Where Do We Go From Here?
"She is a beautiful 4-year-old. She was in the hospital for several months and has a severe brain injury. She can't speak and has difficulty maintaining balance for sitting. She is more like a 2-year-old than a 4-year-old. We know there are many challenges before us in getting all the services she will need throughout her life."
— Jessica's parents, who found their daughter comatose in her crib
at the age of 3 weeks, injured while in the care of her nanny.
"I have headaches and can't concentrate in school. I am a little impatient with my friends, and they don't call like they used to. Maybe I am just over-stressed with sports and schoolwork?"
— Kiesha, 17, a varsity volleyball player, one year after sustaining a concussion
when she hit her head on the gym floor and was returned to play in that game
against the recommendation of the athletic trainer.
"Our son is now 11 and has begun to do poorly in school. We can't figure out what is bothering him. He was a great student until third grade, but he just can't keep up anymore. His friends are a little on the wild side and influence him to do bad things. He is physically fine. Maybe he should play sports and get rid of some of this energy."
— Matthew's parents, discussing academic and behavioral changes in their son,
who was hit by a car when he was 8 years old. Matthew was unconscious for 24 hours,
hospitalized for three days, and discharged home with no further recommendations.
"I served in Iraq. I was injured in a blast and have been home for 11 months. I was discharged and tried working at my old job as a manager at a local pizza shop. But I just could not take the chaos and noise there. I am now enrolled in a local university. Keeping organized for classes, recalling assignments, and listening to lectures is really difficult. Maybe I need counseling for post-traumatic stress disorder. But I was told I only have a minor leg injury and really don't qualify for any service-related assistance. There doesn't seem to be anyone here in the community who knows what I should do."
— Marvin, a 21-year-old who was injured in Iraq
and now is considering dropping out of college.
These quotes — from real families and individuals dealing with traumatic brain injury (TBI) — illustrate the spectrum of traumatic brain injuries and the resulting complexities. The families' words also convey frustrations that can result from a lack of awareness about TBI and its implications for children, adolescents, and young adults, as brain development continues into their 20s.
Some common factors in these experiences are relevant to speech-language pathologists who may be called upon to treat communication difficulties in children and adolescents with TBI:
- The effects of a TBI in childhood are not fully realized right away and, in fact, new challenges can emerge after the individual has become an adult.
- The full scope of cognitive-communicative issues that results from a TBI often are not recognized in school and community environments, and sometimes, not even at home.
- There is a lack of recognition of the full scope of cognitive and communication issues and their impact on lifelong learning and living; as a result, there are significant gaps in the available research, especially with respect to evidence-based methods that are likely to improve outcomes for this population.
- Considerable information exists based on expert opinion about how practitioners and caregivers can support cognition and communication throughout development, but this information is not widely disseminated.
Although professionals often discuss and present on these concerns, positive strides have been made in the past decade and sufficient information exists to guide young TBI patients, their families, and the clinicians who treat them. These advances include increased information about cognitive communication after TBI, research on post-TBI developmental issues, and resources for best practice.
Cognitive communication is the ability to use language and underlying skills such as attention, memory, self-awareness, organization, and problem-solving skills to communicate effectively. Cognitive communication combines thinking skills with language. Language skills may appear to have returned after brain injury, particularly in nonstressful situations. However, when the child most needs to communicate at home, in school, and in the community, the spontaneous and unpredictable nature of communication demands can result in decreased language performance. Changes are most likely to be seen at school under the pressures of time, grades, assignments, the struggle to keep up with curricular requirements, and social pragmatic interactions (DePompei & Blosser, 2003).
The entire spectrum of TBI — from mild through severe injuries—can have an effect on cognitive-communication issues and the complex academic learning and social interactions that can be involved.
A history of a mild brain injury is considered a significant factor that may preclude an athlete from returning to play and may necessitate academic accommodations. The effects of moderate injuries typically are better understood as causing academic struggles as well as an inability to develop adequate social skills. Individuals with severe injuries uniformly receive specialized accommodations in school and community environments within the special education category of TBI.
Strategic learning is essential for success at all educational and social levels and often does not develop properly in students with TBI. Strategic learning, an important function that underlies the brain's capacity to learn, is the ability to extract important information while inhibiting the unimportant features of that information. When a student is presented with a new learning task, the student's ability to identify meaningful information, generalize or abstract this information, and store it for future use may be impaired. Thus, this student may store details related to less important information and be unable to recall the gist of the new learning task efficiently or successfully. Language and cognitive communicative difficulties are often at the root of these problems and treatment is usually indicated (Blosser & DePompei, 2003; Chapman et al., 1999).
Reprinted with permission from "Pediatric Traumatic Brain Injury" by Roberta DePompei. The ASHA Leader, 13, November 2, 2010, pp. 16-20. Copyright 2010. All rights reserved.