By Carolyn M. Sweeney, Lydia K. Mallah, and Jacquelyn Moultrie
This issue of NASET’s Classroom Management series was written by Carolyn M. Sweeney, Lydia K. Mallah, and Jacquelyn Moultrie. Providing behavioral and instructional interventions is cardinal for the success of students with traumatic brain injury in school. Traumatic brain injury happens by accident, which affects a child or adult who may be involved in executive function skills, leading to challenging behavior. Teachers should be cognizant of the negative impact of traumatic brain injury on students’ social skills, communication skills, academic skills, and other health-related problems to provide the appropriate behavioral interventions and evidence-based instructional interventions for the success of those children. This paper describes traumatic brain injury causes and statistical data, academic and behavioral impact, and evidence-based instructional and behavioral interventions that can be used to support students with traumatic brain injury. The paper also recommended areas of further research.
Abstract
Providing behavioral and instructional interventions is cardinal for the success of students with traumatic brain injury in school. Traumatic brain injury happens by accident, which affects a child or adult who may be involved in executive function skills, leading to challenging behavior. Teachers should be cognizant of the negative impact of traumatic brain injury on students’ social skills, communication skills, academic skills, and other health-related problems to provide the appropriate behavioral interventions and evidence-based instructional interventions for the success of those children. This paper describes traumatic brain injury causes and statistical data, academic and behavioral impact, and evidence-based instructional and behavioral interventions that can be used to support students with traumatic brain injury. The paper also recommended areas of further research.
Key Words:Traumatic, Brain, Injury, Behavior, Academic and Interventions.
Introduction
Traumatic Brain Injury (TBI) is a disability that a person is not born with but encounters in life’s journey. Imagine a person leaving their house and being involved in an accident that resulted in a brain fracture, or a child that fell while playing, resulting in a brain fracture, and in the end, being diagnosed with TBI. Even though TBI is considered a low-incidence disability in public education, statistics show that a large pediatric population is affected by TBI each year (Nagele et al., 2019). Research and annual statistics have shown that TBI is a leading cause of disabilities and death in children (Araki et al., 2017). Supporting pediatric TBI survivors in their educational careers is crucial, as it will eventually help them become contributing members of society. Academic success will assist them in contributing to their families and the growth and development of society. In order to do this, educators must ensure that children with TBI receive appropriate behavioral and academic interventions to meet their individual needs following their injuries. This paper aims to describe TBI’s related evidence-based behavioral interventions and provide instructional strategies teachers can use to support children with TBI to succeed in school.
Defining Traumatic Brain Injuries
Traumatic brain injury (TBI) is one of the disability categories recognized by IDEA (Individuals with Disabilities Education Act). However, it is different from other disabilities because of its sudden impact on the trajectory of psychosocial and educational development. It is unique in presenting symptoms as they are neither degenerative nor congenital. TBI consists of primary and secondary damage that ranges from immediate onset to a reactive process that occurs hours, days, or weeks after the injury (Araki et. al., 2017).The effect on a student’s performance level requires support in academics, social interactions, overall communication skills, and physical health (Lucas, 2010). Groups of symptoms can range from mild to severe, demanding individually specialized support and instruction. A student can go from being above average in a general education classroom with a universal design of instruction to being reassigned to a self-contained supported classroom structure in subsequent school years in response to their academic and learning needs (Canto et al., 2014). Federal legislation defines TBI as an acquired injury to the head from an external force that causes partial or complete impairment of functionality and often negatively impacts a child’s educational performance (Lucas, 2010).
A loss of consciousness for an unspecified duration resulting from external physical forces that jolt or penetrate the skull categorizes the implications of TBI as defined by medical professionals (Schuchat et al., 2016). Mild forms of TBI, for instance, a concussion, can result in an alteration of consciousness and are commonly not reported to school professionals. This phenomenon of not communicating with the teachers and administration is a common barrier, as many parents are unaware of the importance of reporting the injury (Nagel et al., 2019). Compounding this lack of communication from parents, they need to be adequately informed by physicians diagnosing and treating their child’s injury and the implications of mild to moderate TBI on their school performance (Canto et al., 2014). Some students with milder forms of TBI can initially reintegrate into the classroom but, over time, reveal areas of needed support. Formalized 504 plans help ensure that students can participate fully in their regular school programming (Bowen, 2005). Students with moderate TBI enrolled in general education classrooms typically require accommodations to the environment and modifications to their curriculum once cleared to resume school activities (Schuchat et. al., 2016). Coordinated care, communication between home and school, and ongoing monitoring of the presentation of symptoms are critical elements to defining the supports necessary to help the student return to school (Canto et. al., 2018).Severe forms of TBI require a team of specialized support staff to create an individualized education plan (IEP) to provide instructional strategies and behavioral interventions that meet the student’s present level of performance.
