TBI in the Classroom
There is no typical case scenario for a child with a Traumatic Brain
Injury (TBI). How a TBI affects each child varies, thus the academic
interventions and behavioral strategies should be individually
prescribed to address the individual student's unique strengths and
weaknesses.
It's important to distinguish that there are
varying degrees of TBI. Probably the first cause that comes to mind
when we talk about Traumatic Brain Injury are those caused by car
accidents or other violent blows to the head which require serious
medical attention. However, because our brains are so magnificient,
intricate, and complicated, even a slight injury can cause a major
disruption in cognitive functioning which directly affects children in the classroom. We have to
consider the gammet of TBI which also includes Mild Traumatic Brain
Injury. The CDC reports that there are approximately 2 million people
per year who sustain head injuries. Of those reported, approximately 80-90% are considered Mild TBI's, and only 10% of those are ever hospitalized.
Looking around your classroom now, is there a child you know who struggles to pay attention, has difficulty following directions, acts impulsively, and/or is rigid in thier thinking, perhaps argumentative? If asked to describe this student, do the words 'unmotivated', or 'no work ethic' come to mind? Unfortunately, these are key words that teachers often use to describe students with TBI or MTBI.
First of all, we have to remember that TBI is defined by it's etiology. In other words, it is defined by its causes, not it's symptoms. If you take nothing else from this page, remember that TBI evolves behaviorally. Children who sustain an injury at a young age often begin to demonstrate behavioral challenges in early adolescence. The literature suggests that some of theses behaviors may be so severe as to mimic psychiatric disorders. That is part of the reason why it is so important to identify students with a TBI as early as possible. As with any disability, intervening as soon as possible prevents problems on down the road.
Behavior is a tricky topic, as it often becomes personal very rapidly to the people who are entangled in it. Try to remember that behavior is simply a form of communication. What is the student trying to communicate, and why is this student having problems when his peers are not? Try to keep your focus on the extrinsic factors. In other words, what can we manipulate in this child's environment so that he can be successful and feel good about what he's doing? To make those decisions, we need to have a better understanding of the affects of Mild TBI and TBI.
Don't
assume that a 'mild' injury constitutes no problems. There is
little research existing on the long term effects of concussions or
mild
TBI's simply because it is hard to establish a control group as children's brains are continually changing and developing. Therefore, while it is understood that MTBI can and does initially impair aspects of cognitive functioning, the long term effects are not completely known.
The bottom line is that even a MTBI can have serious implications in a child's classroom functioning including academic performance, emotional lability, and self regulation (behavior). Please read further for more specific affects and how they might appear in the classroom.
What abilities are affected by brain injury?
Executive Processes
Motor Skills
Speech Language Impairments
Memory
Social Relationships
Processing Speed
Organization (mental and physical)
New Learning
Sensory Changes
Executive Processes - those
that involve problem solving or complex thinking. Utilizing
executive function requires many parts of the brain to work together.
Problems with exeutive function may
present with difficulties in initiation, attention, mental flexibility,
planning and judgment.
Initiation - turning
a thought into an action. Problems with initiation may result in
the child not being able to use study time wisely because they can't
get started on a task. They may be able to repeat back the
directions, but still not be able to start the task.
Attention - the
ability to screen out noises or other distracting stimulus and focus on
the task. It is hard for the student to select what stimulus to attend to
and what can be ignored.
Mental Flexibility - ability
to shift attention from one thing to another. Problems with
mental flexibility include perseveration, (i.e. repeating something over and
over, getting stuck on an idea).
Planning - the
ability to think ahead and percieve the outcome. It is the ability to
break something down from whole to part. Problems with planning may result in difficulty
completing long term projects, behavior, and even simple activities.
Judgment - ability
to consider outcomes even those they've never
experienced. Being able to weigh all aspects of problem solving
and make good decisions quickly. Problems with
judgment can impair the child's ability to have a lack of social
understanding and may lead to harmful activities or putting themselves in danger.
Motor Skills - Motor
skills include both gross and fine motor. Gross motor involves
use of large muscles such as those needed in running, climbing,
crawling, etc. Fine motor skills are small muscle movements which
occur in the fingers. After an accident, teachers on the
playground, the PE teacher or other staff need to be made aware to
watch for balance issues that may affect or endanger the child during
activities that require gross motor skills. Difficulty with fine
motor skills may present itself in what looks like sloppy work.
(i.e. lots of erasures, torn paper from erasing, dark letters from over
pressing, etc.)
Speech Language - While the voice intonation itself may be affected, areas of receptive and expressive language can also be influenced. Receptively,
a student may have difficulty making inferences, generalizations,
catching double word meanings or understanding word humor. It may
be harder for the student to process verbal information such as
directions or written information. Expressively, a student may have difficulty putting their thoughts into words and have difficulty with word retrieval.
Memory - Information
that has been learned and stored in memory is usually the first to come
back because you can access different avenues or routes in the brain to
get to that information. However, new learning is more difficult
to retrieve because for information to be stored in the first place,
certain pathways and processing centers in the brain must be
intact. The areas of the brain responsible for these functions
are often susceptible to injury simply because of their location in the
skull. These centers also require plenty of oxygen.
New Learning - There
are several processes involved in New Learning than can be hindered by
injury. These may include self-organization, processing speed,
cognitive flexibility, memory, and skills. It may become quite
difficult for the student to generalize information or utilize it from
one setting to the next. Students may have difficulty with reading
comprehension, taking organized notes, and using common sense.
Social Relationships - The
nuances of socially interacting are no longer easy. A student may
struggle with initiation of general conversation, behaving in a
socially acceptable manner and regulating his/her emotions.
Frustrations in this area may take it's toll on peer relationships as
well as stressing family ones. The same frustration may lead to
feelings of inadequacies, withdrawal, and stress.
Processing Speed - Processing
speed is almost always reduced after injury. Therefore, a
student's ability to take in information, synthesize it, and respond
may be drastically slower. As a result, the student may fall
behind academically, or spend unimaginable amounts of time completing
homework. In the classroom, the child typically is able to focus
on one piece of information at a time. When the pace of
instruction begins to move more quickly, the student struggles to keep
up and does not get the full instruction. As a result, his/her
notes are 'choppy' and do not include necessary information making
study time confusing.
Hopefully you have a better understanding of the cognitive functions that may be affected by a TBI/MTBI. Visit with your school psychologist, speech pathologist or an occupational therapist if you have specific concerns in these areas regarding one of your students. They are trained to provide specific supports and should be able to provide you with ideas to assist you in a positive educational outcome for a child with TBI/MTBI.
References: BrainSTARS; Copyright 2002 Jeanne Dise-Lewis, Ph.D.
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