomes.
      Intracranial pressure should be monitored and treated if >20 mm Hg in children with
       severe brain injury.
Common Problems following Traumatic Brain Injury
1. Rate of Recovery:
It is generally accepted that children/adolescents recover more fully from illness than adults, and
this has also been applied to TBI. For a period of time, there was even a general presumption
among scientists that the younger a person was when brain injury occurred the more likely they
would recover fully. Research with children/adolescents experiencing TBI, however, has not
been that encouraging. It is clear now that if children/adolescents sustain severe brain injury they
will have long-term deficits as a result of that injury. At no age can one safely say a
child/adolescent will recover fully due to plasticity of the brain or other factors. If
children/adolescents do seem to do better than adults in some areas this may be due to the greater
likelihood of children/adolescents receiving adequate structure and rehabilitation following an
injury. Very rarely do adults have the opportunity of attending school for years after an injury
even though such structure and stimulation may be in their best interest. One area in which
children/adolescents do seem to surpass adults is in survival from head injury.
Children/adolescents seem more likely to leave the ICU alive than adults, but this does not mean
that they have not sustained a brain injury and will not experience deficits as a result.
2. Physical Problems following TBI:
Following acute medical care children/adolescents experiencing TBI are often medically stable.
They often do not require continued medical follow-up or medications. A proportion
(approximately 5-10% for CHI) will experience seizures as a result of their injury. It is not
uncommon for many injured children/adolescents to be placed on anticonvulsant medications
(such as phenobarbital, Dilantin, or Tegretol) as a means of preventing seizures. Fortunately,
most of these children/adolescents have that medication discontinued within a few weeks or
months after their injury if they have not experienced seizures.

As a result of brain injury, children/adolescents may experience some movement difficulties or
problems with sensation. For instance, having double vision is common and usually improves
over several months and returns to normal. Hemiplegia, that is the inability to move one side of
the body, is relatively uncommon with CHI. More likely there is weakness, but still functional
movement, on one side. Problems with balance and coordination are often seen and may last
longer than other motor difficulties. Such children/adolescents may have difficulty participating
in physical education class due to the balance and coordination difficulties. The changes may be
very subtle and noticed only in the more difficult sports or by the individual and his family. The
vast majority of children/adolescents with TBI are able to ambulate and take care of themselves
as one would expect for a child/adolescent their age.

The lack of ongoing medical and physical problems for these children/adolescents is one of the
things that is hard to comprehend. Initially, TBI is a medical disorder, and the expertise required
to deal with such individuals is phenomenal. However, over the long run TBI becomes a
psychological, sociological, and educational problem.

3. Cognitive Difficulties
To the extent that the brain controls our cognitive abilities, any thinking skill can be affected by
TBI. There are several which are more often cited in research and also in comments by family
members, teachers, and friends. While a child/adolescent may exhibit one, two or several of the
following deficits, it is unlikely that a child/adolescent will exhibit all of them. TBI is unique in
the sense that the same cognitive systems are not affected in any two children/adolescents, which
makes the educational program difficult to formulate

      Deficits in attention and concentration.
       After TBI children/adolescents may be noted to be more distractible and unable to
       establish and maintain a focus of attention. Such children/adolescents may need constant
       reminding to stay on task and very specific directions as to what is expected of them.
       They often cannot complete more than one task at a time and even then may require
       prompting. In many respects, these children/adolescents are similar to people with ADD.
      Memory Deficits.
       The child/adolescent with TBI is often able to recall information, from prior to injury so
       they do not forget the things they have learned in school previously, their family
       members, their friends, or where they live. They may be able to remember old skills such
       as how to play particular games and might still do better than some adults (such as with
       video games). This is somewhat deceptive, however, since the problem they encounter is
       often with new learning. They are unable to learn new things as one would expect of the
       average child/adolescent. This leads to a rather peculiar situation in which a
       child/adolescent might be better able to remember what happened last year (before the
       head injury) than what happened yesterday or last week in school. When this occurs
       thechild/adolescent is not being manipulative or obstinate. The deceptive nature of
       memory disorders can lead to some problems in school. For instance, a child/adolescent
       may return to school following a TBI and exhibit age-appropriate academic skills that
       existed prior to the injury. The teacher may then notice over the next few months that the
       student is not learning the new material presented. Thus, over time there is a cumulative
       deficit in which the child/adolescent with TBI falls further and further behind as their
       peers continue to learn new information.
      Problems with reasoning:
       Difficulties in reasoning vary with the age of the child/adolescent.With a very young
       child/adolescent very little in the way of reasoning is expected, whereas with adolescents
       much more is anticipated. The problems with reasoning often relate to difficulties in
       planning, organizing, and predicting what is to happen. We engage in reasoning every
       day automatically. We expect students to be able to do this as a matter of course. For
       instance, if a child/adolescent pays attention in class, then that child/adolescent will know
       what to do on a homework assignment, and if that homework assignment is turned in then
       a passing grade is obtained. This type of reasoning comes easily to us, but may be more
       difficult for a child/adolescent with TBI. In addition, the flexibility in reasoning is
       diminished after TBI in many cases. Once a solution to a problem is generated, the
       child/adolescent is unable to shift to other solutions even though the problem may require
       such a shift. Such children/adolescents tend to perseverate, that is, repeat a previous
       solution even though the situation has changed. Another aspect to the reasoning
       difficulties is that quite often children/adolescents with TBI do not monitor performance
       very well. They do not seem to have the capacity to understand when they are performing
       poorly or well. Due to the difficulties with reasoning, students with TBI often require
       much more guidance and structure than the average student. The consequences of their
       actions need tobe explained very clearly and any shift in the type of material presented
       has to be explained.
      Slowed processing.
       In talking with children/adolescents with TBI others often notice that they seem to be
       somewhat slow in responding to questions. It seems to take them a moment or two longer
       to understand directions and then generate a response. They may also be very slow in
       their physical abilities. For instance, writing may proceed more slowly. As a result, it
       often takes them much longer to complete assignments than the average student.
      Language problems:
       Aphasia ( the absence of language), as might be evident in a person with a stroke, is
       relatively uncommon following TBI. More often there are subtle language problems that
       might not be noticeable in a very short conversation. Due to the difficulties with word
       finding, the child/adolescent may revert to communicating in a more immature fashion,
       using phrases and gestures which might have been suitable for a younger age. Such
       children/adolescents may also have difficulty in comprehending longer instructions.
      Problems with academic skills:
       Injury to specific areas of the brain may result in an acquired dyslexia or dyscalculia (an
       inability to do arithmetic), but this is relatively rare. For the most part, academic skills, as
       they existed prior to the TBI, still exist or are easily re-acquired. Initially,
       children/adolescents may require review of basic concepts and information learned
       during previous school years. Brief review of the material is often sufficient for injured
       children/adolescents to once again perform particular tasks. It is not unusual, therefore,
       for a student with TBI to return to school with academic skills consistent with their level
       of education or consistent with their level of skills exhibited prior to injury or very close
       to it. It may be difficult to understand in the presence of apparently intact academic skills
       that there may still be significant brain injury that is going to affect school performance.

Behavioral/Emotional Difficulties
after TBI Behavioral and emotional difficulties are discussed together largely because it is often
difficult to separate the two. Emotional difficulties may lead to behavioral problems and
behavioral difficulties may be exacerbated by the development of emotional distress. The
difficulties to be discussed in this section are relatively common among TBI students, although
no single student will exhibit all the problems discussed. When such problems are exhibited by
the average student, one might easily think of external causes, such as social difficulties or
family stress, as well as the possibility that the child/adolescent may be somewhat manipulative
towards others. In dealing with children/adolescents after TBI it is important to recognize that
these difficulties may in part be a direct reflection of the brain injury. To help clarify this
relationship, each of the behavioral/emotional difficulties will be explained in terms of the
cognitive deficits which have already been described.

      Restlessness. The child/adolescent may fidget more so than one would expect for that
       ageand may also leave his/her desk without permission. If asked by the teacher for a
       destination, often there is no adequate response. Such children/adolescents are unable to
       be still; even in situations where physical activity is sanctioned, such as at recess, they
       may have difficulty in focusing and directing their energy. On closer examination such
       children/adolescents are often exhibiting severe attentional difficulties. They are unable
       to focus or maintain attention adequately and, therefore, tend to be very distractible and
    move around a great deal. This is not unlike what is seen with ADD children/adolescents
    with hyperactivity.
   Failure to comply with instructions. The child/adolescent following TBI may not
    complete assignments on time or forget to do assignments at all. The teacher may ask
    very specifically for the student to desist in a certain behavior and the student persists. It
    is possible that a child/adolescent in this situation is having some difficulty with language
    comprehension or cannot adequately focus his/her attention on the directions being given
    by the teacher. Memory is another possible factor in that assignments given may not be
    recalled. Finally, because of the slowed processing, such children/adolescents may not
    complete assignments due to inadequate time.
   Irritability towards the teacher and other students. After TBI, children/adolescents
    tend to be somewhat less inhibited in their emotional responses. They may cry more
    easily or exhibit irritability and anger more easily. This may be noticed in the classroom
    when such children/adolescents cannot take any degree of joking or they may snap at the
    teacher. Problems getting along with peers during free time or after school may also be
    noticeable. At least part of this difficulty may be due to reasoning problems. Whereas
    prior to the head injury the child/adolescent may have had an understanding of the
    consequences of his/her behavior, after the injury the association is less clear. In general,
    even children/adolescents with TBI have some idea of what they would like to achieve.
    They have goals (although they may be very vague) but due to the reasoning difficulties
    they do not quite know how to achieve those ends and this generates a great deal of
    frustration. It should not be overlooked that in many cases children/adolescents with TBI
    can recall how they used to perform academically, socially, and cognitively prior to the
    injury. To the extent that they cannot perform in those areas as well after the TBI, the
    potential for frustration exists.
   Withdrawing physically from others. Students have been noted to attempt to stay at the
    back of the crowd or in a group setting find a corner and remain silent and unobtrusive. If
    approached by another person they may seem very nervous and unwilling to participate.
    In part, this behavior may be a functional response to a sense of being overwhelmed. To
    the extent that children/adolescents with TBI may not be able to attend, comply with
    instructions, or reason effectively, they may be easily overwhelmed by events around
    them. This leads to withdrawl, which would occur with virtually anyone in such
    circumstances, although it occurs more quickly among TBI students. Under such
    circumstances teachers should try to diminish stimulation as much as possible.
   ) Turning in sloppy or incomplete work. Children/adolescents with TBI may turn in
    papers in which their writing is skewed, poorly spaced, or the work seems to stop in mid-
    thought. This can be extremely frustrating since it is difficult to give the student credit for
    what they do under such circumstances. It is very easy to attribute the problem to a lack
    of effort. However, in the case of children/adolescents with TBI, it is important to
    remember that fine motor skills and coordination may be impaired, which affects
    handwriting abilities. Such children/adolescents may have difficulty with adequate
    spacing and with making letters small enough to fit within the lines or numbers small
    enough to fit within columns. Attentional problems may also affect performance in that
    the children/adolescents become distracted from their work and therefore do not complete
    a thought or a problem. They also tend to be slow in their performance and may turn in
    work incomplete simply because they feel they do not have the time to finish. Also, these
    children/adolescents may have difficulty in monitoring themselves, which extends to
    their own work output. Incomplete work may also be reflective of poor memory; the
    child/adolescent may not remember the entire assignment.
   Impulsive behavior. The teacher may experience having a student start on an assignment
    before instructions are completed or consistently talk out of turn. These behaviors can be
    very disruptive to the class and also to the performance of the TBI student. Deficits in
    reasoning may be very important in the generation of such behavior. As a result of the
    problems in reasoning, children/adolescents with TBI may be disinhibited in that they see
    something they want to do but do not realize clearly how to achieve that end. Rather than
    go through a reasoning process they simply pursue the goal in the most direct manner
    possible, which may involve blurting out an answer or not waiting to hear instructions.
   Fatigue. It is common for children/adolescents with TBI to become extremely tired
    within a relatively short time. Activities that the average child/adolescent takes for
    granted, such as reading from a book, going to recess, taking a test, or writing a page of
    script may be very tiring to the TBI student. It is important to recognize that once a
    child/adolescent becomes fatigued in this fashion they are deriving very little benefit
    from their school experience. In fact, under such conditions there is the risk of generating
    even more significant behavioral problems due to frustration and irritability if one
    persists in trying to work with a fatigued child/adolescent. Children/adolescents with TBI
    become more fatigued because of the increased concentration required to complete even
    relatively simple tasks. It requires a great deal more effort to do virtually anything, in
    some cases even walk, and therefore students with TBI fatigue more quickly.
   Lack of motivation. Children/adolescents with TBI may be perceived as lacking in
    motivation to perform well in school. If left alone they may sit quietly at their desks and
    stare into space. To perform, they require constant prompting from the teacher. Their idle
    time is not spent in other activities, such as writing notes to other students, playing with
    toys, or even daydreaming. They simply lack the drive to perform. This can be extremely
    frustrating to teachers since it may be perceived as a lack of interest in the class or
    minimal effort. In fact, TBI can interfere with the basic association between motivation
    and outcome. The children/adolescents may not perceive that they will do better if the
    exhibit more effort. It may be a problem with reasoning, which is a necessary component
    for any motivated, directed behavior. In order for us to be directed to do something we
    have a goal in mind that is going to be achieved through our efforts. The child/adolescent
    with TBI may not be able to carry through with this logical reasoning and, therefore, will
    sit quietly unless prompted.
 Traumatic Brain Injury and The Physical
       Problems That May Arise
Injury to the head (traumatic brain injury, or TBI ) may cause interference with normal brain
functions. There are two broad categories used to describe TBIs:

Penetrating Injuries: In these injuries, a foreign object, e.g., a bullet, enters the brain and
causes damage to specific brain parts. This focal , or localized, damage occurs along the route
the object has traveled in the brain. Symptoms vary depending on the part of the brain that is

Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for
example, when the head strikes the windshield or dashboard of a car. These injuries cause two
types of brain damage:

primary brain damage, damage that is said to be complete at the time of impact, and secondary
brain damage , damage that evolves over a period of hours to days after the trauma.

