Speech-language pathologists (SLPs) provide rehabilitative services to patients who have sustained a traumatic brain injury (TBI). The main focus of this rehabilitation is cognitive-communication therapy.

Recovery is a slow process, especially with severe traumatic brain injuries (TBI). Television programs and movies that show people waking up from a coma quickly and behaving normally are not generally realistic.

Research has shown that people demonstrate a predictable pattern of behaviors and abilities when awakening or recovering from TBI. These stages are described by the Rancho Los Amigo Scale or Rancho Levels of Cognitive Functioning.

This scale is used by the medical team to identify, document, and communicate patient progress. By understanding these levels, you will also have a better understanding of what your child with TBI is going through and what to expect.

This scale is a guide and although the pattern is the same, patients can vary in howlong they spend in each stage or whether they skip stages entirely. No one can say how long a person will be in each stage, but therapists and participation in rehabilitation can help patients move to the next stage.

The Rancho Scale can usually be applied to children seven years of age or older, although it has been used with children as young as four years old. The following are descriptions of eight stages and suggestions for things family can do or expect at each stage.

Select a link below to learn how patients react at a certain level of cognition and how friends and family can help support the patient at each stage of recovery.

• Level I: Does not respond
• Level II: Responds in general ways
• Level III: Responds to what you do
• Level IV: Acts confused and agitated
• Level V: Is confused and hard to manage, but not upset
• Level VI: Is confused and much less upset
• Level VII: Can do day-to-day tasks
• Level VIII: Can choose what to do, and do it

Level I: Does Not Respond

Child's Behaviors

• Your child may seem to be in a deep sleep. This is called a coma.

Suggested Behavior for Family and Friends

• Touch and talk to your child because your child may hear you.
• Assume your child is hearing what you are saying even if they are not responding to it.

Level II: Responds in General Ways

Child's Behaviors

• Your child is responding more, but can still be variable.
• He may move his arm when you attempt to move him.

Suggested Behavior for Family and Friends

• Follow Level I suggestions.
• Tell your child what day it is and where she is.
• Communicate what you will do before you do it (for example, “I am going to brush your hair”).

Level III: Responds to What You Do

Child's Behaviors

• Your child’s reactions and responses are likely to be directly related to a stimulus (for example, your daughter may move her foot when you tickle it).
• He or she may turn towards a sound or look at something moving.
• Your child may try to move away from painful things.
• Your child may try to talk.
• He or she will not remember daily events.

Suggested Behaviors for Family and Friends

• Tell your child he or she is safe and taken care of.
• Touch and talk to your child.
• Call your child by name, and tell your child who is in the room with him or her.
• Show your child family photos or bring a favorite toy or animal.
• Say things one at a time and allow time for a response.
• Don’t test your child too much.
• Tell your child what day it is and where they are.

Level IV: Is Confused and Agitated

Child's Behaviors

• Your child may be confused and agitated. He or she may behave in a strange or violent manner.
• He or she may say things you don’t expect or are untrue.
• Your child will still not remember daily events.

Suggested Behaviors for Family and Friends

• Be calm and soothing.
• Use simple words and sentences.
• Give directions one step at a time.
• Expect that your child will forget things. Continue to remind him where he is, what day it is, and that he is safe.
• Correct your child gently, but do not argue.
• Hold or rock your child, play soft music, or read a book.
• Limit noise and the number of people in the room, especially when your child is upset.

Level V: Is Confused and Hard to Manage, but Not Upset

Child's Behaviors

• Your child is beginning to calm down and doesn't get angry so quickly.
• He or she is still disoriented and may not remember the day, month, or year.
• Your child will be able to pay attention for short intervals, but will be easily distracted by his or her environment.
• Your child may get upset when things are hard to do, especially when trying new tasks.

Suggested Behaviors for Family and Friends

• Continue using short and simple sentences.
• Keep tasks simple.
• Encourage your child, praise her often.
• Don’t believe everything your child says.
• When your child gets upset, change the subject and let him rest.
• If your child keeps talking about the same thing, redirect to another topic.
• Some things your child says may not make sense or be true. Your child is not lying.  Redirect to another conversation.

Level VI: Is Confused and Much Less Upset

Child's Behaviors

• Your child is becoming more oriented to time and place.
• He or she will begin to remember daily events, or big things, but not the details.
• Attention is improving, and your child may be able to participate in an activity for as long as 30 minutes.
• Your child will still need help with new tasks or sequencing events.
• He may be aware that he has difficulties with remembering or doing things.

Suggested Behaviors for Family and Friends

• Be clear, and speak to your child normally.
• Use caution with joking -- your child may still not understand your meaning.
• Be direct.
• Ask your child to tell you what she did earlier in the day.
• Set up a schedule and provide a routine for your child.
• Use a chart or book to list things your child needs to do or has done throughout the day.

Level VII: Can Do Day-to-Day Tasks

Child's Behavior

• Your child can do day-to-day tasks but may not initiate activities on his or her own.
• She will be able to have a conversation, but may wait until someone else speaks first.
• Your child will perform better with familiar tasks, and can still get confused with new learning.
• You will see more frustration, confusion, or difficulty in new settings or with advanced tasks.

Suggested Behaviors for Family and Friends

• Have your child practice telling you about her day, with as much detail as possible.
• Identify what your child is able to do safely and independently, versus what tasks your child needs supervision to complete.
• Continue to be careful with joking -- your child may still not understand your meaning.
• Be direct.

Level VIII: Can Choose What to Do, and Do It

Child's Behaviors

• Your child is able to think better, pay attention, and remember tasks.
• Problem solving and decision making may be difficult.
• Your child will need more supervision than he or she did prior to the injury.
• He or she may be impulsive; moods may change rapidly.
• Your child may only be able to attend to one activity at a time and for short periods of time.

Suggested Behaviors for Family and Friends

• Help your child recognize what he can do safely and what he needs help with.
• Use lists or notes to help your child remember things.
• Teach your child what to do when she becomes angry or frustrated.