Teachers’ Perspective: Traumatic Brain Injury in Special Education: Addressing a Neglected Disability

By Dale Starcher, Ph.D., and George W. Niemann, Ph.D.

Traumatic Brain Injury (TBI) is often referred to as the “silent epidemic” because it is the leading cause of death and disabilities among children and adolescents. In spite of this, TBI often goes unrecognized, especially in schools.

In fact, research shows that only one percent of children who have had a severe head injury are identified and receive appropriate services within our schools. Many are identified with other learning disabilities or diagnoses such as attention deficit/hyperactivity disorder (ADHD) when the underlying issue may actually be TBI.

Because symptoms affect learning, behavior, socialization and physical well-being, it is crucial that educational professionals learn to identify children who have sustained a TBI. These children are often misidentified and classified as learning disabled or emotional and behavioral disordered, and are often viewed as unmotivated or having attitudinal issues.

Most TBI is a result of car accidents, bicycle accidents, falls and sports injuries. The severity ranges from mild concussion (mild traumatic brain injury) to severe, where hospitalization is necessary. Professionals treating TBI have become more sophisticated in recognizing the potential health and educational consequences, even in those suffering from supposedly mild injuries like concussion.

There are many common misperceptions about the long-term effects of TBI. Most school staff, including teachers, school psychologists and administrators believe that: TBI is easily observable; these children cannot accomplish normal tasks; there are always physical disabilities; behavioral features are extreme and bizarre; and there is always a significant decrease in intellectual functioning. All of these beliefs are false.

TBI Within a School Setting
Significant cognitive difficulties following brain injury are often not noticed by educators because these students, on the surface, often appear fine. Unfortunately, it is not the physical but the underlying cognitive, social and behavioral symptoms that can have the most serious consequences.
Some students can recover sufficiently from their injury to display pre-injury academic levels of functioning. The false assumption in such cases is that the recovery is complete, when this could not be farther from the truth. It is new learning after brain injury where great difficulties usually occur. In addition, there are usually discrepancies in overall performance where individuals may perform well in some areas, but really struggle in other very important areas of functioning.

A marked change in sense of self is also common among persons with TBI. There are two concerns in particular. The first is a lack of self-awareness concerning the effects of the TBI. It is not denial (which could also exist), as much as an inability to appreciate and observe the changes that the TBI caused. The second issue is that students will often report that they just don’t feel like themselves, or that they have lost a sense of what’s important to them with statements such as: “It’s like I’m in a void,” or “I feel numb inside.” These can trigger either anxious feelings, a sense of boredom or depression. They can also lead to difficulties with social interaction. One of the central issues facing adolescents returning to school after brain injury is the challenge of fitting in.
Since there are many variables contributing to brain injury symptoms in children, it is difficult to make general statements concerning cognitive deficits, patterns of impairment and behavioral manifestations. In addition, performance and behavioral functioning can fluctuate widely from hour to hour, day to day, and week to week. This can confuse teachers or other educational staff who are working with the student.

In addition, the initial severity of the injury does not always correspond to the degree of dysfunction following the injury. Even mild brain injury can have devastating effects on schoolwork, behavior and socialization. We find, for instance, that when greater demands are placed on the student, more severe symptoms will likely appear.

Assessment and Intervention Within the School
When a child has a TBI and returns to school, it is critical that the school be alerted. There are different ways this can happen, but in most cases, this contact is initiated by either the parents or hospital/rehabilitation center. Typically, they will contact the school nurse. One role of the nurse would be to request any medical records, rehabilitation reports and summaries, etc. Because TBI is a medical issue, the school nurse should have at least some understanding of the injury. In addition, the nurse should contact administration to make sure that other pertinent school staff are alerted to the child’s TBI. Once the nurse alerts administration, administration should then take the lead. This starts by informing the child study team members, who will also review the records. They may, and should, do an observation of the child and discuss the TBI with the teacher. They should also conduct an interview with the student’s parents. They should then make their recommendations to administration. Recommendations can vary dramatically, depending on the type of observations and assessments of the child. Of course, all of this depends on how well the child study team understands TBI and the kinds of interventions that may be most necessary.

What kinds of assessments and interventions should we expect from a child’s school? Here are a few examples of how schools can go about addressing a student’s needs.

Response to intervention (RTI). This is a multi-tiered, problem-solving process designed to determine the level of intervention needed. Within public schools, RTI has become the national standard in addressing special needs.

