An Educator’s Guide to the Brain

The brain, our brain, is quite elegantly the supreme organ of learning. All that we do, all that we are, emanates from our brain. Yet, few educators in their undergraduate or graduate work receive detailed information on the brain and how the brain learns or what is happening (or not happening) when the brain does not learn well. Ancient philosophers and scientists did not even recognize the importance of the brain as an entity. Even today in the “Decade of the Brain: we are still exploring our own internal universe to try and gain an understanding of how we learn and who we are. An understanding of the brain is essential if we are to try and gain some knowledge of what happens to the brain after an acquired brain injury. This chapter will highlight our present understanding of the brain from an educational perspective, rather than from a medical perspective. Afterall, the brain is our “learning machine.”

The brain is not a hard musclelike substance, but rather a soft gelatinlike organ that weighs approximately 3 pounds in an adult and about 2 pounds at birth. Brain weight increases more than three times between birth and adulthood. It sits within a rough and bony skull and is bathed in a specialized “cerebral” spinal fluid. The brain is innervated by a sophisticated system of blood vessels which carry blood to and from the heart. There are actually three membranes that cover the brain: the outer dura mater (hard matter) which is like a heavy plastic sheet; the arachnoid (cobweblike) which bridges the brain’s many wrinkles and folds; and the pia mater (tender matter) which molds around every tiny crook and crevice on the brain’s surface. It is between the pia mater and the arachnoid that a teacup full of cerebrospinal fluid flows like a millions of little streams bring nourishment and protection to the nerve tissue. Internally, the brain has four different reservoirs for storing and circulating the cerebrospinal fluid called ventricles. The ventricles are like tiny lakes within the brain that pools the fluid, helps cushion the brain and protect the brain tissue went swelling occurs.

If, for example, the brain is injured by a sudden jolt or bang, it reverberates jellolike oftentimes ripping, tearing, and stretching the blood vessels and delicate nerve tissues apart. To complicate matters the brain rubs against the inside of the ragged and bony skull causing major bleeding. As with other body parts, the brain bleeds and/or swells with blood and fluid causing tremendous pressure within the skull which compresses the brain into itself creating further injury. If you were to trip and sprain your ankle badly, you could either tear muscle, ligament, blood vessels. The swelling created by all the bleeding and fluid accumulation would cause more serious problems which is why we would apply ice or cold compresses to our ankle.

The brain reacts in a similar fashion except our skull is not flexible like the skin on our ankle to handle the swelling. Physicians oftentimes need to relieve this intracranial pressure by inserting specialized monitors into the skull and brain to control the swelling and to surgerically operate and remove any accumulation of blood (hematomas). In some cases the bleeds may be so small that the pressure on the brain builds up over time and may go unrecognized until the person starts to exhibit symptoms. The important issue here is that the blow or insult to the brain is only part of the problem. The swelling, bleeding, and contusion (bruises) injures the internal neural network and is often pervasive and not just localized at the site of initial impact. Like a 3 pound mold of gelatin connected with billions of microscopic threads, a traumatic impact ripples through the entire brain causing many complications. Accidents that cause severe blood loss can cause a lack of oxygen to the brain, called anoxia, which quickly leads to brain injury. Many other nontraumatic brain injuries can cause anoxia. Victims of near drowning, heart attacks, suffocation, smoke inhalation, asthma attacks, sudden infant death syndrome (SIDS), and strangulation suffer anoxia which kills off brain cells.

The billions and billions of tiny cells making up the nervous system are called neurons. Neurons are the “communicators” and other kinds of noncommunicating glial (“glue”) cells support and nourish our neurons. Each neuron has three main parts: cell body, axon (a long, slim “wire” that transmits signals from one cell body to another via junctions known as synapses), and dendrites (networks of short “wires” that branch out from an axon and synapse with the ends of axons from other neurons). The neurons receive and transmit information in a relay where electrical impulses alternate with chemical messengers. The electrical impulses flow through those nervecell pathways the axons and dendrites. Neurochemical transmitters leap the synaptic gaps between each neuron’s axon and the other neurons with which an axon makes contact. Each neuron is its own miniature information center which decides to fire or does not fire off an electrical impulse depending on the thousand or so signals it is receiving every moment. After a child sustains a brain injury, many of these pathways may be torn apart or stretched to a point when information processing is no longer possible. The study of nerve regeneration, repair, and creating new neuronal growth will keep many researchers busy for years to come.

