By Marilyn Lash, M.S.W.

How does the child’s brain recover after a brain injury?

 “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).  The recovery process for children is more complex than for adults because the child’s brain is still developing. Certainly, the severity of the injury to the brain affects outcome, but other factors are also critical including the child’s age when injured and secondary brain damage due to brain swelling. The delivery of emergency medical services directly impacts survival rates as does the provision of expert trauma care.

For a long time, it was believed that children were more resilient than adults after a traumatic brain injury (TBI). It is now understood that the rapid physical recovery often seen in children with TBI can be misleading. As the child emerges from coma and progresses with physical, occupational and speech/language therapies, parents often speak of a “miraculous” recovery.  Because of this rapid initial progress, families often bring their child home with the expectation that progress will continue until the child reaches a full or almost complete recovery

The cognitive recovery process for children continues over many years as the child’s brain develops and matures. The effects of an earlier injury to any part of the brain may not become fully evident until that area develops and is challenged in the classroom. Changes in learning, executive skills and behavior are among the most common long-term effects of brain injuries among children. For the children with a brain injury, time “reveals” rather than “heals” all wounds.

What is the time line for brain injury recovery?

Recent research in the neuroscience and neurorecovery of children with traumatic brain injuries identifies two phases of immediate and latent recovery. The immediate phase is the period from the time of injury up to approximately one year. This is the period where the child may receive emergency medical treatment followed by intensive hospital care and/or rehabilitation services. The latent recovery phase is the period from one year after the injury to years later, even up to young adulthood. It is during this later phase that the full impact of an injury to a child’s developing brain becomes apparent.  (Bond Chapman, 2006).

Dr. Sandra Chapman uses the term neurocognitive stall to describe “…a halting or slowing in later stages of cognitive, social and motor development beyond a year after brain injury. Despite a remarkable recovery during the first year after a severe brain injury, the child may appear to ‘hit a wall’ or ‘fail to thrive’ in terms of continued cognitive growth. It is not so much that the child loses 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.

How do children receive rehabilitation services?

Access to inpatient pediatric rehabilitation care is far more limited for children than for adults. The number of accredited pediatric brain injury rehabilitation programs available is simply far less than for adults. The more rapid physical recovery often seen in children during the initial stages of hospital care also makes it more difficult to obtain insurance approval for transfer to inpatient rehabilitation. The lighter size and weight of children also makes it possible for parents to care for children at home even when there are significant physical demands for caregiving.

Data from the National Pediatric Trauma Registry found that for those children discharged home from a trauma center, referrals for physical therapy, occupational therapy and speech/language therapy were common. However, less than 2% of children and adolescents diagnosed with head trauma were referred to special education services. Despite the fact that traumatic brain injury was added as a specific category to the Individuals with Disabilities Education Act in 1990, trauma discharge teams are underutilizing the education referral process (DiScala and Savage, 2003).

When you combine the limited transition planning and referral patterns between medical and educational systems with the emergence of latent cognitive challenges, it creates a tremendous challenge for school systems as they become the critical arena for learning and cognitive rehabilitation for these children. 

Why are these children underidentified for special education?

It has been a frustrating contradiction for many clinicians, families and advocates that despite the fact that traumatic brain injury is the leading cause of disability among children, they are considered a low incidence population by the US Department of Education. This is reflected in low number of students receiving special education services under the classification of traumatic brain injury in every state. 

Unfortunately, the link between an earlier injury to the child’s brain and emerging cognitive problems in school is often missed. Many factors contribute to this including…

• Poor transition planning between medical and educational systems
• Limited training and experience of educators with this population
• Inadequate screening and history taking to identify previous TBI
• Latent effects of brain trauma mistakenly attributed to emotional or behavioral disorders
• Misidentification of cognitive changes as attention disorders or learning disabilities

What does this mean for therapists and 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 caregiving role and schools often become the sole providers of rehabilitation services. Neither families nor educators have been systematically prepared or trained for this role” (Glang & Lash, 2006). Therapists can have a pivotal role is helping educators and school staff recognize this neurocognitive stall after a brain injury. Therapists are more than clinical resources for the child.  They can also serve as effective advocates and educators for families and school staff about the neurorecovery process.

