Theoretical foundations: Developing a system of services for students with brain injury.

Katherine A. Kimes,Ed.D., CBIS

President ABI Education Services, LLC

412-794-8958 www.ABI-EdServices.com

KKimes@ABI-EdServices.com

Carol A. Kochhar-Bryant, EdD, Professor

Department of Teacher Preparation and Special Education

Graduate School of Education and Human Development

The George Washington University

Keywords: Bronfenbrenner’s Ecological Systems Theory

Environmental Enrichment Theory

Recovery-of-Function Phenomenon

Effective Service Coordination

THEORETICAL FOUNDATIONS:

DEVELOPING A SYSTEM OF SERVICES FOR STUDENTS WITH BRAIN INJURIES

Never underestimate that a small group of thoughtful, committed people can change the world, indeed it’s the only thing that ever has.-- Margaret Mead

Introduction

Developing systems of services for individuals served by the education, health, or social service sectors remains a challenge within the U.S. This is especially true for children with brain injury due to their multi-dimensional needs. It is estimated that 1.4 million people in the United States sustain a brain injury every year (Langlois, Rutland-Brown, Thomas, 2006), with 5.3 million Americans living with the effects of brain injury [Brain Injury Association of America (BIAA), 2001]. However, systems of services for this population are simply unavailable.

Children with brain injury have complex needs especially in relationship medical recovery and reintegration into education, family and the community. In order to bridge this gap, it is important for stakeholders develop a community of practice that brings together research, practice, and policy in order to discuss and understand the implications of brain injury on children’s physical, cognitive, and psychosocial state to ultimately improve outcomes (Kimes, 2009).

A system of services requires that all organizations or service sectors involved in the provision of services to the individual work cooperatively and in a coordinated manner that promotes the highest possible levels of academic, social and career-vocational functioning for each individual (Kochhar-Bryant, 2008). For each child with a brain injury, recovery depends upon the interaction between two domains, a student’s characteristics and his/her learning environment. The learning environment is enriched when services needed to promote recovery are available, timely and well coordinated. This paper examines (1) a theoretical framework for the creation of a system of services that is responsive to the individual’s personal characteristics, unique recovery of function trajectory, and the learning environment. We explore the interrelationships among the following theoretical frameworks: (a) Bronfenbrenner’s Ecological Systems Theory (1992, 1993), (b) Environmental Enrichment Theory, and (c) Recovery-of-Function Phenomenon. A coordinated system of services must be grounded in a coherent theory so that professionals can provide services and supports to improve student outcomes and allow students with brain injury to achieve their greatest full potential.

Brain Injury and the Unique Needs of the Individual

An acquired brain injury (ABI) implies that an individual has “experienced normal growth and development from conception through birth, until sustaining an insult to the brain which resulted in impairment of brain function” (Savage & Wolcott, 1995, p.146). There are two types of ABI, a traumatic brain injury (TBI) and a nontraumatic brain injury (NTBI). A TBI is as acquired injury to the brain, caused by an external physical force that can result in total or partial functional disability, or psychosocial impairment, or both. A NTBI results from internal body occurrences. Although both types of injury can result in damage to the brain, it is important to remember that because the mechanisms of injury are different, the terms ABI and TBI cannot always be used interchangeably. For the purpose of this article, “brain injury” is used as an umbrella term that refers to both ABI and TBI.

As reported by the CDC (2006), each year 50,000 people died from injuries to their brain, while 235,000 are hospitalized and 1.1 million are treated and release from emergency departments (Langlois, et. al, 2006). Those at highest risk of sustaining an injury are children from birth to 4 followed by adolescents 15 to 19 and from 1995-2001, approximately, 475,000 brain injuries occurred among children, birth to 14 years of age (Langlois, et al., 2006). This makes brain injury the leading cause of death and disability in children and adolescents in the United States; however, arriving at exact figures is difficult (Langlois, et al., 2006). The true prevalence rate is under-estimated because “the extent of emergency department and non-emergency department diagnosis and treatment of brain injury is unknown” (Kraus & Chu, 2005, p. 7). Data such as that reported by the CDC on the incidence rate of brain injury suggests a much greater occurrence than those injuries actually reported “based on deaths and hospital admissions” (Elovic & Zanfonte, 2005, p. 727).

