By Annie Pixley

Traumatic brain injury is the leading cause of disability among children and youth.  Students returning to school with traumatic brain injuries may have an entire range of physical, cognitive, behavioral, social and emotional challenges.  Exposure to education can aid in the recovery of these functions. Much as schools promote learning, recovery is a re-learning process, so it is important for educators in the school system to provide support and services to students with brain injuries. 

Unfortunately, brain injury has dropped off our educators’ radar, and often goes unnoticed due to under-reporting and/or misidentification. However, more and more children, adolescents and young adults are surviving their injuries due to advances in medical technology. But students with brain injury who return to school  are often at a disadvantage because they require special accommodations, supports and services of which educators have little knowledge and training. Without these educational programs and services, students with brain injuries are at greater risk for lower academic performance, failing grades and dropping out of high school. If we are to meet the challenge of educating students with brain injuries, then we need to take some major steps toward changing our national educational system. 

Currently, there are 5.3 million Americans living with the effects of a long-term disability due to a brain injury, with 1.5 million sustaining a traumatic brain injury annually. Educators will admit to not knowing much about brain injury.  They believe that they have not had many, if any students in their classrooms who have sustained brain injuries. This, unfortunately, is a wide-spread misconception. The epidemic of TBI in our youth has posed many problems. Effectively educating these students can only occur if educators are given appropriate supports and transitional services. By not knowing how best to support the students, teachers are liable to inhibit the cognitive recovery of their students, compounding the challenges faced by them, and failing to prepare them for adulthood.

The SYSTEM needs to change

Right now, the mission is to increase teachers’ awareness of brain injury so that they can provide effective and appropriate educational supports and transitional services for the student brain injury community.  Access to this information will enable educators to provide students with improved opportunities for their futures – futures that encompass not only academic success, but also include the transition from high school into communities, businesses and higher-learning institutions. 

• Level 1 Change

use professional development to increase the level of competency among  

educators by providing a foundation of knowledge about brain injury

• Level 2 Change

expand educators’ skills to include identification and assessment of cognitive, 

physical and psychosocial challenges

• Level 3 Change

train educators in the learning differences of students with brain injury 

compared to other disabilities

• Level 4 Change

learn instructional strategies

• Level 5 Change

increase educators’ competency regarding awareness of how students’ learning

environments and social interactions can change after brain injury

Achieving any systematic change requires increasing the competency level of not only teachers, but also parents, administrators, professionals and the students themselves.

References

Almli, C. & Finger S. (1992). Brain injury and recovery of function: Theories and mechanisms of functional reorganization. Journal of Head Trauma Rehabilitation, 7(2), 70-77.

American Council on Education (1989). Head Injury Survivor On Campus: Issues and Resources. HEATH Resource Center (pp.1-11). Washington, DC.

Brain Injury Association of America (2001). [Media Resource Kit].

Finger, S. (1999). Margaret Kennard on Sparing and Recovery of Function: A Tribute on The 100th anniversary of Her Birth. Journal of the History of Neurosciences, 8(3), 269-285.

Gray, D.S., (2002). Mechanisms of Brain Injury, Markers of Severity, Classification, Sequelae of Injury and Recovery from Injury. BIRPP. Retrieved October 20, 2002 from Internet.

Johnson DA, Ruston S. & Shaw J. (1996). Virtual reality enriched environments, physical
exercise and neuropsychological rehabilitation. Proc 1st Euro. Conf. Disability. Retrieved October 19, 2002 from Internet.

Perna, R. (2002). Brain Injury: Does Age Really Matter? Brain Injury Source 6(2), 32-34.

Savage, R.C. & Wolcott, G.F. (Eds.) (1994). Educational Dimensions of Acquired Brain Injury. Austin, TX: PRO-ED, Inc.

Wehman, P. (1996). Applications for youth with traumatic brain injury. Life beyond the classroom: Transition strategies for young people with disabilities (pp. 445-478). Baltimore: Paul H. Brookes Publishing Co.

Recommended Reading

These and other books on brain injury symptoms, treatment and recovery are available from Lash and Associates Publishing/Training Inc.

Students with Brain Injury  

By Katherine Kimes, Ed.D., Marilyn Lash, M.S.W. and Ron Savage, Ed.D. 

This TBI manual for educators and parents provides a foundation for understanding the educational needs and behavioral challenges of children with traumatic brain injuries. 

Signs and Strategies for Educating Students with Brain Injuries  

By Marilyn Lash, M.S.W., Gary Wolcott, M.Ed. and Sue Pearson, M.A.

Manual describes the consequences of brain injuries on a student’s learning, behavior, communication, cognition and adjustment in school and at home.