Causes of TBI range from simple to complex and impact an individual’s developmental trajectory according to the Centers for Disease Control (CDC) and Prevention (Schuchat et. al., 2016). Many instances of TBI occur from falls, car accidents, assaults, or firearm-related accidents. On the more straightforward side of understanding the cause of these injuries, unintentional accidents or mistakes are most common among children younger than 14. However, more complex circumstances to understand are abuse, neglect, or socioeconomic status that limits access to foods of high nutritional value and primary healthcare (Schuchat et. al., 2016). The complexity of the impact of TBI can change how students think, feel, navigate the world around them, and manage their inner world of emotions and thoughts. Children with TBI can experience one or more impairments to cognition, language, memory, attention, judgment, abstract thinking and reasoning, processing, speech, physical functions, and psychosocial behaviors (LaRose et al., 2019). While understanding the cause of TBI helps inform school professionals of the type of head injury a student experiences, educators have to meet a learner at their present level of performance and strive to build the capacity for more fundamental knowledge to enhance their repertoire throughout individual development (Bowen, 2005).
Prevalence in the United States: Statistics
It is not debatable whether anyone can get a TBI because people travel daily, and sometimes, little mistakes, even at home, may cause a person to fall and result in a TBI. According to the CDC (2019), 5.3 million people, which is 2% of United States citizens, live with a disability that resulted from a TBI. In the United States alone, about 1.7 million people sustain TBI annually; 275,000 of these people can be hospitalized, and 52,000 people lose their lives (Canto & Eftaxas, 2018; Faul et al., 2010; Finch et al., 2016). This makes TBI a disability that needs attention due to the growing number of people affected daily, leading to permanent disabilities that affect them throughout their lives. According to the CDC (2023), there were 223,135 related hospitalizations in 2019, and in 2021 there were 169,473 TBI-related deaths in the United States. Moreover, daily, there are about 611 hospitalizations and 190 deaths. According to Araki et al. (2017), TBI has been identified as a leading cause of disability and death in children. Araki et al. (2017) reported data from the CDC and Prevention in their study that showed that annually, about 475,000 children in the United States ages 0-14 years have injuries that resulted in TBI, and children ages 0-4 years old have frequently been taken for emergency consultation at 1,035 per 100,000 children.
Moreover, according to Nagele et al. (2019), between the age of 1-19 years old, nearly 145,000 children in the US suffer from TBI, which affects their social, behavioral, physical, and cognitive functioning. Nagele et al. (2019) further asserted that in 2013, only 26,371 of these children were served in special education, based on the US Department of Special Education 2013 report, which might be caused by a lack of awareness on parents’ part of diagnoses or to inform the teacher about the child’s condition. Thus, some children in school with TBI are not receiving the appropriate support because their parents did not inform the schools of their injury. With this estimated number of children that suffer from TBI and with the increase each year, special education teachers should be able to utilize evidence-based behavioral interventions and teaching strategies to help these children succeed in school.
The Impacts of Traumatic Brain Injury
Traumatic brain injury can have immediate and life-long impacts, TBI can negatively impact all areas of an individual’s life and has been linked to effects such as memory problems, impaired executive functioning skills, negative behaviors, slower processing skills, and a reduced ability to gain new knowledge or information (Dang et al., 2017; Millis et al., 2001). While many factors attribute to the ramifications of TBI, such as the age of injury, the severity of TBI, the individual’s skills prior to the TBI, and the amount of time before the individual received medical care, it has been well documented that TBI can affect an individual’s educational success, physical abilities, social skills, and independent functioning (Millis et al., 2001).
Within the literature surrounding TBI in children, a systematic review by Li et al. (2013) suggested that pediatric TBI’s behavioral and psychosocial impacts have been less researched than the effects on physical and cognitive capabilities. Interestingly, the presented behavioral and psychosocial characteristics are more concerning for parents and teachers (Li et al., 2013). Pediatric TBI survivors have been reported to have an increase in internalized and externalized behaviors such as aggression, anxiety, impulsivity, personality changes, oppositional defiance, and the onset of Attention Deficit Hyperactivity Disorder (ADHD) (Li et al., 2013). While some of these behaviors may resolve within the first year (depending on previously listed factors,) sustaining behaviors may stabilize or increase in the years following a TBI (Li et al., 2013).