BRAIN GEOGRAPHY

To better understand how our brain helps us to think, move, and act we need to study some basic neuroanatomy a geography lesson on the brain so to speak. In order to better visualize how the brain looks geographically, take a golf ball in you hand and close your fist around it. Your arm resembles your spinal cord which receives information from our skin and muscles and relays this information upward and, of course, relays information down and out from our brain. Your wrist is your brainstem, a small but important extension of your spinal cord. It is like the “point person” for all incoming and outgoing information and basic life functions. The golf ball you are holding represents your limbic system, a rim or cortical structures which encircle the top of the brain stem and is involved in our emotions and basic elemental feelings. Sitting atop and enveloping the limbic system, like our hands around the golf ball, is our cerebral cortex divided into two hemispheres which are dedicated to our highest levels of thinking, moving, and acting. Lastly, situated in the lower back of our brain is our cerebellum which coordinates, modulates, and stores all our body movement. This interconnecting system of neural structures makes up our brain and who we are and are becoming. To understand this wondrous geography will better help us understand what happens when the brain is injured.

THE BRAIN STEM

A more detailed look at our central nervous system reveals a major trunk, the brainstem, which evolves from the spinal cord. Our brainstem is made up of three integral areas called the medulla, the pons, the midbrain, and the diencephalon. Our brainstem also contains many of the centers for our senses: hearing, touch, taste, balance (except sight and smell). It is in this array of brain structures in our brainstem that a collection of nerve fibers and nuclei called the reticular activating system (RAS) are housed. The reticular activating system modulates our arousal, alertness, concentration, and basic biological rhythms. If you find yourself getting sleepy or have trouble attending to the information in this chapter you need to “turn up” your RAS. It is much like the dimmer switch on a light that we can turn up to make the lighter brighter, or turn down to make it darker. After a brain injury many individuals lose consciousness which can result in coma. Their dimmer switch because of the severity of the injury or the brain swelling may be turned down leaving then unable to respond to even simple commands and unaware of their surroundings. Unfortunately, if the RAS can be depressed to a point where life as we know it ceases to exist.

The first “unit” in the lower part of our brain stem is made up of the medulla and the pons which are involved in many of our basic living functions. The first area is called the medulla The medulla is about one inch of brain tissue that is vital to life and death, as is the rest of the brainstem The medulla controls many of our basic metabolic responses: swallowing, vomiting, breathing, respiration and heart rates, and blood pressure. This is where the polio virus struck and why children had to be placed in the “iron lung” machines of the 1950s to keep them doing what there medullas could no longer perform. When the medulla is injured, as with any area of our brainstem, life is immediately threatened.

Just above our medulla is the pons, a bridge of broad band of nerve fibers that connect the cerebral cortex and the cerebellum. This bridge of nerve fibers enables the “thinking” part of the brain (cortex) to work with the “movement” (cerebellum) part of our brain. Disruption to the pons can cause complete loss of our ability to coordinate and control our body movements possibly leaving us partially or totally paralyzed. Injury to the medulla and/or pons can result in serious metabolic disturbances. Sometimes the upper regions of the brain can sustain catastrophic injury resulting in “brain death” but the person still breathes and their hearts still beat even without life supporting equipment. In this situation the person is said to be in a prolonged coma or “persistent vegetative state.” Unfortunately, this is where the slang term “vegetable” has been used to describe individuals in longterm coma and erroneously describes the circumstances.

