With the increasing rate of survival, even from severe traumatic brain injury (TBI), primary care pediatricians are encountering more children with TBI in their practices. Traumatic brain injury leads to a variety of physical, cognitive, and behavioral impairments. The notion that children are more resilient to these sequelae than adults has been challenged. Children are indeed as vulnerable as adults, but developmental issues have obscured the clinical picture.1 The physical sequelae, when present, usually are obvious, but the cognitive and behavioral sequelae often are more subtle. These unseen impairments are what more profoundly affect the child and family.2
Virtually all children who survive TBI return to educational settings. Recent amendments to federal law governing educational practices have recognized TBI as a disabling condition, thereby making these students eligible for special education services. Unfortunately, educators have only limited experience with this population.3 The pediatrician frequently is called upon by families and school personnel alike in their efforts to optimally address the needs of these children.
NEUROBEHAVIORAL SEQUELAE AND THEIR EDUCATIONAL IMPACT
The numerous neurobehavioral sequelae of TBI have been described as pervasive during the first 6 months following injury.4 Many of these deficits improve spontaneously, at least to some extent, whereas others can present long-term obstacles to learning, social competence, and independence.
Although the problems seen following TBI may resemble those found in children with developmental disabilities, they are uniquely complicated by the child's developmental level. Families and professionals should be cautious not to misinterpret a child's competent performance of what might merely be previously overlearned skills. Following TBI, it is more important to consider the cunent functional status in such areas as the acquisition of new learning or making judgments in activities of daily living. When considering the various sequelae of TBI, it is important to understand that an injury to the brain may affect development in several ways. It may obliterate previously learned skills, reduce the efficiency of skill performance, or reduce developmental potential by altering the future development of skills not yet attained.
Severe TBI is characterized in several ways. An initial Glasgow Coma Scale (GCS) score of 8 or less, a coma duration of more than 6 hours, or a period of post-traumatic amnesia that extends beyond 7 days are among the more widely used definitions. Severe injuries are typically associated with permanent cognitive and behavioral problems.5,6
Moderate TBI, usually defined by an initial GCS score of 9 to 12, also can produce serious cognitive and behavioral deficits, but there is a greater likelihood of improvement. Nevertheless, the possibility of permanent deficits following moderate injuries should not be ruled out.5,6 Mildly injured children (GCS score of 13 to 15) demonstrate few deficits as a result of their injuries, either initially or up to 1 year later.5"7
General intellectual function, as measured by standardized intelligence tests, is impaired after severe TBI.5 As is often the recovery pattern, scores of intelligence tests improve quickly in the first few months and then continue to improve at a slower rate during the remainder of the first year postinjury. Scores on verbal subtests usually rebound fester than performance subtest scores. In the Brink et al series,8 where evaluations of severely injured children were performed 1 to 7 years after injury, children whose intelligence quotient (IQ) fell in the normal range averaged 1.7 weeks of coma, in the borderline range (70 to 84 IQ) averaged 3 weeks of coma, in the mild mental retardation range (55 to 69 IQ) averaged 8 weeks of coma, and in the severe retardation range (25 to 39 IQ) averaged 11 weeks of coma. This dose-response relationship between the severity of the brain injury and the degree of impairment was further documented by Jaffe et al5,6 in their work with children with severe, moderate, and mild TBI. Both in their initial assessments and follow-up at 1 year, the increasing severity of the brain injury was related to the magnitude of impairment on almost all neurobehavioral measures.5,6
After TBI, even when intelligence scores are in the normal range or have returned to pretrauma levels, children may exhibit specific cognitive deficits that prevent normal functioning. These deficits may be in mental processes including attention, perception, memory, problem solving, or reasoning. These processes are necessary to make sense of interactions with the environment. They are referred to as executive functions. Lezak describes the executive system as those mental processes "necessary for formulating goals, planning how to achieve them, and carrying out the plans effectively."9 Acquisition of new concepts and learning strategies in a regular educational program requires a student to employ executive functions.
Memory, or the ability to comprehend, store, and retrieve information, is a mental process clearly critical to the new learning of everything from basic activities of daily living to more complex academic objectives. Levin and Eisenberg4 found memory impairment was the most common cognitive deficit following pediatric TBI. After studying 64 children and -adolescents who had sustained varying degrees of TBI, they found that almost one half exhibited significant memory deficits.4 Without appropriate assessment, persistent memory deficits can go undetected, especially in younger children with subtle or absent neurologic findings. Sufficient improvement of memory and sustained attention gives an indication of a child's readiness to resume school tasks.
