Traumatic Brain Injury (TBI) is often referred to as the “signature injury” of the Iraq and Afghanistan wars, as it is the predominant injury sustained from blasts and explosions.

33% of veterans with severe physical injuries have been diagnosed with TBI, but not all TBIs have been diagnosed.

Each TBI is unique to the individual, so don’t assume each student will show the same symptoms.

Short Term Memory Deficits • If lessons are multi-day or multi-session, consider a quick review of previous items to ensure retention

Poor Problem Solving • Define the problem, work through possible solutions, pick one to try and then evaluate together the success of the solution

Difficulty With Decision Making • If student has trouble making complex decisions, break it into smaller pieces and only present 1 or 2 choices

Poor Organizational Skills • Include as many written materials as possible prior to the lesson (packing lists, schedules, etc.) • Set aside specific staging areas • Give extra time for equipment set up, and assist if requested

Easily Distracted • Give important instructions in areas that are quiet to help with retention

Easily Overstimulated • Have space set aside with little activity where the student can go if the situation becomes overwhelming. Make the transition to the space seem natural and not like a punishment

Decreased Social Skills • Have a set space where student registers/checks in to ensure initial contact with instructor • Make sure student remains engaged in the lesson by asking questions throughout

Impaired Understanding of Relationships • Make clear your relationship is student and teacher. Be friendly but don’t encourage overfamiliarity

Disinhibited • Student may not understand dangers. Don’t let them convince you to take unnecessary risks. (i.e. don’t ski down a black diamond on the first day of a lesson)

Persistence / OCD symptoms / Perseveration • Address the student’s concerns first and then redirect energy to new task

Decreased Processing • Be aware of environment to help anticipate where student could become overwhelmed with sensory information

Visual/Hearing Impairments • Ask student (either upon introduction or in registration form) if they have any hearing/vision issues and what those might be to ensure safety

Decreased Awareness • Point out potential dangers and safety concerns prior to heading out for lesson

Neurofatigue • Student may tire easily, showing increased distraction, decreased attention, more falls, and less communication • When this occurs, shorten the lesson or take more breaks

Poor Impulse Control • Use strategies that bring student back to task or redirect.

Types Of InstructionOne on one or small group instruction is often better for those with TBI or PTSD. Provide expectations and a clear lesson plan at the start.

1. Verbal: Give step by step instructions • Avoid instruction overload by only giving one or two items at a time • Break steps down (like a recipe) first this, second this, third this • Have the individual repeat the instructions back to you as they understand them to ensure comprehension • If there is more than one instructor, identify one as a lead and the other as support • Repetition is key but don’t overdo it • Do not shout – keep calm voice • Throughout the lesson ask if there are any questions or if anything is confusing

2. Visual: Show the participant how to perform a skill • Role play where participant follows your lead • You perform the skill, then the participants performs the skill

3. Hand in Hand: Have participant perform the skill with you. • Always ask permission before using touch to demonstrate skills

Watch for signs of adrenaline overload. The adrenaline rush, which commonly happens from increased activity, may feel good at first, but could cause cognitive difficulties and adverse consequences.

Possible Characteristics of a TBI & Teaching TipsEach TBI is different, with symptoms that vary by individual student and from one day to the next.

Ask your student how their TBI might affect the lesson and adjust your teaching technique accordingly. Be aware that not all students want to talk about their injury, especially in as much detail as you need. Some parts of your assessment may need to be based on observation and in the process of getting to know your student.

If possible, include a question on your registration form asking whether participants have a TBI and how the TBI affects their daily lives so you can help ensure a smooth lesson from start to finish.

INJURY

TBI and Altitude

When participating at elevated altitudes, cognitive skills may be altered even further. This may or may not be resolved as the student acclimates.

Altitude may also affect reactions to medication as it may not absorb properly. TBI patients may self-medicate to adjust. This should always be cleared by a physician.

TBI and Inhibition

Students with TBI may have difficultly judging social cues, and their perception of social interactions may be altered.

Examples include: • Being too personal with people they don’t know well • Saying hurtful or insensitive things • Perceiving setbacks as personal insults

Provide clear expectations for desirable behavior before the lesson. If a student is making inappropriate comments or misperceiving a situation, address their behavior without “calling them out”. Keep calm and don’t overreact as this may further escalate inappropriate behaviors.

Although commonly a rule of thumb for any participant, remember to encourage good diet and non-alcoholic fluid consumption.

Post Traumatic Stress

Post Traumatic Stress Disorder (PTSD) occurs in those who have been exposed to traumatic experiences, often during their military service. It affects a part of the brain involved with learning and memory.

Behavioral signs may include: • Outbursts • Anxiety • Aggression • Poor concentration • Poor short term memory • Flashbacks/Night terrors • Substance abuse • Hypervigilance • Problems with crowds or other public settings • Problems with sudden, loud noises

As an instructor, try to anticipate reactions to certain situations.

Ask about potential triggers (either in registration form or at the beginning of lesson) and communicate any potential issues. (i.e. let student know about blast canons on mountains.)

If a participant ever causes you to feel they, or others, are at risk, contact a caregiver or:

Veteran Crisis Line - 1.800.273.TALK (8255) - press 1  (text 838255)

Equipment Set-Up

• Sets the tone for the day so choose the environment well • Make intentions and schedule known • Let them know plans may change • If plans do change, make them aware as soon as you are able • Make eye contact with participant and ask permission before physically assisting with equipment fittings and set-up

Communication

• Allow extra time to respond if needed • Don’t get technical or use slang • Watch for nonverbal cues • Participants may say one thing but the body’s actions say something else • Check in frequently for comprehension, fatigue, enjoyment, etc. • Talk to therapists or care provider if concerned

FRONT COVER ATTACHES HERE

BACK COVER ATTACHES HERE

with Traumatic Brain Injury and Post Traumatic Stress Disorder

INSTRUCTING ATHLETES

More information and resources: brainline.org | avbi.org | ptsd.va.gov

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