Mental Health of Students After Traumatic Brain Injury: The Impact on Students’ Quality of Life.
Dr. Katherine Kimes has an extensive personal and professional background in the area of brain injury. She has studied acquired brain injury (ABI) and has combined the understanding of the mechanisms of injury with the brain’s innate capacity to heal itself, developing a philosophy of recovery in relationship to the education of students with brain injury. She owns the business, ABI Education Services, which provides consultation, training, transition services and in-school support for students with traumatic brain injury (TBI), concussions and strokes. She has also worked with adults who have sustained TB). At George Washington University’s (GWU) HEATH Resource Center and Disabled Student Services, she has written various articles related to brain injury and special education. Also at GWU, she has guest lectured on the topic of TBI for the Graduate School of Education & Human Development. Katherine earned her doctorate of Education at GWU in the Leaders for System Change in Special Education. She also has an MA from DePaul University in Writing and another MA in Transition Special Education from GWU.
Abstract
Policy change needs to occur at the national level in relationship to the traumatic brain injury (TBI) epidemic. Policy makers and teachers do not understand the devastating implications brain injury has on a student’s life. Educators know little or nothing concerning the mental health issue that encompass brain injury and how such an injury can impact a student’s cognitive and mental health status. The secondary effects, behavioral disorders, associated with brain injury are often misunderstood and misinterpreted. However, it is important that both general and special educators understand the implications TBI has on the quality of life of a student. By understanding the components of injury, educators can begin to understand the multi-dimensional impact of TBI. This document addresses brain injury in students and the mental health issues that can result from such an injury, discussing the relationship between mental health and TBI. It cites possible behavioral challenges that can result from injury and the types of intervention techniques are most effective in decreasing maladaptive behavior and best meet the needs of this population of students. The argument is made that the mental health issues that surround brain injury need further research to help facilitate long-term improvement. Teachers need to be educated on the components of injury and therefore, have a responsibility to provide support, services, and appropriate mental health interventions to accommodate this population of students. The ultimate goal of education is to provide free and appropriate public education to all students despite ability level. However, to provide education regardless of ability level, a systemic change needs to occur. This paper argues for policy change that addresses the cognitive and psychosocial deficits that surround brain injury and the mental health implications that can result.
Introduction
An estimated 5.3 million Americans, a little more than 2% of the US population, currently live with disabilities resulting from traumatic brain injury (CDC, 1999). The incident rate of brain injury is more frequent than multiple sclerosis, spinal cord injuries, HIV/AIDS and breast cancer combined. Every 21 seconds, a person in the United States sustains a TBI (BIA, Brain Injury, 2001). TBI is the largest killer of and cause of disability in children and adolescents in the United States (Savage & Wolcott, 1995). Despite brain injury’s frequency of occurrence, it is seldom acknowledged by the media, the government, or schools.
However, the consequences of TBI are numerous and life-altering. A brain injury can result in not only the loss of a student’s physical abilities, i.e., motor problems such as gait, coordination impairments, spasticity, increased muscle tone causing muscles to constantly contract, and oral motor problems, i.e., difficulties with the mouth such as speech, swallowing and tongue movement, but it also can also cause internal devastation, mental health issues. However, the trauma experienced after TBI is not limited to physical pain, appearance or motor skills. Language and cognitive problems can result as well.
A less obvious, but more predominant sequelea or secondary effects of TBI are related to psychosocial problems such as mental health issues. These effects “[refer] globally to the social, emotional, behavioral, and psychological effects of traumatic brain injury” and typically get worse rather than better over time without effective intervention (Savage & Wolcott, 1994, 239). These secondary effects indicate that the brain is the most vulnerable organ in our bodies. Not only does the brain provide mental health stability, it also gives us our personalities. An injury to the brain is unlike any other type of injury. It doesn’t heal itself over time like a broken bone or a cut.
The purpose of this document is to discuss and examine the psychosocial and mental health needs of individuals after traumatic brain injury; how an injury can impact a person’s quality of life, and effective intervention strategies.
