Key points

TBI can have a serious impact on functional life activities, including the ability to succeed in school or perform on the job. Along with balancing the demands of returning to work or school with receipt of continued medical care, an individual with a TBI may face a difficult adjustment period learning how to function with physical or cognitive impairments resulting from the TBI. Coping with the symptoms of TBI or learning alternative methods to perform activities previously executed with ease can also be emotionally difficult for some patients. The added pressures of having to find proper supports to successfully transition back to life activities can hinder school and employment outcomes for individuals with TBI. Therefore, it is important for communication and collaboration to occur between health care providers (eg, physicians, nurses, and medical staff) and school personnel (eg, teachers, paraprofessionals, and school representatives) or employment service providers (eg, job coaches and case managers).

Introduction to educational issues in traumatic brain injury

Each year approximately 700,000 children aged 0 to 19 sustain TBI and survive. Therefore, more children with TBI are returning to school. Changes in physical, cognitive, and social behavior skills postinjury often result in students needing educational interventions, supports, and services. During the 2009 to 2010 academic year, approximately 25,000 students (0.38% of all special education students) received services under the classification of TBI. Variables that may influence student outcomes include age at injury, developmental status, nature and extent of injury, preinjury psychological status or cognitive status, history of prior injury, postinjury pain or stress, family functioning, socioeconomic resources, and parenting behavior. Several common factors found to mediate and moderate the effects of TBI on school performance have also been identified. For example, earlier age at injury and more severe injuries are associated with poorer school outcomes. Predicting the impact of these changes on school performance is difficult, however, because no 2 injuries are alike. In addition, the same etiologic factor can lead to different outcomes, depending on the student and the context.

In a 2013 review of current issues in education for students with TBI, Glangand colleagues reported that although the impact of TBI on school performance is unique, the most reported sequelae postinjury are lag in academic achievement due to cognitive deficits and disruptions in executive functioning along with social behavior problems. Glang and colleagues also indicated perceptual skills deficits, physical impairments, fatigue, diminished stamina, and the effects of medications on a student’s behavior, attention, mood, and learning can also have an impact on academic performance. Reduced federal funding has led to shorter inpatient rehabilitation and limited access to long-term rehabilitation. Consequently, many students with TBI do not receive the long-term rehabilitation treatment needed. This exacerbates difficulties with adaptive skills, academics, and the development of unwanted behaviors in the classroom. To combat these concerns, Glang and colleagues suggested increased training for school personnel on effective strategies for teaching students with TBI and strengthening links between schools and hospitals treating children with TBI.

After a TBI, health care providers and school personnel should consider the long-term educational challenges a student faces. In 2016, Prasad and colleagues found that although children with complicated mild/moderate TBI were less likely to receive educational services at 2 years postinjury than children with severe TBI, those assessed at 6 years postinjury had comparable services. The researchers concluded that children with complicated mild/moderate TBI are often left vulnerable to the sequential effects of poor academic outcomes for too long. Long-term monitoring of educational performance and service delivery is needed for all students with TBI regardless of severity of injury. Acquiring proper supports requires a movement of information through the correct channels, which does not always seem to happen. Prasad and colleagues stated that schools primarily rely on parent information and often do not get advice or recommendations from health care providers.

Effective planning for returning to school requires a collaborative approach between health care providers and school personnel. Several states have implemented models that require collaboration between parents, the school, and medical rehabilitation professionals. These allow students to return to the classroom with strategies in place and an ongoing plan for communication to make adjustments as needed based on performance. This type of approach prevents students from returning to school with no or only written recommendations from health care providers that parents and the school may find difficult to implement. The likelihood that school reentry is successful is increased if a child receives adequate support to prevent unnecessary adjustment problems when academic and social activities are resumed. Health care providers are uniquely positioned to promote a child’s transition back to school. They can influence outcomes and help children, their families, and school staff meet various challenges associated with this process by