What strategies can therapists use to help students with brain injuries?

There is no one TBI curriculum or set of strategies for students with brain injuries. Unlike the educational field where best practices have been developed based on extensive research on students with autism and learning disabilities, research on effective methods for educating and supporting students with brain injuries is still in the infant stages of development.

What is known, however, is that each brain injury is unique and so each educational program must be individualized to address the learning and social challenges presented after the TBI. Students can have difficulty with processes of attention, memory, planning, organization, pragmatic language and social interactions. Many of these skills are interdependent. Therapists and teachers must work as a team to address these issues in the functional daily activities of the classroom. Some ideas for support in the classroom include:

Strategies for helping attention and concentration:

• Reduce distractions in student’s work area
• Divide work into smaller sections
• Ask student to orally summarize information just presented
• Use cue words to alert student to pay attention
• Establish nonverbal curing system to remind student to pay attention

Strategies to help with organization:

• Provide additional time for review
• Give written checklist of steps for each task
• Assign person to review schedule at start of school day
• Practice sequencing material

Many therapists and teachers will recognize these strategies as techniques they already use with other students. They are not unique to students with brain injury. No one teaching program will apply to all students with brain injuries. By remediation, adapting instruction or modifying the environment, therapists and educators can help the student be more successful in the classroom (Tyler, Blosser & DePompei, 2008).

Why is behavior so difficult for many children with brain injuries?

Damage to the frontal and temporal lobes of the brain can directly affect the child’s behavior.  The most common source of concern by parents and difficulty for educators is changes in behavior including temper outbursts, hitting, swearing, impulsivity and agitation. Therapists can help parents and educators recognize the connection between the brain injury and the behavior that is disrupting the classroom and alienating peers. Traditional approaches to “behavior management” by using consequential strategies such as discipline, time-out or punishment are often ineffective for children with brain injuries. This is because the child may not remember the rules, doesn’t see the consequence as a punishment, does not learn adaptive skills, and can not learn from consequences if this ability has been affected by the injury.

 An alternative approach of antecedent management is much more effective for a child with a brain injury because…

• It looks ahead and is proactive
• Helps the child learn adaptive skills
• Replaces disruptive behaviors with positive tones
• Gives control to the child
• Produces long term change

Any behavior plan requires identifying the changes in behavior, defining the behavior, assessing the behavior, and evaluating the behavior. Some general tips for therapists on working with students with behavioral challenges after brain injury are:

• Set up and reinforce structure and consistency
• Show what comes next (prediction) to decrease anxiety
• Follow through on previously established contracts
• Decide on a set prompting sequence
• Don’t tray to reason if the student is agitated
• Use positive praise; avoid criticism
• Get help early before behaviors escalate

How is communication affected by a brain injury?

Referral to and involvement of a speech and language pathologist is too often overlooked after the child leaves the medical or rehabilitation setting. Many families and educators falsely assume that communication has not been affected by the brain injury once language skills have returned and the child is talking, reading and writing. However, the child’s ability to use language along with the underlying skills of attention, memory, self-awareness, organization, problem solving and reasoning is much more complex. Changes in cognitive communication are most likely to show up at school under pressures of time, being graded, completing assignments, and keeping up with classmates. Therapists can be important resources for assessing and treating changes in the student’s:

• Receptive and expressive skills
• Disorganized speaking or writing
• Concentration and attention
• Confusion with new ideas
• Slower rate of handling information
• Learning of new vocabulary

Tests used in schools to identify language problems are often misleading because children with brain injuries may do better in the quiet testing room than the classroom. When routine communication appears to be intact, subtle changes in cognitive communication are often overlooked. That is why it is important to track a child’s language and communication skills every 3 months for the first 2 years after the brain injury, and then annually. This helps identify changes over time as the child’s brain develops and matures and provides important information for the child’s doctor, teachers, and therapists.

