Glang, A., Ettel, D., Tyler, J. & Todis, B. (2012). Educational issues and school re-entrfor students with TBI. In Brain Injury Medicine: Principles and Practice, 2nd Ed. Zasler, N. et al.(eds.)

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37
Educational Issues and School Reentry for Students
With Traumatic Brain Injury
Ann Glang, Debbie Ettel, Janet Siantz Tyler, and Bonnie Todis
INTRODUCTION
Each year, approximately 40% of traumatic brain injuries
(TBIs) in the United States occur in the pediatric population
(ages 0–19 years) (1). The Centers for Disease Control (CDC)
estimates that more than 60,000 children and adolescents are
hospitalized annually in the United States after sustaining
moderate-to-severe brain injuries from motor vehicle crashes,
falls, sports, and physical abuse; an additional 631,146 chil-
dren are seen in hospital emergency departments and re-
leased (1). In all, nearly 145,000 children aged 0–19 years are
currently living with long-lasting, significant alterations in
social, behavioral, physical, and cognitive functioning follow-
ingaTBI(2).
Reduced federal funding and managed care have re-
sulted in shorter inpatient rehabilitation stays for patients,
fewer services dedicated to families, and lack of access to
ongoing rehabilitative services (3,4). Increasingly, children
with mild-to-moderate TBI are released from treatment with
no plans for long-term rehabilitation support. The result is
that children who may have intense physical and/or cogni-
tive needs return home to families who are largely responsi-
ble for supporting them through the rehabilitation process
with little or no support from medical or community-based
agencies (5,6). As a function of shortened hospital stays and
the chronic problems arising from pediatric TBI, the primary
service provider for children and adolescents has become
the school. This chapter will describe the challenges students
with TBI present to schools and strategies schools can use
to address them.
OVERVIEW OF IMPACT OF TBI ON
SCHOOL PERFORMANCE
Predicting the impact of a pediatric TBI on school perfor-
mance is difficult,in part because no 2 injuries are alike, and
also because the same etiological factor can cause diverse
outcomes depending on the child and the context. Research-
ers (7) suggest that several variables influence student out-
comes, including (a) the child’s age at injury (8), (b)the
severity of the TBI (9), (c) premorbid behavioral and learn-
ing status (10,11), (d) history of previous injury (12–15), and
(e) postinjury pain or stress (16,17).
Academic Achievement, Executive Dysfunction,
and Social Behavior Problems
Although the impact of pediatric TBI on a child’s school
performance is unique and dynamic, some general charac-
teristics typify the course of impact and recovery (7). The
most reported TBI sequelae related to school performance
are (a) a progressive lag in academic achievement (18– 21),
(b) executive dysfunction, and (c) social and behavioral prob-
lems (22–24).
Academic Achievement
Most children make academic gains postinjury, but for stu-
dents with moderate to severe injury, the rate of academic
achievement gains tends to slow progressively over time,
and the effects are long-term (18,25,26). Researchers (27)
found that children with moderate TBI showed impaired
academic skills both postacutely and chronically, whereas
those with severe TBI showed greater impairment with only
partial recovery in certain areas over time. One critical factor
in children’s lag in academic achievement was cognitive def-
icit as a result of brain injury.
In young children with TBI, recovery of cognitive skills
across time may show no improvement (28) or may actually
decline (29), demonstrating a failure to develop age-appro-
priate cognitive skills at typical rates. These cognitive deficits
can be parsed into components of executive dysfunction,
memory problems, diminished attention and impulse con-
trol, and information processing problems, all areas critical
to learning and school success (30–32). Notably, some effects
are immediate, and some sequelae may not become apparent
until the child returns to the school environment or much
later, when the demands for competence in reasoning, execu-
tive functioning, self-regulation, and social skills increase
(33,34). Because TBI cognitive sequelae are diverse and dy-
namic, educator awareness is critical to providing students
with appropriate monitoring and support as needs and is-
sues change, sometimes dramatically, over time.
Executive Dysfunction
Disruptions in executive function (EF), characterized by
skills in attentional control, planning, goal setting, problem

37. EDUCATIONAL ISSUES AND SCHOOL REENTRY FOR STUDENTS WITH TRAUMATIC BRAIN INJURY 603
solving, cognitive flexibility, and abstract reasoning, can
occur as a result of direct damage to frontal regions or from
disruption of connections among these and other brain
regions. Because EF orchestrates so many domains of cogni-
tion, emotion, and behavior, the functional results of exe-
cutive dysfunction are multidimensional and debilitating
(35–37).
At the root of many of the academic, social emotional,
and behavioral issues that can follow a TBI are problems
with self-regulation, the internal control functions that direct
and organize all nonreflexive or nonautomatic behavior,
including social, cognitive, and linguistic behavior (38). The
same regulatory deficits that underlie learning problems
(e.g., trouble focusing on classroom work, irritability, and
impulsiveness) can also negatively affect social-emotional
behavior and interpersonal relationships with peers and
adults (39–42). For example, self-regulation skills required
in a school setting include keeping hands and feet to oneself,
taking turns in a conversation, and maintaining an emotional
state appropriate to the school context. Neural systems that
regulate these behaviors might be compromised, making
both appropriate academic behavior and interpersonal be-
havior challenging for students.
In a school setting, deficits in EF can manifest as impul-
siveness, poor social judgment, disorganization, social disin-
hibition, weakly regulated attention, slowed processing,
ineffective planning, and reduced initiation (31,33). Because
of difficulty with organization and attention, educators
might observe students having problems managing their as-
signments, gathering materials, starting on tasks, or staying
on task. In addition, some students struggle with transitions
from one class to the next, and they might have difficulty
sequencing multistep procedures or recalling assignments.
Thus, executive dysfunction in the classroom presents myr-
iad challenges for students with TBI.
After TBI, students may perform poorly on tasks of sus-
tained, selective, and shifting attention (43). A student may
have difficulty concentrating for extended periods, perform-
ing 2 tasks simultaneously (such as listening while taking
notes), or completing 1 task and switching attention to a
new task. Lack of attentional flexibility can also result in
diminished problem solving skills. For example, a student
who loses a pencil might not be able to generate problem-
solving ideas for replacing it. Both initiation skills and atten-
tional flexibility are needed to keep the lack of a pencil from
being an insurmountable barrier to work completion. For
children with mild injury, inattention and behavior chal-
lenges are the most frequently reported problems (44).
The speed with which students process information
may change dramatically after a TBI (43). Students may take
longer to respond to teacher questions or instructions, or
they may need longer to complete tasks or process teacher
directions. This greater response latency can be misinter-
preted as refusal to respond or begin work. Students should
be allowed adequate time to process and comprehend as-
signments (45). Language production and processing can
also be impaired, resulting in problems in word finding, lan-
guage fluency, receptive language comprehension, reading
comprehension, and writing skills.
TBI often results in memory problems (sensory, work-
ing, and/or long-term memory; retrograde and anterior
grade amnesia) that can negatively affect the assimilation of
new material or skills (46–48). It has been found (49) that
among young children, skills emerging at the time of brain
injury were more vulnerable to disruption than skills already
learned. Previously learned skills might be intact or compro-
mised, and difficulties with working memory can negatively
affect the child’s ability to learn new material. Educators
might notice uneven academic performance, with some
lower level skills missing while more sophisticated skills re-
main intact, making appropriate instruction more chal-
lenging.
