Traumatic Brain Injury Impacts Education and Learning

by Manfred Tatzmann, Kathi A. Clancy, and Jane E. Reagan

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Traumatic brain injury (TBI) is often called a “silent epidemic.” It is called an epidemic because each year the number of individuals who experience a TBI is growing steadily. It is considered a silent epidemic because, in addition to other problems, a TBI can result in cognitive deficits invisible even to the most experienced professionals. Yet, as a public health problem, TBI is still widely ignored and misunderstood. TBI’s growth and misdiagnosis have become increasing problems for educators, family members, and especially students. Although many school administrators often consider TBI to be a low-incidence problem and report no occurances in their schools, the facts tend to contradict this belief (Tyler, 2000).

The growth and misdiagnosis of TBI led the Michigan Department of Community Health (MDCH) to release a report in September 2004 titled Addressing Michigan’s Public Service Gaps for Persons with Traumatic Brain Injury: Final Report of the MDCH TBI Project. Following the report, MDCH continues to work to educate the public about the incidence and impact of TBI in an effort to raise awareness about diagnosis, services, and supports for individuals with a TBI. This FOCUS on Results article provides an overview of the incidence and causes of TBI, the challenges to human services systems (particularly in the public sector), and recommendations for educators and clinicians who work with children and students with a TBI. Finally, the article is intended to stimulate more interest in educators and others to use available resources, make efforts to increase awareness about the various aspects of TBI, and encourage improved support and services for individuals and their families who struggle with TBI.

Understanding Traumatic Brain Injury

A brain injury is defined as any injury that results in brain cell death and loss of abilities. A traumatic brain injury is an injury to the brain caused by blunt or penetrating trauma or from acceleration/deceleration forces, such as from a fall, car crash, or being hit or shaken (Thurman et al., 1994). A TBI may or may not include a loss of consciousness, an open wound, or skull fracture. A brain injury that occurs after birth but was not caused by trauma, such as a near drowning, is categorized as an "acquired brain injury" (ABI). This injury is NOT considered a traumatic brain injury. An ABI can be caused by events such as a TBI, stroke, near suffocation, brain tumor, infections in the brain, throat swelling, choking, strangulation, or crush injuries to the chest, among many others (Brain Injury Association of America, n.d.). Although the cause may be different from that of TBI, often the disabilities, symptoms, and service needs of individuals with an ABI are very similar to those with a TBI.

Causes of TBI in Michigan, All Ages

FIGURE 1 1999-2002 Traumatic Brain Injury Related Deaths by Cause

D

FIGURE 2 1999-2002 Nonfatal Hospitalized Traumatic Brain Injury Cases by Primary External Cause

D Cause of injury coding is not complete for inpatient and emergency department data. Percentages are calculated based on 86% of inpatient TBI cases and 65% of emergency department TBI cases that had a cause recorded. Emergency department data is unweighted.

FIGURE 3 Nonfatal and Nonhospitalized Traumatic Brain Injury Cases by Primary External Cause, 2001 Sample Emergency Departments in Michigan

D

The Increase of TBI

The number of people identified with a TBI has increased significantly in recent years due to faster and more effective emergency care, quicker and safer transportation to trauma centers, and advances in acute medical management. In its three year study that culminated in the September 2004 report, MDCH found that in Michigan 41% of nonfatal, non-hospitalized cases among individuals with TBI, who presented themselves in an emergency department, were children ages 0–14 years. Children ages 0-14 years make up 15% of hospitalized TBI patients.

According to a national study published by the federal Centers for Disease Control and Prevention (Centers for Disease Control and Prevention, 2004), an average of 475,000 TBIs occur across the U.S. each year among children ages 0–14 years. Among older adults (ages 65 years and older), 155,000 TBIs occurred. Reported hospital emergency department visits accounted for a larger proportion of TBIs among children (91.5%) than among older adults (53.6%) (Langlois et al., October 2004).

Very young children, ages 0–4 years, had the highest rate of TBI-related emergency department visits (1,035 per 100,000 population). Nationally, almost 50% of cases of brain injuries to infants, toddlers, and young children were related to assaults, child abuse, and falls. Motor vehicle accidents, including motorcycle and recreational vehicle accidents, accounted for the largest incidence of TBI among the 15–24 year old age group—both in Michigan and nationally (see figures 1, 2, and 3). In fact, the proportion of brain injuries caused by motor vehicle-related accidents increased with age, from 20% in children ages 0 to 4 years, to 66% in adolescents (Silver et al., December 2004).

Overall, at least 1.4 million people sustain a TBI every year. Out of the 1.4 million, about 50,000 individuals died, 235,000 required hospitalization, and emergency departments treated and released another 1.1 million (Centers for Disease Control and Prevention, 2004). In Michigan, emergency departments treat approximately 34,000 people each year for a TBI. Currently, more than 200,000 persons with a TBI reside in Michigan (Michigan Department of Community Health, September 2004).