Prior to returning to school, or when faced with school performance problems after a brain injury, a careful assessment of the executive functions must be completed. The evaluation of the student by a neuropsychologist or a multidisciplinary team of rehabilitation professionals may be indicated. In these cases, educators need to include anecdotal records of such skills as attention, memory, initiation, organization, and problem solving with their school-based data.
Adjustments in educational programming for students with impairments of executive function usually include changes in the structuring of the educational environment, teaching compensatory strategies, and providing external aids. Teaching and therapy objectives become specific to these cognitive processes rather than academic content.
Both reading and mathematics mastery can be affected by TBI. Shaffer et al10 measured reading ability in a group of 88 children who had sustained depressed skull fractures. At least 2 years postinjury, 55% were reading 1 or more years below their age peers; 33% performed more than 3 years behind their chronological ages.
It has been noted clinically that reading recognition returns to pretraumatic levels quickly, presumably because it is so overlearned. Reading comprehension, however, continues to be more problematic due to the primary cognitive disruption of executive function. Similarly, math calculation skills are usually less affected or improve more quickly than the application of mathematical reasoning.
Studies examining school success and the need for special services confirm that a significant proportion of children with TBI require special education.8,11 Upon return to school, all children with TBI should be referred for special education services. Academic assessment after TBI can identify gaps in academic mastery that need to be retaught. If formal assessment of academic performance does not indicate a problem shortly following the injury, posttraumatic cognitive impairments may cause learning disabilities that will be seen only in actual school performance when new learning is attempted. Educational progress must be closely and frequently monitored so that the child or adolescent does not experience school failure.
Patients with comas that last longer than a few days can experience a period of muteness that extends beyond the termination of coma. Disorientation is usually noted in initial language productions. Speech may be dysarthric or dysfluent at this time and typically lacks affective structure. Some patients only demonstrate limited response to questions directed to them, whereas others are verbose. Conversation may be tangential, irrelevant, or confabulatory.
Language function typically improves with increased orientation, but impairments usually persist. Specific language deficits exist even with minimal cognitive impairment. In these cases, children may be considered aphasie. Specific aphasie deficits include inability to name objects or remember names, word retrieval problems, and auditory and reading comprehension deficits.
Disorganized language secondary to impaired cognition is more common following TBI. Attention, memory, conceptual organization, speed of processing, and analysis and synthesis of such things as environmental cues and conversation are all related to language formulation. These executive functions support language processing, and when they are disrupted, language is impaired. More specifically, Ewing-Cobbs et al12 found expressive and graphic functions impaired in at least 20% of their sample of children and adolescents with varying severity of TBI. They demonstrated poor performance on tests that involved describing object function, sentence repetition, fluency, writing to dictation, and copying sentences.12
In educational settings, the speech-language pathologist, along with the special educator, becomes a crucial part of the treatment team. Because cognitive and language function are so intimately interrelated following TBI, teachers and therapists should work in concert, not independently.
Speech-language therapy following TBI often focuses on teaching compensatory strategies to circumvent cognitive disorders. It also may be necessary for the speech-language pathologist to focus on pragmatic skills such as conversational initiation, turn taking, self correction, conciseness, and self monitoring.13 If pragmatics are problematic, the child or adolescent with TBI may become socially isolated because his or her conversation may be fragmented, tangential, or irrelevant.14
Because the traditional role of the school speechlanguage pathologist is to address more specific disorders of speech production and language development, families need to carefully examine the language objectives designed for their child in the Individual Educational Plan. If it is apparent that the school speech-language pathologist is not familiar with TBI, the pediatrician may be able to provide the school with an alternative resource.
Hemiparesis, quadriparesis, spasticity, and ataxia have been the most common motoric impairments following pediatric TBI. Although most resolve rapidly in the early stages postinjury, even those patients experiencing extreme motoric deficits often become functional with assistive devices.
