# data[].attributes.attachment_link.provider_name
National Institute of Neurological Disorders and Stroke

# data[].attributes.attachment_link.readable_text
Harnessing the efforts of the many physicians and scientists working on developing better treatments for TBI requires everyone to collect the same types of information from people, including details about injuries and treatment results. To lay the groundwork for these studies, started the Common Data Elements project. This effort brings the research community together to develop data collection standards.

NIH research projects on TBI and other disorders can be found using NIH RePORTER, a searchable database of current and past research projects supported by and other federal agencies. RePORTER also includes links to publications from these projects and other resources.

Learn About Clinical Trials

Clinical trials are studies that allow us to learn more about disorders and improve care. They can help connect patients with new and upcoming treatment options.

For information about participating in clinical research visit NIH Clinical Research Trials and You . Learn about clinical trials currently looking for people with TBI at Clinicaltrials.gov .

Where can I find more information about traumatic brain injury (TBI)?

# data[].attributes.attachment_link.description
A traumatic brain injury (TBI) can be caused by a forceful bump, blow, or jolt to the head or body, or from an object that pierces the skull and enters the brain. Not all blows or jolts to the head result in a TBI.

# data[].attributes.attachment_link.readable_text
What is a traumatic brain injury (TBI)?

A traumatic brain injury, or TBI, can happen when there is a blow to the head. The injury can be penetrating, such as a gunshot wound, or a non-penetrating injury, such as being struck in the head in a car accident.

Traumatic brain injuries vary in severity. Many people recovery from TBIs within days and more severe forms can cause permanent brain injury or even death.

Who might get a traumatic brain injury (TBI)?

Anyone can experience a TBI, although nearly 80% of them happen to males. TBIs are also more common among people older than 65. People in this age group are more prone to losing their balance, falling and hitting their heads. But even infants can experience TBIs from incidents like falling from a bed or changing table, or more rarely, from abuse.

People involved in certain professions or activities have a higher risk of TBIs, including:

Athletes (both recreational and professional).

Construction workers.

Military members.

Police and law enforcement.

How common are traumatic brain injuries (TBIs)?

TBIs are a leading cause of disability and death in the United States. The most current numbers available from the Centers for Disease Control and Prevention (CDC) are from 2014. That year, TBIs contributed to close to 3 million emergency department visits, hospitalizations and deaths. More than 54,000 adults and 2,500 children died from TBIs that year.

What are the types of traumatic brain injuries (TBIs)?

The severity of the head injury is determined by several different factors, such as loss of consciousness, certain neurological symptoms that happened at the time of the injury, loss of memory for the injury and time surrounding it, and abnormalities on head CT or brain MRI.

There are several different types and grades of TBI:

Mild concussion (mTBI): Concussions are the most common type of TBI. Three out of 4 TBIs every year are concussions. These mTBIs can include brief alterations of consciousness such as feeling "dazed" or loss of consciousness for less than 30 minutes. People who have an mTBI can experience confusion for about one day, which is different from difficulties with attention or memory.

Moderate TBI: this type of head injury is associated with loss of consciousness for over 30 minutes but less than one day. Confusion can last for up to one week.

Severe TBI: individuals with this type of head injury lose consciousness for over one full day. These injuries are typically associated with changes on head CT or brain MRI.

Uncomplicated TBI: Head CT/brain MRI are normal, regardless of mild, moderate or severe grade.

Complicated TBI: Head CT or brain MRI show changes, such as bleeding.

Closed: Most TBIs are closed. A closed TBI means an outside force causes a blow or jolt to the head that did not penetrate the skull. This impact injures the brain, causing it to swell.

Open: Healthcare providers may call open TBI a penetrating TBI. This injury occurs when a bullet, knife or something else goes through the skull. If the object goes into the brain, it directly damages brain tissue.

Nontraumatic: Also known as a hypoxic/anoxic brain injury. Some TBIs aren't from trauma. They can result from strokes, seizures and events like choking and near-fatal drownings. These incidents can deprive the brain of oxygen (cerebral hypoxia).

# data[].attributes.attachment_link.title
Traumatic Brain Injury (TBI): What Is It, Causes, Types

# data[].attributes.attachment_link.description
Traumatic brain injuries damage brain tissue, affecting brain function. Concussions are a mild form of TBI. Falls are a leading cause of TBIs.

# data[].attributes.attachment_link.readable_text
Around one million people visit A&E each year following a head injury. While the majority of these people will experience no lasting effects, many others will be left with a traumatic brain injury (TBI) that can have devastating and lifelong effects.
Traumatic Brain Injury (TBI) is an injury to the brain caused by a trauma to the head (head injury). There are many possible causes, including road traffic accidents, assaults, falls and accidents at home or at work.

A brief period of unconsciousness, or just feeling sick and dizzy, may result from a person banging their head getting into the car, walking into the top of a low door way, or slipping over in the street. It is estimated that 95% of all head injuries fall into this category.

A moderate head injury is defined as loss of consciousness for between 15 minutes and six hours, or a period of post-traumatic amnesia of up to 24 hours. The patient can be kept in hospital overnight for observation, and then discharged if there are no further obvious medical injuries. Patients with moderate head injury are likely to suffer from a number of residual symptoms.

Severe head injury is usually defined as being a condition where the patient has been in an unconscious state for six hours or more, or a post-traumatic amnesia of 24 hours or more. These patients are likely to be hospitalised and receive rehabilitation once the acute phase has passed. Depending on the length of time in coma, these patients tend to have more serious physical deficits.

Effects and recovery

The effects of a traumatic brain injury on an individual depends on a number of factors such as the type, location and severity of injury. Symptoms can be wide-ranging, from physical effects such as balance problems, headaches and dizziness to cognitive, emotional and behavioural effects such as memory problems, fatigue and anger.

Where the effects of brain injury persist or cause problems, a person may be referred to rehabilitation services. Rehabilitation aims to help the brain learn alternative ways of working in order to minimise the long-term impact of the brain injury, and help the survivor and their family to cope successfully with any remaining disabilities.