Some of the Long-Term Effects of TBI

The brain is a very complex organ and every brain injury is different. Recovery after brain injury can range from complete recovery to total loss of function. A TBI is simplistically categorized as mild, moderate, or severe. Seventy-five percent of TBIs are mild, also known as concussions. Depending on the severity of the injury, long-term effects of a TBI in both children and adults may include:

1. Cognitive and sensory issues such as problems with memory, judgment, concentration, learning new information, communication, and organization.
2. Behavior and emotional symptoms such as irritability, impatience, impulse control, difficulty with anger management, increased stress and anxiety, inability to read social cues, excessive mood swings or personality changes, and depression.
3. Physical challenges such as headaches or severe head pain, lack of coordination or balance, problems with sleep, fatigue, slurred speech, trouble swallowing, and seizures.

Whether the injury is the result of a car crash, slip and fall, assault, sports activity, or other occurrence, treatment generally begins at the scene of the incident and continues from emergency medical services through acute care (sometimes in a hospital), rehabilitation, and long-term care.

Often, the disabilities or impairments resulting from brain injury create stress in peer and family relationships. Depression, anxiety, and substance abuse are also widespread among individuals with brain injury. A TBI typically affects an individual’s current information processing, attention, processing speed, memory, and behaviors, while old learning typically remains intact or recovers to pre-injury levels.

What Educators Need to Know About TBI

A TBI is not a learning disability (LD) or cognitive impairment (CI), although after a child suffers a TBI, he or she may have characteristics similar to those of children with a LD or CI. However, there are important differences between children with a TBI and those with a LD or CI that require varying teaching strategies to help them learn in school. For example, TBI survivors eventually recover some functions, sometimes slowly, sometimes quickly, often unpredictably or unevenly. Students with a TBI also may exhibit more severe or exaggerated learning issues as compared to those with a LD or CI. Students with a TBI often relearn previously understood material more easily and quickly than new material. The educator may realize that learning strategies that used to work for the student no longer do.

A TBI is an acquired condition. Problems may arise if a student remembers his or her capabilities before the injury. The differences the student perceives between the old and new comprehension may lead to great anger, frustration, and/or active denial (Hibbard et al., November 2001). This becomes an even greater problem if the student was formerly an athlete or active in other school activities, which subsequently have become reduced or eliminated because of the TBI.

Planning for Student Needs

School personnel involved with the student diagnosed with a TBI will benefit by working with the family and student to set up a plan that meets the student’s needs. The plan should be chronological and provide step-by-step sequencing. For example, rather than waiting for the student to return to school after an incident that caused a moderate or severe TBI, educational team members should consider beginning the planning process before the student is discharged from the hospital. When possible, team members should visit the student at the hospital to observe and learn about the extent of the disability. Facilitating a meeting between the parents, student, school staff, and hospital staff to understand the various issues that exist or are emerging, including determining which therapies have been ordered, is also helpful. It may be useful to schedule a meeting with the hospital discharge planning staff to ensure continuity of the services and supports the student needs and obtain all necessary signed releases for personal and medical record information. Prior to the student’s reentry to school, the team should arrange a follow-up conference to begin the individualized education program (IEP) process.

Once the student returns to school, the school professionals need to understand the student’s:

• Present condition, limitations, and neurological status.
• Therapy requirements.
• Medical equipment needs.
• Self-care plan.
• Medication requirements.
• Communication and/or behavioral concerns.
• Cognitive recovery pattern.
• Need for homebound services, if an assessment reveals the student is not ready to return to the school building.

Useful Strategies

With high quality programming that is thoughtful, individualized, and sensitive to the student’s needs, a student with a TBI should reach his or her potential. There are useful strategies and accommodations that educators and clinicians who work with students with a TBI and/or their families can use to improve learning. Educators should understand that when using any of the strategies or accommodations listed below, the student’s IEP team should be involved, especially the classroom teacher. Other team members can include the student, a service coordinator, appropriate school staff, clinicians, and parents or guardians. Some strategies and accommodations can include:

