Introduction

Traumatic brain injury is among the leading cause of morbidity and mortality among youth, with prior work documenting nearly 500,000 annual cases of TBI in the United States among newborns to 14-year-olds.

Children with brain injury are at increased risk for long-term neurocognitive, emotional, social, and behavioral effects. Such effects place youth at increased risk for poorer educational functioning post-injury. Indeed, prior research shows that children with a history of brain injury have reduced academic achievement and greater educational needs following school re-entry. Yet, pediatric brain injury is under-identified within school settings. Under-identification of pediatric brain injury occurs for multiple reasons, including ineffective communication between medical and education systems as youth return to school. Perhaps more commonly, in the case of mild brain injuries, brain injuries are under-reported, or teachers, parents, and clinicians fail to link academic challenges to said brain injury.

The cognitive domains that are the most severely disrupted by pediatric brain injury include executive functioning, processing speed, attention, and, to a lesser degree, verbal memory, fluency, and planning and problem-solving. Broadly, executive functions are the skills necessary to regulate thoughts, behaviors, and emotions and include skills such as impulse control, self-monitoring, behavioral and emotional modulation, task initiation and completion, problem-solving, and cognitive flexibility. In children with brain injuries, executive difficulties are generally most pronounced in the areas of cognitive flexibility and inhibition. Critically, due to the lengthy nature of brain development, long-term executive functioning effects may not become apparent until adolescence. In TBI populations, prior findings have demonstrated a persistent dose-dependent relationship between injury severity and cognitive outcome. Challenges with memory, attention or working memory, and processing speed tend to remit several months to years after injury, though they remain relatively more pronounced and persistent in those with more severe injuries. Moreover, parents of children with severe TBI continue to perceive executive functioning problems in their children up to three years after their injury. In addition to injury severity, the age of injury has been shown to moderate long-term effects. Recent findings show that executive functioning challenges are often most devastating in children whose TBI was before age 5 years.

Other Issues

Children are at increased risk for externalizing disorders following brain injury. TBI enhances the risk for personality change and disruptive behavior disorders, with prevalence estimates of oppositional defiant disorder and conduct disorder ranging from 12 to 23% . Most often, there are increases in affective lability, aggression, and disinhibition, and less commonly apathetic or paranoid behaviors. Internalizing disorders can also manifest among children with brain injury. Predictors of internalizing disorders following head injuries include premorbid psychosocial adversity and anxiety as well as injury severity. Incidence rates of PTSD are estimated to range from about 6 to 15% in youth with brain injury compared to 5% of adolescents in the general population. Incidence rates of novel internalizing disorders vary based on injury type and severity, age of injury, and time of measurement. Following TBI, post-traumatic stress, anxiety, and depression are present in 20 to 25% of children. For children with mild TBI, anxiety symptoms generally remit within several months after injury; however, in those with severe TBI, anxiety can become more severe over time. Novel anxiety disorder has also been associated with younger age at the time of injury. In contrast, older age at the time of injury, particularly adolescence, is associated with more depressive symptoms. Of note, though, internalizing disorders remit more often than externalizing disorders among youth with a history of TBI.

Broad social challenges and physical changes are also observed in children with brain injuries. Social challenges include reduced social participation stemming from activity restrictions and changes in functioning, distressing reductions in social acceptance, and changes in peer relationships. Generally, those with more severe injuries are more likely to have more interfering and persistent social difficulties.

With regard to physical changes, it is not uncommon for this patient population to present with motoric and sensory changes related to their injuries. Some degree of novel hearing impairment is especially common (i.e., 30%) in children following bacterial meningitis. Other common symptoms associated with pediatric brain injury include headache, nausea, pain, sleep disturbances, and fatigue

Academic Outcomes

Cognitive and psychiatric challenges can greatly influence a child’s school functioning. Not only are children absent from school due to hospitalization, rehabilitative care, and ongoing monitoring appointments, but also ongoing symptomatology can impede learning and participation. Difficulties with attention regulation, processing speed, executive functioning, and memory make it harder for children to engage academically and to acquire and retain new knowledge and skill sets. Significant emotional and behavioral challenges can exacerbate cognitive weaknesses, encumber peer and teacher interactions, and reduce academic engagement. Consistently, children with a history of brain injury show poorer academic functioning in a variety of ways, including lower levels of academic achievement and increased need for educational supports.