Conclusion

Advances in trauma care have directly contributed to the higher survival rates of children with traumatic brain injury. However, more attention and resources need to be directed toward school systems and community programs to address the long-term challenges for neurorecovery. 

References

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

DePompei, R. & Blosser, J. (1996).  Communication: How communication changes over time. Wake Forest, NC: Lash and Associates Publishing/Training, Inc.

DiScala, C & Savage, R. (2003). Epidemiology of Children with TBI Requiring Hospitalization. Brain Injury Source, 8-13.

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.

Marchese, N., Potoczny-Gray, A., Savage, R. (2008) Behavior after Brain Injury: Changes and challenges. Wake Forest, NC: Lash and Associates Publishing/Training, Inc.

Tyler, J,  Blosser, J. & DePompei, R. (2008). Teaching Strategies for Students with Brain Injuries.  Wake Forest, NC: Lash and Associates Publishing/Training, Inc.

Brain Development in Children and Adolescents: What happens after brain injury?

By Ron Savage, Ed.D.

This booklet helps parents and educators understand how the child’s brain develops and why an acquired brain injury can have both immediate and long-term consequences. It shows how a traumatic injury can disrupt the brain’s development and why changes may show up as the child grows up. By understanding how various regions of the brain develop, families and educators will recognize the relationship between and injury and changes in the child’s physical, cognitive, social, behavioral, and communicative skills.

Students with Brain Injury: Challenges for Identification, Learning and Behavior in the Classroom

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.

Communication in Children after Brain Injury

 By Roberta DePompei, Ph.D.

Lash & Associates Publishing/Training, Inc

I often hear the term cognitive communication. What does that really mean?

Communication is much more than words. It involves listening, speaking, and reading, writing and gesturing. Cognitive communication is the combination of thinking skills and language. It is the ability to use language and all the underlying skills for communication.  This includes attention, memory, self-awareness, organization, problem solving and reasoning. When these thinking skills are combined with language, the result is communication.

Our son was doing pretty well in school until he went to junior high school. Now he has a lot more reading assignments and homework. Even though he spends much more time on his homework, he can’t seem to keep up and is falling behind.

As students enter middle, junior high and high school, school work becomes more complex. The student with a brain injury may face new difficulties with reading, writing and thinking. Much of school work now requires abstract reasoning and problem solving. This places new demands on different parts of the brain than were used in earlier grades. Multiple classes and teachers mean different teaching styles and homework assignments.

Any difficulty with these changes is an indication that a student’s cognitive communication abilities need to be reevaluated.

Our son’s speech was really slow and difficult to understand for several months after his brain injury. As he made physical progress, his speech also improved. Is there any reason to have him followed by a speech pathologist now he is back in school?

The ability to speak and hold conversations can be misleading. Language skills often return after a brain injury, but communication can still be affected. While conversation may seem normal in non-stressful situations, this can change when the child or adolescent is tired or under stress.

Changes in communication in youths are mostly likely to show up in school under the pressures of time, being graded, completing assignments and keeping up with classmates. A speech and language pathologist can evaluate ongoing progress, identify problems and help the student develop compensatory strategies. As part of the educational team, the speech pathologist can help others recognize and respond to changes in cognitive communication.

What are some of the changes or warning signs that parents and educators can watch for?

Too often, parents and teachers aren’t concerned until the student is failing or has lowered grades. It is important not to wait until the student is in trouble to get help. Early warning signs that an evaluation by a speech and language pathologist is needed are:

• speaking or writing that is disorganized
• difficulty concentrating and paying attentionconfusion when new ideas are introduced
• confusion when new ideas are introduced
• slower rate of handling information, and
• difficulty learning new vocabulary or grasping ideas.

By evaluating these areas every three months during the two years following a brain injury, difficulties can be spotted early and help provided before the student fails.

How do we find a speech and language pathologist who has experience with students with brain injury?