Historical Context
Legislative History
The Education for All Handicapped Children Act (Public Law 94-142) gave students with TBI access to special education services. However, the label was hidden under the category of Other Health Impairments (OHI). Even though the OHI category guaranteed students with brain injury access to special education services, it was not until 1990 that TBI was designated its own separate special education category. The passing of the Individuals with Disabilities Education Act (IDEA) (Public Law 101-476) in 1990 was monumental because with the category came the recognition of the ramifications on students’ educational potential. This historic legislation was the beginning, not the end, of acknowledging Free and Appropriate Public Education (FAPE) for students with brain injury.
The Code of Federal Regulations, Title 34, Section 300.7(b)(12) defines TBI as, “an acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a child's educational performance. The term applies to open and closed head injuries resulting in impairments in one or more areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; information processing; and speech. The term does not apply to brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma” (National Archives and Records Administration, 2006). Identifying brain injury as a disability is a start, but it has not completely solved the problem surrounding FAPE.
Tracing Our Understanding of the Psychosocial Impact
As Dr. Irwin Pollack, an Emeritus Professor of Psychiatry from the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School writes, “[e]very TBI of any consequence causes some disturbance in a number of systems integral to the individual, including those responsible for motor, cognitive, and emotional function” and therefore, “no single approach to treatment is sufficient” to address all areas of deficits (2005, 641). The psychosocial issues that stem from TBI can cause dramatic changes is a student’s cognition, behavior, emotions, and daily interactions. The degree of psychosocial impairment is dependent on several factors such as the student’s: pre-existing abilities, medical history, economic status, level of maturation, severity, type, and location of injury, response to injury, and degree of family support (Arlinghaus, K., Shoaib, A. & Price, T., 2005). Therefore, it is important to highlight all the factors of brain injury that influence the mental health of a student with brain injury and ultimately provide intervention strategies that address all these dimensions.
History of Assessment Procedures
The effects of traumatic brain injury can be measured through various forms of assessment procedures. The initial assessment scale to measure the impact of brain injury at the scene of the injury is the Glasgow Coma Scale (GCS). This scale is used to “determine a patient’s level of consciousness” and severity of coma (Venes, 2001, 878). Other scales that are used to assess include the Rancho Los Amigos Scale, which classifies a, “patient’s level of cognitive dysfunction according to behavior” and includes eight levels of functioning (Venes, 2001, 1824) and a neuropsychological evaluation. A neuropsychological evaluation is a type of
assessment that provides “a better understanding of the brain-behavior relationship” after injury (Zelek, 2006, ¶ 8). It provides a comprehensive profile of a student’s strengths and weaknesses and is a good why to track a student’s recovery progress.
The Relationship Between TBI and Mental Health
Challenges Resulting from Injury
Behavior is ultimately social in nature, and therefore, the emotional and behavioral disturbances cause by TBI can be devastating to a student’s emotions, behaviors, and life in general (Blackerby, 1988). Behavior stems from the constant, complex communication of neurotransmitters within the brain. Therefore, if damage occurs within any regions of the brain disruptive, maladaptive and/or inappropriate behaviors can result. These mental health disturbances caused by traumatic brain injury (TBI) can ultimately affect student’s quality of life.
Emotion is the external expression of feeling; it is what the world sees. It is a complex interaction of behavior, biology and cognition (Campbell, 2002). As Eames explains, “[d]isorders after head injury result from the interaction between the injury and its affects, the patient, and the environment in which it manifest” (1988, 5). Behavioral and psychosocial disorders are the result of a complex interaction between the neurological damage created by the brain injury and its sequelea, the student’s pre-injury history and the environment in which the behavior is the most observable (Eames, 1988). “Specific neurological components of injury may directly influence behavioral control and emotional expression” (Savage & Wolcott, 1995, 89) and this means that the neurotransmitters in a student’s brain have been damaged and can no longer effectively perform their job. Therefore, it is important to not only treat the individual with the injury, but it is also important to treat the underlying brain dysfunctions because the subjective, internal rating of the quality of life for students with TBI is strongly correlated to psychosocial factors surrounding mental health and social support (Chase, Colantonio, Ratmiff, Steadman-Pare, & Vernich, 2001).
There are six important factors, or environmental stimuli, that can contribute to the frequency, duration, and rate of both observable and unobservable maladaptive behaviors after injury. These include: 1. age at the time of injury; 2. severity and length of coma; 3. pre-existing intelligence and personality traits; 4. type of pre-injury and post-injury environment (in relationship to mental health); 5. motivation to recover lost function (face/avoid problems) and 6. family support (Savage & Wolcott, 1995).