• Shorten the school day. Fatigue can be a significant issue for TBI survivors.
• Schedule time for physical rest if necessary. Sometimes a simple 30-minute nap can provide TBI survivors with the time to recoup and continue their day.
• Reorganize the school day so academics are first. Adjusting the sequence of courses can make a huge difference to a student with a TBI. For most of these individuals, concentration is best in the morning and wanes as the day continues. Scheduling the more difficult courses in the morning can be a valuable strategy.
• Assign him or her a buddy. Having a one-on-one buddy to help navigate the noisy, crowded hallways of a larger school can help the student with a TBI make his or her way to class on time and be ready to learn, instead of getting lost, confused, or even scared in the maze of school halls. Often the buddy system is ideal for helping the student stay organized (Kohon, January 2005)..
• Help the student reenter the school environment slowly. When a student with a TBI returns to school, provide as much one-on-one support as needed. Encourage other students, whenever possible, to aid and assist the student in keeping track of class schedules. Refamiliarize the student with unwritten nuances of school life (from bus protocols to cafeteria norms).
• Implementing simple techniques. Often, to deal with the challenges of short-term memory loss, repeat, review, and get feedback from the student with a TBI about instruction.
• Give instructions both orally and in writing. Since each student’s learning occurs differently, it is better to provide information using the different senses. Above all, always keep instructions simple.
• Provide assistive technology. For many TBI survivors, physical agility has been compromised or other disabilities are now present. Computers, talking boards, software, and other innovations help make the curriculum accessible to all students. Take advantage of them! (For more information visit, www.cenmi.org/matr.)
• Offer accommodations to the student with a TBI. Accommodate by allowing the student with a TBI more time to process information and complete tasks. Allow the student to provide feedback orally and use other methods of tests or demonstrations to help him or her grasp the information being taught.

Post-Secondary Transition Issues

For older students facing transition to post–secondary life, unique issues exist. These students need preparation for a world different from their high school. They need to learn that there are no IEPs in college or the workplace.

Prepare students with coping mechanisms to help make unexpected behavior more tolerable. For example, some students have flashbacks of their accident and act out. Coping mechanisms can help students survive in a college classroom or work break room. It may be helpful to discuss the student’s past hopes and dreams and how those compare to the new reality of his or her post-TBI status. Confronting disabilities and accepting new abilities is not easy for many TBI survivors. (View various Michigan transition resources at www.cenmi.org/tspmi.)

Michigan Addresses the Challenges of TBI

The MDCH received a grant from the federal Health Resources and Services Administration (HRSA) within the Maternal and Child Health Bureau of the Department of Health and Human Services. For more than four years, this grant project examined the problem of TBI and deficiencies in the public service delivery system. The Michigan Department of Education (MDE), the Department of Human Services (formerly FIA—the Family Independence Agency), and the Brain Injury Association of Michigan partnered with the MDCH in this effort. The partners published the final grant report in September 2004, identifying the incidence of TBI in Michigan, the cost, and the gaps in services (Michigan Department of Community Health, September 2004). The Office of Special Education and Early Intervention Services (OSE/EIS) at the MDE provided a copy of the report’s Executive Summary to all administrators of special education in Michigan and all directors of public school academies. The OSE/EIS also sent intermediate school district (ISD) superintendents a copy of the full report.

Dr. Jacquelyn J. Thompson, Director of the OSE/EIS, said that the publication of the TBI project report is an important step toward increasing awareness of a complex issue. “The outreach and education must continue beyond reading the report,” she said. “I look forward to hearing from school staff who have strong interest and expertise to share as we educate more Michigan citizens about TBI.”

As part of the grant, the partners selected three geographic areas of the state (Michigan’s Upper Peninsula, Southeast Michigan, and Southwest Michigan) as pilot areas to test training of professionals in public agencies and several school districts. In addition, based on separate requests, the grant project provided TBI in-service training to staff at Barry ISD and Berrien ISD. These professional development opportunities were so well received that the TBI grant project used them as a basis for development of a curriculum for an online professional development course. The project anticipates implementing the course in April 2006.

More Ideas for Improving Services for Students With TBI

According to the National Resource Center for TBI (Frequently Asked Questions, n.d.), researchers used to think that the brain was more "plastic" at younger ages and able to compensate for injury during the course of development. More recent investigations indicate that younger children who sustain moderate to severe injuries are more likely than older youth to display impaired language and memory functioning; inattention and hyperactivity; slower recovery of motor, visual-spatial, and somatosensory skills; and decreased novel problem solving. Some evidence suggests that disruption of basic skills in the early years of development (e.g., language, memory, or motor skills) interferes with later development of higher order skills (e.g., reasoning, problem solving). Even children who seem fully recovered from injury may experience "late cognitive effects" or the appearance of academic problems and declining skills over time. Such apparent declines in functioning may be due to delayed recognition of cognitive problems or to increasing performance demands as the child grows older.

Problem Areas in Service Delivery

School staff training, along with improved school program planning, are important to meeting the needs of students with a TBI. A TBI impacts not only the child/student but the school system, and others in many ways. School staff need more tools to improve decision-making about when a student is ready to reenter the school setting after the trauma.