Social Behavioral Problems
Social dysfunction might be the most debilitating of all the
TBI sequelae, affecting not only functional aspects of daily
living but also quality of life (50). Unfortunately, much of
the research focus has been on the effect of TBI on physical
and cognitive domains, and social-emotional skills have not
received as much attention. Children with an early brain
injury (especially before 2 years of age) are at risk of signifi-
cant social impairment (50). Social and emotional problems
can become increasingly apparent during the transition from
childhood to adolescence, when expectations for the use of
appropriate social skills increase (51–53). Students with TBI
might display disruptive behavior, emotional distress, poor
conduct, and problems with empathy, moral reasoning, and
peer relationships (35). Addressing potential social behavior
deficits is just as critical to successful school functioning as
addressing academic and cognitive skills— perhaps more so
(54–56).
Sometimes overlooked is the emotional grief, sadness,
or anger resulting from loss of preinjury abilities or identity.
Even years after their injury, adults who sustained a child-
hood TBI report differences in self-concept postinjury, with
the current self viewed more negatively than the preinjury
self, and development of new identity as an ongoing process
(57). Unfortunately, counseling or therapeutic support ad-
dressing post-traumatic stress or grief is often lacking for
students with TBI. Grief and recovery from emotional
trauma, especially when combined with poor impulse con-
trol, can lead to unpredictable emotional outbursts, irritabil-
ity, labile affect, and depression. Educators might observe
social withdrawal behaviors, poor adaptive behaviors, or ap-
parent egocentrism as a result (58,59). The combination of
these deficits can also result in problems with delinquency
if not identified and addressed with appropriate interven-
tion and support. High rates of incarceration among people
with TBI have been noted (60).
A commonly noticed area of concern is lack of self-
awareness, particularly of students’ own skill deficits. For
example, a student might express an emotional response
inappropriate for a given situation (e.g., laughing when dis-
cussing a serious topic) and remain unaware of the inappro-
priateness of the action despite negative reactions from
peers. These deficits in insight can cause misperceptions or
distortions of social cues and interactions, affecting how the
student relates to others or interprets their intentions and
behaviors, resulting in confusion, misunderstanding, and
conflict. Peers may be frustrated with the student if he or
she misses important social cues, fails to regulate behaviors
such as talking out of turn, or denies postinjury deficits and
rejects support offered. Ironically, some research (58) has
found awareness of the discrepancy between the preinjury

604 VII. PEDIATRIC TBI
and current (postinjury) self negatively correlated with self-
esteem and positively correlated with depression; that is,
lack of self-awareness is associated with 1 set of problems,
whereas increased awareness has its own array of psycho-
logical costs (61).
Other functional areas pertinent to school performance
include perceptual skill deficits and physical impairment.
Sensorimotor changes can occur, resulting in increased sensi-
tivity to environmental stimuli such as hypersensitivity to
light and sound or diminished ability to screen out back-
ground sounds. For example, students who once had no dif-
ficulty copying notes from a blackboard might find the task
coordination difficult because of visual– motor changes
(62,63). Classrooms are highly stimulating environments—
visually, aurally, and kinesthetically—that can overtax the
cognitive abilities of a student in recovery from a brain in-
jury. A student with poor impulse control might react inap-
propriately to such stimuli.
Educators also need to be aware that students can expe-
rience extreme fatigue (64), especially early in the postacute
recovery phase when ordinary tasks might require greater
mental exertion by the student because of difficulty in pro-
cessing, organizing, initiating, and maintaining academic
engagement. The student’s physical stamina might be com-
promised, requiring increased rest or shortened school days
or class periods to address fatigue and support the recovery
process. In addition to fatigue, the student might have sus-
tained other physical injuries that can adversely affect school
performance. Furthermore, anticonvulsant or other medica-
tions may be prescribed prophylactically to reduce the like-
lihood of seizures or address behavioral or attentional
concerns. Educators should be made aware of the intended
and unintended effects of any such prescriptions on student
behavior, attention, mood, and learning (65).
Mediating and Moderating Factors
Several factors have been found to mediate and moderate
the effects of TBI on school performance. The most com-
monly noted factors include (a) age at injury, (b) severity of
injury, and (c) family environment.
Age at Injury
It was previously thought that the developing brain was
more resilient to trauma because of neuroplasticity, the flexi-
bility of the young brain to reorganize or reassign tasks from
one functional area to another area (66,67). Newer evidence
has shown that early injury is associated with poorer out-
comes than later injury (29,49,68). As young children with
TBI develop, behavioral and cognitive problems might con-
tinue to emerge (51,69).
Other specific outcomes associated with early injury in-
clude deficits in executive functioning, expressive language,
attention, academic achievement, and social skills, and less
recovery of cognitive skills compared with children injured
later (18,29,68,70–73). Longitudinal studies have shown that
early age at injury negatively impacts outcomes in likelihood
of postsecondary education enrollment, employment, and
independent living. Early age at injury and severe injury
were associated with employment in primarily entry level
or low-skilled jobs, fewer hours worked per week, and lower
pay for both males and females (29,68).
Injury Severity
In young children with TBI, severity of injury also predicted
postacute effects on cognitive and school readiness skills,
including memory, spatial reasoning, and EF. More severe
TBI predicted more negative outcomes (74–78). However,
some studies found mixed results of the impact of injury
severity on outcomes, with severity of injury becoming less
predictive of outcomes 1 year postinjury (79). A severe injury
at an early age has been associated with the poorest long-
term outcomes, including cognitive skill recovery (24,68,80).
Family Environment
Particularly in relation to social and behavioral outcomes,
family environmental characteristics—such as socioeco-
nomic status (SES), overall family functioning, and parenting
behavior—can significantly affect student educational per-
formance (26,32,55,81–84). Premorbid child and family func-
tioning have been linked to outcomes; children with prior
psychiatric disorders and families already struggling are
more likely to manifest negative postinjury psychosocial ef-
fects (80,85–90). Negative social outcomes from TBI are exac-
erbated by postinjury family environments that are lower
SES, lacking resources, and have poorer family functioning
(55). Other researchers (84) reported a ‘‘double hazard’’ ef-
fect in which family socioeconomic disadvantage combined
with severe injury to lead to the poorest long-term outcomes.
Although family variables can moderate psychosocial out-
comes for children with TBI (especially behavioral adjust-
ment and social competencies), this moderating influence
can wane with time among children with severe TBI (74,91).
Specific parenting behaviors have also been associated
with children’s outcomes after TBI. It was found (74) that
high levels of permissive or authoritarian parenting were
associated with increased behavior problems in children
with TBI, particularly for those with severe injury. Poorer
outcomes associated with these parenting styles are in con-
trast to those from authoritative parenting, characterized by
parental warmth, clear boundaries and expectations, con-
sistent rule application, and active parental monitoring.
Authoritative parenting was associated with better psycho-
social outcomes (74). In general, strong family social support
and cohesion was predictive of students’ better adaptive
functioning, social competence, and global functioning post-
injury (26,82). Other family variables believed to interact
with factors predicting recovery include family expectations,
stress and functioning (32,92–94), and genetic vulnerability
(95,96). These factors interact with each other to mediate ef-
fects, but all predictors also directly affect all outcomes (74).
Outcomes by Age Group
Preschool-Aged Children
Young children (birth to age 5) who experience a TBI are at
greater risk for deficits in expressive language, attention, and
academic achievement than children who are injured at later
ages (18,29,63,68,71,74,97). An early injury affects a develop-
ing brain that has not yet formed critical features necessary
for mature function, potentially interrupting or hindering
the developmental process. Some suggest that poorer out-
comes in children injured early in life might be caused by
the developing brain’s greater susceptibility to diffuse brain

37. EDUCATIONAL ISSUES AND SCHOOL REENTRY FOR STUDENTS WITH TRAUMATIC BRAIN INJURY 605
insult, resultant abnormalities in neurogenesis, or resultant
difficulties in acquiring new skills postinjury (18,70,71,98,99).
