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Common Problems following Traumatic Brain Injury
1. Rate of Recovery:
It is generally accepted that children/adolescents recover more fully from illness
than adults, and this has also been applied to TBI. For a period of time, there was even a general
presumption among scientists that the younger a person was when brain injury occurred the more likely
they would recover fully. Research with children/adolescents experiencing TBI, however, has not been
that encouraging. It is clear now that if children/adolescents sustain severe brain injury they will have
long-term deficits as a result of that injury. At no age can one safely say a child/adolescent will recover
fully due to plasticity of the brain or other factors. If children/adolescents do seem to do better than
adults in some areas this may be due to the greater likelihood of children/adolescents receiving adequate
structure and rehabilitation following an injury. Very rarely do adults have the opportunity of attending
school for years after an injury even though such structure and stimulation may be in their best interest.
One area in which children/adolescents do seem to surpass adults is in survival from head injury.
Children/adolescents seem more likely to leave the ICU alive than adults, but this does not mean that
they have not sustained a brain injury and will not experience deficits as a result.
2. Physical Problems following TBI: Following acute medical care children/adolescents experiencing
TBI are often medically stable. They often do not require continued medical follow-up or medications.
A proportion (approximately 5-10% for CHI) will experience seizures as a result of their injury. It is
not uncommon for many injured children/adolescents to be placed on anticonvulsant medications (such
as phenobarbital, Dilantin, or Tegretol) as a means of preventing seizures. Fortunately, most of these
children/adolescents have that medication discontinued within a few weeks or months after their injury
if they have not experienced seizures.
As a result of brain injury, children/adolescents may experience some movement difficulties or problems
with sensation. For instance, having double vision is common and usually improves over several months
and returns to normal. Hemiplegia, that is the inability to move one side of the body, is relatively
uncommon with CHI. More likely there is weakness, but still functional movement, on one side.
Problems with balance and coordination are often seen and may last longer than other motor difficulties.
Such children/adolescents may have difficulty participating in physical education class due to the
balance and coordination difficulties. The changes may be very subtle and noticed only in the more
difficult sports or by the individual and his family. The vast majority of children/adolescents with TBI
are able to ambulate and take care of themselves as one would expect for a child/adolescent their age.
The lack of ongoing medical and physical problems for these children/adolescents is one of the things
that is hard to comprehend. Initially, TBI is a medical disorder, and the expertise required to deal with
such individuals is phenomenal. However, over the long run TBI becomes a psychological, sociological,
and educational problem.
3. Cognitive Difficulties
To the extent that the brain controls our cognitive abilities, any thinking skill
can be affected by TBI. There are several which are more often cited in research and also in comments
by family members, teachers, and friends. While a child/adolescent may exhibit one, two or several of
the following deficits, it is unlikely that a child/adolescent will exhibit all of them. TBI is unique in the
sense that the same cognitive systems are not affected in any two children/adolescents, which makes the
educational program difficult to formulate
- Deficits in attention and concentration.
After TBI children/adolescents may be noted to be more
distractible and unable to establish and maintain a focus of attention. Such children/adolescents
may need constant reminding to stay on task and very specific directions as to what is expected of
them. They often cannot complete more than one task at a time and even then may require
prompting. In many respects, these children/adolescents are similar to people with ADD.
- Memory Deficits.
The child/adolescent with TBI is often able to recall information, from prior to
injury so they do not forget the things they have learned in school previously, their family members,
their friends, or where they live. They may be able to remember old skills such as how to play
particular games and might still do better than some adults (such as with video games).
This is somewhat deceptive, however, since the problem they encounter is often with new learning. They
are unable to learn new things as one would expect of the average child/adolescent. This leads to a
rather peculiar situation in which a child/adolescent might be better able to remember what happened
last year (before the head injury) than what happened yesterday or last week in school. When this
occurs thechild/adolescent is not being manipulative or obstinate. The deceptive nature of memory
disorders can lead to some problems in school. For instance, a child/adolescent may return to school
following a TBI and exhibit age-appropriate academic skills that existed prior to the injury. The
teacher may then notice over the next few months that the student is not learning the new material
presented. Thus, over time there is a cumulative deficit in which the child/adolescent with TBI falls
further and further behind as their peers continue to learn new information.
