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Pediatric traumatic brain injury: Issues in the educational setting

Improved communication across settings and more appropriate training for school personnel is needed to assist children with TBIs

By Ashley S. Fournier

A traumatic injury to the brain sustained during childhood has been conceptualized as a serious public health concern for children (Anderson & Yeates, 2010). A recent estimate of prevalence indicates that between 200 and 500 per 100,000 children each year sustain a traumatic brain injury (TBI). Another estimate suggests that pediatric TBI results in around 3,000 deaths, 29,000 hospitalizations, and 400,000 emergency department (ED) visits annually (Marguiles & Coats, 2010). Although a traumatic injury to the brain can result in significant dysfunction at any point throughout the lifespan, injuries sustained during development carry different implications than those sustained during adulthood (Anderson & Yeates; Prins, Giza, & Hovda, 2010). Children are expected to gain academic and social knowledge and skills during this time; however, an injury to the brain can be disruptive to this process.

Given children spend the majority of their time in the educational setting, academic and social skills are predominantly gleaned here. In recognition of the fact that a TBI can be significantly disruptive to students' overall educational functioning, the Individuals with Disabilities Education Act (IDEA) allows students who have sustained a TBI to receive special education services (Merrell, Ervine, & Gimpel, 2006). The IDEA defines a TBI as "an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance" (p. 120). This applies to both open- and closed-head injuries with resultant deficits in a broad range of areas including cognition, language, memory, attention, sensorimotor abilities, and social functioning. Despite the presence of this seemingly straightforward definition, misclassification of students who have sustained a TBI is common within the educational setting.

(Mis)Identification of Students with TBI Research suggests that the majority of children who sustain a TBI are released from the ED shortly after arriving (Glang, Tyler, Pearson, Todis, & Morvant, 2004). Around 30,000 of these children will "be left with long-lasting, significant alterations in social, behavioral, physical, and cognitive functioning" (p. 220). Although these deficits are present, research has indicated that students with TBIs are rarely referred for any services, including those that are hospital-, community-, and school-based, following release from the hospital setting (Cronin, 2000). Cronin noted that of 24,021 children who had been hospitalized for TBI, 27 percent left the hospital with some form of functional limitation as determined by hospital staff. Among these children with functional limitations, 75 percent were released to the home. Only 1.8 percent were later referred for special education services despite experiencing limitations with activities of daily living.

In addition, Glang et al. (2004) found that between 1992 and 2001, the number of students receiving services under the TBI eligibility category of the IDEA increased by only 1,360 students. Given that these authors estimate 30,000 children experience deficits associated with TBI each year, this number should have been closer to 130,000. Dise Lewis, Lewis, and Reichardt (2009) estimate that around 76 percent of students "meet criteria for a diagnosis with a 'novel' psychiatric disorder within two years of [sustaining] a moderate to severe TBI" (p. 167). These studies clearly indicate difficulties with appropriate identification of students with TBI. While labeling students is not of primary importance, accurate identification of eligibility can and should facilitate appropriate intervention. Given the tendency toward misclassification or a general lack of classification, it would be reasonable to assume that the implementation of evidence-based interventions (EBI) with this population is lacking. Given these implications, the exploration of potential explanations for this misclassification is warranted.

One possible contributing factor to the misidentification of students with TBI is related to communication across settings. Communication between the hospital and school settings has been described as inadequate (Cronin, 2000). Particularly with regard to general hospitals where pediatric issues are not paramount, communication with the educational setting can be viewed as nonexistent. The United States contains about 250 hospitals that specialize in pediatrics; however, only 50 of these hospitals are freestanding. In contrast, there are around 5700 general or community hospitals; thus, the majority of individuals, including children, requiring emergency care are treated within this setting. This is particularly salient for individuals residing in rural settings given that there are about 2000 community hospitals and virtually no pediatric hospitals located in this setting. Given this information, it would be reasonable to conclude that the majority of children placed in the ED in association with a TBI are initially transported to general hospitals. Depending on the severity of injury, a pediatric patient may be transferred to a children's hospital where communication with the educational setting 4 becomes more likely; however, research has indicated that the majority of children admitted to general hospitals are promptly discharged from the ED following injury (Glang et al., 2004).

