General Information for Parents and Educators on TBI

There may or may not be long-lasting consequences when a child has a brain injury. Most children who have mild brain injuries or concussions will recover fully with no long-term effects. Other children, who have more severe injuries, may have more serious and long-lasting consequences. Still other children will reveal the full effects of the brain injury as the brain matures and the student grows up. Consequently, it is important to pay attention to changes in a child’s behavior, communication, emotions, memory, and ability to think or learn after a both a concussion or a more intrusive injury.

Your child’s educational needs may change because of the brain injury. The need for assistance may be greatest as your child transitions back into school after the brain injury with a decline over the next months. For others, the need for support may become more evident over time. Sometimes, this may be years after the injury. Some children may need no accommodations or specially designed instruction as a result of the injury. Some students are able to do well academically with support from home. Some students may have serious social and physical challenges (such as fatigue and headaches) to work around. In other words, every brain injury is different and every student with a brain injury has different needs. In other words, every brain injury is different and every child with a brain injury is unique.

Types of brain injuries

The term “brain injury” includes both traumatic and acquired brain injuries.

A traumatic brain injury is caused by an external physical force such as: shaking, striking the head against an object, a collision with speed and force, or a fall. This injury can be either an open injury in which the skull is penetrated or opened in some way or a closed brain injury where the skull remains intact.

An acquired brain injury is an injury from an internal event such as a stroke or tumor. It can also be caused by lack of oxygen to the brain, such as a choking, or near drowning. Other sources of acquired brain injuries include poisoning (ingesting lead or other chemicals), illnesses (viral, meningitis, etc.)

Primary injuries are those that occur directly as a result of the injury.

• The area of the brain directly damaged as a result of the brain injury.
• Coup-contra coup or the injury that occurs on the opposite side of the skull from where the brain was first damaged. This injury occurs by the momentum or force of the brain moving inside the skull and hitting the opposite wall of the skull.
• Shearing and rotation injuries occur as the brain moves in a circular motion within the skull.

Secondary effects or secondary injuries happen within the brain after the initial injury.This can include swelling and bleeding that cause compression within the skull that injures brain tissue or damage to the brain caused by infections or strokes that occur as a result of the initial brain injury.

Severity of Brain Injuries

Brain injuries have also been defined as mild, moderate or severe. The effects of mild, moderate and severe brain injuries are almost as variable as the injuries themselves.

Mild brain injury usually indicates the child did not lose consciousness or was unconscious only for a brief amount of time. Post-concussion syndrome happens after a child has had a concussion but does not fully recover. About 90% of students who have had a concussion have no long lasting effects. However some children continue to demonstrate confusion, headaches, or nausea afterward. Often damage does not appear on brain imaging tests with mild injuries.

Moderate brain injury is a term used when the student was unconscious for more than 20–30 minutes but less than 24 hours. There may or may not have been skull fractures or bleeding. This type of brain injury is likely to show on a brain scan or imaging device. About 1/3 to 1/2 of these students will have long-term problems leading to the need for greater support in education.

Severe brain injury is a term that is used when a child is in a coma for more than 24 hours. Some may remain in a lessened state of consciousness and about 80% will have long term difficulties. ^1,2  

Incidence of Brain Injuries

Brain injuries are the leading cause of death and disabilities in children. It is estimated that about 1/500 school age students are hospitalized annually for TBI. The causes of brain injury vary by age. For infants, physical abuse is the leading cause. For toddlers, falls and motor vehicle crashes are the leading causes. Preschoolers tend to get brain injuries from motor vehicle crashes, falls and being hit as a pedestrian. Elementary school age children have brain injuries most often from motor vehicles crashes as passengers or as pedestrians, and bicycle falls/collisions, or other forms of recreation. ^1,2

Brain Injuries in Children

There are several ways that children respond to brain injuries differently than adults.

• Children are less likely to lose consciousness.
• Children have higher survival rates for serious injuries compared to adults.
• Children tend to have faster physical recovery of motor skills than adults.
• Children have a harder time learning new skills because the damage happens to a brain that is still growing and developing.
• Some of the skills a child will need as an adult have not yet developed, but may still be impacted by the brain injury. The full effects of the brain injury are unknown until higher thought processes develop. ²

Possible Changes in Your Child

Children with traumatic brain injuries may display some changes over time. Some may resolve as the child heals. Following is a list of changes that may or may not occur in your child as a result of the brain injury.