Consistent underreporting of brain injury among the general population corresponds to the underidentification of brain injury within the population of primary and secondary school–aged children, those at highest risk of sustaining such an injury. As reported by the CDC, most children sustain brain injuries as a result of falls (Langlosis, et al., 2006). Children also sustain injuries at a high rate due to motor vehicle accident, while infants and toddlers typically sustain injuries due to abuse, i.e., shaken baby syndrome, or neglect (Langlosis, et al. 2006, Schoenbrodt, 2001; Sellars & Vegetr, 1996; Savage & Wolcott, 1994).

The Complex Educational and Social-Emotional Needs of School-Aged Children with Brain Injury

The CDC identifies that brain injury as the leading cause of death and disability among school-age children (Langlosis, et al., 2006), however, research evidence indicates that teachers and professionals do not understand the repercussions of a brain injury (Glang, Tyler, Pearson, Todis, & Morvant, 2004; Savage, 1996; Traumatic Brain Injury State Grant Program, 2002), or the individualized services and educational needs that are typically required after a student sustains such an injury (Glang, et al., 2004; Savage, 1996; Traumatic Brain Injury State Grant Program, 2002). Currently, little is known about how school systems are meeting the needs of those in this population. Therefore, general and special education teachers as well as related service personnel need to understand how to best educate, provide appropriate supports, and services, to this growing population of students (Kimes, 2009).

In addition, many school districts face very real problems in meeting the federal requirement [IDEA, §613(f), 1997; IDEA §1400, 2004; NCLB, §1120B, 2002] to coordinate services for students with brain injury and currently do not provide these children with appropriate services (Savage & Wolcott, 1994; Legislative Members of the Interim Committee on Head Injury, 1999; Traumatic Brain Injury State Grant Program, 2002). Therefore, it is important to build a system of services in the United States for students with brain injury (Kimes, 2009).

It is also important for stakeholders to understand the repercussions of brain injury are not limited to motor deficits, since impairments that result from injury depend on the area of brain damage. Impairments can also include cognitive impairments such as deficits in language comprehension, memory, concept formation, attention, reasoning, organizing, abstract thinking, judgment, problem solving, sensory and perceptual motor abilities, psychosocial behavior, physical functions, information processing, and speech (McCullagh & Feinstein, 2005; Traumatic Brain Injury Medical Treatment Guidelines, 2005; Brain Injury Association of America, 2001; Clark, 1996).

The less obvious, but more predominant, secondary effect of brain injury are related to behavioral and emotional or psychosocial problems. These psychosocial effects “[refer] globally to the social, emotional, behavioral and psychological effects of…brain injury” (Savage & Wolcott, 1995, p. 239). Behavioral impairments typically occur to some degree with almost all brain injuries and get worse rather than better over time without effective intervention techniques (Clark, 1996; Kimes, Lash, & Savage, 2008; Savage & Wolcott, 1994; Traumatic Brain Injury Medical Treatment Guidelines, 2005). Every brain injury is different and the resulting impairments are highly idiosyncratic, as are the rates of recovery. Ultimately, recovery depends upon the interaction between two domains, a student’s characteristics and his/her learning environment.

Building a Theoretical Framework for a System of Services

Introduction and Interrelationship of Concepts

There is a logical and hierarchical relationship among the assumptions of ecological systems theory (1992, 1993), enriched environment, system coordination, and recovery of function. These theories are discussed in relation to how a student’s cognitive recovery after brain injury is contingent on the proceeding theoretical construct (see Figure 1). This section discusses the ecological systems theory, service coordination, and the recovery-of- function phenomenon and how these three theories are interrelated. Environmental enrichment, an important component of the ecological systems theory, helps to promote brain plasticity because it stimulates neurons to create new neural connections. Environmental enrichment is also an important component of service coordination because service coordination helps to create new neural connection by enriching the school environment (Kimes, 2009).