Academic Achievement

TBI in preschool-aged children is associated with reduced school readiness, which, in turn, is predictive of lower academic achievement later in development. Further, school-aged children with a history of TBI show academic underachievement, though weaknesses may vary across subject areas. Word-reading tends to be preserved across TBI especially if the injury occurs after the development of early reading abilities. Conversely, TBI has been associated with poorer outcomes on measures of mathematical ability, particularly among those with severe TBI. Severe TBI has also been associated with poorer performance on measures of decoding, reading comprehension, spelling, and arithmetic when compared to mild and moderate TBI samples, and group differences remained over a five-year follow-up period.

In addition to formal measures of academic achievement, other indicators have been used to examine academic functioning following brain injury. Compared to an orthopedic control group, children with a history of moderate or severe TBI are more likely to be diagnosed with a learning disability and have lower academic competency, per parent or teacher report. Concussion, often synonymously referred to as mild TBI, has been associated with greater GPA declines, especially for individuals with a history of two or more concussions. Whereas concussion does not appear to impact graduation rates, severe childhood TBI has been associated with greater drop-out rates and an increased likelihood of unemployment during adulthood .

Need for Academic Supports

Paralleling the data on reduced academic achievement among youth with brain injury, there is greater need for educational supports among this population as they begin or re-enter school.

Notably, provision of academic support for less severe TBI groups may increase over time since injury. Taken together, academic needs among youth with mild or moderate TBI may increase over time, likely as a function of greater academic demand and emergent executive functioning challenges across grade levels. This trend may also demonstrate the under-recognition of educational needs among less severe TBI during the early stages of returning to school.

Moderators of Academic Outcomes

Several factors moderate the degree of academic difficulties following brain injury, including injury severity, degree of cognitive changes, age of injury, and level of premorbid functioning. Greater injury severity tends to predict poorer outcomes, including higher rates of educational supports. Similarly, TBI severity is associated with poorer academic achievement, higher rates of academic need, and greater provision of school supports. it is also worth restating that academic needs among youth with a history of less severe TBI may be under-recognized and/or may become more apparent over time.

Greater injury-related cognitive change contributes to subsequent academic functioning. In particular, greater levels of executive dysfunction following TBI are associated with weaker academic performance.

Changes in other cognitive domains have been linked to poor academic outcomes. Among youth with TBI, greater language or intellectual impairment is associated with amount of school adaptations, greater short-term verbal memory impairment is associated with greater listening comprehension difficulty, and greater long-term verbal memory impairment is associated with greater arithmetic difficulty.

Age of injury has also been linked to academic outcomes. Early age of TBI has been linked to flatter trajectories of academic achievement over a five-year span.

Premorbid functioning is a strong predictor of post-injury functioning, especially within the TBI literature. Stronger preinjury educational abilities are predictive of better post-TBI word reading, spelling, arithmetic, and listening comprehension skills. Conversely, greater degree of premorbid (preinjury) challenge has been associated with poorer outcomes post-injury. Children with a pre-existing diagnosis of attention deficit hyperactivity disorder (ADHD) or learning disability take longer to return to school following a mild TBI than those without a premorbid neurodevelopmental disorder. Similarly, youth with greater levels of anxiety symptoms prior to sustaining a mild TBI have a more delayed return to school than their relatively lower-anxiety counterparts. A higher number of prior head injuries has also been shown to predict poorer post-TBI outcomes. Number of prior concussions has been positively associated with GPA decline and with more academic dysfunction.

