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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 & 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, G. (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.
To learn more about neurodevelopment and brain injury in children, please visit http://www.lapublishing.com. You will find a free catalog, tip card offer and many resources for therapists, educators, families and children.
Featured Authors and Organization: Lash & Associates Publishing/Training Inc.
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Lash & Associates Publishing/Training, Inc. publishes practical, informative, and affordable materials on traumatic brain injury in children, youths, adults and veterans. Their audience includes families, persons with brain injuries, health care professionals, rehabilitation specialists, educators and community staff. In addition to an impressive library of written offerings, Lash & Associates offers CEU Online Training in the area of traumatic/acquired brain injury for professionals including therapists.
About the Authors:
Marilyn Lash M.S.W., uses her social work experience and research in pediatric rehabilitation to develop sensitive and practical guides for families, educators, and professionals. Marilyn’s specialty is helping families cope with the emotional impact of brain injury and developing strategies for negotiating the complex service system. Now Director and Senior Editor of Lash & Associates Publishing/Training Inc., she focuses on developing user friendly publications for families, educators, and clinicians.
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