By Carolyn Rocchio

Puberty is the initiation of many hormonal and physical changes in the body – all of which frame a teenager’s identity, sense of self, independence and world view (Barton & Tepper).

The transition from childhood to adolescence is fraught with many physical and emotional changes. It can be a difficult time for the child and parents alike. Most families experience a period of major adjustment to the child’s changing mannerisms, quest for privacy and greater independence. When a child experiences a brain injury, either at a younger age or during this period of transition, it commonly creates many more problems than a child arriving at this age without a brain injury.

What does research tells us about adolescents and brain injury?

Research has been limited but a few studies have indicated that these youngsters:

•  have more than average difficulties in how they view themselves

•  often experience depression

•  function better when gender identity was well established before the injury.

•  will have difficulty with social behavior, such as, inappropriate touching, sexual aggression, and exhibitionism.

Rehabilitation professionals need to be knowledgeable about sexual development when treating these youngsters.  Sexual development includes physiological development, psychological development, social development and development of sexual knowledge (Barton & Tepper). Puberty is a time when adolescents can be highly emotional as they try to figure out issues relative to their development of self-esteem.  Changes in communication skills after a brain injury can make it even more difficult for adolescents to develop socially, understand relationships, identify gender roles, comprehend sex education, use contraception, and take responsibility for their actions.

Just as adults may experience hyposexuality and hypersexuality, so too do adolescents. When adolescents seem to have little or no interest or curiosity about sexuality, as most youngsters normally do at an age when hormones begin raging, they may be experiencing hyposexuality. The opposite effect of hypersexuality can become a very difficult behavior management issue. These adolescents often make crude remarks indiscriminately, masturbate or exhibit their genitals in public, tell off color jokes and display socially unacceptable behavior.

Congenital vs. Acquired Brain Injury

Adolescents normally experience a myriad of changes during adolescence.  Transitioning through this phase can be very emotional and puzzling at times as their bodies change along with their self perception. An injury at birth prepares a child very differently for the adolescent experience. Congenitally injured youngsters are often subjected to many tests and evaluations as they pass through their developmental years.  They may view their bodies as objects of evaluations. “Human touch has objectified the child’s body and it is not uncommon for children born with brain injuries to be unable to distinguish {good touch} from {bad touch.” (Barton and Tepper). They may experience a blurring of the line between what is right and what is wrong.

When the brain injury occurs after birth, yet during the developmental years, the adolescent period will still have the usual changes. However, the issues may be somewhat different depending on the level of learning, life experience and cognitive preservation. All adolescents experience some degree of cognitive change as a normal consequence of hormonal changes, such as:

•  poor problem solving and judgment

•  impaired reasoning skills 

•  memory and attention difficulties

•  mood swings

•  disinhibited thought and actions, an inability to judge what is private and what may be appropriate in public settings

•  inability to read social cues from others and poor ability to manage relationships

These common problems may be magnified as a result of brain injury, making management very difficult for parents as well as extended family, teachers and peers whom, for lack of understanding, often choose to distance themselves from the adolescent.

Promoting Healthy Sexual Attitudes

Sex education is vital for developing wholesome attitudes about sex. All instruction should be clear and structured and leave the adolescent knowledgeable about body parts, sexual acts, safe sex and awareness that sexual health is not just intercourse. The goal is to help adolescents with brain injuries understand that although they may have some residual cognitive and physical deficits, they are still sexual beings. They must feel free to communicate with family, providers and others appropriately and comfortably about sexual issues and have opportunities to meet with and form relationships with others as appropriate. Families must be vigilant about monitoring abuse in all settings particularly when others besides the family are providing care. All adolescents with brain injury need help in realizing their dream to be like their peers.

References:

Barton, B, Tepper, M. Adolescence, Brain Injury, and Sexuality: Promoting Sexual Health. Brain Injury/Professional. 7(1) 18-20, 2010.

Recommended reading:

This Fact Sheet is based on an article: Adolescence, Brain Injury, and Sexuality: Promoting Sexual Health. Brain Injury/Professional. 7(1) 18-20, 2010. Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Brain Injury Professional is published jointly by NABIS and HDI Publishers. Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to order the entire issue or become a member.

Books on brain injury symptoms, treatment and recovery are available from Lash and Associates Training/Publishing, Inc.

Tool Kit for Life Care Planners and Case Managers on Teens with Brain Injury

This Tool Kit provides families with…

• Information on cognitive and behavioral issues for teenagers with brain injury.
• Strategies to help adolescents with social skills and peer relationships
• Planning for transitions within school and after high school

By Carolyn Rocchio

Treatment for cognitive functioning after brain injury

Cognitive rehabilitation is a “systemically applied set of medical and therapeutic services designed to improve cognitive functioning and participating in activities that may be affected by one or more cognitive domains” (Katz, Ashley, et al, 2006).