Limitations in Identification

Many students who experience a brain injury, especially a mild injury, go untreated and/or do not report the event to hospitals or schools. Canto et al  indicated that, across a two-year period at a Florida school district, approximately 1300 school children in its district were treated for TBI at the local hospital but only 129 students were being served by the school district’s TBI program. The findings point to how many students with brain injury—in that study, TBI specifically—are not being screened or identified by school districts for appropriate services under Section 504 or IDEA.

Still more students with brain injury are not seen at hospitals nor identified by school districts. These issues point to the fact that many students with milder forms of brain injury are not being identified and are not receiving any form of educational support. Such support may be lacking for the simple reason that school personnel are uninformed about the brain injury and, thus, injury- related issues may be mistaken for other high-incidence disabilities such as emotional or behavioral disturbance, specific learning disability, or speech/language impairment, which may misguide the identification of the most appropriate services. Even in the case of more moderate or severe injuries, there can be problematic communication gaps between medical and educational systems. In one study, over 20% of parents of children with brain injury indicated that school systems did not receive any communication or information regarding the injury. Communication between medical and education sectors tend to be more reliable for youth who are involved in inpatient rehabilitative care or who receive transitional services.

Obtaining medical documentation of the injury is essential in the evaluation process for students with TBI. Because TBI is considered a medically related disability such as ADHD, states require formal validation from a provider attesting that a TBI occurred and that it affects educational performance. The primary issue is that often brain injury is not formally documented by medical staff for children with mild brain injury, even if they are taken to an emergency room. Difficulties obtaining such documentation may complicate the evaluation process and may increase the risk for an inappropriate classification. Importantly, though, if a school has good reason to suspect a student’s poor/declining educational performance is due to TBI but overlook it in favor of an “easier,” more expedient, IDEA disability category, it could lead to a FAPE violation and legal proceedings.

Avenues for next steps

Solutions for ensuring youth with brain injury are properly identified and effectively supported in schools include (but are not limited to): \

(a) improving hospital to school transition services/models;

(b) providing effective professional development and in-service education to administrators and teachers about brain injury and legal responsibilities under IDEA and Section 504;

(c) enhancing the IDEA identification process in schools;

(d) training parents on how to be more effective in communicating with schools about their child’s educational needs; and

(e) changing state-level policies designed to assist schools in identifying and serving students with brain injury more efficiently.

(Vanderlind, Demers, Engelson,Fowler, and  McCart, 2022)

What is Traumatic Brain Injury?

A traumatic brain injury (TBI) is an injury to the brain caused by the head being hit by something or shaken violently. (The exact definition of TBI, according to special education law, is given below.) This injury can change how the person acts, moves, and thinks. A traumatic brain injury can also change how a student learns and acts in school. The term TBI is used for head injuries that can cause changes (impact learning) in one or more areas, such as:

• thinking and reasoning,
• understanding words,
• remembering things,
• paying attention,
• solving problems,
• thinking abstractly,
• talking,
• behaving,
• walking and other physical activities,
• seeing and/or hearing, and
• learning.

The term TBI is not used for a person who is born with a brain injury. It also is not used for brain injuries that happen during birth.

What Are the Signs of Traumatic Brain Injury?

The signs  (characteristics and issues of adaptive behavior) of brain injury can be very different depending on where the brain is injured and how severely. Children with TBI may have one or more difficulties, including:

Physical disabilities: Individuals with TBI may have problems speaking, seeing, hearing, and using their other senses. They may have headaches and feel tired a lot. They may also have trouble with skills such as writing or drawing. Their muscles may suddenly contract or tighten (this is called spasticity). They may also have seizures. Their balance and walking may also be affected. They may be partly or completely paralyzed on one side of the body, or both sides.