Primary injuries may include some or all of the following:

      Skull fracture : Breaking of the bony skull
      Contusions/bruises : Often occur right under the location of impact or at points where
       the force of the blow has driven the brain against the bony ridges inside the skull
      Hematomas/blood clots: Occur between the skull and the brain or inside the brain itself
      Lacerations: Tearing of the frontal (front) and temporal (on the side) lobes or blood
       vessels of the brain (The force of the blow causes the brain to rotate across the hard
       ridges of the skull causing the tears).
      Diffuse axonal injury: Arises from a cutting, or shearing, force from the blow that
       damages nerve cells in the brain's connecting nerve fibers.

Secondary injuries may include brain swelling ( edema ), increased pressure inside of the skull (
intracranial pressure ), epilepsy, intracranial infection, fever, hematoma, low or high blood
pressure, low sodium, anemia, too much or too little carbon dioxide, abnormal blood
coagulation, cardiac changes, lung changes, and nutritional changes.

Physical Problems

Physical problems may include hearing loss, tinnitus (ringing or buzzing in the ears), headaches,
seizures, dizziness, nausea, vomiting, blurred vision, decreased smell or taste, reduced strength
and coordination in the body, arms, and legs.

Communication Problems
Individuals with a brain injury often have cognitive and communication deficits that significantly
impair their ability to live independently. These deficits vary depending on how widespread
brain damage is and the location of the injury.

Brain injury survivors may have trouble finding the words or grammatical constructions they
need to express an idea or explain themselves through speaking and/or writing, as if the words
they need are "on the tip of their tongues." It may be an effort for them to understand both
written and spoken messages, as if they were trying to comprehend a foreign language. They
may have newfound difficulties with spelling, writing, and reading, skills that presented no
problem prior to their injury.

Deficits in social communication skills may alter the individual's ability to take turns in
conversation, maintain a topic of conversation, use an appropriate tone of voice, interpret the
subtleties of conversation (e.g., the difference between sarcasm and a serious statement), respond
to facial expressions and body language, or keep up with others in a fast-paced conversation.
Individuals may seem overemotional (overreacting) or "flat" (without emotional affect). Most
frustrating to families and friends, a person may have little to no awareness of just how
inappropriate he or she is acting. In general, communication can be very frustrating and

In addition to all of the above, functioning of speech muscles may also be affected. Muscles of
the lips and tongue may be weaker or less coordinated affecting the ability to speak clearly.
Breathing muscles may be weaker, affecting the ability to speak loud enough to be heard in
conversation. Muscles may be so weak that the person is unable to speak at all. Weak muscles
may also limit the ability to chew and swallow effectively.

Cognition Problems

Cognition refers to thinking skills. Cognition includes an awareness of one's surroundings,
sustained attention to tasks, memory, reasoning, problem solving, and executive functioning
(e.g., goal setting, planning, initiating, self-awareness, self-inhibiting, self-monitoring and
evaluation, flexibility of thinking). Cognitive difficulties are highly common in persons who are
traumatically brain injured, and problems again vary depending on the location and severity of
the injury to the brain.

      Patients frequently have trouble concentrating when there are internal and external
       distractions, e.g., carrying on a conversation in a noisy restaurant or dividing attention
       among multiple tasks/demands.
      The processing or "taking in" of new information is generally slower. Longer messages
       may have to be "chunked," or broken down into smaller pieces. The patient may have to
       repeat/rehearse incoming messages to make sure he or she has processed the crucial
       information. Communication partners may have to slow down their rate of speech to
       accommodate the patient's processing needs.
      Recent memory is affected, making new learning difficult, e.g., students may have trouble
       learning and retaining new concepts taught in class. Long-term memory for events and
       things that occurred pre-injury, however, is generally unaffected, e.g., the patient will
       remember names of friends and family.
      Impairments in executive functioning diminish the ability to initiate tasks and set long-
       term and short-term goals for task completion. Planning and organizing the job at hand is
       an effort, and it is difficult to self-evaluate work. Consequently, these individuals seem
       disorganized and unable to negotiate their lives without the assistance of families and
       friends. They also may have difficulty solving problems, and they may react impulsively
       (without thinking first) to situations.

The Speech-Language Pathologist (SLP)

The speech-language pathologist works collaboratively with other rehabilitation and medical
professionals (doctors, nurses, neuropsychologists, occupational therapists, physical therapists,
social workers, employers, and teachers) and families to provide a comprehensive evaluation and
treatment plan for the patient with traumatic brain injury.

      Assessment . The speech-language pathologist completes a formal evaluation of speech
       and language skills . An oral motor evaluation checks the strength and coordination of
       the muscles that control speech. Understanding and use of grammar ( syntax ),
       understanding and use of vocabulary ( semantics ), reading and writing are evaluated.
       The SLP will evaluate the person's ability to relate an extended narrative ( language
       sample ). Can he or she explain something or retell a story, centering on a topic and
       chaining a sequence of events together in a logical order? Is narrative coherent or is it
       difficult to follow?
      Social communication skills ( pragmatic language ) are evaluated with formal tests and
       the role-playing of various communication scenarios. The person may be asked to discuss
       stories and the points of view of various characters. Does he or she understand how the
       characters are feeling, and why they are reacting a certain way? Can he or she explain
       how different characters' actions affect what happens in the story? The person may be
       asked to interpret/explain jokes, sarcastic comments, or absurdities in stories/pictures
       (e.g., what is strange about a person using an umbrella on a sunny day?).
      The speech-language pathologist will assess cognitive-communication skills. Is the
       person aware of surroundings? Does he or she turn towards a voice? Does the person
       know his or her name, the date, where he or she is, what happened to him or her (
       orientation)? Recent memory skills are assessed, e.g., whether the main details in a short
       story are retained. Executive functioning is evaluated. The speech-language pathologist
       assesses the patient's ability to plan, organize, and attend to details (e.g., completing all of
       the steps for brushing teeth). The SLP may read an incomplete story and ask for a logical
       beginning, middle or conclusion. The person may be asked to provide solutions to
       problems ( reasoning and problem solving ). For example, what would you do if you
       locked your keys in your car? How can this problem be avoided in the future?.
      If problems are observed, the speech-language pathologist will evaluate swallowing and
       make recommendations regarding management and treatment. The focus of this
       evaluation will be to insure that the individual is able to swallow safely, and receive
       adequate nutrition. Additional swallowing tests may be recommended by the speech-
       language pathologist as a result of this evaluation.
      If necessary, the speech-language pathologist may also evaluate the benefit of a
       communication aid or device to express basic needs and ideas.

Treatment The treatment program will vary depending on the stage of recovery, but it will
always focus on increasing independence in everyday life.

      In the early stages of recovery, e.g., during coma), treatment focuses on getting general
       responses to sensory stimulation. The family is given information about the best
       techniques for interacting with the loved one.
      As an individual becomes increasingly aware of surroundings, treatment will focus on
       helping to sustain attention for basic activities. The speech-language pathologist will also
       work to decrease the patient's confusion by orienting him or her to the date, to where he
       or she is, and what has happened.
      Later on in recovery, treatment will focus on helping the person compensate for
       difficulties remembering (e.g., using a memory log to keep track of daily happenings).
       The person will work with the clinician individually and in small groups to learn
       strategies to help problem solving, reasoning, and organizational skills. He or she may
       work in social skills groups to help with conversational skills. Treatment will always
       focus on increasing awareness of deficits in order to help self-monitoring in the hospital,
       home, and community.
      Eventually, individuals may be taken on community outings to practice outside the
       hospital what they have learned. They are asked to plan, organize and carry out these
       trips using memory logs, organizers, checklists, and other helpful aids. Later on in
       recovery, the speech-language pathologist may work with a vocational rehabilitation
       specialist to help with transition back into work or school or with employers and/or
       educational specialists to implement strategies in these settings. The SLP may work on
       modifying the work/school environment to meet the person's cognitive needs.
      Individual therapy may focus on improving language skills as needed. If weak
       musculature is an issue for speaking and swallowing, treatment will focus on
       strengthening affected muscles for talking and eating. If the person is learning how to use
       an augmentative or alternative communication device, treatment will focus on increasing
       efficiency and effectiveness with the device.

Use ProSearch to find a speech-language pathologist near you.

Who Is Affected?

The medical and allied health literature indicate that an estimated 1.5 to 2 million individuals
each year in the United States sustain a TBI (1-3). Approximately 270,000 people experience a
moderate or severe TBI (4). Approximately 50,000 to 70,000 people die from head injury (2, 4).
TBI is a major public health problem, especially among male adolescents and young adults ages
15 to 24, as well as among elderly people of both sexes 75 years and older (4, 5). Half of all TBIs
are due to transportation accidents, and are the major cause of TBI in people under age 75. For
those 75 and older, falls are the cause for the majority of TBIs (4). The leading cause of TBI
hospitalizations among persons aged at least 65 years are falls (6). Males are about twice as
likely as females to sustain a TBI (7).

The following web sites can provide information and support for patients and their families and

       NIDRR TBI Homepage:
       The Coma Waiting Page:
       The Brain Injury Association:
       The Brain Injury Information Network:
       The Head Injury Awareness Foundation:
       The TBI Chatroom:
       Head Injury Hotline (a non-profit clearinghouse founded and operated by a head injury
        activitist since 1985)


       Langlois, J.A., Kegler, S.A., Butler, J.A., et. al. (2003, June). Traumatic brain injury-
        related hospital discharges. MMWR Surveillance Summary, 52(4): 1-20.
       National Center for Injury Prevention and Control, Centers for Disease Control and
        Prevention. (2003, October 8). Traumatic brain injury. >.
       Stierwalt, J.A., & Murray, L.L. (2002, May). Attention impairment following traumatic
        brain injury. Seminars in Speech and Language, 23(2): 129-138.
       National Institute of Neurological Disorders and Stroke. (2002, October 10). Traumatic
        brain injury: Hope through research. >.
       Thurman, D., Alverson, C., Dunn, K., et. al. (1999). Traumatic brain injury in the United
        States: A public health perspective. Journal of Head Trauma and Rehabilitation, 14(6):
       [No authors listed]. (2003, April 4). Nonfatal fall-related traumatic brain injury among
        older adults – California, 1996-1999. MMWR, 52(13): 276-278.
       Centers for Disease Control and Prevention. (1997). Traumatic brain injury – Colorado,
        Missouri, Oklahoma, and Utah, 1990-1993. MMWR, 46(1): 8-11.
    Traumatic Brain Injury and Pituitary
                    by Flora Hammond, M.D. and Rhona Shapiro, RN, MSN

        Pituitary hormone deficiency may result from head trauma or subarachnoid hemorrhage.
Two recent studies show that one or more pituitary hormones may be affected by traumatic brain
injury or subarachnoid hemorrhage.1,2

        Symptoms of hormone deficiency can mimic other effects of a traumatic brain injury,
which can prevent suspicion of this disorder. A deficiency of one or more of the hormones
regulated by the pituitary gland may have physical and/or psychological effects such as:

      reduced muscle mass
      weakness
      decreased exercise capacity
      fatigue
      irritability
      depression
      impaired memory
      reduced sex drive.

       Most patients do not even realize that they have the hormone deficiency until specific
laboratory tests for this disorder are performed. However, individuals with a history of a
moderate to severe brain injury are more likely to have a pituitary deficiency than those with a
mild brain injury.

       The likelihood of pituitary damage exists even if the injury occurred years ago and a
good rehabilitative outcome has been achieved. The pituitary gland, hypothalamus, and
surrounding structures, including their blood supply, may have been injured.

       Damage to the pituitary gland causes a condition called hypopituitarism: a loss or
reduction in the normal activity of the pituitary gland. Hypopituitarism means that any pituitary
hormone can be deficient.

        The pituitary is a pea-sized gland at the base of the brain. Pituitary hormones are
important because they regulate other hormones from the thyroid, gonads (ovaries and testes),
and adrenals (cortisone). Prolactin, oxytocin, and ADH (antidiuretic hormone) may also be
effected by brain injury, but the incidence is less common. These hormones are chemical
messengers that target vital organs that control vital functions.
       Listed below are the hormones produced by the pituitary along with the symptoms
commonly seen with a deficiency of each. Diagnostic testing for pituitary hormone deficiency
involves blood and urine testing. Hormonal replacement requires monitoring by a physician.

