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Traumatic brain injury-Traumatic brain injury - Symptoms & causes - Mayo Clinic

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If a head injury causes a mild traumatic brain injury, long-term problems are rare. But a severe injury can mean significant problems.

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What is traumatic brain injury?

Traumatic brain injury (TBI) happens when a sudden, external, physical assault damages the brain. It is one of the most common causes of disability and death in adults. TBI is a broad term that describes a vast array of injuries that happen to the brain. The damage can be focal (confined to one area of the brain) or diffuse (happens in more than one area of the brain). The severity of a brain injury can range from a mild concussion to a severe injury that results in coma or even death.

What are the different types of TBI?

Brain injury may happen in one of two ways:

Closed brain injury. Closed brain injuries happen when there is a nonpenetrating injury to the brain with no break in the skull. A closed brain injury is caused by a rapid forward or backward movement and shaking of the brain inside the bony skull that results in bruising and tearing of brain tissue and blood vessels. Closed brain injuries are usually caused by car accidents, falls, and increasingly, in sports. Shaking a baby can also result in this type of injury (called shaken baby syndrome).

Penetrating brain injury. Penetrating, or open head injuries happen when there is a break in the skull, such as when a bullet pierces the brain.

What is diffuse axonal injury (DAI)?

Diffuse axonal injury is the shearing (tearing) of the brain's long connecting nerve fibers (axons) that happens when the brain is injured as it shifts and rotates inside the bony skull. DAI usually causes coma and injury to many different parts of the brain. The changes in the brain are often microscopic and may not be evident on computed tomography (CT scan) or magnetic resonance imaging (MRI) scans.

What is primary and secondary brain injury?

Primary brain injury refers to the sudden and profound injury to the brain that is considered to be more or less complete at the time of impact. This happens at the time of the car accident, gunshot wound, or fall.

Secondary brain injury refers to the changes that evolve over a period of hours to days after the primary brain injury. It includes an entire series of steps or stages of cellular, chemical, tissue, or blood vessel changes in the brain that contribute to further destruction of brain tissue.

What causes a head injury?

There are many causes of head injury in children and adults. The most common injuries are from motor vehicle accidents (where the person is either riding in the car or is struck as a pedestrian), violence, falls, or as a result of shaking a child (as seen in cases of child abuse).

What causes bruising and internal damage to the brain?

When there is a direct blow to the head, the bruising of the brain and the damage to the internal tissue and blood vessels is due to a mechanism called coup-contrecoup. A bruise directly related to trauma at the site of impact is called a coup lesion (pronounced COO). As the brain jolts backward, it can hit the skull on the opposite side and cause a bruise called a contrecoup lesion. The jarring of the brain against the sides of the skull can cause shearing (tearing) of the internal lining, tissues, and blood vessels leading to internal bleeding, bruising, or swelling of the brain.

What are the possible results of brain injury?

Some brain injuries are mild, with symptoms disappearing over time with proper attention. Others are more severe and may result in permanent disability. The long-term or permanent results of brain injury may need post-injury and possibly lifelong rehabilitation. Effects of brain injury may include:

Can the brain heal after being injured?

Most studies suggest that once brain cells are destroyed or damaged, for the most part, they do not regenerate. However, recovery after brain injury can take place, especially in younger people, as, in some cases, other areas of the brain make up for the injured tissue. In other cases, the brain learns to reroute information and function around the damaged areas. The exact amount of recovery is not predictable at the time of injury and may be unknown for months or even years. Each brain injury and rate of recovery is unique. Recovery from a severe brain injury often involves a prolonged or lifelong process of treatment and rehabilitation.

What is coma?

Coma is an altered state of consciousness that may be very deep (unconsciousness) so that no amount of stimulation will cause the patient to respond. It can also be a state of reduced consciousness, so that the patient may move about or respond to pain. Not all patients with brain injury are comatose. The depth of coma, and the time a patient spends in a coma varies greatly depending on the location and severity of the brain injury. Some patients emerge from a coma and have a good recovery. Other patients have significant disabilities.

How is coma measured?

Depth of the coma is usually measured in the emergency and intensive care settings using a Glasgow coma scale. The scale (from 3 to 15) evaluates eye opening, verbal response, and motor response. A high score shows a greater amount of consciousness and awareness.

In rehabilitation settings, here are several scales and measures used to rate and record the progress of the patient. Some of the most common of these scales are described below.

Rancho Los Amigos 10 Level Scale of Cognitive Functioning. This is a revision of the original Rancho 8 Level Scale, which is based on how the patient reacts to external stimuli and the environment. The scales consist of 10 different levels and each patient will progress through the levels with starts and stops, progress and plateaus.

Disability Rating Scale (DRS). This scale measures functional change during the course of recovery rating the person's disability level from none to extreme. The DRS assesses cognitive and physical function, impairment, disability, and handicap and can track a person's progress from "coma to community."

Functional Independent Measure (FIM). The FIM scale measures a person's level of independence in activities of daily living. Scores can range from 1 (complete dependence) to 7 (complete independence).

Functional Assessment Measure (FAM). This measure is used along with FIM and was developed specifically for people with brain injury.

The Brain Injury Rehabilitation Program

Rehabilitation of the patient with a brain injury begins during the acute treatment phase. As the patient's condition improves, a more extensive rehabilitation program is often begun. The success of rehabilitation depends on many variables, including the following:

Nature and severity of the brain injury

Type and degree of any resulting impairments and disabilities

Overall health of the patient

Family support

It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence.

The goal of brain injury rehabilitation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life- physically, emotionally, and socially.

Areas covered in brain injury rehabilitation programs may include:

Self-care skills, including activities of daily living (ADLs): feeding, grooming, bathing, dressing, toileting, and sexual functioning

Physical care: nutritional needs, medicines, and skin care

Mobility skills: walking, transfers, and self-propelling a wheelchair

Communication skills: speech, writing, and alternative methods of communication

Cognitive skills: speech, writing, and alternative methods of communication

Socialization skills: interacting with others at home and within the community

Vocational training: work-related skills

Pain management: medicines and alternative methods of managing pain

Psychological testing and counseling: identifying problems and solutions with thinking, behavioral, and emotional issues

Family support: assistance with adapting to lifestyle changes, financial concerns, and discharge planning

Education: patient and family education and training about brain injury, safety issues, home care needs, and adaptive techniques

The Brain Injury Rehabilitation Team

The brain injury rehabilitation team revolves around the patient and family and helps set short- and long-term treatment goals for recovery. Many skilled professionals are part of the brain injury rehabilitation team, including any or all of the following:

Types of Brain Injury Rehabilitation Programs

There are a variety of brain injury treatment programs, including the following:

Acute rehabilitation programs

Subacute rehabilitation programs

Long-term rehabilitation programs

Transitional living programs

Behavior management programs

Day-treatment programs

Independent living programs

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Acquired brain injury hapens when a sudden, external, physical assault damages the brain. It is one of the most common causes of disability and death in adults.

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Learn about causes, groups at risk, and potential effects.

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A traumatic brain injury (TBI) is defined as a blow to the head or a penetrating head injury that disrupts the normal function of the brain. TBI can result when the head suddenly and violently hits an object or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate or severe, depending on the extent of damage to the brain. Mild cases may result in a brief change in mental state or consciousness, while severe cases may result in extended periods of unconsciousness, coma or even death.

About 1.7 million cases of TBI occur in the U.S. every year. Approximately 5.3 million people live with a disability caused by TBI in the U.S. alone.

Annual direct and indirect TBI costs are estimated at $48-56 billion.

There are about 235,000 hospitalizations for TBI every year, which is more than 20 times the number of hospitalizations for spinal cord injury.

Among children ages 14 and younger, TBI accounts for an estimated 2,685 deaths, 37,000 hospitalizations and 435,000 emergency room visits.

Every year, 80,000-90,000 people experience the onset of long-term or lifelong disabilities associated with TBI.

Males represent 78.8 percent of all reported TBI accidents and females represent 21.2 percent.

National statistics estimate between 50-70 percent of TBI accidents are the result of a motor vehicle crash.

Sports and recreational activities contribute to about 21 percent of all TBIs among American children and adolescents.

The mortality rate for TBI is 30 per 100,000, or an estimated 50,000 deaths in the U.S. annually. Of those who die, 50 percent do so within the first two hours of their injury.

Deaths from head injuries account for 34 percent of all traumatic deaths. Beginning at age 30, the mortality risk after head injury begins to increase. Persons age 60 and older have the highest death rate after TBI, primarily because of falls, which have a rising incidence in this age group.