Some researchers (70) have stressed the link between early
developmental level and TBI; those injured very young
demonstrate persistent deficits in academic skills (reading,
decoding, comprehension, spelling, and arithmetic). Diffi-
culties in global cognitive function, adaptive behavior, EF,
and nonverbal abilities have been observed as well (74,97).
Others (74) have found that preschool-aged children with
TBI had weaknesses in nonverbal abilities and EF and recom-
mended the use of memory cues and direct instruction teach-
ing methods—structured curricula, multiple presentations,
and many opportunities for students to practice new skills.
Children injured when young might present no imme-
diately observable deficits; however, such children should be
monitored for the potential emergence of latent TBI sequelae
that might appear as task and setting demands increase. For
example, behavior difficulties after early injury may not be
apparent until the child attends elementary school, when
expectations for self-regulation, control of attention, and task
complexity rise appreciably (100).
School-Aged Youth
Issues for school-aged youth with TBI (grades K–12) become
heightened as the task and setting demands of school pro-
gressively increase. Some (88) have found that children who
sustained moderate-to-severe TBI during their school years
were likely to need special assistance in school at 1 year
postinjury. Others (101) reported that reading skills are often
compromised by TBI, and still others have found greater
academic deficits in arithmetic, possibly because of arithme-
tic’s necessary component skills in attention, memory, and
executive functioning (102). Students are expected to become
more independent learners, demonstrate self-regulatory
skills (staying on task, completing work, keeping hands to
self, answering when called on), and master increasingly
complex skills and more abstract concepts. For the school-
aged child with TBI, these can all present challenges in the
school setting. In addition to the academic expectations, the
child’s social focus shifts from family to peers, where inter-
personal social skills take on increasing importance and
begin to include communication, negotiation, reciprocal in-
teraction, and social participation (54,56,103). In summary,
educators need to be aware that school-aged youth with TBI
might be challenged by the increasing cognitive, academic,
and behavioral demands in the school setting and by the
increasing importance and complexity of their developing
social relations with peers.
Post-High School Outcomes
A growing body of research indicates that for many students
with TBI, post-high school outcomes are poor (68,104–106).
The second National Longitudinal Transition Study (108)
found that fewer than half of students with TBI who had
been out of school a year or more had a paid job outside the
home. Young adults (ages 18 years or older) with TBI who
received special education were employed and enrolled in
postsecondary education at lower rates than peers in the
general population (107).
Furthermore, rates of engagement in employment and
postsecondary training and education remain low through-
out early adulthood. In a recent longitudinal study of post-
high school outcomes (68), the highest rate of enrollment
in postsecondary education was 34% at age 21. Enrollment
decreased with being male, earlier age at injury, and lower
SES (68). A key finding was that although few students in-
jured before age 14 enrolled in postsecondary education, stu-
dents who sustained a TBI during adolescence attempted
to pursue their preinjury college plans, often with negative
results. Unable to meet academic, social, and independent
living demands, many study participants struggled for sev-
eral years before leaving college without degrees. A few
were able to set new goals, discover helpful strategies, and
eventually complete 2- or 4-year degree programs (106). Par-
ticipants in the same study also experienced challenges in
the area of employment, working fewer hours for lower
wages than their nondisabled peers. None of the student
participants worked more than 30 hours per week, and
wages averaged slightly above minimum wage. At age 25,
most still worked at entry level or low-skilled jobs as their
nondisabled peers were moving up to higher paid, skilled,
and professional positions (108). Earlier age at injury and
more severe injury were associated with fewer hours worked
per week and lower pay (68).
In a qualitative study with the same study sample, re-
ceipt of postsecondary transition services (in which individ-
uals were linked with support agencies and disability ser-
vices) was associated with completion of postsecondary
programs (106). Focus on the modifiable variables that affect
postsecondary outcomes is important for improving the lives
of students with TBI.
MODIFIABLE FACTORS IN TBI OUTCOMES
In addition to child- and family-centered factors, a range of
other external or environmental variables affect outcomes
among children with brain injury. Challenging as it can be
to address these factors, they hold promise for improving
outcomes for students with TBI because they can be modi-
fied through improved training and changes in policy and
practice.
Lack of Educator Awareness
Effective educational practices implemented by trained edu-
cators can contribute to successful school outcomes for chil-
dren and youth with TBI (106). However, many teachers
receive little or no training in childhood TBI (119,110). In a
recent survey of educators working with students with TBI,
92% reported having no training in the academic effects of
TBI (111). Furthermore, a recent analysis of university text-
books revealed that TBI is rarely discussed in current special
education texts and is virtually absent from the general edu-
cation texts reviewed (112). The lack of information about
TBI for educators leads to a continued lack of awareness
about the school-related implications of TBI and absence of
strategies for addressing them. This lack of awareness leads
to a perception among school personnel that TBI is a ‘‘low-
incidence disability,’’ which in turn contributes to the under-
identification of children with TBI for special education.

606 VII. PEDIATRIC TBI
Underidentification and Misidentification
The most recent special education census data suggest that
there continues to be a significant discrepancy between the
incidence of TBI and the identification of children with TBI
for special education services (113). Approximately 145,000
children live with persistent disability following TBI (2).
However, according to the most recent figures from the US
Department of Education, the total number of students re-
ceiving special education services under the TBI category is
23,509 (114). This rate is likely an underestimate, given that
60,000 children are hospitalized each year for TBI (1). Rates
of identification for special education are higher for students
with severe TBI, problem behavior, poor academic perfor-
mance, and socioeconomic disadvantage (88,115–118). Of
particular concern, given the changing needs of children as
they grow older and school demands increase, is that special
education identification rarely occurs after the first year post-
injury (118). Although it is likely that some children with
TBI receive services under different disability labels (e.g.,
speech-language, physical disability, or ‘‘other’’) (118–120),
it is unclear whether such services meet the cognitive and
behavioral needs of students with TBI. Because most chil-
dren with TBI rely on schools rather than medical settings
for rehabilitation services, the underidentification and misi-
dentification of children with TBI presents a significant ob-
stacle to the provision of effective services.
Lack of Hospital–School Communication
There continues to be a weak link between the hospitals that
treat children for TBI and the schools who educate them—in
terms of both their respective understanding of one another’s
worlds and their mutual communication and coordination
efforts (121,122). Between April 1994 and January 1999, the
National Pediatric Trauma Registry tracked children ages
5– 19 who were hospitalized with TBI in participating trauma
centers and children’s hospitals across the United States and
who were discharged to their homes following treatment.
Of this group, 13.2% had documented cognitive impairments
resulting from their brain injury at the time of discharge,
and 11.6% had behavioral impairments; yet less than 1% of
these children were recommended by medical staff for refer-
ral to special education (121). A critical modifiable factor
contributing to identification of students with TBI for formal
services is communication and linkage between hospitals
and schools. Although informing educators that a student
has a TBI does not guarantee that appropriate services will
follow, not being informed by hospital personnel or parents
decreases the likelihood that educational services will be tai-
lored to the student’s specific needs (122).
Parent–Educator Relationships
A critical factor that influences school outcomes for children
with TBI is the degree of collaboration between the child’s
parents and educators (123). When parents and educators
have trouble working in partnership, conflicts arise, and the
student’s education suffers (124–126). Unfortunately, par-
ent–professional relationships can easily become adversarial
because of the many stressors both families and school staff
face in designing educational programs for students with
TBI. From the school’s perspective, families often have un-
realistic expectations and/or are unable to support the
school’s efforts (127). Parents, on the other hand, often retain
preinjury expectations about academic achievement and per-
ceive school staff as having low expectations that do not
change, even as the child’s school performance improves
(127). Furthermore, because prior to the injury, most children
with TBI progressed typically through school, parents are
often unfamiliar with the provisions of the Individuals with
Disabilities Education Act and their role and rights in the
educational process.