Figure 1.1. The Conceptual Framework

Kimes, K. (2009). From Service Coordination to Recovery-of-Function Phenomenon: A Paradigmatic Case Study of One School District's Efforts to Improve Outcomes for Students With Brain Injury. (Doctoral Dissertation, The George Washington University, 2009). UMI Dissertations Publishing. (UMI No. 3359749).

Bronfenbrenner's Ecological Systems Theory Bronfenbrenner’s (1979) ecological theory, derived from general systems theory, views a child’s development within the context of the system of relationships that forms their environment. The theory represents a developmental perspective and is rooted in the belief that we are active participants in self-development and the environment. Bronfenbrenner’s theory defines complex ‘layers’ of environment, each having an effect on a child’s development. He defined a whole-system, or ecological perspective, and theorized that in order to create a change in a system, we have to examine all the parts of that system -- personnel, relationships, roles, resources, leadership, organization, and others -- and how they are related to each other in context (Bronfenbrenner, 1979). Bronfenbrenner (1986) later refers to a social context system that involves interaction among people who influence the student at multiple levels of a student’s social organization – family, peers, school, and wider community. An application of this model is the concept of interdisciplinary teaming (Hart, Zafft & Zimbrich, 2001). The collaborative team model is compatible with social system context theory, since the focus is on the individual, at the center of the system.

The ecological system theory (1977) is especially relevant to the brain injury population. Because every brain injury is different, the repercussions of injury are different for every individual. This is why, it is important to ultimately enrich the Microsystem level in Bronfenbrenner’s (1979) systems theory in order to promote recovery of brain function.

Environmental Enrichment Theory

Environmental enrichment can be instrumental in promoting brain plasticity and is also an important component of system coordination. Examples of environmental enrichment include service coordination such related services as occupational therapy, physical therapy, counseling, and speech and language therapy. In addition environmental enrichment can refer to particular types of academic support and services offered through education programs in the classroom such as individual tutoring, hands-on experience, or group discussion. Environmental enrichment stimulates the neurons in the brain and helps to create new neurons to form new neural connections. It is the systems coordination within a student’s Microsystem environment that helps to enrich the student’s in-school environment. Bronfenbrenner’s (1992, 1993) ecological systems theory model correspond to the neuroplasticity, or recovery-of-function phenomenon, and system coordination because an enriched environment help and enhances students’ “learning and development” (Muuss, 1996, p.324). The changes produced by system coordination depend upon the individual characteristics of the student and the particular environment in which they live and learn, and the interaction between these two domains.

Recovery after brain injury, therefore, is typically enhanced with the exposure to enriched environments and environmental influences (Raine, Reynolds, Venables, & Mednick, 2002; Peterson, 2002). Recovery is ultimately a relearning experience because many previously attained cognitive, behavioral, physical, and social skills need to be relearned. According to the NIH, “many of the mechanisms that drive initial neuronal development reappear during regeneration and recovery” (2002, ¶3). These mechanisms that stimulate new neuronal connection in the brain are influenced by exposure to an enriched environment (Raine, et al., 2002). Environmental feedback and stimulation are two critical components in recovery of brain function (Perna, 2002) because the more complex a task the greater the rewards because environmental enrichment promotes neural development (Johnson, Ruston, & Shaw, 1996; Raine, et al., 2002). Here again, Bronfenbrenner’s ecological systems theory model can be emphasized to reiterate the importance of how an enriched environment, through service coordination, can ultimately affect a student’s developmental and brain recovery process.

Recovery-of-Function Phenomenon

Recovery of function was addressed by Margret Kennard, a pioneer of the 1930s and early 1940s, who experimented with brain lesions in primates. She introduced two important terms, recovery of motor function and functional reorganization of dendrites, processes that extend from neurons and receive information, or brain signals (Kennard, 1942). She brought to light the capacity of the central nervous system to functionally reorganize and the fact that “reorganization takes place within the remaining portions of the [brain]” (Kennard, 1942, p. 238). She concluded that reorganization is a slow process. Dr. Kennard also discovered the growth of dendrites, and the way they proliferate and reorganize to form new connections during recovery (Kennard, 1942).