• •
  

  Collaborating to increase educators’ and other school personnel’s knowledge about pediatric TBI

  
  
• •
  

  Understanding students’ rights, their state’s educational system, and the requirements related to students accessing various types of interventions, supports, and services

  
  
• •
  

  Determining and assigning interdisciplinary roles, functions, and responsibilities that promote successful return to school

Introduction to educational issues in traumatic brain injury

Each year approximately 700,000 children aged 0 to 19 sustain TBI and survive. Therefore, more children with TBI are returning to school. Changes in physical, cognitive, and social behavior skills postinjury often result in students needing educational interventions, supports, and services. During the 2009 to 2010 academic year, approximately 25,000 students (0.38% of all special education students) received services under the classification of TBI. Variables that may influence student outcomes include age at injury, developmental status, nature and extent of injury, preinjury psychological status or cognitive status, history of prior injury, postinjury pain or stress, family functioning, socioeconomic resources, and parenting behavior. Several common factors found to mediate and moderate the effects of TBI on school performance have also been identified. For example, earlier age at injury and more severe injuries are associated with poorer school outcomes. Predicting the impact of these changes on school performance is difficult, however, because no 2 injuries are alike. In addition, the same etiologic factor can lead to different outcomes, depending on the student and the context.

In a 2013 review of current issues in education for students with TBI, Glangand colleagues reported that although the impact of TBI on school performance is unique, the most reported sequelae postinjury are lag in academic achievement due to cognitive deficits and disruptions in executive functioning along with social behavior problems. Glang and colleagues also indicated perceptual skills deficits, physical impairments, fatigue, diminished stamina, and the effects of medications on a student’s behavior, attention, mood, and learning can also have an impact on academic performance. Reduced federal funding has led to shorter inpatient rehabilitation and limited access to long-term rehabilitation. Consequently, many students with TBI do not receive the long-term rehabilitation treatment needed. This exacerbates difficulties with adaptive skills, academics, and the development of unwanted behaviors in the classroom. To combat these concerns, Glang and colleagues suggested increased training for school personnel on effective strategies for teaching students with TBI and strengthening links between schools and hospitals treating children with TBI.

After a TBI, health care providers and school personnel should consider the long-term educational challenges a student faces. In 2016, Prasad and colleagues found that although children with complicated mild/moderate TBI were less likely to receive educational services at 2 years postinjury than children with severe TBI, those assessed at 6 years postinjury had comparable services. The researchers concluded that children with complicated mild/moderate TBI are often left vulnerable to the sequential effects of poor academic outcomes for too long. Long-term monitoring of educational performance and service delivery is needed for all students with TBI regardless of severity of injury. Acquiring proper supports requires a movement of information through the correct channels, which does not always seem to happen. Prasad and colleagues stated that schools primarily rely on parent information and often do not get advice or recommendations from health care providers.

Effective planning for returning to school requires a collaborative approach between health care providers and school personnel. Several states have implemented models that require collaboration between parents, the school, and medical rehabilitation professionals. These allow students to return to the classroom with strategies in place and an ongoing plan for communication to make adjustments as needed based on performance. This type of approach prevents students from returning to school with no or only written recommendations from health care providers that parents and the school may find difficult to implement. The likelihood that school reentry is successful is increased if a child receives adequate support to prevent unnecessary adjustment problems when academic and social activities are resumed. Health care providers are uniquely positioned to promote a child’s transition back to school. They can influence outcomes and help children, their families, and school staff meet various challenges associated with this process by

• •
  

  Collaborating to increase educators’ and other school personnel’s knowledge about pediatric TBI

  
  
• •
  

  Understanding students’ rights, their state’s educational system, and the requirements related to students accessing various types of interventions, supports, and services

  
  
• •
  

  Determining and assigning interdisciplinary roles, functions, and responsibilities that promote successful return to school