EFFECTIVE EDUCATIONAL PRACTICES
Because of the physical, cognitive, academic, and psychoso-
cial sequelae of TBI, students may require special education
services, special assistance, or accommodations on returning
to school, with many students continuing to require such
services throughout their education. From the hospital-to-
school transition to the post-high school transition to com-
munity-based services, training, and employment, the hub of
the support system for students with TBI and their families is
the school.
Coordinated Hospital-to-School Transition
One of the most critical points in a child’s rehabilitation pro-
cess is at the transition from hospital to school. It is at this
point that the child can most easily gain access to formal
services through communication between hospital and
school staff (122). Recommendations regarding school reen-
try planning include having school personnel observe the
student in the hospital, attend hospital predischarge meet-
ings, and obtain information from the hospital before the
child’s school reentry (128–130). Although it may be difficult
under managed care for hospital staff to fully participate in
the transition process, the hospital–school communication
link should begin early in the child’s hospital stay, so that
protocols are in place for hospital staff to alert school staff
to those students with brain injuries, even those with mild
injury (131,132). Referral is also needed for students who
were already receiving special education services at the time
of their injury (e.g., for a learning disability or a behavior
disorder), as moderate-to-severe TBI can cause significant
additional cognitive impairment in children with preexisting
learning difficulties, and programming modifications are
often needed after injury (133).
The Individuals with Disabilities Education Improve-
ment Act of 2004 (IDEA) (134), provides guidelines for refer-
ral, evaluation, eligibility determination, parent involvement
in decision-making, individual education plans, and deliv-
ery of specially designed instruction and related services.
Given the eligibility requirements of IDEA, and the cur-
rent underidentification of students with TBI, TBI research-
ers and advocates are exploring ways to assure that all
students with TBI who need special education services are
able to access them. Recent research has demonstrated that
in addition to severity of injury, the provision of hospi-
tal–school transition services is strongly related to being
identified for formal services (either via individual education

37. EDUCATIONAL ISSUES AND SCHOOL REENTRY FOR STUDENTS WITH TRAUMATIC BRAIN INJURY 607
plan [IEP] or 504 plan) (128). Although hospital-to-school
transition support emerged in this study as a strong predic-
tor of being identified for formal special education services,
only half (50.9%) of students in this study received any form
of transition information or guidance from the hospital.
Stated briefly, informing educators that a student has TBI
does not guarantee that appropriate services will follow, but
not being informed by hospital personnel or parents de-
creases the likelihood that educational services will be tai-
lored to a student’s specific needs.
Two promising practices are currently being evaluated
and could improve identification processes at the state level.
The School Transition Re-entry Program (STEP) is a system-
atic notification system designed to increase effective transi-
tion from hospital to school (135). Essential elements of this
model are (a) hospital staff obtain a release from parents
and notify an identified contact at the state Department of
Education (DOE) about the child, (b) DOE notifies a regional
transition facilitator that a child who has been treated for
TBI is returning to school in that region, and (c) the transition
facilitator contacts the child’s school and family to offer re-
sources and support. Preliminary analyses suggest that
among students who do not receive hospital rehabilitation
services, students receiving STEP services—systematic tran-
sition from hospital to school—are identified significantly
more often for special education than those who do not re-
ceive systematic transition. Furthermore, students in the
STEP group received more services, and their parents re-
ported significantly greater satisfaction with the school and
found a greater number of school staff helpful compared
with parents of students in the control group (135). Thus,
the STEP intervention appears to provide the essential link
from hospital to school previously available only to students
receiving rehabilitation services.
A second promising approach systematically tracks and
supports students with mild TBIs as they transition back to
school athletic and academic activities. The Reduce, Educate,
Accommodate and Pace (REAP) model is a systematic notifi-
cation system to increase effective concussion management
from emergency department to school (www.youthsport-
smed.com). A person at the emergency department obtains
a release from the family and provides the REAP manual of
concussion management. That person then faxes the release
and an information form to an identified contact at a central-
ized site. The centralized site contacts a point person at the
child’s school within 48 hours. The point person then coordi-
nates concussion management within the school until the
child recovers, tracking and monitoring for latent concerns.
Concussion management may also include providing infor-
mation on physical and academic accommodations and
other ways educators can reduce the cognitive, emotional,
and physical load on students recovering from mild TBI.
These are 2 models of systematic communication be-
tween hospitals and schools. Central to both models is the
presence of school-based professionals trained in TBI who
can ensure the student receives the support necessary to suc-
ceed in school.
Special Education Law
When the provision of special education in public schools
became federal law in 1975 (136), guaranteeing all students
a ‘‘free and appropriate public education,’’ no specific cate-
gory for TBI was included. TBI was not introduced as a sepa-
rate disability category until 1991 in IDEA. Before that time,
students with TBI were identified for special education as
‘‘other health impaired’’ or under a specific learning disabil-
ity. Some students received services under Section 504 of
the Rehabilitation Act of 1973, and others were not served
through either mechanism (122). Given the long-term effects
of underidentifying students with TBI for special education
services (137–139), accurate and appropriate assessment is
critical to identify and address students’ needs for educa-
tional support (119,140).
Referral Process
Parents, teachers, therapists, medical personnel, or others
can begin the process of evaluating the child’s educational
needs by making a referral to the school’s support services
team or administrator. The team—made up of teachers, spe-
cialists, administrators, and others—is charged with evalu-
ating the child’s educational needs in all areas of suspected
disability and determining whether the student meets eligi-
bility criteria (as a child with a disability) to receive special
education services. Each category of disability has specific
eligibility criteria in the law.
Eligibility for Special Education Services
To determine whether a child is eligible for services, an
evaluation based on the guidelines specific to the area of
suspected disability must be conducted. The evaluation re-
quirements for TBI are outlined in Table 37-1.
Issues in Assessment and Instruction
of Students With TBI
Because of the diversity within the population of students
with TBI, there is no one TBI assessment; each assessment
must be tailored to the student’s unique and changing needs.
Several general principles and strategies, however, are rec-
ommended to guide educators (34,131,138,142,143). First,
accurate interpretation of assessment results requires an
understanding of the potential effects of TBI on students’
learning and response patterns. For example, students’ per-
formance may be uneven across academic domains. They
might show relatively strong performance on material mas-
tered preinjury, although evidence of new learning could be
lacking. Also, because content and skill gaps could be pres-
ent throughout the range of skills, examiners might need
to suspend typical basal and ceiling rules of standardized
measures to more accurately capture student performance.
Second, the potential for both skill recovery and skill
deterioration over time makes ongoing formative assess-
ment and frequent monitoring especially important for
students with TBI (144,145). Educators should rely on eco-
logically valid sources of information, such as parent and
teacher behavior scales and interviews, curriculum-based as-
sessment, and permanent product evaluation, and they
should choose methods closely tied to instruction and inter-
vention (138,146). In addition to being more relevant to in-
struction, these measures are more sensitive to small changes
in student performance and could prove more beneficial to

608 VII. PEDIATRIC TBI
TABLE 37-1 IDEA Criteria for Special Education Eligibility Under Traumatic Brain Injury
IDEA CRITERIA FOR ELIGIBILITY UNDER TRAUMATIC BRAIN INJURY
Definition of TBI An acquired injury to the brain caused by an external physical force resulting in total or partial
functional disability or psychosocial impairment, or both, that adversely affects a child’s
educational performance. The term applies to open or closed head injuries resulting in
impairments in one or more areas, such as cognition; language; memory; attention;
reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor
abilities; psychosocial behavior; physical functions; information processing; and speech. The
term does not apply to brain injuries that are congenital or degenerative, or to brain injuries
induced by birth trauma.