However, the primary reason, or underlying principle, that causes maladaptive behaviors after brain injury is the state of the brain after injury. The neurological damage incurred from injury, the damaged brain areas “may directly influence behavioral control and emotional expressions” (Savage & Wolcott, 1995, 89). After an injury the neurotransmitters, or the electrical signals transmitted between nerve cells, can no longer effectively perform their job because the signals cannot to reach their target cells. This damage can ultimately result in a student’s inability to recognize that some behaviors are inappropriate because the student lacks the cognitive or social skills to control the maladjusted behavior.
The second reason that causes maladaptive behaviors to occur after brain injury is due to personal and environmental reactionary disturbances. Some examples of these types of reactionary disturbances are: agitation, confusion, depression, denial (as a psychological reaction to the injury), psychosomatic pain, generalized loss of self-esteem, mood swings, anxiety, sleep disturbances, suicidal thoughts, and anti-social behavior (Senelick & Ryan, 1998).
The third reason maladaptive behaviors occur after injury deals with mental health disorders and stems from the individual’s pre-existing conditions and abilities. An individual’s pre-existing personality traits are typically magnified post-injury and may become more frequent. For example, a student who abused drugs pre-injury may be more likely to increase his/her use of drugs post-injury therefore, causing the drug problem to further escalate. In addition to a substance abuse problem, less dangerous, but equally damaging mental health issues include: verbal and/or physical outbursts, aggressiveness, emotional liability, egocentricity, insensitivity, promiscuity, rigidity and inflexibility, impulsivity, lack of self-awareness, low tolerance, anxiousness, passivity, inappropriateness, irritability, self-induced isolation, poor judgment, and age inappropriate behavior (i.e., tantrums, crying, pouting).
The previous lists of examples of the state of the brain after injury, reactionary disturbances, and pre-existing conditions and abilities can all affect a student’s mental health status after brain injury. The behaviors expressed in all three categories are quite similar to the problems faced by student with EBD. Students with EBD also have “an inability to build or maintain satisfactory interpersonal relationships with peers and teacher; inappropriate types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness or depression”, etc. (Wagner, 1995, 9). Often, students with TBI are misdiagnosed as being EBD because the injury occurred early in the child’s development and the injury has been long forgotten.
Discussion
From the accumulative information provided thus far, it is understandable why addressing the mental health needs of students with TBI is of the utmost importance. This section discusses the implications brain injury has on current teachers and ends with various ways to effectively provide support for maladaptive behaviors after TBI.
Implications for Teachers
While students with TBI are legally eligible to receive support services (as they have been since the passing of Public Law 94-142 in 1975), teachers are frequently providing these students with inadequate supports and services. Most up-incoming teachers are not sufficiently taught, through their post-secondary course-work, how to provide appropriate supports and services to students with brain injuries. Therefore, teachers’ competency levels needs to increase in order to provide appropriate supports and services for these students because “[w]hen children with TBI return to school, their educational and emotional needs are often very different than before the injury” (NICHY, 2006, ¶ 12).
Even in 2006, a majority of teachers are still not being instructed on how to appropriately educate children with brain injury. Therefore, teachers are not aware of or can even recognize how these students are unique in their educational pursuits and endeavors. An example of one such unique difference is that the cognitive deficit the child is experiencing was acquired through an injury. The child was not born with the deficit like a child who has learning disabilities, autism, mental retardation, ADHD, and behavioral or conduct disorders (Kimes, ¶ 2005). However, this single, basic component, that the injury was acquired, can drastically affect a student’s educational development and academic potential.
Due to the fact that teachers and schools are typically uninformed and are unaware of this population’s special educational needs, they are unable to provide FAPE to students with TBI. Unfortunately, this has resulted in a poor implementation and coordination of services. States are ultimately responsible for implementing appropriate services and supports (as required under IDEA). This is why “it is important…to understand the differences between TBI and LD as they pertain to students’ academic abilities.” (Kimes, 2005, ¶1). Therefore, it is important to keep in mind the “unique characteristics and specialized needs of…students with TBI to help them succeed both in education and in life” (Kimes, 2005, ¶2).