Sources:

Centers for Disease Control and Prevention (CDC), Traumatic Brain Injury (TBI): Incidence and Distribution, 2004.

Traumatic Brain Injury Model System, University of Alabama at Birmingham, Introduction to Brain Injury - Facts and Stats, February, 2000

Symptoms vary greatly depending on the severity of the head injury, but may include any of the following:

Vomiting

Lethargy

Headache

Confusion

Paralysis

Coma

Loss of consciousness

Dilated pupils

Vision changes (blurred vision or seeing double, not able to tolerate bright light, loss of eye movement, blindness)

Cerebrospinal fluid (CSF) (which may be clear or blood-tinged) coming out of the ears or nose

Dizziness and balance problems

Breathing problems

Slow pulse

Slow breathing rate, with an increase in blood pressure

Ringing in the ears or changes in hearing

Cognitive difficulties

Inappropriate emotional responses

Speech difficulties (slurred speech, inability to understand and/or articulate words)

Difficulty swallowing

Body numbness or tingling

Droopy eyelid or facial weakness

Loss of bowel control or bladder control

If a TBI is suspected, call 911 immediately or take the person to an emergency room.

When discussing TBI, the term "mass lesion" is often used. This refers to an area of localized injury that may cause pressure within the brain. The most common mass lesions related to TBI are hematomas and contusions.

A hematoma is a blood clot within the brain or on its surface. Hematomas may occur anywhere within the brain. An epidural hematoma is a collection of blood between the dura mater (the protective covering of the brain) and the inside of the skull. A subdural hematoma is a collection of blood between the dura mater and the arachnoid layer, which sits directly on the surface of the brain.

A cerebral contusion is bruising of brain tissue. When examined under a microscope, cerebral contusions are comparable to bruises in other parts of the body. They consist of areas of injured or swollen brain mixed with blood that has leaked out of arteries, veins or capillaries. Contusions are seen most commonly at the base of the front parts of the brain, but they may occur anywhere.

An intracerebral hemorrhage (ICH) describes bleeding within the brain tissue, which may be related to other brain injuries, especially contusions. The size and location of the hemorrhage helps determine whether it can be removed surgically.

Subarachnoid hemorrhage (SAH) is caused by bleeding into the subarachnoid space. It appears as diffuse blood spread thinly over the surface of the brain and is seen commonly after TBI. Most cases of SAH associated with head trauma are mild. Hydrocephalus may result from severe traumatic SAH.

TBI can produce microscopic changes that cannot be seen on CT scans that are scattered throughout the brain. This category of injuries is called diffuse brain injury, which may occur with or without an associated mass lesion.

Diffuse axonal injury refers to impaired function and gradual loss of some axons, which are the long extensions of a nerve cell that enable such cells to communicate with each other even if they are located in parts of the brain that are far apart. If enough axons are injured in this way, then the ability of nerve cells to communicate with each other and to integrate their function may be lost or greatly impaired, possibly leaving a patient with severe disabilities.

Another type of diffuse injury is ischemia, or insufficient blood supply to certain parts of the brain. It has been shown that a decrease in blood supply to very low levels may occur commonly in a significant number of TBI patients. This is crucial because a brain that has just undergone a traumatic injury is especially sensitive to even slight reductions in blood flow. Changes in blood pressure during the first few days after head injury can also have an adverse effect.

No treatment is required for most linear skull fractures, which are simple breaks or "cracks" in the skull. Of greater concern is the possibility that forces strong enough to cause a skull fracture may also have caused some damage to the underlying brain. Fractures of the base of the skull are problematic if they cause injury to nerves, arteries or other structures. If a fracture extends into the sinuses, there may be leakage of cerebrospinal fluid (CSF) from the nose or ears. Most leaks will stop spontaneously. Sometimes, however, it may be necessary to insert a lumbar drain, which is a long, thin, flexible tube that is inserted into the CSF space in the spine of the lower back. This provides an alternate route for CSF drainage so that the dural tear that is responsible for the CSF leak in the base of the skull has time to seal.

Depressed skull fractures are those in which part of the bone presses on or into the brain. These may require surgical treatment. The damage caused by depressed skull fractures depends upon the region of the brain in which they are located and also upon the possible coexistence of any associated diffuse brain injury.

Like all trauma patients, persons with TBI need to undergo a systematic yet rapid evaluation in the emergency room. Cardiac and pulmonary function is assessed first. Next, a quick examination of the entire body is performed, followed by a complete neurological examination. The neurological examination includes an assessment utilizing the Glasgow Coma Scale (GCS). In addition to the GCS, the ability of the pupils to become smaller in bright light is also tested. In patients with large mass lesions or with high intracranial pressure (ICP), one or both pupils may be very wide or "blown". The presence of a wide or dilated pupil on only one side suggests that a large mass lesion may be present on the same side as the dilated pupil. Brainstem reflexes including gag and corneal (blink) may also be tested.

A computed tomography scan (CT or CAT scan) is the gold standard for the radiological assessment of a TBI patient. A CT scan is easy to perform and is an excellent test for detecting the presence of blood and fractures, which are the most crucial lesions to identify in medical trauma cases. Plain x-rays of the skull are recommended by some as a way to evaluate patients with only mild neurological dysfunction. However, most centers in the U.S. have readily available CT scanning, which is a more accurate test. For this reason, the routine use of skull x-rays for TBI patients has declined.

Magnetic resonance imaging (MRI) is not commonly used for acute head injury because it takes longer to perform MRI than a CT. MRI is not as practical for acute trauma because it is difficult to transport an acutely-injured patient from the emergency room to the MRI scanner. However, after a patient has been stabilized, MRI may demonstrate the existence of lesions that were not detected on the CT scan. This information is generally more useful for determining prognosis than for influencing treatment.

Many patients with moderate or severe head injuries are taken directly from the emergency room to the operating room. In many cases, surgery is performed to remove a large hematoma or contusion that is significantly compressing the brain or raising the pressure within the skull. After surgery, these patients are usually observed and monitored in the intensive care unit (ICU).

Other head-injured patients may not go to the operating room immediately, but instead are taken from the emergency room to the ICU. Contusions or hematomas may enlarge over the first hours or days after head injury, so some patients are not taken to surgery until several days after an injury. Delayed hematomas may be discovered when a patient's neurological exam worsens or when their ICP increases. On other occasions, a routine follow-up CT scan that was ordered to determine if a small lesion has changed in size indicates that the hematoma or contusion has enlarged significantly. In many cases, removing the lesion before it enlarges and causes neurological damage may be the safest approach for the patient.

At surgery, the hair over the affected part of the head is usually shaved. After the scalp incision is made, the bone that is removed is usually taken out in a single piece or flap, which is then replaced after surgery. Sometimes, however, the bone may be shattered or heavily contaminated. In these cases, the contaminated or shattered fragments may be removed and not replaced. The dura mater is carefully cut to reveal the underlying brain. After any hematoma or contusion is removed, the neurosurgeon ensures that the area is not bleeding. He or she then closes the dura, replaces the bone and closes the scalp. If the brain is very swollen, some neurosurgeons may decide not to replace the bone until the swelling decreases, which may take up to several weeks. The neurosurgeon may elect to place an ICP monitor or other types of monitors if these were not already in place. The patient is then returned to the ICU for observation and additional care.

At the present time, there is no medication or "miracle treatment" that can be given to prevent nerve damage or promote nerve healing after TBI. The primary goal in the ICU is to prevent any secondary injury to the brain. The "primary insult" refers to the initial trauma to the brain, whereas the "secondary insult" is any subsequent development that may contribute to neurological injury. For example, an injured brain is especially sensitive and vulnerable to decreases in blood pressure that might otherwise be well tolerated. One way of avoiding secondary insults is to try to maintain normal or slightly elevated blood pressure levels. Likewise, increases in ICP, decreases in blood oxygenation, increases in body temperature, increases in blood glucose and many other disturbances can potentially worsen neurological damage. The prevention of secondary insults is a major part of the ICU management of head-injured patients.

Various monitoring devices may assist health care personnel in caring for the patient. Placement of an ICP monitor into the brain itself can help detect excessive swelling of the brain. One commonly used type of ICP monitor is a ventriculostomy, which is a narrow, flexible, hollow catheter that is passed into the ventricles, or fluid spaces in the center of the brain, to monitor ICP and to drain CSF if ICP increases. Another commonly used type of intracranial pressure monitoring device involves placement of a small fiberoptic catheter directly into the brain tissue. Additional catheters may be added that measure brain temperature and brain tissue oxygenation. Placement of an oxygen sensor into the jugular vein can detect how much oxygen in the blood is arising from the brain and can indicate how much oxygen the brain is using. This may be related to the degree of brain damage. Many other monitoring techniques are currently under investigation to see if they can help to improve outcome after head injury or provide other critical information about caring for TBI patients.