Evaluation must include (a) A medical or health assessment statement indicating that an event may have resulted in a
TBI.
(b) A comprehensive psychological assessment, using a battery of instruments to identify
deficits associated with TBI, administered by a licensed school psychologist or the state
Board of Psychological Examiners or others having training and experience to administer
and interpret tests in the battery.
(c) Other assessments, as needed, such as motor, communication, and psychosocial
assessments
(A) Other information related to the child’s suspected disability, including preinjury
performance and a current measure of adaptive ability.
(B) Observation in the classroom and at least 1 other setting.
(C) Other additional assessments needed to determine the effect of the suspected
disability on the child’s educational performance for his/her age group.
(D) Other assessments needed to identify the child’s educational needs.
Conditions must be met (a) Must have an acquired brain injury caused by external physical force
(b) Condition is permanent or expected to last for more than 60 calendar days
(c) Injury results in an impairment in 1 or more areas:
(A) Communication
(B) Behavior
(C) Cognition, memory, attention, abstract thinking, judgment, problem-solving,
reasoning, and/or information processing
(D) Sensory, perceptual, motor, and/or physical abilities
The evaluation must determine (a) The child’s disability has an adverse effect on the child’s educational performance
(b) The child needs special education services as a result of the disability
Definition of TBI excludes Brain injuries that are congenital, degenerative, or induced by birth trauma
From idea.ed.gov (141).
student progress than norm-based measures standardized
on noninjured student populations.
Third, schools could consider bringing neuropsy-
chological experts into the planning process by including
independent neuropsychologists in the assessment of and
planning for students. The neuropsychologist’s expertise in
the clinical and neuropsychological aspects of functioning
after TBI combined with the school psychologists’ familiarity
with academic assessment, instruction, and contextual issues
within the school setting makes for a comprehensive assess-
ment team (146,147). Also, building the capacity of existing
staff by offering further neuropsychological training for
school psychologists and others and improving in-service
for staff to include basic information on the cognitive, aca-
demic, and behavioral profiles of students with TBI can in-
crease the capacity of the broader school community (rather
than a few select individuals) to support these students’
unique needs across contexts.
Fourth, contextual assessment is a good framework for
assessing the student with TBI in the educational setting
(138,148). Contextual assessment, also referred to as ecologi-
cal assessment (149), stresses the importance of multisource,
multidimensional assessment, gathering relevant informa-
tion about the child’s strengths and needs including (a) ob-
servations within the school setting; (b) parent interviews;
(c) review of medical records; (d) file review of preinjury
performance; (e) interviews with medical personnel, includ-
ing rehabilitation teachers and home instruction staff; (f)
behavior rating scales and checklists; (g) motor, sensory, and
physical assessments as needed; (h) standardized and curric-
ulum-based performance measures; and (i) adaptive behav-
ior (146,147,150). Adaptive behaviors or activities of daily
living are not routinely assessed in the school setting apart
from evaluations for students with serious developmental
delay. For students with TBI, the activities of daily living
(e.g., independent skills in walking, talking, getting dressed,
going to school, going to work, preparing a meal, cleaning
the house, and adapting to the demands of one’s environ-
ment) might be compromised by injury and need to be
addressed.
Comprehensive Assessment
Within the student’s school, home, and community, func-
tional domains to be assessed include cognition, language,
memory and concentration, sensory recognition and percep-

37. EDUCATIONAL ISSUES AND SCHOOL REENTRY FOR STUDENTS WITH TRAUMATIC BRAIN INJURY 609
TABLE 37-2 Tests Commonly Used With Students With Traumatic Brain Injury
DOMAIN TEST
Cognition •Cognitive Assessment System (152)
•Comprehensive Test of Nonverbal Intelligence, 2nd ed. (153)
•Differential Abilities Scale, 2nd ed. (154)
•Kaufman Assessment Battery for Children, 2nd ed. (155)
•Stanford-Binet Intelligence Scales, 5th ed. (156)
•Wechsler Preschool and Primary Scale of Intelligence, 3rd ed. (157)
•Wechsler Abbreviated Scale of Intelligence (WASI) (158)
•Wechsler Intelligence Scale for Children, 4th ed. (159)
•Woodcock Johnson, 3rd ed.; Tests of Cognitive Abilities (160)
Neurospsychological •Children’s Category Test (161)
•Functional Independence Measure (FIM) (162)
•ImPACT (Immediate Postconcussion Assessment and Cognitive Testing) (163)
•NEPSY-II, 2nd ed. (164)
•Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) (165)
Memory Children’s Memory Scale (166)
Continuous Performance Test-II (167)
Logical Memory I and II (168)
Wechsler Memory Scale–IV (169)
Wide Range Assessment of Memory and Learning 2 (WRMAL2) (170)
Executive function Behavior Rating Inventory of Executive Function (BRIEF) (171)
Delis-Kaplan Executive Function System (172)
Executive Control Battery (173)
Stroop Color and Word Test (174)
Trail Making Test—Part B (175)
Wisconsin Card Sorting Test (176)
Attention/concentration Delayed Gratification Task (177)
Digit Span (Forward and Reversed) (Wechsler scales) (178)
Language/verbal learning Boston Naming Test (179)
Children’s Auditory Verbal Learning Test (180)
Multilingual Aphasia Examination (181)
Token Test—Short Form (182)
Visual perception Developmental Test of Visual Perception, 2nd ed. (183)
Test of Visual Perceptual Skills (184)
Academic-general Kaufman Tests of Educational Achievement, 2nd ed. (185)
Peabody Individual Achievement Test-III (186)
Wechsler Individual Achievement Test, 3rd ed. (187)
Woodcock Johnson, 3rd ed.; Tests of Academic Achievement (188)
Academic-targeted Key Math Diagnostic Test (189)
Woodcock Reading Mastery Tests, 3rd ed. (190)
Behavior Child Behavior Checklist (ASEBA Preschool and School Age) (191)
Social behavior Behavior Assessment System for Children, 2nd ed. (BASC-II) (192)
School Social Behavior Rating Scale (SSBR) (193)
Adaptive behavior Adaptive Behavior Assessment System, 2nd ed. (ABAS-II) (194)
Scales of Independent Behavior-Revised (SIB-R) (195)
Vineland Adaptive Behavior Scales, 2nd ed. (VABS-II) (196)
Motor skills Grooved Pegboard (197)
tion, academic achievement, behavior, and personality. In
addition to input from parents and educators, a neuropsy-
chologist, school psychologist, or other certified specialist
may use individually-administered tests to assess the stu-
dent’s skills in the aforementioned domains. Two recent re-
views (146,151) provide examples of the neuropsychological
and psychoeducational tests used in schools (Table 37-2).
These batteries or more narrowly focused tests should
be used, when necessary, to target specific areas of suspected
disability or concern in conjunction with observation, behav-
ior checklists, curriculum-based measurement, and other
context-based measures as described earlier. Many of the
aforementioned tests require standardized administration,
including timed tasks, specific cut-off points, and scripted
instructions for items in order to provide scorable results
based on testing norms. However, students with brain injury
often require additional time to process information, and
would be penalized for slow or partial responses on such

610 VII. PEDIATRIC TBI
standardized measures. If the goal of the assessment is to
compare the student’s performance with typically develop-
ing peers, then measures should be administered as directed.
If, however, the goal is to gather information about the
student’s ability to perform given appropriate accommoda-
tions and modifications (additional time on tests), then the
efficacy of various accommodations could be tested during
the assessment.