Impact of TBI on Academic Performance
TBI’s academic impacts can be profound and extensive depending on the provided variables. Six months following TBI, academic skills are typically negatively impacted, regardless of the severity of the TBI (Prasad et al., 2017). The academic implications of TBI are widespread and have been documented in nearly all academic settings and domains, including reading, writing, and math. For instance, TBI has been linked to lower levels of executive functioning skills, which may also impact a child’s reading, writing, and math capabilities (Prasad et al., 2017). While some improvement in academic performance occurs typically 6 to 12 months after TBI, several studies have shown that pediatric TBI is related to continuing academic challenges (Arnett et al., 2013; Bowen, 2005; Canto et al., 2014; Prasad et al., 2017; Shultz et al., 2016). Children with TBI do develop new skills; however, they are typically at a slower rate, and they may struggle to meet age and grade-level expectations (Prasad et al., 2017).
Within the educational community, TBI is considered a low-incidence disability; however, the special education and support services necessary after TBI show that the need for educator awareness and training is crucial (Prasad et al., 2017). Only about 21% of children with severe TBI receive academic instruction in the regular education curriculum and are promoted to the next grade with average testing scores (Prasad et al., 2017). Upon returning to school, 25% of students presenting with mild-moderate and severe TBI received special education services, while 41% received some form of academic support (Prasad et al., 2017). In a study conducted one year post-TBI, 45% of children presenting with moderate and severe and 6% with mild TBI were receiving new special education services under the Individuals with Disabilities Education Act (IDEA).
Behavioral Impacts of Traumatic Brain Injury
Schools are an established learning environment, allowing students to practice and sharpen their social skills. Creating an atmosphere of cooperation and collaboration requires students to be capable of engaging in socially acceptable behaviors consistently. Behavioral impacts of TBI on social interactions within the classroom can be mildly disruptive, like speaking out of turn, to extreme instances, like property destruction and safety concerns (Bowen, 2005). For students with TBI to succeed in school, teachers need to conduct functional behavior assessments and implement evidence-based interventions that will help these students succeed.
There is a growing body of research regarding survivors of pediatric TBI and the onset of Attention-deficit/hyperactivity disorder (ADHD) following their injury (Asarnow et al., 2021; CDC, 2022; Narad et al., 2020; Shultz et al., 2016; Yang et al., 2016). The CDC (2022) lists brain injury as a possible cause of ADHD and states manifestations of inattention and hyperactivity or impulsivity. Children with ADHD must present with certain behaviors for a set time frame, at least six months, and must exhibit five to six (depending on the individual’s age) traits prior to diagnosis. In addition to physical and academic deficits, children with TBI and secondary ADHD may be forgetful, struggle to focus in academic or play settings, make careless or simple mistakes, labor to remain still or in their seats, and lose essential items or school work (CDC, 2022).
Citing previous studies, Yang et al. (2016) questioned the solid relationship between TBI and ADHD. So, they proposed using a nationwide population-based longitudinal study to determine whether their relationship could be confirmed. Their study, conducted in Asia, was stated as the first comprehensive study based on a large-scale examination of 10,416 children under 12 with TBI. This study followed those children for the following nine years, and researchers determined that children with TBI had a higher chance of presenting with ADHD symptoms and characteristics (Yang et al., 2016). Similarly, Narad et al. (2020) also conducted a study investigating the onset of Secondary-ADHD (SADHD) in 120 children and adolescents who did not present with ADHD traits prior to injuries. Narad et al. (2020) focused on functional impairments and executive functioning skills. Researchers stated that 16% of children with TBI exhibited characteristics of ADHD six months after their injury. Additionally, children with moderate TBI were twice as likely, and those with severe TBI were four times more likely to exhibit ADHD traits than those children with orthopedic injuries (OI), in which children with OI were used as a control group (Narad et al., 2020). Researchers determined that their study provided significant evidence to support the connection between SADHD and TBI in young children. Subsequently, parental reports on the negative impacts on self-regulation and independent functioning skills were magnified for those children with TBI. Based on their research, Narad et al. (2020) suggested that children and adolescents with TBI and SADHD are at a higher risk of struggling as they transition from structured environments with academic and social support to settings that require developed independent and executive functioning skills. Educators should be willing to provide the students with empirically proven support to assist students with TBI, as well as interventions and strategies that support students with ADHD, as the positive correlation between the two has been documented.