Further contributing to difficulty in accurate identification, general hospitals may not be aware of the educational implications of even mild TBI and the potential to receive educational supports in association with this injury. Thus, encouragement by hospital staff of parents/guardians to share information associated with a child's TBI with school personnel may also be nonexistent. Ultimately, parents/guardians may not understand the importance of disclosing this information to school personnel. Further, should parents/guardians actually disclose this information to school personnel, there is no guarantee that the individual with whom the parent/guardian speaks will have a good working knowledge of the IDEA. This may be particularly true for general education teachers given only about 8 percent of special education teachers obtain information regarding TBI prior to being employed by a school district (Walker, Boling, & Cobb, 1999).

Another potential barrier to correct identification among this population is general difficulty in obtaining and completing the necessary paperwork to accurately document the presence of this injury. Since a TBI represents a medical condition within the educational setting, the presence of this injury must be verified and documented via a physician before the Individual Education Program committee could consider services (Merrell et al., 2006). However, because general hospitals do not specialize in pediatric health issues such as community or school reintegration following injury, they are unlikely to be aware of the need for clear and specific documentation of TBIs among children. When coupled with the fact that most children sustaining TBIs are quickly released from the ED, it becomes increasingly likely that appropriate documentation will not be obtained. Although educational supports through other entities may be put in place or services may be implemented through special education through use of a different IDEA eligibility category, the difficulty in completing paperwork clearly contributes to inaccurate identification and inappropriate, ineffective intervention with this population.

A final contributing factor to accurately identifying this population is related to limitations in the training of school personnel. Given the broad range of functioning that can exist among children who have sustained a brain injury, a variety of individuals may be required for effective evaluation, transition, and intervention. Not least among these is special education teachers and school psychologists; however, research has suggested that these individuals are rarely prepared to effectively serve this population (Walker et al., 1999). As previously mentioned, only a minority of special education teachers have training in managing TBI. In addition, research has indicated that only 23 percent of doctoral programs offering training in school psychology require a complete course in neuropsychology. Programs that offer this training typically focus on neuroanatomy and characteristics and effects of brain injury as opposed to assessment of, intervention with, and placement issues surrounding students with TBI. Thus, the extensive training in cognitive rehabilitation and behavioral modification techniques that many school psychologists have is often not applied specifically to students with TBIs. Given the pervasive nature of these limitations, adequate training of school personnel, such as school psychologists, was identified as the number one national need by those "charged with 6 identifying strategies addressing the needs of children with TBI" (Glang et al., 2004, p. 222).

Prevention of Misidentification The frequent misidentification within the educational setting of children with brain injuries and the potential reasons for doing so underscore the importance of raising awareness of this issue among school and hospital personnel. However, the school psychologist may engage in a few basic practices that may assist in ensuring he/she does not contribute to the misclassification of this population. When receiving any referral, it is incumbent upon the school psychologist to conduct a thorough developmental history with parents/guardians and specifically inquire about head injuries. This is particularly important since children appear to experience fewer deficits following TBI compared with adults; however, these deficits typically emerge later as the child becomes neurologically mature (Cronin, 2000; Dise-Lewis et al., 2009; Glang et al., 2004). Thus, it may be difficult for significant adults in a child's life to connect current neurocognitive deficits to past head injuries; therefore, they may be more likely to neglect mentioning these events. A thorough review of a child's records, particularly medical, can also assist in determining whether a substantial head injury has occurred. If this is the case, then it would also be incumbent upon the school psychologist to educate the parent/guardian with regard to intervention options and guide him or her through the process of appropriately documenting this injury.

The school psychologist can also do much in the way of raising awareness with regard to the misidentification of students with TBIs among school personnel. It may be prudent to conduct a campus-based training oriented toward combating the aforementioned barriers to appropriate identification. Simply making school personnel, such as general education teachers, aware of the possibility for educational supports following a TBI may result in this injury among students being communicated to more appropriate school personnel such as school psychologists or speech-language pathologists. Increased awareness among school personnel of the general educational, cognitive, and social implications of TBIs among children may also promote more appropriate identification of these students. A comprehensive program that assists in the education of school personnel such as school nurses and other school professionals (e.g. teachers, counselors, school psychologists) with regard to the implications of TBI has been developed (Clay, 2011). The "Heads Up to Schools: Know Your Concussion ABCs" program provided in part by the Centers for Disease Control and Prevention (CDC) can be obtained at no cost. Similar programs directed specifically toward coaches are available as well.

