School-based interventions for treating social adjustment difficulties in children with traumatic brain injury

Journal of Instructional Psychology, Sept, 2003 by Bruce F. Dykeman

Children with Traumatic Brain Injury (TBI) face many challenges when moving from the rehabilitation to school setting. Many of these challenges involve the acquisition of social skills needed to function within the school's social environment. Diagnostic criteria of TBI are described and stages of recovery are reviewed. Behavioral and cognitive interventions are explained.

Children with Traumatic Brain Injury (TBI) have an acquired open or closed injury to the brain from an external physical force that results in a functional disability or psychosocial impairment, or both, that adversely affects educational performance. The sources of such physical forces are many and varied; yet often include automobile and pedestrian accidents, bicycle accidents, or sudden falls at home or on the playground. TBI affects the performance of children across a number of educational domains, including physical functioning; sensory-motor processing; cognition, attention and memory: speech and language; and social behavior. Disorders of executive functioning are common, including difficulties in organizing, evaluating and carrying out goal-directed activities relevant to academic expectations and social behaviors.

The purpose of this paper is to review literature describing typical social difficulties experienced by children with TBI and to describe intervention strategies that assist in the acquisition and reacquisition of those social skills needed to facilitate social adjustment in the schools. In this regard, this paper focuses upon those intervention strategies available to educators as they assist the social adjustment of TBI children returning to the school environment.

Over one million children sustain a TBI each year, which represents approximately one-sixth of all pediatric hospital admissions (Batchelor & Dean, 1996). The incidence rate for boys varies from 150 to 200 per 100,000 prior to age 5, and increasing to 400 per 100,000 at age 15; while the incidence rate for girls varies from 100 to 170 per 100,000 prior to age 5, and increasing to 300 per 100,000 at age 15 (Batchelor & Dean, 1996). The adjustment to a traumatic brain injury can be a difficult and devastating process for both the patient and the family.

Many children with TBI withdraw temporarily from school while participating in rehabilitation at a hospital setting. These children often experience a significant reduction of school or academic performance dating from the trauma. After short-term recovery is established, these children usually return to their school. Successful readjustment to the school environment depends partly upon the quality of the transition plan. Adaptation of the learning environment to compensate for physical and cognitive deficits assists the child's academic performance. In addition, support services from counselors, social workers, and school psychologists can also assist the child's social and emotional needs.

The consequences of an acquired brain injury have not been adequately researched (Teeter & Semrud-Clikeman, 1997), which is particularly problematic given that an acquired brain injury is considered a separate handicapping condition requiring special education support. Consequently, school personnel face the challenging task of assisting with the rehabilitation health-care plan while, at the same time, developing an individual education plan that will assist with the child's adjustment to the school environment.

Symptoms. Children with TBI experience a variety of symptoms. For some children. TBI involves a postconcussional syndrome that includes: (1) a period of unconsciousness lasting for more than 5 minutes after the brain trauma, (2) a period of posttraumatic amnesia lasting for more than 12 hours, and (3) a new onset of seizures that occurs within the first 6 months after the injury (American Psychiatric Association, 1994).

For other children, TBI may not involve a loss of consciousness. Nonetheless, symptoms of TBI often include combinations of emotional lability, insensitivity and egocentricity. Withdrawal, disinhibition, aggression and confrontational behavior. In addition, symptomatic children often experience fatigue, disruptions to the sleep schedule, headaches. Irritability, anxiety, depression, and apathy.

The manifestation of symptoms depends, in part, upon the extent of injury and the pre-morbid level of brain maturation prior to the injury itself (Spreen, Risser & Edgell, 1995). At preschool, symptomatic children with brain injury may experience frustration, fearfulness, withdrawal, irritability, anxiety, crying, and temper tantrums. At the elementary level, symptomatic children often experience short attention span. impulsivity, hyperactivity, aggression and inappropriate social interaction. Symptomatic adolescents often experience decreased social judgment, frustration over the loss of social and academic skills, depression and withdrawal, decreased anger control, inappropriate risk taking, and occasionally, the use of illegal drugs and inappropriate sexual behavior. At all developmental levels, the social and emotional status of symptomatic patients is often compromised (Paniak, Reynolds, Phillips, Toller-Lobe, Melnyk & Nagy, 2002). These symptoms affect the emotional disposition of the child, with consequent influence upon social demeanor and social skills.