Find out more in the Effects of brain injury section.

# data[].attributes.attachment_link.description
Provides an overview of Traumatic Brain Injury (TBI), which is an injury to the brain causes by an impact such as a road traffic incident, assault or fall.

# data[].attributes.attachment_link.readable_text
The long-term effects of brain injury can be catastrophic for students at any level. Early on, students with the most severe injuries are unable to attend school. Some require home schooling until they recover enough to travel and attend classes with other students.

Research shows that brain injury often harms basic cognitive abilities such as memory, learning, attention and concentration, word finding, and visual perception. Injury can also harm important academic abilities such as reading, arithmetic reasoning, vocabulary, writing, and spelling. Parents and students often worry about falling grades and failure. Concerns about passing the school year, graduating high school, or graduating from college with a degree are often expressed.

Frequent complaints from students with brain injury include:

I study for twice as long as I used to, but I'm doing much worse.

I can't remember anything I read no matter how many times I re-read the same thing.

I study hard and feel like I know the material. Then I go into the test and can't come up with the answers.

Essay exams are murder. I need 20 minutes to think of what I want to say and then the time has run out.

I get so tired I can barely get through the school day. At night, I'm just too tired to do my homework.

I'm so distracted. I can pay attention for five minutes and then my mind wanders.

I go to every class, but nothing sinks in.

Most of the time, school systems are very willing to provide accommodations to students with brain injury. "What are accommodations?" you might ask. Accommodations are special services or arrangements designed to help survivors overcome and offset injury related limitations.

Students and parents often don't know that many kinds of accommodations are available to help students succeed. Many are also unaware of what accommodations are appropriate and reasonable for them. Having a thorough evaluation of academic and cognitive abilities is a first step toward understanding a student's special needs. Evaluations can be performed by neuropsychologists, educational psychologists, and school psychologists. Students and parents are encouraged to seek an experienced brain injury professional who can thoroughly document academic strengths, limitations, and recommended accommodations. Nearly all schools require documentation of disability and recommendations in order to provide accommodations.

To help you understand what accommodations might be appropriate for you or your student, we have prepared a partial list of commonly recommended accommodations on the next page. Talk to the psychologist or educational specialist helping you to determine what is best for your situation.
Classroom Accommodations:

Allow additional time to complete in-class assignments

Allow for extra or extended breaks

Provide student with instructor's notes or help student obtain quality notes from other students

Allow student to audio record lectures for later playback

Provide both oral and written instructions; clarify instructions

For lectures, provide student with an outline or study guide when available

Allow use of a portable computer with spelling and grammar checks for assignments and note-taking

In grading work, reduce emphasis on spelling and grammatical errors unless it is the purpose of the assignment

Permit referencing a dictionary or thesaurus for assignments

Provide preferential seating at or near the front of the classroom

Reduce quantity of work required, in favor of quality.

Avoid placing student in high pressure situations (e.g., short time frames, extensive volume of work; highly competitive)

Exempt student from reading aloud in front of classmates because of impaired reading skills.

Test Accommodations:

Allow additional time to complete tests.

Provide for completion of tests in a quiet, individual environment with the goal of minimizing distractions.

Administer long examinations in a series of shorter segments with breaks allowed between sections.

Allow oral examinations and assist student in having responses scribed, as needed.

Assess knowledge using multiple-choice instead of open-ended questions.

Allow student to clarify and explain responses on exams (and assignments).

Permit student to keep a sheet with mathematic formulas for reference, unless memorizing the formulas is required.

Permit student's use of a calculator.

Permit the student to utilize a dictionary and thesaurus in writing test responses.

If two exams are scheduled on the same day, allow student to reschedule one for another day.

# data[].attributes.attachment_link.title
Accommodations Guide for Students with Brain Injury | BrainLine

# data[].attributes.attachment_link.description
A brain injury can often harm a student's important academic abilities like reading, arithmetic reasoning, vocabulary, writing, and spelling. Learn what accommodations are available in school to help.

# data[].attributes.attachment_link.authors[].name
Center for Parent Information and Resources

# data[].attributes.attachment_link.title
School Planning & Educational Strategies Following Traumatic Brain Injury

# data[].attributes.attachment_link.readable_text
What Teachers Should Know

A severe traumatic brain injury (TBI) is damage to the brain caused by an injury that changes the way the brain normally works. Concussions are sometimes called mild TBIs, and most have a temporary effect on brain function. Severe TBIs usually have longer-lasting effects.

Severe TBIs can cause temporary or permanent impairments in:

memory and attention

coordination, balance, and mobility

language and communication skills

hearing, vision, touch, smell, and taste

emotions, resulting in depression, anxiety, aggression, poor impulse control, and personality changes

Severe TBIs can affect all aspects of students' lives, including:

relationships with family, friends, classmates, and teachers

how they learn and participate in classroom and extracurricular activities

Students with TBI may:

have short- and long-term memory loss

need frequent breaks due to inability to concentrate for long periods of time

require seating accommodations or assistive devices in the classroom

need help and/or extra time getting to other classes

struggle with writing, reading, and other academic tasks they used to be able to do

have seizures or other neurological changes

seem depressed, anxious, or show aggressive or inappropriate behaviors

miss classroom time for medical appointments and to visit the school nurse for medicine

benefit from individualized education programs (IEPs) or 504 education plans

need extra time to complete homework and assignments

What Teachers Can Do

The effects of a TBI vary from person to person. Speak with your student's parents or guardians, the school counselor or psychologist, and special education staff to find ways to customize your instruction.

Students with TBIs often face a long-term healing process. To help students with problems related to concentration, organization, and memory, you can:

reduce distractions in the classroom

break assignments into smaller tasks

repeat and review assignments and have students write them down

provide a checklist of tasks to complete each day

give extra time for tests and assignments

Date reviewed: November 2019

# data[].attributes.attachment_link.title
Severe Traumatic Brain Injury Factsheet (for Schools)

# data[].attributes.attachment_link.description
What teachers should know about severe TBIs, and how to help students who've had a TBI.

