March 2013: Academic Outcomes for Children After Traumatic Brain Injury

Overview

Did you know that the most frequent neurological disorder and cause of academic and cognitive difficulties in both children and adolescents in the United States is traumatic brain injury (TBI)? According to the Centers for Disease Control and Prevention, “A TBI is caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain.” Not all traumas to the head result in TBI. Most children with TBI (90%) have an injury that is classified as mild, which means there is no significant loss of consciousness, no deterioration after the injury, and no positive findings on neurological examination or neuroimaging reports. There is little evidence for long-term consequences of mild TBI after the initial recovery from the accident, which is fortunate because children bang their heads frequently. Because common consequences of moderate and severe TBI include academic and language difficulties, children and adolescents with TBI are able to receive special education services in the “other health impairment” eligibility category, with documentation of educational need. However, less than 2% of students with TBI are identified for special education services (Glang, Tyler, Pearson, Todis, & Morvant, 2004). We can presume that this significant difference between the numbers of youngsters with moderate or severe TBI and those identified for special services exists because many students with TBI are misidentified or unidentified (Carney et al., 1999). Because students with TBI often exhibit cognitive and language difficulties, instructional attention that includes remediation and instructional adaptations is likely needed.

Study Purpose

This study provides a summary of many related studies of TBI. A systematic, quantitative analysis of findings from related studies is referred to as a meta-analysis. These authors conducted a meta-analysis of studies of the effects of the different levels of TBI severity (mild, moderate, and severe) over time on the academic and language outcomes of youngsters. In a previous meta-analysis, Babikian and Asarnow (2009) reported that youngsters with mild TBI demonstrated little or no impairment in neurocognitive areas and that students with moderate or severe TBI often performed poorly on areas of intellectual functioning and processing speed—problems that persisted for several years. These students also appeared to fall further behind over time.

As a result of these findings, the authors concluded that it would be valuable to determine the effects of the different levels of TBI severity (mild, moderate, and severe) over time on academic and language outcomes by answering three different but related questions:

1. How do mild TBI, moderate TBI, and severe TBI influence students’ academic learning and language development over time?
2. How much does severity of injury influence students’ outcomes and when?
3. How much do students recover academically and on language measures, based on whether their TBI is mild, moderate, or severe?

Summary of Study Results

1. How did researchers decide whether students had a mild, moderate, or severe TBI?

For all of the studies in the meta-analysis, injury severity was defined by the Glasgow Coma Scale (Teasdale & Jennett, 1974) and often confirmed by clinical findings. In practice, definitions of mild TBI also incorporate neurological and imaging findings.

2. What were the postinjury time bands?

Postinjury time bands included Time 1, which was immediately after injury to 5 months after injury; Time 2, which was 6 to 23 months after injury; and Time 3, which was 24 or more months after injury.

3. How did mild TBI, moderate TBI, and severe TBI influence students’ academic learning and language development over time?

For students with mild TBI, there were no differences relative to non-brain-injured comparison groups on academic and language outcomes, either initially or over time.

For students with moderate TBI, there were differences on academic outcomes but not on language outcomes relative to non-brain-injured comparison groups.

For students with severe TBI, there were large differences academically and for overall language outcomes relative to non-brain-injured comparison groups at all three time points. Because of this finding, it would be expected that students with severe TBI would demonstrate observable challenges in academic tasks such as reading comprehension and mathematics problem solving and that these challenges would persist over time and across grades.

Recommendation 1: It is encouraging that the study found no differences between the cognitive and language performance of the vast majority of students with mild TBI and that of healthy students at any point in time after injury. This finding suggests that mild TBI is not likely to require specific remediation or referral for special needs, based on academic or language performance. We recommend that educators, counselors, and other personnel provide the social and emotional support needed to assist students in recovering successfully from mild TBI.

Recommendation 2: Students with moderate or severe TBI are likely to express academic and language difficulties; for most students with severe TBI, these difficulties persist for an extended period of time (2 years or more). This finding suggests that these students, particularly those with severe TBI, are likely to require specific remediation and support and that some of these students will require referral for special needs, based on their academic and/or language performance.

4. How much did severity of injury influence students’ outcomes and when?

Severity of TBI had a significant influence on both the academic and language outcomes of students immediately and over time. Students with severe TBI performed significantly worse on measures of reading and mathematics as well as on overall language outcomes than both non-brain-injured students and students with mild or moderate TBI. Furthermore, these students’ poor performance persisted even 2 or more years after injury.