The second “unit” in the upper part of our brainstem contains the midbrain and the diencephalon and is responsible for alertness and arousal. Interestingly, the smallest part of our brainstem is the midbrain, yet, as small as the midbrain is, elementary forms of seeing and hearing are possible. Only centimeters above the midbrain is the diencephalon (comprised of the thalamus, hypothalamus, and other structures). This is a master relay center for forwarding information, sensations, and movement. The hypothalamus, in particular, is the control center for eating, drinking, sexual rhythms, endocrine levels, and temperature regulation. It is also involved in many of our complex responses like anger, fatigue, memory, calmness, and serves as the “conductor” of our emotional orchestra. The thalamus sits on the very top of the brain stem just beneath the cortex. It acts as a major relay station for incoming and outgoing sensory information. Each of our senses (except smell) relays its impulses through the thalamus.

Individuals who suffer injury to this part of their brains can experience severe attention and concentration problems, difficulty with memory storage and retrieval, weakened mental stamina, decreased sensory information, difficulty in reacting to stress, difficulty with hyper or hypoemotional responses, and disorders in eating/drinking, sleeping, and sexual functioning. Since the hypothalamus is the major brain region which manages the release of body hormones, survivors of brain injury may end up with many complex problems. The brain is also the largest “chemical” factory in the body. Disruption to our hormonal, endocrine, and/or neurochemical systems can be just as devastating as injury to the neural network.

THE LIMBIC SYSTEM

Situated above, around, and interconnected with the diencephalon is our limbic system, an area of the brain which is represented by the golf ball you are holding in your hand. Many “neuro” professionals (neurosurgeons, neurologists, neuropsychologists, neuroeducators, etc.) argue about which particular areas of the brain best fit into certain systems. Is the diencephalon with its thalamus and hypothalamus part of the limbic system or the upper brain stem? Arguments like these are moot if one believes that the brain is a highly interconnected and complex system that integrates many units into a beehive of internal and external responses and actions. Thus, even the golf ball you hold in your hand is only a gross representation of the limbic system and its connectiveness to the other regions of our brains. While chopping up the brain geographically may help us better appreciate various components and systems, it is only for convenience that we do this.

No single part of the brain can ever be discussed with connecting it to the whole. Just to talk about “attention” involves the brainstem, limbic system, and cortex.

As we take a more detailed look at the limbic system we find increasing complexity and connectiveness with other parts of our brains, especially the cerebral cortex. Some brain researchers have referred to the “middle” part of the brain as the mammalian brain, the evolutionary, animallike part of the brain that houses our basic elemental drives, emotions, and survival instincts. The two major structures usually associated with the limbic system include the hippocampus and the amygdala. Injury or damage to any of these structures can leave longterm and devastating problems for survivors. The hippocampus is a pairedorgan, one on each side of the brain sitting within the temporal lobes. The hippocampus is most commonly associated with memory functioning and is particularly susceptible to loss of oxygen. Injury to the hippocampus causes survivors to have a great deal of difficulty with short term memory, turning short term memories into long term memories, and organizing and retrieving previously stored memories. The hippocampus is like the pole in your closet on which you hang your clothes. If the pole was pulled out your clothes would fall into a heap. Your entire system of hanging like clothes in certain areas would be completely disrupted. As you went to store new clothes there is no pole (organizational structure) to efficiently help you. Thus, your clothes end up in a mess on the floor which makes it difficult to find anything.

Close to the hippocampus is your amygdala, a “fight flight” structure that seems to be more closely tied with emotional memories and reactions. There is speculation that when a perception reaches the cerebral cortex, it will be stored within the amygdala if it arouses emotions. Our hidden “fears” of snakes, spiders, and creatures of the night may cause us to run or stand our ground depending on the emotional response from the amygdala. Interestingly, both the hippocampus and amygdala are directly tied with our olfactory fibers which is why many survivors in the early stages of recovery benefit from smell stimulation their mother’s perfume, familiar clothes, favorite food odors. While all our sensations sight, sound, taste, touch evoke memories, both smell and taste seem to be the most powerful stimulants for recollection.

Injury or disruption to the limbic system can produce a serious of complex problems involving our basic emotional responses to the world and ourselves and how we perceive and “feel”. Our actions so often guided by our emotions can become uncontrollable. We can become locked into over or underreacting to even the simplest of situations. One minute everything is all right, the next the world seems to be crashing down. Survivors may feel that they no longer have any control over their actions they become impulsive, haphazard, disconnected from their family and friends. The limbic system seems to run wild and the injured cerebral cortex cannot keep in balance the vast emotions that show (or do not show) themselves. As thinking, feeling, and moving beings if we are not in balance, our actions may bring us only further complications.