# data[].attributes.attachment_link.title
Classroom Interventions for Students with Traumatic Brain Injuries | BrainLine

# data[].attributes.attachment_link.description
There is a lot to know about helping children with TBI successfully return to the classroom.

# data[].attributes.attachment_link.readable_text
Every year, hundreds of Virginia children will experience traumatic brain injury (TBI), changing their lives forever. In addition to the long-term emotional, physical, and intellectual challenges often posed by brain injuries, children with TBI often face difficulties navigating the educational and social obstacles posed by traditional classrooms.

This begins with communication. When healthcare providers, parents, and teachers and educators communicate openly about a child's brain injury and its potential effects, they are able to collaborate on solutions inside and outside of the classroom to help those students meet their full potential.

It takes a village of dedicated parents, medical professionals, TBI experts, adaptive school administrators, and supportive and patient teachers to help students with traumatic brain injuries adjust to a new kind of education. But when they work together and employ a well-honed knowledge of the student's circumstances and brain injuries in general, they can achieve incredible accomplishments in the classroom.
That's why we put together this guide: to help educators, school administrators, teachers, parents, and even students understand and communicate about traumatic brain injuries in children, how to adapt to students with these special needs, and how to prevent TBI in future children.
Every brain injury is different and manifests as different symptoms from child to child, and even from minute to minute. But by understanding these symptoms and how to alleviate them, we can provide these students with the support-and lives-they deserve.
Contents
Part I: What is a Pediatric Traumatic Brain Injury?

A pediatric traumatic brain injury is an injury that disrupts a child's normal brain functionality. A traumatic brain injury-or TBI-is often caused by trauma to the head, which results in a head injury.

Types of Pediatric Brain Injuries

There are two types of traumatic brain injuries in children:

Closed brain injuries occur when a blow to the head does not penetrate the skull but damages the brain. The rapid forward and backward movement of the head-such as in a fall or car accident-causes the brain to move within the skull, leading to bruising and bleeding.

Open brain injuries occur when a blow to the head penetrates the skull, and the skull is crushed or fractured. In addition to the damage to the brain, they can also require surgery to close the wound.

In addition to traumatic brain injuries, non-traumatic brain injuries are also significant injuries to the brain that can cause long-term effects. Also known as acquired brain injuries, these injuries occur when internal conditions-such as a brain tumor, stroke, meningitis, or kidney disease-result in the swelling of and damage to the brain.

Why are Pediatric TBIs So Serious?

Traumatic brain injuries are the most common cause of both death and disability in children 14 and below. ₁ Injuries to the skull are particularly traumatic for children because structural changes to the skull are still occurring at this young age. It's also more difficult to evaluate neurological changes in children because they may not be able to vocalize their symptoms, or they may be easily mistaken for symptoms of other conditions.

Part II: Common Causes of TBI in School-Age Children

Each year, some 50,000 to 60,000 children in the US are hospitalized because of traumatic brain injuries. ₂ These injuries often occur while children are pursuing everyday activities, like playing sports, riding bikes, or riding in a car.

Developing awareness around the most likely causes of a TBI in a child's age group can help parents and teachers develop the precautions and habits to keep them safe. It can also help educators recognize the activities that may lead to brain injury, in or outside the classroom, and how that injury may affect the student's behavior or performance. Combined with an understanding of TBI symptoms, this can ensure adults efficiently seek support for a child if they suspect a brain injury.

Common Causes of TBI in Preschoolers
Children aged four and under-including preschoolers-are the most likely to experience TBI.
According to one study, 1,256 per 100,000 of children in this age group visited the ER with a brain injury. ₃

"One of my biggest concerns is young children who experience an injury before they're in school, that 0 to 5 group," says Juliet Haarbauer-Krupa, PhD, Senior Health Scientist in the Division of Injury Prevention at the Centers for Disease Control & Prevention, adding that this age group has experienced the highest number of emergency department visits in their data reporting for many years.

In this age group, Dr. Haarbauer-Krupa says, "TBI may or may not be recognized depending on the symptoms they're showing, and they are more at risk for long term effects because they're young and [symptoms could last] across their entire life."

The most common causes of TBI in preschoolers include:

Common Causes of TBI in Elementary-Age Children

As children age from toddlers through elementary school, they continue to develop motor skills and coordination. As those skills develop, they are more prone to accidental head injury through falls and recreation.

"Looking across mechanisms of injury across the pediatric life span, as children age beyond age six, sports-related injuries increase," adds Dr. Haarbauer-Krupa.

The most common causes of TBI in elementary school-age children are:

1. Vehicular accidents: Children in this age group may continue to use car seats, which can help protect them from TBI in the case of vehicular accidents. However, these accidents remain the primary cause of traumatic brain injuries in children 5-14, accounting for 55.8% of TBI-related deaths in this age group, according to the CDC. ₆

3. Falls: Falls remain a common cause of traumatic brain injury in school-age children. While most falls in children result in minor head injuries, they can lead to a TBI. ₇ These injuries may occur when the child falls from a bed, off playground equipment, down stairs, from an adult's arms, or even from ground level.

4. Recreation: Elementary school children engage in more recreational activities than preschoolers, from climbing higher playground equipment at school to beginning group sports and activities. Unfortunately, these recreational activities contribute to TBI rates in children of this age, and teachers, parents, and coaches should carefully monitor the activities of children.

Common Causes of TBI in Adolescents

A study from 2013 indicated that rates of TBI hospitalizations in adolescents decreased in the years prior. In the years the study cited (2005 to 2009), annual adolescent TBI hospitalizations decreased by 21%. ₈ However, traumatic brain injuries are still a matter of concern for adolescents.

The most common causes of traumatic brain injuries in adolescents include:

1. Vehicular accidents: Vehicular accidents are the most common cause of TBI in adolescents, attributing to 35% of TBI in this age group.₈ Vehicular accidents are the primary cause of TBI in older children in this age group (14-19 years old), perhaps because children in this age group begin to drive with or without adult supervision.