Therefore, it is not only the teacher’s responsibility to educate student with brain injury, but the ultimate responsibility lies in the effective coordination of all services to meet the student’s overall needs. These systems include: state departments of education, hospitals, rehabilitation facilities, and mental health systems. In order to provide an appropriate education, all systems need to be coordinated to work together, in unison, to best serve the student’s educational needs.
Some of the greatest limitations of TBI are those that are social—the lack of recognition and awareness of its uniqueness and predominance in society. This limitation transfers to the school level. Teachers who have had limited interaction with individuals with brain injury assume that TBI is similar to every other disability they have encountered in the schools. Therefore, teachers may not feel the need to be educated on the mechanisms of brain injury because they mistakenly believe that they what they’ve already learned will transfer. This is why it is important for educators “to understand that students with TBI are often very different from students with other kinds of special needs” (Kimes, 2005, ¶1). When working with students with brain injury, teachers’ competency levels need to substantially increase.
Not only do teachers’ competency levels need to increase in relationship to providing cognitive recovery, but also their awareness of students’ learning environments and social interactions, i.e., mental health issues surrounding TBI needs to increase. Brain injury can impact not only students’ behaviors, but also their social interactions and quality of life as well. Therefore, it is important that educators are knowledgeable concerning how to provide intervention strategies through environmental modifications and positive behavioral support. For a student to successfully improve his/her quality of life and mental health status, self-understanding and self-advocacy are two important components that need to be addressed.
It is important to understand that emphasis should not only be place on treating the student with TBI, but it is also important to treat the underlying brain dysfunctions caused by the injury. It is by using a person-centered approach to help the student with brain injury return to his/her highest degree of independence in relationship to his/her physical, cognitive, psychosocial, and mental well being. Therefore, it is not only necessary to treat the mental health disorder in a neurologically brain-based, direct way, in order to stimulate neuroplasticity, but it is equally important to reduce the frequency and eliminate the student’s behavioral disturbance(s).
In order to help the student achieve mental health, improvement in his/her quality of life, it is important to understand the concept of recovery of function, i.e., neuroplasticity. Neuroplasticity enhances the potential for functional recovery following brain injury. It is important to point out that functional recovery not only applies to physical recovery, but also mental health recovery. Recovery of function, or neuroplasticity, involves the growth of surviving brain cells. Recovery after brain injury involves having the undamaged parts of the brain ‘take over’ for the damaged area. It is important to remember that recovery is typically enhanced through the exposure to enriched environments and rehabilitation. Environmental enrichment encourages plasticity because as the level of difficulty increases with each task, structural and functional changes occur within the brain (Johnson, Ruston & Shaw, 1996). Therefore, recovery of brain function is a re-learning process and contingent on the growth of surviving brain cells.
Ways to Effectively Address Maladaptive Behaviors
Management of behavior is largely determined by the recovery stage the student with TBI has reached. Eames (1988) explained that early after injury mental health is best managed through eliminating environmental precipitants. However, later stages of recovery emphasized the goal of and return to the highest level of independent, physical, and psychosocial functioning when interacting with environmental precipitants.
Currently, there are various intervention techniques that can decrease maladaptive behaviors after injury. These techniques that promote recovery of mental health function include: pharmacological drugs, token economies, punishment: extinction and response cost, differential reinforcement of incompatible behavior, rational behavior therapy and positive behavioral supports both which promote learning through: applied behavior analysis, behavioral change programs, and antecedent behavioral interventions.
Pharmacological Interventions
Just like maladaptive behaviors do not occur in a vacuum, pharmacological drugs should not be the only method of treatment for behavioral disorders after TBI. Psychological and behavioral management techniques should be used in conjunction with administration of these drugs. However, pharmacological drugs “may be useful in a variety of affective and behavioral disturbances associated with TBI” (NIH, 1998, 42) because “psychoactive drugs that stimulate appropriate neurotransmitter pathways have the potential to enhance or modulate synaptic function…in order to sharpen attention in childhood behavioral disorders” (NIH, 2002, ¶4). However, pharmacological drugs should always be used as a last resort in the treatment of disruptive behaviors because they alter a student’s already fragile neurological functioning.