Thyroid stimulating hormone deficiency may cause...

              reduced memory                             slowed metabolism

              reduced energy                             altered mood

              failure to thrive                          slowed growth

              lethargy                                   muscle aches

              cold intolerance                           decreased appetite

              dry hair or skin                           numbness or tingling in extremities

Adrenocortical stimulating hormone deficiency may cause...

              weakness                                   fatigue

              altered mood                               electrolyte abnormalities

              weight loss                                low or fluctuating blood pressure

              increased body fat                         decreased bone mass

              reduced exercise capacity

Sex hormone deficiency may cause...

      decreased energy
      depression
      decreased muscle mass

   in Males:

      decreased sex drive
      shrunken testes
      loss of beard growth
      decreased sperm production

   in Females:

      infertility
      amenorrhea (lack of menstruation)
      loss of female characteristics

Growth hormone deficiency may cause:

      decreased lean body and muscle mass, particularly in the shoulders
      increased fat mass, especially around the waist and trunk
      high ―bad‖ cholesterol levels (higher ldl and lower hdl) which may increase risk of stroke
       and heart disease
      decreased bone density, which may cause osteoporosis
      fatigue, regardless of the amount of sleep.
      decreased interest in socialization
      a sense of isolation
      depression

   1. Kelly DF, Gaw Gonzalo IT, Cohan P, Berman N, Swerdloff R, Wang C. Hypopituitarism
      following traumatic brain injury and aneurismal subarachnoid hemorrhage: a preliminary
      report. J Neurosurg.2000; 93: 743-752.
   2. Lieberman SA, Oberoi AL, Gilkison CR, Masel BE, Urban RJ. Prevalence of
      neuroendocrine dysfunction in patients recovering from traumatic brain injury. J Clin
      Endocrinol Metab. 1998:83:382-395.

About the Authors…

Flora Hammond, M.D.

       Dr. Hammond is the Director of Research at the Charlotte Institute of Rehabilitation
(CIR) in Charlotte, NC. She also serves as Principal Investigator and Director of CIR‘s
Traumatic Brain Injury Model System program funded by the National Institute of Disability
Rehabilitation and Research. Much of her research on traumatic brain injury has focused on
outcome prediction, post-traumatic irritability, depression, relationships, and motor and cognitive
recovery over time.

      She graduated from the Tulane University School of Medicine in 1990 in New Orleans,
LA. Her Physical Medicine and Rehabilitation residency was done at Baylor College of
Medicine. Dr. Hammond earned a Brain Injury Fellowship at the Rehabilitation Institute of
Michigan in Detroit, Michigan. She is a diplomat of the American Board of Physical Medicine
and Rehabilitation. She has served as an invited participant to both the Aspen Conference and
Galveston Brain Injury Conference (brain injury think tanks). Her excellence in research,
teaching, and administration were acknowledged by her receipt of the 2001 Young Academician
Award from the Association of Academic Physiatrists (AAP), and the 2001 AAP Best Faculty
Paper Presentation Award.

Contact Information:

Flora Hammond, MD
Research Director ~ Charlotte Institute of Rehabilitation
1100 Blythe Blvd
Charlotte, NC 28203
phone: 704-355-4330

Rhona Shapiro, RN, MSN

       Rhona Shapiro is an experienced nursing educator and clinician. She specializes in adult
growth hormone deficiency and in traumatic brain injury and pituitary deficiency.

        An experienced educator, she has also served as nursing faculty in a community college
setting. A member of the Endocrine Nurses‘ Society, Ms Shapiro is an experienced clinician in
both acute care and home care settings.

Contact information:

Rhona Shapiro, RN, MSN
Nurse Educator, Innovex
10 Waterview Blvd.
Parsippany, NJ 07054
phone: 215-704-1220

This article is not a substitute for medical advice. Please contact your physician for more
information and questions about your condition.
    Behavioral Challenges in Children:
       Linking School and Home
           Thomas Kay, PhD, Judy Spaulding and Lola Smerdon
Focus of the Article
This article will highlight the importance of consistent communication between the school and
family in order to meet the behavioral challenges of students who have sustained a traumatic
brain injury. The authors work in a TBI Program that is part of the Special Education
Department of the Putman/Northern Westchester Board of Cooperative Educational Services
(BOCES) located approximately 40 minutes north of New York City. The program serves
students between the ages of five and twenty-one who have been classified as "Traumatic Brain
Injured" under the New York State definition and who have been referred to the program by their
local school district.

The TBI Program actually began prior to the 1990 Reauthorization of the Individuals with
Disabilities Act (IDEA), which included TBI as a special education classification. In September
1994, BOCES received a grant from the New York State Education Department to provide
technical assistance to staff in surrounding school districts that were working with students with
acquired brain injuries (ABIs). The TBI Program continued to expand the services provided
during the three years of the grant, and now is financially independent.

Depending on the severity of the students' injury, their academic and cognitive needs and the
availability of local resources, a continuum of educational placements is available. Some
students remain in their home school district in mainstreamed classes, or in a self-contained
special education class with mainstreaming opportunities. Other students may be referred to a
BOCES Program, such as a class for students who have multiple disabilities, communication
disorders or emotional and behavioral difficulties. Older students may be involved in the
BOCES alternative high school, vocational program or the Community Outreach Program that
provides experiences in community work and social interaction.

The core of the program is an interdisciplinary team consisting of a supervisor,
neuropsychologist, social worker, educational specialist, speech-language pathologist,
occupational therapist, physical therapist and teacher of students with visual impairments.
Depending on the needs of the student over time, some or all of this team works directly with the
student in the appropriate educational placement and consults with the local school team (i.e.,
classroom and/or resource room teacher (s), aides, therapists). Periodically, planning meetings
are held which include the TBI team, the local school team, and the family--and depending on
age and nature of injury--the child. The goal is for the TBI team to bring its expertise to the local
school and help establish, train and maintain a cohesive network of services for the student, as
well as to integrate school and home approaches. The ideas in this article are the product of
clinical experience in this program, and not a review of ideas presented in the literature.

Integrating Children with Traumatic Brain Injury into the Educational System

It is well known that students who have sustained a TBI do best reentering the educational
system when there has been advance communication and coordination between the rehabilitation
hospital and the school system. The hospital, family or school often notify the BOCES TBI
Program of a child's injury prior to his/her return to school. The goal is for BOCES to meet with
the family to gather medical information and information about the child's functional physical,
cognitive, behavioral and Activities of Daily Living (ADL) status, to assist the family in
negotiating the special education system in order to receive to receive appropriate TBI services.
BOCES also meets with local school personnel prior to the child's re-entry to provide training
about TBI in general and to familiarize the school with the child's specific needs. Additionally,
direct contact between the hospital and school is encouraged.

In comparison to adults re-entering the community after TBI, children have both potential
advantages and realistic disadvantages. On the positive side, virtually all children will return to
an organized setting with educators who, by training, are experts in learning and the cognitive
processes that underlie it. Federal law mandates that students be provided with appropriate
services toe enable them to access their educational environment in the least restrictive setting.
These are advantages. Realistically, however, school personnel often are ill-equipped to deal
with the idiosyncrasies of children with an ABI and lack the wherewithal to organize a team of
teachers and therapists that maintains ongoing, consistent communication. This is especially true
for older children who have multiple teachers in multiple classrooms.

In addition, most families are accustomed to their child living in two quite different worlds--
school and home. Face-to-face contact with classroom teachers traditionally occurs during
required parent-teacher meetings, or when there is a crisis. When school and home remain
separate worlds following a TBI, it is akin to the child living with left and right hemispheres, but
no corpus callosum (i.e., the band of fibers that integrates functioning across the two sides of the
brain). The child lives in a split world, which can hopefully--at best--be non-conflicting. In
reality, it probably will lack the integration of information, feedback, organization and
reinforcements necessary for optimal functioning.

What the child who has sustained a TBI needs most is consistent integration within and across
settings. At school, there needs to be a cohesive plot line for the entire cast of characters. At
home, consistency between the parents and other caretakers is critical. Most importantly, there
needs to be consistency of communication and approach across the worlds of school and home.
This takes active effort to achieve; it does not happen automatically.

Special Needs of Children with TBI

In the broadest sense, a child's behavior after TBI is determined by the interaction among four
factors: personality, neurological damage, the family system and the environment.
Personality Factors

Personality factors play a large role in outcome following brain injury. Some children seem to
have an ease and grace about them that is not destroyed by the brain injury; these children often
find ways to "seduce" responsivity out of their environment despite neurologically devastating
injuries. On the other hand, not all negative behaviors are the result of brain injury. Many
children premorbidly displayed defiant or aggressive behavior or had learning or attentional
problems, which the TBI only serves to exacerbate. Knowing, understanding and factoring in
the preexisting personality traits is extremely important in working successfully and realistically
with children with TBI.

Neurological Damage

Neurological damage is known to affect behavior. Damage to the frontal and temporal lobes,
which is particularly common following a TBI, is known to cause changes in personality,
emotional functioning and control of behavior, as well as in those executive functions (i.e.,
planning, organizing, anticipating, judging, self-monitoring, decision-making) which are
cognitive functions directly related to behavior. At times, psychiatric disorders (i.e., depression,
anxiety disorders, obsessive-compulsive disorders, psychoses) can be the direct result of
neurological damage. In general, however, it has been our experience that the neurological
severity of the injury probably has less direct effect on behavior than the other three factors.

The Family System

Children are extensions of their families. They are, so to speak, the tip of the family iceberg.
Whether it is the child who succeeds unbelievably despite all odds after a brain injury, or the
child who seems to create chaos around him/her despite the best plans and interventions, there is
an almost uncanny consistency between the behavior of the child and the personality of the
family. Dysfunctional children come form dysfunctional families; adaptive children come from
adaptive and resourceful families. This is a gross overgeneralization, of course, but it is true
enough to justify investing a large amount of energy in engaging the family in a productive
working relationship. On the other side of the coin, it also is true that families need to look at
when their own dynamics may be detrimental to the progress of their child and be courageous
enough to get help and guidance they need.


Given a child with a certain personality in a specific family with a particular neurological injury,
the remaining variability in behavior is accounted for by the environment in which the child
operates. A child processes his/her environment differently after TBI. The needs for clarity,
structure and anticipation often are much different from what they were prior to the injury.
While parents are dedicating all their energy to learning about and adapting to a tragedy in their
family's life, teachers are trying to blend the needs of one individual child with brain injury into a
complex set of multi-child demands. Their attention must be shifting constantly across multiple
students, all of whom deserve the same help as the child with TBI. The result is that the school
environment often is at odds with the needs of the child. In fact, negative behaviors can be
elicited or reinforced simply out of a lack of awareness. It is important to remember that the
environment is the one variable over which teachers, therapists and families have the most
control. Personality, family dynamics and neurological damage are not controlled as easily;
however, we can create the home and school environments that usually make the difference
between success and failure for a child with TBI.

While the academic nature of school implies that cognitive issues should take center stage after
TBI, whether a child thrives or deteriorates in a particular school usually has more to do with
behavior than cognition. The eager, compliant child will win the teacher's attention, rewarding
his/her efforts in ways that will lead to positive outcomes despite cognitive impairments that are
often quite severe. On the other hand, a child's cognitive potential does not matter if he/she has
alienated peers and teachers with impulsive, aggressive and generally non-compliant behavior.
These children will fail both to learn and often even to stay in school. The difficult behaviors of
a child with TBI provide the greatest challenge to the school and family.

Behavioral Issues After TBI

The behaviors that children with TBI may exhibit in the classroom can be divided grossly among
"positive" and "negative." "Positive" does not mean good; rather it indicates that the active
expression of a behavior as a problem, as opposed to the lack of something as a problem (a
"negative" behavior). The following is a list of some of the positive and negative problem
behaviors which commonly are observed in students who have sustained a TBI.

Positive Problem Behaviors

Positive problem behaviors (meaning behaviors that occur or happen) include:
    Aggressiveness: Aggression--verbal or physical--is the single largest behavioral problem
       following brain injury. Aggressive behavior can be understood as some combination of:
       (1) possible pre-existing personality variables, (2) a possible family dynamic which is
       being replayed at school, (3) possible direct neurological damage to the brain and, most
       importantly, (4) of environmental contingencies. Children may criticize or yell at other
       children or teachers thoughtlessly or act aggressively with their bodies, shoving into other
       children's space or pushing or hitting them. They may respond to real or imagined
       criticism or mocking by lashing out verbally or physically, at times in ways that require
       physical restraint or even removal from the class.

       It is extremely important to "read" the environment from the child's point of view in order
       to understand the antecedent causes of aggression, as well as to identify unwitting
       reinforcement of the aggressive behavior. The best antidote to aggression is prevention;
       knowing what the child needs in order to feel organized, in control, with choices and not
       overwhelmed. Alternate options to the aggression need to be identified and anticipated.
       Medications often are critical adjuncts to a child's ability to control his/her aggression,
       and should not be shied away from. Despite everyone's best efforts, however, it
       sometimes is not possible to prevent a level of aggression that makes it possible for a
       child to stay in any given educational setting. The potential for aggression also is
       heightened and complicated when there is a specific sensory deficit such as deafness.

      Impulsivity/Disinhibition: Children with TBI--especially when there has been
       pre=frontal cortical damage--often have difficulty inhibiting all aspects of their behavior
       (i.e., responding to verbal cues, touching or otherwise provoking other children).
       Children may: (1) call out in class, (2) do quick, sloppy work, (3) hit, grab or impulsively
       pull items out of their desk, (4) bolt from the room and/or (5) itch or expose any or all
       parts of their body without awareness of propriety. Periods of transition during the day,
       unstructured settings, fatigue and decreasing blood levels of certain medications all will
       increase tendencies toward impulsivity. A myriad of techniques (i.e., careful structuring
       of the environment, redirection, simple confrontation, feedback, providing breaks,
       frequent changing of tasks, medication) exist to help a child stay focused and reduce

      Oppositional/Defiant: This problem can be differentiated from aggression, although the
       two often co-exist. In our experience, oppositional and defiant behaviors often reflect
       some combination of personality and family dynamic issues. Avoiding power struggles,
       giving options and incentives--in combination with unavoidable negative consequences--
       all are part of the repertoire of dealing with oppositional and defiant behaviors. Our
       experience has been that individual counseling in the school setting with someone who is
       familiar with the child's routine and service providers often is very helpful.