Another group of brain structures that works together as a special system is called the basal ganglia. The four nerve cell clusters of the basal ganglia or “nerve knots” help to handle physical movements by relaying information from the cerebral cortex to the brainstem and cerebellum. Most of all the basal ganglia centers serves as a “checking” system that comes to attention when something is not working the way it should be. An injured or diseased (Parkinson’s disease) basal ganglia affects voluntary motor nerves, results in slowness and loss of movement (akinesia), muscular rigidity, and tremor which can be localized or diffuse. It is the neurons in the basal ganglia that respond when someone loses their balance and tells the muscles to restore lost equilibrium.

THE CEREBELLUM

The interconnectedness of the brain as we have seen is difficult to separate as distinct working units since the brain is a complicated organization of multiple systems. Wedged between the brainstem and the cerebral cortex, hitched to the back of the head in the cerebellum. (Our armwristballhand analogy does not represent the cerebellum her unless you want to glue a pingpong ball to the back of your wrist.)It is about 1/8 of the brain’s mass and has its own distinctive arrangement of brain cells. Medieval anatomists called the cerebellum “Arbor vitae,” the tree of life, because the layers of cells fan out in a striking foliate pattern. The cerebellum governs our every movement and monitors impulses from our motor and sensory centers (brainstem, basal ganglia, motor/sensory cortex) to help control direction, rate, force and steadiness of our movements. It enables us to develop and store the motor skills to play sports, ride a bike, do aerobics exercises, perform martial arts routines, drive a car, and to train our “mind and body” to accomplish amazing athletic feats. Many athletes who train rigorously over months and years coordinate their movements into “automatic” routines, ways to move without even thinking about what we are doing. Responding in milliseconds to an opportunity to score the winning point.

Injury or disease to the cerebellum does not produce muscle weakness or changes in our ability to sense things. A person with a damaged cerebellum may look “drunk” when they walk. The person may not even be able to walk a marked straight line or sit without support. The eye and hand coordination so necessary in life may be disabled to the point that the person cannot even reach out and pick up a glass of water. Or the person’s movement may become so awkward that trying to brush one’s teeth may result in a crushing blow to their own face. Since the cerebellum is responsible for coordinating muscle tone, posture, eye/hand movements, damage to the cerebellum can seriously inhibit a person’s movement within their community. Once common routines like getting dressed, writing your name, and getting from class to class in a school become frustrating and impossible to control.

The Cerebral Cortex

By far the most complicated structural component of the brain is the cerebral cortex made up of the right hemisphere and the left hemisphere, each with four lobes bounded by three fissures. As you make a fist out of you hand, the cerebral cortex is represented by you hand and fingers. The cortex is full of wrinkles and folds, in fact, if you take your cortex and flatten it out it would be the size of a pillowcase. The wrinkling and folding of cortex helps us pack brain mass much more into our skulls. It is the fact that we have two brains, two hemispheres, that has lead researchers to marvel at the information processing abilities and differences of the cortex. History abounds with references to the “duality of the mind”, but it wasn’t until the 1960s when Dr. Roger Sperry and Dr. Joseph Bogen gave detailed reports of their patients who had undergone surgery to alleviate their seizures by cutting the corpus callosum, a complex band of nerve fibers that exchanges information between the two hemispheres. Soon “right brain left brain” differences became topics for common discussion. The Bogen/Sperry studies showed that the two hemispheres of the brain, while seeming alike, had their own unique ways of processing information. The right hemisphere was more holistic, visualspatial, and intuitive while the left hemisphere was more linear, verbalanalytic, and logical. From a geographical perspective, comparing the two hemispheres is like comparing the two halves of the United States. They have a major river, the Mississippi, running between them (like the corpus callosum) that serves as a major divider and connector at the same time. While they have similar “rules and regulations”, they also have their own distinct styles. The similarities and differences between Californians and New Yorkers exemplifies this. Interestingly, the cerebral hemispheres control opposites sides of the body, thus if a person receives an injury to the right hemisphere he or she will have difficulty controlling their left arm or leg.

