Traumatic Brain Injury: Perspectives from Educational Professionals

J. Darrell Mohr and Lyndal M. Bullock, Preventing School Failure (Heldref Publications)

Given the fact that over 1 million children and youths sustain brain injury each year (Clark, Russman, & Orme, 1999), one might assume that adequate numbers of educators are being prepared to support this population of students in schools. However, there is evidence indicating that this may not be the case (Chapman, 2000; Clark, 1996; Semrud-Clikeman, 2001). Although traumatic brain injury (TBI) was added as a separate disability category within the Individuals With Disabilities Education Act (IDEA) in 1990, many educators still are not aware of the unique challenges involved in providing educational and social support to this student population (Chapman). This article examines some of the critical aspects of brain injury that educators should be familiar with in order to meet the needs of students with TBI. The information herein is derived from the brain-injury literature and from two focus groups involving educators. The purpose of the focus groups were to identify (a) educators’ perceptions of their ability to meet the needs of students with TBI, (b) when and how they obtained their knowledge of TBI, (c) what more they would like to know about TBI, and (d) their concerns regarding meeting the challenges presented in working with this population of students. The discussion presents highlights from the focus groups, and comments on them with regard to what the TBI literature deems important for educators to know regarding TBI.

Focus Groups

The idea behind conducting the focus groups was to discover more about educators’ perceptions regarding their ability to support students with TBI. We wanted to discover how educators felt about their own training with regard to TBI, and how they felt about the adequacy of existing training resources for educators in general. Finally, we were interested in the kinds of questions and concerns they currently have about serving students with TBI.

Our focus groups consisted of a total of 15 professional educators, composed of special education teachers, diagnosticians, and behavior specialists. Prior to the focus groups, we asked the participants to complete a short questionnaire that consisted of five questions in a Likert scale format (see Appendix). The questionnaire was designed to (a) focus the participants’ attention on the topic, (b) prepare them mentally for the focus group, and (c) collect data regarding major points of interest.

TBI Awareness

For over 2 decades, education researchers in the field of brain injury have been attempting to assemble a convergent database of information that will help professional educators effectively support students with TBI. Although the literature now contains many promising practices and tools for educators, this valuable information is yet to be effectively disseminated.

Although most of the participants were at least somewhat familiar with TBI, only half had received any type of formal training with regard to the subject. Formal training, according to the participants, took the form of either an in-service session offered by their school district or education service center, or as part of a college course. Interestingly, all of those who received information through a college course did so as graduate students— none were offered information about TBI as part of their undergraduate teacher preparation. One educator expressed concern that not only had her undergraduate program been devoid of preparation for working with students with TBI, but that she had never heard of the term until she met her first student with TBI. Others, upon being notified that they would soon be working with a student with TBI, took the initiative to learn as much about it as they could. The Internet was the most popular informal source of information for those who engaged in self-study. When asked about the importance of having college coursework devoted to brain injury within teacher preparation programs, 71% said they felt it was very important, and 14% viewed it as extremely important.

With the exception of one participant, who was aware of TBI staff development opportunities at her education service center, most comments from the participants seemed to indicate that information regarding TBI was disseminated on a "need-to-know" basis within their districts. This may be because of the perception that TBI is rare, and does not justify wide-scale training. One participant relayed the story of how she was quickly briefed by a diagnostician the day prior to a brain-injured student’s return to school. The briefing consisted of basic background information, but no strategies were offered on how to work with the student. Another educator told us that she found out about a student’s history of brain injury as she searched his file for clues regarding his unusual behavior. No one had mentioned his TBI to her, and she found out about it from his records. These types of stories are probably not uncommon, and should cause concern among educators, administrators, and parents.

Regarding their preferred source of TBI information, the respondents identified a variety of sources, including college course work, seminars, conferences, district clearinghouses, and online resources. Most of those who had already received formal training indicated the desire to have someone who specializes in rehabilitation, such as a neuropsychologist or TBI specialist, supplement the information that they received. They felt that such personnel would be best qualified to provide information regarding cognitive retraining. All but two of those who had no previous training in TBI expressed the belief that staff development opportunities and periodic consultation with a psychologist would suffice. Such in-service training has been identified as an essential component for providing an adequate level of educational services to students with TBI (Bullock, Gable, & Mohr, 2005; Mira & Tyler, 1991).

Many participants expressed the importance of providing quality training for all teachers who work with a child with TBI. According to one teacher, the lack of information regarding TBI impedes collaboration because of the varying expectations held for the student—"It is setting the student up for failure." This view is supported in the literature (e.g., Semrud- Clikeman, 2001; Tyler & Mira, 1999).