For expressive and receptive language outcomes, there were no differences between mild and moderate TBI groups at any of the three time points. For overall language outcomes, there was a small difference between mild TBI and moderate TBI (students with moderate TBI having lower scores) at the first and second time point but not the third. For reading, there were no differences between mild TBI and moderate TBI at the first and second time points, but there were significant differences at the third time period (lower scores for students with moderate TBI). For arithmetic, there were differences between mild TBI and moderate TBI at all time periods (lower scores for students with moderate TBI).

For reading and receptive language outcomes, students with severe TBI performed more poorly than students with moderate TBI initially and over time. For expressive language, there were no differences at times 1 and 2 but moderate differences by time 3 (poorer performance for students with severe TBI). For arithmetic, spelling, and overall language, there were significant differences at Time 1 for students with moderate and severe TBI, but these differences reduced considerably over time.

Recommendation 3: Educators, counselors, school psychologists, and parents should be aware that the initial performance of students with TBI on academic and language measures may not be maintained 6 months later or 2 years later. For some outcomes, typically arithmetic, these students’ performance is likely to improve. For some outcomes, typically reading comprehension and mathematics, students’ performance is likely to decline (Ewing-Cobbs et al., 2006). These findings suggest that monitoring these students’ academic and reading progress is important and that it is necessary to align instruction to their current needs.

Recommendation 4: Many students with moderate TBI and most students with severe TBI need intensive interventions to support their academic and language needs immediately after injury; further, most students with severe TBI need these interventions for years.

Recommendation 5: Appropriate, intensive interventions in language, mathematics, and reading are necessary for many students with moderate or severe TBI. Even for students with moderate or severe TBI who initially demonstrate adequate performance, particularly in reading, it may be important to provide intervention to prevent the later lags in reading comprehension that occur for many of these students.

5. How much did students recover academically and on language measures, based on whether their TBI was mild, moderate, or severe?

Students with severe TBI did not demonstrate significant recovery over time on measures of reading, receptive language, and overall language. However, for arithmetic, spelling, and reading comprehension, these students showed a small recovery from Time 1 to Time 2 and then no recovery thereafter. Though arithmetic skills were more impaired initially in students with severe TBI, there was also greater recovery over time. 

For reading and expressive and receptive language, despite demonstrating less impairment initially, students’ performance had a flat slope, indicating low levels of recovery.

Students with moderate TBI demonstrated academic difficulties initially and over time.

Recommendation 6: Although the trajectories for many academic and language skills for students with severe TBI are not promising, these trajectories may be altered with appropriately intensive interventions designed to remediate academic and language outcomes. These treatments are likely to be necessary for sustained periods (more than 2 years).

Conclusions

• Remember that individual student performance may not align with the findings from these studies. Students’ response to TBI is extremely variable.
• Timely and ongoing evaluation and progress monitoring are essential.
• Necessary and appropriate interventions aligned with students’ instructional needs are crucial.
• Many students with TBI have underlying impairments in cognitive processing and working memory. Educators who are mindful of these challenges provide tasks that allow extra time when appropriate, break tasks into achievable units, and otherwise respond to students’ processing and memory challenges.
• Students with TBI are underidentified for special services, possibly as a function of these students’ confusing patterns of performance—adequate performance in some areas and challenges in others.
• A more sophisticated and responsive tracking system is needed to assure that the academic and language performance of these students is monitored over time and that appropriate treatments are provided.

References

Babikian, T., & Asarnow, R. (2009). Neurocognitive outcomes and recovery after pediatric TBI: Meta-analytic review of the literature. Neuropsychology, 23, 283–296. doi:10.1037/a0015268

Carney, N., du Coudray, H., Davis-O’Reilly, C., Zimmer-Gembeck, M., Mann, N. C., Krages, K. P., & Helfand, M. (1999). Rehabilitation for traumatic brain injury in children and adolescents (Evidence reports/technology assessments, 2S). Rockville, MD: Agency for Health Care Policy and Research.

Ewing-Cobbs, L., Prasad, M. R., Kramer, L., Cox, C. S., Baumgartner, J., Fletcher, S., . . . Swank, P. (2006). Late intellectual and academic outcomes following traumatic brain injury sustained during early childhood. Journal of Neurosurgery, 105, 287–296. doi:10.3171/ped.2006.105.4.287

Glang, A., Tyler, J., Pearson, S., Todis, B., & Morvant, M. (2004). Improving educational services for students with TBI through statewide consulting teams. NeuroRehabilitation, 19, 219–231.

Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 2, 81–84. doi:10.1016/S0140-6736(74)91639-0