According to modern brain scanning, electroencephalograph research, and studies of people who have had their hemispheres separated by surgerically sectioning the corpus callosum, the left and right hemispheres to demonstrate some processing differences as well as many similarities. The left hemisphere processes information in a logical and linear manner which helps it better understand and use language (speaking, reading, writing, calculations), while the right hemisphere responds to information in a more holistic and spatial sense (shapes, faces, music, art). It is not that the right hemisphere cannot use language, simple words like book, dog are recognized, but words of higher conceptual demand like honesty or perseverance. The uniqueness in our cerebral hemispheres is that they do communicate to each other a thousand times a second through the corpus callosum. This 4 inch long, pencil thick band of complex nerve fibers allows our two hemispheres to work in tandem. When a student sustains a brain injury the swelling or impact may seriously damage this precious relay system and result in impaired processing of information. Students can have major damage to one hemisphere plus have damage to the corpus callosum pathway. Such injuries create very complex cognitive difficulties for people and many compensatory strategies need to be developed to help rehabilitate people.

In order to more fully understand the impact of an injury to the brain, we need to remember that when one part of the brain is impacted, it reverberates throughout the brain like shock waves through our jello mold. Students with traumatic brain injuries will not appear as “one sided” people who have had a stroke in a particular hemisphere. Each brain injury manifests itself differently depending on the type and severity of injury and the age of the student. Children before the age of ten, for example, may sustain an injury which effects their speech center in the left hemisphere, yet be able to develop speech in the opposite area in the right hemisphere. This does not mean that language will progress normally since speech is only one small part of a child’s overall language functioning.

We also need to look more closely at the role of the four lobes frontal, parietal, temporal, and occipital to better understand the effects of an injury. Because we have two hemispheres our lobes comprise both a leftside and a rightside involvement. Thus, we have a left frontal lobe and a right frontal lobe, each working together, yet displaying many processing differences just like our hemispheres. These four lobes or areas of brain anatomy are named after the main skull bone that covers it. These landmarks help us to map the surface of the brain, but our lobes do not necessarily match brain areas designated for different tasks. Like the hemispheres with its corpus callosum, our lobes are interconnected by complex neural fibers. The projection fibers fan out from the brainstem and relay impulses and information to and from the cortex. The association fibers loop and link together different section of the same hemisphere and modulates the cerebral cortex. These two neural fiber systems help the four lobes of our cortex work together and keep it connected intricately with both the limbic system and our brainstem.

The frontal lobe includes everything in front of the central fissure. It is particularly vulnerable to injury since it sits in the front of the skull. The frontal lobe also has extensive connections with the limbic system (emotions) and the other brain lobes. When it is injured or damaged a student’s ability to synthesize signals from the environment, assign priorities, make decisions, initiate actions, control emotions, behave and interact socially, make plans, and other executivelike functions is severely compromised. While injury to any designated part of the brain creates problems, injury to the frontal lobe is especially debilitating since the frontal cortex is where ideas are initiated and these ideas have to “go” someplace. It is as if our entire personality changes, a person does not seem to be “like” the person they once were. Our prefrontal cortex in particular is responsible for various emotional responses we have to circumstances. Rather than just responding to situations intellectually, we may respond with delight, anxiety, hope, pessimism or a range of other higher level emotions.

Frontal lobe injuries in young children often go unnoticed since the children are at an age when caregivers in a sense become their frontal lobes as teachers and parents we organize, plan, and direct our childrens’ lives. Yet, as the child gets older and enters early adolescence the need for more independent frontal lobe functioning has been diminished by the earlier injury. Students may begin to experience a lack of control over a wide range of behaviors not because they are misbehaving, but because their frontal cortex is not responding normally. Attempts to merely discipline or punish children with frontal lobe injuries does not help them to understand or compensate for their loss. Ways to deal with complex behaviors need to be taught to students just like new learning or memory strategies would be introduced.