2. Sports and recreation injuries: Newer studies-including one from 2019-indicate that sports injuries may be the leading cause of nonfatal TBI in adolescents.₉ Injuries caused by riding bicycles and playing football are particularly common causes of traumatic brain injuries.

3. Assault: Injuries caused by firearms are more prevalent in the adolescent age group, leading to 43.8% of TBI in one study of this age group.₁₀ Assault in adolescents is often the result of youth violence, like bullying, as well as abuse at home.

How to Prevent Brain Injury in Children

While there are many resources parents, teachers, and school administrators can use to support students with traumatic brain injuries, the best support of all is prevention. Preventing TBIs in children requires the attention and support of all of these communities.

Some strategies for preventing brain injuries in children include:

Practice proper car safety. Parents should always use the correct car or booster seat for their child's weight and height.

Wear a helmet. Ensure your child wears a helmet when engaging in recreational activities such as riding a bike, skateboard, or horse, playing contact sports, or skiing or snowboarding.

Keep your home safe. For younger children, use safety gates on the stairs and don't leave them alone on high pieces of furniture. Keep firearms locked in a cabinet. Use side rails on bunk beds.

Keep your children safe outdoors. Monitor children on playground equipment, and check the equipment to make sure it's safe before they play. Avoid trampolines.

Sports and recreational injury strategies. Dr. Haarbauer-Krupa notes that making changes in certain sports to reduce risk can help children in middle and high school.

Part III: How to Recognize Brain Injuries in Children & Adolescents

Understanding the common causes of brain injury in children can help adults protect children in order to prevent these injuries. Prevention is not always possible, however, which is why it is just as important to recognize the signs of brain injury in children.

The symptoms of brain injury in children may be subtle or change over time.

Younger children may be unable to communicate these symptoms, making them even harder to recognize. Sometimes they are mistaken for other conditions, such as bad behavior or natural mood changes, so it's important educators and parents alike be able to differentiate between these symptoms.

Symptoms of Pediatric TBIs

By learning how to recognize these signs of a TBI, parents, teachers, administrators, and other guardians can help children receive medical attention quickly to prevent the onset of more debilitating side effects. The symptoms of a brain injury may be physical, cognitive, and/or emotional and may include:

Physical Impairments

Loss of consciousness

Inability to awake

Severe and persistent headache

Drainage of clear or bloody fluids from orifices like nose or ears

Recurrent vomiting or nausea

Changes to sleeping habits

Changes to eating habits

Drowsiness

Seizures or convulsions

Dilation of pupils

Weakness or numbness in extremities (fingers and/or toes)

Uncoordinated movement

Scalp swelling

Cognitive impairments

Emotional impairments

Mood changes, especially sadness or depression

Irritability or combativeness

Increased or inconsolable crying

Lack of interest in favorite activities or toys

If you recognize any combination of these symptoms in a child, medical attention should immediately be sought for him or her.
If a teacher recognizes these symptoms, notify a parent immediately.

If any of the symptoms above appear in a child under your care, or if more mild symptoms worsen or do not subside over time, a guardian should seek medical attention or contact the child's parents.

Parents and teachers alike should keep in mind that symptoms may vary from one age group to another.

"Children younger than five may not show the same symptoms as older children," says Dr. Haarbauer-Krupa, referencing a recent study that indicates younger children, "for example, may have incontinence or excessive crying, which are not on the school age checklist." ₁₄

Long-term Symptoms of TBI

Experts note the symptoms of a TBI may not manifest for weeks or, in some cases, years. In that case, it is often easier for a parent or teacher to disregard the symptoms as something else, rather than connecting them to a previous brain injury.

Dr. Brenda Eagan-Johnson, CBIST, a board member of the Academy of Brain Injury Specialists for the Brain Injury Association of America, and a child, adolescent, and young adult brain injury neurodevelopmental consultant, points out that it's often students with moderate brain injuries who fall into this category.

"It's those moderate traumatic brain injuries that schools aren't finding out about until a few years later when their effects kick in as their brain matures and develops," she says. When symptoms manifest years later, they're often misdiagnosed.

"For instance, if a young child injures their frontal lobe, those higher order thinking skills in the frontal lobe aren't being tapped into in first grade," explains Dr. Eagan-Johnson. "So we may not see those issues manifest until middle school when the frontal lobes that were injured in first grade are going through a rapid maturation. And when they're called upon to perform these higher-order thinking skills, that could be when we see deficits in organization and initiation in motivation self-regulation-all of that can sometimes fall apart."

It's important for parents to inform schools about their children's brain injuries, not just immediately following the accidents, but possibly for years to come. Doing so will help educators evaluate and support students with TBI, even if their symptoms change.

How to Check the Seriousness of a School Head Injury

While most head injuries in children do not occur at school, it is possible that a child could have a TBI during a school activity.

"I work with schools daily in the field of brain injury, and we're seeing almost half of the students with concussions are from non-sports related injuries," says Dr. Eagan-Johnson.

"We see a lot of motor vehicle accidents, a lot of physical education class and recess injuries, bus accidents or incidents where the bus doesn't actually get in an accident, but maybe it runs over a landscape rock and everyone hits their head, things like that."

If a child sustains a head injury at school-whether as the result of a fall, recreation, or some other accident-carefully monitoring the child and following up with medical attention if symptoms escalate or appear can greatly impact the outcomes in the case of TBI.

If a child sustains any injury to the head worse than a mild bump, teachers should contact the child's parents, who should contact their doctor. A doctor will be able to offer next steps, including whether or not medical attention is necessary.

If a child under your care sustains a minor head injury and none of the symptoms outlined above are present, you should do the following:

Address any injuries. If the injury occurred at school and caused a small wound on the head, a school nurse should clean the area with soap and water, then apply pressure using a sterile cloth. If bleeding continues for 10 minutes or longer, you should seek medical attention.