Special Test Considerations
Prior to assessment, examiners should be familiar with
strategies to address potential problems confronting many
students with TBI. These include cognitive and physical fa-
tigue (198–199), attention deficits (200), memory problems
(201), delayed processing and response time, low motivation
or apathy (202), and impulse control deficits. For example,
a test requiring extended focus and engagement may be bro-
ken into subtests administered at separate times to minimize
cognitive fatigue. Attention problems may be managed more
effectively in a quiet setting with few distractions (hallway
noise, clocks, alarms, people entering and leaving the room),
and may require more frequent and consistent reinforcement
of student effort with age-appropriate positive contingencies
(203). For tests that are untimed, examiners should allow
the student sufficient time to respond to questions. Potential
problems with motivation could be addressed prior to test-
ing by asking parents or teachers to identify things that are
reinforcing to the student (202,204). If the test is nonstandar-
dized (or administered in a nonstandard way) students with
short-term memory deficits may benefit from precorrections
(reminders of the expected response type) before each re-
sponse set. Examiner awareness of the challenges often asso-
ciated with TBI can help build therapeutic rapport with the
student so that a valid sample of performance is obtained
during testing.
Individual Education Plan Development
Once a student is found eligible for special education ser-
vices, the team (including parents) develops the student’s
IEP that describes the type and amount of specially designed
instruction, the settings in which instruction takes place, and
any accommodations or related services the student needs
to benefit from school. Related services could include in-
struction from a speech-language pathologist, a behavioral
plan for the classroom, and/or participation in a social skills
group. The IEP written for a child with TBI will require pro-
cedures that vary from traditional IEP development in sev-
eral ways (205). Because of the underlying medical cause of
the disability, the initial IEP requires a joint venture among
the health care facility, the school, and the family. Informa-
tion from a variety of sources and disciplines outside the
school system needs to be translated and used to determine
the child’s current levels of functioning. Rapidly changing
needs will require the child’s IEP review to be conducted
more frequently than required by law (e.g., every 3–4
months initially).
Related Services
Ideally, students returning to school following a TBI have
access to a variety of concomitant outpatient services with
therapists specially trained to serve pediatric and adolescent
TBI populations. Unfortunately, although access to such
services is sometimes available in large urban settings (if the
child has the appropriate insurance or qualifies for govern-
ment assistance), in reality there is generally a lack of such
services for most children in the school setting (206,207).
A variety of supportive services that may be required
to assist the child to benefit from special education are also
available through IDEA. These related services can include
physical therapy, occupational therapy, speech-language
therapy, audiology services, psychological services, recrea-
tion therapy, counseling services, social work services,
school health services, parent counseling and training, and
transportation.
As a child with TBI transitions from the hospital/reha-
bilitation setting back to school, questions often arise as to
funding sources for related services, as there is no clear de-
marcation between rehabilitation services and those services
that are a necessary part of the child’s education. According
to IDEA, children are entitled to receive ‘‘related services’’
deemed ‘‘educationally relevant.’’ How individual districts
interpret educational relevance is often open to debate. For
example, a school district might argue that physical therapy
to increase the head control of a student who is severely
injured is rehabilitation therapy; others could argue that it
is educationally relevant therapy because increasing head
control might allow the student to use a head switch to access
a computer in the school setting. In many cases, as students
with TBI transition from the medical or rehabilitation setting
to school, they receive a combination of educationally based
therapy at school and outpatient medical therapy that is paid
for by their insurance providers or Medicaid.
Special Education Placements and Settings
Although IDEA requires that students with disabilities, in-
cluding TBI be educated in the least restrictive environment
(LRE) ‘‘to the maximum extent possible,’’ a full continuum
of options regarding where children can receive services is
available. This can include general education classes, special
education classes (e.g., resource rooms, self-contained
classes), special education schools, hospitals, public or pri-
vate institutions, and instruction at home. There are many
factors to consider in making a decision about the LRE deci-
sion and there are no standardized procedures to follow
(208–210). However, IEP teams can use both case law and
guidelines put forward by researchers who have examined
LRE placement policy to inform their decision-making (e.g.,
Cheatham et al. [211]; Rozalski and Stewart [212]). In general,
the child’s team, based on considerations of the child’s
unique needs and the LRE in which those needs can be ad-
dressed, makes placement decisions. Frequent progress
monitoring of student performance is helpful in guiding
changes and adaptations in support provided, which might
include changes in instructional setting and content.
For example, a school team may decide that a student
returning to school with moderate deficits in memory, pro-
cessing speed, and verbal comprehension following a TBI
may best be served in the general education classroom with
support from the special education teacher delivered within
the child’s own classroom. In another case, a school team
may determine that the most appropriate placement for a
student with severe language and learning problems as a
result of a TBI is a self-contained classroom in the student’s
home school. There the student can receive more needed

37. EDUCATIONAL ISSUES AND SCHOOL REENTRY FOR STUDENTS WITH TRAUMATIC BRAIN INJURY 611
one-on-one learning time, yet still participate with general
education peers in daily activities such as lunch, recess, art,
and music class. In keeping with the intent of the law, it is
unusual for a school team to recommend a placement such
as a special day school or residential placement. These
options are costly and are not available in many areas. More-
over, with school systems currently serving a number of stu-
dents who have severe or profound disabilities as a result
of various conditions, the medical needs of the child with
TBI should not be a hindrance to an education in the LRE.
In some cases, a residential placement or special school may
be necessary if a school district is unable to provide supports
that allow the student to benefit from the educational pro-
gram. In the end, the child’s IEP team, including medical
and rehabilitation providers who have treated the student,
must consider the specific needs of the student, the quality
and type of resources available within the school district,
and the legal mandate to place the child in the LRE to makes
recommendations about school placement.
Specially Designed Instruction
Regardless of the setting, the term special education involves
‘‘specially designed instruction,’’ which IDEA defines as in-
struction that ‘‘adapts the content, methodology, or delivery
of instruction to address the unique needs of the child that
result from the child’s disability’’ [34 CFR §300.39(b)(3)]. The
purpose of the specially designed instruction is to ensure
TABLE 37-3 Evidence-Based Instructional Practices and Strategies
INSTRUCTIONAL STRATEGY DESCRIPTION TBI CHARACTERISTIC
Appropriate pacing Delivering material in small increments and requiring •Fluctuating attention
responses at a rate consistent with a student’s
processing speed increases acquisition of new
material
•Decreased speed of processing
High rates of success Acquisition and retention of new information tends to •Memory impairment
increase with high rates of success
•High rates of failure
Task analysis Careful organization of learning tasks, including •Organizational impairment
systematic sequencing of teaching targets
•Inefficient learning
Sufficient practice and Acquisition and retention of new information is •Inefficient learning
review (including increased with frequent review
cumulative review)
•Inconsistency
Corrective feedback Learning is enhanced when errors are followed by •Inefficient feedback loops
nonjudgmental corrective feedback
•Implicit learning of errors
Teaching to mastery Learning is enhanced with mastery at the acquisition •Possibility of gaps in the knowledge base
phase
Facilitation of Generalizable strategies and general case teaching •Frequent failure of transfer
generalization (wide range of examples and settings) increases
generalization
•Concrete thinking and learning
Ongoing assessment Adjustment of teaching based on ongoing assessment •Inconsistency
of students’ progress facilitates learning
•Unpredictable recovery
From Ylvisaker et al. (132).
the child gains access to the general curriculum so that he
or she can meet the educational standard that applies to all
children within the jurisdiction of the public agency (school
district or state). Although there is very little empirical evi-
dence of the effectiveness of interventions to promote posi-
tive educational outcomes for children and youth following
a TBI (213,214), a number of promising practices can be iden-
tified from research with children with other disability labels
(131,144). Because children with TBI share commonalities
with children with other disabilities, this research can pro-
vide guidance for educators working with students with TBI.
