Appendix C

Traumatic Brain Injury in Children: Incidence, Causes, and Intervention

Irene Topor
Jane Erin

Traumatic brain injury (TBI) affects 475,000 children each year who are under the age of 14. Of this group, 39% are injured by falls and 11% by automobile accidents; various causes account for the remaining 50% (Langlois, Rutland-Brown, & Thomas, 2006). Youth from ages 15-19 also have high rates of brain injuries, and males are more likely to sustain head traumas at every age level (Langlois et al.). TBI can be mild, with a loss of consciousness or confusion that lasts less than 30 minutes and causes long-term effects such as headaches or memory problems that are not always obvious. A brain injury can also be severe, with extended loss of consciousness and permanent changes in physical, communicative, and cognitive functions (Lenrow, Finegan, & Cohen, n.d.).

Almost any type of TBI can result in cerebral or cortical visual impairment (CVI) (Soul & Matsuba, 2010; Roman-Lantzy, 2010). The most common cause of acquired low vision in infants is CVI, which can result from inflicted brain injuries (e.g., shaken baby syndrome) (Flodmark & Jacobson, 2010). See Appendix C for CVI that impacts students who have multiple disabilities resulting from traumatic insults to the brain, predominately at birth. In this appendix, the term “cerebral visual impairment” pertains to academic students who acquire CVI from a post birth insult to the brain. Dutton and Lueck (2015) use habilitation to define the progressive assistance of skill development for individuals with congenital brain damage (i.e., CVI) and rehabilitation to define the building on existing skills gained prior to acquired brain damage (i.e., TBI).

The complex nature of TBI makes treatment, recovery, and educational planning a highly individualized process. Not only does the extent and duration of recovery vary widely among children, but the degree of medical support and rehabilitation can be different among individuals based on available health care, financial resources, and family and social support. Families who have children recovering from head trauma are challenged to reorganize their lives according to their child’s needs, which may result in stress factors that ultimately affect the child’s recovery experience. Additionally, the behaviors of the injured child may vary widely; aggression, irritability, communication difficulties, and physical fatigue may affect the child’s ability to respond to the environment, including visual stimuli.

For many children with TBI, vision is affected temporarily or permanently. Kapoor and Ciuffreda (2002) estimated the range to be 30% to 85%, depending on the severity of the trauma. This article considers visual variations that result from sudden and traumatic injuries to the brain, and it describes educational considerations related to children whose TBI affects vision. Head trauma can result in a variety of short- and long-term injuries and behavioral changes, and the interaction of cognitive, emotional, and attentional factors with visual responses can make assessment and treatment of visual impairment especially complex in an individual with TBI. The area of the brain that is affected may relate to the location and nature of the head injury, and because the eyes may not be visibly affected, behaviors such as vestibular and gait difficulties may not be immediately associated with changes in vision.

Educational definition of traumatic brain injury

Beginning in 1997, the Individuals with Disabilities Education Act (IDEA) included traumatic brain injury as a separate category of special education. IDEA defines a 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. Traumatic brain injury 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; psychosocial behavior; physical functions; information processing; and speech. Traumatic brain injury 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)] (U.S. Department of Education, 2006).

Although a diagnosis of TBI can qualify a child for special education services under this definition, the nature of services varies widely according to the effects of the injury. The student may require educational support related to behavior, communication, cognition, or physical and sensory abilities, including visual impairment.

Visual effects of traumatic brain injury in children

The visual effects of TBI may vary, and they may be related to the eye and optical pathways as well as to the more generalized structures of the brain. Common effects include visual loss, reduced acuity, changes in muscle balance that result in double vision (diplopia), nystagmus, difficulty in perceiving distance, and photophobia (Lenrow et al., n.d.).

The variability of visual effects makes it difficult to generalize the nature and potential for recovery following a head injury. Poggi et al. (2000) reported on a group of 56 children with head trauma who were tested at least 6 months after the accident. Of these children, 45% had visual acuity loss, associated with the length of coma and frontal lobe lesions; 83% had some degree of optic nerve atrophy; 50% had difficulties with convergence, associated with longer comas; 43% had strabismus; and 22% had nystagmus. The authors noted that children with optic nerve damage had the most severe neurological impairment and the longest duration of coma; they commented that optic nerve damage creates a fragmented image that requires “subjects to analyze single parts of the image in order to put them together later” (p. 843). There are few studies that separate visual outcomes of children with brain injury from the general literature on cerebral visual impairment, which mainly includes children with cerebral disease, neonatal conditions, and anoxic events. Boot, Pel, van der Steen, and Evenhuis (2010) reviewed perceptive visual effects of brain damage; they identified only two articles on children with head injuries that met the criteria for the study, and both articles reported reduced visual memory among subjects.