Encourage rest. Rest is an important part of their recovery. If at school, encourage them to pursue a quiet, relaxing activity, like reading.

Treat swelling. A large bump may appear on the skull where the child was injured. A school nurse should apply an ice pack to the swelling for 20 minutes. Swelling should subside in the following hours and days, but if not, let the parents know they should visit their doctor.

Treat pain and other mild symptoms. If a child is nauseous or vomiting, offer them clear liquids, like clear juice or soda.

Monitor symptoms. If any of the following occur, the child should seek medical assistance. If at school, administrators should immediately contact their parents and, if necessary, call 911.

Seek medical attention if the child:

Continues to vomit for hours following the injury

Becomes more drowsy or lethargic

Develops neck stiffness

Their headache worsens

Their behavior becomes abnormal or they seem confused

Has a seizure or convulsions

Cries uncontrollably

Develops any weakness or numbness in extremities

Exhibits any concerning behavior or looks increasingly sick

Preparing for a TBI Medical Visit with Your Child

Be prepared to discuss the details of the accident and how your child's injury occurred. If you suspect the injury may have been intentionally inflicted by another child or an adult, it is necessary for you to communicate those concerns to the doctor.

You should also be prepared to discuss your child's exact reaction to the injury and any symptoms that have appeared.

It is unlikely that your child will require an imaging test like a CT scan. These tests are performed to check for bleeding in the brain, a skull fracture, or other brain injuries. If your child is exhibiting more severe symptoms and a CT scan is needed, it should only take about 15 minutes.

If doctors are not sure whether or not an imaging test is necessary, they may decide to observe your child for four to six hours to monitor how their symptoms change. Observation usually takes place in the emergency department.

Part IV: How Do Traumatic Brain Injuries Affect Students?

No two traumatic brain injuries are the same, and neither are their effects. Depending on the severity of the TBI, its location, and innumerable other factors, children who experience a traumatic brain injury may make a full recovery or experience lifelong side effects.

The side effects experienced by children with TBI are multifaceted and can be cognitive, emotional, or behavioral. All of these can have implications on the academic and social abilities of the child and the environment and tools with which they will do best.

The needs-physical, emotional, and educational-of students with TBI will likely be different than before their injury. Some of these changes that parents, teachers, and the students themselves can expect include:

Physical Effects

Vision loss

Hearing loss

Speech loss

Paralysis

Seizures

Persistent headaches

Lethargy or less stamina

Changes in motor skills, like incoordination or imbalance

Perceptual deficits, like difficulty distinguishing between parts of the body

Children may experience physical side effects that impact their motor and/or sensory skills. Typically, children are more likely to resolve issues with their motor skills through means such as physical therapy and adaptive equipment.

Sensory deficits-such as a loss of vision or hearing, seizures, and response to touch and temperature-are more likely to persist. That is because these are not as easily addressed through therapies or equipment.

Emotional & Behavioral Effects

Mood swings

Denial

Anxiety

Lower self-esteem

Irritability or aggression

Sadness or depression

Easily frustrated and/or overstimulated

Difficulty understanding social rules or queues

Lack of motivation

Noncompliance

Impulsive and/or lack of self-control

With most disorders, the emotional and behavioral reactions of children are somewhat predictable or habitual. With students with TBI, however, their emotional reactions are completely unpredictable. They may exhibit some of the side effects above at times, and other side effects at other times.

The behavioral side effects of TBI also vary greatly between age groups. Preschool and elementary-aged students are more often hyperactive, distractible, or lack emotional control. Adolescent students are more likely to be irritable or agitated and have trouble inhibiting their verbal responses.

Cognitive Effects

Difficulty concentrating and easily distracted

Inability to organize information

Difficulties with creative problem solving

Rigid thinking and inability to generalize

Lack of judgment

Delayed response time or processing time

Compromised perceptual and spatial skills

Difficulties with memory

Decreased language function

Learning disabilities

Difficulties reading or writing

Children with TBI who receive inpatient treatment with promising results may suddenly express the cognitive effects of their injury upon their return home or to school. As more demands are placed on the student, more cognitive effects manifest.

Academic Effects

The cognitive effects of TBI are perhaps easiest to connect to the academic impacts of TBI on students. A lack of memory skills, for example, can have a clear effect on academic ability.
In one study, 94.4% of students with mild or moderate brain injuries who had memory problems had difficulty with their school assignments.
However, the behavioral effects of TBI can also have a significant impact on students as they experience difficulty transitioning back into a traditional educational environment and the social and emotional trials such a situation demands. Adaptations may also need to be put in place to support the physical effects of the students' TBI.

Part V: Plan for Returning to School

Because the side effects of TBI are so unpredictable, it can be difficult for educators, as well as parents and students, to prepare for their return to the classroom. A patient's first year following such an injury greatly impacts their outlook, ₁₂ and for students, this includes their long-term academic outcomes.

Plans for Parents & Students

Communicate with your student's school.

As a parent, it is your responsibility to begin preparing your student and their school administrators for a return to school as soon as possible. You should maintain communication with your child's school following their injury so that the school can connect them with any resources that may make their return to school easier.

"If parents were involved and working with the school, their kids got much more success and accommodations," says Dr. Haarbauer-Krupa, referring to her Report to Congress on The Management of TBI in Children. ₁₅

That communication, she says, should include, "Letting the school know that their child experienced an injury, asking the school to evaluate them-and not just evaluate them at the time of injury, but parents and school should be monitoring them over time because they may not see things at the time of injury, they may show up later."

Ask your doctor about what to expect moving forward.

Unfortunately, there is sometimes a lack of communication or a misunderstanding between healthcare providers and parents about the extent of a brain injury. When parents hear that their child will be "fine," says Dr. Eagan-Johnson, "they don't know that that doesn't mean he's not going to return to normal."

That's why it's important for healthcare providers to present parents with materials and information regarding what to expect in the coming weeks, months, and even years. If your healthcare provider doesn't provide this information upfront, ask about it.

