Transcript Growing up with an acquired brain injury: neuro

Growing into an acquired
brain injury:
key problems faced by
children and adolescents while
in education
Beth Wicks
Specialist Education Consultant
Issues to explore

‘Normal’ neuro development

Usual curriculum and teaching methods in
schools

Effects of brain injury
Children are not mini-adults
Their brains are not small adult brains
It is important to take into account the
different effects of acquired brain injury in
children, compared with adults
It is important to take their age at injury into
account
Brain development
Early years
Major time of accelerated development, not
only physically but in key areas:

Cognitive

Social/behavioural

Language/communication
Young children show:
Improvement in their motor skills; ability to
form images; and understanding of cause
and effect and sequences.
As their frontal executive system starts to
develop, this begins to exert control over
socio-emotional and purposeful behaviour
from about 3 or 4 years and they also begin
to develop tactics for solving problems.
Language development from single words to full
sentences and constant questions promoted
primarily through adult interactions and
modelling
“Pre-schoolers acquire cognitive skills in part by
internalising social processes in their everyday
interactions with adults and older children.”
(Vygotsky, 1978)
Progress from object specific, to parallel and
eventually co-operative play (play being the
natural context for learning and cognitive
development)
Impulsive, egocentric, inflexible behaviour,
gradually modified e.g. when development
supports social role play, and early development
of theory of mind to see the world from the
perspective of others
Later in childhood
Development of ability to link behaviour and
consequence from about 7 onwards.
Development of language skills enable
more abstract thought and logical problem
solving.
Basic ability to resist distraction and
emerging impulse control.
(Anderson, 2001)
Also development of skills, for instance, to
reason, estimate and to calculate according
to rules.
Pre-teens
This is largely a time of consolidation and
maturation of previously developing skills.
There are also improvements to the ability
to plan and to divide attention
(Anderson, 2001)
Early to mid Teens
The visuo-auditory, visuo-spatial, and
somatic systems of the brain continue
developing.
(Savage, 1999)
Young people gradually develop dialectic
ability.
They are able to review formal operations,
find flaws with them, and create new ones.
Frontal lobes
The level of development of this area of the
brain is exclusive to our species.
(Human evolution has been termed “the age
of the frontal lobes”)
The frontal area is ‘the gatekeeper’ –
strategic problem solving, personality
control, planning and sequencing,
expressive language, response inhibition
etc.
Gap between reason and emotion
Possible lack of synchronicity between
development of different brain systems:
Cognitive understanding of and solving a
problem matures prior to balancing long
term consequences with current
social/emotional concerns
(Steinberg, 2008)
Plus increased reward seeking behaviour
= the ‘teenage brain’
Adult reasoning but Heightened need for short-term rewards
compared with longer-term gains
 Lowered capacity to avoid responses to
immediate influences, e.g. from peers

= risky decision making
“Starting the engines without a skilled driver
behind the wheel” (Dahl, 2001)
During adolescence young
people:

test boundaries

challenge authority

increase risk taking behaviour

develop social frameworks and judge
themselves in relation to their peers
Late teens to early adulthood
Maturation of the frontal regions where
executive functions are subsumed.
Young people begin to question
information they are given, reconsider it,
and form new hypotheses incorporating
ideas of their own.
(Savage, 1999)
How is this development reflected in the
process and methodology of education ?
Very Young children
●
Concrete thinking
●
Short attention spans
●
Ego-centric behaviour
●
Live in the here and now – poor
appreciation of consequences
●
Impulsive
●
Limited behavioural control
●
Disinhibited
Then…
•
Thirst for knowledge (Why? Why? How?)
•
Development of motor skills
•
Development of language skills (receptive
and expressive)
•
Development of ability to problem solve, to
process and retain information and to build
a bank of experiential knowledge
•
Begin to see things from other people’s
point of view
As a result of the usual developmental
capabilities of young children they are
taught and supervised:
• Explicitly
• Directly
We begin to teach (directly and by example):

Academic skills

Social skills

Behavioural boundaries
Once children begin to develop the ‘building
blocks’, this accelerates their learning
e.g. they learn to read
then read to learn
then learn to learn (metacognition)
As children mature there is an
increasing expectation for :
• Greater independence
• Increased self management and
awareness
• Extraction of principles from exemplar
situations
• Recognising parallels between a new
problem and an old, solved problem
• Indirect and experiential learning
• Forward planning
Some often recognised general
sequelae of acquired brain injury
Impaired attention/concentration
Poor memory
Slowed information processing and visuomotor skills
 Language and communication deficits
 Perceptual problems and hypersensitivity
 High levels of fatigue
 Impaired executive skills
 Impaired interpersonal skills
 Inappropriate behaviour
But
 Often relatively good recovery of physical ability
and superficial conversational speech