Various visual disabilities can result from damage that is specific to one area of the brain or the visual pathway. Hemianopsia (loss of half the visual field in each eye) may occur on the opposite side from the head injury if the injury is in the posterior sections of the brain (Windsor & Windsor, n.d.). Visual neglect is also common; with this condition, the individual seems to ignore information on the left side unless his attention is brought to it (Flom, 2004). Visual neglect usually results from damage to the brain in the right parietal lobe (Bartolomeo, 2007).

Sometimes vision in children with TBI is affected significantly, but visual recovery can be rapid (Good, Jan, Burden, Skoczenski, & Candy, 2001). Recovery may happen within 24 hours, as with a 3-year-old girl reported by Hochstetler and Beals (1987) and five of six children with head injuries who were studied by Kaye and Herskowitz (1986). The sixth child reported by these authors, who had been struck on the head with a baseball bat, experienced significant visual loss for 2 weeks, and after that time continued to be affected by an inferior field loss although his acuity returned to 20/20. However, according to Soul and Matsuba (2010), full recovery depends on the location and severity of the injury. Continued evidence of optic nerve atrophy suggests a poor visual prognosis.

Padula, Shapiro, and Jasin (as cited in Moss, n.d.) describe a range of possible effects, including diplopia, poor concentration and visual memory, postural difficulties, field loss, blurred vision, difficulty in attending to non-moving objects or print, photophobia, and accommodative difficulties. Padula and Argyris (1996) detail two separate processes of the visual system: the focal process and the ambient process. The focal process includes mainly the macula, and it allows the viewer to aim the eye at a desired target. The ambient process provides feedback to the individual about location in space, which affects balance, posture, and movement. According to these authors, even a relatively mild head injury can create an imbalance in the ambient system, a state that they label Post-Trauma Vision Syndrome. They recommend optometric intervention through the use of yoked prism lenses that help to change the viewer’s perception of midline. Moss (n.d.) notes that the brain of a child with a sudden TBI does not have the capacity to suppress vision in one eye, whereas the brain of a child with congenital or early onset strabismus does have the capacity to adapt by suppressing the dissonant images from one eye.

Given the variation in visual effects and the integration of attentional, behavioral, and cognitive changes with vision, it is clear that assessing and addressing educational needs related to vision is a complex task. The educational team must balance the complex needs of the child and family with the benefits to be gained by including a wide variety of specialized professionals on the team. To provide an appropriate education for the student, team members must have clear documentation of the child’s physical and visual abilities as well as the family’s perspective on the child’s function and recovery.

Educational approaches and interventions

Direct instruction to support student cognitive and behavioral learning. Teaching a student who has TBI/VI requires a teacher and other professionals to know alternative strategies to ensure that the student learns. Lajiness-O’Neill, Erdodi, and Bigler (2010) identified 15 research-based characteristics of students with TBI, for example, variable attention and concentration, memory impairment, decreased speed of information processing, organizational impairment, and concrete thinking and learning. Instructional strategies suggested for each, respectively, were appropriate pacing, methods that ensure high rates of success, task analysis, advanced organizational support, and facilitation of transfer/ generalization. Loftin and Koehler (1998) maintain that children with visual impairment and neurodegenerative disease may benefit from the following strategies:

  • Use the specific environmental modification of block scheduling that minimizes a child’s time moving from room to room.
  • Alternate a child’s favored activities with less favored activities.
  • Schedule related services in the classroom rather than pulling the child for the service.
  • Allow the child to do high energy activities when she or he is rested, which will lead to more compliance.

Selectively schedule activities and allow the child to participate in the decision making process to decide how to adapt an activity. This helps the teacher to recognize that variable levels of energy of performance and modifications to once easily performed tasks are necessary to make learning successful for children with neurodegenerative disease and visual impairment.