More subtle problems involving the motor system have been noted as long-term effects of TBI in both children and adults. Children with moderate and severe TBI have shown impairments in the speed of visual-motor performance and in manual dexterity. Levin and Eisenberg found visual-spatial impairment for block construction and copying tasks in approximately one third of their sample of children with TBI. Somatosensory skills were reduced in approximately one fourth of the cases on measures of finger localization, graphesthesia, and stereognosis.4
Reduced motor speed and problems in copying tasks have obvious implications for the writing demands of an educational setting. In the absence of any prominent cognitive sequelae, these motor impairments may go unnoticed until the child has already experienced school failure. When these impairments are present in conjunction with cognitive impairment, additional modifications of instructional methods need to be made.
Patients sometimes exhibit agitation, hallucinations, and sleep- wake disturbances when emerging from coma. The appearance of behavioral disturbances is related to several factors: the severity of the injury, the location of the injury, the pretraumatic behavioral status of the child, and the family's premorbid level of psychosocial functioning. Brown et al, in their study of severely brain injured children, found that more than half of the children without preexisting psychiatric problems developed them by 28 months postinjury.15
Posttraumatic psychiatric disorders are those same disorders that can occur in any child or adolescent. Specific behavioral disturbances associated with frontal lobe injuries are: aggression, disinhibition, childishness, and apathy. Other behavioral symptoms frequently noted after TBI are overactivity, impulsivity, depression, and disregard for social convention. Patients are frequently without insight into these problems, having lost the ability to self-monitor and self-evaluate.
Behavioral and psychiatric sequelae are not like the neuropsychologic impairments that are initially more severe and gradually improve. Behavioral problems can emerge as other cognitive and motor improvements occur. Late psychiatric disorders are not uncommon.
Management will depend upon the type and severity of the problem. Most pertinent to the school setting is the use of firm, consistent behavioral management. Following brain injury, a behavioral management program needs to be devised with careful consideration of the complete profile of cognitive and behavioral impairments. It must be implemented consistently by all school staff and generalized to the home as well. For some psychiatric disorders, and when cognitively appropriate, a psychiatrist may choose to treat the child using psychotherapy. A third route of treatment might be pharmacological. It is important that the psychiatrist or psychologist become familiar with the efficacy of each of these treatment options following TBI.
Prior to returning to school, or when faced with school performance problems following TBI, adjustments to the educational program are usually necessary. At this point, a thorough multidisciplinary evaluation is necessary to identify cognitive strengths and weaknesses, assess academic mastery, rule out sensory motor disturbance, and establish baseline behavior.
Children who have sustained TBI are each unique, and their cognitive, psychomotor, and psychosocial profiles are unpredictable. Variability is evident throughout all stages following the injury. The evaluation of these students is best done by professionals with prior TBI experience. Referral to a neuropsychologist or a team of rehabilitation professionals is usually indicated. School-based professionals can provide important information in the form of anecdotal records of their observations of the student in skills such as attention, memory, initiation, organization, and problem solving.
Because TBI is not a developmental disability, comparison to normative groups has limited usefulness. Whether formal test scores or anecdotal data are being considered, it is crucial to use the child's premorbid level of functioning as a mechanism for comparison in determining educational placement and support services. Although it is not practical in an educational setting, in their research, Jaffe et al have used carefully selected controls to distinguish between postinjury impairments and pretraumatic characteristics.5'7
Consideration of several physical factors is necessary in the evaluation of a student with TBI. Fatigue is a common problem. Testing sessions should be administered according to the child's stamina. Sensory disturbances such as blurred vision or visual field defects are common following TBI. Visual stimuli may need to be enlarged or presented to the nonaffected side. Impaired speech may interfere with administering a test that requires a verbal response mode. Similarly, motor impairment may inhibit performance on written or constructional assessment tasks.
A complete multidisciplinary evaluation should also include a naturalistic assessment. This includes observation of performance through interviews, questionnaires, performance rating scales, and actual behavioral observations. For example, observing a child with TBI having lunch in the cafeteria can yield information regarding the ability to process information in a noisy environment, communicative competence with peers, ability to operate under time constraints, level of distractibility, and problem solving skills. This type of information can be invaluable and is not captured in standardized assessments.
Because variability in performance is common in children with TBI, it is important that ongoing assessment take place. Progress should be monitored and discussed as frequently as every 30 to 60 days in the first year following injury. After spontaneous improvement ends, the uncertainty of the effects that the brain injury will have on continuing brain development also complicates the ability to predict success and may necessitate more frequent review of student progress than is standardly done.