- Problems with reasoning:
Difficulties in reasoning vary with the age of the child/adolescent.With
a very young child/adolescent very little in the way of reasoning is expected, whereas with
adolescents much more is anticipated. The problems with reasoning often relate to difficulties in
planning, organizing, and predicting what is to happen. We engage in reasoning every day
automatically. We expect students to be able to do this as a matter of course. For instance, if a
child/adolescent pays attention in class, then that child/adolescent will know what to do on a
homework assignment, and if that homework assignment is turned in then a passing grade is
obtained. This type of reasoning comes easily to us, but may be more difficult for a child/adolescent
with TBI. In addition, the flexibility in reasoning is diminished after TBI in many cases. Once a
solution to a problem is generated, the child/adolescent is unable to shift to other solutions even
though the problem may require such a shift. Such children/adolescents tend to perseverate, that is,
repeat a previous solution even though the situation has changed. Another aspect to the reasoning
difficulties is that quite often children/adolescents with TBI do not monitor performance very well.
They do not seem to have the capacity to understand when they are performing poorly or well. Due
to the difficulties with reasoning, students with TBI often require much more guidance and structure
than the average student. The consequences of their actions need tobe explained very clearly and
any shift in the type of material presented has to be explained.
- Slowed processing.
In talking with children/adolescents with TBI others often notice that they seem
to be somewhat slow in responding to questions. It seems to take them a moment or two longer to
understand directions and then generate a response. They may also be very slow in their physical
abilities. For instance, writing may proceed more slowly. As a result, it often takes them much
longer to complete assignments than the average student.
- Language problems:
Aphasia ( the absence of language), as might be evident in a person with a
stroke, is relatively uncommon following TBI. More often there are subtle language problems that
might not be noticeable in a very short conversation. Due to the difficulties with word finding, the
child/adolescent may revert to communicating in a more immature fashion, using phrases and
gestures which might have been suitable for a younger age. Such children/adolescents may also
have difficulty in comprehending longer instructions.
- Problems with academic skills:
Injury to specific areas of the brain may result in an acquired
dyslexia or dyscalculia (an inability to do arithmetic), but this is relatively rare. For the most part,
academic skills, as they existed prior to the TBI, still exist or are easily re-acquired. Initially,
children/adolescents may require review of basic concepts and information learned during previous
school years. Brief review of the material is often sufficient for injured children/adolescents to once
again perform particular tasks. It is not unusual, therefore, for a student with TBI to return to school
with academic skills consistent with their level of education or consistent with their level of skills
exhibited prior to injury or very close to it. It may be difficult to understand in the presence of
apparently intact academic skills that there may still be significant brain injury that is going to affect
school performance.
Behavioral/Emotional Difficulties
after TBI Behavioral and emotional difficulties are discussed
together largely because it is often difficult to separate the two. Emotional difficulties may lead to
behavioral problems and behavioral difficulties may be exacerbated by the development of emotional
distress. The difficulties to be discussed in this section are relatively common among TBI students,
although no single student will exhibit all the problems discussed. When such problems are exhibited
by the average student, one might easily think of external causes, such as social difficulties or family
stress, as well as the possibility that the child/adolescent may be somewhat manipulative towards others.
In dealing with children/adolescents after TBI it is important to recognize that these difficulties may in
part be a direct reflection of the brain injury. To help clarify this relationship, each of the
behavioral/emotional difficulties will be explained in terms of the cognitive deficits which have already
been described.
- Restlessness. The child/adolescent may fidget more so than one would expect for that ageand may
also leave his/her desk without permission. If asked by the teacher for a destination, often there is
no adequate response. Such children/adolescents are unable to be still; even in situations where
physical activity is sanctioned, such as at recess, they may have difficulty in focusing and directing
their energy. On closer examination such children/adolescents are often exhibiting severe attentional
difficulties. They are unable to focus or maintain attention adequately and, therefore, tend to be very
distractible and move around a great deal. This is not unlike what is seen with ADD
children/adolescents with hyperactivity.
- Failure to comply with instructions. The child/adolescent following TBI may not complete
assignments on time or forget to do assignments at all. The teacher may ask very specifically for
the student to desist in a certain behavior and the student persists. It is possible that a
child/adolescent in this situation is having some difficulty with language comprehension or cannot
adequately focus his/her attention on the directions being given by the teacher. Memory is another
possible factor in that assignments given may not be recalled. Finally, because of the slowed
processing, such children/adolescents may not complete assignments due to inadequate time.