Evidence-Based Behavioral Interventions
Explicit instruction is identified as one of the most effective evidence-based strategies for teaching children with TBI (Utley et al., 2019). Rosenshine (1987) described explicit instruction as “a systematic method of teaching with an emphasis on proceeding in small steps, checking for student understanding, and achieving active and successful participation by all students” (p. 34). This type of instruction involves providing guidance for students and demonstrating the rationale for which these skills should be taught. This teaching method is explicit because it is systematic and designed to teach students the skills they need to learn by providing various scaffolding support. This involves the teacher defining the study’s objective and modeling the lesson step-by-step for the students to see and receive feedback that learning has occurred (Hughes et al., 2018). Using explicit instruction, the teacher can incorporate the “I do, we do, you all do, and you do” method of gradually releasing responsibility to teach children with TBI to become independent learners. By using explicit instruction, educational professionals can begin to implement evidence-based interventions to meet the behavioral needs of pediatric survivors of TBI.
Instructional evidence-based interventions are a pillar in teaching special education students with dynamic needs in their learning and behavior. Antecedent strategies and task analysis visuals are incorporated into classroom interventions, encouraging students to practice independent functioning in a supportive environment (Bowen, 2005). Explicit instruction, scaffolding, and self-regulated learning are instructional interventions with proven efficacy to support students in managing the effects of TBI on academic performance, social skills, overall communication, and physical health (Vaughn et. al., 2014).
The Gradual Release of Responsibility (GRR) instructional model utilizes a combination of explicit instruction, scaffolding, and self-regulated learning practices for a strategic, evidence-based approach to support academic progress and behavior regulation skills for students with TBI (Vaughn et. al., 2014). The biggest challenge students with TBI encounter when they return to school and manage the adjustments needed to function at their best. GRR is ideal for teaching students with TBI because of the flexibility it allows the teacher to move through the four levels of instruction. Explicit instruction modeled is the first step of the GRR model, and the teacher explains the lesson and modeling skills like metacognition in addition to setting up the expectations required to complete the assignment. The next level of guided practice permits the use of scaffolding by the teacher as an instructional strategy to begin releasing responsibility to the student. For students returning to school from a TBI, guided practice will allow them to feel supported while demonstrating what they have learned. After guided practice, the next level of the GRR encompasses peer-to-peer collaboration, and students can apply what they have learned and receive immediate performance feedback from the teacher or their peers. Another excellent way for students impacted by TBI to reintegrate into a structured classroom environment is to practice their social skills with peers meaningfully. The fourth level of the GRR model promotes independent practice, and they assume all responsibility for their learning. The ability to complete a task requires the development of planning, time management, problem-solving, and emotional control. Another evidence-based instructional strategy of self-regulation learning can be used simultaneously with the independent practice portion of the GRR model (Hall et. al, 2021). Self-regulation learning puts the responsibility on the student to monitor, evaluate, instruct, and reinforce their behaviors. Students with TBI who may need additional support to independently understand the task may require additional one-to-one time with the teacher to review concepts. GRR is essential for assisting teachers with effective interventions to support their students affected by TBI (Hall et al., 2021).
While children with TBI will face many challenges as they return to school, both physical and academic, it is essential as educators that we are aware of the social impacts of TBI. Shultz et al. (2016) conducted a study on adaptive functioning and executive functioning skills following TBI. Their sample consisted of children and adolescents who were at least three years old at the time of their injury; coincidentally, most participants were approximately four years old. The participants were currently between 8 and 13 years of age and had been hospitalized for a complicated mild to severe TBI. Parents of the participants were asked to complete the Adaptive Behavior Assessment System-Second Edition (ABAS-11). The ABAS-11 rates a participant’s ability to perform in nine domains: (a) communication, (b) self-direction, (c) functional academics, (d) leisure, (e) social, (f) self-care, (g) home living, (h) health/safety (i) community use. Parents also completed the Behavior Assessment for Children-Second Edition (BASC-2), which rates areas such as functional communication, leadership, social skills, daily living, and adaptability. Lastly, they were asked to complete the Child and Adolescent Scale of Participation (CASP), which determines the extent to which an individual is involved in certain environments. Upon completion and analysis of the instruments, Shultz et al. (2016) were able to determine that children with severe TBI struggled more in adaptive functioning than those with mild or moderate TBI. This data confirms previous research in this area of study. The researchers stated that with this data, they hypothesized that pediatric survivors face challenges in adaptive functioning, specifically in the social domain(s), and that children with TBI who may have reduced processing speed may find it difficult to initiate or maintain social interactions.