Speech and language pathologists may be licensed in their state and may also be certified by the American Speech-Language-Hearing Association. When choosing any professional, it is important to ask questions to make the right fit between a specialist, your child and your family. Look for a speech and language pathologist who has experience with brain injury and who has worked with children of similar age. If your child is in school, look for a speech and language pathologist who regularly works with schools and is familiar with special education.

For more information by Dr. DePompei, see:

Communication: How communication changes over time 

By Roberta DePompei Ph.D. and Jean Blosser Ed.D.

Brain injury can affect a child’s speech, language and communication. Tip card gives information for parents, educators and therapists to identify changes in language development and learning in school.

All About Me!

By Roberta DePompei Ph.D. and Bob Cluett

Interactive booklet helps elementary school age children identify the physical, cognitive, and behavioral effects of traumatic brain injury and describes help needed in school.

Learning and Cognitive Communication Challenges

By Roberta DePompei Ph.D. and Janet Tyler

Manual with teaching strategies for students with acquired brain injury and challenges with behavior, attention, cognition and language.

Athletes with Concussion or Mild Brain Injuries

By Phil Hossler

ATC Certified Athletic Trainer ATSNJ & NATA Halls of Fame

How common is concussion?

A mild brain injury, often called a concussion, is the most common brain injury in sports. Parents, teachers, school nurses and coaches see children and youth with concussions every day.  The Centers for Disease Control and Prevention estimate that there are over 300,000 concussions in the United States each year.

Is a concussion anything to worry about?

Although the majority of concussions have no lingering effects, some concussions result in persistent long-term and even devastating disabilities. Every concussion is a brain injury and injuries need evaluation, adaptations in routine and time to heal. This is especially true in adolescents whose brain tissue has increased vulnerability when compared to that of an adult (1). Phil Hossler and Ron Savage take a unique approach to concussion in schools by addressing everyone in the athlete’s “neighborhood” including teachers, the athlete, parents, friends, the school nurse, coach, physician, and certified athletic trainer.

What should teachers do when a student has a concussion?

Teachers are often the first to notice subtle changes in the student’s ability to concentrate, remember new information and interact with classmates after a concussion. Teachers can help by being aware of the student’s need for mental rest and by making accommodations in the classroom and for homework while the athlete is still feeling the effects of a concussion. Example: Tests taken while the student still has symptoms of a concussion may affect academic achievement levels.

What can the athlete do after a concussion?

The athlete usually is disappointed when faced with sitting out practice or games. The athlete may be incapable of thinking clearly after a concussion. It is important that the athlete not dismiss any changes and report any headaches, worsening vision or ringing in the ears. Example: Be honest with yourself. Your brain is too important to gamble with; when in doubt, sit out.

How can parents help their child recover from a concussion?

Parents know their child better than any other person in the neighborhood. They are best suited to pick up subtle changes in a child’s behavior, problem solving and organizational skills after a concussion. Example: Parents need to know and watch for the danger signs of a blood clot forming on the brain after a concussion.

How can friends help?

The athlete’s friends are a vital source of information. They are often there when the athlete’s guard is lowered and true feelings are expressed. A friend to an athlete with an undiagnosed concussion might be the first to suspect that “something just isn’t right.” Example: Peers may be annoyed by their friend’s behavior if they aren’t aware of the signs of a concussion.

How can the school nurse help the student and teachers understand the effects of a concussion?

School nurses play a very important role in monitoring the concussed athlete during recovery. They can notify teachers so that accommodations are made in the classroom. They can be the communication link between parents and school staff. Example: A student may report to the nurse’s office complaining of a headache.

What do coaches need to know about concussion?

 Every coach should know how to recognize the signs and symptoms of a concussion and be prepared to help the athlete deal with its effects. Coaches must not ignore signs and symptoms on the field. They must help the athlete still feel “part of the team” while recovering. Example: When I asked Tim why he missed those last two passes, he didn’t remember the plays.