There is no longer any doubt about the effectiveness of cognitive and behavioral rehabilitation   following brain injury. However, insurance companies too frequently move patients with brain injury out of the medical model more rapidly for cost savings.  Children and youth comprise a very low percentage of those who receive any meaningful extended rehabilitation of functional impairments.  Most children and youth are discharged home to the care of parents and school systems.

Children are not “little” adults…their brains are still developing

During the developmental years, the child’s brain is not yet fully formed.  Nor is it as sophisticated as the brain of an adult.  In these developmental years which extend through the late teens and early twenties, children are expected to reach a number of milestones as they grow and mature.  A brain injury interrupts the normal developmental process.  This can subsequently have an impact on the child’s academic achievement and ability to socially interact with family and peers.  In most cases, the burden and responsibility of follow up care and remediation of the child’s deficits fall to parents and educators.

Parents are usually neither educated nor prepared to recognize and assess how the injury has affected their child’s learning capabilities and interactions within the family.  Yet parents ultimately become the case managers for their child’s follow-up services at school and in the community.  Educational systems vary significantly nationwide; however, all must comply with the Individuals with Disabilities Education Act which is the foundation for special education in all states. 

The student with a brain injury will have changing educational needs as the latent effects of the trauma to the brain emerge over time.   So it is important for educational programs for these students to include check points and flexibility to address the student’s emerging and developing special needs after an acquired brain injury.  Parents and educators can be most effective when they work as partners on behalf of the child and student. 

Cognitive rehabilitation for children requires special considerations

The following key factors must be considered when designing and providing cognitive rehabilitation for children and youth:

• Effects of the injury may be delayed; the younger the child when injured, the more likely that expected developmental milestones may be delayed or unattained.
• Youngsters with brain injuries need different approaches to learning to compensate for cognitive deficits in school.
• Increased guidance and cognitive models of rehabilitation can provide necessary checkpoints and flexibility to support optimal maturation when brain injury negatively impacts the child’s interactions with family and peers.
• Dual roles of parenting and case management increase stress for parents.  They require educational resources, information and support to successfully assist with the child’s transition from the medical and rehabilitation arena to the school system and community.

Transition from hospital to school after brain injury is critical

Ideally, day cognitive rehabilitation programs resembling school-like environments can provide children with individually designed approaches to academic achievement with feedback from therapists experienced in brain injury rehabilitation.  These programs facilitate the child’s transition from medical to school systems and the community.  This transition is critical as schools focus on learning and achievement, not on remediation of cognitive deficits.  A few hospital to school transition programs for children with acquired brain injuries exist within some large urban pediatric medical centers; however, overall their availability ranges from scarce to non-existent in local communities.  

Cognitive rehabilitation for children requires partnerships with parents and monitoring the brain injury’s effects on the child’s development and academic achievements.  The future holds the promise of greater interventions to enhance the progress of children with brain injuries. Research that is more focused on longitudinal studies can provide the information that will ultimately lead to the development of more comprehensive models of care for children with acquired brain injuries.

References

Katz, DI, Ashley, MJ, O’Shanick, GJ & Connors, S. Cognitive Rehabilitation: The evidence for funding and case for advocacy in brain injury. Retrieved January 16, 2009 from Brain Injury Association of America website at www.biausa.org/policyissues.htm.

Haarbauer-Krupa, J (2009).  Cognitive Rehabilitation for Children and Youth: Moving toward collaborative partnerships. Brain Injury/Professional 6(2) 20-22.

Recommended reading

This Fact Sheet is based on a special issue of Cognitive Rehabilitation: Efficacy and Best Practice of the Brain Injury/professional (vol. 6, issue 2) 2009.

Brain Injury/professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Brain Injury/professional is published jointly by NABIS and HDI Publishers.  Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to join.

Students and Brain Injury Recovery

By Marilyn Lash, M.S.W.

Lash and Associates Publishing/Training Inc.

The child’s brain is injured

An injury to a child can be an emotionally devastating event for families. Whether it is caused by a car crash, fall, sports injury or biking collision, many parents feel that have failed to protect their child from harm.

“Traumatic brain injury in childhood is the most prevalent cause of death and long term disability in children and affects all socioeconomic levels” (Bond Chapman, 2006).

How do children recover?

The recovery process for children with a brain injury is complex because the child’s brain is still developing. A new view of brain injury recovery in children describes two phases.

