The numbers are startling. Brain injury is the leading cause of death and disability in children and young adults with nearly a half million children and adolescents treated in emergency rooms yearly. The N.J. Department of Health and Senior Services Center for Health Statistics recorded 1,231 children in New Jersey between the ages of 0-17 were hospitalized with a Traumatic Brain Injury (TBI) in 2007, and 22,436 more children ages 0-17 were taken to emergency rooms with a TBI. Yet, only 1,260 students in New Jersey who are in special education are classified as TBI.

How could this happen? It’s simple. Families and educators may be unaware that special attention is needed following a brain injury.

Since 1998, the N.J. Administrative Code for Special Education has included TBI (an insult to the brain caused by an external physical force that may produce a diminished or altered state of consciousness, which results in impairment of cognitive abilities and/or physical functioning) as a category for special education and related services under the federal Individuals with Disabilities Education Act. This category also includes acquired brain injuries (an injury to the brain that is not hereditary, congenital or degenerative) from other than a physical force such as anoxia.

The majority of students with brain injuries are TBI cases caused by falls from shopping carts, bike riding, skateboarding, and roller blading as well as shaken baby syndrome (now referred to as abusive head trauma), motor vehicle crashes, and sports injuries. Acquired brain injuries are medically related and include strokes, meningitis, brain tumors, deprivation of oxygen from near drowning or surgery, and metabolic disorders.

Educators as ongoing advocates

Over the last 25 years that I have been advocating for students with brain injuries, I have heard too often that schools did not need to have an inservice on the topic. Administrators weren’t aware of students who had prior brain injuries because families chose not to report it. Parents mistakenly believed that their children could simply pick up where they left off prior to their injuries. Some children may have been injured in their preschool years, and no one has made the connection to current cognitive/learning, psychosocial, language, or physical challenges.

There are additional reasons why under-identification and misidentification of brain injuries occurs. The effects of brain injury may mimic other disabilities such as ADHD and emotional problems. Sometimes the deficits are so subtle that they are not apparent until the student is required to process and recall new learning over time. Symptoms may not show immediately as the focus is on improving the physical difficulties. New deficits may be evident in later years, well after the injury occurred. When brain maturation does not keep up with physical development, there is often no realization that these latent effects are related to an earlier brain injury.

Educators have the experience and knowledge to identify and advocate for students with brain injuries. You may be the first person to recognize academic and/or behavioral changes. You may also notice changes in attention and concentration, in relating to other students, in processing information, or in memory. Such alterations in a student’s performance should alert a teacher to investigate further by contacting the school nurse and speaking with parents. You should also refer a student to the Child Study Team when you are concerned about changes in cognition, behavior, communication, physical, or academic performance.

What may have been considered an inconsequential hit on the head may be a mild brain injury that requires diagnosis and intervention. By becoming familiar with signs of brain injury, teachers can support students through their recovery. For a complete list of characteristics of students with brain injuries, see the sidebar on page 19.

Brain injuries and learning disabilities: similarities and differences

Brain injuries and learning disabilities can both be manifested by difficulties in attention, memory, impulse control, executive functioning including organization, time management, planning, self-monitoring, and problem-solving. Generalization of skills, abstract reasoning, and social judgment can also appear in either case.

It's not impossible, however, to tell the difference between brain injuries and learning disabilities. Specifically, after a brain injury, students continue to rely on prior learning strategies that may no longer work for them but are unable to figure out why or how to alter them. Youngsters who were high achievers may find that after their brain injury, they cannot concentrate, have difficulty with new learning, cannot remember what was taught but have no idea what to do. This can lead to depression, anxiety, and embarrassment. But with proper intervention, a student’s skills improve over time.

Many strategies used for students with brain injury are the same as those for students with learning disabilities. The difference is that students with brain injury may never have had to rely on strategies before their injury and find it very difficult to accept them. Complicating this is their short-term memory deficit, which they may not realize they have, so they do not recall what works for them.

It is important that a brain injury be distinguished from a learning disability as early as possible, as recovery from the injury can improve with proper treatment and support. Other factors that affect recovery are age at injury; cause, location, and severity of injury, time since injury, length of coma (if any); and intellectual abilities and psychosocial functioning prior to injury.

Case history and classroom teaching

Richard sustained a severe brain injury from a motor vehicle crash when he was 14. Following six months in a coma, he spent months in outpatient rehabilitation and returned to school on a part-time basis. Prior to his injury, Richard was very bright and earned high grades. He had a large circle of friends.