Dr. Haarbauer-Krupa of the CDC agrees.

"We currently have two external funding projects where we're working on, based on our pediatric model TBI guideline with health care providers, how to give discharge instructions that parents can use in the school," she says.

"It's very important that healthcare professionals provide discharge instructions to parents and encourage them to report the injury to school and work with the school."

Foster connections between the school and medical experts.

You should also serve as a facilitator in connecting the school personnel with the medical professionals, including rehabilitation experts, who are helping your child recover. Together they can create a plan and educational strategies to help your student. It is possible that your state's Office of Special Education has a brain injury educational consultant who can help special educators in your school provide the right services for your student.

"There's huge variation from state to state about what happens to kids once they get to school and what health care providers are telling them," says Dr. Haarbauer-Krupa of the CDC.

"The importance of engaging stakeholder groups like healthcare professionals, parents, teachers, and students, especially high school students, all need to be involved in this to make sure it gets accomplished."

Address behavioral issues at home.

While the teachers and administrators at your child's school will work directly with your student to address some of the behavioral issues your child may exhibit, this work begins with you. There are many strategies for managing your child's behavior, ₁₃ some of which include specific communication, creating structure and consistency in their days, and building positive support systems.

Understand your child's rights.

According to Virginia law, schools must meet the requirements of both Section 504 of the Rehabilitation Act and the Individuals with Disabilities Education Act (IDEA). Among other rights, these acts ensure that students with disabilities, including brain injury, receive the same education as their peers. The school must provide an Individualized Education Program (IEP), and, as parents, the school is required to include you as part of the IEP team.

Prepare students.

"Things that can be done for students with TBI that are returning to school is review things such as class schedules, names of their educational staff and peers, and information like bus and classroom numbers (homeroom)," says says Tiffany White, Director of School Services at the American Speech-Language-Hearing Association (ASHA).

"If allowable, it may be helpful to visit the school prior to the reopening to navigate the hallways to assist with locating classrooms and other areas within the school that the student would be expected to attend throughout the school day."

Parents can help support students by obtaining syllabi and curricular information to help students prepare for the coursework.

"Another important thing that parents can do to assist their child transitioning back to school is working on self-advocacy skills, as students may need to request assistance or additional supports to help them complete their work (i.e., asking to have the directions repeated, state when they do not understand something, etc.)," White says.

Plans for Teachers

Know what to expect.

Before the student enters your classroom, you can prepare for their arrival through consistent and detailed communication. You should set up communication with their medical and rehab teams, as well as the student's parents, to better understand the current abilities of the student, as well as suggested accommodations.

"If we immediately support students when they return to school with the appropriate academic support to alleviate cognitive overexertion, which can cause TBI symptoms to spike, they should recover faster," says Dr. Eagan-Johnson.

Anticipate behavioral issues.

In addition to the cognitive challenges you and your student may face together, there will also likely be behavioral issues you'll have to navigate. Anticipating these issues will help you best serve both your student with TBI and your entire classroom.

Some behaviors to expect include:

Temper tantrums

An inability to stay on task

A lack of motivation

Impulsive behavior

A lack of control over emotions

Easily frustrated

Easily overstimulated, which can lead to emotional distress

Learn how to address challenging behavior.

While these behaviors could be disruptive for the teacher, student, and other classmates, understanding how to create an environment that supports the student can help prevent or address these challenging behaviors.

Some practices that may work in your classroom include:

Time-out, which gives the student time to refocus.

Structure and consistency in scheduling and expectations.

Positive reinforcement to encourage positive behaviors.

Clear communication, including explaining plainly why bad behavior is not acceptable.

Avoid "punishment" for bad behaviors and instead reinforce good behaviors with praise.

Ensure the student understands you are a team and are working together to help him or her succeed.

Allow the student to rest. With symptoms like fatigue and headaches, they may need time to rest in the midst of a busy school day.

Work with your school administrators on appropriate accommodations. See below.

Coordinate with Speech-Language Pathologists and Psychologists

"In order to support students with TBI, teachers should collaborate with the school's Speech-Language Pathologist and Psychologists," says White of the ASHA.

"These two professionals will be able to provide information regarding how the effects of the TBI may manifest within the classroom and home setting. They can also provide recommendations regarding the supplemental aids and services that would be most beneficial for the student."

Working together, these professionals will be able to identify the best accommodations and modifications for the student.

"For instance, some students with TBI may demonstrate issues related to memory and organization and would benefit from the use of graphic organizers and visual support within the classroom setting," White adds.

"If a student demonstrates difficulty with processing orally presented information, they may benefit from extra processing time, repetition of information, and chunking of information (providing information in pieces instead of all at one time)."

Communicate with other students.

In younger children especially, there can be a lot of misunderstandings about brain injury and its effects.

"I can't tell you how many times we've heard children think that they can catch a brain injury like a virus," says Dr. Eagan-Johnson.

Teachers should communicate with students about brain injuries and what to expect as their fellow student returns to the classroom. Dr. Eagan-Johnson suggests conversations like, "Your friend's coming back. They hurt their brain; they're going to be the same person, but they might be a little different."

By equipping other students (and teachers) with knowledge about brain injury, you can cultivate understanding and empathy in the classroom.

Encourage friendship and peer acceptance.

Most children and adolescents don't have the social tools to navigate the difficulties of TBI, and they may withdraw. For many students with TBI, one of the most devastating consequences of their injury is the loss of their friendships.

Teachers can help all of their students better understand and support students with TBI through the following strategies:

Explain the circumstances to your students. If you know the student with TBI may have trouble with social queues, explain this to your students and discuss ways they can support their peers.

Choose a peer volunteer. A peer volunteer can help the student with TBI with the physical requirements of school-such as guiding them through a busy hallway-as well as social support.

Incorporate social activities into your lesson plans. Rather than separating students throughout the school day, it can help a student with TBI to have scheduled social time through assignments or activities.