In general, the results obtained from the standardized testing battery should be interpreted with caution. While standardized testing is important in the evaluation process, it is necessary to remember that most instruments have not been normed for the population with brain injury. The interpretation of scores will prove to be insightful into the strengths and weaknesses of the student but should not be definitive. Premorbid learning and behavioral and psychosocial characteristics must be distinguished from those caused by the brain injury.5'7
TRENDS IN EDUCATIONAL SERVICES TO STUDENTS WITH TBI
Currently, there are few structured learning environments designed specifically to serve students with TBI. Meeting their needs has been impeded for two reasons: the educational system had no formal identification or tracking system until recently, and special and general education teachers have not been formally instructed to recognize the resultant disabilities of TBI or the methods necessary to teach these students.
With the recent reauthorization of Public Law 94-142 in Public Law 101-476, the Individuals with Disabilities Education Act, the committees of the US Senate and House of Representatives supported the inclusion of students with TBI in the category of those eligible to receive special education services.
Traumatic head injury is an injury to the brain caused by an externa! force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance. The term applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition, language, memory, attention, reasoning, abstract thinking, judgement, problemsolving, sensory, perceptual and motor abilities, psychosocial behavior, physical functions, information processing, and speech. The term does not apply to brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma. (IDEA; Section 300.5 [b]).3
Figure. Continuum of educational services.
The recognition that these students have unique deficits now allows school systems to identify and track these students. Acceptance of the TBI diagnostic category definition also enables school districts to work with insurers to cover some of the costs of providing services to these students.
With the passage of this legislation has come a new level of awareness. Whereas many individual schools and districts had worked to reintegrate individual students with TBI, now the whole public education system has been mandated to consider these students as a unique category. In turn, this has led to the beginning of efforts to train teachers in management of students with TBI. Rehabilitation professionals are increasingly being requested to provide inservice training to school personnel. Universities also are beginning to include TBI in their teacher training curricula.
Still, because there are so few programs designed specifically for this population, children with TBI often return to school settings where they are placed in programs for the learning disabled, mentally retarded, or emotionally handicapped. This often is inappropriate because students with TBI exhibit deficits that usually coexist with areas of competence, yielding a more uneven profile than is seen in most children with developmental disabilities. Programs designed specifically for students with TBI are transitional classrooms that address cognitive variability, behavioral difficulties, and the ongoing changes that are commonly seen. The goal of these programs is to prepare the student to return to the general education settings when their improvements have slowed or reached a plateau. Once returned to these general education settings, students with TBI are offered a full range of special education services, ranging from consultation to residential placement (Figure).
Some school districts have developed brain injury teams. Created from among their current staffa districts have sought out individuals with knowledge and experience or training in TBI. This team, usually consisting of a psychologist, a speech-language pathologist, and a special educator, provide evaluation and consultation when a student with TBI returns to school or experiences difficulty in school performance.
Despite the new legislation, many school systems recognize only those students with severe brain injury. Students with more moderate brain injury often are overlooked, either because they have not been identified by the acute medical care providers or because their needs are not understood by the educational community.16 Communication from the primary care pediatrician is most important in these cases.
In addition to the recent legislative changes, the rapidly evolving educational practice is to include students with disabilities in the general education classroom and serve them through collaborative consultation with related service providers such as occupational, physical, and speech language therapy. Classroom-based services provide the natural environment and realistic constraints in which the student has to usually function. This practice is more meaningful to the student and promotes generalization of the learned skills to other environments. Students with severe deficits are still frequently placed in self-contained special education classrooms.
Virtually all children who survive TBI return home to community medical care and educational services. Their problems are not only physical but also cognitive and behavioral. The sudden onset of these disturbances during normal development creates a unique set of problems for each child. This, along with the relatively low incidence of this population in any single school district, contributes to the inappropriate provision of educational and community support services for many children.
With the inclusion of TBI as an eligibility category for special education services, school systems now have an increased awareness of TBI. They are beginning to provide appropriate training and to establish enlightened policies for the educational management of students with TBI.
Community pediatricians are needed to serve as the link between the acute care facility and the educational setting. Lack of knowledge regarding TBI appears to be the biggest obstacle in providing appropriate community support services to these children. For educational and community reintegration to occur successfully, a cooperative relationship must exist between the family, school, and pediatrician.
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