Behavioral Considerations Associated with Brain Injury

ABSTRACT: Children who sustain traumatic brain injury (TBI) can experience significant cognitive deficits. These deficits may signifi­cantly impair their functioning in the class­room, resulting in the need for academic and behavioral modifications. Behavior and social problems can be the direct or indirect result of brain injury. Difficulties in paying attention, staying on task, and predicting the conse­quences of actions may be associated with behavior problems (M. Ylvisaker,T. Feeney,& F. Szekeres, 1998). A neuropsychological evaluation provides information to parents and teachers about the extent of the child’s cogni­tive deficits and explains cognitive strengths and weaknesses. When teachers are provided with this information, they are able to develop appropriate strategies to optimize the child’s ability to learn and function in the classroom.

Children who sustain traumatic brain injuries (TBI) have impaired func­tioning in many areas, including neuro­logic and endocrine, neuromuscular and orthopedic, neurocognitive, and neu­ropsychiatric (Guthrie, Mast, Richards, McQuaid, & Pavlakis, 1999). The extent of these deficits is not fully understood or evident immediately after the injury. Even after acute hospitalization and rehabilita­tion, it is difficult to know the child’s recovery process. Although the word “recovery” is used frequently during the healing process, the implication may be better expressed with the word “improve­ment.” With recovery linked to a return to normal, parents may develop unrealistic hopes (Lezak, 1986). Immediately after the injury, parents are focused on whether the child will live, and they may not be able to think about any subsequent physi­cal, motor, cognitive, and behavioral deficits that may result from the injury. In addition, there is little information about the recovery process or the time required to recover. Moreover, when information is provided in the acute setting, parents often are unable to hear or understand what is being said to them. All they know is that they want their child back. However, when the child enters an edu­cational environment, many factors affect the way the child learns and behaves. Chil­dren who have obvious physical deficits associated with their TBI are most easily understood, and accommodations are readily provided. When a child enters the class­room in a wheelchair or with a walker, we as educators are quickly reminded that the child has sustained injuries. In contrast, when children are seemingly age-appro­priate (e.g., walking and talking with no obvious physical deficits), it is easy to assume that they have made a complete recovery and require no academic or behavioral assistance. If the child had a cast on his or her head, that would serve as a reminder that the child will require mod­ification, academically and behaviorally, for some time.

Psychosocial Effects of TBI

During the initial phase of recovery from the TBI, the primary focus of par­ents and family is on the recovery of the child, and there is little evidence to sup­port family dysfunction (Anderson et al., 2001; Lezak, 1986). Although the family may experience stress and fatigue, they remain hopeful for a full recovery, with the stressors masking any significant fam­ily problems or dysfunction (Anderson et al.). They focus on minute signs of improvement, believing that when they take their child home, all will return to normal. Parents often assume that once their child is with family and friends, recovery will be quick. However, as time passes, the hope for a complete recovery becomes less evident, especially for the child who has sustained a severe head injury, and permanent difficulties become more evident. Lezak described stages in the evolution of family reactions when a child has sustained a TBI. During the six stages, the caregiver’s perception of the child is described initially as a little diffi­cult (0–1 to 3 months postinjury), then progresses to not cooperating, not moti­vated, self-centered (1–3 months to 6–9 months postinjury), irresponsible, self-centered, irritable, lazy (6–9 months to 9–24 months postinjury), a different, dif­ficult, childlike person (9 months or later postinjury to possibly indefinitely), and a difficult, childlike, dependent person (15 months or later postinjury to unknown). As recovery becomes less evident, care­givers are less hopeful, and reactions change from happy to discouraged to mourning the loss of the child that they had prior to the injury. After the family has reached this stage, they are, typically, more open to counseling and coping strategies to help their child.

According to Anderson et al. (2001), the stressors caused by the head injury do not specifically have an effect on one component of the family structure but on everyone involved, including the parents and children. Behavior problems incurred by the child who has sustained the trau­matic brain injury result both in poor sib­ling outcomes and general family dys­function (Swift et al., 2003). The poor sibling outcomes may be evidenced by negative sibling relationships, which are more prominent in mixed-gender dyads than same-gender dyads. Swift et al. indi­cated that mixed-gender dyads may have had more conflict before the injury, whereas same-gender dyads may have had a previous history of participating in joint activities and are thus more willing to make efforts to work together.