      Sexual Acting Out: Sexuality is the single biggest unaddressed issue after brain injury,
       usually coming to attention when a child acts in sexually inappropriate ways. This most
       often takes the form of inappropriate comments to other children, some kind of self-
       exposure or, for older children, engaging in normal sexual activities at the wrong place
       and time. At times, simple information about what is appropriate--with repeated
       reminders--is necessary and appropriate. Group discussion of sexuality and sexual
       language and behavior may be helpful with older children. Communicating with families
       about how sex is discussed and responded to at home also is critical. Frank discussions
       with teenagers and their families about sexual activity and partners is as much a part of a
       child's education as learning math and history. This is particularly true for the child with
       TBI who may lack the expected knowledge, judgment and control over impulses. A
       strong school-family liaison is essential.

Negative Problem Behaviors

While the positive behaviors noted above are the most disruptive and elicit the strongest
responses, the "negative" problem behaviors (meaning the lack of certain behaviors happening),
actually are more common. They also are more insidious in that they can go unnoticed and
unattended for long periods of time, to the child's serious disadvantage. Negative problem
behaviors include the following:
     Lack of Initiation: The flip side of a pre-frontal cortex that is unable to contain limbic
        (i.e., emotional) impulses is a pre-frontal cortex that is unable to recruit emotional energy
        to drive behavior. The resulting "lack of motivation," which may be a psychological
    issue for a child who is not injured, can become a neurological issue after brain injury.
    Children with injuries lower in the frontal system (i.e., brainstem injuries) may show a
    related lack of consistent arousal or "cortical tone." In larger classrooms not adapted to
    the need of a child with TBI, these children quietly may get lost in the shuffle. There is a
    need to work individually with them to create an interactive dynamic that elicits and
    sustains goal-oriented behavior.
   Social "Cluelessness": Although this phenomenon has more technical names, it can be
    defined in a common sense as simply "not understanding social interactions." This
    behavior becomes more of a problem as: (1) children get older, (2) more subtleties are
    required both in reading and responding to social situations and (3) flirtatious and sexual
    behavior becomes, at times, the norm during the teenage years. This behavioral lack of
    sophistication is the result of failing to read and integrate social cues, as well as the lack
    of finely tuned judgment as to how to act. It can have the devastating effect of leading to
    the erosion of friendships. Education about social cognition may be a critical dimension
    in the classroom experience of a child with TBI. While social skill groups, modeling and
    role-playing all have some value in learning about social behaviors, the most powerful
    intervention is on-the-spot (i.e., immediate) feedback when some social interaction
   Depression/Low Self Esteem: Strictly speaking, these are internal affective states--not
    behaviors--but they are common after TBI in children and lead to behavior that is listless,
    self-defeating or irritable and hypersensitive to negative stimuli in the environment. It is
    important to understand when such behavior is a reflection of some combination of
    depression and low self-esteem, which are separable but often co-exist. Depression and
    low self-esteem are common and in a sense "normal" secondary to awareness of loss of
    functioning in a person--regardless of age. More intelligent children with greater self-
    awareness may become more depressed; this actually is a positive prognostic sign for the

    Depression also can be the direct result of neurological damage to the brain. While it is
    always best to avoid medications in children when possible, the opposite extreme (i.e.,
    the refusal to consider helpful medication when a child is suffering) is equally
    irresponsible. The more a child feels he/she is in control of the environment, and the
    more they feel they are learning and succeeding--which are the normal challenges of
    childhood--the less likely they are to become or remain depressed.

Other Factors Influencing Behaviors

Finally, a number of other factors can influence behavior and need to be considered. Drug
and alcohol abuse can exacerbate or create negative behaviors in older children. Seizure
disorders can lead to medically determined behaviors that need to be managed specially.
Additionally, alterations in brain functioning between seizures may introduce a variety of
psychiatric dimensions into a child's behavior. Cultural factors also can influence strongly a
family's tolerance of and response to negative behaviors, especially those that become defiant
to the elderly or those in authority. Cultural biases concerning the role of women also can
color a family's ability to respond to the mapping out of behavioral plans by school
personnel--who are traditionally female--particularly when they call for organizations and
discipline at home what runs counter to cultural expectations.

The Range of Behavioral Interventions

Programming to manage difficult behaviors in children after
TBI effectively is a topic that far exceeds the scope of this article. The reader is referred to
the excellent chapters in Mark Ylvisaker's book entitled Traumatic Brain Injury
Rehabilitation (1998) for an in-depth discussion of this topic. The central point to be made is
that management of difficult behaviors after TBI is not a matter of having a plan of how to
respond once those behaviors occur. Rather, it is the knowledge of a child's abilities and
inabilities, the anticipation of what they need to feel in control in their environment and the
structuring of a consistent environment to meet these needs, that is the key to managing
difficult behaviors. This does not mean that traditional rewards--and at times punishments--
are not used, for they certainly are. It does not mean that anticipating the circumstances out
of which difficult behaviors occur will be much more effective in preventing those behaviors
rather than attempting to eliminate the behaviors once they occur, or even trying to elicit and
reward more positive behaviors without an awareness of the antecedent causes of the difficult

We also need to be aware that children are not passive responders to environmental stimuli,
but are capable of shaping the environment to meet their needs. For example, the child with
brain injury who has an inattentive father at home may learn that by "mouthing off" to Dad
he finally is able to get his attention. The male classroom teacher who allows the same child
to work to long without attention, inexplicably may find himself being talked back to for no
apparent reason. Difficult behaviors are often a communication ("I need more help or
attention than I am getting!"), and apparently dysfunctional behaviors (i.e., disrupting class)
may serve a function from the child's point of view (i.e., to get the teacher to focus on his/her

The issue of behavior modification often comes up when discussing the management of
difficult behaviors. The reality is--whether we subscribe to the principles of behavioral
modification or not--teachers, parents and therapists constantly are responding or not
responding to behavior, and therefore modifying it in some way (i.e., either eliciting it, or
making it more or less likely to happen again). "Soft" behavioral programs of providing
incentives and disincentives can be useful adjuncts for managing difficult behaviors (i.e., the
child who knows he/she can earn 10 minutes of computer time at the end of the day if he/she
can remain seated for the entire period may be better able to meet that goal.) "Hard"
behavioral programs built around tokens or points are artificial in school settings and,
frankly, do not work unless the entire environment can be controlled consistently. On the
other hand, a "soft point system" where a student can earn points toward a special reward
may work well for a particular student. Most importantly, all persons involved with the
student must be aware of the potential their own behavior has to reinforce or extinguish the
student's behavior.
An awareness of the student's needs and structuring the environment to meet those needs is
Formal therapeutic interventions also have a place in managing difficult behaviors. Many
children--given sufficient awareness and verbal skills--will benefit from individual
counseling. Ideally, this is provided by a school social worker or psychologist who has
knowledge about the impact of brain injury; if not, by an outside therapist. Savvy therapists
may create an interactive therapeutic by seeing the student with brain injury interact with one
or two peers in order to address behavioral issues in parallel to other cognitive goals.
Pushing interventions within the classroom also can be scheduled to engage a peer for similar
purposes. For some children who have sufficient awareness and memory to generalize to
other situations, social skill groups may provide learning and practice in adaptive social
behaviors. In addition, a well-trained, instinctively on-target aide is sometimes the best
therapeutic tool for implementing the necessary cues and options to help prevent and manage
difficult behaviors. Aides always should be included in planning meetings, especially when
plans are being developed to deal with difficult behaviors. Finally, medications have been
mentioned as an often essential--although never first line--response to behavioral challenges.

Principles of Consistency

The approaches outlined above are more effective when there is consistency among all staff
working with the student, school and the family. The following principles will be helpful in
promoting a consistent, integrated approach.

      Consistency within the School

Every general and special education teacher, aide and therapist must be on the same page in
both anticipating and responding to behavioral issues. There needs to be a central
"behavioral care plan" for the student that all persons are aware of and implement. If certain
principles work to decrease the likelihood of aggressiveness (i.e., frequent breaks, choices,
rewards, clarification), then each person needs to be implementing them in his/her
interactions with the student. If there is a certain response to the onset of aggressive behavior
(i.e., distraction) or impulsive outbursts (i.e., therapeutic timeout), then each person--
regardless of role--needs to be aware of and prepared to carry out the response.

      Communication within the School

In order to carry out the first principle, people need to be communicating with each other
about what works and what does not, and to formally develop a behavioral plan for the
student. This communication includes both formal and informal levels. Release time needs
to be provided so teachers, aides and therapists can meet on a regular basis--before a crisis
occurs--to make necessary revisions to the plan. One person needs to be responsible for
formulating the plan in written form and ensuring that all persons on the team have the
information. Informally, service providers should touch base in the halls and by phone about
the progress of the child, sharing information about day-to-day events and any noted
idiosyncrasies (i.e., fatigue level, illness, difficult weekend or vacation, fight with a peer).

      Communication between School and Home
This is critical. At an informal level, there should be a communication book--separate from
the homework assignments--that goes back and forth daily, in which both teachers and
parents can write observations, concerns and questions. Phone calls should be encouraged at
specified times to talk through issues that cannot be resolved through the communication
book. Periodically throughout the year, there should be formal meetings where the parents
are invited to sit down with all school personnel to discuss the child's progress and make
revisions to the program. Younger children can be involved in parts of these meetings for
feedback, support and input. Adolescents may be present during the entire meeting,
depending on the student. These meetings particularly are important at transition times (i.e.,
going from the hospital to school, graduating from one grade level or school to the next, at
the start of a new school year). Reducing the frequency of meetings and, perhaps, limiting
attendance may make sense during periods of relative stability.

      Communication among the Community Professionals, School and Family

Children with TBI often are involved on a regular basis, especially in the period immediately
following the injury. It is very important that there be open lines of communication among
those professionals, the school and the family. In part, this is for informational purposes, as
school personnel need to know the latest information about the medical treatment the child is
receiving or the goals of therapy. More importantly, it is for consistency of approach. This
is especially true if the child is receiving parallel treatments in school and at home (i.e., PT,
OT, SLP, counseling). The child will benefit most if all persons working with him/her share
a common formulation of the issues, problems, and goals. With regard to difficult behaviors,
there needs to be agreement on how to structure the environment and respond to incipient or
full-blown problem behaviors. Consistency of response is crucial. Disruptive behaviors are
maintained powerfully by periodic (i.e., inconsistent) reinforcement. Ongoing
communication also will make it possible to shift directions when one approach is not
working and another needs to be tried. Nothing is worse for a child than multiple,
fragmented and inconsistent interventions.

      Consistency between School and Home

The bottom line regarding the successful management of difficult behaviors is consistency of
structure and response across school and home. If the classroom teacher responds one way to
an outburst and Dad responds another way, no functional learning will occur. If Mom knows
how to structure homework time with breaks and rewards, but this is not appreciated by the
classroom or resource room teacher, the child will not be able to learn and contain their
behavior on a consistent basis. Consistency of approach is a prerequisite for internalization
of adaptive behaviors and long-term behavioral change. Taking time in school-family
meetings to talk through and write down a behavioral plan will pay dividends. Identifying
one person to take minutes in the meeting, write them up and distribute them to all
participants--including the family--has worked well in the BOCES TBI program. Identifying
in these minutes any changes in or revisions to the plan, as well as actions to be taken, allows
for a quick review of these issues at the next meeting and the probability that the goals will
be addressed consistently.

Families vary enormously in how eager they are to be involved in the child's school program.
It is the school's responsibility to reach out to each family, establish cooperative lines of
regular communication and develop, with the family, a consistent plan for structuring the
environment and responding to difficult behaviors. It is the responsibility of families to work
closely with the school--after all, they know their child better than anyone--and to initiate and
insist on the interactive process of the school fails to set it in motion. The child will be the
beneficiary of a cooperative approach, and that is as it should be.

Thomas Kay, Ph.D., received his bachelor's degree in English literature from Dartmouth College, a Master's degree in English
literature from the University of Rochester and a PhD in clinical psychology from Emory University. He did his internship at the
University of Washington Medical Center, and a post-doctoral fellowship at NYU Medical Center (Rusk Institute). He is
currently assistant professor of clinical rehabilitation at NYU, where for 18 years he has conducted research and taught. In
private practice, he is the consulting Neuropsychologist to the Putnam/Northern Westchester County BOCES TBI program. His
private practice involves treatment of adults with TBI, consultation to children with TBI in the school system and forensic
personal injury evaluations. He is also an adjunct professor in the neuropsychology program at Queens College of the City
University of New York. Dr. Kay has served on the boards of numerous professional and consumer organizations, and has
numerous publications and presentations internationally in the area of TBI.

Judy Spaulding has been the supervisor of the traumatic brain injury program at the Putnam/Northern Westchester Board of
Cooperative Educational Services (BOCES) in Yorktown Heights, NY since 1992. She coordinates the interdisciplinary team
that works with local school districts and the student's family to determine an appropriate educational program that integrates
all areas of the student's functioning. Ms. Spaulding also supervises the BOCES program for students with multiple disabilities.

Lola Smerdon is the social worker for the Putnam/Northern Westchester BOCES Traumatic Brain Injury Program. She has
worked at BOCES for 16 years serving children with various disabilities and has been with the TBI program since 1994. Ms.
Smerdon provides direct counseling to children who have sustained a brain injury. In addition, she works with staff and parents
to help them better understand the impact a brain injury can have on a child's life.


