Beth Wicks Specialist Education Consultant

1. Growing into an acquired brain injury:key problems faced by children and adolescents while in education Beth Wicks Specialist Education Consultant

2. Issues to explore • ‘Normal’ neuro development • Usual curriculum and teaching methods in schools • Effects of brain injury

3. 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

4. Brain development

5. Early years Major time of accelerated development, not only physically but in key areas: Cognitive Social/behavioural Language/communication

6. 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.

7. 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)

8. 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

9. 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.

10. 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)

11. 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.

12. 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.

13. 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’

14. 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)

15. During adolescence young people: • test boundaries • challenge authority • increase risk taking behaviour • develop social frameworks and judge themselves in relation to their peers

16. 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)

17. How is this development reflected in the process and methodology of education ?

18. 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

19. 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

20. As a result of the usual developmental capabilities of young children they are taught and supervised: • Explicitly • Directly

21. 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)

22. 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

23. Some often recognised general sequelae of acquired brain injury • Impaired attention/concentration • Poor memory • Slowed information processing and visuo-motor 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

24. 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

25. 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)

26. 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

27. 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

28. 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.

29. 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

30. 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’.

31. 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)

32. 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)

33. 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)

34. 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)

35. 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

36. Frontal lobe - attending vs. impulsivity - organising, prioritising (executive function) Temporal lobe - new learning - emotional A potent recipe for growing problems

37. Formal assessment may compensate for: • 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

38. ABI in adulthood Normal progress Recovery and rehabilitation Brain injury

39. ABI in childhood Normal progress Progress after injury Brain injury

40. Implications and answers? Awareness raising of an often ‘invisible disability’ Empowering and skilling Supporting

41. 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

42. Their ability and attainment must be compared and monitored over time

43. 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)

44. 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.

45. 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.

46. 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.

47. 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 neuro-development can affect future potential