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Behavioral Considerations Associated with Traumatic Brain Injury Joan Mayfield, Preventing School Failure (page 3 of 6) Page 3 of 6

Slower recovery on motor and visu­al–spatial tasks has been found in younger adolescents than in older adoles­cents who experienced a similar head injury (Thompson et al., 1994). Repeated neuropsychological assessment of motor, visual–spatial, and somatosensory skills revealed that younger children with severe injuries recovered more slowly than older children with similar injuries, and also children of the same age with milder head injuries. These results sup­port the belief that neurological develop­ment continues until at least 12 years of age, and that the frontal lobes are the last neurological structure to mature, at around 12 to 14 years (Lord-Maes & Obrzut, 1997). As children with brain injuries mature and cognitive demands increase, executive functioning skill deficits emerge and may include prob­lems with (a) planning and organization, (b) initiating tasks and/or inhibiting behavior, (c) concept formation, (d) cog­nitive flexibility, and (e) problem-solving (Lowenthal, 1998; Rutter, 1982).

Risks Commonly Faced by Children/Adolescents With TBI

Following TBI, behavior patterns that emerge are unique to each child or ado­lescent. Although some children and ado­lescents are able to successfully return to school and reestablish previous friend­ships with ease, other children struggle when they attempt to resume their previ­ous activities and subsequently exhibit behavior problems. Fletcher et al. (1996) reported postinjury problems in approxi­mately 30% of children with severe brain injury. Common consequences of brain injury include problems with impulsivity, inattention, and restlessness. Preschool and elementary school-aged children often exhibit hyperactivity, distractibility, impulsivity, and temper tantrums after brain injury. However, this is not always the case, and some young children with brain injuries exhibit reduced initiative and sparsity of behavior. Older children and adolescents have more problems inhibiting behavior that may be expressed through impatience, irritability, agitation, and inappropriate comments. A child may act on an impulse that he or she could have ignored before the injury.

Examples of common impulsive behav­iors include grabbing at something with­out permission, running from a person he or she would rather avoid, or making foul, insulting remarks. Some children with severe brain injury may seek out sensory stimuli, and common behaviors may include picking at skin lesions, rocking, or biting (Guthrie et al., 1999). In extreme cases, behavior in adolescents with brain injury can include conduct problems, temper outbursts, inappropriate sexual behavior, and an increased possibility of dropping out of school (Deaton & Waa­land, 1994). For adolescents with brain injury, substance abuse increases the risk of seizure activity, poor impulse control, and further injury. The emergence of chal­lenging behaviors after a brain injury may be consistent with or an exaggeration of preexisting behaviors. There is a dispro­portionate number of children and adoles­cents who sustain traumatic brain injuries because they were participating in at-risk behaviors associated with a history of maladaptive or risk-taking behaviors, abuse of alcohol or drugs, or an inability to self-regulate behaviors (Ylvisaker, Feeney, & Szekeres, 1998).

In the early weeks and months after a severe brain injury, challenging behaviors may be a direct result of the injury. Dam­age to the prefrontal areas of the brain, the most common site of lesion in closed head injury (Levin, Goldstein, Williams, & Eisenberg, 1991), can result in disinhi­bition, impulsiveness, reduced anger con­trol, aggressiveness, and poor social judg­ment (Stuss & Benson, 1987; Varney & Menefee, 1993). Furthermore, prefrontal injury may reduce an individual’s ability to associate normal feeling states with memories for events. This lack of associ­ation may reduce the child’s ability to learn from consequences (Damasio, Tranel, & Damasio, 1990). In addition, a child may be unaware of the error in social judgment and, therefore, do noth­ing to correct it (Lezak, 1986).

Behavior and social problems also can be an indirect result of a brain injury. Dif­ficulties in paying attention, staying on task, and predicting the consequences of actions may be associated with behavior problems when caregivers expect preinjury levels of performance (Ylvisaker et al., 1998). A normal physical appearance can mask underlying cognitive deficits; how­ever, children and adolescents often are aware that they have altered abilities after brain injury. Many children act out or with­draw as a reaction to the changes in their life associated with the injury (Ylvisaker et al.). A child or adolescent who cannot per­form as he or she did before an injury may struggle at school and in social interactions and subsequently lose friends. This loss, in turn, easily results in depression, anxiety, and anger, which are associated with social withdrawal and acting-out behaviors (Deb & Crownshaw, 2004; Rosenthal, Chris­tensen, & Ross, 1998).

As one might expect, preinjury func­tioning plays a major role in postinjury behavior. The results of previous research have identified premorbid vulnerabilities as significant risk factors following a TBI (Anderson et al., 2001). Some researchers indicate that a disproportionate number of children and adolescents who experience a TBI are at risk for injury because of challenging environmental circumstances (i.e., poor family functioning or econom­ic difficulties) or personal characteristics that placed them at risk (Asarnow, Satz, Light, & Neumann, 1991). For example, children with preexisting Attention­Deficit/Hyperactivity Disorder (ADHD) are at increased risk for head injury (Max, Smith, Sato, & Mattheis 1997; McGuire, Burright, Williams, & Donovick, 1998). A study by Gerring et al. (1998) found that children with a premorbid diagnosis of ADHD accounted for 20% of the chil­dren in a group with moderate to severe head injury. Because ADHD is found in approximately 3–5% of the general pop­ulation, results of a study by Guthrie et al. (1999) suggest that children with ADHD are more likely to suffer a head injury than children in the general population. The frequency with which predisposing psychiatric disorders and environmental circumstances are discovered should motivate a thorough exploration of all aspects of the child’s life in developing a comprehensive treatment plan to assist with recovery and rehabilitation (Ylvisaker et al., 1998).

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

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