Family dynamics before the injury play a role in the child’s postinjury behavior and family functioning (Anderson et al., 2001; Rivara et al., 1993). Good social support and family cohesion are reported to be predictive of good adaptive func­tioning, social competence, and global functioning 1 year after the injury (Rivara et al.). Children who have sustained a TBI are more dependent on a positive and sup­portive family to help them gain the required assistance they may need to meet their cognitive deficits. A supportive fam­ily provides behavioral adjustments and helps the child learn compensatory skills by providing an environment that includes great stimulation and appropri­ate support (Taylor et al., 2002). In sum­mary, the findings of Taylor et al. indicate that “the development of behavioral and academic competence after TBI is better for children from more advantaged envi­ronments . . .” (p. 24).

In contrast, Taylor et al. (2002) explain that children from socially disadvantaged environments may exhibit more behavior and academic problems than children from more advantaged environments. These problems may be related to the families’ limited resources to aid in the child’s recovery process or other person­al stressors that distract from the need for remedial assistance.

Because family dysfunction, ineffective child management, negative parent–child interactions, and deviant models of behavior are more common in disadvan­taged environments, another possibility is that these characteristics mediated the effects of social disadvantage on child outcomes. (Taylor et al., 2002, p. 23)

Risks in the Developmental Process

A significant proportion of children who suffer a TBI are at risk for impair­ments in the developmental process. A wide range of factors interacts to deter­mine the extent and nature of impair­ments following brain injuries in chil­dren. The type and severity of injury sustained are closely related to outcome (Lowenthal, 1998). Researchers have also found that developmental issues, includ­ing age at injury and preinjury abilities, have an impact or ongoing development postinjury (Anderson & Moore, 1995; Taylor & Alden, 1997). Children sustain­ing early injuries may present with simi­lar patterns of impairment, but have poor­er outcomes than do children sustaining their injuries later in childhood (Ander­son & Moore; Wrightson, McGinn, & Gronwall, 1995). As a child matures and societal demands increase in complexity, problems with cognition and executive function may emerge (Guthrie et al., 1999). The full extent of the effects of brain injury in children may not be real­ized for some time because the long-term consequences may involve impairments in planning, execution of personal goals, and social behavior. 

The brain injury sustained by a child occurs concurrently with development and may create an incomplete collection of abilities (Brazzelli, Colombo, Della Sala, & Spinnler, 1994). When a child suffers a brain injury, damaged brain cells cannot regenerate or repair themselves; however, new neural connections can form between the intact areas of the brain. These new connections allow areas of the developing brain to take over the functions of the injured brain cells (Lowenthal, 1998). However, this reorganization of brain functions usually results in a cost to the child’s overall cognitive capacity. For example, some research has indicated that the young child’s right hemisphere can assume the language functions of the dam­aged dominant left hemisphere (Keefe, Feldman, & Holland, 1989). Other studies, however, reported that general language functioning is compromised in young chil­dren when the right hemisphere has to take over language development (Hemphill et al., 1994).

Because the young child’s brain is incompletely developed, infants and tod­dlers who sustain a brain injury are vul­nerable to significant and persistent neu­robehavioral deficits following insult (Anderson et al., 1997). In the event of a brain injury, the skull of a young child is able to absorb more of the impact of the blow to the head; however, there is greater diffuse injury than would occur in the mature brain (Bruce, 1995). Adverse effects of brain injury often are not appar­ent in young children because there are limited cognitive skills established at a young age. However, as infants and tod­dlers mature, delays are more evident and children may “grow into” their deficits, with new impairments emerging as expected developmental gains are not achieved (Bannich, Cohen-Levine, Kim, & Huttenlocher, 1990; Dennis, Wilkin­son, Koski, & Humphreys, 1995). Chil­dren who sustain a TBI during the preschool years are susceptible to later linguistic (Ewing-Cobbs et al., 1997; Wrightson et al., 1995) and motor deficits (Ewing-Cobbs et al.; Haley, Baryza, Lewin, & Cioffi, 1991). Young survivors of brain injury may exhibit delays in expressive vocabulary and rapid naming of objects. The acquisition of expressive vocabulary may be more difficult for these children than receptive vocabulary, because the former requires word retrieval and pragmatics, whereas the lat­ter requires only word recognition (Hemphill et al., 1994).

In the area of motor skill development, timing of the injury in the maturation process is critical. If the brain injury occurs concurrently with the develop­ment of the neuroskeletal system in which motor skills are emerging, then current and future motor functioning may be compromised (Haley et al., 1991). In toddlers with moderate to severe brain injury, problems with gross motor coordination and balance are com­mon. Other impairments that may occur later in development include deficits in gross and fine motor skills (Chaplin, Deitz, & Jaffe, 1993) and difficulties in planning and initiating body movements (Wilkening, 1997).