One of the most widely used systems to classify outcome from head injury is the Glasgow Outcome Scale (GOS). Patients with mild head injury (usually defined as GCS score on admission of 13-15) tend to do well. They may experience headaches, dizziness, irritability or similar symptoms, but these gradually improve in most cases.

Patients with moderate head injuries fare less well. Approximately 60 percent will make a positive recovery, and an estimated 25 percent will be left with a moderate degree of disability. Death or a persistent vegetative state will be the outcome in about 7 to 10 percent of cases. The remainder of patients will have a severe degree of disability.

The group comprised of severely head-injured patients has the worst outcomes. Only 25 to 33 percent of these patients have positive outcomes. Moderate disability and severe disability each occur in about a sixth of patients, with moderate disability being slightly more common. About 33 percent of these patients do not survive. The remaining few percent remain persistently vegetative.

The above statistics apply to patients with so-called closed head injuries. For penetrating head injuries, which today are caused most commonly by handguns, outcomes follow a different pattern. More than 50 percent of all patients with gunshot wounds to the head who are alive upon arrival at a hospital do not survive because their initial injuries are so severe. However, most of the remaining patients tend to do fairly well, largely because their injuries are relatively mild (GCS score of 13-15). Relatively few patients suffer injuries of intermediate severity (GCS score of 9-12) from gunshot wounds, but it is this group that has the most variability in outcomes.

Despite its usefulness, the GOS is not a good tool with which to measure subtle emotional or cognitive problems. Several months after a severe head injury, patients who have a good score on the GOS may in fact have significant neuropsychological disabilities. Tremendous effort is being directed into finding better ways to evaluate these problems, into improving the quality of prehospital, acute and rehabilitative care, and into research to learn more about the effects of head injury and potential treatment options.

Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Lancet 1974; 81-84.

Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir 1976; 34:45-55.

Once head-injured patients leave the acute-care hospital, some may benefit from a rehabilitation program. Prime candidates for rehabilitation are patients that had less severe initial injuries or those that have started to show significant improvement. In some cases, further recovery may be expedited by transfer to a rehabilitation hospital or to the rehabilitation service of a large hospital. For more severely injured patients or for those whose recovery is slow, constant vigilance is required to prevent the gradual onset of problems with joint mobility, skin integrity, respiratory status, infection and many other physiological functions. Patients with moderate or mild injuries, as well as severely injured patients who have improved sufficiently, may be candidates for outpatient therapy.

Regardless of the setting, most head-injury rehabilitation centers emphasize compensatory strategies, which essentially help patients learn to reach the maximum level of function allowed by their impairments. The concept of cognitive retraining, which presumes that at least some of the brain's cognitive capacity can be restored by constant repetition of certain simple tasks, is more controversial but is also emphasized at many centers. Another major goal of head injury rehabilitation is working with patients' families to educate them about what they can realistically expect and how they can best help their injured family member.

Wear a seatbelt every time you drive or ride in a motor vehicle.

Never drive while under the influence of drugs or alcohol or ride as a passenger with anybody else who is under the influence.

Keep firearms unloaded in a locked cabinet or safe, and store ammunition in a separate, secure location.

Remove hazards in the home that may contribute to falls. Secure rugs and loose electrical cords, put away toys, use safety gates and install window guards. Install grab bars and handrails if you are frail or elderly.

Buy and use helmets or protective head gear approved by the American Society for Testing and Materials (ASTM) for specific sports 100 percent of the time.

Supervise younger children at all times, and do not let them use sporting equipment or play sports unsuitable for their age. Do not let them use playgrounds with hard surface grounds.

Follow all rules and warning signs at water parks, swimming pools and public beaches.

Do not dive in water less than 12 feet deep or in above-ground pools. Check the depth - and check for debris in the water before diving.

Wear appropriate clothing for the sport.

Do not wear any clothing that can interfere with your vision.

Do not participate in sports when you are ill or very tired.

Obey all traffic signals, and be aware of drivers when cycling or skateboarding.

Avoid uneven or unpaved surfaces when cycling, skateboarding or in-line skating.

Perform regular safety checks of sports fields, playgrounds and equipment.

Discard and replace sporting equipment or protective gear that is damaged.

Never slide head-first when stealing a base.

Agnosia - failure to recognize familiar objects even though the sensory mechanism is intact

Agraphia - the inability to express thoughts in writing

Alexia - the inability to read

Amnesia - lack of memory about events occurring during a particular period of time

Anosmia - loss of the sense of smell

Anoxia - a condition in which there is an absence of oxygen supply to an organ's tissues although there is adequate blood flow to the tissue

Aphasia - loss of the ability to express oneself and/or to understand language

Arachnoid - middle layer of membranes covering the brain and spinal cord

Ataxia - shaky and unsteady movements that result from the brain's failure to regulate the body's posture and the strength and direction of movements

Axon - the nerve fiber that carries an impulse from the nerve cell to a target and also carries materials from the nerve terminals back to the nerve cell

Brain Stem - the stemlike part of the brain that connects to the spinal cord

Closed Head Injury - impact to the head from an outside force, without any skull fracture or displacement

Concussion - a disruption, usually temporary, of neurological function resulting from a head injury or violent shaking

CSF - a clear fluid surrounding the brain and spinal cord

Contusion - a bruise; an area in which blood that has leaked out of blood vessels is mixed with brain tissue

Coup-Contrecoup Injury - contusions that are both at the site of the impact and on the complete opposite side of the brain

Depressed skull fracture - a break in the bones of the head in which some bone is pushed inward, possibly pushing on or pressing into the brain

Diplopia - a condition in which a single object appears as two objects; also called double vision

Dura mater - the outermost, toughest and most fibrous of the three membranes (meninges) covering the brain and the spinal cord

Dysarthria - speech that is characteristically slurred, slow and difficult to understand

Edema - collection of fluid in the tissue causing swelling

Epidural - located on or outside the dura mater, the outermost, toughest and most fibrous of the three membranes (meninges) covering the brain

Hemiplegia - paralysis of one side of the body as a result of injury to neurons carrying signals to muscles from the motor areas of the brain or spinal cord

Hemiparesis - weakness, paralysis or loss of movement on one side of the body

Hemianopsia - loss of part of one's visual field in one or both eyes

Hydrocephalus - a condition in which excess CSF builds up within the ventricles (fluid-containing cavities) of the brain and may cause increased pressure within the head

Hypoxia - a condition in which there is a decrease of oxygen to the tissue despite adequate blood flow to the tissue

Intraparenchymal - inside the parenchyma of the brain

Ischemia - a reduction of blood flow that is thought to be a major cause of secondary injury to the brain or spinal cord after trauma

Locked-in Syndrome - a rare neurological condition in which a person cannot physically move any part of the body except the eyes

Open head injury - trauma to the brain resulting in loss of consciousness due to the penetration of the brain by a foreign object, such as a bullet

Subarachnoid hemorrhage - Blood in, or bleeding into, the space under the arachnoid membrane, most commonly from trauma or from rupture of an aneurysm

Subcortical - the region beneath the cerbral cortex

Subdural - the area beneath the dura covering the brain and spinal cord

Vasospasm - spasm of blood vessels which decreases their diameter

Ventricles (brain) - four natural cavities in the brain which are filled with CSF

The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult his or her neurosurgeon, or locate one in your area through the AANS' Find a Board-certified Neurosurgeon online tool.

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A traumatic brain injury (TBI) is defined as a blow to the head or a penetrating head injury that disrupts the normal function of the brain. TBI can result when the head suddenly and violently hits an object or when an object pierces the skull and enters brain tissue.

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Classroom Interventions for Students with Traumatic Brain Injuries | BrainLine

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There is a lot to know about helping children with TBI successfully return to the classroom.

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Provides Resources in different states with links and phone numbers.

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Traumatic Brain Injury in the Classroom: Support & Intervention

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There are supportive services available for helping survivors with traumatic brain injury in the classroom. Here's what to expect.

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Helping Your Child Adjust

Introduction

Although no two children or their brain injuries are alike, many children struggle with similar emotions and challenges after TBI. These include:

denial that the injury will have a long-term impact,

grief over their loss of function and skill,

changes in how they relate to others,

rustration with the recovery process, and

limited awareness of the differences in themselves.