Ylvisaker M: Traumatic Brain Injury Rehabilitation: Children and Adolescents (Second Edition). Boston: Butterworth-
Heinemann, 1998.
        Traumatic Brain Injury and IDEA
Traumatic brain injury (TBI) is the leading cause of death and disability for children in this
country. The disability is most frequently caused by automobile accidents, sports, child abuse,
and falls. It is estimated that nearly 1 million children each year suffer head injuries in the United
States with about 16% of them requiring hospitalization.

Problems related to TBI vary greatly depending on the severity and location of the brain injury.
Difficulties stemming from TBI may be temporary or permanent and may cause partial or total
disabilities. Traumatic brain injury may cause physical, cognitive, psychosocial, behavioral, or
emotional impairments. Physical impairments may include lack of balance, paralysis, seizures,
loss of hearing, vision problems, and speech difficulties. A nonexhaustive list of cognitive
impairments includes communication difficulties, troubles with reading and writing skills, slower
information processing, a lower memory capacity, and a shorter attention span. Possible
psychosocial, behavioral, or emotional impairments include depression, mood swings, fatigue,
restlessness, and lack of motivation.

The Individuals with Disabilities Education Act (IDEA) lists TBI as a distinct disability.
According to IDEA, TBI does not include brain injuries that result from birth trauma or that are
congenital or degenerative; instead, TBI encompasses brain injuries that are caused by some
external force. For a student to qualify as having a TBI under IDEA, the injury is defined as a
total or partial psychosocial impairment and/or functional disability that has a negative effect on
a student‘s ability to gain an education. Under this definition, TBI includes open and closed head
injuries that cause adverse effects in educational relevant areas like cognition, language,
attention, abstract thinking, reasoning, memory, speech, and perceptual and motor abilities.

Although children with TBI function similarly to children born with disabling conditions,
children with TBI often require different services. The reason is that children with TBI often
remember what they were like before the injury. As a result, they may develop the above-
mentioned emotional and psychosocial difficulties.

A student with TBI is eligible to receive special education and related services. Nevertheless, the
required special education or related service may not be provided to a student suffering from TBI
because the student may be inaccurately diagnosed. Often, students with TBI are inappropriately
classified as having learning disabilities, emotional disturbances, or being developmentally
disabled. It is important that a student be appropriately classified so that a school can develop an
adequate individualized education plan.

There are many steps educators should take in helping a student suffering from TBI to adjust to
an educational setting. First and perhaps most importantly, an educator should try to help the
student‘s self esteem because of the negative effects that a TBI may have on the student‘s self
perception. Second, a relationship between the trauma center/rehabilitation hospital and the
special education department should be established. Next, educators should be aware that
students suffering from TBI may have to relearn old material. In addition, teachers should expect
that a student may forget what has been recently taught because of difficulties with short-term
memory. Other ways to help a student with TBI include having a distraction-free environment,
providing repetition, using demonstrations or providing examples for new concepts, and using
strategies to increase memory.
Classroom Interventions
1. Changes in the classroom.
In general, schools are arranged to decrease excess stimulation for the students to encourage
learning new material. Thus, schools tend to be quiet places where play activities are discouraged
and calm behavior reinforced. To the extent that this is true for the average student, it is even
more necessary for the child/adolescent with TBI. Changes in the physical setting in the school
need to be considered in order to further promote a decrease in stimulation and encourage a focus
on learning.

      Many children/adolescents with TBI do not function adequately in a regular classroom, in
       part, due to the size of the class. When there are 20 or 30 other children /adolescents in
       the class, that represents 20 or 30 sources of excess stimulation which are distracting to
       the child/adolescent with TBI. Decreasing the size of the class decreases the excess
       stimulation by simply removing those other bodies. A class size of 10 is the upper limit
       for a child/adolescent returning to school after TBI who is exhibiting attentional
       difficulties. Optimally, a class size of five would be even better with as much
       individualized attention provided as possible.
      Individual work stations would be helpful at school for children/adolescents with TBI.
       Setting up study carrels that serve to block extraneous stimulation would be appropriate.
       If these are not available, arranging work stations or centers would be appropriate where
       one or two students work at a time.
      Avoid placing children/adolescents with TBI in classrooms in close proximity to a great
       deal of activity. For instance, having a classroom right by the front entrance of the school
       where people are coming and going all day and thus creating auditory and visual
       distraction would not be appropriate. Also having a class with many windows facing out
       on a playground would not be helpful. If there are windows with some degree of
       distraction, using window blinds could be considered.
      Seating a child/adolescent with TBI close to the teacher would be appropriate for several
       reasons. First of all, to the extent that the child/adolescent responds to more structure and
       prompting than the average student, this can be accomplished more easily with the
       teacher in close proximity. Second, whatever intervention initiated by the teacher can be
       done in an unobtrusive fashion so that it does not become a topic for class discussion.
       Third, if the student is sitting near the teacher it usually means they are near the front of
       the class. This puts the other students, who are a potential source of distraction, behind
       the child/adolescent with TBI.
      It is often beneficial for the child/adolescent with TBI to stay in the same classroom as
       much as possible. The teacher may change, but the physical setting of the classroom
       should remain the same. Anytime a child/adolescent moves to a new class it is a source of
       distraction due to the new stimuli involved. When attempting to minimize excess
       stimulation, it makes sense to stay in the same classroom.

2. General Teaching Ideas
Every teacher has methods that have been developed through practice in dealing with students.
One teacher may be more directive than another. One uses time-out as a disciplinary measure
while another uses extra work. These practices should not be forsaken simply because there is a
TBI child/adolescent in the classroom. However, the teacher should be flexible in the use of such
strategies since they may not work as effectively after TBI. The following suggestions are
obvious in many cases and are already utilized with average students. In the case of the
child/adolescent with TBI, however, most likely these need to be more clearly identified and

      Children/adolescents with TBI benefit from as much individualized attention as possible.
       In any group activity they have the chance of being lost due to their attentional
       difficulties, behavioral problems, or over-stimulation leading to withdrawal. Realistically,
       the classroom teacher may not be able to provide one-on-one attention on a consistent
       basis. For this reason classrooms with a TBI child/adolescent should be provided with an
       aide or volunteer help on a regular basis.
      The teacher should anticipate having to repeat directions/comments and review past
       materials more often than with the average student. At the beginning of the day, it would
       be beneficial to briefly review the materials which were covered the previous day, then
       introduce new material with repetition of that material several times during the day. This
       repetition can be provided in one-on-one sessions or through extra work which does not
       necessarily have to be given to other students. The goal is to provide a framework for the
       student based on what has been learned in the past, then add to that framework with the
       new material and strengthen the framework with repetition.
      When a child/adolescent is struggling to provide a particular answer or generate a correct
       word, it is appropriate to provide cues before the teacher provides the answer.
       Oftentimes, the student knows the answer but cannot generate the actual wording. If the
       teacher can provide cues, with the student then actually remembering the item, it provides
       a source of self-esteem and acknowledgment that the student is still learning. For
       instance, in trying to recall a specific fact, it might be helpful for the teacher to provide
       background information about what is to be recalled and, if that is not sufficient, then the
       first sound of the word. Of course, if the child/adolescent is becoming frustrated and has
       made attempts after cueing and still cannot derive the correct information, then the
       teacher should provide that information with reassurance that next time it will be easier.
      It is often more effective to redirect inappropriate behavior on the part of
       children/adolescents with TBI than to discuss it with them, particularly within the context
       of a classroom situation. Children/adolescents with TBI may not fully understand brief
       comments made by teachers concerning their behavior, and a lengthy discussion in the
       midst of class is often impossible. It is also important not to draw attention to
       misbehavior since this may prove reinforcing or may prove embarrassing to the
       child/adolescent with TBI. Simply reminding the child/adolescent in a gentle way about
       what he is supposed to be doing is the best initial approach. Sometimes this can be
       accomplished with a visual cue known only to the student and teacher.
      As a teacher, do not underestimate the impact of positive reinforcement. We all like
       encouragement ourselves and as a general rule none of us believe we can get enough of
       it. However, we forget to encourage others. Even the simplest of comments, such as
       "Good job" or "I like your effort" can have tremendous impact on motivation and self-
       esteem. For younger children it may also be possible to use physical reinforcements, such
       as stickers or a check mark system with great impact. One must remember that
       children/adolescents with TBI are often having significant difficulties with self-esteem.
    They can often remember how well they used to perform and now cannot perform as
    well. So any means the teacher can use to improve self- esteem through positive
    reinforcement will likely pay dividends in the future.
   Working with computers is appropriate but likely requires greater attention on the part of
    the teacher than with the average student. A child/adolescent with TBI generally cannot
    direct his/her own computer program even when prompted by the computer. Someone is
    needed to give instruction. Thus, it would be inappropriate to expect a TBI
    child/adolescent to initiate interaction with the computer in a center without supervision.
   Children/adolescents with TBI require more frequent rest breaks than the average student
    due to rapid fatigue. Taking a break of five to 10 minutes every hour or so may be
    necessary. This does not necessarily involve lying down but simply focusing on non-
    academic activities, such as coloring, putting together a puzzle, or reading a magazine.
    This serves as a rejuvenation period for the injured child/adolescent and also serves as a
    demarcation between subject areas. This minimizes the chance for perseveration of
    responses when shifting to new areas of study.
   On a daily basis, the child/adolescent with TBI should write down homework
    assignments in a designated notebook. All assignments should be written in the same
    notebook used on a daily basis. The teacher should check each day to ensure that the
    assignments were written correctly and also at the end of the day check to make sure the
    student is taking home the necessary texts to accomplish the homework assignments.
    Wherever the student goes, the assignment notebook should be with him.
   If class changes are involved, it would be appropriate to write down the student's
    schedule and post it on the front of the homework assignment notebook. Due to the
    memory problems often encountered following TBI, the child/adolescent may require
    prompting in order to get to the proper class. By glancing at the schedule, the student may
    need less help from others in this regard.
   Due to motor slowness, the TBI child/adolescent may have difficulty getting to classes on
    time if there are class changes. It is not unreasonable to let him/her go a minute or two
    before the bell rings so they might get a "head start." If there is any concern about
    memory for direction and the student potentially getting lost, sending a friend along
    would be appropriate. To prevent confusion, it would likely be best if it is the same
    person who accompanies the student each time.
   Many TBI individuals cannot write fast enough to keep up with notes in class. They are
    at double jeopardy since, due to memory problems, they often cannot remember what is
    said in class adequately. Under such circumstances it is fair to designate a notetaker for
    the TBI student, who will then offer his notes on a daily basis for copying. This should be
    a formal relationship in which a person is asked to serve as notetaker on a consistent
    basis. It would not be appropriate for the notetaker to vary a great deal since this will lead
    to confusion.
   It is often beneficial when teachers give instructions one step at a time. The next
    instruction should be provided only after the preceding one is completed. As a corollary
    to this, it is often very helpful to divide large tasks into smaller components for the TBI
    student. Thus, giving an assignment of writing a report may be appropriate to the average
    student but may leave the TBI student overwhelmed. The teacher may want to break up
    that assignment into selecting a topic, seeking reference materials, outlining a report, and
    finally writing the report.
   To avoid sloppiness on papers turned in, the teacher could provide a specific format that
    is to be followed by the TBI student and others as well. This may involve having the
    name, date, and any other important information in a specific and set location. It would
    also be beneficial for the teacher to specify spacing. Sometimes, for instance, it is helpful
    to have TBI students write on every other line of the paper or to use larger ruled paper. In
    doing math assignments, the teacher should specify that only a certain number of
    problems be done on a single page. Giving the student an example of the format would be
    helpful, which can then be kept in the homework assignment notebook.
   Because of the frustration experienced by many students with TBI, it would be helpful if
    the teacher would learn to recognize early signs of irritability and intervene at that point.
    It may be possible for the student and teacher to develop a cueing system such that the
    student can unobtrusively signal when he/she is feeling overwhelmed and thus subject to
    distress. A subtle hand signal or placement of a specific object on the desk may be all that
    is required. The teacher will then know to give that student some space and time to regain
    his composure without the necessity of temper outbursts.
   Children/adolescents with TBI, due to reasoning difficulties, frustration,and disinhibition,
    may behave in socially inappropriate ways. Peers are often made uncomfortable by such
    behavior, and as a means of tension release will often laugh, making light of the situation.
    This could either embarrass the child/adolescent or encourage the behavior further. More
    so than with the average student, it is important that the teachers do not "laugh off"
    inappropriate behavior and that they discourage other students from doing so.
    Children/adolescents with TBI are often searching for means to regain the attention of
    their peers, which they perceive as having been lost as a result of their injury. it is very
    easy for them to derive attention in inappropriate ways, and at such times they need clear
    feedback concerning appropriate behavior.
   ) When inappropriate behavior occurs it is important that teachers not just correct the
    behavior by noting its inadequacy. The student with TBI needs to be told very directly
    what is expected and, if possible, the teacher and other students should model the
    behavior and provide on-the-spot practice to the TBI child/adolescent. An excellent
    example is raising the hand in class. If the student with TBI is not doing this the teacher
    needs to explain to the student that raising the hand is expected by showing the student
    what that looks like and asking the student to follow their example.
   Children/adolescents with TBI often do not respond well to embarrassment or teasing,
    particularly in group situations. Many children/adolescents can cope with teasing from
    the teacher or others because their self-esteem is such that they know that even in the face
    of such teasing they are still adequate persons. Unfortunately, the child/adolescent with
    TBI is often confused as to his inadequacy, and teasing only serves to create further
    frustration. It is also important to avoid confrontation with the student since very little is
    to be gained by forcing the student into an inflexible posture which he might not
    otherwise take.
   Use of visual cues with a TBI student may be appropriate since they do not interfere with
    the ongoing class process and do not draw attention to the TBI student, which the latter
    may find embarrassing. Using a hand gesture, such as a timeout sign, to generate quiet
    has been helpful in many instances, as has a pointing response if the student's attention is
      If there are to be any changes in the school routine for the child/adolescent with TBI, it is
       important that, if possible, the student be notified in advance. For instance, if a teacher is
       going to be out for the next several days , it might be helpful if that could be explained to
       the student in advance. Also, scheduling changes, such as having to attend an assembly,
       need to be discussed in advance if at all possible. If it is not possible to discuss such
       changes in advance, then the child/adolescent ought to be notified and provided more
       time than the average student to adjust.
      Consistency in the classroom is extremely important to children/adolescents with TBI.
       Maintaining a routine is often like an anchor in a storm for the student. Students with TBI
       may be having difficulty figuring out things around them and rebuilding their self-
       esteem, but if they can return to a routine there is a sense of structure and confidence.
       Teachers that tend to be relatively unpredictable and engage in activities on the spur of
       the moment often have difficulty working with TBI children/adolescents.
      Use of humor may be very important to the recovery of the TBI child/adolescent. The
       humor should not extend to ridicule and should likely take place in a one-on-one setting
       between the teacher and the student. Allowing the student to laugh at himself and others
       provides perspective on problems and may provide an opportunity for intervention which
       might otherwise be very difficult. The child/adolescent may need modeling in order to
       engage in this sort of behavior and therefore the teacher in a one-on-one setting should be
       able to laugh at himself.
      As a general rule, teachers should plan on having more contact with the parents of the
       TBI student than parents of the average student. In some cases, daily contact through
       notes or a checkmark system may be necessary to implement behavioral management
       strategies. For instance, a student may receive a reward at home if he/she performs well
       during the school day. This requires some communication on a daily basis between the
       teacher and parent. Conferences with parents at school should be planned more regularly
       than with the parents of the average student. Teachers need to be aware of problems
       arising at home since these may begin to surface at school as well. An excellent example
       is aggressive behavior towards others. Often this is first noticed at home towards siblings
       and then may become evident at school.
      When it comes to behavioral or emotional problems the teacher should set realistic goals
       in addressing the problem. It is unrealistic in most cases of TBI to expect a total cessation
       in misbehavior. The goal, therefore, should be a decrease in the frequency or intensity of
       the behavior rather than a total abolishment of the behavior. An excellent example is
       failure to raise the hand in class at appropriate times. If with a reinforcement and cueing
       program the child/adolescent is able to decrease the incidence of the behavior from six
       occurrences a day to two, this would be considered a success.
      Children/adolescents with TBI often do not cope well with decisions due to reasoning
       difficulties. They can be easily overwhelmed by what others might consider simple
       decisions, such as what to get for lunch. Teachers may help with this problem by
       decreasing the number of choices involved, and if necessary, making it a yes/no decision.
       If this is too difficult, then the teacher can make the decision for the child/adolescent.

