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

While these challenges are prevalent for children recovering from a TBI, they are far from insurmountable. By equipping our schools, teachers, and even medical professionals with the knowledge and tools to support these students, they are able to succeed in new ways.

As a traumatic brain injury law firm in Richmond and Virginia Beach, the attorneys at Breit Biniazan have witnessed the incredible effects of providing compassionate and knowledgeable support to children with TBI. 

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

It takes a village of dedicated parents, medical professionals, TBI experts, adaptive school administrators, and supportive and patient teachers to help students with traumatic brain injuries adjust to a new kind of education. But when they work together and employ a well-honed knowledge of the student’s circumstances and brain injuries in general, they can achieve incredible accomplishments in the classroom. 

That’s why we put together this guide: to help educators, school administrators, teachers, parents, and even students understand and communicate about traumatic brain injuries in children, how to adapt to students with these special needs, and how to prevent TBI in future children. 

Every brain injury is different and manifests as different symptoms from child to child, and even from minute to minute. But by understanding these symptoms and how to alleviate them, we can provide these students with the support—and lives—they deserve. 

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Part I: What is a Pediatric Traumatic Brain Injury? 

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

The damage inflicted by a TBI is usually two-fold. There is the injury that occurs as the initial blow to the head, which is referred to as the primary injury. The brain may bounce back and forth inside the skull, causing the brain to bruise, bleed, or nerve fibers to tear. 

Following this initial damage, the brain will swell. The damage caused by the swelling of the brain is the secondary injury, and it may be even more dangerous than the primary injury. As the brain swells, it presses against the confines of the skull. Doing so deprives the brain of blood and oxygen, which can have debilitating long-term effects. 

Types of Pediatric Brain Injuries 

There are two types of traumatic brain injuries in children:

• Closed brain injuries occur when a blow to the head does not penetrate the skull but damages the brain. The rapid forward and backward movement of the head—such as in a fall or car accident—causes the brain to move within the skull, leading to bruising and bleeding. 
• Open brain injuries occur when a blow to the head penetrates the skull, and the skull is crushed or fractured. In addition to the damage to the brain, they can also require surgery to close the wound. 

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

Why are Pediatric TBIs So Serious? 

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

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

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

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

Common Causes of TBI in Preschoolers

Children aged four and under—including preschoolers—are the most likely to experience TBI. 

According to one study, 1,256 per 100,000 of children in this age group visited the ER with a brain injury.₃ 

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

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

The most common causes of TBI in preschoolers include: 

1. Physical abuse and assault: Unfortunately, physical abuse is one of the most common causes of traumatic brain injuries in preschool-aged children. It is important for educators to know how to recognize the signs of abuse so that necessary action can be taken to protect these children. 
2. Falls: Serious falls—whether at home or at school—are another common cause of TBI in preschool-aged children. According to some studies, 54% of TBI-related hospitalizations and deaths in children, from infancy to 14 years old, are the result of falls.₄ From 2001 to 2013, some 139,001 children age 0–4 years were treated every year in in US emergency departments for nonfatal, fall-related TBI.₁₆ 
3. Vehicular accidents: Vehicular accidents are the third most likely cause of TBI for this age group. While children of pre-school age and younger may be protected by specially designed car seats, studies indicate that car seats may not be entirely effective at preventing brain injury in the case of high-speed accidents. ₅

Common Causes of TBI in Elementary-Age Children

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

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

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

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

2. Bicycle accidents: As elementary-age children begin to learn how to ride a bike, the likelihood of TBI from bicycle accidents increases. It’s important to teach children to always wear a helmet when riding their bikes in order to prevent a TBI. Teachers should make sure children who ride bikes to and from school always wear a helmet. 