Use of Behavioral Interventions
Token economies. When used properly, behavioral intervention such as token economies, are very beneficial because they help foster a structured environment because they show that a relationship exists between behavior and its effects. In this type of setting the individual is motivated to engage in positive behavior and ultimately rewarded for enacting desirable behaviors. The goal is to optimize a person’s quality of life by using reinforcements as memory aids and behavioral cues. It helps to promote self-determination and control.
Punishment. Punishment, or aversive intervention, involves strategies that decrease the chances of a behavior from occurring again. There are two types: extinction and response cost. The goal of extinction is to find out what the purpose is behind the maladaptive behavior by eliminating those factors that are reinforcing the behavior. For example, whenever a disruptive behavior occurs, the enforcer or cause of the behavior needs to be removed from the environment. Response cost, on the other hand, is when something of value is lost when the student engages in a disruptive behavior. However, “[e]ffective intervention…focuses more on antecedents than on consequences” because punishment strategies teach the student how to suppress disruptive behaviors and can further exasperate mental health issues (Ylvisaker & Feeney, 1998, 37).
Differential Reinforcement. Differential Reinforcement is a technique used when an undesirable behavior is decreased and a desirable behavior is increase through the reinforcement of that desirable behavior. A desirable behavior is substituted for a disruptive one. Differential Reinforcement involves presenting choices to the student by reinforcing one or more positive alternatives in place of the disruptive behavior. In differential reinforcement is it important to acknowledge the student’s feelings, communicate the limits, and target acceptable alternatives (Bailey, 2003). Differential reinforcement has been shown to be effective to help to reduce aggression in individuals with TBI and is easily used to set up desirable behavior patterns (Hegal & Ferguson, 2000).
Rational Behavior Therapy (RBT). This mental health strategy believes that environments and not people plateau in brain injury recovery, but rather environments fail to provide individuals with adequate learning opportunities in order to grow (Seaton, 1995). Behaviors and emotions are the result of cognitive processes (or as in brain injury, the absence of them). It is not the situation that causes a reaction, but rather what a person believes about the situation. In RBT, everyone creates his/her own reality. This intervention strategy has proven successful in treatment of individuals with TBI. It helps to alleviate the sense of helplessness; acknowledges the loss of control, and the existence of fear.
Applied Behavior Analysis (ABA). ABA is a positive behavioral support that promotes learning. It is an intervention strategy developed to change inappropriate behaviors and measures those behaviors before, during and after intervention. Its six steps include: identifying the target behavior; measuring the frequency of the behavior; analyzing the behavior, using the A-B-C paradigm (antecedent-behavior-consequence); developing a plan for intervention; generalizing the behavior to different environments and empirically evaluating the results (Burke & Wesolowski, 1988). Applied Behavior Analysis therapy focuses on using the A-B-C model for managing disruptive behaviors. This therapy mimics that of learning because students with brain injury have to relearn various behaviors after injury.
ABA is often referred to as behavior modification, which can cause great apprehension in both the public and professional arena. People believe that ABA causes students to change against their will. However, this belief is irrational because human behavior is continually being modified and evolving everyday by environmental conditions beyond our control. Ultimately, ABA helps to teach students with brain injury effective stills and provides an opportunity to relearn lost abilities in order to improve their quality of life.
Behavior Change Programs. These types of programs help to shape disruptive behaviors by developing positive adaptive skills and decreasing disruptive behaviors with the ultimate goal of increased independence. This helps to facilitate a student’s positive mental health. The seven steps in implementing an effective behavior change programs include: 1. defining the problem behavior (observable and measurable); 2. identifying the function, the cause and rate of the target behavior (baseline data); 3. identifying resources for behavioral intervention; 4. identifying strategies for behavioral change (altering antecedent, using reinforcers); 5. implementing the BIP (Behavior Intervention Plan) as designed; 6. evaluating, modifying and reimplementing the BIP as necessary; 7. maintaining behavioral change with decreased levels of intervention support—shifting the control back to the individual with TBI and 8. generalizing the change to other settings (Glang, Singer & Todis, 1997). This behavioral approach believes through changing both the antecedent and consequence, the behavior can also change. This approach helps to reinforce lasting change in students with brain injury.