Difficulties with thinking: Because the brain has been injured, it is common that the person’s ability to use the brain changes. For example, children with TBI may have trouble with short-term memory (being able to remember something from one minute to the next, like what the teacher just said). They may also have trouble with their long-term memory (being able to remember information from a while ago, like facts learned last month). People with TBI may have trouble concentrating and only be able to focus their attention for a short time. They may think slowly. They may have trouble talking and listening to others. They may also have difficulty with reading and writing, planning, understanding the order in which events happen (called sequencing), and judgment.

Social, behavioral, or emotional problems: These difficulties may include sudden changes in mood, anxiety, and depression. Children with TBI may have trouble relating to others. They may be restless and may laugh or cry a lot. They may not have much motivation or much control over their emotions.

A child with TBI may not have all of the above difficulties. Brain injuries can range from mild to severe, and so can the changes that result from the injury. This means that it’s hard to predict how an individual will recover from the injury. Early and ongoing help can make a big difference in how the child recovers. This help can include physical or occupational therapy, counseling, and special education.

It’s also important to know that, as the child grows and develops, parents and teachers may notice new problems. This is because, as students grow, they are expected to use their brain in new and different ways. The damage to the brain from the earlier injury can make it hard for the student to learn new skills that come with getting older. Sometimes parents and educators may not even realize that the student’s difficulty comes from the earlier injury.

Although TBI is very common, many medical and education professionals may not realize that some difficulties can be caused by a childhood brain injury. Often, students with TBI are thought to have a learning disability, emotional disturbance, or an intellectual disability. As a result, they don’t receive the type of educational help and support they really need.

When children with TBI return to school, their educational and emotional needs are often very different than before the injury. Their disability has happened suddenly and traumatically. They can often remember how they were before the brain injury. This can bring on many emotional and social changes. The child’s family, friends, and teachers also recall what the child was like before the injury. These other people in the child’s life may have trouble changing or adjusting their expectations of the child.

Therefore, it is extremely important to plan carefully for the child’s return to school. Parents will want to find out ahead of time about special education services at the school. This information is usually available from the school’s principal or special education teacher. The school will need to evaluate the child thoroughly. This evaluation will let the school and parents know what the student’s educational needs are. The school and parents will then develop an Individualized Education Program (IEP) that addresses those educational needs.

It’s important to remember that the IEP is a flexible plan. It can be changed as the parents, the school, and the student learns more about what the student needs at school.

Susan’s Story

Susan was 7 years old when she was hit by a car while riding her bike. She broke her arm and leg. She also hit her head very hard. The doctors say she sustained a traumatic brain injury. When she came home from the hospital, she needed lots of help, but now she looks fine.

In fact, that’s part of the problem, especially at school. Her friends and teachers think her brain has healed because her broken bones have. But there are changes in Susan that are hard to understand. It takes Susan longer to do things. She has trouble remembering things. She can’t always find the words she wants to use. Reading is hard for her now. It’s going to take time before people really understand the changes they see in her and how to best meet her learning needs.

(Center for Parent Information and Resources, 2015)

The following text is an excerpt from:

DeMatteo CA, Randall S, Lin C-YA and Claridge EA (2019) What Comes First: Return to School or Return to Activity for Youth After Concussion? Maybe We Don’t Have to Choose.

Concussion

Concussion has become an epidemic in children and youth. The number of reported head injuries in Emergency Departments among youth playing sport has increased in the past decade by over 40% . The symptoms of concussions can often interfere with participation and performance in home, school, and community activities. The current consensus for standard concussion management is the six-stage Berlin Return to Play recommendations. This statement and much of the literature now suggest a more conservative approach to the management of children/youth with concussion. It is, however, still unclear as to what “more conservative” entails. When they are symptomatic, children and youth are advised to rest for 48 hours, then gradually resume regular activity with incremental increases in physical and cognitive activity within symptom tolerance. Depression and anxiety may result as a secondary sequelae if youth are socially isolated and removed from normal activity and participation for prolonged periods of time. Prolonged rest can lengthen recovery time and contribute to deconditioning, therefore protocols for children must contain a balance of activity and rest to promote physical, emotional and cognitive recovery.