Should the child’s physician be involved?

Doctors are the legal/medical guardians of the athlete’s health. They should be included in the athlete’s evaluation at an early stage of care and communicate with all parties involved to ensure the athlete’s safe return to activity. Example: Doctors should know the clinical guidelines for return-to-play decisions and use them.

What about the certified athletic trainer?

Athletic trainers who are certified by the National Athletic Trainers’ Association are gatekeepers of the athlete’s health during sports. They are first on the scene and make key decisions related to injury severity and referral. Seeing the athlete daily, speaking with parents, coaches, teachers and the school nurse ensure comprehensive care of the athlete with a concussion. Example: Always insist on safety first, participation second.

Conclusion

Health care professionals are learning more about the recognition and management of the physical demands and restrictions associated with concussions. However, close scrutiny, care and management do not always accompany athletes when they return to school. Academic accommodations may be needed as part of the overall management plan for student-athletes to ensure their health and to promote educational growth. Thus, an entire “neighborhood” program needs to be put into action so that all members are aware of their roles when a student athlete has a concussion. These roles are explained in the manual Getting A-Head of Concussion - Educating the student-athlete’s neighborhood by Phil Hossler and Ron Savage.

References:

(1) Collins MW, Iverson GL, Lovell MR, McKeag DB, Norwig J, Maroon J. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clinical Journal of Sport Medicine 2003:13:222-229

For more information, see:

Getting A-Head of Concussion

By Phil Hossler, ATC and Ron Savage, Ed.D.

Concussion is the most common type of brain injury among children and adolescents in school.  By describing the student-athlete’s neighborhood, this manual takes an innovative and comprehensive approach to educating parents, teachers, physicians, coaches, athletic trainers, school nurses, and peers about how the effects of mild brain injury.

How Has the Brain Injury Affected Your Child?

 By Marilyn Lash, M.S.W.

Lash & Associates Publishing/Training, Inc

What does the term assessment mean after a brain injury?

Assessment asks the fundamental question of all parents after their child is injured, “How has this brain injury affected my child?” While clinicians and therapists may conduct formal testing, examinations and consultations to answer this question, assessment is a skill that need not be limited to doctors, case managers, therapists or educators. Parents are also capable of “assessing” their child. Rather than thinking of this in the formal jargon of assessment, consider it as a description of your child’s history, strengths and challenges. No one will ever know a child better than parents – both before and after the injury.

How can I help others understand the effects of my child’s brain injury?

Rather than feeling like an outsider, parents can and should play a central role in any discussion about their child. They have unique experience and perspective. The ability to quickly and accurately describe their child is a skill that parents can use repeatedly whether they are meeting with the neurologist, speech and language pathologist, neuropsychologist or special education coordinator. Think of it as putting together a verbal snapshot of your child. Ask yourself, “What are the most important things for this person to know about my child?”

What information should I provide about my child’s brain injury?

It is easier to organize your information if you do this in three steps. The first step is figuring out what information is needed. This depends on who you are talking with but there are some fundamentals or basics that everyone needs to know including:

• Current age of child 
• Length of coma 
• Age when injured
• Medical and rehabilitation treatment
• Cause of injury
• Current grade in school
• Severity of brain injury
• Changes seen at home
• Changes seen at school

The second step is to describe your child’s abilities and needs. When thinking about this, consider…

• Comparison of abilities before and after the injury
• Changes seen over time 
• Changes in behavior at home
• Talking with your child 
• Your child’s strongest abilities
• Your child’s major difficulties

The third step is to advocate and negotiate for the help and services that are needed for your child.

• Keep track of grades at school
• Talk with teachers, therapists and specialists
• Review educational plans, medical and rehabilitation reports
• Set up a 3 ring binder notebook to organize reports and information
• Summarize what help or services is your child receiving now
• Consider how effective current help or services are
• Identify what other help is needed 
• Explain why additional help or services are needed.

By using these skills, families can have a more active role in working with educators and therapists to understand the needs of their child and to develop programs and services that will help their child.