Antecedent Behavioral Interventions: Positive Everyday Routines. Antecedent control procedures emphasis positive everyday routines and do not place emphasis on consequent management procedures. This procedure demonstrates effective results; establishes “positive behavioral momentum” and involves the individual with TBI in the planning and decision making processes (Feeney & Ylvisaker, 1995, 69). Positive everyday routines have proven to be important in both short and long-term behavioral management control for individuals with TBI because this intervention technique generalizes into real-world contexts. Its purpose is to facilitate individual growth by giving the individual personal insight and effective behavioral improvement. This intervention strategy is effective of because it places the choice and control in the hands of the individual with TBI.
Nontraditional Approaches to Change
There are various nontraditional approaches students can use to improve disruptive behaviors. These are known as the Humanistic-holistic approaches and have been shown to be effective in reducing mental health issues after TBI. These include: meditation and relaxation therapy, music, poetry, and dance and movement therapy, neuromuscular and deep tissue massage, chiropractic, acupuncture, nutritional support, and homeopathy, and holistic medicine. Although there is not much, if any, quantitative research to scientifically back the effectiveness of these alternative, holistic techniques, there does exist individual, qualitative research that has proven the nontraditional approach as being effective in treating mental health issues after brain injury.
Recommendations
As the previous literature indicates, there is an abundance of techniques to effectively manage disruptive behaviors after TBI in order to increase a student’s positive mental health. However, behavior management techniques for brain injury are still in their philosophical infancy. The educational implementation of the previously discussed intervention strategies has not yet been realized. In order for continued growth, teachers need to be made aware of the implications of TBI on a student’s mental health needs, which can be accomplished through continuing education. Once teachers are made aware of students’ mental heath needs, they need to observe their students’ behavior and document disruptive, isolating mental health issues. It is in this way reactive interventions are changed to proactive interventions, emphasizing the importance of person-centered support.
The mental health issues of students with brain injury, not only needs our attention, but in order to make the intervention lasting and effective, system collaboration needs to occur. Therefore, the school system needs to engage outside, community resources, such as the health department, various agencies, and TBI advocacy organizations in order to identify their responsibilities to these students.
Creating a system of collaboration is the first recommendation. Schools systems need to build services of support that will help facilitate a student’s cognitive and mental health recovery. This recommendation can be realized through utilizing service coordination. Service coordination uses the three communication tools the: Individual Education Plan (IEP), Individual Service Plan (ISP), and Individual Transition Plan (ITP). These three communication tools ultimately enhance the overall educational experience and learning process of a student with brain injury.
The first recommendation is contingent on the second recommendation, the training of educators. This training not only includes the components surrounding TBI, but the recovery of function principle. Teachers no little or nothing concerning how to provide behavioral intervention techniques for students with brain injury. Therefore, it is necessary to not only to have continuing education programs for those veteran teachers, but also to educate novice and up-and-coming teachers on brain injury. By including the component of TBI in teacher certification, they will become highly qualified in understanding, monitoring, and providing intervention techniques for maladaptive behaviors of these students. However, it is not only the teachers who need to be educated on the components of TBI, but school administrators, those individuals who have control over money allocation within the school systems, should also be educated. Administrators are the ones who can ultimately initiate a systemic change.
This recommendation is the most promising approach for mental health intervention for this population of students. By educating teachers on the urgency of the TBI epidemic, students’ mental health needs can be met. In promoting national awareness of TBI, brain injury professionals can also stress how essential it is to establish in-school behavioral interventions for these students to help orchestrate a systemic change.
The third recommendation goes hand in hand with the previous two, it deals with providing a curriculum to students with TBI that is both enriching and stimulating. By providing an enriching curriculum, possible structural and functional changes can occur within the brain, which can also help to facilitate behavioral changes. Structural changes within the brain can ultimately encourage neuroplasticity and neuroplasticity can ultimately help these students regain cognitive abilities that were lost due to the injury. By enriching these students’ academic curriculum, these students’ quality of life and mental health status will also be enriched. Recovery from a brain injury is essentially a re-learning process, a re-learning process that is best orchestrated through a coordinated curriculum that is structure through an IEP, ISP, and an ITP.