Your child's ability to cope with or develop strategies for dealing with these changes will vary depending on many factors. Some of these may include your child's previous coping skills, her intellect and personality, the support available from friends and family, her emotional health, the strength of her relationships, the stage of development she was in when injured, and the extent of the injury.

As a parent, you will play a key role in helping others understand your child. Thanks to your unique experience parenting your child, you will be able to provide professionals with valuable information and insight into your child's individual traits. During the rehabilitation process, parents' involvement and commitment are often seen as pivotal to their child's recovery and return to home and school.

To help you better help your child, this chapter will examine some of the changes that children with TBI commonly face during the acute, rehabilitation, and back-at-home phases of the recovery process. It will also offer suggestions for helping your child cope with and adjust to these changes.

Your Child During the Acute Phase

Once your child's condition is stabilizing and she is beginning to emerge from coma, you feel some reassurance. There is joy, relief, and hope but still uncertainty. You try not to be overjoyed, as the road ahead is still uncertain, but you experience some slight relief, a small lift of the burden. This was the small step, the sign that everyone has been waiting for. From this moment forward, your experience of parenting your child is changed forever.

In the acute phase, as you are trying to manage your emotional roller coaster, you find yourself asking, "What should I be doing for my child?" Below are some suggestions for supporting your child as she emerges from coma.

Emerging from Coma

Emerging from a coma is a frightening experience for a child. One child recalled the experience this way: "I remember being scared and wondering where I was. I remember there were doctors and nurses and I saw my mom sitting by the side of my bed." Each child's beginning steps of recovery are unique and marked by varying memories. The environment is unfamiliar and your child's memories leading up to the injury may be unclear and uncertain. Usually, there is no memory of the actual injury. Uncertainty and unfamiliarity mark the beginning of the road ahead that your child now faces in coping with the changes in herself.

When your child is emerging from coma, there will be times when she is not alert or responsive. Providing stimulation, support, voice, and touch can be helpful to your child. Even if your child is not responsive, providing this support can help you feel connected to your child. If possible, surround your child with familiar items, including pictures of family members and friends, mementos from home, and familiar music. Try to create a familiar environment within the unfamiliar hospital room. When you are ready, encourage close family members to visit your child. You and your family members should keep talking to your child, providing those familiar voices and reassuring words of love and support.

Your Child During the Rehabilitation Phase

The work begins. Your child may be faced with many physical, cognitive, and emotional challenges. As a parent, you are constantly observing and encouraging your child, hoping for changes, slight improvements that might ultimately lead to larger accomplishments. Your child may experience difficulty walking, managing personal care, expressing wants and needs, and remembering: things that she once did without any thought or effort. Now is the time in the recovery phase where the effort to regain previously mastered skills begins. Demands are placed and goals are set, as a variety of specialists begin challenging your child to reach her potential. Your child begins making small, slow steps toward larger accomplishments.

During the rehabilitation phase, your child may have difficulties with memory, self-awareness, and problem solving. She may have sudden changes in her emotions (emotional lability) or show no emotions at all (flat affect). She may also become easily frustrated, fatigued, and irritable, and have changes in her behavior and personality. These changes often lead to poor social behavior and interactions with others.

Confronted with Changes

Recovery is a gradual and challenging process with no clear endpoint. It varies depending on the injury and the child. As your child begins to slowly emerge and progress, deficits become more apparent. Your child may be discouraged by the slowness of progress and the ups and downs that come with recovery. Seemingly simple activities may now by difficult to perform. She may also be faced with accepting changes in her physical appearance. Often there are healing wounds that are difficult for a child to accept. Hair may have been shaved immediately following the injury. Your child may not be comfortable with changes in her appearance. Additionally, she may be frustrated by her new physical limitations. For instance, a once very active 14-year-old basketball player with artistic talents was very frustrated by the difficulties he experienced in walking, and in using his dominant hand to eat, care for personal needs, and draw as he used to.

Difficulties with Insight and Awareness

Sometimes children are not aware of other emerging differences aside from the physical differences. They may not agree that their academic performance, memory, language skills, behavior, personality, or social behavior have changed. Often children lack insight into their cognitive deficits, as it is easier to see, understand, and focus on rehabilitation of the physical differences. This can be particularly challenging for family members who are able to observe both the physical and cognitive difficulties their child is facing.

Developmental Stages

During the rehabilitation phase your child is working hard to regain a multitude of lost skills. Your child has experienced a tremendous amount of change in herself in a very short period of time. How your child views those changes will likely depend on her stage of development. For instance, an infant or toddler will have little understanding of her differences. Older children and adolescents have more capacity to understand these changes in self that can affect identity, self-perception, peer relations, previously mastered skills, and goals for the future.

Often children and adolescents experience grief, anger, a decrease in self-esteem, and depression, as the loss of skills and changes in personality, social behavior, academic performance, communication, language skills, and appearance become more apparent. During adolescence, children normally struggle with the formation of their identity and have often formulated negative attitudes toward those who are different, less capable, and less "cool." The discrepancy between an adolescent's former and current self can be problematic.

What You Can Do for Your Child during the Rehabilitation Phase

During this rehabilitation phase, your family will become central to recovery and the primary support for your child. You can provide professionals with specific information that can't be gleaned by testing, serving as a window into your child. You know your child best, and have the commitment to become her lifelong advocate. Below are some suggestions that will help you and other family members support your child.

Focus on Daily Successes

During the rehabilitation phase, your child may be discouraged by the slow process of recovery, experiencing periods of ups and downs. Help her to see recovery as a long process by focusing on the daily positives and progress already made. You can compare specific challenges to other times in life when accomplishing a goal took time and was challenging. For example, you might remind her of the time when she practiced her flute every day and took private lessons to prepare for her audition for the school orchestra. Praise your child for her accomplishments since the injury. Be supportive and encouraging while maintaining realistic goals. Try not to evoke additional frustration by focusing on the negative, putting extra pressure on your child to perform, or setting goals that she is not ready for.

It may be difficult to see your child struggle with physical needs as well as cognitive demands. You can help, however, by re-instilling confidence while she is relearning and regaining skills. When appropriate, encouraging her to be independent can help your child feel a sense of self-worth.

Your child's feelings and motivation may fluctuate as she faces numerous changes during the recovery period. Family members can help by providing consistency, support, and encouragement. Focus on the positive, and minimize critical feedback. Again, you know your child best--what motivates her, her personality, her previous coping style, and her level of acceptance. Communicate this knowledge to professionals who work with your child.

Your role in supporting your child in her daily coping may seem like a high-wire balancing act, but remember that your family is her primary source of support. It is well worth your efforts to do whatever it takes to help your child regain her participation in the outside world.

Managing Changes in Appearance

How much of an emotional impact your child's physical changes have on her will depend on her age and stage of development. Your child may not like the way she now appears to others and may therefore be uncomfortable with visits by friends and family members. Helping your child understand the importance of family and friends in her life may help to ease her discomfort. In the meantime, it is fine to respect her wishes and minimize the number of visitors until she feels more comfortable.

Help your child feel as comfortable as possible with her appearance. For example, allow her to wear a baseball cap or clothing that covers her injuries if it makes her feel more secure.

If your child feels comfortable discussing her differences (for example, hair, stitches, cuts, scars, braces/splints), encourage her to talk about them and how they affect how she perceives herself. Discuss how these physical changes also take time to heal. Hair grows back and some cuts and scars will fade over time. It may help your child to see photographs of herself before the injury and during the course of recovery so that together you can observe and realistically discuss changes.

If your child does not seem comfortable discussing her appearance, take her lead. Minimizing the attention placed on physical appearance may reduce the importance of this in your child's mind. Listen to your child if she wishes to talk about her appearance, but do not keep bringing up the topic if it seems to be a sore subject for her. Once again, you know your child best.

Understanding Cognitive Changes

It is often difficult for a child to conceptualize the magnitude of a brain injury and its effects on memory, problem-solving ability, language, and personality. With the assistance of professionals, you can help your child to understand all that the brain controls, while emphasizing the importance of, and length of time for, recovery. Tell your child that just like an injured arm or leg, the brain needs time to heal and to be exercised. Be sensitive to your child's reaction to these deficits and changes. Allow her to express thoughts and feelings associated with the anger and grief surrounding the loss of skills. Seek the assistance of professionals to help your child feel that it is OK to have such difficult feelings about deficits, the recovery process, and thoughts about the future.