For more information, see:

Families as Managers  

By Marilyn Lash, M.S.W. 

Information and tips for families on adapting professional case management skills and applying them to managing care and services for a brain injury survivor at home and in the community.

Parents and Educators as Partners 

By Marilyn Lash, M.S.W. and Bob Cluett

 Workbook for parents of children and youth with acquired brain injury shows how to work more effectively as partners with educators by applying 6 essential skills used by professional case managers. Included with the manual is a CD with over 60 pages of printable worksheets.    

 By Mar­­ilyn Lash, M.S.W.

Lash and Associates Publishing/Training, Inc.

Where do I start after my child has a brain injury?

This is the question often asked by parents of recently injured children as they enter the complex system known as special education. Educating a student with a brain injury is a complex and challenging process that constantly changes over time.

The informed consumer and special educaton

Now what?

Parents can only be effective advocates for their child if they are knowledgeable. The federal law on education, the Individuals with Disabilities Education Act (IDEA), has a specific category for traumatic brain injury under special education. The federal definition is limited to traumatic injuries to the brain that are caused by an external physical force (such as a blow to the head). Many states have broadened this definition to include acquired brain injuries (strokes, tumors, encephalitis, meningitis, near drowning). Readers can find out how their state defines brain injury by contacting the Department of Education in their state or their local special education director. 

The diagnosis of a brain injury does not automatically qualify a student for special education. The diagnosis is just a beginning. Once a referral for special education has been made, the school conducts a multidisciplinary evaluation. This evaluation determines how the brain injury has affected the student’s ability to learn and function in school. Federal and state laws provide very specific procedures and timelines for this process.

The education law guarantees parents certain rights and responsibilities. It is important for parents to know their rights under this law and to be involved. This article identifies two important resources for parents, advocates and educators injury.

NICHCY

This is the National Information Center on Children and Youth with Disabilities. It is an excellent place to begin to understand how special education works. This federally funded national clearinghouse provides information on disabilities in children and youth (birth to age 22). It specializes in fact sheets and guides that are written just for parents. Many materials are free or have a minimal charge. Their Publications Catalog lists their many products and is a gateway to information. You can even find a list of Resources in your state.

You can check it out on the web at www.nichcy.org or call 1-800-695-0285 or 202-884-8200 . NICHCY’s address is PO Box 1492, Washington, DC 20013-1492.

Fact Sheet on traumatic brain injury

NICHCY also has a four-page fact sheet on TBI that provides an excellent overview of the consequences of brain injury and its effects upon a student’s learning. It describes how a brain injury can affect a student and provides tips for teachers and parents. Resources direct readers to books and manuals about students with brain injuries. It can be ordered at the above numbers through NICHCY.

Special education IEP checklist for a student with a brain injury

Once a student has been found eligible for special education, the educational team develops an individualized educational program (IEP) to meet the student’s special needs. This is the blueprint for the student’s education. Parents are an integral part of this plan. The IEP is not just a pile of paperwork that sits in the student’s folder. It is a flexible and critical tool that should change, as the student’s needs change.

Because a brain injury affects each student differently, there is no standard content for this IEP. This IEP checklist identifies common changes after a brain injury. It lists student accommodations or assistance that may be needed for thinking and communication, developing social skills, and adjusting to physical changes. Teaching strategies, methods for giving instructions and assignments, and types of adaptive aids are listed for use is the classroom.

For more information, see:  

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

Lash and Associates Publishing/Training, Inc.

Why does our child behave so differently since the brain injury?

Changes in behavior may be a direct result of an injury to the brain. Common changes in behavior include mood swings, withdrawal, emotional lability, temper outbursts, impulsivity, irritability and disinhibitions.

Why has our child’s behavior become so difficult to manage since the brain injury?

Surprise Surprise Surprise!