Behavioral variances in the learning environment become more pronounced among children with neurodegenerative disease and visual impairment (Loftin & Koehler, 1998). Careful determination of why a child appears noncompliant is necessary because the ability to do tasks may fluctuate. Loftin and Koehler suggest teachers provide frequent breaks so the child can rest between activities on days he or she has low energy, involve the child in decision making for task adaptations to decrease frustration level, and develop a repertoire of previously mastered tasks that the child can do when he or she experiences performance fluctuations. Use a calendar system to help the child focus on activities, but provide a concrete way to signal “change of activity” for the child (Loftin & Koehler). Plan an educational program to promote learning and behavioral compliance that is specific and unique to each child. The program should vary depending on the nature of the neurodegenerative disease and accompanying visual impairment.

An image depicts an expandable calendar box with objects in it.

A calendar box signals “change.”

Instruction to support movement. Given the certainty that a child with neurodegenerative disease and visual impairment will have difficulties moving in the environment, a well thought-out program that includes strategies from the orientation and mobility instructor, and physical and occupational therapists is important to enable the child to “want” to move and continue to explore his or her environment. The neurodegenerative disease may decrease the physical ability of the child to move and take a toll on the emotional ability to want to move, which may lead to no movement because it is strenuous. Active routines established through calendar systems and block scheduling can help encourage a child to move, but Loftin and Koehler (1998) identify other variables that might inhibit a child’s movement. Cane skills are complex to learn, and even if a child masters a skill on a given day, there is no guarantee that similar performance of that same skill will appear on subsequent days. Loftin and Koehler provide useful suggestions that teachers can use to increase the chances that a child will move. First, consultation with the physical and occupational therapists is essential to determine what types of movements create less physical demand for a child, especially if there is great deterioration in physical ability. Second, follow physically demanding activities with relaxing, less demanding ones. Third, identify physical prompts that are non-intrusive and agreed upon by teachers and related service providers, for example, a hand on the shoulder of the child is a prompt to take a step forward.

Three photos depict a female teacher holding a storybook for a male child at three different viewing locations. In the first photo, the teacher holds the storybook to her left side. In the second photo, the teacher holds the storybook on a table before the child. In the third photo, the teacher holds the storybook to her right side.

A child fixates on storybook pages held at different viewing locations.

Instruction to enhance sensory processing. Before one can plan and implement an intervention program for a child to enhance sensory processing, one must consider a variety of variables. In her chapter on overview of intervention methods to enhance use of vision, Lueck (2004) summarizes the planning process and identifies five compensatory methods that professionals can consider to give a child the broadest options for approaches to learn. For many children with TBI, methodical vision skills instruction is an intervention method that facilitates the child’s recovery of vision. A comprehensive assessment of these skills is necessary to know which visual skills to teach a child with TBI/VI. If the child has a recent brain injury, recovery of visual skills may be taught best through intervention related to the visual attending behaviors (Lueck, 2004). Lueck (p. 264) lists these visual skills as

  • fixating or the child’s ability to point the eye so that the object of interest is on the retina or PRL (preferred retinal locus);
  • shifting gaze or the child’s ability to change fixation to a new object of interest;
  • scanning or the child’s ability to make a series of fixations in order to inspect a large area visually;
  • localizing or the child’s awareness of the location of an object of interest in the environment from visual, auditory, or kinesthetic cues so that one can fixate toward it;
  • tracking or the child’s ability to fixate on a moving object of interest using pursuit movements where the head, eyes, or both are turning; and tracing or the child’s ability to make a series of saccadic eye movements to shift fixation progressively along a line or border.

Lueck (2004) notes how important it is for the child to first acquire these visual skills in highly structured, motivating environments that may be isolated from the activities routinely done in the home, school, or community. An example of this type of visual skill instruction is to teach a child to visually search for and fixate on a large food item with much contrast and color present to make the food very visible. Color and contrast variations are examples of visual environmental management instruction, which in this example has been integrated with the visual skill instruction. Once the child shows mastery of this visual skill, one can incorporate instruction on searching, fixating, and using a guided reach to independently grasp the food item. It depends on the nature of the brain injury, but the teacher and family may need to continually reinforce visual skills instruction, especially if there is a neurodegenerative disease accompanying the visual impairment.