Collaboration and information dissemination

Health care providers need to know how to support a child’s return to school. Communication between health care providers and school personnel ensures that the school supports and interventions a student requires are put into place in a timely manner. Health care providers need to provide specific information to the school system, such as diagnosis, medical reports stating why the child is under a physician’s care, and length of time the child is expected to be absent. Guidelines that need to be followed on return to school should also be communicated to school personnel, including partial-day versus full-time attendance, plan to transition to full day, need for rest breaks, need to attend medical and therapy appointments, and participation in certain classes or sports. Information from health care providers regarding type or severity of impairment may also be needed for a student to meet eligibility for educational supports and services. In addition, educators and other school staff need to understand how to translate medical findings into meaningful individualized interventions, supports, and services for a particular student. A list of questions health care providers need to answer is presented in Box 1 .

Providing patient-specific information increases the likelihood that a student has access to what is needed.

Educational services for students with disabilities

Health care providers need to be familiar with basic special education laws, including the referral process and eligibility requirements for their state. They also need to understand the various types of educational supports schools can offer students, such as interventions and accommodations available as a general education student, with a Section 504 accommodation plan or with special education supports and services under the Individuals with Disabilities Education Act (IDEA) through an Individualized Education Program (IEP). An IEP specifies a student’s academic goals and states how these goals will be obtained through specially designed instruction and related services. A Section 504 accommodation plan is provided under federal law, of the Rehabilitation Act of 1973. The Act is designed to protect the rights (ie, prevent discrimination) of individuals with disabilities in programs and activities that receive federal financial assistance from the US Department of Education (ie, public schools and private schools receiving federal funding). A child must have “a physical or mental impairment that substantially limits one or more major life activities (eg, walking, learning, thinking or concentrating) have a record of such impairment or is regarded as having such impairment” to be covered under this law. Special education provides specialized academic instruction, supports, and services as stated within an IEP. As stated previously, an IEP is a requirement under the IDEA, because public schools are mandated to provide a free and appropriate education to eligible children with disabilities.

Assessment of a student’s current level of academic and functional performance is necessary to determine if the child is eligible for special education services. The request should be made in writing to school administration (eg, principal) with a copy sent to the school district’s special education office. An authorization to release medical and or therapy records to the schools also is required. Most states require a medical doctor to make a diagnosis of TBI and use that report as evidence. An assessment plan (which includes reviewing information provided by parents and the medical staff) is made by the school district, signed off on by a parent, and performed within a specified timeframe. Once assessments are completed, an IEP meeting is held. The time frame to complete assessments and an IEP meeting varies state to state but is typically 60 days. With information in hand, appropriate school personnel (ie, school nurse or school psychologist), parents, student (to the degree possible), and treating medical team should come together to discuss services and establish a timeline for the student to return to school. Health care providers and parents may need to be informed about the special education process, services, and the student’s rights under the law. For example, the parents need to know that if they do not agree with the school’s assessment findings, they can follow procedures to request an Individual Education Evaluation at the district’s expense by a qualified professional with expertise in evaluating students with TBI. In addition, some students, with obvious disability, may require less information to qualify for special education.

Additional evaluations may be held after the initial assessment or after a child is found eligible to determine if related services can help the student benefit from special education. Services can vary from state to state. Some examples of related services include medical services for diagnostic or evaluation purposes, physical therapy, occupational therapy, assistive technology assessments, parent counseling and training, and transportation. Schools are obligated to provide educationally relevant opposed to medically relevant therapies. A student who receives medical therapy outside of school may also be eligible for school-based therapy. The approach to school therapies is different from what is found in a medical setting. To receive school-based therapy, a student is assessed by the school-based therapist. If eligible, goals are written and implemented in group or individual therapy sessions. For example, in the school setting, a physical therapist might focus on improving a child’s posture or mobility or enhancing functional life skills, such as eating or drinking. Knowledge of available educational services can help health care providers be involved in planning and referral in the most beneficial manner possible.