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Up to one million diagnosed Traumatic Brain Injuries are acquired each year by school age children who return to their everyday general education classroom while still in recovery. The transition from their medical or rehabilitation caretakers back into the general education setting entails a long and complex recovery process that must be passed into the hands of the education system. Students with this injury must rely on the teachers and administrators to continue their growth and healing from the injury while ensuring their academic and social success and development. This research describes what can be expected from the student with the brain injury, the academic setting and challenges, as well as resources that form the basic guidance for the reintegration process.
Key Words: Traumatic Brain Injury (TBI), Reintegration
Reintegrating Students Suffering from a TBI Resulting in Cognitive Impairment and Inability: Sustaining Cognitive Development and Student Achievement
Traumatic Brain Injuries (TBIs) lie on a spectrum as vast as that which is more commonly seen in the classification of student's with Autism. The injury can range from mild to severe and the effects of it can be anywhere from life-lasting impairments or deficits, to temporary inabilities. A student suffering from a TBI can experience mild to severe physical impairments that are easily accommodated using specific augmentative aids and services, in addition to cognitive or learning disabilities that are hard to distinguish from natural born inabilities without an extensive look into the student's academic history and a medical guide to TBI on hand. The research here is to provide an insight into what the regular classroom teacher(s) can expect when reintegrating a student suffering from a TBI back into the general education curriculum as well as what is expected of the student, school staff, and administrators. Resources, recommendations, and guides to handling and/or addressing the needs of these students are also provided as a means to show that just as any other learning disability under the special education categories, a TBI should be treated as such whether accommodations are permanent or temporary.
With statistics indicating that up to one million children suffer from a TBI each year, one can see the profound importance of understanding this injury and all that it may entail during the recovery process (Bowen, 2005). Psychologist Julie M. Bowen from the Jordan School District in Salt Lake City, Utah, reported that most children who've sustained a TBI will eventually return to a general education classroom setting upon medical release from hospitalization or a rehabilitation center. Bowen states that due to the varying length of time it may take for a student to recover from this injury (several months to years) many "continue to have rehabilitation needs and cognitive impairments and will return to school while still in the recovery stages" (2005). This is when it often does become the responsibility of the school, educational system, and/or the Student Support Team (SST) to assist in the continuing recovery process by providing the necessary aids and services to help the student(s) maintain academic and social success or function (Bowen, 2005).
Behavioral expectations of students returning to school after sustaining a brain injury may first be noticeable as motor problems, which can include struggles in gait, stamina, coordination, spasticity, and speech. However, motor skills are often the quickest to recover after a brain injury, making it very easy for educators to make the mistake of viewing the child as fully functional and rehabilitated (Clark, 1996). This mistake is made when educators are unaware of the many internal problems that result from a TBI. For instance, language problems such as impaired receptive language or higher level communication skills, deficits in pragmatics, verbal fluency, word finding, concept formation, and verbal comprehension typically follow a moderate to severe TBI (Clark, 1996) and should be considered as well as compensated for, even when there are no outward physical signs. Also, a closed head injury (no visually noticeable physical injury) can be very hard to distinguish from natural born inconsistencies in the child. When dealing with a closed head injury, one may not appear to be impaired at all. The damage is done to the brain on the inside and cannot be seen without an MRI or other cerebral scan, or an extensive neuropsychological exam/testing. This is a challenge as the teachers, administration, and even the student with the TBI may not be fully aware of all the areas in which the student may be lacking in function. Upon release from the hospital or rehabilitation setting and returning to the school, some degree of normalcy is often expected from the student as opposed to an immediate action plan of accommodations and assistance. When a child suffers from a broken leg or their dominant arm is broken in an accident, the predictable accommodation is to provide assistance with writing and or movement from one place to the next (transitioning). Those students suffering from a closed head injury are not treated in the same manner as the outcome of the injury is not predictable. Still, cognitive problems are of the most common in moderate to severe brain injuries. These include problems in attention, memory, language comprehension, concept formation, integrating, organizing, generalizing information, problem solving, and judgment (Clark, 1996). All of these problems have a huge impact on a student's academic success. In addition, the damage to these areas of cognitive function can lead to several disorders such as test-taking anxiety or social problems caused by poor decision making as a result of lapses in judgment. Consideration for these types of "internalized" problems (Clark, 1996) must be incorporated into the goal-setting design for the student whether an Individualized Education Plan (IEP), 504 plan, Student Support Team, or Special Education plan is established.