Spanning our brain like earphones are two adjacent bands of cortex that trigger movement (motor cortex) and register sensations (somatic sensory cortex). This motor sensory strip connecting the frontal and parietal lobes controls every voluntary movement from the simple pointing of a finger to coordinating our lips and tongue to make sounds. The parietal lobe caps the top of the brain behind the central fissure and merges into the occipital lobe. The parietal lobe is the “touchy, feely” part of the brain that responds to touch, heat, cold, pain, and body awareness. Injury to the parietal lobe can cause a loss of these sensing abilities. A student with damage to the right side of their parietal lobe may not even recognize that anything is even wrong with movement of the left side of their body not out of psychological denial but basic neurology. Even more complex functions like attention can be effected by damage to the parietal lobe. The interconnectedness of the brain can impact on our motivational states. For example, when we smell food and turn our visual attention (eye movement) towards the source and respond by moving towards the food a complex array of responses are generated through the limbic system to the frontal lobe to the parietal lobe and so on. There are also nerve cells extending as far down as the brain stem to provide the necessary arousal to the situation. Since so much of school involves movement and motivational states, students with injured parietal lobes will experience a host of complex problems in their sensorymotion systems.

The occipital lobe is our primary visual center, yet it is positioned as far away from our eyes as possible in the back of our skull. This is why when you fall and hit the back of your head you will oftentimes see “stars” in effect you have stimulated your occipital lobe. Our visual cortex is connected to our eyes by our optic nerves. No other sense involves so many nerve cells and vision neurologically speaking is a complex process. As incoming light rays pass through our eyes and are changed into electrochemical impulses, nerve fibers arrange and code these impulses. Near the back of the eyes, the optic nerves carrying these signals meet at a “crossing” called the optic chiasma. At this crosspoint, optic fibers from the inner half of each retina cross to the opposite hemisphere of the brain. Thus, the left optic track carries signals from our rightside field of vision, and the right optic track takes signals from the left so that both sides of our brains in a sense “see” the same thing.

After these signals pass through a relay station in the thalamus and reach the left and right occipital cortex the whole image is reassembled and processed by different visual areas for size, shape, position, recognition, color, etc. Most of what we “see” derives its meaning significance from what it means to us, prior learnings and symbolic representations. And like other areas of the brain, to separate vision from movement, or sound, or anything else does not really describe vision in its broadest sense. Unfortunately, injury to the brain often disrupts “what we see” because the complexity of this sense. Visualperceptualmotoric damage can create may problems for students.

The temporal lobes rest on both sides of the brain and are the centers for language, hearing, and maybe where memories are permanently stored. More than a century ago a French surgeon, Paul Brocca, and a German neurologist, Karl Wernicke, discovered that damage to particular areas of the left temporal and parietal lobes left people unable to speak or unable to understand language. The so called Brocca’s area of the brain is located in the lower portion of the motor cortex in the left frontaltemporal lobe. This are controls muscles of the face and mouth and enables the production of speech. Wernicke’s area in the left temporalparietal lobe governs our understanding of speech and our ability to make sense of our thoughts when we speak. Together these two areas direct the smooth transfer of thought and expression into speech.

The process of hearing, like vision, is very complicated but also different. As sound waves are picked up and passed through our outer and middle ear to our inner ear, a series of events take place. The transmitted sound waves vibrate thousands of tiny sensitive hairs in the organ of Corti. Each hair is connected to thousands of nerve fibers which send signals through the eighth cranial (acoustic) nerve to our brainstem. There, many of the nerve fibers cross over before taking signals up to the tops of our temporal lobes for analysis. A brain injury can produce a breakdown of this process either neurologically or mechanically. While many “mechanical” disruptions to the outer and middle ear can be restructured, damage to the inner ear and temporal lobe can produce more serious consequences.