Perhaps the most critical factor in educating students
with TBI is ensuring high levels of accuracy in their academic
work; there is a strong correlation between maintaining high
rates of learner success and increased acquisition and reten-
tion of newly learned information (215–217). The provision
of guided practice (218–221) and cumulative review (222)
address inefficient and inconsistent learning characteristics
of students with TBI. Students with TBI also benefit from
using well-rehearsed instructional routines or strategies. In-
structional routines consist of a set of steps applicable across
a range of examples (e.g., consistent sequence of steps for
solving math story problems) (218,221,223). Brisk instruc-
tional pacing, appropriately adjusted to the student’s re-
sponse rate, can increase the acquisition rate of new material
(224). Providing systematic corrective feedback (225,226) is
important for students with learning and memory problems
after TBI (216,227,228); immediate, nonjudgmental feedback

612 VII. PEDIATRIC TBI
is critical to improving accuracy when the task is presented
again. Table 37-3 presents a summary of research-based in-
structional strategies that address cognitive characteristics
common to many students with TBI.
In addition to the evidence supporting specific instruc-
tional strategies, there is substantial research on the efficacy
of metacognitive interventions in promoting student success
(217,218). Designed to facilitate a strategic approach to diffi-
cult academic tasks, metacognitive strategies are procedures
that students can use to improve their performance across
a variety of academic tasks. Strategies can be task specific
or more general. For example, a self-regulatory self-talk
strategy like ‘‘I need to check my work’’ is generally applica-
ble to a wide variety of academic tasks. Using a graphic
organizer for writing a story is an example of a metacognitive
strategy that is task-specific.
Educational Accommodations
Educational accommodations allow students with disabili-
ties to access the same curriculum as their peers through
changes in teaching methods and/or materials. For example,
a student with memory problems may require multisensory
presentations or a child with vision deficits may require large
print books to be able to work towards the same goals as
their classmates in the general education classroom. Chil-
dren returning to a general education setting following TBI
will more than likely require multiple accommodations.
Table 37-4 presents examples of educational accommoda-
TABLE 37-4 Educational Accommodations
COMMON DEFICITS
FOLLOWING TBI CLASSROOM EXAMPLES POSSIBLE ACCOMMODATIONS
Fatigue Student struggles to stay alert in class; physical ex- Modified school day; schedule most taxing courses
haustion impacts student’s learning early in day; rest breaks
Attention/concentration Student is unable to sustain or maintain focus to Reduce distractions in student’s work area; divide
complete task or activities; is easily distracted; if work into smaller sections; use verbal or nonverbal
interrupted cannot go back and pick up where cueing system to remind student to pay attention
he or she left off
Memory Student has difficulty remembering instructions; is Provide written instructions for student; shorten
able to read assigned chapter, but cannot recall reading passages; frequently repeat and summa-
what was read; does well on daily assignment, rize information; link new information to student’s
but poorly on tests relevant prior knowledge
Organization Student is often late to class; comes to class without Assign person to review schedule at start of school
necessary materials; does not automatically carry day and organize materials for each class; use
out the class schedule; does not remember what color-coded materials for each class (book, note-
class is next; leaves out steps in a project or when book, supplies); provide written schedule of daily
solving a complex problem routine and give reinforcement for referring to
schedule; provide written checklist for complex
tasks
Processing speed When called on in class, student does not respond Give student advanced notice he or she is going to
right away, gives appearance of not attending or be called on; allow extra time for the student to
knowing the answer; has difficulty carrying out respond when answering; supply written set of di-
multi-step directions; performs poorly on timed rections; provide extended time on assignments
tests and tests
Visual–motor Student has difficulty copying problems from the Assign someone to take notes for student during lec-
blackboard; decreased motor speed makes tures; provide copy of problems on blackboard;
keeping up with taking lecture notes impossible; allow for alternatives to paper-pencil writing (oral
visual field deficit causes student to ignore infor- responses, computer); provide preferential seat-
mation presented on right side ing to maximize visual field
tions that address cognitive and physical characteristics com-
mon to many students with TBI. These accommodations can
be successfully employed in general education settings or in
the context of special education environments. Accommoda-
tions such as these minimize the student’s deficits and allow
him or her to remain in a less restrictive school environment.
Behavioral and Social Support Strategies
Individual education plans for students with TBI often in-
clude social and behavioral goals, as difficulties with EF,
including impulse control and control of attention, are com-
mon sequelae of TBI (22,24,203). Addressing behavioral chal-
lenges is often difficult and time intensive for school staff,
however, appropriate school and social behavior is critical
to student success (229). There is a large research base on
strategies to support students with behavioral issues includ-
ing Functional Behavior Assessment; monitored trials of ac-
commodations and modifications, for example, modified
schedule, preferential seating, and so forth; small group in-
struction; and individual behavioral interventions (230). Col-
laboration with district or outside agency specialists such
as vocational rehabilitation counselors, transition specialists,
therapists, and so forth, may also be useful (146). Table
37-5 includes validated approaches to behavioral and social
intervention.
504 Eligibility
Although TBI often affects learning, not all students with
TBI need, or are eligible for, assistance under IDEA. Some

37. EDUCATIONAL ISSUES AND SCHOOL REENTRY FOR STUDENTS WITH TRAUMATIC BRAIN INJURY 613
TABLE 37-5 Integrated Approaches to Behavioral and Social Intervention
APPROACH DESCRIPTION TBI CHARACTERISTIC
Self-awareness/ Facilitation of students’ understanding of their •Decreased self-awareness
attribution training role in learning; validated for students with •Denial of deficits
learning difficulties (231)
Cognitive behavior Facilitation of self-control of behavior; validated •Weak self-regulation related to frontal lobe
modification with adolescents with ADHD and aggressive injury
behavior (232) •Disinhibited and potentially aggressive behavior
Positive, antecedent- Approach to behavior management that focuses •Impulsive behavior
focused behavior primarily on the antecedents of behavior (in a •Inefficient learning from consequences
supports broad sense); validated in developmental •History of failure
disabilities and with some TBI subpopulations •Defiant behavior
(233,234) •Initiation impairment
•Working memory impairment
Circle of friends A set of procedures designed to support •Frequent loss of friends
students’ social life and ongoing social •Social isolation
development; validated in developmental •Weak social skills
disabilities and TBI (235,236)
Abbreviations: ADHD, attention deficit hyperactivity disorder. From Ylvisaker et al. (132).
students are able to participate in the general education pro-
gram with supports and accommodations provided through
a Section 504 plan (237). This civil rights act protects individ-
uals from discrimination based on their disability, ensuring
individuals’ equal rights to participate in and have access to
program benefits and services, including public education.
The definitions of disability in this law are broader and more
inclusive than those in IDEA; an individual with a disability
is someone with a physical or mental impairment that sub-
stantially limits 1 or more major life activities, such as caring
for oneself, walking, seeing, hearing, speaking, breathing,
working, performing manual tasks, and learning (238). The
Rehabilitation Act Section 504 is a civil rights law that applies
to all settings, not just public school, so it continues to protect
individuals from discrimination after high school gradua-
tion. A written 504 plan might include accommodations to
address physical, cognitive, or behavioral needs, including,
for example, a reduced schedule to compensate for fatigue,
a note taker for fine motor difficulties, or increased time to
complete tests and assignments to compensate for process-
ing delays.