Defining Success

We asked the participants to think of critical success factors for a student returning to school following the acute phase of recovery. Although participants unfamiliar with TBI could only produce vague ideas, such as "make accommodations," "monitor the student’s progress," and "formulate a contingency plan," those who were familiar with TBI had no trouble offering more specific suggestions. The following are some of the key points mentioned:

Establish a system of communication early between school, family, and rehabilitation centers prior to the student’s discharge from the rehabilitation facility. This concept has been mentioned as being particularly important to successful school reentry (Deidrick & Farmer, 2005; Farmer, Clippard, Luehr-Wiemann, Wright, & Owings, 1996; Farmer & Peterson, 1995; Savage, 2005). Failure to plan early and communicate decreases the probability of successful outcomes for the student.
Obtain information about the injury along with successful interventions or strategies used in the rehabilitation setting, and use this information to help prepare staff and peers for working with the student. The chances of success upon school reentry are increased if planning and preparation are undertaken with the specific strengths and limitations of the injured child in mind (Bowen, 2005; Mayfield, 2005; Mira & Tyler, 1991; Savage & Wolcott, 1988; Semrud-Clikeman, 2001;
Establish a schedule that allows a shortened school day to accommodate the student’s need for physical recuperation. Researchers (Clark, 1996; Deidrick & Farmer, 2005; Farmer & Peterson, 1995; Schoenbrodt, 2001; Semrud-Clikeman, 2001) have emphasized the importance of structuring the student’s school day so that he or she can be most productive. Vol. 49, No. 4 PREVENTING SCHOOL FAILURE 55 This may require accommodations, such as scheduling the most intensive classes at times when the child is most alert, and shortening his or her school day to provide for rest.
Appoint a staff member to be the liaison between rehab and school staff. Appointing a person to be responsible for ensuring that information is shared among school, family, and rehabilitation personnel is an essential component to obtaining successful outcomes. Ideally this "case manager" is someone who is specially trained in issues related to school reentry and planning, and can facilitate a smooth transition for the injured child and family (Deidrick & Farmer, 2005; Tyler & Mira, 1999).
Take the family’s needs into consideration and empower them by getting them involved in the planning and monitoring. Family involvement is vital to the success of the student’s reentry, and as a major part of the planning team, the family’s needs and strengths should be carefully considered (Bowen, 2005; DePompei & Blosser, 1993).
Structure the physical environment to accommodate the student’s needs and be prepared to make changes according to the student’s results. One of the most important, yet sometimes most overlooked, aspects of preparing for the child’s return to school is the learning environment itself. In fact, assessment of the environment, as well as instructional materials, instructional methods, and task demands, should occur repeatedly throughout the student’s recovery (Bowen, 2005; Semrud-Clikeman, 2001).

It was clear that those participants who had not had the benefit of TBI training were generally unaware of some of the most unique aspects of brain injury recovery. They tended to believe that the current system of supporting students with special needs is adequate for all students, including those with TBI. In addition, the general consensus among those less familiar with TBI was that if educators (a) exhibit patience and sensitivity toward students with brain injury, (b) carefully administer academic assessments, (c) take time to become familiar with the individual’s needs, and (d) develop the educational plan accordingly, then students with TBI should have positive academic outcomes. To the contrary, however, research has led to the development of reentry models that call for a structured process for the return to school and development of education programs for students with TBI (Bowen, 2005; Deidrick & Farmer, 2005; Hibbard, Gordon, Martin, Rashkin, & Brown, 2001; Lash,Wolcott, & Pearson, 2000; Ylvisaker, 1998). In fact, some have developed checklists and guides to ensure that the education team takes a structured approach and does not inadvertently omit essential components of the process (Bowen, 2005; DePompei, Blosser, Savage, & Lash, 1998; Tyler & Mira, 1999).

Perceptions Regarding the Effects of TBI

Although some of the participants were aware of many aspects of TBI, most expressed an interest in enhancing their knowledge. Many of the comments made during the focus group clustered around two of the three functional domains that are often affected by brain injury: cognitive and psychosocial/behavioral (Mayfield, 2005). The following is background information regarding the effects of TBI as they relate to the functional domains.

Although every brain injury is different and every individual affected by TBI is unique, effects of TBI can be categorized into three broad domains: (a) physical, (b) cognitive, and (c) psychosocial. It is easy to imagine how difficulties in any, or all, of these domains could result in the injured child experiencing difficulties at school. However, because most disabilities involve one or more of these domains, it is often assumed that the needs of children with TBI can simply be addressed using existing practices of assessment and instruction. Consequently, educators who believe this may become frustrated and confused by the lack of positive outcomes. For example, a youngster who exhibits an uneven pattern of recovery, gaps in knowledge, and multiple needs across all three functional domains may exasperate the teacher who is accustomed to supporting students with learning disabilities. The ideal approach to assessment and instruction is one that appreciates the complex problems associated with brain injury, and remains flexible as the student with TBI changes during the recovery process (Bowen, 2005; Mayfield, 2005; Savage, 1991; Semrud- Clikeman, 2001; Stavinoha, 2005; Tyler & Mira, 1999).