Kennard’s case studies marked a new era in helping to further understand the mechanisms of the brain (Finger, 1999) and brought to the forefront both the utilization and the manipulation of the brain’s neuroplastic capabilities, the phenomenon of the reorganization of neurons to include recovery of function, in order to help optimize a person’s quality of life after brain injury. Kennard was a major influence on the thinking surrounding recovery of function, helping to launch the modern era of research in this area (Finger, 1999).

There is gathering evidence through the research related to recovery of function that neuroplasticity is possible (Almili & Finger, 1992; American Psychological Association, 2006; Gautschi & Clarke, 2007; Growdon, Locascio, Corkin, Gomez-Isla, & Hyman, 1996; Munson, Schroth, & Ernstet, 2006); unfortunately, the potential for recovery is not fully understood, especially in relationship to how the brain’s components work together in order to achieve recovery of function.

It was with the discovery of neurotrophic factors (NTF) that scientists realized that brain cells could redevelop. Brain regeneration is made possible through NTF which are a specific type of nerve growth factor that occur as proteins in the brain and promote the growth and survival of neurons during the development of a child, for the maintenance of adult nerve cells, and after trauma (Huntington’s Outreach Project for Education, at Stanford, 2005). NTF are a key component in developing and keeping neurons alive, promoting plasticity and are vital in helping to support healthy adult neurons maintain and regenerate their processes (Naimark, et al., 2007; Shmizu, Fulp, Royo, McIntosh, 2005; Society for Neuroscience, 1994; World Intellectual Property Organization, 1997).

NTF fit into neuron receptors much like a key fits into a lock, unlocking future potential. A neuron’s dendrite conducts impulses to the cell body of the neuron in the form of NTF (Society for Neuroscience, 1994). For example, dendrites 1) receive impulses across the synapse, or space between the junction of two neurons and 2) carry the impulse away from the cell body to the axonal transport of the neighboring, or target neuron, where 3) it reaches the neuron’s nucleus.

Research has shown that NTF are (a) present in early development of the nervous system and responsible for the initial growth and development of neurons in the peripheral and central nervous systems; (b) released by target tissue of growing neurons and, depending on whether or not the neuron reaches its target, develop (those that don’t reach the target die); and (c) capable of making damaged neurons grow their processes in a test tube and in animal models (Naimark, et al., 2007; Russel, & Duman, 2003; Society for Neuroscience, 1994). These three findings represent exciting possibilities for reversing devastating degenerative neurological disorders like brain injury. The use of NTF, that is, nerve growth factors, hold promise as agents for promoting recovery after brain injury (Kondziolka, Wechsler, Tyler-Kabara, & Achim, 2002; Shimizu, et. al, 2005).

Over the years, researchers have defined the term recovery of function in different ways. A healthy brain maintains a certain level of plasticity and functional reorganization throughout life. In order to develop interventions to overcome the sequelae of brain injury, it is extremely important to understand the underlying factors of brain plasticity (Rocca, & Filippi, 2006), because “recovery of function tends to be equated with plasticity” (Perna, 2002, p. 32).

The present-day definition of recovery of function following brain injury is described as enhancing the potential for functional recovery, involving two alternatives: (a) neuronal sparing, or to prevent nerve cells from dying (Almili & Finger, 1992; Gautschi, & Clarke, 2007; Growdon, et al., 1996) and (b) neuronal reorganization, to control the growth of nerve cells that survive the injury (Almili & Finger, 1992; Munson, et al., 2006). In regard to brain injury, recovery is based on reorganization of neurons within the damaged system(s) of the brain or growth of surviving brain cells (Finger, 1999; Munson, et al., 2006). For example, nerve cells can change in form, structure, and function, something known as the neural reorganization phenomenon.

Brain injury causes neurons to die or sever and those neurons that survive the injury reorganize and undergo reactive synaptogenesis to establish new neural connections with neighboring, or target neurons (Reeves, Prins, Zhu, Povlishock, & Phillips, 2003). This innate phenomenon has enormous implications for the brain injury community. However, without further research on the possible implications of neural reorganization, the potential of these repercussions is still unknown, because it has not been determined whether or not these new synaptic connections contribute to the recovery of function, to additional brain injury impairments, or are benign.