In young school-age children who sus­tain a brain injury, impairments are most evident in areas of nonverbal functioning, attention, memory, and learning. Postin­jury performance IQ scores, which involve nonverbal functioning, visuomo­tor ability, and processing speed, are a more sensitive correlate of severity of injury than verbal IQ scores (Max et al., 1998). Perceptual difficulties may persist for many of these children. After suffering a TBI, children may have difficulties with spatial concepts and often have difficulty navigating around the hospital, school, and neighborhood (Guthrie et al., 1999). School-age children who suffer a brain injury often exhibit problems with atten­tion that hinder new learning in the class­room. Anderson et al. (1997) found that children who had moderate to severe brain injury displayed greater impairment in sustained and divided attention, whereas focused attention was relatively intact. In the areas of memory and learning, chil­dren with brain injuries often retain older, overlearned information; however, they have problems with encoding, storing, and retrieving novel information (Reid & Kelly, 1993).

Slower recovery on motor and visu­al–spatial tasks has been found in younger adolescents than in older adoles­cents who experienced a similar head injury (Thompson et al., 1994). Repeated neuropsychological assessment of motor, visual–spatial, and somatosensory skills revealed that younger children with severe injuries recovered more slowly than older children with similar injuries, and also children of the same age with milder head injuries. These results sup­port the belief that neurological develop­ment continues until at least 12 years of age, and that the frontal lobes are the last neurological structure to mature, at around 12 to 14 years (Lord-Maes & Obrzut, 1997). As children with brain injuries mature and cognitive demands increase, executive functioning skill deficits emerge and may include prob­lems with (a) planning and organization, (b) initiating tasks and/or inhibiting behavior, (c) concept formation, (d) cog­nitive flexibility, and (e) problem-solving (Lowenthal, 1998; Rutter, 1982).

Risks Commonly Faced by Children/Adolescents With TBI

Following TBI, behavior patterns that emerge are unique to each child or ado­lescent. Although some children and ado­lescents are able to successfully return to school and reestablish previous friend­ships with ease, other children struggle when they attempt to resume their previ­ous activities and subsequently exhibit behavior problems. Fletcher et al. (1996) reported postinjury problems in approxi­mately 30% of children with severe brain injury. Common consequences of brain injury include problems with impulsivity, inattention, and restlessness. Preschool and elementary school-aged children often exhibit hyperactivity, distractibility, impulsivity, and temper tantrums after brain injury. However, this is not always the case, and some young children with brain injuries exhibit reduced initiative and sparsity of behavior. Older children and adolescents have more problems inhibiting behavior that may be expressed through impatience, irritability, agitation, and inappropriate comments. A child may act on an impulse that he or she could have ignored before the injury.

Examples of common impulsive behav­iors include grabbing at something with­out permission, running from a person he or she would rather avoid, or making foul, insulting remarks. Some children with severe brain injury may seek out sensory stimuli, and common behaviors may include picking at skin lesions, rocking, or biting (Guthrie et al., 1999). In extreme cases, behavior in adolescents with brain injury can include conduct problems, temper outbursts, inappropriate sexual behavior, and an increased possibility of dropping out of school (Deaton & Waa­land, 1994). For adolescents with brain injury, substance abuse increases the risk of seizure activity, poor impulse control, and further injury. The emergence of chal­lenging behaviors after a brain injury may be consistent with or an exaggeration of preexisting behaviors. There is a dispro­portionate number of children and adoles­cents who sustain traumatic brain injuries because they were participating in at-risk behaviors associated with a history of maladaptive or risk-taking behaviors, abuse of alcohol or drugs, or an inability to self-regulate behaviors (Ylvisaker, Feeney, & Szekeres, 1998).

In the early weeks and months after a severe brain injury, challenging behaviors may be a direct result of the injury. Dam­age to the prefrontal areas of the brain, the most common site of lesion in closed head injury (Levin, Goldstein, Williams, & Eisenberg, 1991), can result in disinhi­bition, impulsiveness, reduced anger con­trol, aggressiveness, and poor social judg­ment (Stuss & Benson, 1987; Varney & Menefee, 1993). Furthermore, prefrontal injury may reduce an individual’s ability to associate normal feeling states with memories for events. This lack of associ­ation may reduce the child’s ability to learn from consequences (Damasio, Tranel, & Damasio, 1990). In addition, a child may be unaware of the error in social judgment and, therefore, do noth­ing to correct it (Lezak, 1986).