It is important for schools and service providers to be able to identify the student’s energy level, attention and concentration span, memory capacity, and organizational abilities. It is important to know how well the student will be able to handle different levels of stimulation before he or she returns to the school setting. Many times, this is not clearly identified until the student returns to school. After a trial and error period, educators will figure out where the student is functioning in order to build and rebuild a program that is truly individualized. Schools typically under-identify students with a TBI. This can happen because those in the health care and education professions may not ask the right questions regarding the possibility that a student may have suffered a TBI. Thus, schools struggle with student behaviors or fatigue, incorrectly calling them conduct disorders, apathy, or laziness (Silver et al., December 2004). Students who move frequently from school to school offer another challenge.

An important key in recognizing that symptoms may be TBI-related involves gathering a complete and accurate health and incident history of the child. This is not always as easy as it sounds because parents may not understand that an event as minor as a concussion that occurred years ago is affecting their child. Children who have experienced a TBI may be at risk for learning or behavior problems, particularly if the injury was moderate to severe. The events that cause a moderate or severe TBI are usually significant enough for a parent to easily recall and report, even if the event was years ago.

A common difficulty for school professionals is not knowing the child had a TBI. Generally, seventy-five percent of TBI injuries are considered “mild.” If there was no hospitalization, no skull fracture, no "significant" event that caused the TBI and is easily linked to the child’s behavior, or if the TBI-causing event happened years ago, it is possible the parent would not report it, or link the child’s current behavior to it, unless prompted or asked during collection of the child’s history.

Conclusion

Imagine a world where most schools used similar or standard evaluation tools, common assessments, and standard questions that are scientifically-based and driven by current data—all to improve the quality of a student’s education. Our students could thrive if the professionals and staff in the various systems working with the student with a TBI had a common thread of shared reference points.

Although students with a TBI share common characteristics with students who have other disabilities, it is the differences between them that are so important. It is best to identify those students not yet identified as having a TBI and then work collaboratively with all those in touch with the students to assist them. This will result in the best plan possible for success. As those students begin to feel they are part of a friendship community of family, school, hospital, and other agencies, they will come to know that the entire team is working for their success.

Authors

Manfred Tatzmann, State TBI Project Director/Area Manager & Customer Services, Michigan Department of Community Health, (517) 241-2534, (517) 335-6775 (fax), tatzmann@michigan.gov. Kathi A. Clancy, Director, Special Education, Public Schools of Petoskey, (231) 348-2342, Clancy.Ka.M@petoskeyschools.org. Jane E. Reagan, MPA, Department Specialist, Michigan Department of Education, Office of Special Education and Early Intervention Services, (517) 335-2250, (517) 373-7504 (fax), ReaganJ@michigan.gov.

References

Brain Injury Association of America. (n.d.). Brain Injury Association of America’s Facts & Stats. Retrieved January 24, 2006, from http://www.biausa.org./Pages/facts_and_stats.html

Brain Injury Association of America. (n.d.). Brain Injury Association of America, Types of Brain Injury. Retrieved February 6, 2006, from www.biausa.org/Pages/types_of_brain_injury.html#symptoms%20two

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (October 2004). Traumatic Brain injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths, Division of Injury and Disability Outcomes and Programs.

Hibbard, M., Gordon, W., Martin, T., Raskin, B., & Brown, M. (November 2001). Students with Traumatic Brain Injury: Identification, Assessment and Classroom Accommodation. Research & Training Center on Community Integration of Individuals with Traumatic Brain Injury.

Kohon, M. (2005, January 25), Taking the next step, The Lansing State Journal.

Langlois, J. A., Rutland-Brown, W., & Thomas, K.E. (October 2004). Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Michigan Department of Community Health. (September 2004). Addressing Michigan's Public Service Gaps for Persons with Traumatic Brain Injury: Final Report of the MDCH TBI Project. Retrieved January 24, 2006, from http://www.michigan.gov/documents/TBI_Report_2004_107941_7.pdf

National Resource Center for Traumatic Brain Injury. (n.d.). Frequently Asked Questions. Retrieved January 24, 2006, from http://www.neuro.pmr.vcu.edu/

Silver, J.M., McAllister T.W., & Yudofsky S.C. (December 2004). Textbook of Traumatic Brain Injury. Arlington: American Psychiatric Publishing, Inc.

Thurman, D.J., Sniezek, J.E., Johnson, D., Greenspan, A., & Smith, S.M. (1994). Guidelines for Surveillance of Central Nervous System Injury. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC.

Tyler, S.T. (Revised 2000). Traumatic Brain Injury Inservice Training Module. Kansas City, Kansas State Department of Education, Traumatic Brain Injury Project, University of Kansas Medical Center, KS: University of Kansas Medical Center of Special Education.

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