The scientific mechanisms of the recovery-of-function phenomenon in relationship to how service coordination can promote a student’s cognitive recovery after brain injury, are an unexplored area of research (Kimes, 2009).

Summary

As previously discussed, there is gathering scientific evidence that neural reorganization does occur following brain injury. Unfortunately, recovery of function still depends upon a number of unknown factors; and so additional research is needed to identify the brain chemicals (e.g., nerve growth factors) that influence the consequent survival and growth of neural cells after injury.

Rehabilitation and therapeutic exercise are of vital importance when used in conjunction with enriched environments, those activities that alter a student’s “macro-environmental experiences” and help to stimulate and regenerate new neural pathways (Peterson, 2002, p. 36). For example, special education is systematic support that a student receives in the form of coordinated, related and academic services in his/her classroom environment. These coordinated services can be provided in the form of the related services a student receives such as occupational therapy, physical therapy, counseling, and speech-language therapy, but also can refer to particular types of academic supports and services offered through education programs in the classroom environment in the form of individual tutoring, hands-on experience, or group discussion. Therefore, environmental feedback and stimulation are critical components in recovery of brain function (Perna, 2002) because environmental enrichment helps promote recovery of brain function after injury (Raine, et. al, 2002).

Once a student is discharged from a rehabilitation facility, recovery does not have to end. Environmental enrichment helps to promote brain plasticity and is also the foundation that helps to provide effective service coordination for students with brain injury (Kimes, 2009). A student’s environment can be enriched by way of the services and supports provided through individualization of coordinated services provided for in the student’s Individual Education Plan (IEP). A student can achieve cognitive and functional brain recovery by enriching the environment and stimulating the brain to form new neurons and new neural connections.

Therefore, it is very important for educators to have a working knowledge of the underlying principle of neuroplasticity (Kimes, 2009). “Academic and cognitive function impairments make school reentry and long-term educational success a great challenge” (Max, 2005, p 490). The primary reason for stakeholders’ need to understand the recovery-of-function phenomenon is to create the most fair and appropriate, developmental, and enriching educational environment for the student with brain injury (Raine, et al., 2002). In order to develop interventions that utilize brain plasticity to overcome the impairments caused by brain injury, it is important to understand the underlying factors of brain plasticity. Educators can thereby best utilize their resources and support services to influence and triumph over the developmental barriers of brain injury (Kimes, 2009). It is therefore important to understand the status of current and emerging research about the recovery-of-function phenomena. The true value of examining a service system is the role in accelerating recovery.

The scientific proof of plasticity remains. The brain is not a static organ. Even as a person grows older, the brain maintains some level of its plasticity. The organ is clearly dynamic. As quoted by Parent, “You don’t have to perfectly rebuild the brain to improve significantly [a student’s] quality of life…[i]f we could learn how to repair even half the damage, it may be enough” (University of Michigan, 2002, ¶12). Parent’s sentiment reiterates the importance of the neuroplastic principle: if any level of recovery of function is attainable and can improve a student’s life for the better, recovery of function is a worthwhile pursuit. Neuroplasticity is a viable option yet to be fully addressed, explored, and embraced by academia and the brain injury community (Kimes, 2009).

Elements for A Coordinated Service System

An individual’s environment can be enriched by coordination of services and supports in association with the academic program. Expectations for collaborative practices are embedded in the Individuals With Disabilities Education Improvement Act of 2004, the No Child Left Behind Act of 2001 (NCLB), the TBI Act (1996), as well as a variety of additional laws aimed at protecting the civil rights of individuals with disabilities. IDEA (2004) and NCLB (2001) define the specific educational services and supports that must be provided to eligible students, collaboration and coordination refer to how the process works to ensure that quality services are provided to meet the educational needs of each student. Learning from the mental health field, schools are increasingly recognizing that the educational performance of all children, particularly those who are placed at-risk, will not improve unless efforts are made to remove the barriers to learning created by problems that begin outside the classroom walls. Linking students and schools to integrated health and human services is one strategy. Collaboration across agency lines and among public and private providers is one of the most significant – yet challenging -- developments in human services in recent years.