Bowen suggests specific teaching strategies and manipulative aids for students with a TBI in the general education classroom. Her article, "Classroom Interventions for Students with Traumatic Brain Injuries," provides an extensive breakdown of the common cognitive impairments seen with a TBI and the strategies or outer/manipulative aids recommended to address them. Specifically, she has broken cognitive impairments into four groups that can strongly affect the student's academic progress; Attention, Memory, Organization, or Writing and Information Processing Speed (2005). As an example, the writer of this paper personally experienced a Traumatic Brain Injury that was sustained after being in a formidable car accident at sixteen years of age. The most noticeable impairment when returning to the school setting was in information processing speed and memory. The damage the writer suffered from caused the inability to achieve "maintenance" (Gibb & Dyches, 2007) of a skill. When a student achieves a "statement of maintenance" they have shown that "he [or she] has not only mastered, but retained the skill" through a series of consistent, measurable assessments over a consecutive period of time (Gibb & Dyches, 2007). An example of this would be spelling 20 out of 20 words correctly three out of three times for three consecutive weeks. To further assist students in the areas of Attention, Memory, Organization, and Information Processing Speed, Bowen recommends checklists, post-its, calendars, planners, setting a timer or alarm to remind when a task needs to be done, tape recorders for review, visual aids or photocopies of textbooks to promote highlighting skills as alternative aids or tools to assist memory discrepancies (2005). For information processing speed deficits such as the inability to comprehend spoken language at a fast rate or without repetition, inability to complete work within regular classroom time constraints, diminished higher level communication skills, etc., the use of tape recorders for review, a peer tutor, or augmentative devices such as word processors or a Dictaphone are recommended (Bowen, 2005). Incorporating these services into the classroom for the student is tremendously important in order to promote the healing process of the TBI. Again, most students' with a TBI enter the classroom in the midst of their rehabilitation so as a member of the student's Student Support Team (SST); the regular classroom teacher must take on the responsibility as a facilitator of the student's recovery (Bowen, 2005). Bowen's article also provides several assessment forms and tables available for observing and documenting specific behavior discrepancies following a TBI. These resources are very useful in developing a Behavior Intervention Plan (BIP) or in completing a Functional Behavior Assessment (FBA) if and/or when the change in behavior or additional behavior "significantly interferes with [the student's] academic or social progress" (Opella, 2002). As student's suffering from a moderate to severe TBI (resulting in damage to areas of the brain that regulates emotional control) are often prone to emotional outbursts, resulting from issues such as, increased aggression, poor anger/impulse control, or hyperactivity, a BIP is a first step solution for this type of issue. In designing a BIP, a functional behavior assessment (FBA) must be given and documented first so as to ensure that all the needs of the student are addressed and the SST or IEP team is able to develop an effective plan (Opella, 2002).
Federal law P.L. 101-476 was passed in 1990 to include Traumatic Brain Injury (TBI) as a special education category (Clark, 1996). This law, titled the Individuals with Disabilities Education Act (IDEA), marked the beginning of mandated aids and services for those students suffering from a TBI in the educational setting (Clark, 1996). Even with the passing of this law, some notable challenges that a student and his or her family may face when returning to the educational setting are common understatements of how much the student is suffering from the injury. A solution to this challenge is to bring in the student's neurologist, neurosurgeon, neuropsychologist, or other brain injury expert to explain and insure an understanding of what is going on in the student's brain as a result of the damage and what is to be expected throughout the recovery process. IDEA recommends developing an Individualized Education Plan (Gibb & Dyches, 2007) and this is an ideal time to include a medical expert. These experts should also be an involved member of the Student Support Team throughout the duration of the transition into the school setting and the continued rehabilitation while in school just as the school psychologist is involved and necessary to interpret a student's psychological assessments to the rest of the team. The overall challenge is keeping the student on track with the general education curriculum if possible and ensuring that this injury remains a milestone that they can overcome and still achieve academic and social success.