He was never like this before. Certain areas of the brain, such as the frontal and temporal lobes, monitor and direct behaviors. When these are damaged, a child may have difficulty controlling temper, actions and feelings. Even the child’s personality may seem different. Common changes in behaviors after brain injury include restlessness, hitting, swearing, impulsiveness, and difficulty following directions. Many children and adolescents remember how they were before their brain injury. This can also result in emotional reactions that contribute to changes in behaviors as youths struggle to gain a new sense of self.

Will traditional behavior management techniques work for a child with a brain injury?

The traditional approach to managing behavior is based on the model of antecedent, behavior and consequence. The antecedent is what happens before the behavior. The behavior is the action. The consequence is what happens as a result of the behavior. For example, if a child is asked to turn off the television (antecedent), refuses and throws a tantrum (behavior), the child may be sent to bed or given a time-out (consequence). This approach emphasizes the consequence of the behavior. Most children learn to change their behavior to avoid negative consequences or punishment. This consequential management often does not work for children with brain injuries. The child may not remember the rules. Changes in insight and self-awareness may make it difficult for this child to learn from the consequences of behaviors. Think of the old saying, “The horse is already out of the barn.” Punishing children AFTER the behavior has occurred may not help them learn how to self monitor or recognize when they are overwhelmed or confused.

A more successful approach for youths with brain injuries emphasizes managing what is going on before the behavior occurs. Once the antecedents are identified, they can be changed to prevent the behavior from happening. For example, a student may not be following instructions or paying attention in class because of distractions from other students or hallway activity. This distractibility and difficulty focusing can be the direct result of a brain injury that will not improve with detention and reprimands. Instead, by moving this student’s desk to the front row, distractions may decrease and attention improve.

What is a neuropsychologist and how can this person help?

This is a psychologist with additional special training in the relationship between the brain and behavior. A neuropsychologist can evaluate how a brain injury affects a child or adolescent’s learning, communication, planning, organizational skills and relationships with others. Once the causes of the behavior are understood, the neuropsychologist can recommend compensatory strategies for use and help parents and educators respond to behaviors.

How do I know what is “normal” adolescent behavior and what is related to the brain injury?

This is one of the most difficult questions to answer and one of the most frequently asked by parents. Adolescence is known for its emotional turmoil with the many physical and hormonal changes occuring at the same time as social and academic pressures are increasing. The brain continues to develop right up through adolescence so new difficulties may now emerge, especially if the frontal lobes which affect impulse control and emotions have been damaged. The impulsiveness and mood swings that we expect from adolescents may be compounded and worsened by a brain injury that affects these control centers. An evaluation by a neuropsychologist can help identify behaviors that are directly related to the brain injury.

Will medications help?

Many children with brain injuries have short attention spans, are easily distracted and have difficulty following instructions and directions. Some become fidgety, impulsive and hyperactive. Because these symptoms are similar to those in children with attention deficit disorders, many parents and educators ask if medication will help.

This requires careful evaluation by a physician. When a child has a brain injury, it can cause physical injury to the neurons (brain cells) and to brain tissue. But it can also cause chemical changes in the brain. Some medications are designed to help children learn and pay attention better; others are used to control seizures or help manage challenging behaviors. But some medications have side effects that can affect alertness, memory, moods, sleep, or appetite. Any consideration of medication requires a physician experienced in brain injury and careful monitoring.

For more information by Ron Savage on behavioral changes in children and adolescents with brain injury see…

Behavior after Brain Injury Changes and Challenges 

By Nina Marchese, Andrea Potoczny-Gray and Ron Savage, Ed.D.

Information for schools and teachers on effects of brain injury on behavior in children and students at home and in school. 

Managing Behaviors after Brain Injury in School

By Ron Savage, Ed.D., Roberta DePompei, Ph.D., Stephen Bruce,MEd, BCBA, CBIS and Marilyn Lash, M.S.W.

Information and tips for parents and educators on behavior changes in children and students with acquired brain injury. Gives guidelines and strategies for changing behavior in students with TBI. Explains functional analysis of behavior. 