The school psychologist can also raise awareness among local hospital personnel by simply providing these individuals with relevant information. This may take the form of an informational brochure detailing the educational implications of mild, moderate, and severe TBIs among children. The potential for obtaining appropriate educational supports within the school setting may also be outlined. It seems particularly important to assist hospital personnel in understanding the importance of appropriate documentation in order to obtain later supports. Although not likely, it may be especially helpful to conduct a training session with these individuals as well. Hospital staff such as ED physicians, physicians' assistants, and nurse practitioners may also be open to receiving materials provided by the CDC such as the "Heads Up: Brain Injury in Your Practice" 8 toolkit. This toolkit can assist in raising awareness of the educational implications of TBIs among children.

EBIs for Students with TBI Students found to have sustained a TBI who are subsequently experiencing neuropsychological or neurobehavioral sequelae impacting their educational functioning are eligible to receive services (Merrell et al., 2006). Educational supports may be implemented through such systems as Response to Intervention (RTI), Section 504, and IDEA. Significant individuals such as school personnel, parents/guardians, and the student may choose to utilize RTI or Section 504 when a TBI has not been definitively documented. These sources may also be utilized when neurocognitive deficits do not approximate what would be required to receive services through IDEA. This may occur, for example, when students exhibit adequate neurocognitive skills with the exception of a significant deficit in the area of processing speed. Educational supports through the TBI eligibility category of IDEA may be utilized when the injury has been clearly documented and there is a clear educational need for services. Unfortunately, students who are actually identified as having a TBI rarely receive EBIs for this condition.

Although the lack of EBIs in the school setting is somewhat related to limitations in training among school personnel, it is also important to note that research in this area is lacking (Morrison, 2011). Most typically, interventions implemented with children with TBIs are downward extensions of interventions used with other pediatric clinical populations or adults with TBIs; however, research has suggested the efficacy of some interventions specifically with children. Although the neurocognitive and neurobehavioral sequelae following TBI are extremely broad, students typically experience executive dysfunction and memory, attention, and processing speed deficits (Felmingham, Baguley, & Green, 2004; Morrison); thus, these areas will be focused upon here. In general, this population has been found to respond to structured cognitive rehabilitation. This can be defined as a "systematic, functionally oriented service of therapeutic cognitive activities and an understanding of the person's behavioral deficits" (The Society for Cognitive Rehabilitation, 2004, p. 8). These services are undertaken in order to "reinforce, strengthen, or establish previously learned patterns of behavior, or establish new patterns of cognitive activity or mechanisms to compensate for impaired neurological systems" (p. 8).

A specific, structured and comprehensive cognitive rehabilitation program includes Brainwave-R: Cognitive Strategies and Techniques for Brain Injury Rehabilitation (Malia, 1997); however, other programs are available. The structured training in this program may be oriented toward attention, memory, executive functioning, information processing, and social skills deficits. It has also been recommended that a family training module accompany this type of training (Morrison, 2011). Additional information about cognitive rehabilitation can be obtained from Sohlberg and Mateer (2001) and Sohlberg and Turkstra (2011). Although not focused specifically on cognitive rehabilitation, an additional program that has received support in the literature with regard to this population is the BrainSTARS: Strategies for Teams and Reeducation for Students with Acquired Brain Injury program (Dise-Lewis et al., 2009). This comprehensive program was developed specifically for use in the educational setting and focuses upon training school personnel to work appropriately with students with TBIs. 

In summary, research has indicated that children with TBIs represent an underidentified and underserved population within the educational setting (Cronin, 2000; Glang et al., 2004; Walker et al., 1999). However, recognition of this fact highlights the need for better communication across settings and more appropriate training for school personnel such as school psychologists. These needs become increasingly important given research has suggested a student's ability to succeed at school following a brain injury is largely dependent upon the quality of transition across settings (Gfroerer, Wade, & Wu, 2008). Awareness of this significant issue among school psychologists, who can be considered "front-line responders," can allow these individuals to take preliminary steps toward a resolution.


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About the author

Ashley S. Fournier is a fourth-year doctoral candidate in the school psychology program at Texas Woman's University in Denton, Texas.