3. Curriculum issues
Placement of a TBI student in a curriculum is often one of the more difficult decisions that has to
be made. The classroom teacher can consult with a rehabilitation team, including a speech
therapist and neuropsychologist, as well as specialists in the school system. It is often beneficial
for individuals who are familiar with head injury and the child/adolescent's particular
performance at the time of school entry to talk with representatives from the school and, if
possible, the classroom teacher. Improved communication can only help. It should also be
recognized that placement in a particular curriculum or program may be short lived for the TBI
student since progress is evident over time. A common progression for the child/adolescent with
TBI is to start with a homebound education program while still receiving intensive outpatient
therapies at a rehabilitation center. In many cases, rehabilitation centers now have homebound
teachers on site. This may be followed by reintroduction into a classroom setting on a half-day
basis, necessitated by the fairly rapid fatigue experienced by the child/adolescent. An initial
placement in special education services, such as for children/adolescents with learning
disabilities, provides a smaller class size and the attention of teachers who are accustomed to
learning difficulties.

For those students who might need a review of material from previous school years, it is often
uncertain as to where to start. As a general rule, it is logical to start approximately two grade
levels below the level of ability existing prior to the injury and then review material in a
sequential fashion. In many cases it is possible to review and move on quickly since with some
basic reminding the skills may return. On the other hand, the teacher needs to be sensitive to the
presence of gaps in recall which will require more review and study time. For instance, a
younger student may be able to perform addition and subtraction quite well after a quick review
but then struggle with multiplication. The closer one gets to skills which existed at the time of
injury the more likely these gaps are to occur.

Testing of children/adolescents with TBI is often a very difficult experience due to their
slowness, memory difficulties, and problems in expressing themselves. Teachers should
anticipate that children/adolescents with TBI will require more time than the average student to
complete assignments and tests. For instance, it may be possible to have the student complete
part of the test in class and take the rest of the test during a study hall or at home that evening.
Sometimes it is also beneficial to alter the presentation of the test or the response required. For
instance, if a student has significant problems with handwriting slowness, it may be possible to
allow verbal responses. Also, if there is significant difficulty with reading slowness, having the
test read to the child/adolescent might be beneficial. In most cases it is advisable to avoid
comprehensive tests for children/adolescents with TBI, although this becomes increasingly
difficult as they progress in their education. Comprehensive tests place a great deal of emphasis
on memory and "cramming" skills. The amount of time it takes a TBI child/adolescent to study
for a comprehensive test can be phenomenal and the results marginal.

It is important not to overload children/adolescents with TBI with homework. Recall that the
level of fatigue is greater among these children/adolescents and their slowness in completing
tasks must be considered. Homework assignments for these children/adolescents might be the
same as for other students but less demanding. For instance, assigning half the number of
problems in math or answering two instead of four questions. Because of the child/adolescent's
difficulty in completing homework assignments, teachers should be wary of parents helping the
children/adolescents too much and actually completing the homework assignments. This is a
tempting situation when one sees a child/adolescent struggling, becoming fatigues, and
increasingly frustrated. It might be helpful for the teacher to provide some guidelines for the
parents as to how much help they can give the student. It might be appropriate, for instance, for
the parents to cue the student without providing specific answers. Because of the difficulty in
completing assignments, it is often beneficial for children/adolescents with TBI to be allowed
extra credit that might not be available to the average student. For instance, completing a simple
project reflecting some understanding of what has gone on in class or doing some extra work that
is not under time constraint could be considered.

Placement of children/adolescents with TBI in a special education curriculum is often a necessity
since they may not function well in a standard curriculum. However, difficulties often occur due
to the designation of the TBI child/adolescent based on special education criteria. It is not
uncommon for TBI children/adolescents to not fit the criteria for EMR, LD, or EC. A relatively
popular designation over the past several years has been Other health Impaired (OHI), which
places children/adolescents with TBI with students who have persistent health problems, such as
diabetes or muscular dystrophy. Unfortunately, there is no specific training program for OHI
teachers in most areas of the country. These classrooms are often not large enough to stand on
their own and therefore these students are blended with the other existing special education
programs. Most likely, the number of children/adolescents with TBI identified in schools will
increase since federal law now recognizes TBI as a special education designation. Unfortunately,
guidelines for teachers dealing with TBI students are still lacking. This manual, part, is intended
to address those gaps in understanding.
  Assessment - What Does this Really Mean
              for Your Child?
                                    by Marilyn Lash, MSW

  Assessment is a term used by professional case managers. It can involve anything from
determining a person's need for intensive rehabilitation to setting up temporary home health care
to developing a financial plan for life long care. Therapists and educators and also use
assessment to identify needs, strengths and difficulties as they design treatment and educational
plans. Assessment is a preliminary and necessary step before setting goals.

  While formal testing, examinations and consultations are often used by professionals in this
process, assessment is a skill that need not be limited to doctors, case managers, therapists or
educators. Parents are also capable of assessing their child. Once you take away the jargon,
assessment really asks the fundamental question of all parents after their child has had a brain
injury, "How has this affected my child?"

  No one will ever know a child better than parents. They see their child in all types of situations
- when rested or tried, when relaxed or under stress, when focused or confused, during the day or
at night. Parents are also eyewitnesses to their child's ongoing recovery from the brain injury as
well as their child's ongoing growth and development.

  Yet too often, parents voice frustrations of not being taken seriously by medical or
rehabilitation staff. As one parent said, "The only initials I have after my name are MOM."
Sitting in a roomful of educators at a special education team meeting can be intimidating as
reports are given and goals and objectives negotiated.

  Rather than feeling like an outsider, parents can and should play a central role in any
discussion about their child. They have unique experience and perspective. The ability to quickly
and accurately describe their child is a skill that parents can use repeatedly whether they are
meeting with the neurologist, speech and language pathologist, neuropsychologist or special
education coordinator. Think of it as putting together a verbal snap shot of your child. Ask
yourself, "What are the most important things for this person to know about my child?"

  As children leave the medical or rehabilitation program, parents become the critical link for
passing on information to educators, consultants, and others who may be less familiar with brain
injury. By developing this verbal picture, parents can help others understand their child. This is
the first step in negotiating or advocating for services.
                                             Step 1.

 What needs to be included? There are some fundamentals or basics to include:

Current age of child                               Length of coma
Age when injured                                   Medical & rehabilitation treatment received
Cause of injury                                    Current grade in school
Severity of brain injury                           Changes seen at home
Changes seen at school


  My son, Tom, is now 14 years old and in the 8th grade. He was 11 when he had a brain injury
after being hit by a car while riding his bike. His injury was so severe that he was in a coma for 6
days. After spending 2 weeks in the hospital, he was moved to a rehabilitation program where
he stayed for 6 weeks until he came home. While he has physically recovered really well, school
is much harder for him now and he repeated the 6th grade. His biggest problems are his short-
term memory. He's having a much harder time in school this year since he changes classes and
teachers 6 times a day. At home, we notice that he still needs more sleep and everything is just a
bit harder for him when he gets overtired.

  By giving specific information about Tom's injury, the effects are clear. Compare the above
example to the parent who focuses on dissatisfactions with the school.

  The problem is that the teachers just don't understand brain injury and don't know how to help
him. I've tried talking to them and nothing has changed. He stayed back last year and he's still
failing three subjects this year. They've got him in special education but none of the aides have
had any training in brain injury so how can they help him? I don't know what to do next.

  While this parent has legitimate concerns about the school's experience and training, the focus
here is on the what's wrong with the school, not how to help the student. When this approach is
taken, it usually results in a stand off with teachers becoming defensive while parents' frustration
and anger mounts. There is a time to blow off steam and there is a time to build relationships by
sharing information. In the example above, educators still know little about the child, but they
know a lot about this parent's feelings.

 Step 2 Once the basic history of the injury has been given, parents can describe their child's
                     abilities and needs. When thinking about this, consider...

What are your child's strongest abilities?
What are your child's major difficulties?
What help or services is your child receiving now and how effective are they?
What other help do you think is needed and why?
Example Tom has great social skills. He's a great talker and can charm anyone. It's one of the
  ways that he compensates or covers up for his difficulties. But that's also why it's hard for his
     teachers to understand that he needs special help. He's easily distracted and has trouble
   organizing himself because of the damage to his frontal and temporal lobes. That's why his
  homework is often late or incomplete. We know he can do the work, it's the organization and
                        paying attention to his work that's hard for him.

  At home, we now go over his homework assignments before he starts, check midway through,
and then double-check that everything is done before he goes to bed. This has helped a lot. The
problem is that he doesn't get a head start on his homework at school, so it takes him all evening
to finish up. I'm going to ask the aide who works with him at school to set up a similar system in
his homeroom and study periods so he can get an earlier start on his homework.

 Step 3 Assessing the effects of a child's brain injury is an ongoing process for parents. It is
constantly changing as your child grows up and as school changes each year. The following tips
can help parents describe their child as they advocate and negotiate for the help and services that
                                            are needed.

Compare abilities before & after the injury
Look at changes over time
Look at changes in behavior at home
Talk with your child
Keep track of grades at school
Talk with teachers, therapist and specialist
Review educational plans, medical and rehabilitation reports
Set up a 3 ring binder notebook to organize reports and information
Gathering Information When a Student has a
               Brain Injury
                                        by Marilyn Lash

Each school year brings many changes for students, teachers and parents.

Fears, frustrations and uncertainties may accompany exciting changes when a student has a brain
injury. Will classmates treat me differently now? Will the teacher know how to help me? What if
I can‘t keep up?

Not only do classmates, teachers, room assignments and books change, but the content and type
of school work changes with each grade. As schoolwork becomes more complex with each
passing year, the brain is challenged in new ways. Recovery from the injury and ongoing brain
development are occurring simultaneously for this student. It is over time that the long-term
effects of a student‘s brain injury become fully evident as learning becomes more complex and
schoolwork is more challenging.

Begin with Information

There is a lot going on and it‘s not surprising that educators, students and parents often aren‘t
quite sure how to begin. The place to start is with information. Regardless of when the student
was injured, information is the key to helping the educational team understand and meet the
needs of this student. The following list helps parents and educators get started. Try to include
the student in this process whenever possible.

Step 1. Set up a meeting with parents and all teachers and staff involved with the student.

Step 2. Review medical and rehabilitation information about the severity of the student‘s injury,
current medications and side effects, and ongoing therapies.

Step 3. Review reports from specialists, including therapists and neuropsychologists, to
understand which parts of the brain were injured and possible consequences for learning and

Step 4. Have samples of the student‘s work from the previous school year, including

      effective instructional strategies
      compensatory strategies for memory, organization, and planning
      techniques for managing behaviors
      adaptive devices
      schedule changes because of fatigue
Step 5. Review what special services or supports were provided last year, what worked and what
was not helpful. Make sure everyone has a clear understanding of this student‘s strengths,
difficulties and needs.