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

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

Common Causes of TBI in Adolescents

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

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

1. Vehicular accidents: Vehicular accidents are the most common cause of TBI in adolescents, attributing to 35% of TBI in this age group.₈ Vehicular accidents are the primary cause of TBI in older children in this age group (14–19 years old), perhaps because children in this age group begin to drive with or without adult supervision. 
2. Sports and recreation injuries: Newer studies—including one from 2019—indicate that sports injuries may be the leading cause of nonfatal TBI in adolescents.₉ Injuries caused by riding bicycles and playing football are particularly common causes of traumatic brain injuries.  
3. Assault: Injuries caused by firearms are more prevalent in the adolescent age group, leading to 43.8% of TBI in one study of this age group.₁₀ Assault in adolescents is often the result of youth violence, like bullying, as well as abuse at home. 

How to Prevent Brain Injury in Children 

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

Some strategies for preventing brain injuries in children include: 

• Practice proper car safety. Parents should always use the correct car or booster seat for their child’s weight and height. 
• Wear a helmet. Ensure your child wears a helmet when engaging in recreational activities such as riding a bike, skateboard, or horse, playing contact sports, or skiing or snowboarding. 
• Keep your home safe. For younger children, use safety gates on the stairs and don’t leave them alone on high pieces of furniture. Keep firearms locked in a cabinet. Use side rails on bunk beds. 
• Keep your children safe outdoors. Monitor children on playground equipment, and check the equipment to make sure it’s safe before they play. Avoid trampolines. 
• Sports and recreational injury strategies. Dr. Haarbauer-Krupa notes that making changes in certain sports to reduce risk can help children in middle and high school. 

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

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

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

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

Symptoms of Pediatric TBIs

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

Physical Impairments

• Loss of consciousness
• Inability to awake 
• Severe and persistent headache
• Drainage of clear or bloody fluids from orifices like nose or ears
• Recurrent vomiting or nausea
• Changes to sleeping habits
• Changes to eating habits
• Drowsiness
• Seizures or convulsions 
• Dilation of pupils
• Weakness or numbness in extremities (fingers and/or toes)
• Uncoordinated movement
• Scalp swelling

Cognitive impairments

• Inability to focus
• Confusion 
• Slurred speech
• Memory loss

Emotional impairments

• Mood changes, especially sadness or depression
• Irritability or combativeness 
• Increased or inconsolable crying
• Lack of interest in favorite activities or toys

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

If a teacher recognizes these symptoms, notify a parent immediately. 

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

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

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

Long-term Symptoms of TBI 

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

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

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

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

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

How to Check the Seriousness of a School Head Injury 

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

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

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

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

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

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

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

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

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

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

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

Seek medical attention if the child:

• Continues to vomit for hours following the injury
• Becomes more drowsy or lethargic 
• Develops neck stiffness 
• Their headache worsens
• Their behavior becomes abnormal or they seem confused
• Has a seizure or convulsions 
• Cries uncontrollably
• Develops any weakness or numbness in extremities
• Exhibits any concerning behavior or looks increasingly sick

Preparing for a TBI Medical Visit with Your Child

• Be prepared to discuss the details of the accident and how your child’s injury occurred. If you suspect the injury may have been intentionally inflicted by another child or an adult, it is necessary for you to communicate those concerns to the doctor. 
• You should also be prepared to discuss your child’s exact reaction to the injury and any symptoms that have appeared. 
• It is unlikely that your child will require an imaging test like a CT scan. These tests are performed to check for bleeding in the brain, a skull fracture, or other brain injuries. If your child is exhibiting more severe symptoms and a CT scan is needed, it should only take about 15 minutes. 
• If doctors are not sure whether or not an imaging test is necessary, they may decide to observe your child for four to six hours to monitor how their symptoms change. Observation usually takes place in the emergency department. 

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Part IV: How Do Traumatic Brain Injuries Affect Students?