Behavior and social problems also can be an indirect result of a brain injury. Dif­ficulties in paying attention, staying on task, and predicting the consequences of actions may be associated with behavior problems when caregivers expect preinjury levels of performance (Ylvisaker et al., 1998). A normal physical appearance can mask underlying cognitive deficits; how­ever, children and adolescents often are aware that they have altered abilities after brain injury. Many children act out or with­draw as a reaction to the changes in their life associated with the injury (Ylvisaker et al.). A child or adolescent who cannot per­form as he or she did before an injury may struggle at school and in social interactions and subsequently lose friends. This loss, in turn, easily results in depression, anxiety, and anger, which are associated with social withdrawal and acting-out behaviors (Deb & Crownshaw, 2004; Rosenthal, Chris­tensen, & Ross, 1998).

As one might expect, preinjury func­tioning plays a major role in postinjury behavior. The results of previous research have identified premorbid vulnerabilities as significant risk factors following a TBI (Anderson et al., 2001). Some researchers indicate that a disproportionate number of children and adolescents who experience a TBI are at risk for injury because of challenging environmental circumstances (i.e., poor family functioning or econom­ic difficulties) or personal characteristics that placed them at risk (Asarnow, Satz, Light, & Neumann, 1991). For example, children with preexisting Attention­Deficit/Hyperactivity Disorder (ADHD) are at increased risk for head injury (Max, Smith, Sato, & Mattheis 1997; McGuire, Burright, Williams, & Donovick, 1998). A study by Gerring et al. (1998) found that children with a premorbid diagnosis of ADHD accounted for 20% of the chil­dren in a group with moderate to severe head injury. Because ADHD is found in approximately 3–5% of the general pop­ulation, results of a study by Guthrie et al. (1999) suggest that children with ADHD are more likely to suffer a head injury than children in the general population. The frequency with which predisposing psychiatric disorders and environmental circumstances are discovered should motivate a thorough exploration of all aspects of the child’s life in developing a comprehensive treatment plan to assist with recovery and rehabilitation (Ylvisaker et al., 1998).

Children and adolescents who did not exhibit behavioral difficulties prior to injury are sometimes less likely to develop behavioral difficulties following a trau­matic brain injury than are those children who had behavioral difficulties before the injury. However, it is important to remem­ber that behavioral problems related to brain injuries often do not appear until sev­eral months or years following an injury (Deaton & Waaland, 1994). Children and adolescents who suffer more severe head injury tend to develop behavioral difficul­ties earlier in their course of recovery than do those who suffer a mild to moderate brain injury (Guthrie et al., 1999).

Interventions

Many of the behavioral problems that are exhibited in the classroom are direct­ly related to cognitive deficits. Children with TBIs may exhibit cognitive deficits related to attention, memory, expressive and receptive language, visual and visu­al–spatial problem solving, and process­ing speed, which is directly related to new learning. Children with severe head injuries have difficulty retrieving newly learned information and have impaired capacities for control, regulation, and adaptation of complex behaviors (Lezak, 1986). Impaired executive functioning includes the inability to plan, organize, initiate a task, inhibit responses, and self-monitor behaviors. Deficits in these areas are common after a head injury, especial­ly if the frontal lobes are affected. A neu­ropsychological evaluation provides information about the extent of the cog­nitive deficits to parents and teachers, and explains cognitive strengths and weak­nesses. When teachers are provided with this information, they are able to develop strategies to optimize the child’s ability to learn and function in the classroom. An effective behavior management program provides caregivers and educators with the tools necessary to promote positive behavior in children with TBIs. Several recommendations to assist with behavior management are listed below.

In a behavior management program, being able to determine the antecedent prior to the behavior is critical. Children with severe head injuries may not be able to inhibit responses or self-monitor behaviors. Ylvisaker et al. (1998) have recommended setting up antecedent control procedures, realizing that the child may not be able to control his or her reaction to stimuli. This may include