Step 6. Set up a plan for regular feedback and communication between the educational team and
parents. Don‘t wait for problems to develop.

Step 7. Identify resources within and outside the school who can provide in-services on brain
injury and consultation.

Step 8. Be flexible. Recovery is a continuous process, especially in the first 1-2 years after brain
injury. Goals and objectives need to be continually revised as the student‘s needs and abilities
change. The educational plan needs to a flexible tool, not a fixed written document.

Step 9. Prepare for transitions. Consistency and structure are very important for the student with
a brain injury. Any change, not matter how small, needs careful preparation for the student to

Step 10. Look ahead. Time passes and students grow up. The ultimate measure of a student‘s
education is preparation for adulthood. Don‘t wait until senior year to think about what happens
next. Transition planning under special education must begin when the student is age 14. A plan
must be put into action by age 16.

Parents have a special role and perspective in gathering information. No one knows their child
better. They not only have the comparison of their child before and after the injury, but they have
seen their child progress through the various stages of medical care and rehabilitation. Parents
are the link between various teachers, classes and schools. Use their experience to understand
how to teach this student effectively and plan on involving parents in this process. If parents are
to be able to help students with homework and support the efforts of teachers, they must be an
integral part of the educational team. Only if parents and educators work together can there be an
effective educational plan that will truly benefit this student.
          Interviewing is a Two Way Street
           Between Parents and Educators
                                     by Marilyn Lash, MSW

Too often I hear a parent say, "But I'm just a Mom...." Yet Moms and Dads are the most
important people in a child's life. They are also critical resources for information when a student
has a brain injury. Although involvement of parents is required under the law for students
receiving special education, too often involvement is limited to infrequent meetings that focus
more on the paperwork of special education than a mutual discussion of the child's needs and

It's not always easy for parents and educators to communicate. Schedules of working parents
and teachers often don't match easily. When teachers meet after a full day of classes and parents
take time off from work or arrange for childcare for other children, time to sit down together may
be limited.

Yet it is the communication between educators and parents that can be so beneficial in
understanding how this child is doing at home and in school. Both parties have valuable
information and perspectives to exchange. But communication is often stymied if educators or
parents are unsure of where to begin or what to ask. Here are two checklists to help parents and
educators initially open up channels for communication. Think about how you can use these as a
starting point and how to modify them for your situation.

 Checklist for Educators
 Start by setting up a meeting...

  before the student returns to school after an injury
  when the students moves to a new grade or school or
  if any changes in grades or serious difficulties are reported.

 Step 1 Ask a parent to describe the student's brain injury, including...

  when the student was injured                        how it happened
  how serious the brain injury was                    if the student was in a coma and, if yes, for
                                                     how long
  if there were other injuries                        how long the student was in the hospital
  if the student went to a rehabilitation program?
Step 2 Ask a parent to describe the student

While medical records provide a lot of detail and educational testing gives even more
information, parents are with their child every day. Gathering testing and writing reports can
take many weeks or months, but the teacher is in the classroom with the student every day.
The educator doesn't have the luxury of waiting to gather testing reports before teaching the
student. Involving parents as early as possible in the school year can help educators know
what to expect and develop strategies for the classroom. Don't wait until there is a problem to
contact parents. Gathering information from parents can help prevent problems down the

Ask a parent to describe how the injury has affected the student...

Parent reports changes in:

                              Yes        No                                      Yes     No
      physical abilities      ____     ____            energy and fatigue      ____   ____
      speech and language     ____     ____            vision                  ____   ____
      hearing                 ____     ____            behavior                ____   ____
      judgment                ____     ____

Other _________________________________

Ask a parent about the child's thinking and learning since the brain injury...

Parent reports changes in:

                               Yes       No                                      Yes     No
      attention               ____     ____            concentration           ____   ____
      memory                  ____     ____            organization            ____   ____
      planning                ____     ____            reasoning               ____   ____
      problem-solving         ____     ____

Other _______________________________
Ask a parent how the injury has affected the student emotionally...

Parent reports changes in:

                              Yes      No                                     Yes     No
      confidence             ____    ____             temper and            ____   ____
      friendships            ____    ____              irritability          ____   ____
      social skills          ____    ____             awareness of others   ____   ____
                                                       sexual comments or

Other _____________________________
Ask a parent to describe how help is given at home...

Parent reports student needs help with:

                              Yes      No                                     Yes     No
      reminders and          ____    ____             organization and      ____   ____
       memory aids                                      planning
      cueing strategies      ____    ____             homework              ____   ____
      managing behaviors     ____    ____             making decisions      ____   ____
      reading                ____    ____                                    ____   ____
      communicating          ____    ____             writing

Other _____________________________
Ask a parent for thoughts about how the student is doing in school including...

      areas where the student is doing well             difficult subjects, classes or special
      strategies used by teachers that have              areas
       been helpful                                      changes in grades since the injury
      completion of homework

Other _____________________________

Checklist for Interviewing Specialists

There are many situations that can lead to a request for consultation or training by a specialist
in brain injury. Members of the educational team may feel that they need someone more
experienced in brain injury to guide them. Parents may question the experience of school staff
and ask that a consultant or specialist be involved. Negotiating this request can be quite
simple or difficult. Sometimes resistance to outside specialists or consultants by the
educational team is based on disappointing experiences in the past. Concerns about the
expense may be raised.

Both educators and parents agree that the goal of involving a specialist is to better understand
and help the student. Yet not all professionals experienced in brain injury are effective in
working with educators. Making this match is an important part of the process, regardless of
whether the specialist is a neuropsychologist, speech and language pathologist, occupational
therapist, social worker, or any other discipline.

Because many educators are unfamiliar with the consequences of brain injuries for learning,
finding local experts can save a lot of trial and error. Finding the right specialist is largely a
matter of asking the right questions. Children and adolescents are very different than adults.
While there may be many professionals experienced with adults with brain injuries, their
knowledge and skills may not necessarily be what you are looking for to work with students.
Making the right match can avoid a lot of frustration, disappointment and expense.

The following list serves as a guide for parents and educators when interviewing professionals
about their experience with students with brain injury.

Checklist for Interviewing Specialists or Consultants (check as many as apply)

                                                                               Yes       No
Do you have experience with children or adolescents with brain injury?         ____     ____
Do you only see youths in medical or rehabilitation settings?                  ____     ____
Do you primarily see youths within the first year of their injury?             ____     ____
Have you worked with youths more than one year after their injury?             ____     ____
Do you have experience working with school systems?                            ____     ____
Do you prefer to see the student...

                              Yes      No
      in your office         ____    ____
      at school              ____    ____
      in the classroom       ____    ____
      at home                ____    ____

Are you available to talk with...

                              Yes      No
      parents                ____    ____
      educators              ____    ____
      therapists             ____    ____
      team members           ____    ____
      peers/classmates       ____    ____

Can you provide...

                                                   Yes     No
      in-services for school staff                ____   ____
      education for peers/classmates              ____   ____
      observation of student in classroom         ____   ____
      meetings/discussion with educational team   ____   ____
      input at IEP meetings                       ____   ____
      other_________________________

Do you provide...

                                                   Yes     No
      testing                                     ____   ____
      functional evaluations                      ____   ____
      on-site observation                         ____   ____
      consultation for problem-solving            ____   ____
      written reports                             ____   ____
      other_________________________

What kind of follow-up can you give...

                                                   Yes     No
      written reports                             ____   ____
      telephone consultation                      ____   ____
      school based meetings                             ____      ____
      office meetings                                   ____      ____
      other__________________________                   ____      ____

What is your time frame...

                                                   Yes             No
      available immediately                    ____            ____
      waiting list (how long) ________________

Use the Grapevine

One of the best resources for checking out specialists is other schools. Many school
psychologists, case managers, social workers and special education directors have experience
with consultants and are willing to provide feedback on their services. Parents also have a
network of contacts with other parents, as well as professionals, and can be active partners in
selecting a consultant.
         Learning about Special Education
                                        by Marilyn Lash

Where do I start? This is the question often asked by parents of recently injured children as they
enter the complex system known as special education. Educating a student with a brain injury is
a complex and challenging process that constantly changes over time. As one parent commented,
"The only constant is change."

The Informed Consumer

Parents can only be effective advocates if they are knowledgeable. The federal law on education,
the Individuals with Disabilities Education Act (IDEA), has a specific category for traumatic
brain injury under special education. The federal definition is limited to traumatic injuries to the
brain that are caused by an external physical force (such as a blow to the head). But many states
have broadened this definition to include acquired brain injuries (strokes, tumors, encephalitis,
meningitis, near drowning). Readers can find out how their state defines brain injury by
contacting the state Department of Education or their local special education director.

The diagnosis of a traumatic or acquired brain injury does not automatically qualify a student for
special education. The diagnosis is just a beginning. Once a referral for special education has
been made, the school conducts a multidisciplinary evaluation. This evaluation determines how
the brain injury has affected the student‘s ability to learn and function in school. Federal and
state laws provide very specific procedures and timelines for this process.

The education law guarantees parents certain rights and responsibilities. It is important for
parents to know their rights under this law and to be involved. This article identifies four
important resources for parents, advocates and educators injury.


This is the National Information Center on Children and Youth with Disabilities. It is an
excellent place to begin to understand how special education works. This federally funded
national clearinghouse provides information on disabilities in children and youth (birth to age
22). It specializes in fact sheets and guides that are written just for parents. Many materials are
free or have a minimal charge. Their Publications Catalog lists their many products and is a
gateway to information. You can even find a list of Resources in your state.

You can check it out on the web at or call 1-800-695-0285 or 202-884-8200.
NICHCY‘s address is PO Box 1492, Washington, DC 20013-1492.

Fact Sheet on Traumatic Brain Injury
NICHCY also has a four-page fact sheet on TBI that provides an excellent overview of the
consequences of brain injury and it effects upon a student‘s learning. Sections include What is
TBI? How Common is TBI? and Signs of TBI. The section on school describes how a brain
injury can affect a student and provides tips for teachers and parents. Resources direct readers to
books and manuals about students with brain injuries. It can be ordered at the above numbers
through NICHCY.

Special Education IEP Checklist for a Student with a Brain Injury

Once a student has been found eligible for special education, the educational team develops an
individualized educational program (IEP) to meet the student‘s special needs. This is the
blueprint for the student‘s education. Parents are an integral part of this plan. The IEP is not just
a pile of paperwork that sits in the student‘s folder. It is a flexible and critical tool that should
change, as the student‘s needs change.

Because a brain injury affects each student differently, there is no standard content for this IEP.
This IEP checklist identifies common changes after a brain injury. It lists student
accommodations or assistance that may be needed for thinking and communication, developing
social skills, and adjusting to physical changes. Teaching strategies, methods for giving
instructions and assignments, and types of adaptive aids are listed for use is the classroom.

This tip card is available for free by contacting Lash and Associates Publishing/Training at 708
Young Forest Drive, Wake Forest, NC 27587 (919)562-0015 email at or visit their web site at

Parent Centers

Children with birth related conditions, mental retardation, chronic illness and cancer have wide
informational networks and advocacy systems. This includes Parent Training and Information
Centers in each state.

Parents of children with brain injury often overlook these centers. However, they are valuable
resources because they "know the special needs system" in their state, especially the laws and
regulations for special education. Parent Centers are excellent resources for gathering
information, asking questions and meeting professionals and parents. Many even provide
advocacy workshops for families, training programs, conferences, newsletters, and support

To find links to state resources for parents on special education, go to

Broaden Your Network

Look beyond the diagnosis. Parents of children with other disabilities can be valuable mentors
and sources of information. They may have years of experience negotiating special education
services, finding funding for uninsured expenses, locating recreation programs, and maneuvering
through the red tape of bureaucracy. Their savvy can help parents of recently injured children
understand how the system works and what to do when it gets stuck or breaks down. Learn from
each other.
Frequently Asked Questions About Brain
  Injury In Children And Adolescents
It is not unusual for...

       parents to know little about brain injury until their child is hurt
       relatives to be unsure what to say and how to help
       educators to have no experience teaching a student with a brain injury until there is a
        student in their class
       friends to drift away over time because they don't understand why a child with a brain
        injury seems "different"
       professionals in the community to have little training in brain injury.

This is because many children, adolescents and young adults with brain injuries did not survive
until 15-20 years ago. Due to the advances in emergency medical services and trauma care, the
number of survivors of brain injuries has increased. Now brain injury is the number one cause of
disability among children. Because this is a relatively new population of survivors, many
educators and professionals did not receive information about brain injury during their education
or training. It is often when it happens to your family, when there is a student in your school, or a
patient in your care, that gathering information becomes important and necessary.

                            Behavior After Brain Injury FAQs

Why does our daughter act much younger than her peers do since her injury?

Social immaturity is one of the common consequences of brain injury. Some children and
adolescents seem "stuck" at an earlier developmental stage. This can make it difficult for peers
and friends to relate and may even lead to ridicule or social isolation for the child with a brain
injury. Altered social skills can be very difficult for adolescents with brain injuries when peer
pressures for dating, appearance and "fitting in" increase.

After a brain injury, a child may not be able to remember as well as before. This child will need
to be taught strategies to help remember things. The same holds true for social skills. A child
with a brain injury may need to be taught particular social skills that before the injury would
have been learned naturally. Teaching a child how to greet new people, how to recognize
nonverbal communication, how to look well groomed and clean, or how to act in public are all
skills that may need to taught and practiced with a child with a brain injury.

