School-based interventions for treating social adjustment difficulties in children with traumatic brain injury.

Children with Traumatic Brain Injury (TBI) face many challenges when moving from the rehabilitation to school setting. Many of these challenges involve the acquisition of social skills needed to function within the school's social environment. Diagnostic criteria of TBI are described and stages of recovery are reviewed. Behavioral and cognitive interventions are explained.

Children with Traumatic Brain Injury (TBI) have an acquired open or closed injury to the brain from an external physical force that results in a functional disability or psychosocial impairment, or both, that adversely affects educational performance. The sources of such physical forces are many and varied; yet often include automobile and pedestrian accidents, bicycle accidents, or sudden falls at home or on the playground. TBI affects the performance of children across a number of educational domains, including physical functioning; sensory-motor processing; cognition, attention and memory: speech and language; and social behavior. Disorders of executive functioning are common, including difficulties in organizing, evaluating and carrying out goal-directed activities relevant to academic expectations and social behaviors.

The purpose of this paper is to review literature describing typical social difficulties experienced by children with TBI and to describe intervention strategies that assist in the acquisition and reacquisition of those social skills needed to facilitate social adjustment in the schools. In this regard, this paper focuses upon those intervention strategies available to educators as they assist the social adjustment of TBI children returning to the school environment.

Over one million children sustain a TBI each year, which represents approximately one-sixth of all pediatric hospital admissions (Batchelor & Dean, 1996). The incidence rate for boys varies from 150 to 200 per 100,000 prior to age 5, and increasing to 400 per 100,000 at age 15; while the incidence rate for girls varies from 100 to 170 per 100,000 prior to age 5, and increasing to 300 per 100,000 at age 15 (Batchelor & Dean, 1996). The adjustment to a traumatic brain injury can be a difficult and devastating process for both the patient and the family.

Many children with TBI withdraw temporarily from school while participating in rehabilitation at a hospital setting. These children often experience a significant reduction of school or academic performance dating from the trauma. After short-term recovery is established, these children usually return to their school. Successful readjustment to the school environment depends partly upon the quality of the transition plan. Adaptation of the learning environment to compensate for physical and cognitive deficits assists the child's academic performance. In addition, support services from counselors, social workers, and school psychologists can also assist the child's social and emotional needs.

The consequences of an acquired brain injury have not been adequately researched (Teeter & Semrud-Clikeman, 1997), which is particularly problematic given that an acquired brain injury is considered a separate handicapping condition requiring special education support. Consequently, school personnel face the challenging task of assisting with the rehabilitation health-care plan while, at the same time, developing an individual education plan that will assist with the child's adjustment to the school environment.

Symptoms. Children with TBI experience a variety of symptoms. For some children. TBI involves a postconcussional syndrome that includes: (1) a period of unconsciousness lasting for more than 5 minutes after the brain trauma, (2) a period of posttraumatic amnesia lasting for more than 12 hours, and (3) a new onset of seizures that occurs within the first 6 months after the injury (American Psychiatric Association, 1994).

For other children, TBI may not involve a loss of consciousness. Nonetheless, symptoms of TBI often include combinations of emotional lability, insensitivity and egocentricity. Withdrawal, disinhibition, aggression and confrontational behavior. In addition, symptomatic children often experience fatigue, disruptions to the sleep schedule, headaches. Irritability, anxiety, depression, and apathy.

The manifestation of symptoms depends, in part, upon the extent of injury and the pre-morbid level of brain maturation prior to the injury itself (Spreen, Risser & Edgell, 1995). At preschool, symptomatic children with brain injury may experience frustration, fearfulness, withdrawal, irritability, anxiety, crying, and temper tantrums. At the elementary level, symptomatic children often experience short attention span. impulsivity, hyperactivity, aggression and inappropriate social interaction. Symptomatic adolescents often experience decreased social judgment, frustration over the loss of social and academic skills, depression and withdrawal, decreased anger control, inappropriate risk taking, and occasionally, the use of illegal drugs and inappropriate sexual behavior. At all developmental levels, the social and emotional status of symptomatic patients is often compromised (Paniak, Reynolds, Phillips, Toller-Lobe, Melnyk & Nagy, 2002). These symptoms affect the emotional disposition of the child, with consequent influence upon social demeanor and social skills.

Despite the developmental nature of symptom presentation, the specificity of symptoms often depends upon location and severity of brain injury (Rourke, Bakker, Fisk & Strang, 1983). The effects of brain trauma often relate to functions subserved by the specific area of brain damage. Closed head injuries often have diffuse effects, which may impact a number of cognitive, social and emotional functions. Despite such variability, both open head and closed head injuries often result in social skills difficulties. In some cases, social skills deficits may be long lasting, whereas in other cases, the injured child can reacquire skills needed in establishing and maintaining social relationships.