A coordinated interagency service system can be defined as follows:

A coordinated interagency service system means a systematic, comprehensive, and coordinated system of education and support services for individuals with disabilities, which is provided in their communities in the most integrated settings possible, and in a manner that promotes individual choice and decision-making (Kochhar, 2003).

A synthesis of the literature on planning for educational services for students with disabilities (Kochhar, 2003) shows that there are several important elements of a coordinated system.

A formal long-range interagency plan for a system of education and support services for students in integrated settings, from early intervention through postsecondary transition.
Special supports for the critical ‘passages’ or transitions between educational settings, such as from early intervention to preschool, elementary to middle school, and high school to post-secondary education.
A statewide system of personnel development to prepare teachers and support personnel to work within a coordinated interagency system of services, which includes pre-service preparation as well as continuing (inservice) preparation and the training of parents.
Innovative cooperative partnerships among public schools, related service agencies, area colleges and universities, private service providers, related services agencies, and parents to achieve common goals for the including students with disabilities into mainstream education.
Ongoing evaluation of system coordination efforts and student outcomes (Dunst & Bruder, 2002; National Center on Outcomes Research, 2001).

System coordination is a cornerstone in the educational success of individuals with disabilities and their families.

Evidence of a Link Between Student Achievement and Professional Collaboration

Accumulating research is providing evidence of links between student achievement and collaboration: professional-to- professional, teacher to student, special educator to general educator, teacher-to-parent, IEP Team collaboration, and school to community professional coordination. Effective collaboration and system coordination have been linked to a variety of student, family and professional outcomes. These include the following:

Gains in student achievement, motivation, attendance, conduct and other measures of commitment to learning
Improved collaboration among teachers and related services personnel and systematic assistance and support to beginning teachers
An expanded pool of ideas, methods and materials that benefit all teachers
Greater engagement of parents in their children’s education
Improved coordination among schools and school-linked agencies to support student services and school improvement planning (Dettmer, Dyke & Thurston, 2005; Knight & Boudah, 2003).

Creating a professional collaborative culture may be the most important factor in successful school improvement initiatives to improve student outcomes (Gordon, 2004; Lambert, 2003).

In order for system coordination to occur, collaboration needs to occur at both the system and individuals levels (Kochhar-Bryant, 2008). This systematic process is a process of interdependency: system collaboration, system coordination, and interpersonal collaboration. The linkage that helps to establish a foundation for effective service coordination is that which connects system coordination with interpersonal collaboration. The “dimensions of system coordination” helps to describe the function of effective service coordination and assists in promoting the involvement of teachers, parents, community professionals, and individual students within the educational process (Kochhar-Bryant, 2008, p. 67).

Need for Interagency Agreements

A ‘systematic’ approach to interagency service coordination means developing strategies to address the complex needs of children and youth in an organized and coordinated manner to support healthy development and academic success. A coordinated interagency service system is defined as a systematic, comprehensive, and coordinated system of support services in primary or secondary education that allows students placed at risk and students with disabilities to receive services in the most integrated settings possible, and in a manner that promotes individual choice and decision-making (Kochhar-Bryant, 2008). Interagency service coordination may also be defined as a strategy for mobilizing and organizing all of the appropriate resources to link the student and family with needed services in order to achieve individual goals and successful long term outcomes. Such an approach requires that schools reach out beyond their boundaries and seek a shared responsibility from the many agencies that provide support services for students.

A coordinated interagency service system is both an ideal and a strategy. It is a service structure for responding to individuals with special needs, within their communities, in the most integrated setting possible, and in a manner that promotes individual decision making. The general goal of service coordination is to ensure that students with complex, multiple needs receive the education and support services in a manner that is timely, appropriate, accessible, comprehensive and flexible.

