Best Practices for Teachers with Students with a Traumatic Brain Injury (TBI)

I started my college journey six months after brain surgery and my subsequent release from the hospital and retirement from the military.  I was apprehensive and nervous going back to school as I realized I was not able to function at the same level I performed at even six short months before.  It took me four times longer to read a passage or text, my recall wasn’t nearly as immediate or robust as it was previously, I had difficulty sustaining focus on a single task, I was constantly searching for words and my speech was slowed, and I had to relearn how to learn.  The remnants of the incident had since healed, but the mental scars still lingered and manifested themselves on a near daily basis.  Unfortunately, my story is a fairly common tale.  As a student veteran who suffered from a traumatic brain injury (TBI) and treated for post-traumatic stress disorder (PTSD), I know first-hand the struggles many individuals, especially veterans, face when entering a higher education setting after an injury.  However, as we are each unique in our own way, the specific manifestation of a TBI or PTSD is also unique to each individual.  As my exact condition might not be identical to another’s, the basic tenets of what I learned as both a student, and since then as an educator, have given me an invaluable perspective which I hope to share in this post.

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Definition of a TBI

For background, a TBI is a specific type of brain injury resultant of an external force via a bump, blow, jolt, or barometric wave of energy to the head causing either an open or closed injury that disrupts the function of the brain (Faul, 2010).  A TBI can occur when a head hits a windshield during a car accident, shrapnel enters the brain after a blast, or even from the pressure of a nearby explosive event.  Conversely, not all head injuries result in a TBI, and the severity can range from mild (brief loss of consciousness) to severe (extended period of unconsciousness and memory loss) (CDC, 2011).

The recent rise in instances of TBI over the past decade can be attributed to the growth of knowledge in the subject and the attention it is receiving from the media and sports industry.  Although TBIs are often undiagnosed and not reported, it is more prevalent than multiple sclerosis, breast cancer, and HIV combined (Leibson et al., 2011).  Unfortunately, there is a dichotomy in perception with TBI.  It is becoming more apparent and stressed upon by the medical community that TBIs need be to seen and treated as a disability, but the majority of the population still do not see the critical nature of having these injuries examined.  This creates the larger problem of individuals going undiagnosed, which is especially difficult in higher education as the most common age range for a TBI is 15-26, and these individuals are less likely to seek medical attention on their own (Novak & Bushnik, 2008).

Symptoms and Characteristics

Although, higher educational institution are required to abide by the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973, I want to reference the Individuals with Disabilities Education Act of 1990 (IDEA), regulation 300.8(c)(12).  This regulation specifically defines a TBI and lists thirteen separate categories of impairments that an individual can sustain from a TBI.  They are impairments to cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual and motor abilities; psychosocial behavior; physical functions; speech; and information processing

This underlies the inherent difficulty in working with an individual with a TBI – no two injuries are alike, and the individual can manifest deficits in one, none, or all of these categories to varying degrees, regardless of the specific injury incurred.  Another aspect of TBI is that the trauma to the brain lasts far longer than the physical, visible trauma to the rest of the body.  This means that there might not be specific outward signs present in all cases that yields instant diagnoses (CDC, 2011).  In fact, the majority of the diagnosis of a mild TBI comes from the patient’s own report of symptoms such as dizziness, confusion, fogginess, headache, “seeing stars”, or loss of consciousness.  The list of symptoms is fairly all-encompassing and easily crosses in developmental, functional, and functional academic skill sets.  Unfortunately, there is no one specific assessment that can be used to fully understand the array of processing and mental issues an individual might have following a TBI, and one of the best things a person can do is ask the suspected patient if they have had a recent injury or accident (Thompson et al., 2013).

 

Suggestions for Instructors

As the awareness of TBI and its effects have become more mainstream, there is a growing body of literature and research on the education, learning, and challenges faced by these students.  The most common issues students with a TBI face revolve around attention and working memory to includes deficits dealing with fatigue, lethargy, concentration, inattention, initiation, and forgetfulness – all of which are critical skills for a student in higher education.    .  It is important to note that with any teaching strategy used, there are three basic components that have to be addressed – instructional, environmental, and assessment.  The instructional strategies are those to help the student learn and work past the deficit, the environmental component affects the setting to support the student, and the assessment portion are those modifications that can be put in place when the student has to complete an assignment or test (Levin, 2007).  Some techniques an instructor can consider when teaching a student with a brain injury are listed below.