Your injured child's lack of insight into her actions and behaviors and recently acquired limitations will present new challenges for your family. Where you may have once felt comfortable with your child out of your sight, you may now feel just the opposite. This can be particularly difficult with teens and children with active lifestyles. Again, you are balancing on the high wire. One of the greatest challenges is for you to re-instill a sense of responsibility in your child while providing what may now be a greater level of safety and supervision than ever before.

Without insight and awareness into the reasons for heightened supervision, your child may feel mistrusted. It's best to continually discuss this issue and help her achieve a sense of responsibility in other, possibly new and creative ways. For example, find things for your child to do around the home where she can feel a sense of responsibility within a safe environment. If it was previously your child's responsibility to mow the lawn, you might change her responsibility to the equally important chore of getting the mail.

To balance your child's desire to regain her previous autonomy and freedom around the neighborhood with the need to keep her safe, you may consider asking for help from trusted friends and neighbors. Talk to adults and responsible children in the neighborhood about your child's limitations and the importance of safety while she is recovering. Ask adult neighbors and friends' parents to help supervise and monitor the safety of your child's activities. Maintain open communication throughout the recovery process and continually focus on the length of the recovery process in working toward future progress.

The Peer Network

When a friend suffers a brain injury, peers often struggle with the same emotions that parents and family members experience, including guilt, fear, anger, sorrow, and concern. Your family will need to decide which peers need to know what and who will be the one to share this information with them.

While your child is beginning the recovery process, it is important to involve peers who are responsible and close to your child. Like your family, your child's friends are wondering if your child will ever be the same and need to learn to accept some of the obvious and more subtle differences. Peers need to be educated about brain injury and recovery . . . to relearn and readjust to your child, their friend.

When it is comfortable for your family, involve peers in the rehabilitation process. How much peers are involved may vary depending on your child's age and comfort level, as well as distance/accessibility of the rehab facility. Identify a handful of responsible and devoted friends whom you know and trust, and whom you can envision being your child's eyes and ears once she returns to school. Encourage peers to contact your child in the hospital through phone calls, letters, cards, and face-to-face visits when the time is appropriate. This will help friends to cope with the changes in your child and adjust to and understand her new needs. It will also help your child begin to accept the changes in herself. Educating and exposing peers along the way will help with the inevitable transition to home and school, and with the understanding of differences, limitations, and changes in personality and behavior. If supportive peers understand your child's needs, this will hopefully lead to a positive and accepting transition back into the community.

Changes in Self-Esteem

As your child becomes more involved in the rehabilitation phase, her self-esteem can suffer. The noticeable changes in herself and her skills, as well as differences in behavior, moods, cognition, and personality can challenge your child's self-esteem. For example, this is how one parent described the changes in her child:
"Before his injury, Tom was so positive and confident. He was always the first to try something and most things came easily for him, be it school work, sports, artistic endeavors. Since his injury, he no longer has the use of his right arm and hand and requires a cane to help with walking. It takes him longer to process information, and math, which was once easy, is now a chore. He is a different person now, ashamed of what his friends might think of him, frustrated that he can no longer do things the way he used to, and unwilling to try new things. You see, Tom wanted to be an electrical engineer and play basketball in high school and college. I know that when he thinks about his future now it scares him."
The evolution of such changes, coupled with the uncertainty of recovery, is extremely frustrating for a child with TBI and can cloud a previously favorable and confident self-perception.

As a parent, watching your child struggle with the emotional impact of the injury can be very painful and difficult. Often you have shared the same hopes and aspirations for your child. You may feel as if you want to take this struggle away, since your child already has so much to manage.

Again, encouraging and rewarding progress while remaining sensitive to the length of the recovery process will help your child feel supported and recognize her accomplishments. Be patient and communicate with your child. Help her to know that it is OK to talk about her feelings and experiences, and allow frustrations to be expressed. Never try to talk your child out of her feelings. Your child's feelings are what she feels-they are neither right or wrong. The losses that your child is experiencing are real and will inevitably be accompanied by a variety of emotional expressions and reactions. The support and strength provided by your family will help your child through all stages of the recovery process.

If your child seems to need more emotional support than your family can provide, do not hesitate to seek supportive therapy for her, as well as your family, from psychologists, social workers, or counselors experienced with traumatic brain injury.

Your Child Back at Home

After weeks, possibly months, of recovery in the hospital setting, your child is now ready to transfer her recovery process to the home and community. As a parent, you may feel both positive and negative emotions about this step. On the one hand, you know that your child has made progress and that there is hope for continued success once your child returns home. You will probably become more confident as time at home increases, experiencing some relief and hope. You will also probably welcome the longed-for semblance of normalcy in your life, with your family again reunited at home.

On the other hand, you may feel ambivalent, scared, and worried about how this transition home will play itself out. You know there may need to be physical changes made to your home as well as changes in roles and expectations. You have been part of the team process, working and training closely with professionals who have provided care for your child 24 hours a day. You have come to rely on the support of professionals, and now your family is expected to carry out this lifetime mission back at home.

With practice and experience, families can learn to adjust to the changes at home and continue to support their child. This section details some of the changes to expect.

Changes in Family Roles and Responsibilities

When your child returns home, many of the physical and cognitive difficulties that she experienced during the rehabilitation phase will continue, only now these issues will play themselves out in your family's everyday life experiences. You may find that the demands and challenges increase and that roles within the family shift. For example, younger siblings may take on more of a big brother or big sister role in the family, with greater responsibilities. Siblings may assist your injured child with her homework or daily care routines. Or they may take on chores and responsibilities for their recovering brother or sister.

I'm Home, I'm OK

Depending on the injury and level of recovery, children with TBI often feel that they have returned to pre-injury life once they are home. Now, more than ever, parents will struggle to balance their instincts to overprotect their child with the need to allow for some independence within the constraints of safety and supervision. Your child may not value or understand the need and importance of safety and close supervision, particularly if she is an older child or adolescent who has previously been granted some independence and freedom. Often when children return home, they feel that this is the permission they have been waiting for to resume previously enjoyed social activities. "I'm out of the hospital, so now I'm better and I can do what I want," they may think.

For children who do not show any physical signs of a traumatic brain injury, yet have cognitive challenges, restrictions on activities may be difficult to adjust to and understand. The reaction of this sixteen-year-old who was struck by a car while crossing the street is typical: "Since I've been home from the hospital, my mom won't let me out of her sight. She won't even let me ride my bike or go swimming unless she is watching me. She says she's worried that I may injure my brain again." It is difficult for children who previously had very active lifestyles and enjoyed such activities as football, soccer, roller-blading, skateboarding, or swimming to now see these activities as risky and potentially dangerous.

In short, although the return home is a positive and significant step in recovery, it often exposes your child to more restrictions and limitations than could be imagined while hospitalized. As your child re-enters her life at home and in school, the discrepancies between what she could do before and what she can do now become more evident.

Your Child's Losses

As your child adjusts to home, losses that were beginning to be apparent during the rehabilitation phase may intensify and become more real. In addition to the previously discussed cognitive and physical losses, additional losses may begin to surface once at home. These may include the loss of roles and responsibilities within the family, changes in friendships and social groups, and adaptations to goals and dreams for the future.

Once home, the emotions associated with loss will resurface throughout your child's and your family's life cycle, depending on the specific loss and how it affects your child and family at a specific point in time. For example, as your child reaches the age when milestones often occur - learning to drive, high school graduation, college acceptance - your child and family may feel a sense of loss if those milestones aren't reached on schedule.

Peer Involvement and Response

With the early and timely involvement of close friends, these friends will hopefully become an integral piece of your child's transition back to home and school. Many times, peers are able to cope with the changes in their friend and can provide the support and understanding that your child will need. Other times, friends can become less supportive, unsure how to respond to the numerous changes they see. Often the injured child's social behavior may be inappropriate or disruptive, or seem immature and even embarrassing to friends. They may think, "Before her injury she was quieter and liked to do different things. Now she is always embarrassing me with her comments and never invites me to do anything." It is often difficult for peers to understand that these changes in their friend are the result of the brain injury and that behaviors, emotions, personality, and moods may now be very different.

Returning to School

Preparing to return to school is yet another milestone in the recovery process that evokes a variety of emotions for children with TBI and their families. Again, there may be positive feelings about this transition, yet, it can be another time of ambivalence and concern. Depending on what kinds of extra help your child will need and what is specifically provided by the school, your child may be better served at a different school. (See Chapter 9 for a thorough discussion of these issues.)