Will traditional behavior management techniques work for a student with a brain injury?
The traditional approach to managing behavior is based on the model of antecedent, behavior
and consequence. The antecedent is what happens before the behavior, the behavior is the action,
and the consequence is what happens as a result of the behavior. For example, if a child is asked
to turn off the television (antecedent), refuses and throws a tantrum (behavior), the child may be
sent to bed or given a time-out (consequence). This approach emphasizes the consequence of the
behavior. Most children learn to change their behavior to avoid negative consequences or

This consequential management often does not work for children with brain injuries. The child
may not remember the rules. Changes in insight and self-awareness may make it difficult for this
child to learn from the consequences of behaviors. Think of the old saying, "The horse is already
out of the barn." Punishing children AFTER the behavior has occurred may not help them learn
how to self monitor or recognize when they are overwhelmed or confused.

A more successful approach for youths with brain injuries emphasizes managing what is going
on before the behavior occurs. Once the antecedents are identified, they can be changed to
prevent the behavior from happening. For example, a student may not be following instructions
or paying attention in class because of distractions from other students or hallway activity. This
distractibility and difficulty focusing can be the direct result of a brain injury that detention and
reprimands will not change. By moving this student's desk to the front row, the student may be
less distracted and better able to pay attention to the teacher.

Why has our child's behavior become so difficult to manage since the brain injury? He was
never like this before the accident.

Certain areas of the brain, such as the frontal and temporal lobes, monitor and direct behaviors.
When these are damaged, a child may have difficulty controlling temper, actions and feelings.
Even the child's personality may seem different. Common changes in behaviors after brain injury
include restlessness, hitting, swearing, impulsiveness, and difficulty following directions.

Many children and adolescents remember how they were before their brain injury. This can also
result in emotional reactions that contribute to changes in behaviors as youths struggle to gain a
new sense of self.

What a neuropsychologist and how can this person help?

This is a psychologist with additional special training in the relationship between the brain and
behavior. A neuropsychologist can evaluate how a brain injury affects a child or adolescent's
learning, communication, planning, organizational skills and relationships with others. Once the
causes of the behavior are understood, the neuropsychologist can recommend compensatory
strategies for use and help parents and educators respond to behaviors.
How do I know what is "normal" adolescent behavior and what is related to the brain

This is one of the most difficult questions to answer and one of the most frequently asked by
parents. Adolescence is known for its storminess with the many rapid physical and hormonal
changes that are going on at the same time as social and academic pressures are increasing.

The brain continues to develop right up through adolescence so new difficulties may now
emerge, especially if the frontal lobes which affect impulse control and emotions have been
damaged. The impulsiveness and mood swings that we expect from adolescents may be
compounded and worsened by a brain injury that affects these control centers. An evaluation by
a neuropsychologist can help identify behaviors that are directly related to the brain injury.

Will medications help?

Many children with brain injuries have short attention spans, are easily distracted and have
difficulty following instructions and directions. Some become fidgety, impulsive and
hyperactive. Because these symptoms are similar to those in children with attention deficit
disorders, many parents and educators ask if medication will help.

This requires careful evaluation by a physician. When a child has a brain injury, it can cause
physical injury to the neurons (brain cells) and to brain tissue. But it can also cause chemical
changes in the brain. Some medications are designed to help children learn and pay attention
better; others are used to control seizures or help manage challenging behaviors. But some
medications have side effects that can affect alertness, memory, moods, sleep, or appetite. Any
consideration of medication requires a physician experienced in brain injury and careful

                    Brain Injury in Children and Adolescents FAQs

Does a brain injury affect a child differently than an adult?

Unlike an adult, a child's brain is still developing right up through adolescence. An injury
interrupts this development. Different parts of the brain develop at different ages or stages of a
child's maturation. Consequently, the full impact of a child's brain injury may not become
evident for many months, or even years, until the brain matures. It takes longer for the effects of
a brain injury to be seen in children and the consequences can change over time.

By comparison, an adult's brain is fully developed. This accounts for the dramatic "before and
after the brain injury" changes that are so common. Unlike children, an adult has a lifetime of
skills, knowledge and experience of education and work that can be used to adjust to the changes
caused by the brain injury. This does not mean that it is easier for the adult who has had a brain
injury; it is different because the life experience is different.

How is a child with a brain injury different from a child with a birth related disorder?

Children with birth related conditions often have diagnoses that are related to heredity, prenatal
development, or delivery complications. Examples are mental retardation and cerebral palsy. The
child's development is altered or at risk from infancy. Diagnosis is often made early when the
child does not progress and reach the normal developmental milestones.

By contrast, it is the ongoing "normal" brain development and functioning that is interrupted in
children with brain injuries. It can occur at any age. From that point on, the child's development
may be delayed or altered because the brain has been injured and damaged.

There are two types of brain injuries. Traumatic brain injuries are the result of an external force
from a trauma or blow to the head. Examples are when the child's head hits the windshield
during a car crash or strikes the floor or ground after a fall. Acquired brain injuries are caused by
internal changes as the result of a stroke, tumor, or disease like meningitis or encephalitis.

Does the age at which a child has a brain injury make a difference?

Yes. The younger the child is when injured, the less developed and more vulnerable to injury is
the brain. It used to be thought that younger children were more resilient and "bounced back"
after a brain injury. Now, we understand that it simply takes longer for the effects to be seen. It is
important to track progress and change over time as the young child's brain develops and

Does a history of a traumatic brain injury mean a child is eligible for special education?

The category of traumatic brain injury was added under the federal education act in 1991
(Individuals with Disabilities Education Act). The category is used in all states. However, the
diagnosis or history of a traumatic brain injury does not automatically qualify the student for
special education. It must be shown that the brain injury has affected the student's ability to learn
and function in school. Once a referral for a special education evaluation has been made, the
school conducts a comprehensive assessment to determine if the effects of the brain injury and
the student's needs meet the requirements for eligibility for special education under the state's
Does it make any difference what category or classification is used under special education,
as long as the student is found eligible and receives services?

Yes. Before the change in the education law, many students with brain injuries were incorrectly
described as mentally retarded, learning disabled, or emotionally disturbed. A brain injury can
have unique consequences for learning, behavior, and communication. Identifying the student
accurately under the classification of traumatic brain injury helps educators recognize the
condition and it consequences. They can then develop educational strategies and programs that
are individually designed for that student.

                Speech and Communication After Brain Injury FAQs

I often hear the term cognitive communication. What does that really mean?

Communication is much more than words. It involves listening, speaking, and reading, writing
and gesturing. Cognitive communication is the combination of thinking skills and language. It is
the ability to use language and all the underlying skills for communication, including attention,
memory, self-awareness, organization, problem solving and reasoning. When these thinking
skills are combined with language, the result is communication.

Our son was doing pretty well in school until he went to junior high school. Now he has a
lot more reading assignments and homework. Even though he spends much more time on
his homework, he can't seem to keep up and is falling behind.

As a child grows up, new difficulties in learning or language can appear as reading, writing and
thinking become more complex in school. It is important to monitor a student's language
development and learning skills through adolescence.

As students enter middle, junior high and high school, the nature of school work changes. Much
of school work now requires abstract reasoning and problem solving that places new demands on
different parts of the brain than were used in earlier grades. Multiple classes and teachers mean
different teaching styles and homework assignments. Any difficulty with these changes is an
indication that a student's cognitive communication abilities need to be reevaluated.

Our child is non-verbal. I hear a lot about augmentative communication and technology,
but it sounds complicated. Could this help and how expensive is it?

Augmentative communication doesn't always require technology, such as computers, and it
doesn't have to be expensive. An augmentative communication system means that devices or
methods help existing communication skills. Sign language, picture notebooks, word boards, and
tape recorders can be part of an augmentative communication system. Even when computers are
involved, prices vary. Choosing the level of technology depends on how and where the device
will be used, costs, maintenance, and repairs. The personal choice of the user is a major factor in
the decision. There are so many options that they are often described under three categories of
"no, low or high" technology.

Who pays for communication systems?

There are many possible sources but getting approval can be complicated, especially for more
costly systems. If the system is needed for learning, then funding through special education is
possible. A doctor's prescription may help with payment under insurance plans. Funding through
the Medicaid program of Bureau for Children with Medical Handicaps is possible, but
regulations vary from state to state. Vendors can provide advice on funding options.

Because funding is complicated, it is important to try out or rent a system before purchasing it.
Many companies have loaners for trial use. Renting a system may be preferable if the child's
needs are rapidly changing. Advocacy by parents and professionals, and even appealing denials
for payment, can lead to approval.

Our son's speech was really slow and difficult to understand for several months after his
brain injury. As he made physical progress, his speech also improved. Is there any reason
to have him followed by a speech pathologist now he is back in school?

The ability to speak and hold conversations can be misleading. Language skills often return after
a brain injury, but communication can still be affected. While conversation may seem "normal"
in non-stressful situations, this can change when the child or adolescent is tired or under stress.

Changes in communication in youths are mostly likely to show up in school under the pressures
of time, being graded, completing assignments and keeping up with classmates. A speech and
language pathologist can evaluate ongoing progress, identify problems and help the student
develop compensatory strategies. As part of the educational team, the speech pathologist can
help others recognize and respond to changes in cognitive communication.

How do we find a speech and language pathologist who has experience with students with
brain injury?

Speech and language pathologists may be licensed in their state and may also be certified by the
American Speech-Language-Hearing Association. When choosing any professional, it is
important to ask questions to make the right fit between a specialist, your child and your family.
Look for a speech and language pathologist who has experience with brain injury and who has
worked with clients of similar age. If your child is in school, look for a speech and language
pathologist who regularly works with schools and is familiar with special education.

What are some of the changes or warning signs that parents and educators can watch for?

Too often it is failing or lowered grades that signal difficulty. It is important not to wait until the
student is in trouble to get help. Early warning signs that an evaluation by a speech and language
pathologist is needed are: speaking or writing that is disorganized, difficulty concentrating and
paying attention, confusion when new ideas are introduced, a slower rate of handling
information, and difficulty learning new vocabulary or grasping ideas. By evaluating these areas
every three months during the two years following a brain injury, difficulties can be spotted early
and help provided before the student fails.

If technology is needed for communication, what should we look for?

Hardware (the machine or equipment) and software (the program that run the computer) can be
standard "off-the shelf" items found in most computer stores or can be customized for the
individual's needs. Look for what methods are used to select messages (pointing, typing or
pressing a switch). Voice output produces sounds so that messages are stored in a device and
retrieved by choosing a key or picture on the board (digitized output). A device can even speak
once messages are typed in or stored (synthesized output). There are many choices for keyboard
design such as pictures, bigger or smaller keys, and keys with guides to help position fingers.
Some screens speak when touched or have menus that lead to message screens. The size and
weight of a devices is another consideration as if affects how portable it is. The point is that there
is no one answer for everyone. Technology must be carefully matched to the needs and
preferences of the user.
       Schools should be more aware of head injuries

05 Aug 2004

New research from the University of Warwick examining return to school and classroom
performance following head injury reveals that teachers are often unaware of the injury and that
children only very rarely receive specialist help, despite having attention and memory problems.

The results show that regardless of injury severity many children have difficulties in retrieving
and retaining information, and these impairments are particularly handicapping in the classroom.
The study of 67 children aged 5-15 years admitted to hospital with TBI (35 mild, 13 moderate,
19 severe) reveals that one third of injured children performed below average in the classroom.

Children in the severe group had a mean IQ significantly lower than average- half had a reading
age one year below their chronological age, and one third were reading at least two years below
their chronological age. A further two thirds of children with TBI had difficulties with
schoolwork, with half having attention, concentration and memory problems.

Traumatic brain injury is common among children. Most injuries are relatively mild, but every
year over 3000 UK children acquire significant neurological or cognitive difficulties as a result
of TBI. Many then return to school following a severe head injury without support or

The follow-up treatment for children with head injuries is poor, which impacts on their
education. At present, schools rely on parents to inform them about a TBI, and rarely receive
information on possible long-term consequences.

Only one third of teachers were aware that the child had received a head injury. Teachers
reported that for 31% of children no one informed the school about the injury, and often when
the child then changed schools the relevant teachers were not informed of the injury. Only 18
parents (27%) reported that schools made special arrangements for their child's return after the

Children who suffer any form of head injury may be at long-term risk of complications,
including persistent intellectual, academic and personality problems. Approximately 40% of
children with head injuries performed below the class average on their ability to focus their
attention on tasks.
Teachers reported that around half the children with mild/ moderate injuries had problems with
memory and attention, and that 95% of children with memory problems had difficulties with
schoolwork. Further, even when informed teachers were rarely conversant with possible long-
term effects of brain injury and often did not link performance with the injury.

The report recommends that at hospital discharge, health professionals should provide schools
with information about TBI and possible long-term impairments, so that children returning to
school receive appropriate support.

Dr Carol Hawley, from the University of Warwick, said: "Many children with brain injury do not
receive follow-up after discharge from hospital, yet a significant proportion of them do have
some lasting problems which may affect their ability to learn. The absence of tracking and follow
up is causing children to get 'lost' in the system. This lack of awareness of long term effects and
lack of communication between hospitals and schools is putting some pupils with head injuries at
a disadvantage at school."

Few researchers have investigated the effects of brain injury impairments on learning and
educational performance. Until recently it was assumed that children made good recoveries after
brain injury because of the plasticity of the brain. However, the research shows that because the
brain is developing, children are particularly vulnerable to traumatic brain injury (TBI).

For more information contact: Jenny Murray, Press Officer, University of Warwick, Tel: 2476-
574-255, Mobile: 7876-21-7740, or

Dr Carol Hawley, Warwick Business School, University of Warwick, Tel: 2476-522459, Mobile:

Contact: Jenny Murray
University of Warwick

Article URL:

To top