The implications of an acquired brain
injury during different
ages/developmental stages
Early Years
Children under 3 years are at double the risk of
sustaining TBI (the highest incidence cause of
ABI) compared with any other group through
childhood (Anderson et al, 2012)
Young children’s brains are particularly
vulnerable, e.g. because of their immature
network of neural connections
Studies (early injuries)
Kennard ‘principle’ - neuroplasticity can give
some protection but often at a cost,
compromising other skills or causing
‘crowding’ (Tonks et al, 2009)
Subsequent studies indicated very poor
outcomes and increasing difficulties with
reduced intellectual ability, behavioural
problems (including poor self-control) and
social problems, including isolation and
poor theory of mind
(e.g. Koskiniemi et al, 1995; Eslinger et al,
1992)
Recent 10 year follow-up study (Anderson
et al, 2012) Children injured between 2 & 7
years
Initial follow-up studies showed protracted period
of disrupted development post-injury (up to 3
years)
10 year follow-up showed opportunity for some
progression - not catch up but developmental
gains
Supports premise of effectiveness of intervention
even many years post-injury
But severe (and diffuse) injuries provoke lasting
impairments and significant effects on IQ
Suggests ‘recovery’ trajectories plateau between
5 – 10 years
We now know
Some weaknesses (and strengths) may not be
apparent until later in development – ‘the
sleeper effect’
 These children do make progress but the
learning process is frequently effortful and
inefficient.
 The demands of the education system (and
social expectations) rely increasingly on
characteristic areas of impairment
 So progress is often slow and the gap does
widen in some areas, particularly academically

Skills that are developing at the time of the
injury may be most vulnerable to being
disrupted (Anderson et al, 2010)
Cognitive abilities that children rely on to
learn new information and to generalise or
apply new skills may be compromised.
When the ‘mechanics’ of basic literacy skills
are well established they are often resistant
to the effects of ABI but children injured
before these skills are established often
face significant difficulties obtaining these
Numeracy may also be affected, but
sometimes less so as the acquisition of
concepts and learning in Maths is
established over a longer period
Adolescence
The second highest risk group for ABI and
the time increased or evolving problems
may become manifest following injuries
sustained earlier.
Skills developed and consolidated earlier in
development but application and
generalisation of these interrupted during
time of accelerated frontal development.
Plus – acquired problems overlaid on a
‘teenage brain’.
Like their non-injured peers, teenagers with
ABI returning to school just want to ‘fit in’
(Sharp et al, 2006)
Most reported problems in adolescence are
with behaviour, particularly relating to social
skills (Burke et al, 1990)
Other often reported difficulties are with
planning and problem solving (Anderson et
al, 2009)
Adolescents with TBI tend to perceive
themselves as “different” and are “painfully
aware of their physical, cognitive,
emotional, and behavioural changes as well
as their loss of abilities.”
(Sherwin & O’Shanick, 1998, citing
Bergland & Thomas, 1993)
As teenagers with ABI may often present with
problems regulating their behaviour;
impulsivity; poor social judgement; and
decreased awareness of their own emotional
state, they show a relatively high risk for
offending behaviour.
Brain injury to anterior brain regions shows
links with violent and criminal behaviour and an
increased risk of impulsive aggression (Bower
& Price, 2001. Blake et al, 1995)
Many studies from around the world show
consistent percentages of those within the
criminal justice system with TBI (most often
sustained during childhood or
adolescence).
For instance, UK study:
60% some form of TBI
16.6% moderate – severe TBI
Those with TBI on average 5 years younger
at time of first prison sentence (16
compared with 21)
(Williams et al, 2010)
A challenge to Education
Young learners who:
Have not established the ‘building blocks’ of
basic skills
Have impaired ability to take on new
learning in conventional ways
Struggle to progress from direct, explicit
forms of instruction
Frontal lobe
- attending vs. impulsivity
- organising, prioritising
(executive function)
Temporal lobe
- new learning
- emotional
A potent recipe for growing problems
Formal assessment may
compensate for:
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Deficits in new learning
Attention deficits
Decreased endurance and persistence
Poor task orientation and impaired flexibility
Lack of initiation and spontaneous problem
solving
Weakness in speed and efficiency of
information processing
ABI in adulthood
Normal progress
Recovery and
rehabilitation
Brain injury
ABI in childhood
Normal progress
Progress after
injury
Brain injury
Implications and answers?
Awareness raising of an often ‘invisible
disability’
Empowering and skilling
Supporting
Damage to brain structures and connections
takes effect within the developing brain from
the moment of injury.
Thereafter the repercussions are like
ripples in a pool and complicated at future
stages when new skills would normally
‘come on line’ –
The sleeper effect
Their ability and attainment must be
compared and monitored over time
It is important to consider:
The developmental stage at the time of injury
What would normally be developing just after
that time and in the future
“There is increasing evidence that skills in a
rapid state of development at injury may be
more vulnerable to the effects of severe TBI.”
(Goldstrohm et al, 2005)
The young person’s progression may be
further complicated as a result of normal
development of some skills at a subsequent
stage which can serve to ameliorate some
previous difficulties.
An early brain injury does not just affect the
child
It affects that person’s road towards
maturity
…and the adult that they will become.
Literature reviews do not show much
evidence of good outcome measures for
intervention (Chevignard et al, 2012.
Turkstra & Burgess, 2010) and we need
more of these
but anecdotal evidence and personal
experience shows that appropriate
intervention can make a difference in
maximising potential and minimising or
compensating for deficit.
So...
We must raise awareness of the ongoing
and potential lifelong effects of ABI in
childhood and the need to adapt and modify
usual programmes or policies.
These young people are square pegs and
they do not fit in the round holes of our
usual systems.
Appropriate intervention throughout neurodevelopment can affect future potential