Whether your child returns to her school or transfers to another school, there will be challenges to face. If your child now requires special education services, becoming involved with the special education system may be a new experience for your family. Children often perceive that there is a stigma attached to special education services that reinforces the permanence of differences in themselves, causing a change in identity. Whether or not your child needs special education services, she may be worried about changes in academic performance and about how peers may respond to physical and cognitive changes. On the other hand, your child may not have the insight into her differences, and may view herself as unchanged, believing that everything will be the same. Regardless of your child's level of insight and understanding into the complexity of such changes, educational services and supports need to be designed for her specific needs.

Social Behavior

As your child rejoins the community, social situations that once seemed natural and appropriate to your child's development may now present challenges. For example, your once outgoing, social child may now be quiet and withdrawn and appear confused at birthday parties. Or she may be disinhibited and impulsive, blurting out comments without thinking and engaging in risky behavior. Adolescents may struggle with peer interactions, requiring the re-teaching and rehearsing of social skills. Sometimes this can result in social isolation, and a growing distance between your child and her peers.

What You Can Do for Your Child at Home

As described above, returning home presents its own set of challenges for your family and your child. Over time your family will gradually adjust its life to address these changes. This section describes things you can do for your child to help with this transition back to the home and community.

Encouraging Family Communication

One of the most critical steps you can take to help your family weather your child's transition back home is to facilitate and encourage open dialogue between family members as to how these changes are affecting each individual. Important issues to discuss include:

Feelings about changes in household roles, routines, and responsibilities;

Siblings' feelings about your injured child's new behaviors and how they are managing at school and in the neighborhood;

Feelings your injured child has about her siblings being allowed to do things that she is not.

Consider holding regular family meetings to gather feedback from family members. Set a time during the week when all family members are expected to attend and discuss what is and is not working within the home. Ongoing open communication within your family will help to establish a foundation for solving problems, alleviating stress, and strengthening relationships within the family.

Setting Limits and Encouraging Other Activities

There are ways to provide safety and supervision for your child while enabling her to have some sense of control and responsibility. First, encourage activities to take place in your home or the home of a trusted adult so that supervision can be unobtrusively provided. Second, set limits with siblings, friends, and your child regarding activities that are safe and appropriate so that your child does not feel pressured or confused in social situations. Third, schedule time together as a family to explore and encourage new activities or interests that present less of a risk for re-injury. Fourth, continue to communicate openly with your child, allowing her to express her frustrations with restrictions. Lastly, educate and inform others as you learn new ways of keeping your child safe. The more people know about the importance of providing a safe environment for your child, the less likely your child is to be put in compromising social situations.

One mother of a sixteen-year-old sat down with her son and his friends and listed activities that Jimmy was allowed to participate in, activities that would require adult supervision, and activities that were completely off limits. This particular mother developed valuable relationships with friends and neighbors early on in her son's recovery process through educating and informing. Several months following her son's return home, she felt comfortable with a handful of trusted friends who understood the importance of safety and were willing to look after her son in social situations.

Managing Losses

Helping your child to manage losses can be a challenging and difficult task, especially when you are likely experiencing and managing your own losses. Establishing a strong support network of family, neighbors, friends, members of religious and community institutions, school personnel, and other professionals is critical. When comfortable, encourage your child to express herself to you and other people in her life.

As mentioned above, there are many times when support from outside professionals can be very helpful. It is worth getting outside help whenever your family does not seem to be coping well, and the neutral, objective perspective and support from a professional might help you over a hump. Additionally, you should seek professional assistance if your child is feeling very distressed, angry, overwhelmed, stressed out, frustrated, depressed, or isolated from peers. In these instances, it is likely that your child's emotional struggles are affecting the whole family.

One way to seek out professional help is to utilize school resources, including school social workers, guidance counselors, and psychologists. Your child may also benefit from counseling services provided by a professional who is experienced with traumatic brain injury. Additionally, family counseling or support groups may help all family members, as issues of loss and change cycle throughout one's life and will likely need to be revisited.

Memory Book

Many families use memory books as a tool to help their child understand what has happened to her from the point of injury through the recovery process. Often these books include:

photographs of the child taken at different points during recovery;

significant dates, times, and events during recovery; and

pictures and comments of professionals who have helped the child and family along the way.

By providing a chronology of the events that happened, the memory book can reinforce the seriousness of the injury to your child, let your child see that she is recovering, and help her integrate this trauma into her lifetime experiences. This tool can also be used to encourage conversation with your child and help in educating others.

Some families reserve a section of the memory book or make a separate memory book to help their child remember information needed for day-to-day life. For example, as an aid to remembering, they list names, dates, times, phone numbers, school schedules, and the steps needed to complete daily living tasks or routines within the classroom or home.

Managing Social Situations

As discussed above, children with TBI often experience social isolation as a result of changes in behavior, personality, mood, and awareness. This can be extremely difficult for your child if she has previously had solid peer relationships. If your child struggled with relationships before her injury, making and keeping friends will probably be even more challenging now. In addition, difficulties with insight, good judgment, and social awareness could place your child in vulnerable situations. For example, your child might be pressured to do something that could place her at risk for another injury. If she is feeling anxious to be liked and accepted by the group, she might take the risk.

Again, help your child by educating her friends and school personnel about recovering from, and long-term effects of, a brain injury. If your child's friends seem to be backing away from her, try offering them more information about your child's condition to help them understand the changes in her. It may help to talk to the parents of your child's friends to better understand the friends' perspectives.

Listen to your child's frustrations about social situations. With the assistance of professionals specializing in traumatic brain injury, you may need to re-teach and rehearse social skills with your child by role playing or by practicing responses to scenarios that your child may be confronted with. Encourage your child to initiate social activities and conversations with her friends, serving as a role model for appropriate behavior.

Returning to School

Returning to school can be a difficult yet positive experience for you and your child. It will be very important to establish close and frequent communication between your family and school personnel (social workers, guidance counselor, teacher). Communication is the key to better understanding and helping your child. Often a communication log or notebook that travels between home and school is the easiest way for the school and family to communicate and is helpful in tracking and planning for the needs of your child. Parents can ask questions about what is happening at school and write about progress and difficulties that their child is having related to school. Likewise, teachers can use the notebook to record what they observe, respond to questions, and have an ongoing dialog with parents.

Your child may feel anxious about returning to school or beginning a new school. Anxiety could be the result of insight into changes in herself, concerns with changes in academic performance or physical appearance, concerns about peer reactions and acceptance, or worries about being placed in special education or the amount of time missed from school.

It is natural and appropriate for your child to worry about returning to school, yet there are some ways to help to ease this process for your child. First, professionals who are experienced with traumatic brain injury can help by educating peers and school personnel before your child's first day at school. Professionals can educate staff and students through in-services to help others less familiar with brain injury to better understand your child. Second, your child should have access to a school professional, such as a social worker, guidance counselor, or nurse, who is available to discuss her concerns about returning to school. Third, as a parent, you can ask to meet with school personnel to discuss your child's educational needs at any time. In fact, you will probably find that advocating for your child will be critical to your own well-being. And finally, it may help for your child to be paired with a "buddy," a trusted and responsible peer who can look out for your child and help to guide her during the school day. Your child may be able to help choose this buddy. Ultimately, however, the buddy should be a responsible student with whom both your family and school are comfortable.

If your child is placed in special education, she may worry about the perceived stigma. Be available to talk with your child regarding the unfairness and unkindness of this stigma and help her to understand the purpose of special education services. In addition, make sure that school personnel are attuned to this issue and available for your child during the transition period. Maintaining frequent contact with your child's school prior to her return, at the time of re-entry, and throughout the school year will help you help your child adjust to the changes in herself and her school program.

Community Resources

Community resources can be vital in helping your family and child adjust to your new way of life. Become connected with support groups and organizations where you can share your experiences and learn from others. Become active in your local chapter of the National Brain Injury Association, groups and organizations involved with special needs, and the local educational system. Use the supports of church and community members in bringing understanding and awareness to others. Go online and get virtual support and real information from some of the Internet resources listed in the Resource Guide. Most importantly, establish connections with others who have shared similar experiences. This will open doors for extended emotional support while acquainting you with other families who have faced, problem-solved, and made it through varying phases along this lifelong process. See the Resource Guide at the back of this book for organizations that can help you get started in seeking support.