Social skills are essential in academic settings but also extend to an individual’s quality of life. Educational professionals must be prepared to meet the needs of students with TBI regarding social interactions. One strategy that can be implemented is the use of a Social Story™, depending on the developmental age of a pediatric survivor. A Social Story™, as described by Wahman et al. (2019), has specific criteria: It must identify the social situation, highlight the target behavior, and provide context for the social situation. There are six types of sentences found in Social Stories™ (a) descriptive, which identifies the social situation (b) directive, which should describe the socially appropriate behavior (c) perspective, response reactions (d) affirmation (e) control, which should help the child understand the situation (f) cooperative, who will help and how they will help. Within their review of the literature regarding Social Stories™, Wahman et al. (2019) cited several studies that supported using Social Stories™ as an evidence-based practice when teaching social skills. However, upon completing their meta-analysis, Wahman et al. (2019) cautioned against using Social Stories™ as an evidence-based practice as their findings varied among the twelve studies that met their criteria. However, Park’s (2017) meta-analysis of sixteen worldwide studies confirmed the use of Social Stories™ for the instruction of social skills and reducing interfering behaviors. The target across all twenty-eight studies was to use Social Stories™ to decrease negative or aggressive behaviors and increase prosocial behaviors.
Additionally, positive behavior interventions and support have been proven to be effective evidence-based practices when working with students with TBI to improve their behaviors. Ylvisaker et al. (2007) conducted a systematic literature review with 65 studies and 172 experimental participants, including children and adults, to assess the effectiveness of three evidence-based practices for behavior intervention for children and adults with TBI; the intervention included contingency management, positive behavior interventions, and supports and combined. The result showed improvement in behavior. They concluded that contingency management and positive behavior support procedures are evidence-based treatments for people with TBI. Also, Feeney and Ylvisaker (2008) conducted a single-subject reversal design study with two elementary children with growing aggressive behavior due to TBI. The study was intended to gather information on the effect of combined behavior, cognitive, and executive functioning based on the frequency and intensity of their behavior and how it impacted their work. The intervention included positive behavior support, cognitive support, and an executive function routine. The findings indicated a reduction in aggressive behavior and increased task completion. Thus, positive behavior support is an effective evidence-based behavior intervention for children with TBI. The Association for Positive Behavior Support (PBS) (n.d.) describes PBS as a research-based set of evidence-based strategies that can be used to decrease problem behavior and increase positive behavior by teaching new skills to replace the negative or problem behavior in people with challenging behavior. This involves identifying the problematic behavior, identifying behavior that will be taught to replace the problem behavior, modifying the environment, and removing anything that may trigger the problem behavior, using the adaptive curriculum, allowing students to make choices, having a well-organized schedule, and always rewarding positive behavior.
The behavior momentum intervention is also considered an effective evidence-based intervention for children with TBI. According to Bowen (2005), it begins with starting the child with a very easy task that the child can perform without encountering any challenges. In the process, the teacher can capitalize on the momentum, reinforcing positive behavior as the students perform, followed by behavior the child does not like to engage easily with. For most noncompliant students, the teacher could give them a task they are likely to comply with, referred to as high probability (high P) instruction (Sweigart, 2021). This can be immediately followed by a task the child is less likely to comply with. This is referred to as low probability (low P) instruction. In the process, the behavior momentum created by the compliance to the high probability can encourage the child to comply with the low P instruction (Sweigart, 2021).
Areas of Further Need and Research
Evidence-based behavioral interventions for children with TBI seem to be an area that needs more research. Limited current studies present evidence-based behavioral interventions for children with TBI. There are instructional strategies that are identified for children with TBI, but there is limited current research that presents behavioral interventions specifically for children with TBI. The interventions presented in this study are also workable for other disabilities. There was no specific intervention that applied to only children with TBI. Also, there is a need for research to be conducted to gain further insight into why parents are not reporting cases of TBI to schools. The report from the CDC for children diagnosed with TBI presented above is high, but the percentage of children that receive special support in school is less. For instance, only 21% of children with severe TBI receive specialized support. Therefore, research should identify why these cases are not reported. Additionally, several studies reviewed for this article regarding social impacts and interventions were limited; many of the studies located by the authors focused mainly on adult survivors of TBI. Further research should be conducted on the social impacts of pediatric TBI and evidence-based interventions.
Conclusion
For a teacher to effectively work with a particular disability, it is essential to understand the disability. TBI is different from other disabilities because a person is not born with it but encounters it in life’s journey. TBI negatively impacts a person by affecting their memory, impairing their executive function skills, causing them to present challenging behaviors, and reducing their ability to gain new knowledge. Children affected by TBI may need academic support, social skills training, functional communication skills, and physical health support. A student who was a high achieving student may need specialized support if experiencing TBI. The authors of this article have described TBI and related evidence-based behavioral interventions and instructional strategies that can be used to support children with TBI to succeed in school. This was done to add to the body of literature surrounding TBI and assist professional educators in their efforts to support students with TBI.
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