Transition Planning or Services
Under IDEA, transition services are mandated for all stu-
dents with disabilities beginning at age 16 (141). The law
specifies that each student have an IEP to facilitate move-
ment from school to post-school life, that the plan take into
account the student’s abilities, preferences, and interests, and
include measurable postsecondary goals (239). The plan
must include instruction, services, experiences, development
of objectives for employment and adult living, and acquisi-
tion of living and vocational skills. The National Secondary
Training and Technical Assistance Center (NSTTAC) recom-
mends that transition plans incorporate the following evi-
dence-based practices: (a) transition planning focused on
post-school goals and self-determination; (b) help coordinat-
ing postsecondary plans with adult agencies; (c) instruction
in academic, vocational, independent living, and per-
sonal–social content areas; (d) support for completing high
school; and (e) paid job training while in the program and
help securing employment or entering postsecondary train-
ing on leaving the program (240).
Building Capacity of Educators: Recommendations
for Teacher Training
There continues to be a lack of awareness of the impact of
TBI on school performance (112). Numerous resources exist
for educators who want to learn more about childhood TBI
(e.g., http://cokidswithbraininjury.com/, http://www.la-
publishing.com, http://www.projectlearnet.org/, http://
www.brainlinekids.org/). Further, with the increased aware-
ness of the impact of concussion on young learners and the
need for schools to address these students’ needs, a variety
of new resources have been developed (e.g., http://
brain101.orcasinc.com/, http://www.cdc.gov/concussion/
HeadsUp/schools.html).
The challenge remains that many teachers leave their
university training programs with little or no training in TBI
(241–243). Training for general education teachers in work-
ing with students with TBI is minimal (109,110,244), and
most special education teacher preparation programs offer
training in strategies designed to support students with
higher incidence disabilities (e.g., Specific Learning Disabil-
ity and attention-deficit/hyperactivity disorder) (245).
More comprehensive teacher training efforts in TBI have
focused on training educators who are currently working in
schools (137,138). The past 30 years of research on profes-
sional development for educators points to a number of criti-
cal components for effectiveness regardless of the particular
subject or method being taught. To have an impact on stu-
dents, training and support for educators must
䊏
require teachers to practice new skills in the school envi-
ronment (246–250);
䊏
provide access to sufficient organizational supports
(251);

614 VII. PEDIATRIC TBI
䊏
include information about the causes, incidence, treat-
ment, outcomes, and challenges of TBI;
䊏
include a variety of evidence-based strategies (252,253);
䊏
include consultation on implementation of new skills in
the instructional setting (e.g., Bowen [254]; Fuchs and
Fuchs [255]; Gersten et al. [256]; Sailors and Price [257]);
and
䊏
be of sufficient duration (e.g., 7–8 sessions) to produce
long-term sustained use of new strategies in the instruc-
tional setting (250,258,259).
There are currently 2 teacher training models that incor-
porate these features in use with educators serving students
with TBI: the TBI Consulting Team model (137) and Brain-
STARS (260–262). Although these models show promise,
both lack evidence of impact on child outcome, which is
the standard for evaluating the effectiveness of professional
development models (263–265).
CONCLUSION
Although hospitals treat children and adolescents with TBI
in their initial course of recovery, it is ultimately the school
system that serves as the long-term provider of services for
this population. Because TBI has significant and on-going
effects on academic, cognitive, and psychosocial functioning,
in 1991 TBI was added to the list of disabilities that qualify
students for special education services under IDEA, and thus
students, if identified, can receive an array of supports to
address individual needs. However, despite the fact that the
foundation for providing appropriate service to students
with TBI exists in special education law, students with TBI
continue to experience significant challenges in school and
as a group experience poor post-secondary outcomes.
For students with TBI, school performance is most often
affected by executive dysfunction, social behavioral prob-
lems, and a progressive lag in academic achievement. Sev-
eral factors have been found to mediate and moderate the
effect of TBI on school performance. Early injury is associ-
ated with poorer outcomes than later injury, and generally
more severe TBI is associated with more negative outcomes.
Family environmental characteristics, such as SES, overall
family functioning, and parenting behavior can also signifi-
cantly affect student educational performance. In addition to
child- and family-centered factors, a range of environmental
variables negatively affect student outcomes. For example,
the lack of training in TBI for educators, as well as ineffective
hospital–school communication, has led to underidentifica-
tion of children with TBI for special education. Adversarial
parent–educator relationships have often hampered the de-
sign of educational programs for students with TBI.
Like other students with disabilities, students with TBI
need and deserve to be promptly and accurately identified
so they can be appropriately served by educators who are
knowledgeable about the challenges they experience and
who can implement effective instructional and behavioral
strategies. Because most parents of students with TBI will
have had no prior experience with special education, school
systems should provide information and link parents with
skilled advocates. Linking students with TBI and their fami-
lies to community-based resources— throughout their school
years but especially at transition from high school—should
be a high priority for the IEP team.
These improvements in service delivery will involve
systemic changes. Well-developed preservice and in-service
training programs for school personnel will help educators
accurately identify students with TBI, implement effective
educational practices, develop strategies for collaborating
with parents, and link students to appropriate community-
based supports as they leave high school. Well-established
hospital–school linkages with school reentry protocols will
help to increase identification rates and ensure smooth tran-
sitions back to school. Significantly improving outcomes for
students with TBI will require comprehensive research ef-
forts that examine these and other efficacious interventions
and bringing these interventions into broader use through
a coordinated process of development, training, technical
assistance, and dissemination.
KEY CLINICAL POINTS
1. Reduced hospital stays have resulted inchildren with sig-
nificant needs returning to school with little or no support
from medical or community-based agencies; the primary
service provider for children and adolescents has become
the school.
2. For students with moderate to severe injury, the rate of
academic achievement gains tends to slow progressively
over time, and the effects are long-term. Changes in social
behavior affect not only functional aspects of daily living
but also quality of life.
3. A growing body of research indicates that post-high
school outcomes for many students with TBI are poor.
4. Effective instructional and behavioral support strategies
implemented by trained educators can help mitigate the
academic and behavioral challenges associated with
childhood TBI.
5. Instructional methodologies that have proven effective
with learners with different disability labels but similar
functional challenges can be used effectively with stu-
dents with TBI.
6. Improved identification of students with TBI for special
education services could lead to more effective provision
of educational and social/behavioral support strategies
tailored to students’ specific needs.
7. To lead to positive student outcomes, training and support
for educators must include training in evidence-based in-
terventions, supervised practice in both the training site
and classroom, and continued mentoring, feedback, and
consultation in the classroom.
KEY REFERENCES
1. Babikian T, Asarnow R. Neurocognitive outcomes and
recovery after pediatric TBI: meta-analytic review of the
literature. Neuropsychology. 2009;23(3):283–296.
2. Taylor HG, Swartwout MD, Yeates KO, Walz NC, Stancin
T, Wade SL. Traumatic brain injury in young children:
postacute effects on cognitive and school readiness skills.
J Int Neuropsychol Soc. 2008;14(5):734–745.
3. Todis B, Glang A, Bullis M, Ettel D, Hood D. Longitudinal
investigation of the post-high school transition experi-

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Trauma Rehabil. 2011;26(2):138–149.
4. Yeates KO, Anderson V. Childhood traumatic brain in-
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Anderson V, Jacobs R, Anderson PJ, eds. Executive Func-
tions and the Frontal Lobes: A Lifespan Perspective. Philadel-
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5. Ylvisaker M, Todis B, Glang A, et al. Educating students
with TBI: themes and recommendations. J Head Trauma
Rehabil. 2001;16(1):76–93.
RECOMMENDED WEBSITES
http://www.cbirt.org
http://www.projectlearnet.org
http://www.cokidswithbraininjury.com
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