General Guidelines

Below is a collection of basic guidelines for helping your child adjust following a traumatic brain injury:

1. Encourage and praise progress.

2. Involve peers, school, and the community when the time is right for your family.

3. Listen to your child and provide support.

4. Serve as a role model for social behavior.

5. Encourage your child to have relationships with friends.

6. Explore finding a counselor experienced with traumatic brain injury for your child and the family.

7. Consider family counseling to address role changes, sibling issues, understanding of differences, and the impact of this trauma on the family life cycle and development.

8. Encourage your child to focus on one day at a time by setting small goals as steps toward accomplishing larger ones.

9. Encourage independence with supervision. Be creative with this!

10. Seek the support and services of community members (professionals, church members, support groups).

11. Communicate! (with your child, family members, neighbors, friends, professionals, and the school).

12. Help your child understand her injury and recovery. (Let her know that the brain needs time to heal like other body parts.)

13. Instill confidence in creative ways--draw on previous skills and interests, applied in new ways.

14. Create a Memory Book. (Memory difficulties are often frustrating. This will also help to document events and reinforce progress.)

15. Encourage a normal lifestyle, predictability, and routine as much as possible.

Above all, remember that this is challenging and a lifelong process!

Parent Statements

I prayed to the good Lord to bring her back to me. He didn't say how she would be. Now I've got to deal with what I've got.

We've got this huge modified, accessible bathroom and a tiny laundry room. The bathroom is like the part of my life devoted to my child's needs and the rest of my life is like the laundry room - squeezed into a very small space.

Joe has done some things that have my heart floating - like walking to our neighbor's house independently!

Tommy's friends were really supportive when he went back to school after his bicycle accident, but now they seem to have moved on. He can't understand why they don't want to spend time with him anymore.

Sometimes I wish she could just see her problems so she would accept the fact that she needs help, but most of the time I'm glad she doesn't see.

The social worker has been the constant, predictable factor in a situation where nothing is predictable. When I'm in her office, I can pause and think and be myself.

He is doing really well now. When other kids ask him why he walks that way or why he can't use his right arm, he tells them "Somebody very bad hurt me once, but he is in jail now." Then he says, "Let's play." Because he handles it so calmly, other kids handle it well too. Sometimes he still is upset or confused about it, so we talk and practice ways he can respond to other kids' questions. He really is a terrific kid and everybody loves him.

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Children with Traumatic Brain Injury: A Parents' Guide | BrainLine

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Although no two children or their brain injuries are alike, many children struggle with similar emotions and challenges after TBI. These include: denial that the injury will have a long-term impact, grief over their loss of function and skill, changes in how they relate to others, rustration with the recovery process, and limited awareness of the differences in themselves.

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Finding helpful resources for your TBI recovery isn't always straightforward. If you're also providing care to your child after a TBI, searching for help can add to the already stressful season.

It should be easier to find the resources you need to help get through this period. After all, you want to provide your child with the best care and support possible.

Here are the 10 most supportive traumatic brain injury resources for parents.
Looking for personalized TBI therapy services? Moody Neurorehabilitation is here to help. We offer outpatient and residential care and can help families find accommodations during the process. Contact us to learn more.
1. Brain Injury Association

The Brain Injury Association offers many helpful resources on traumatic brain injury. From educational guides to support groups, you can find help on their website.

Moreover, they offer a list of state rehabilitation programs.

2. Office of Acquired Brain Injury

The Office of Acquired Brain Injury (OABI) helps TBI patients and caregivers learn more about TBI. Furthermore, the organization raises awareness about brain injuries and how to prevent them.

Additionally, you can find information on local support groups.

3. Comprehensive Rehabilitation Services (CRS) Program

The Comprehensive Rehabilitation Services (CRS) Program helps eligible TBI patients with the rehabilitative process and their recovery goals. They also assist patients with finding support services and may even pay for them.

4. The CDC

The Centers for Disease Control and Prevention (CDC) offers more than updates on the pandemic. They also offer the latest studies on traumatic brain injury.

Additionally, they have a special Heads Up page where parents can find support as they help their children recover from TBI.

5. Your Texas Benefits

Your Texas Benefits is a resource that simplifies finding financial aid for healthcare, food costs, and support services. After answering basic questions, you'll be able to see which benefits you can receive. Or if you're looking for support services, you can sign up for updates about available options.
Moody Neurorehabilitation offers many services for patients with TBI and their families - all through the latest technology and therapy programs. Reach out to us today to start the process.
6. The Coalition for Barrier Free Living, INC.

The Coalition for Barrier Free Living, INC. offers services and programs that help those with disabilities. Their goal is to promote equal opportunity for those with traumatic brain injuries.

The organization teaches those in recovery how to live independently, find peer support, and learn practical skills. Workshops cover money management, public transportation, and more. Community integration is the focus of this group.

7. Texas Workforce Commission

The Texas Workforce Commission helps people with disabilities find meaningful employment. They do this through free, vocational rehabilitation programs for both adults and youth.

For example, the group helps teach job skills and connects those in recovery with employers.

8. Texas Department of Public Safety

The Texas Department of Public Safety (TDPS) helps people with TBI sign up to take their driving tests.

The ability to drive is a privilege and freedom teenagers look forward to. Adolescents with a TBI aren't doomed to always be driven by mom and dad.

9. 211 Texas

Another resource to keep in mind is 211 Texas, a Texas Health and Human Services Commission program. At their core, they provide information about local services. From food and housing to support groups and counseling, 211 Texas can help your family with basic needs.

10. Moody Neurorehabilitation

Moody Neurorehabilitation has been leading the way in rehabilitation programs since 1982. In each of our four locations, we provide outpatient and residential care as well as a wide range of therapeutic services.
Contact us today to learn more about the right program for your child.

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Traumatic Brain Injury Resources for Parents | Moody Neurorehabilitation

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Finding helpful resources for your TBI recovery isn't always straightforward. If you're also providing care to your child after a TBI, searching for help can add to the already stressful season. It should be easier to find the resources you need to help get through this period.

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Links updated, July 2015
In This Publication:
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Susan's Story

Susan was 7 years old when she was hit by a car while riding her bike. She broke her arm and leg. She also hit her head very hard. The doctors say she sustained a traumatic brain injury. When she came home from the hospital, she needed lots of help, but now she looks fine.

In fact, that's part of the problem, especially at school. Her friends and teachers think her brain has healed because her broken bones have. But there are changes in Susan that are hard to understand. It takes Susan longer to do things. She has trouble remembering things. She can't always find the words she wants to use. Reading is hard for her now. It's going to take time before people really understand the changes they see in her.

What is Traumatic Brain Injury?

A traumatic brain injury (TBI) is an injury to the brain caused by the head being hit by something or shaken violently. (The exact definition of TBI, according to special education law, is given below.) This injury can change how the person acts, moves, and thinks. A traumatic brain injury can also change how a student learns and acts in school. The term TBI is used for head injuries that can cause changes in one or more areas, such as:

thinking and reasoning,

understanding words,

remembering things,

paying attention,

solving problems,

thinking abstractly,

talking,

behaving,

walking and other physical activities,

seeing and/or hearing, and

learning.

The term TBI is not used for a person who is born with a brain injury. It also is not used for brain injuries that happen during birth.

How is TBI Defined?

The definition of TBI below comes from the Individuals with Disabilities Education Act (IDEA). The IDEA is the federal law that guides how schools provide special education and related services to children and youth with disabilities.

IDEA's Definition of "Traumatic Brain Injury"
Our nation's special education law, the Individuals with Disabilities Education Act (IDEA) defines traumatic brain injury as...
"...an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance. The term applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psycho-social behavior; physical functions; information processing; and speech. The term does not apply to brain injuries that are congenital or degenerative, or to brain injuries induced by birth trauma." [34 Code of Federal Regulations §300.8(c)(12)]

How Common is Traumatic Brain Injury?

Approximately 1.7 million people receive traumatic brain injuries every year. ( 1) Of children 0-19 years old, TBI results in 631,146 trips to the emergency room annually, 35,994 hospitalizations, and nearly 6,169 deaths. ( 2)

What Are the Signs of Traumatic Brain Injury?

The signs of brain injury can be very different depending on where the brain is injured and how severely. Children with TBI may have one or more difficulties, including:

Physical disabilities: Individuals with TBI may have problems speaking, seeing, hearing, and using their other senses. They may have headaches and feel tired a lot. They may also have trouble with skills such as writing or drawing. Their muscles may suddenly contract or tighten (this is called spasticity). They may also have seizures. Their balance and walking may also be affected. They may be partly or completely paralyzed on one side of the body, or both sides.