Effective Service Coordination for Students with Disabilities

There are three main components that are essential in helping to ensure effective service coordination of students with disabilities in schools (Kimes, 2009). All three of these components correspond to Bronfenbrenner’s ecological systems theory (1992, 1993). The three components that help to promote effective service coordination include:

Broad based support and participation of administration, community leaders, youths, and families to include positive attitudes towards the process (Pandiani, Banks, & Schacht, 2001; Provan, Nabama, Vebie, Teufel-Shone, & Huddleston, 2003; Salisbury, Marlowe, & Husband, 2003);
Collaborative communication between constituents to include interagency communication (Zanglis, Furlong, & Casas, 2000; Bruder, Harbin, G., Whitbread, K., Conn-Powers, M., Roberts, R., Dunst, C., Van Buren, M., Mazzarella, C., & Gabbard, 2005; Dunst & Bruder, 2006).
Training, support, and technical assistance of service coordinators to help build a comprehensive system of services (Harbin, Bruder Adams, Mazzarella, Whitbread, Gabbard, & Staff, 2004; Wright, Russel, Anderson, Kooreman, & Wright, 2006).

All three components work together to help ensure effective service coordination occurs within the school system and help to strengthen and build an effective system of service coordination for students with brain injury (Kimes, 2009).

Implications for a Coordinated System of Services for Individuals With Brain Injury

There are various implications surrounding the development of a coordinated system of services for students with brain injury to help integrate them into school in order to increase their educational endeavors. It is by focusing on what is necessary in a system of education for students with brain injury that we acknowledge their inalienable rights to a free and appropriate education to further encourage decision-making skills, to increase self-image, and to help broaden their perception to their future possibilities. By increasing the knowledge-base of and understanding of how to provide effective service coordination to students with brain injury, a coordinated system of services will ultimately improve outcomes for these students. It is only with awareness comes understanding. It is through the acknowledgment of the legality of providing appropriate, quality services to students with brain injury that schools will begin to implement collaborative and effective services within their coordinated system of care.

Recommendations for Developing a System of Services for Students with Brain Injury

There are different levels within the system change process that needs to take place prior to implementation of a brain injury service model within a school district. These two levels include both professional roles and the creation of a system of supports, or a brain injury service model within the school system. These two levels are discussed followed by various recommendations to help initiate and develop the change process.

Professional roles within the school system

It is important everyone within the school system who has direct contact with the student with brain injury to understand the mechanisms of injury and the brain’s capability to recover function. This knowledge is of particular importance when developing a coordinated system of services for student with brain injury. While there are various roles within the system change process, there are three roles that are of particular importance when discussing system change and include three roles: administrator, teachers, and parents.

The first recommendation is that administrators, teachers, and service providers within the school system understand the level of services, supports and system of coordination required for students with brain injury within the system of education (Kimes, 2009). The role of the administrator is important when deciding teacher training, and program development because it is the administrator who determines which program is provided funding. The administration plays an important role in helping to foster change in systemic policy because s/he allocates the funds necessary to support the system change effort and helps to set the professional tone of the change effort. The administrator plays an important role in effective reform because a change in school policy is ultimately contingent upon an attitude change among professionals within the school system.

It is important to elevate teacher standards in relationship to general knowledge surrounding the implications and repercussions of brain injury (Kimes, 2009). It is important to increase the competency level of both pre-service and veteran teachers. Professional development of teachers needs to occur at the pre-service level r continuing education level, while the issues of curriculum, assessment, instruction, and transition services are also addressed to improve system coordination.

School systems can help to alleviate parents’ confusion and isolation by developing cooperative relationships (DePompei & Williams, 1995). Schools need to provide a supportive environment to help parents become skilled advocates for their child with brain injury. If schools help support parents, parents will be able to support their child and will ultimately promote the child’s self-reliance. It is essential school systems provide opportunities to help educate parents on the implications of brain injury on their child’s life.

Implementation of a Brain Injury Service Model

In order for a student with brain injury to receive an appropriate and free education it is important for school systems to develop a brain injury service model. As Figure 2 illustrates (see pg. 25) there are various components that are essential when developing a system of services because successful coordination is essential if this service model is to flourish within a system.