Functional assessment: A problem-solving approach. With most TBI, an assessment directly related to TBI that addresses academic, emotional, and behavioral factors is highly recommended. This approach enables staff to set specific target goals and track whether improvements have occurred, as well as what will be done if the child is not progressing in particular areas. These plans and tracking devices should be discussed with all staff who interact with the student, as well as the student and parents. By structuring these goals as problem solving, we can create an explicit and practical sequence of steps for each goal. For example, for a child who has organizational issues, visual cues, written instructions, use of planners, etc., can be used to help the child stay on track. The teacher, parent, and others can review these approaches with the child to make sure they are working and being used in a very functional and adaptive manner. This provides a solid basis for future interactions.

Goal attainment: Making sure the functional assessment is student-centered. As part of RTI, an approach that will help a school track the child’s improvements, but within a child-centered framework, is through the use of a goal attainment tracking system. This approach, first used in mental health centers, is a way to evaluate the individual goals of the student concretely and systematically. Goals are first set within general domains. For sake of discussion, let us take three general domains: cognitive, emotional, and behavioral. To assess whether the student’s goals are achieved, a number of pre- and post-assessments need to be administered that will cover these domains. Within the cognitive domains, common goals are concentration, memory, planning, and organization. Within the emotional domain, one of the most common goals is the need for social acceptance. And in the behavioral domain, most students will want to focus on anger/aggression and/or depression/loss of interest.

Emotional support, stress reduction, and self-regulation. Emotional support for a child with TBI is essential. Anxiety, depression, a weakened sense of self, anger, as well as impulsivity, are some of the issues that will need to be addressed. Besides supportive counseling, stress reduction and self-regulation strategies can go a long way in helping a child process and develop effective coping mechanisms. It is important to mention that there is a direct relationship between stress and brain injury symptoms. In other words, the more stress a student experiences, the more likely certain symptoms will increase, especially those related to cognitive and emotional factors. Even when a student makes a good recovery and no longer shows any visible signs of injury, stress will often cause many of the previous symptoms to recur, at least temporarily. Because of this, it is critical that the child learn robust coping and stress management skills to help reduce the likelihood that symptoms will reemerge.

Family involvement. Research has shown that family involvement is critical in helping children and adolescents make the most progress. Guidelines for working with families would include recognition of the child’s developmental level, matching the intervention to the particular family’s needs, educating the family about TBI, offering family support and counseling, making the proper adjustments in the home, school, and community to accommodate the child, and providing training to the child and family around building new skills. Support groups for the person with TBI, as well as family members, has also been shown to be very helpful during recovery and re-integration into school and community.

How Schools Can be Better Prepared to Help a Child with TBI
Schools have a responsibility to take the issue of TBI seriously and not assume that it is the responsibility of outside services to address the child’s needs. Many school staff would be willing to be more involved if administration made it a priority and supported them in terms of additional training, as well as creating an organizational structure within the school that addresses TBI. Because many children who have sustained a TBI can be mis-classified under some other special education label, it is more imperative to actively identify such children and utilize all resources available to provide them with the most appropriate and effective program. It is through such measures that greater cost-effectiveness and educational gains can be achieved.

Resources:

Brain Injury Association of NJ (BIANJ)
http://www.bianj.org/
BIANJ is a statewide organization whose sole purpose is to educate and provide support for those with TBI, their families, and professionals. They offer a short introductory course for educators on-line and at no cost.

Brain Injury Association of America
http://www.biausa.org/
The Brain Injury Association of America (BIAA) has a nationwide network of more than 40 chartered state affiliates and hundreds of local chapters and support groups.

North American Brain Injury Society (NABIS)
http://www.nabis.org/
NABIS is comprised of professional members involved in the care or issues surrounding brain injury. The principal mission of the organization is moving brain injury science into practice.

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Dale Starcher, Ph.D., is the Clinical Director at Garfield Park Academy, a state-approved private school for students ages 5-21 with disabilities in Willingboro, NJ. The school is home to the Compass TBI School Re-entry program. Starcher serves on the Executive Board of the NJ Association for School Psychologists and the Committee for Children and Adolescents for the Brain Injury Association of New Jersey.

George Niemann, Ph.D., is the Director of Clinical Development at the Center for Neurological and Neurodevelopmental Health (CNNH). He holds a doctorate in Neuropsychology from McGill University in Montreal, Canada. He developed community and school programs for brain injury and has established commissions on accreditation and professional training in the fields of brain injury rehabilitation and education.