Difficulties with thinking: Because the brain has been injured, it is common that the person's ability to use the brain changes. For example, children with TBI may have trouble with short-term memory (being able to remember something from one minute to the next, like what the teacher just said). They may also have trouble with their long-term memory (being able to remember information from a while ago, like facts learned last month). People with TBI may have trouble concentrating and only be able to focus their attention for a short time. They may think slowly. They may have trouble talking and listening to others. They may also have difficulty with reading and writing, planning, understanding the order in which events happen (called sequencing), and judgment.

Social, behavioral, or emotional problems: These difficulties may include sudden changes in mood, anxiety, and depression. Children with TBI may have trouble relating to others. They may be restless and may laugh or cry a lot. They may not have much motivation or much control over their emotions.

A child with TBI may not have all of the above difficulties. Brain injuries can range from mild to severe, and so can the changes that result from the injury. This means that it's hard to predict how an individual will recover from the injury. Early and ongoing help can make a big difference in how the child recovers. This help can include physical or occupational therapy, counseling, and special education.

It's also important to know that, as the child grows and develops, parents and teachers may notice new problems. This is because, as students grow, they are expected to use their brain in new and different ways. The damage to the brain from the earlier injury can make it hard for the student to learn new skills that come with getting older. Sometimes parents and educators may not even realize that the student's difficulty comes from the earlier injury.

Is There Help Available?

Yes, there's a lot of help available, beginning with the free evaluation of the child. The nation's special education law, IDEA, requires that all children suspected of having a disability be evaluated without cost to their parents to determine if they do have a disability and, because of the disability, need special services under IDEA. Those special services are:

Early intervention | A system of services to support infants and toddlers with disabilities (before their 3rd birthday) and their families.

Special education and related services | Services available through the public school system for school-aged children, including preschoolers (ages 3-21).

To access early intervention: To identify the EI program in your neighborhood, ask your child's pediatrician for a referral. You can also call the local hospital's maternity ward or pediatric ward, and ask for the contact information of the local early intervention program. There, you can have your child evaluated free of charge and, if found eligible, your child can begin receiving early intervention services.

To access special education and related services: We recommend that you get in touch with your local public school system. Calling the elementary school in your neighborhood is an excellent place to start. The school should be able to tell you the next steps to having your child evaluated free of charge. If found eligible, he or she can begin receiving services specially designed to address your child's needs.

In the fall of 2011, nearly 26,000 school-aged children (ages 3-21) received special education and related services in our public schools under the category of "traumatic brain injury." ( 3)

What About School?

Although TBI is very common, many medical and education professionals may not realize that some difficulties can be caused by a childhood brain injury. Often, students with TBI are thought to have a learning disability, emotional disturbance, or an intellectual disability. As a result, they don't receive the type of educational help and support they really need.

When children with TBI return to school, their educational and emotional needs are often very different than before the injury. Their disability has happened suddenly and traumatically. They can often remember how they were before the brain injury. This can bring on many emotional and social changes. The child's family, friends, and teachers also recall what the child was like before the injury. These other people in the child's life may have trouble changing or adjusting their expectations of the child.

Therefore, it is extremely important to plan carefully for the child's return to school. Parents will want to find out ahead of time about special education services at the school. This information is usually available from the school's principal or special education teacher. The school will need to evaluate the child thoroughly. This evaluation will let the school and parents know what the student's educational needs are. The school and parents will then develop an Individualized Education Program (IEP) that addresses those educational needs.

It's important to remember that the IEP is a flexible plan. It can be changed as the parents, the school, and the student learn more about what the student needs at school.

Tips for Parents

Learn about TBI. The more you know, the more you can help yourself and your child. The resources and organizations listed below will connect you with a great deal of information about TBI.

Work with the medical team to understand your child's injury and treatment plan. Don't be shy about asking questions. Tell them what you know or think. Make suggestions.

Keep track of your child's treatment. A 3-ring binder or a box can help you store this history. As your child recovers, you may meet with many doctors, nurses, and others. Write down what they say. Put any paperwork they give you in the notebook or throw it in the box. You can't remember all this! Also, if you need to share any of this paperwork with someone else, make a copy. Don't give away your original!

Talk to other parents whose children have TBI. There are parent groups all over the U.S. Parents can share practical advice and emotional support. To locate parent groups near you, including your Parent Training and Information Center, have a look at our short brief, Parent Groups.

If your child was in school before the injury, plan for his or her return to school. Get in touch with the school. Ask the principal about special education services. Have the medical team share information with the school.

When your child returns to school, ask the school to test your child as soon as possible to identify his or her special education needs. Meet with the school and help develop a plan for your child called an Individualized Education Program (IEP).

Keep in touch with your child's teacher. Tell the teacher about how your child is doing at home. Ask how your child is doing in school.

Tips for Teachers

Find out as much as you can about the child's injury and his or her present needs. Find out more about TBI through the resources and organizations listed below. These can help you identify specific techniques and strategies to support the student educationally.

Give the student more time to finish schoolwork and tests.

Give directions one step at a time. For tasks with many steps, it helps to give the student written directions.

Show the student how to perform new tasks. Give examples to go with new ideas and concepts.

Have consistent routines. This helps the student know what to expect. If the routine is going to change, let the student know ahead of time.

Check to make sure that the student has actually learned the new skill. Give the student lots of opportunities to practice the new skill.

Show the student how to use an assignment book and a daily schedule. This helps the student get organized.

Realize that the student may get tired quickly. Let the student rest as needed. Reduce distractions.

Keep in touch with the student's parents. Share information about how the student is doing at home and at school.

Be flexible about expectations. Be patient. Maximize the student's chances for success.

Resources of More Information

American Academy of Family Physicians. (2010). Traumatic brain injury. Online at: http://familydoctor.org/familydoctor/en/diseases-conditions/traumatic-brain-injury.html

CDC | Centers for Disease Control and Prevention. (2010). Traumatic brain injury. Online at: www.cdc.gov/TraumaticBrainInjury/

Center on Brain Injury Research and Training. (n.d.). Traumatic brain injury: An overview (interactive learning module). Online at: http://www.cbirt.org/resources/interactive-learning-modules/

National Institute of Neurological Disorders and Stroke. (2014, July). NINDS traumatic brain injury information page. Online at: http://www.ninds.nih.gov/disorders/tbi/tbi.htm
Organizations Brain Injury Association of America
Main website: http://www.biausa.org/

Find your state BIA affiliate: http://www.biausa.org/state-affiliates.htm

National Brain Injury Information Center: 1.800.444.6443 (brain injury information only)

National Resource Center for Traumatic Brain Injury (NRCTBI)
http://www.tbinrc.com/

TBI Educators
http://cbirt.org/resources/educators/

Brainline
Information available in English and Spanish.
info@BrainLine.org
http://www.brainline.org/

Center on Brain Injury Research and Training
http://cbirt.org/

Family Caregiver Alliance
Information in English, Spanish, Chinese, Korean, and Vietnamese.
https://caregiver.org/

TBI Recovery Center
http://www.tbirecoverycenter.org/

References

1 | National Center for Injury Prevention and Control. (2012). Traumatic brain injury. Available online at the Centers for Disease Prevention and Control (CDC) website: http://www.cdc.gov/TraumaticBrainInjury/index.html

2 | CDC. (2010). Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths, 2002-2006. Available online at: http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf

3 | Data Accountability Center. (2012). Data tables for OSEP state reported data. No longer available online.

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Links updated, July 2015 In This Publication: ______________________ Susan was 7 years old when she was hit by a car while riding her bike. She broke her arm and leg. She also hit her head very hard. The doctors say she sustained a traumatic brain injury.

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Definition

A traumatic brain injury means an acquired injury to the brain caused by an external physical force resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects educational performance. The term applies to mild, moderate, or severe, open or closed head injuries resulting in impairments in one (1) or more areas such as cognition, language, memory, attention, reasoning, abstract thinking, judgment, problem-solving, sensory, perceptual and motor abilities, psychosocial behavior, physical functions, information processing, or speech. The term includes anoxia due to trauma. The term does not include brain injuries that are congenital, degenerative, or induced by birth trauma. This definition is found in State Board of Education Rule 6A-6.030153, F.A.C.

State Lead Contact

Florida Rule

Florida Department of Education Resources

Bureau of Exceptional Student Discretionary Projects

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Children and Brain Injury - Brain Injury Florida

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Children are not just little adults! Their brains are still developing, with the greatest periods of brain maturation occurring between ages 0-3 and continuing to develop more specialized skills through young adulthood.