Physical Effects

With regard to physical deficits, individuals with TBI may have an array of problems ranging from sensory deficits to difficulty with mobility. Headaches and fatigue are common, especially during the early stages of recovery. Their muscles may be weak, hypotonic, or spastic, which could interfere with learning activities such as writing and keyboarding. They may also have seizures. In general, schools are more adept at making physical accommodations for students, so it is not surprising that, for the most part, the focus group participants indicated a relative level of comfort in their skills and abilities to accommodate physical effects of TBI.

Cognitive Effects

Although the prospect of accommodating the physical effects of TBI posed no problems for the focus group participants, they did not view themselves to be so adept at meeting cognitive needs of students with TBI. Cognitive difficulties are common following a brain injury and some may seem quite perplexing to educators unfamiliar with TBI. For example, children with TBI may have short-term memory problems, yet may be able to easily recall information learned prior to their injury. This phenomenon has significant implications for assessment purposes. For example, it is possible for a student to perform well on some widely used standard assessments using his or her prior knowledge. Such a false indication of the student’s current level of functioning may prevent the brain-injured individual from getting all the services needed. A few participants of the focus group pointed out and briefly discussed this potential pitfall as an important consideration. Some participants correctly mentioned that to avoid this pitfall, several different methods of assessment should be used when attempting to determine the needs of a student recovering from TBI (Deidrick & Farmer, 2005; Mayfield, 2005; Savage, 1991).

Psychosocial Effects

Difficulties that result from changes in the student’s social, emotional, and behavioral functioning are known as psychosocial effects. The organic changes in the brain resulting from the injury, along with stress and anxiety brought on by rehabilitation and recovery, may cause children with TBI to exhibit unusual emotional states, such as dramatic mood swings. Such emotional dynamism can bring negative reactions from peers and teachers and makes it difficult to maintain positive relationships. When children with TBI return to school, their educational and emotional needs are often very different than before the injury. What sometimes makes things worse is when the injured students remember how they were before the brain injury and feel embarrassed, ashamed, or frustrated that they can no longer perform as they once could. Of the various types of difficulties resulting from brain injury, the psychosocial effects have proven to be the most challenging for school personnel and parents to manage (Clark, 1996; Mayfield, 2005; Tyler & Mira, 1999).

Ideas for Improvement

We asked participants to mention some things that should occur to facilitate the success of students with TBI in schools. Again, those participants who had benefited from some type of formal training had the most to offer, and their answers were generally aligned with specific recommendations found in the literature.

TBI should be regularly represented through informational sessions at education conferences, because many educators rely on them as their primary source of professional development.
There are students who, for what-ever reason, seem to fall through the cracks. Perhaps their injury was not deemed significant enough at the time to warrant a lot of attention, but later on, problems emerge. An effort should be made by educators to maintain attention to the TBI, from the point of injury through graduation. Educators and families should create a system that maintains continuity of communication and support.
More should be done to put systems in place that support parents and families, because they are an important part of the equation in the child’s recovery. They provide valuable information and the opportunity for continuity in the effort to recover skills and abilities. Schools should empower parents so that they do not feel helpless—they can help their child, and help themselves, in the process.
Who could form coalitions with existing support groups—those who have already experienced TBI could share their personal experiences with educators and parents.
Who should consider developing expert teams within the district whose members get ongoing, specialized training from medical and rehabilitation personnel. These teams could then train school personnel and parents when the need arises in their school.

Educators' Concerns

Some of the concerns mentioned regarding meeting the needs of students with TBI coincided with those that have been voiced by educators around the country (Bowen, 2005; Bullock et al., 2005; Chapman, 2000; Deidrick & Farmer, 2005). Most of the participants (86%) felt that there is an overall lack of knowledge regarding the diverse educational needs of students with TBI. This initial concern appeared to be directly related to the participants’ perception that there is a lack of formal training opportunities for educators. In addition, all participants who received formal training expressed the need for the course work/staff development to be supplemented with some direct handson experience working with individuals with TBI. As for the teachers’ levels of self-confidence in being able to handle the challenges associated with having a new student in their class following a severe brain injury, 63% indicated that they would be intimidated, given their current level of knowledge about TBI.

Besides those concerns directly related to TBI, some felt there was a need for more work to be done on the systems that support students. For example, some expressed a desire to see more attention paid to the improvement of teaming and collaboration in general. This makes sense, because if professionals are not skilled and practiced at working together, education services are likely to be disjointed and inadequate, at best.

Conclusion

Although the research base regarding school-aged children with TBI is extensive and has produced many valuable resources for educators, whether that information is reaching adequate numbers of school personnel remains questionable. It is clear that educators see the importance of obtaining the best training available and are eager to learn more in order to offer the best support possible to students and their families. We must continue to work to find effective ways of preparing educators to meet the diverse needs of students with TBI.

References

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Chapman, J. K. (2000). Traumatic brain injury: A regional study of rural special and general education preparation. Rural Special Education Quarterly, 19(2), 3–14.

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APPENDIX
Traumatic Brain Injury (TBI) Questionnaire

Using the scale provided, please rate the following items with regard to supporting students with TBI:

1. In your opinion, how prepared are typical teachers today when it comes to effectively supporting students who are recovering from TBI?