Recovery process. The course of recovery for the brain-injured child varies according the site and extent of injury: however, the recovery typically involves three stages (Corbett & Ross-Thomson, 1996). Stage 1 of recovery process often includes displays of agitation, impulsivity, and confusion. Often, the child shows impaired efficiency of information processing. This stage is usually apparent in the rehabilitation setting, but can also occur in the schools. Children in Stage 2 of recovery process often show intolerance for stimulation, with a denial of cognitive disability and with increasing behavioral demands placed upon the teachers and caregivers. Often, the child displays disinhibition and may emit behaviors that seem inappropriate and immature. Children in Stage 3 of the recovery process begin to show an increased understanding of the nature and type of cognitive and social deficits associated with the brain injury along with an increased understanding of the lasting nature of these deficits. Consequently, children in the third stage often become susceptible to anxiety, depression, frustration. and anger.

At each stage of the recovery process, the child with brain injury experiences some deficits of cognitive and social-emotional functioning that were not apparent at pre-injury. Cognitive impairments may include difficulties on tasks requiring attention, memory, organization and problems solving. Emotional impairments may include apathy, irritability, anxiety, fearfulness and depression. Social impairments may include withdrawal, anger and aggression. The degree of intervention needed depends, in part, upon the stage of recovery, with more advanced recovery requiring less intensity of support. In most cases, however, interventions that target specific aspects of disability assist the child's reintegration into the school environment.

In addition to the location and severity of brain injury, the course of recovery is also influenced by the environmental support provided during recovery process (Horton, 1994). In some cases, the child may exhibit little change in behavior. For other children, there may be an exacerbation of problematic pre-injury behaviors. Yet, in other cases, the child may display marked changes in behavior that were seldom, if ever, noticed at pre-injury. Consequently, an observational assessment of social behavior in the school provides a contemporary and meaningful supplement to assessments from rehabilitation personnel.

Observational assessment. Principles of applied behavioral analysis are often used when assessing the social behaviors of children with TB I (Horton, 1994). This strategy of assessment assumes that behavior is best explained by the antecedents that precede and the consequences that follow that behavior. In this regard, the antecedents and consequences of problematic, inappropriate social behavior become the targets of therapeutic intervention. Generally, applied behavior analysis involves: (a) identifying and describing the problem behavior: (b) measuring the frequency, intensity and duration of the behavior; and (c) identifying the antecedents and consequences that maintain the behavior and the function of that behavior.

In this manner, the observational assessment of social behavior in the classroom looks at factors within the student's environment that contribute to the challenging behaviors (Haynes & O'Brian, 2000). For many children with TBI, physical factors affect social-emotional functioning, including (a) the number of children in the class, (b) activity level within the classroom, (c) amount of available physical space, and (d) the intensity of light and noise. Often times, behavioral difficulties are time dependent, with some children showing difficulties early in the school day, while other children showing difficulties as they become more fatigued later in the day. The social behavior of the child may depend upon academic expectations of a specific setting, with some maladaptive behaviors noted in classes that are more academically or socially demanding. Or, quality and appropriateness of social behavior may depend upon the amount of instructional and social support available during the classroom period. As noted, variability of behavior is often noticed. Therefore, periodic observational assessments in a variety of classroom environments will assist the staff in identifying those specific factors that either contribute to or modulate social and emotional difficulties experienced by TBI students.

Intervention. The purpose of classroom intervention is to assist the child in reducing inappropriate social behaviors associated with the traumatic brain injury and increasing the appropriate social behaviors as the child progresses through Stage 3 of the recovery process. In this regard, the child's incremental progress can be assisted by both the recovery of brain function as well as adaptations made to the environment. Principles of cognitivism and behavioral modification are often used to assist the recovery process.

A variety of strategies are commonly used to develop and increase useful and appropriate social behaviors (Wollcott, Lash & Pearson, 1995). Reinforcement of positive behaviors commonly utilizes a combination of primary and secondary reinforcers, with tangible reinforcers having a rich fixed ratio reinforcement schedule to establish new behaviors, and social reinforcers having a variable reinforcement schedule to maintain socially appropriate behaviors. Many times, it is necessary to reinforce the small steps of improved behavior that successively approximates the desirable behavior. with such shaping of behavior carried out as a long-term intervention strategy. Modeling appropriate social behaviors, either as a live or videotaped presentation, can be useful for students capable of observational and imitative learning. Prompting and cueing socially appropriate behavior assists students in carrying out previously acquired behaviors, with combinations of verbal and physical prompts reduced as the student gains skills needed to maintain appropriate behavior. Contracting with students to maintain recently acquired behaviors helps to generalize behaviors over time and setting. Reinforcement delivered through multiple exemplars (viz., teacher, counselor, parent) can assist the transfer of social skills to new settings.