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

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

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

Physical Effects

• Vision loss
• Hearing loss
• Speech loss
• Paralysis
• Seizures
• Persistent headaches
• Lethargy or less stamina
• Changes in motor skills, like incoordination or imbalance
• Perceptual deficits, like difficulty distinguishing between parts of the body 

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

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

Emotional & Behavioral Effects

• Mood swings
• Denial 
• Anxiety
• Lower self-esteem
• Irritability or aggression
• Sadness or depression
• Easily frustrated and/or overstimulated
• Difficulty understanding social rules or queues
• Lack of motivation 
• Noncompliance 
• Impulsive and/or lack of self-control 

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

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

Cognitive Effects

• Difficulty concentrating and easily distracted
• Inability to organize information 
• Difficulties with creative problem solving
• Rigid thinking and inability to generalize
• Lack of judgment
• Delayed response time or processing time
• Compromised perceptual and spatial skills
• Difficulties with memory 
• Decreased language function
• Learning disabilities
• Difficulties reading or writing 

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

Academic Effects

The cognitive effects of TBI are perhaps easiest to connect to the academic impacts of TBI on students. A lack of memory skills, for example, can have a clear effect on academic ability. 

In one study, 94.4% of students with mild or moderate brain injuries who had memory problems had difficulty with their school assignments.₁₁

However, the behavioral effects of TBI can also have a significant impact on students as they experience difficulty transitioning back into a traditional educational environment and the social and emotional trials such a situation demands. Adaptations may also need to be put in place to support the physical effects of the students’ TBI. 

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Part V: Plan for Returning to School 

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

That’s why it’s so important for educators to work closely with the child’s medical team and family to curate an Individual Education Plan (IEP) that best suits the individual student. By working together, educators can develop a plan through which the child can transition back into the classroom with the best results possible. 

Plans for Parents & Students

Communicate with your student’s school. 

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

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

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

Ask your doctor about what to expect moving forward.

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

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

Dr. Haarbauer-Krupa of the CDC agrees. 

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

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

Foster connections between the school and medical experts. 

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

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

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

Address behavioral issues at home. 

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

Understand your child’s rights. 

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

Prepare students. 

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

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

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

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

Plans for Teachers 

Know what to expect. 

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

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

Anticipate behavioral issues. 

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

Some behaviors to expect include: 

• Temper tantrums 
• An inability to stay on task
• A lack of motivation
• Impulsive behavior
• A lack of control over emotions 
• Easily frustrated 
• Easily overstimulated, which can lead to emotional distress

Learn how to address challenging behavior. 

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

Some practices that may work in your classroom include: 

• Time-out, which gives the student time to refocus.
• Structure and consistency in scheduling and expectations.
• Positive reinforcement to encourage positive behaviors.
• Clear communication, including explaining plainly why bad behavior is not acceptable.
• Avoid “punishment” for bad behaviors and instead reinforce good behaviors with praise.
• Ensure the student understands you are a team and are working together to help him or her succeed. 
• Allow the student to rest. With symptoms like fatigue and headaches, they may need time to rest in the midst of a busy school day. 
• Work with your school administrators on appropriate accommodations. See below. 

Coordinate with Speech-Language Pathologists and Psychologists 

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

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

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

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

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

Communicate with other students. 

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

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

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

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

Encourage friendship and peer acceptance. 

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

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

• Explain the circumstances to your students. If you know the student with TBI may have trouble with social queues, explain this to your students and discuss ways they can support their peers. 
• Choose a peer volunteer. A peer volunteer can help the student with TBI with the physical requirements of school—such as guiding them through a busy hallway—as well as social support. 
• Incorporate social activities into your lesson plans. Rather than separating students throughout the school day, it can help a student with TBI to have scheduled social time through assignments or activities. 
• Encourage interactions. Introducing students with TBI to new activities and social groups can help them find a new place in the school where they feel welcome. 

Plans for Schools & Administrators

Conduct a TBI School Evaluation.

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

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

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

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

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

Establish a Concussion Management Team. 