• Tires easily and needs extra rest
• Has trouble with memory or is forgetful
• Has difficulty concentrating
• Has difficulty following directions
• Becomes easily irritable or short tempered
• Becomes easily distracted
• Has changes in academic performance
• Shows changes in behavior such as greater impulsivity
• Has difficulty interpreting social situations

Moving from the Hospital to the School: One of Many Transitions

When your child leaves the hospital, it is helpful to gather information that will help with the transition back to school. Even if your child needs to be at home at first due to medical needs, it is important to begin to include the school right away in planning for education. For some students, this means having a tutor come to the house for a brief amount of time. Other students may return for part of the school day and increase their time at school gradually as their physical condition improves. What is important is that all students be treated as individuals with individual needs.

If your child has multiple physical needs you will want to allow the school a few days to prepare and train staff for safe transfers, toileting and programming. Even though your child has the right to be at school right away, this can assist in your student’s safety and create a more positive experience at school.

Tips for Getting Useful Information

If you get a report on your child’s status upon leaving the hospital or rehabilitation center, check for the following information.
Does the report:

• State that your child had a brain injury?
• Describe how your child acts, thinks, learns, behaves, and moves?
• Describe your student’s strengths, preferences and difficulties?
• Outline current work habits and endurance?
• Include coping strategies for how your student deals with changes from the injury?
• Explain causes of behavioral changes, emotions and give suggested responses?
• Include neuropsychological reports?
• Suggest follow-up, further tests or evaluations?

Getting Information to the School

It will be important for a designated person at the school to gather the following list of information to help with the transition and to determine if further evaluation or support is needed.

• Present physical condition.
• Physical limitations
• Activity limitations such as needing rest breaks or a shortened day
• Therapy requirements
• Any assistive devices used for writing, speaking, eating, etc.
• Self care abilities, walking, toileting, stability, etc
• Medications (& side effects)
• Communication ability
• Behavioral concerns
• Cognitive recovery pattern
• Evaluation results

Some physical therapists prefer to make a home visit prior to the student returning to school to evaluate the student’s mobility and physical needs at school.

Helping the Student Reenter School

• Set up a planning meeting with school personnel BEFORE the student returns to school. This is extremely important especially if the student has challenges such as fatigue, toileting, transportation, mobility needs, changed behaviors, etc. It is vital that staff be trained to meet the student’s needs and that adaptive equipment be in place for toileting, feeding, etc. prior to the student arriving at school. If needed, set up a limited duration plan for providing education and informal evaluation while the student is at home just prior to returning to school.
• Meet with school personnel (include your child if appropriate) to plan for the transition
• Request that the school provide in-service training for school-based staff who have contact with the student and need to use specialize techniques or devices
• Begin to plan for short and long term needs and goals for your child
• Consider having the student return to school on a shortened day, if needed, to assist with fatigue or becoming overwhelmed with multiple sources of information, noise, etc.
• Plan for more meetings During first year to meet the changing skills and needs of the student

Becoming the Link to School

You as the parent or caregiver may be the only person who has seen your child progress through many stages of care and recovery. You will become an expert on brain injury. Your child’s teachers, classes and schools will change over time. Many times, important information about a child’s brain injury is forgotten as children grow and change over time. As the parent of a student with a brain injury, it is important to:

• Provide information to new teachers and staff about your child’s needs and progress
• Share observations of your child’s strengths and areas of difficulty
• Coordinate the flow of information between teachers, classes and schools over time
• Remember that educating a student with a brain injury is a long-term process not a one-shot deal
• Work with your TBI team member or Regional Liaison to help find experts on brain injury in your community to consult with the school as needed.
• Work with your child’s school as partners rather than adversaries
• Explore your child’s hopes and goals to build a vision of the future

Changes in Behavior After Brain Injury

Some behaviors may occur as your child recovers. Some may need to be addressed directly. Here are some ideas to help your child learn or relearn appropriate behaviors:

• Establish a daily structure with consistent times.
• Remind the student about behavioral expectations before the behavior occurs. For example before you approach the line say, “ In the store we have to stand in line like everyone else.” Or “We have to speak quietly in the restaurant.”
• Develop strategies to help with alarm clocks, cell phones, planners, etc.
• Rehearse or role-play a situation before it happens to coach your child through it.
• Use words, pictures, gestures or objects to remind your child how to behave in a specific situation.