The memory processing and storage capacities of the temporal lobes is not entirely understood. While the brain can store shortterm memories in the hippocampus, longterm memories seemed to be holistically stored throughout the brain. The temporal lobes with their connections to the hippocampus may help in this longterm storage of permanent memories in terms of their meaning, retaining concepts and relationships, instead of just words themselves. Students with brain injuries often have difficulty with new learning while exhibiting a good memory for information learned previous to the injury. Their memory system for understanding, storing, and/or retrieving new information has been disrupted by the injury to their brains. When attention, concentration, and memory problems co handinhand, the student will be unable to connect new learnings with prior knowledge and their academic work will seriously suffer.

RECOVERY AND CONTINUED NEUROLOGIC DEVELOPMENT

The recovery from brain injury is as unique as the injury itself and the child as an individual. Different injuries have different recovery rates and degrees of recovery. A child who suffers a lack of oxygen to his/her brain (i.e., near drowning, strangulation, suffocation, smoke inhalation, cardiac arrest, etc.) tends to have a slow rate of recovery and depending on the severity of the brain damage varying prognosis for good recovery. A child who sustains a penetrating head injury (i.e., gun shot wound) may have a more rapid recovery and, again depending on severity, have varying prognosis for recovery.

Professionals commonly use the Rancho Los Amigos Levels of Cognitive Functioning (IVIII) to measure the degree of recovery. The Rancho Levels of Consciousness scales provided below are for infants, 6 months to 2 years; 2 5 year olds; and 5 years and older; and for older adolescents and adults.

Rancho Los Amigos Cognitive Scales

Level of Consciousness Records – Head Trauma Patients

Infants, 6 Months to 2 Years

Level I: Interacts with Environment

a) Shows active interest in toys; manipulates or examines before mouthing or discarding.
b) Watches other children at play; may move towards them purposefully.
c) Initiates social contact with adults; enjoys socializing.
d) Shows interest in bottle.
e) Reaches or moves toward person or object.

Level II: Demonstrates Awareness of Environment

a) Responds to name.
b) Recognizes mother or other family member.
c) Enjoys imitative vocal play.
d) Giggles or smiles when talked to or played with.
e) Fussing is quieted by soft voice or touch.

Level III: Gives Localized Response to Sensory Stimuli

a) Blinks when strong light crosses field of vision.
b) Follows moving object passed within visual field.
c) Turns toward or away from loud sound.
d) Gives localized response to painful stimuli.

Level IV: Gives Generalized Response to Sensory Stimuli

a) Gives generalized startle to loud sound.
b) Responds to repeated auditory stimulation with increased or decreased activity.
c) Gives generalized reflex response to painful stimuli.

Level V: No Response to Stimuli

a) Complete absence of observable change in behavior to visual, auditory or painful stimuli.

Preschool – 2 to 5 Years

Level I: Oriented to Self and Surroundings

a) Provides accurate information about self.
b) Knows he is away from home.
c) Knows where toys, clothes, etc., are kept.
d) Actively participates in treatment program.
e) Recognizes own room, knows way to bathroom, nurses station, etc.
f ) Is potty trained.
g) Initiates social contact with adults. Enjoys socializing.

Level II: Is Responsive to Environment

a) Follows simple commands.
b) Refuses to follow commands by shaking head or saying “no”.
c) Imitates examiner’s gestures or facial expressions.
d) Responds to name.
e) Recognizes mother or other family members.
f ) Enjoys imitative vocal play.

Level III: Gives Localized Response to Sensory Stimuli

a) Blinks when strong light crosses field of vision.
b) Follows moving object passed within visual field.
c) Tuns toward or away from loud sound.
d) Gives localized response to painful stimuli.

Level IV: Gives Generalized Response to Sensory Stimuli

a) Gives generalized startle to loud sound.
b) Responds to repeated auditory stimulation with increased or decreased activity.
c) Gives generalized reflex response to painful stimuli.

Level V: No Response to Stimuli

a) Complete absence of observable change in behavior to visual, auditory or painful stimuli.

School Age – 5 Years & Older

Level I: Oriented to Time & Place: Is Recording Ongoing Events

a) Can provide accurate, detailed information about self and present situation.
b) Knows way to and from daily activities.
c) Knows sequence of daily routine.
d) Can find own bed; knows where personal belongings are kept.
e) Is bowel and bladder trained.