Immediate recovery phase

This is the time from the injury up to about one year. During this phase, the child may receive emergency medical treatment as well as intensive hospital care and rehabilitation with dramatic improvements in cognitive, motor and social skills. Because of this rapid change, families often bring their child home with the expectation of a full or almost complete recovery (Bond Chapman, 2006).

Latent recovery phase

This the period from one year after the injury to years later, even up to young adulthood. The full impact of an injury to a developing brain becomes apparent during this later phase (Bond Chapman, 2006).

Definition of neurocognitive stall

Dr. Chapman proposes that children with severe brain injuries are at risk for displaying a neurocognitive stall during the latent phase of recovery. She defines is as “…a halting or slowing in later stages of cognitive, social and motor development beyond a year after brain injury. Despite remarkable recovery during the first year after severe brain injury, children may appear to ‘hit a wall’ or ‘fail to thrive’ in terms of their continued cognitive growth. It is not so much that they lose already acquired skills as it is a failure or lag in development of later emerging cognitive milestones.” (Bond Chapman, 2006).

Children with severe brain injury are at greatest risk for a neurocognitive stall. With the lapse of time, they appear to grow into rather than out of their deficits. This often becomes evident during adolescence when the frontal lobes have rapid rates of growth and development from age 13 up to age 25 (Bond Chapman, 2006).

School work becomes more complex and so do social pressures with adolescence. These youth may have new difficulties keeping up with classmates and peers as they struggle to reach more complex cognitive levels in the classroom and with homework. The latent effects of earlier damage to the child’s brain emerge with time. Unfortunately, the link between an earlier injury to the child’s brain and emerging cognitive problems in school is often missed. When families and educators do not recognize the latent effect of a childhood brain injury, their behaviors are misidentified as symptoms of learning disability, ADHD or emotional disorders (Glang & Lash, 2004).

What does this mean for schools?

While there have been many advances and promising research in the acute care and rehabilitation of children with brain injuries, there has not been comparable progress in psychosocial and educational research on children. This population is underidentified and underserved in local schools.

“The challenge of addressing the latent developmental effects of childhood brain injuries is compounded by the fact that families often must assume the primary care giving role and schools often become the sole providers of rehabilitation services. Neither families nor educators have been systematically prepared or trained for this role, despite the inclusion of traumatic brain injury as a category under the Individuals with Disabilities Education Act in 1991″ (Glang & Lash, 2004).

So what can be done?

By taking a holistic approach, families and educators can be better prepared and develop the required skills to support and educate children with brain injury

Develop innovative approaches to family training

Families need information to build a knowledge base about their child’s brain injury. They also need home based training on strategies for managing their child’s cognitive, behavioral and physical challenges. Training must also include advocacy skills for negotiating services at school. It also requires preparing parents to manage services over the course of their child’s development and education. It is important to recognize the emotional trauma of parents and to help them develop coping skills, find support for grieving, and reduce caregiver stress (Glang & Lash, 2004).

Look at instructional strategies used with other student populations

Little research has been done on the effectiveness of educational strategies for students with traumatic brain injury. Yet there is a large body of research on effective instructional and behavioral strategies for students with other disabilities but similar functional challenges such as problems with attention, memory, impulse control, etc. This knowledge must be examined to determine how it can be applied and modified, if necessary, for students with brain injury. This approach builds on the strengths and skills of educators (Glang & Lash, 2004).

Build capacity of educational systems

Ongoing training and brain injury consulting teams are effective models for increasing the identification of students with brain injury and for providing educators with new strategies and skills (Glang & Lash, 2004).

Support parents as educational advocates

A child’s return to school after a brain injury introduces parents to an unfamiliar and confusing educational system involving special education and 504 plans. Training programs for parents of children with special needs have demonstrated that families can become effective advocates support, training and guidance. Parents of children with brain injury need comparable programs as well as mentors through other families (Glang & Lash, 2004).

References

Bond Chapman, S. (2006). Neurocognitive Stall: A paradox in long term recovery from pediatric brain injury. Brain Injury/professional 3(4), 10-13.

Glang, A & Lash, M. (2006). A Holistic Approach for Improving Educational Outcomes of Students with TBI: Promising practices and new directions for research. Brain Injury/professional 3(4), 16-18.

Recommended reading

This Fact Sheet is based on a special issue of Pediatrics and TBI of the Brain Injury/Professional (vol. 3, issue 4) 2006.

Brain Injury/Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society (NABIS). Brain Injury Professional is published jointly by NABIS and HDI Publishers.  Members of NABIS receive a subscription as a benefit of NABIS. Visit www.nabis.org to become a member.

Lash and Associates Publishing/Training, Inc. has a full line of manuals on educating students with brain injury in school.