- Irritability towards the teacher and other students. After TBI, children/adolescents tend to be
somewhat less inhibited in their emotional responses. They may cry more easily or exhibit
irritability and anger more easily. This may be noticed in the classroom when such
children/adolescents cannot take any degree of joking or they may snap at the teacher. Problems
getting along with peers during free time or after school may also be noticeable. At least part of this
difficulty may be due to reasoning problems. Whereas prior to the head injury the child/adolescent
may have had an understanding of the consequences of his/her behavior, after the injury the
association is less clear. In general, even children/adolescents with TBI have some idea of what they
would like to achieve. They have goals (although they may be very vague) but due to the reasoning
difficulties they do not quite know how to achieve those ends and this generates a great deal of
frustration. It should not be overlooked that in many cases children/adolescents with TBI can recall
how they used to perform academically, socially, and cognitively prior to the injury. To the extent
that they cannot perform in those areas as well after the TBI, the potential for frustration exists.
- Withdrawing physically from others. Students have been noted to attempt to stay at the back of the
crowd or in a group setting find a corner and remain silent and unobtrusive. If approached by
another person they may seem very nervous and unwilling to participate. In part, this behavior may
be a functional response to a sense of being overwhelmed. To the extent that children/adolescents
with TBI may not be able to attend, comply with instructions, or reason effectively, they may be
easily overwhelmed by events around them. This leads to withdrawl, which would occur with
virtually anyone in such circumstances, although it occurs more quickly among TBI students.
Under such circumstances teachers should try to diminish stimulation as much as possible.
- ) Turning in sloppy or incomplete work. Children/adolescents with TBI may turn in papers in which
their writing is skewed, poorly spaced, or the work seems to stop in mid-thought. This can be
extremely frustrating since it is difficult to give the student credit for what they do under such
circumstances. It is very easy to attribute the problem to a lack of effort. However, in the case of
children/adolescents with TBI, it is important to remember that fine motor skills and coordination
may be impaired, which affects handwriting abilities. Such children/adolescents may have difficulty
with adequate spacing and with making letters small enough to fit within the lines or numbers small
enough to fit within columns. Attentional problems may also affect performance in that the
children/adolescents become distracted from their work and therefore do not complete a thought or
a problem. They also tend to be slow in their performance and may turn in work incomplete simply
because they feel they do not have the time to finish. Also, these children/adolescents may have
difficulty in monitoring themselves, which extends to their own work output. Incomplete work may
also be reflective of poor memory; the child/adolescent may not remember the entire assignment.
- Impulsive behavior. The teacher may experience having a student start on an assignment before
instructions are completed or consistently talk out of turn. These behaviors can be very disruptive
to the class and also to the performance of the TBI student. Deficits in reasoning may be very
important in the generation of such behavior. As a result of the problems in reasoning,
children/adolescents with TBI may be disinhibited in that they see something they want to do but
do not realize clearly how to achieve that end. Rather than go through a reasoning process they
simply pursue the goal in the most direct manner possible, which may involve blurting out an answer
or not waiting to hear instructions.
- Fatigue. It is common for children/adolescents with TBI to become extremely tired within a
relatively short time. Activities that the average child/adolescent takes for granted, such as reading
from a book, going to recess, taking a test, or writing a page of script may be very tiring to the TBI
student. It is important to recognize that once a child/adolescent becomes fatigued in this fashion
they are deriving very little benefit from their school experience. In fact, under such conditions there
is the risk of generating even more significant behavioral problems due to frustration and irritability
if one persists in trying to work with a fatigued child/adolescent. Children/adolescents with TBI
become more fatigued because of the increased concentration required to complete even relatively
simple tasks. It requires a great deal more effort to do virtually anything, in some cases even walk,
and therefore students with TBI fatigue more quickly.
- Lack of motivation. Children/adolescents with TBI may be perceived as lacking in motivation to
perform well in school. If left alone they may sit quietly at their desks and stare into space. To
perform, they require constant prompting from the teacher. Their idle time is not spent in other
activities, such as writing notes to other students, playing with toys, or even daydreaming. They
simply lack the drive to perform. This can be extremely frustrating to teachers since it may be
perceived as a lack of interest in the class or minimal effort. In fact, TBI can interfere with the basic
association between motivation and outcome. The children/adolescents may not perceive that they
will do better if the exhibit more effort. It may be a problem with reasoning, which is a necessary
component for any motivated, directed behavior. In order for us to be directed to do something we
have a goal in mind that is going to be achieved through our efforts. The child/adolescent with TBI
may not be able to carry through with this logical reasoning and, therefore, will sit quietly unless
prompted.
Table of Contents
From: Educating the Traumatically Brain-Injured Student
By: Tom Novack, PhD and Sandy Caldwell, MA
© 1999 Board of Trustees of the University of Alabama
Published by: The UAB Traumatic Brain Injury Care System, Birmingham, AL 35233-7330.
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