Level II: Is Responsive to Environment

a) Follows simple verbal or gestured requests.
b) Initiates in purposeful activity.
c) Actively participates in therapy program.
d) Refuses to follow request by shaking head or saying “no”.
e) Imitates examiner’s gestures or facial expressions.

Level III: Gives Localized Response to Sensory Stimuli

a) Blinks when strong light crosses field of vision.
b) Follows moving object passed within visual field.
c) Tuns toward or away from loud sound.
d) Gives localized response to painful stimuli.

Level IV: Gives Generalized Response to Sensory Stimuli

a) Gives generalized startle to loud sound.
b) Responds to repeated auditory stimulation with increased or decreased activity.
c) Gives generalized reflex response to painful stimuli.

Level V: No Response to Stimuli

a) Complete absence of observable change in behavior to visual, auditory or painful stimuli.

Many educators will see that the Rancho Levels of Consciousness scales for children are assessing the child’s awareness of and interaction to the environment, the child’s orientation to self, other people and surroundings, and responses to sensory stimuli. Such assessments are not unlike many of the developmental inventories that educators use to evaluate children. The difference is a that child with an acquired brain injury is “recovering” from a specific event in time and their injury has implications for the child’s immediate needs as well as his/her continued development over time.

Thus, brain injury for a child is different than brain injury is for an adult even when the exact same areas/systems of the brain have been damaged. A child’s brain is still growing and developing, thus, an injury to a child’s brain in the early years may not exhibit the same or as serious an array of problems as similar injury might with an adult. Unfortunately, as the child develops and matures, over time, early brain injuries can create more problems. A baby who falls and injures the frontal lobes of their brain may appear very normal in the ensuing years. However, when the child approaches puberty and the frontal lobes are being called on more and more to handle the complexities of life, the child’s previously injured brain may not respond as it normally should. When we look at a brain injury to children we need to look at it from a developmental perspective.

Brain growth during development inside the womb and in the five years after birth is extremely accelerated when compared to other parts of the body. A newborn baby’s brain has reached one quarter of its adult weight although the baby is only one twentieth as heavy as the adult it will become. Prebirth growth of the brain results from cells multiplying in the brain in a series of “spurts.” After birth the baby’s brain grows not only in weight, but in complexity. Yet, even though the newborn baby’s brain has almost all the neurons its brain will ever hold, they have not yet to form the connections and systems that develop the brain into and organized and integrated organ. This is an especially important point to note when discussing injury to infants and toddlers. It is difficult to assess the extent of damage of children who have been abused, fell, or were injured in motor vehicle accidents since their brain is still so immature. However, early damage to an already underdeveloped and immature brain does not mean that the child will just “grow out of it.” The often held notion of brain plasticity and ability to rebound from serious injury does no necessarily hold true when it comes to the brain. Consequently, children who have been badly shaken and/or struck by a parent, or have sustained a blow to the head in a car accident or fall may end up with long term neurologic problems that may never be compensated for or overcome.

Developmentally parallel to this is the concern about children who injure their brains at other ages and what happens to them over time. Many educators, pediatricians, psychologists and child life specialists have presented the concept that children and youths are “developing” over time. Children are not merely miniature adults, but are beings in their own right with their own wants and needs. Unfortunately, many of the measurement instruments we use to assess brain injury were developed for adults and commonly used on children. Many of these measurement tools give us a false impression of the child’s injury and needs. In fact, many socalled “mild” brain injuries may create a host of cognitive and behavior problems for children.

The critical issues of brain growth and development and subsequent injury to a child’s brain are areas in need of indepth and long term study. While we have certainly begun to discover how our brains work, we have only scratched the surface of our neurological wonders. The brain is certainly the most precious and complicated organ in our body. Quite simply our brain is who we are and will become. When the brain of a child is injured it can become a lifetime experience which deeply effects the child and the family.

An understanding of the brain and what happens when it is injured will help educators better plan their teaching strategies and materials. Knowing how the brain develops, grows, and works will enable us to develop educational plans that can focus on the strengths and needs of children as they continue their lives.

Reproduced with permission and copyright The Perspectives Network