Traumatic Brain Injury

A traumatic brain injury (TBI) involves a disruption of normal brain function as a result of exposure to an external physical force. The trauma may involve a direct impact from an object striking the head or the head striking an object. TBIs may have mild to profound effects on physical, psychological, emotional, and/or social functioning.

1. Qualified Professional
   • Professionals conducting assessments, rendering diagnoses, and making recommendations for appropriate accommodations for individuals with traumatic brain injury (TBI) must be qualified to do so.
   • The name, title, and professional credentials of the evaluator, including information about license or certification (e.g., licensed psychologist) as well as the area of specialization.
   • The following professionals would generally be considered qualified to conduct evaluations provided that they have additional training and experience in evaluating traumatic brain injury: clinical psychologists; neuropsychologists; neurologists; occupational therapists, speech and language pathologists, and medical doctors with demonstrated training and experience in the assessment of traumatic brain injury.
2. Currency of Documentation
   • It is critical that the documentation submitted for review should be recent and accurately reflect the individual’s current functional status. Recovery from TBI is an evolving, dynamic process, with wide variability in its timing and completeness across individuals. Also, it is possible for secondary complications such as seizures or mood dysfunction to arise well after the initial event.
3. Documentation Criteria
   • Because TBI is a complex condition, documentation may need to be gathered from a variety of professionals including medical, psychological, academic, and/ or vocational professionals.
   • A diagnostic report should include: specific diagnosis or diagnoses, description of current as well as residual symptoms (frequency, intensity, and duration), medical information, medications and side effects, and current treatment.
   • In most cases, a neuropsychological or psychoeducational evaluation will be useful in clarifying the functional impact of the diagnosed disability and in supporting the underlying rationale for accommodations in an academic setting.
   • If the brain injury primarily affects sensory and/or motor functioning, a neuropsychological or psychoeducational evaluation may not be necessary. In these cases, documentation from a professional such as a neurologist, optometrist, or occupational therapist may be sufficient.
   • A diagnostic interview should provide the following information: history of presenting symptoms, severity of symptoms and evidence of current impairment, co-existing conditions, and relevant medical history.