At times, students fail to apply recently acquired social skills and relapse into behaviors that are problematic for self and others. These relapses often occur when experiencing other symptoms of brain trauma, i.e., fatigue, irritability, anxiety, depression, headache. Time-outs are often helpful in removing the student from environmental events contributing to the symptomatic behavior, particularly when the student is excessively stimulated by academic and physical stimuli. Other strategies used to reduce inappropriate behaviors include (a) planned ignoring of the inappropriate behavior until such time as the student is able to apply behavioral control, and (b) reinforcing alternative, more acceptable behaviors that can occur at the same time as the negative behavior. In addition, verbal and physical cueing can often prompt the student to the more appropriate social behavior.

Cognitive strategies are often introduced to treatment as the child becomes more able to use cognitive and memory skills needed to self-monitor and self-modify social behavior. Indeed, self-monitoring alone has been shown to produce reactive effects leading to behavioral change (Kanfer and Gaelick-Buys, 1991). By drawing the student's attention to his or her behavior, the child with TBI can often redirect behavior in a more socially appropriate direction. Individual counseling that focuses on social problem solving often assists the student's ability to formulate appropriate goals, generate alternative solutions, identify the consequences of these solutions, choose a good solution, implement a plan and evaluate the results. Often times, students with TBI have difficulty reading the social cues of others and understanding the social context in which the social cues were delivered. In this manner, cognitive strategies often develop student abilities to engage in active-reflective listening for purposes of identifying content, affect and context of delivered messages.

Cognitive strategies help students to use prepared scripts when facing a perplexing and confusing situation. In this manner, prepared scripts allow students to get through difficult situations, while buying time to discuss the manifestations of that situation within an individual counseling relationship. Anxiety management strategies are introduced to assist the student's ability to recognize and identify sources of anxiety, while relaxation strategies are taught to improve the student's ability to modulate the debilitative effects of anxiety.

Some students benefit from structured didactic class activities. Numerous commercially prepared programs are available, including Elliot's and Gresham's (1991) The Social Skills Intervention Guide, McGinnis's and Goldstein's (1984) Skillstreaming series, and Stephens's (1992) Social Skills in the Classroom. These classroom programs provide opportunities for students to develop and practice emerging social skills, with repeated rehearsal to strengthen these skills through use of scripts and multiple role-plays.

Additional social-cognitive strategies use group counseling to provide peer models of appropriate social behaviors and to provide feedback and support as the student practices new social behaviors. Group counselors can observe behavioral progress to determine if the student has a skill deficit (i.e., has never acquired the skill) or a performance deficit (i.e., does not perform a previously acquired skill). Observations of group behavior can assist the group facilitator in identifying those behavioral excesses in need of reduction and those behavioral deficits in need of development. In addition, groups can serve as a circle of friends that provide social support needed in the recovery process.

Conclusion. There are many myths about the effects of TBI. For instance, some people believe that the inappropriate behaviors of TBI children are intentional; however, these children seldom have the pre-morbid levels of inhibitory skills needed to control impulsivity. Many people believe that behavior following brain injury cannot be changed because of the physical damage to the brain: however, with appropriate intervention, children with TBI learn to respond to environmental stimuli with increasing levels of self-control. Many people believe that cognitive and behavioral strategies should focus exclusively on reducing maladaptive behaviors; yet, many children with TBI respond well to interventions that not only reduce maladaptive behavior but also increase prosocial behavior.

The recovery from traumatic brain injury has wide variability within the client population. While some children may not show visible evidence of cognitive and social impairment after a brain injury, others will show profound effects, with the speed of recovery dependent on many interacting factors. Some children will recover lost functions over time, and others will show lingering cognitive and social impairments for many years.

The school is an important component in the rehabilitation process, particularly as it relates to the child's ability to function in a social setting. Indeed, many children with TBI find it difficult cope with the complexity of social stimuli found in the school's social environment. To this end, the individual education plan addresses the social limitations often experienced by children with an acquired brain injury. Numerous behavioral and cognitive strategies are available that assist with this social adjustment.

Students with traumatic brain injury often struggle with a sense of loss, which stems from the impairment of previously acquired skills as well as the reduced ability to develop new, age-expected skills. The difficulties faced by these children often affect how they look upon and feel about themselves; and they frequently experience a lowered sense of self-efficacy, particularly in their ability to interact with others in the social environment. Cognitive and behavioral strategies can help the child adjust to sources of frustration in the social environment and can develop their skills to interact more effectively with peers and adults. In this manner, intervention strategies implemented in the school environment offer much hope for children with TBI as they move through the recovery process.

References

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Correspondence concerning this article should be addressed to Dr. Bruce F. Dykeman. Associate Professor, College of Education. Roosevelt University, Chicago. IL 60605.

Bruce F. Dykeman, Ph.D., Associate Professor. College of Edcation. Roosevelt University.