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

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

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

Those supports may include: 

• Building breaks automatically into the day, rather than waiting for the student to ask for a break. 
• Giving students copies of the teacher’s notes because taking notes can trigger symptoms. 
• Removing them from loud, overstimulating environments in the initial weeks. 
• Reducing key learning content and repetition. 

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

Help Teachers Identify TBI

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

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

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

• Has your child ever lost consciousness? 
• Has your child ever fallen and hit their head? 
• Has your child ever had to go to the emergency room from hitting their head? 

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

Determine the student’s level of educational performance. 

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

Put accommodations in place to support the student. 

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

• Asking for a consultation from an expert in traumatic brain injury.
• Allowing additional time for the student to complete work, especially on tests.
• Offering the student breaks as needed.
• Prioritizing the quality of the student’s work, rather than the quantity. 
• Providing the student with more detailed instructions.
• Repeating instructions.
• Recording classroom instruction for the student to revisit later.
• Providing assistive technology for the student where necessary.
• Seating the student near the teacher and at the front of the classroom.
• Excusing the student from presentations.
• Offering oral examinations.
• Utilizing multiple-choice questions.  
• Utilizing small-group instruction.
• Keeping track of daily progress.
• Connecting the students with peer tutors.
• Maintaining contact with the student’s parents.
• Considering a special class placement, like a resource classroom or self-contained class, where the student can receive support from a special education teacher. 

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About Breit Biniazan

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

In our many years practicing law in Virginia Beach and Richmond, we have witnessed the debilitating impact of TBI, as well as the miraculous recoveries made when communities come together to support these children. 

In addition to medical professionals, educators, and parents, an important element of this support system is an experienced law firm that can protect the rights and futures of children affected by brain injury. 

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

For more information on identifying TBI in children, preparing students for TBI for a return to the classroom, and more, please visit the CDC’s Heads Up information center. 

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References

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2. Andrew J. Schneier, Brenda J. Shields, Sarah Grim Hostetler, Huiyun Xiang and Gary A. Smith, “Incidence of Pediatric Traumatic Brain Injury and Associated Hospital Resource Utilization in the United States.” Pediatrics, August 2006. https://publications.aap.org/pediatrics/article-abstract/118/2/483/69006/Incidence-of-Pediatric-Traumatic-Brain-Injury-and?redirectedFrom=fulltext?autologincheck=redirected
3. US Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, “Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths, 2002–2006.” March 2010. https://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf
4. BrainLine, “Facts About Traumatic Brain Injury.” 2017. https://www.brainline.org/article/facts-about-traumatic-brain-injury
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11. C A Hawley , A B Ward, A R Magnay, W Mychalkiw, “Return to school after brain injury.” Archives of Disease in Childhood, February 2004. https://pubmed.ncbi.nlm.nih.gov/14736628/
12. Kayla A. Steward, Adam Gerstenecker, Kristen L. Triebel, Richard Kennedy, Thomas A. Novack, Laura E. Dreer, Daniel C. Marson, “Twelve-month recovery of medical decision-making capacity following traumatic brain injury.” Neurology, September 06, 2016; 87 (10). https://www.neurology.org/doi/10.1212/wnl.0000000000003079
13. Dominique Dupont, Cindy Beaudoin, Naddley Désiré, Maria Tran, Isabelle Gagnon, Miriam H Beauchamp, “Report of Early Childhood Traumatic Injury Observations & Symptoms: Preliminary Validation of an Observational Measure of Postconcussive Symptoms.” The Journal of Head Trauma Rehabilitation, April 2021. https://pubmed.ncbi.nlm.nih.gov/33935228/
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15. Juliet Haarbauer-Krupaa, Tadesse Haileyesus, Julie Gilchrista, Karin A. Mack, Caitlin S. Law, Andrew Joseph, “Fall-related traumatic brain injury in children ages 0–4 years.” Journal of Safety Research, Volume 70, September 2019, Pages 127-133. https://www.sciencedirect.com/science/article/abs/pii/S0022437518308910