If the child successfully uses visual attending skills, fixates, follows, shifts gaze, scans, and so forth, in isolation but does not use these skills in certain tasks in which the use of vision would ensure completion with greater efficiency, use visually dependent task training that encourages visual attention to task components. If needed, use systematic and contingent reinforcement techniques. If the child in the previous example learned to search and fixate for his food successfully, one could then teach this child to use these visual skills to guide his purposeful reach for food during snack time or mealtime. Earlier, Lueck (2004) recommended that a child be taught the visual skills needed for a task in isolation through systematic instruction before that child is put in a situation where the visual search and fixation are needed together to assist with the guided reach for a food item. Lueck’s (personal communication, June 11, 2014) current research employs a new model that includes teaching skills in isolation and teaching them within a motivating daily routine simultaneously, once it has been established that a child is able to attend visually to the stimulus targeted for instruction in the typical setting. Most attainment of visual skills occurs immediately after insult or injury to the brain, so intervention through teaching visual attending skills soon after the injury will lead to a better outcome for improved visual skills. If the visual skill instruction is not effective with a student, one can use sensory substitutions to teach a child to gather information. For more information about this type of intervention, read Lueck’s chapter (2004).

A photo shows a female teacher teaching a male child using a “now” container.

Using a “now” container is a ritualization to reduce visual distractibility.

A child slides his finger from one target to another on a storybook page.

While specific instruction in visual skills is important for children to improve their visual efficiency, there are other considerations for the child with TBI. Many children with TBI do not have the ability to position their bodies to allow visual function to occur. Langley (2005) provides teachers with a list of considerations before one is able to assist a child to learn visually. She advocates for weight-bearing experiences to the palms of the hands and soles of the feet to promote midline visual organization; be mindful of postural changes as they will affect how the child concentrates and controls movement, and this may override the use of vision. It is important to remember that a child practices and learns visual skills best when his or her posture is stabilized, with special consideration to head and neck alignment.

Visual environmental management is a compensatory method that will affect the ability of a child who has brain injury/CVI to use vision (Lueck, 2004). Langley (2005) summarizes the ways in which an environment can be constructed to reduce visual distractibility and enhance visual function:

  • Use of illuminated toys or gently twinkling light sources such as My Little Pony® and other popular children’s character figures
  • Movement of stimuli to alert and direct gaze
  • Presentation of a single stimulus at a time
  • Use of color to highlight aspects of objects, shapes, and print
  • Wide separation of an array of objects
  • Simple picture books with a single picture to a page
  • Elimination of details that are not critical to the content of pictures
  • Emphasizing contrast between foreground and background
  • Ritualization for the presentation of activities
  • Clear marking of the beginning and ending of an activity
  • Encouraging the child to slide a finger from one target to another to manage the crowding phenomenon (p. 108)

Future implications for educational approaches to sensory processing for TBI/VI children

There is still need for evidence-based instructional methods that will facilitate visual skills for academic children with TBI/VI or CVI. [See Appendix B for The CVI Range (Roman-Lantzy, 2010) and the Pediatric View study (Roman Lantzy & Lantzy, 2010) for children with multiple disabilities.] Special learning environments that promote visual skills for children with TBI/VI and/or CVI in addition to the visual environmental management adaptations suggested by many (Loftin & Koehler, 1998; Langley, 2005; Lueck, 2005) need to be systematically studied. Lueck (2005) also proposes that more investigation to determine the most effective interventions for visual processing dysfunctions in complex tasks such as reading, facial recognition, and orientation and mobility is needed to determine if one can improve these visual processing skills.

Presently, we have a framework to promote sensory processing among children with TBI/VI or CVI; however, Lueck (2005) notes that researchers have obtained and may still obtain mixed results of improved functional vision when providing a systematic program of vision skills intervention. It is important for researchers to investigate intervention strategies that affect the development or improvement of visual skills for children with TBI/VI and/or CVI and then for educators to create the instructional climate to promote these skills.

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Proper Trademark Notice and Attribution. My Little Pony® is a registered trademark of Hasbro.

Dr. Jane Erin is a retired professor from the University of Arizona, where she coordinated the program in Visual Impairment. From 1984 to 1994 she was on the faculty at the University of Texas, and previously she was a teacher and supervisor at the Western Pennsylvania School for Blind Children.

Dr. Irene Topor is an associate professor of practice for the Specialization in Visual Impairment at the University of Arizona in Tucson. She worked 5 years as a resource teacher of children who are blind or visually impaired; 5 years as supervisor for Tucson and statewide parent outreach services for infants, toddlers, and preschoolers; and coordinator of the center-based program, Visually Impaired Preschooler’s Center. Dr. Topor worked 4 years as an educational consultant for a pediatric ophthalmologist and 1 year as a certified low vision therapist for students attending Arizona State Schools for the Deaf and the Blind.