Strategies for Managing Challenging Behaviors of Students with Brain Injuries

By Stephen Bruce, MEd, BCBA, CBIS, Lisa Selznick Gurdin, MS, BCBA, CBIS-CE and Ron Savage, Ed.D.

Brain injury behavior manual with CD for educators and therapists shows how to use applied behavior analysis in the classroom for students with challenging behaviors after brain injury.

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

Lash & Associates Publishing/Training, Inc

Does a brain injury affect a child differently than an adult?

Unlike an adult, a child’s brain is still developing right up through adolescence. An injury interrupts this development.

Different parts of the brain develop at different ages or stages of a child’s maturation. Consequently, the full impact of a child’s brain injury may not become evident for many months, or even years, until the brain matures. It takes longer for the effects of a brain injury to be seen in children and the consequences can change over time.

By comparison, an adult’s brain is fully developed. This accounts for the dramatic “before and after the brain injury” changes that are so common. Unlike children, an adult has a lifetime of skills, knowledge and experience of education and work that can be used to adjust to the changes caused by the brain injury. This does not mean that it is easier for the adult who has had a brain injury; it is different because the life experience is different.

How is a child with a brain injury different from a child with a birth related disorder?

Children with birth related conditions often have diagnoses that are related to heredity, prenatal development, or delivery complications. Examples are mental retardation and cerebral palsy. The child’s development is altered or at risk from infancy. Diagnosis is often made early when the child does not progress and reach the normal developmental milestones.

By contrast, it is the ongoing “normal” brain development and functioning that is interrupted in children with brain injuries. It can occur at any age. From that point on, the child’s development may be delayed or altered because the brain has been injured and damaged.

There are two types of brain injuries. Traumatic brain injuries are the result of an external force from a trauma or blow to the head. Examples are when the child’s head hits the windshield during a car crash or strikes the floor or ground after a fall. Acquired brain injuries are caused by internal changes as the result of a stroke, tumor, or disease like meningitis or encephalitis.

Does the age at which a child has a brain injury make a difference? 

Yes. The younger the child is when injured, the less developed and more vulnerable to injury is the brain. It used to be thought that younger children were more resilient and “bounced back” after a brain injury. Now, we understand that it simply takes longer for the effects to be seen. It is important to track progress and change over time as the young child’s brain develops and matures.  

Does a history of a traumatic brain injury mean a child is eligible for special education?

The category of traumatic brain injury was added under the federal education act in 1991 (Individuals with Disabilities Education Act). The category is used in all states. However, the diagnosis or history of a traumatic brain injury does not automatically qualify the student for special education. It must be shown that the brain injury has affected the student’s ability to learn and function in school. Once a referral for a special education evaluation has been made, the school conducts a comprehensive assessment to determine if the effects of the brain injury and the student’s needs meet the requirements for eligibility for special education under the state’s regulations.

Does it make any difference what category or classification is used under special education, as long as the student is found eligible and receives services?

Yes. Before the change in the education law, many students with brain injuries were incorrectly described as mentally retarded, learning disabled, or emotionally disturbed. A brain injury can have unique consequences for learning, behavior, and communication. Identifying the student accurately under the classification of traumatic brain injury helps educators recognize the condition and it consequences. They can then develop educational strategies and programs that are individually designed for that student.

For more information, see:

ELVIN The Elephant Who Forgets 

By Heather Snyder and Susan Beebe, illustrator

This children’s book is about a little elephant named Elvin, who has a brain injury when a tree branch falls on his head!

Since his head injury, he can’t count his figs anymore, gets mixed up at school and doesn’t get along with his friends. A visit to the neuropsychologist helps him understand that he’s not a bad little elephant… he has a brain injury.

Billy Butterfly Tries  

By Cindy Koneczny

A delightful story book with colorful illustrations for young children features Billy Butterfly as he tries to compete in the Insect Olympics with a sore wing. Written and illustrated by a survivor of a severe brain injury, this is a story of perseverance, hope and overcoming the challenges of having a disability.