It is unfortunate, but the previously discussed behavioral intervention strategies have only occurred as single case studies and qualitative research. Therefore, they do not transfer into quantitative statistics that can be generalized into findings for students with TBI. Because every TBI affects every student differently and deficits vary from injury to injury, not every behavioral intervention technique works for every student. Therein lies the problem. Citing the existence of a best practice behavioral intervention strategy to improve a student’s mental health after injury that is 100% effective 100% of the time is implausible. Different behavioral management strategies work differently and more effectively from one student to the next. There is not a one-size fits all strategy that has all the answers and has the potential to improve every mental health problem.
This leads to the fourth recommendation. It focuses on increasing research in the area of mental health issues that are co-current with brain injury. By focusing on research, the taxing question of whether or not behavioral interventions are effective in treating mental health after TBI would be eliminated. Research would provide statistical data on behavioral interventions’ effectiveness. It would conclusively provide substantial data to support the supposition that behavioral intervention strategies are beneficial for a student’s improved mental health after injury.
As previously discussed, eight out of the nine behavioral interventions addressed have positive implications on recovery from disruptive behaviors associated with TBI. Each of these eight interventions has the potential to ultimately improve a student’s mental health and quality of life after injury. Therefore, the fifth recommendation is to place more emphasis on a student’s capacity to improve his/her mental health status after injury. Rather than believing mental health recovery after injury is not possible, educators need to understand, with proper intervention, change is possible. Behavioral interventions can ultimately promote long-term improvement benefits in regards in helping students’ to learn how to manage their behaviors and thus improve their overall mental health status.
Despite the fact that there are no widespread behavioral intervention strategies available to students with TBI, as medical technology and procedures advance, more and more children are surviving their injuries, returning to school and being educated without the appropriate supports and services, without any attention to the repercussions these types of injuries have on students’ psychosocial and mental health needs.
Central to this issue of needs, is emphasis on individual students, a person-centered support. The focus needs to be directed towards identifying these students’ needs, supports, and accommodations. Therefore, learning strategies should be tailored to fit the needs of each student. Strategies that can be used with students with TBI can ultimately enhance their learning environments, social interactions, transition plan, mental health status, and overall quality of life.
Conclusion
This document argues that educators should be highly qualified to teach all students. This begs the rhetorical question; does that include the education of students with TBI? Should educators be required to learn how to appropriately accommodate and educate these students? If not, are educators supposed to stand idly by and ignore the legal rights of this population and accept these gaps in services as an educational norm—casualties that slid under the IDEA radar?
Often, students who have sustained a brain injury in childhood are misidentified and are unfortunately receiving services under IDEA categorized as EBD rather than TBI. The hospital never contacted the school and therefore, the brain injury was never identified. These types of scenarios are the result of a break down in communication. In order to overcome these gaps, a system change needs to occur. An essential component of this system change is communication. Educators need to establish communication between themselves, students, parents, and stakeholders.
However, the challenges educators’ face are not in only correctly identifying students as TBI, but also providing appropriate, collaborative mental health services, services that are unique to this population of students. The emphasis on continued assessments is also an important component that needs to be also included in teachers’ professional development. The IEP development process should not only reflect these students’ unique needs, but also reflect access to related services, collaboration, and long-term goals. These students should have services that are coordinated. Various factors such as: prior ability and status, severity of injury, impairments, emotional functioning, family support systems, community resources, and revised life goals need to be addressed when planning service coordination.
Self-understanding plus self-advocacy can help these students achieve social inclusion after injury. Therefore, it is important that instructional plans be continually developed in relationship to their cognitive, behavioral, and social recovery. The neuroplasticity principle of recovery of function makes it possible, if not probable, students are capable of regaining pre-injury mental health status. This principle, this unidentified potential, ultimately provides an umbrella of opportunity for educators to help these students reclaim their pre-injury mental health status and ultimately improve their overall quality of life.
It is a basic human obligation to provide mental health interventions to students with brain injury. If medical procedures are advanced enough to provide students a second chance at life after TBI, these students also need to be provided with strategies to help improve their mental health to pre-injury status. By providing mental health services in school, students with brain injury have the potential to achieve optimum mental health, and therefore, are more likely to experience a positive transition into society. Not only is it mandatory to provide a person with life after TBI, but it is also mandatory to provide a life worth living.
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