Both Return to School (RTS) and Return to Activity/Play  (RTA) protocols for pediatric concussion management should be conservative and individualized. A number of protocols guiding families and youth through progressive recovery steps for safe Return to School (RTS) and Return to Activity/Play (RTA) have now been developed, are widely-accepted and are important aspects of pediatric concussion management.

Download Return to School Guidelines https://www.frontiersin.org/articles/10.3389/fneur.2019.00792/full#supplementary-material

Youth return to school faster than they return to play in spite of the self-reported, school-related symptoms they experience while moving through the protocols. Youth can progress simultaneously through the RTS and RTA protocols during the early stages 1–3. Considering the numbers of youth having school difficulties post-concussion, full contact sport, stage 6, of RTA, should be delayed until full and successful reintegration back to school has been achieved. In light of the huge variability in recovery, determining how to resume participation in activities despite ongoing symptoms is still the challenge for each individual child. There is much to be learned with further research needed in this area

*Research sample mean age of the research is “46% male, 13 yrs. of age.

(DeMatteo, Randall, and Lin, 2019)  The Full article and references can be accessed at: https://www.frontiersin.org/articles/10.3389/fneur.2019.00792/full#h14

Classroom Interventions and Accommodations

Brainline is a comprehensive resource about TBI. There are many articles available related to teaching school age children with TBI. The required reading for this course is Julie Bowen’s article on Classroom Interventions for Students with Traumatic Brain Injury.  There is a wealth of important information on Brainline under the “Chilean with TBI” and “Teens with TBI” tabs. In this one week module these readings are optional. Do bookmark these resources for future reading.

Assistive Technology

Focus specifically on AT for memory and organization.  There are two critical areas that affect learning and day to day life.

Brainline, (n.d.) Using External Aids to Compensate for Memory and Organization Post-TBI. from https://www.brainline.org/article/using-external-aids-compensate-memory-and-organizational-problems-post-tbi

Optional Extended Learning / Teacher Resources

• From the Wisconsin Department of Public Instruction Mild Brain Injury Brochure for Educators
• Colorado Dept. of Education, (2012). Brain Injury in Children and Youth A Manual for Educators. Retrieved from  http://www.cde.state.co.us/cdesped/tbi_manual_braininjury
• Brain Injury Association of VA, (2013) Brain Injury and the Schools: A Guide for Educators, Ch. B & C, Educational Implications. Retrieved from http://www.doe.virginia.gov/special_ed/disabilities/traumatic_brain_injury/brain_injury_schools.pd

References

Bowen, J. M., (2008) Classroom Interventions for Students With Traumatic Brain Injuries, Preventing School Failure: posted on brainline.org, https://www.brainline.org/article/classroom-interventions-students-traumatic-brain-injuries 

Brainline, (n.d.) Using External Aids to Compensate for Memory and Organization Post-TBI. from https://www.brainline.org/article/using-external-aids-compensate-memory-and-organizational-problems-post-tbi

Center for Parent Information and Resources, (2015), Traumatic Brain Injury. Retrieved 4.1.19 from https://www.parentcenterhub.org/tbi/ public domain

DeMatteo CA, Randall S, Lin C-YA and Claridge EA (2019) What Comes First: Return to School or Return to Activity for Youth After Concussion? Maybe We Don’t Have to Choose. Front. Neurol. 10:792. doi: 10.3389/fneur.2019.00792 This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY).

Vanderlind, W.M.; Demers, L.A.; Engelson, G.; Fowler, R.C.; McCart, M. Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury. Children 2022, 9, 1321. https://doi.org/10.3390/ children9091321  Creative Commons Attribution (CC BY) license

updated 6.19.23