Behavioral Considerations Associated with Traumatic Brain Injury Joan Mayfield, Preventing School Failure (page 1 of 6) Page 1 of 6

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).

From Preventing School Failure magazine. Heldref Publications. Reprinted with permission. www.heldref.org.

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