• (a) removing triggers from the environ­ment, (b) setting up a schedule or rou­tine, (c) preparing the child in advance for any changes in the routine, (d) being aware of the child’s psychological status and his or her ability to cope with the demands, and (e) redirecting the child at the first stage of disruptive behavior.
• Some children may fail to respond appropriately in the classroom because they do not have an understanding of rules, roles, routines, or social scripts (Ylvisaker et al., 1998). Educators should provide short, concise instructions. They should explain the rules that provide spe­cific rewards and consequences for behaviors. Children with head injuries may not generalize from one situation to another. Providing verbal feedback for appropriate or inappropriate behaviors will help classify a child’s behaviors and process generalizations. In addition, pro­viding role-play social situations will help develop a script for behavior and allow the child to rehearse appropriate responses.
• Children may have difficulty self-monitoring their behavior and, therefore, may not be able to distinguish between when their behavior is appropriate or inappropriate. It is important to focus on appropriate behavior. One way to do this is to tape a 3- x 5-in. index card on the corner of the child’s desk. The teacher explains to the child that they are work­ing as a team to correct a behavior, such as talking out in class. Every time the child raises a hand, the teacher places a check on his or her card. At the end of the day, the teacher rewards the child either verbally or with a point system for talk­ing at appropriate times. The child then takes the card home, and the parents are able to reinforce the positive behavior.
• Children who have sustained a frontal lobe injury may have a lack of initiation. This means that the child may fail to do what the teacher wants him or her to do based on an impairment of activation or initiation (Ylvisaker et al., 1998). It will be important for the teacher to monitor whether a child has initiated a task. Chil­dren with TBIs may require additional explanation or demonstration to begin the task. Avoid providing too many direc­tions, as the child may have difficulty beginning the task if he or she is over­whelmed. If multiple steps or instructions are needed, provide the child with a list so that he or she may check off the steps as they are completed.
• Activities that many children may perceive as enjoyable may be overstimu­lating to the child who has sustained a TBI. The lunchroom, music class, gym­nasium during physical education, or the playground during recess may be over­whelming. As the child becomes over­stimulated, he or she may overreact to the environment and experience a fight or flight reaction. It may be difficult for the child to explain his or her response, but he or she may voice a need to be removed from the busy environment. The over-stimulation may manifest in crying, anger, or anxiety. Allowing the child to go to a quiet place away from the overstim­ulation will allow the child to become calm and relax.
• The child who has sustained a head injury may experience confusion and dis­orientation (Ylvisaker et al., 1998). Cre­ating a routine and preparing the child for any deviation in routine will be important. A buddy system may be useful to help the child maneuver between classes. Allow­ing time in the morning for the teacher or the buddy to help the child gather all required materials for morning classes might be necessary. The child will need to repeat this activity at lunch and at the end of the day. Again, a peer may help with this activity. This will help eliminate frus­tration and facilitate the learning process.
• Children may continue to experience physical complaints after they return to the classroom. It is necessary to monitor for headaches or other physical symp­toms. These problems are often exacer­bated as the child fatigues. Providing breaks during the day can help with fatigue. Children with a TBI may need to rest or nap during the school day. In addi­tion, having the schedule alternate between academic and nonacademic classes will decrease fatigue and increase productivity in the classroom.

• Many children with right hemisphere injuries may have a lack of insight into the extent of their injuries or may deny their disabilities. Speak to the child in light of his or her cognitive strengths and weaknesses rather than deficits. Help the child verbalize his or her needs and teach to the child’s strongest learning modality (visual, auditory, tactile; Deaton & Waa­land, 1994).

• The child with a TBI may experience poor emotional control. Tasks that the teacher considers to be easy may be diffi­cult for the child, and this may result in an overreaction, such as crying. Whenev­er possible, redirect the child and refocus on another aspect of the assignment. Be sensitive to nonverbal cues by the child when he or she is overwhelmed. Be aware of mood swings, reorient students to pos­itive goals, and provide realistic encour­agement (Deaton & Waaland, 1994; Ylvisaker et al., 1998).
• Should a child become aggressive in the classroom, it is important to realize that this behavior could have been pre­cipitated by a number of events, including fatigue, overstimulation, or frustration. Remove the child from the situation and provide him or her with a quiet place to calm down. One should speak quietly to the student and remain calm. Help him or her state the problem and determine an appropriate coping behavior. If the child is fatigued or overstimulated, provide a quiet rest period. Enlist the help of the school counselor or psychologist to pro­vide ways for the child to learn to self-monitor behaviors and realize when he or she is becoming agitated or irritable. In learning to self-monitor behaviors, the child can remove himself or herself from the situation (Deaton & Waaland, 1994).
• Teachers should maintain communi­cation with parents, and both parties should work together as a team to provide support for the child. Teachers inform the parents of the child’s behavior and progress in learning. Teachers also need to keep parents informed about assign­ment due dates and pertinent information regarding activities in the classroom. Par­ents need to provide the teacher with feedback as to what the child is doing when he or she comes home from school in reference to fatigue, emotional status, and ability to complete work.

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