Encourage interactions. Introducing students with TBI to new activities and social groups can help them find a new place in the school where they feel welcome.

Plans for Schools & Administrators

Conduct a TBI School Evaluation.

Before the student returns to school, the school should conduct an evaluation to determine the current status of the student and the necessary accommodations to support them. The assessment should include the student's medical records regarding their TBI and a psychological assessment administered by a psychologist (like a licensed school psychologist or one licensed by a State Board of Psychological Examiners).

These psychological assessments will include areas of study such as memory, attention, overall behavior, cognition and understanding, abstract thinking, judgment, reasoning, problem-solving, and ability to process information.

The TBI School Evaluation may also include other assessments around motor skills, communication, and psychosocial skills. Other factors to keep in mind are the student's performance before his or her injury and how adaptive they seem.

The Evaluation should also include various interviews with parents, rehab specialists, former teachers, and especially the student him or herself. It should also include a classroom evaluation and an evaluation in one other setting, such as a playground.

With all of this information, administrators, teachers, and guardians will be able to establish an IEP or accommodations for the student that will best support his or her return to school.

Establish a Concussion Management Team.

Depending on the severity of the student's brain injury, Dr. Eagan-Johnson points out that he or she may need an IEP, a 504 plan (accommodations), or simply informal classroom supports to help them navigate the first few weeks at school. A Concussion Management Team can help a school identify the correct support systems for the student.

"A school needs to have a concussion management team for a return to learning," she says.

"They have processes in place; they have forms; they have communication. When that student returns to school, they immediately implement support to alleviate cognitive overexertion."

Those supports may include:

Building breaks automatically into the day, rather than waiting for the student to ask for a break.

Giving students copies of the teacher's notes because taking notes can trigger symptoms.

Removing them from loud, overstimulating environments in the initial weeks.

Reducing key learning content and repetition.

About 70% of students will recover in the first four to six weeks in school, says Dr. Eagan-Johnson. The 30% of students who need support beyond that time may need a more formalized education plan such as a 504 plan or IEP for special education.. A concussion management team can help identify if a student needs long-term support in the classroom.

Help Teachers Identify TBI

Oftentimes a brain injury may not be reported to the school, in which case it's important for teachers to recognize the symptoms of such an injury and put a plan in place to support the student. And as Dr. Eagan-Johnson points out, sometimes those symptoms may not manifest until years after the injury.

"It's not until they're failing or struggling behaviorally that we then have to wade through and try to figure out what's going on, and in order for a school to figure out what's going on, if the parents haven't notified them of the brain injury, they need to be asking the right questions," she says.

Simply asking if a student experienced a TBI might not be helpful, she says. Instead, teachers should ask questions such as:

Has your child ever lost consciousness?

Has your child ever fallen and hit their head?

Has your child ever had to go to the emergency room from hitting their head?

Coupled with an understanding of the symptoms of TBI, asking these questions can help educators and teachers identify undiagnosed injuries in students and provide them with the support they need in the classroom, as well as communicate their concerns to parents.

Determine the student's level of educational performance.

Developing a successful IEP also demands administrators and educators determine the student's level of educational performance. He or she should be evaluated in core areas, including math, science, reading, and writing. Understanding the student's current skill level or academic performance can help educators put supportive accommodations in place to help them succeed. Learn more here (section B).

Put accommodations in place to support the student.

Accommodations are designed to support the student so they can receive the same level of education as their peers. Common accommodations that help students with TBI include:

Asking for a consultation from an expert in traumatic brain injury.

Allowing additional time for the student to complete work, especially on tests.

Offering the student breaks as needed.

Prioritizing the quality of the student's work, rather than the quantity.

Providing the student with more detailed instructions.

Repeating instructions.

Recording classroom instruction for the student to revisit later.

Providing assistive technology for the student where necessary.

Seating the student near the teacher and at the front of the classroom.

Excusing the student from presentations.

Offering oral examinations.

Utilizing multiple-choice questions.

Utilizing small-group instruction.

Keeping track of daily progress.

Connecting the students with peer tutors.

Maintaining contact with the student's parents.

Considering a special class placement, like a resource classroom or self-contained class, where the student can receive support from a special education teacher.

About Breit Biniazan

Breit Biniazan is a Virginia law firm dedicated to supporting those wronged by life's catastrophes, and there are few events more catastrophic than a childhood TBI.

In our many years practicing law in Virginia Beach and Richmond, we have witnessed the debilitating impact of TBI, as well as the miraculous recoveries made when communities come together to support these children.
For more information on identifying TBI in children, preparing students for TBI for a return to the classroom, and more, please visit the CDC's Heads Up information center.
In addition to medical professionals, educators, and parents, an important element of this support system is an experienced law firm that can protect the rights and futures of children affected by brain injury.

Our expert lawyers work as a team to provide children and their parents with legal support, as well as compassionate understanding and resources, to help them receive the compensation and justice they need to build a bright future.

References

1. Takashi Araki, Hiroyuki Yokota, and Akio Morita, "Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management." 2017. US National Library of Medicine, National Institutes of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5341344/

2. Andrew J. Schneier, Brenda J. Shields, Sarah Grim Hostetler, Huiyun Xiang and Gary A. Smith, "Incidence of Pediatric Traumatic Brain Injury and Associated Hospital Resource Utilization in the United States." Pediatrics, August 2006. https://pediatrics.aappublications.org/content/118/2/483.short

3. US Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, "Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths, 2002-2006." March 2010. https://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf

4. BrainLine, "Facts About Traumatic Brain Injury." 2017. https://www.brainline.org/article/facts-about-traumatic-brain-injury

5. Camille L Stewart , Megan A Moscariello, Kristine W Hansen, Steven L Moulton," Infant Car Safety Seats and Risk of Head Injury." Journal of Pediatric Surgery, January 2014. https://pubmed.ncbi.nlm.nih.gov/24439608/