Within a brain injury model system, service coordination initiates as soon as a child is admitted to the hospital. Once the student is ready to be discharged from the hospital s/he can enter into a learning center to receive support through individual tutoring as deemed appropriate. Once the student is ready to be immersed into a comprehensive school site, the least restrictive school setting is chosen from a list of ABI School Placement Criteria. In addition to the specialized school placement, a student has access to related services such as OT, PT, and Speech and Language Therapy as needed.

An important component of the coordination of services initiative within the model system is that students have access to a brain injury class, which addresses various topics related to their injury through out the year. For example, this class would be a platform to focus on brain education for students to 1) understand what happened to their brain, 2) hold group discussions, 3) learn memory strategies and problem-solving techniques to compensate for their injuries, and 4) learn compassion, 5) provide peers support, and 6) build altruism. All of these components of service/system coordination are presented in Figure 2. Relationship of Service Coordination to the Recovery-of-Function Phenomena (page 23). Figure 2 demonstrates a system linkage between how environmental enrichment, through service coordination, can help to foster brain recovery in a student and provides students access to an enriched environment to ultimately can help them recover brain function and improve their quality of life (Kimes, 2009).

Figure 2. Relationship of Service Coordination to the Recovery-of-Function Phenomena in the SDUSD Service Model.

Kimes, K. (2009). From Service Coordination to Recovery-of-Function Phenomenon:

A Paradigmatic Case Study of One School District's Efforts to Improve Outcomes for Students With Brain Injury. (Doctoral Dissertation, The George Washington University, 2009). UMI Dissertations Publishing. (UMI No. 3359749).

Figure 2. illustrates that there is a promising relationship between the development of a brain injury services model and how services are coordinated within a school system. The environmental conditions provided in a coordinated service or system correspond to the neuroplasticity, or recovery-of-function phenomenon, and how service coordination works congruently with Bronfenbrenner’s (1992, 1993) ecological systems theory (Kimes, 2009). Therefore, the changes produced by service coordination also depend upon the individual characteristics of the student, the particular environment in which they live and learn, and the interaction between these two domains. Evidence-based research has emphasized the benefits of collaboration and system coordination because, according to a Bryk and Schneider study (2002), “[i]mprovements in areas such as classroom instruction, curriculum development, teacher preparation, and professional development have little chance of succeeding without improvements in a school's [collaborative] climate” (as cited in Kochhar-Bryant, 2008, p. 121). “Effective collaboration and system coordination have been linked to a variety of student, family and professional outcomes” (Kochhar-Bryant, 2008, p. 127).

Closing

Due to its underreporting and misidentification, brain injury, has gone unnoticed by our system of education (Savage & Wolcott, 1994). However, 5.3 million Americans are living with the effects of a long-term disability and 1.4 million American sustaining a TBI annually (BIAA, March 2001). Those at highest risk are children from birth to 4 followed by adolescents 15 to 19 (Langlois, et. al, 2006) and directly correspond to the population of primary and secondary school–aged children. As medical technology advances, more and more children, adolescents, and young adults are surviving their injuries. However, these students are at a disadvantage because stakeholders know little to nothing about providing appropriate services, supports, or teaching to these students once they reenter the school system (Kimes, 2009).

In order to help rectify the problem of school systems not providing appropriate services to these students, it is important for stakeholders within the system of education to understand the dimensions of system/service coordination and how these systems can ultimately help to improve a student’s quality of life (Kochhar, 2008). Stakeholders’ need to understand the interconnecting theories that form the foundation of system/service coordination and how each theory is contingent on the proceeding one, i.e., Bronfenbrenner’s ecological systems theory, environmental enrichment, and the recovery-of-function phenomenon (Kimes, 2009). Stakeholders’ need to begin a dialogue that addresses how to appropriately meet the educational needs of student’s with brain injury and to be educated on the theories that underlie effective system/service coordination with the goal of developing cooperative systems of services and supports for these students to help elevate their overall quality of life (Kimes, 2009). A student who has access to a rich variety of specialized support services is more likely to experience cognitive and functional recovery than a student who does not have access (Kimes, 2009).

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Katherine KimesJuly 12, 2020