  • Refer the student to support resources on your campus. Central Penn College has a counselor and a disability coordinator who can work with the student to assess the educational environment and identify what accommodations might be recommended or necessary.
  • Provide all accommodations, support, and assistive devices indicted by the student’s disability counselor. This
  • Make learning experiences meaningful and present material in context that helps to reinforce the memory of that material
  • Reinforce and provide feedback about the process of thinking
  • Provide cognitive mediation (practices and strategies for thought-organization)
  • Teach skills and concepts in small, manageable chunks
  • Provide opportunities for the student to paraphrase and practice what they are supposed to be learning
  • Use task analysis – the strategy of breaking down a task or activity into small steps
  • Consider removing timed tests in favor of alternate assessment methods
  • Reduce cognitive load – making material easier, reducing the amount of material given, reducing expectations, and providing supports to complete the material.
  • Maintain regular communication with the student
  • As an advisor, consider recommending a reduced course-load and courses that match the student’s abilities at that time
  • Be patient. Offer multiple trials for the student to make errors, and be mindful of the fact that there is a psychological process for accepting a disability.

All educators today need to be aware of the disability that is a TBI, as it is highly likely that you will instruct or already have instructed an individual with a TBI.  As information becomes more readily available, the seriousness of the injury becomes more evident and on the forefront of society’s consciousness, the incidence rate will only rise further.  As such, instructors in general need to know the signs to look for in their students, and how to help those students manage their disability.

 

References

Arroyos-Jurado, E., & Savage, T. (2008). Intervention strategies for serving students with traumatic brain injury. Intervention in School & Clinic, 43(4), 252-254. doi:10.1177/1053451208314907

Bowen, J. M. (2005), Classroom interventions for students with traumatic brain injuries. Preventing School Failure, 49(4), 34-41.

Centers for Disease Control.  (2011). Injury prevention and control: Traumatic brain injury.  Retrieved from http://www.cdc.gov/

Department of Defense. (2007). Traumatic brain injury: Defining and reporting. Retrieved from http://mhs.osd.mil/content/docs/policies/

Fann, J. R., Burington, B., & Leonetti, A. (2004). Psychiatric illness following traumatic brain injury in an adult health maintenance organization population. General Psychiatry, 61, 204-213

Faul, M., Xu, L., Wald, M. M., & Coronado, V. G. (2010) Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002–2006. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Helms, K. T., & Libertz, D. (2014). When service members with traumatic brain injury become students: Methods to advance learning. Adult Learning, 25, 11-19. doi:10.1177/1045159513510145

Jorge, R. E. (2008). Mood and anxiety disorders following traumatic brain injury. Psychiatric Times. Retrieved from www.psychiatrictimes.com

Levin, H., Hanten, G., Max, J., Li, X., Swank, P., Ewing-Cobbs, L., . . . Schachar, R. (2007) Symptoms of attention-deficit/hyperactivity disorder following traumatic brain injury in children. 28(2), 108-118.

Mathilde, P. C., Servant, V., Mariller, A., Abada. G., Pradat-Diehl, P., & LaruentVannier, A. (2009). Assessment of executive functioning in children after TBI with a naturalistic open-ended task: A pilot study. Developmental Neurorehabilitation, 12(2), 76-91. doi:10.1080/17518420902777019

Novak, T., & Bushnik, T. (2008). Understanding TBI part 3: The recovery process.

O’Donnell, M. L., Creamer, M., Pattison, P., & Atkin, C. (2004). Psychiatric morbidity following injury. American Journal of Psychiatry. 161, 5007-514.

Schonberger, M., Ponsford, J., Olver, J., & Ponsford, M. (2010).  A longitudinal study of family functioning after TBI and relatives’ emotional status.  Neuropsychological Rehabilitation, 20(6), 813-829.

Sigel, D. J. (2010). Mindsight: The new science of personal transformation New York, NY: Bantom Books

Thompson, M., Thompson, L., Reid-Chung, A., & Thompson, J. (2013). Managing traumatic brain injury: Assessment and a rationale for using neurofeedback and biofeedback to enhance recovery in postconcussion syndrome. Biofeedback, 41(4), 158-173. doi:10.5298/1081-5937.4.07

Thurman, D., Alverson, C., Dunn, K., Guerrero, J., & Sniezek, J. (1999) Traumatic brain injury in the United States: a public health perspective. Journal of Head Trauma Rehabilitation, 14(6), 602-615.

 

About the Author

Benjamin Lipschutz is an instructor in the School of Business at Central Penn College. He holds degrees in Accounting, Business, Business Education, and Special Education with PA State certifications in Business Education and Special Education Pre K-8 and 7-12. His focus is in student-centered learning and engagement, and he enjoys teaching at all levels, from students here at Central Penn College to kindergartners with Junior Achievement.

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