6. Centers for Disease Control and Prevention, Percent Distributions of TBI-related Deaths by Age Group and Injury Mechanism - United States, 2006-2010." 2016. https://www.cdc.gov/traumaticbraininjury/data/dist_death.html

7. Nir Samuel , Ron Jacob, Yael Eilon, Tania Mashiach, Itai Shavit, "Falls in Young Children with Minor Head injury: A Prospective Analysis of Injury Mechanisms." Brain Injury, 2015. https://pubmed.ncbi.nlm.nih.gov/25955119/

8. Anthony O Asemota , Benjamin P George, Steven M Bowman, Adil H Haider, Eric B Schneider, "Causes and Trends in Traumatic Brain Injury for United States Adolescents." Journal of Neurotrauma, January 2013. ​​https://pubmed.ncbi.nlm.nih.gov/22989254/

9. Bina Ali, Bruce A. Lawrence, Ted Miller, Jennifer Allison, "Products and Activities Associated with Non-fatal Traumatic Brain Injuries in Children and Adolescents - United States 2010-2013." Brain Injury, Volume 33, 2019 - Issue 11. https://www.tandfonline.com/doi/abs/10.1080/02699052.2019.1631483?journalCode=ibij20

10. Galinos Barmparas, MD, Navpreet K. Dhillon, MD, Eric J.T. Smith, James M.Tatum, MD, Rex Chung, MD, Nicolas Melo, MD, Eric J. Ley, MD, Daniel R. Margulies, MD, "Assault in children admitted to trauma centers: Injury patterns and outcomes from a 5-year review of the national trauma data bank." International Journal of Surgery, Volume 43, July 2017. https://www.sciencedirect.com/science/article/pii/S1743919117304533

11. C A Hawley , A B Ward, A R Magnay, W Mychalkiw, "Return to school after brain injury." Archives of Disease in Childhood, February 2004. https://pubmed.ncbi.nlm.nih.gov/14736628/

12. Kayla A. Steward, Adam Gerstenecker, Kristen L. Triebel, Richard Kennedy, Thomas A. Novack, Laura E. Dreer, Daniel C. Marson, "Twelve-month recovery of medical decision-making capacity following traumatic brain injury." Neurology, September 06, 2016; 87 (10). https://n.neurology.org/content/87/10/1052

13. Brain Injury Association of Virginia, "Brain Injury and the Schools: A Guide for Educators." 2013. https://www.doe.virginia.gov/special_ed/disabilities/traumatic_brain_injury/brain_injury_schools.pdf

14. Dominique Dupont, Cindy Beaudoin, Naddley Désiré, Maria Tran, Isabelle Gagnon, Miriam H Beauchamp, "Report of Early Childhood Traumatic Injury Observations & Symptoms: Preliminary Validation of an Observational Measure of Postconcussive Symptoms." The Journal of Head Trauma Rehabilitation, April 2021. https://pubmed.ncbi.nlm.nih.gov/33935228/

15. Centers for Disease Control & Prevention, "Report to Congress on The Management of TBI in Children." Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2016. https://www.cdc.gov/traumaticbraininjury/pubs/congress-childrentbi.html

16. Juliet Haarbauer-Krupaa, Tadesse Haileyesus, Julie Gilchrista, Karin A. Mack, Caitlin S. Law, Andrew Joseph, "Fall-related traumatic brain injury in children ages 0-4 years." Journal of Safety Research, Volume 70, September 2019, Pages 127-133. https://www.sciencedirect.com/science/article/abs/pii/S0022437518308910

# data[].attributes.attachment_link.title
Brain Injuries in Children: A Guide for Virginia Educators | Breit Biniazan

# data[].attributes.attachment_link.description
This guide discusses traumatic brain injuries in school-age children, including the causes, symptoms, and how to develop a plan for students returning to school.

# data[].attributes.attachment_link.description
Links to websites of groups that study or provide information about TBI.

# data[].attributes.attachment_link.readable_text
TBICoE offers a variety of educational information and resources to help patients and their families learn about mild, moderate, severe or penetrating TBI. The topics covered include signs and symptoms, coping and recovery, and prevention. Through fact sheets, booklets and guides-service members, veterans, their families and caregivers-can learn more about the common challenges experienced after sustaining a traumatic brain injury.

Check out the sections below and download these resources for yourself, a friend or family member, or to help with patient education if you are a medical provider.

Outreach Network

TBICoE fulfills its mission through outreach and educational activities for active-duty service members, veterans, their families, and health care providers about TBI management from prevention to recovery. Through the effort of Regional Education Coordinators and the A Head for the Future initiative, TBICoE aims to increase awareness about how to prevent and reduce the consequences of mild-to-severe TBI.

Back to School: A Guide to Academic Success After Traumatic Brain Injury

Service members and veterans often aspire to further their education for improved career satisfaction while in service or after departing active duty. Those who have sustained a traumatic brain injury may face unique challenges, and this guide provides information and resources on how to navigate higher education while still prioritizing brain health care. This guide includes topics on:

Getting started in the return-to-school decision-making process

Financial considerations

Disability services and accommodations information

Strategies for academic success

Prioritizing health while in school

Student resources

Download the Back to School Guide now.

TBI Fact Sheets

Are you wondering about the common symptoms of mild traumatic brain injury, also known as concussion, and how to manage them? Need resources to help educate patients about TBI? Here are free, downloadable fact sheets that discuss various topics related to TBI-symptom management, awareness and prevention, clinical education, family resources and more. Whether you're a service member, family member or health care provider, there are resources for you.

These fact sheets provide general information about TBI-common signs and symptoms, coping and recovery tips, and the importance of treatment.

Family and Caregiver Guides

This section is devoted to families and friends, who play a critical role in supporting the health and well-being of individuals with TBI recognizing the emotional, physical, and financial toll that is so often associated with caregiving. Check out our new fact sheets!

Find and download resources for families and caregivers of those who have sustained a TBI.

# data[].attributes.attachment_link.description
TBICoE is committed to providing TBI resources to help service members, veterans, family members, caregivers, and health care providers.