But following the injury, deficits were identified in:

  • Attention, concentration, memory and short-term memory
  • Speed of processing
  • Word retrieval
  • Abstract language
  • Higher level thinking.
  • Decreased vocabulary and poor spelling
  • Reading and math skills far below grade level
  • Writing weakness
  • Inability to keep pace with class discussions
  • Inability to keep pace with his class.

Neurofatigue is common following a brain injury; even a mild injury can affect the emotional, behavioral, cognitive, and neurological systems. It can cause headaches, memory loss, attention and concentration impairments, decreased processing, and a general lack of mental energy despite great effort. This fatigue is real, not an attempt to withdraw from working or socializing and is evident following mental and/or physical effort.

Because of Richard’s neurofatigue, he had to rest one period daily, spending it in the nurse’s office. He could not participate in after-school activities. Initially he was incapable of monitoring and adapting his behavior, leading to social isolation and depression. His friends did not understand and therefore could not accept a new Richard.

So, in conjunction with input from outside specialists, the Child Study Team, his parents and Richard himself, his teachers adopted the following guidelines:

  • Avoid overstimulation
  • Gradually increase the rate and amount of information
  • Use repetition and consistency at all times as a compensation for reduced memory
  • Avoid completion tests due to word retrieval deficit
  • Provide structure (put in writing what is expected, changes in the routine, etc.)
  • Allow extra time to respond in quizzes and tests
  • Avoid copying or note-taking due to poor motor skills (use a computer for all written work)
  • Provide immediate feedback after each task; analyze the strategy he used and discuss what worked, what didn’t, and how to change it for the next task.

When Richard appeared confused, he would restate the information in his own words so his teacher could check for accuracy. He left class early to avoid the chaos in the hallways.

Resources are available from BIANJ

Students with brain injuries need time, encouragement, and positive reinforcement as they strive to figure out who they are, what they need to do to achieve, and develop new relationships as their former friends may have abandoned them.

It is critical that school staff become better educated about this silent epidemic. The following resources for educators have been developed through the Brain Injury Association of New Jersey (BIANJ) to assist school staff:

  • “Brain Injury in Students, a free two-hour presentation available as an inservice training for school professionals
  • “Brain Injury Primer, a free online course for school professionals that offers 10 professional development hours, developed in partnership with Rutgers University and available at https://catalog.cerkit.rutgers.edu/ (using the search words “brain injury”)
  • Brain Injury: A Guide for Educators, Brain Injury: A Guide for School Nurses, and Preparing for Life After High School, free publications available for download from www.bianj.org. Hard copies can be ordered online or by calling 732-745-0200.
  • Free webinars on topics related to school professionals
  • Free online articles about working with students with brain injuries
  • A free book and video library
  • A free helpline to assist those affected by brain injury and those working to assist them
  • Free materials and trainings on preventing brain injury in students, including those focused on transportation safety and teen driving, sports concussion, helmet safety awareness, and more.

For more information about any of the BIANJ’s free programs and services, or about working with students with brain injury, contact the helpline at 800-669-4323, 732-745-0200, email info@bianj.org, or visit www.bianj.org.

Other online resources are:

  • www.biausa.org - Brain Injury Association of America is the leading national organization serving and representing individuals, families, and professionals who are touched by a life-altering, often devastating, traumatic brain injury.
  • www.tbied.org- TBI Educator, a product of the Oregon Teaching Research Institute, provides information and resources for people working with students who have a brain injury.
  • www.projectlearnet.org - Project LEARNet is a resource of the Brain Injury Association of New York designed to help parents, educators, and other professionals who serve students with brain injury.
  • www.lapublishing.com - Lash and Associates Publishing/Training, Inc. specializes in information and books on brain injury for the rehabilitation and treatment of brain injury, concussion, and special needs and disabilities in adults and children.  

>>Characteristics of students with brain injury

Lois Mishkin has spent the last 30 years evaluating and treating children, adolescents and adults with brain injuries as well as consulting and presenting trainings to schools. Most recently she was on the child study team in Scotch Plains-Fanwood and presently is in private practice where she works with brain injuries, ADHD and executive functioning deficits, and language-based learning disabilities.

Mishkin has presented nationally and locally on brain injuries and co-authored a chapter in a textbook on brain injuries in 1996. Through the Brain Injury Association of N.J., she has co-written manuals on brain injuries for educators. She has received the Distinguished Clinical Award for Advocating Interdisciplinary Approaches to Rehabilitation by the N.J. Speech, Hearing and Language Association and the Silvio O. Conte Award for Public Awareness and Education by the Brain Injury Association of N.J. Contact her at mishkinl@hotmail.com.