School of Nursing and Midwifery, Queen’s University Belfast, UK.
Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, UK.
This paper seeks to highlight the important role educators play in the lives of children who sustain a traumatic brain injury (TBI). Given the importance of success at school for academic attainment, socialisation and future employment,1 educators are uniquely placed to aid in supporting recovery following TBI. By determining how teachers perceive childhood survivors of TBI, and uncovering what they know on the topic, we should be better able to target resources and implement training and appropriate interventions.
The central role that many teachers play in the lives of children under their care places them in a position of great influence. A word of encouragement from a teacher can inspire a pupil to improve their academic performance while an unfair criticism can have damaging consequences. The hidden nature of TBI may mean that children are expected to behave in a manner consistent with the norms of their peer group. 2If they are unable to meet these expectations they may be labelled as difficult or disruptive. If teachers lack understanding of the child’s condition they are more likely to unfairly judge unruly behaviour as wilful, rather than an act of frustration, or impaired behavioural control.3
The majority of children who sustain a TBI will return to mainstream school.4 However, many of these children will be returning to school without the benefit of specialist support.5, 6 For some, their teachers may not even be aware that they have had a TBI. 7 The implication of this lack of awareness is that these children may not be offered the interventions or support strategies which could help them succeed at school.
Children with TBI can have a range of difficulties which may affect their ability to function in the classroom. These include fatigue, memory problems, concentration and attention difficulties, comprehension problems, language difficulties and behavioural problems.8 When teachers are not aware that these problems are associated with TBI, the child is less likely to receive the assistance and support he or she needs.9 In consequence, the child may fall behind the rest of the class, and his or her schoolwork will suffer. Scott-Jupp and colleagues 10 found that children with TBI perform significantly worse than controls in terms of information processing and classroom performance. Furthermore, long-term studies suggest that, rather than improving over time, problems associated with TBI tend to persist or worsen as children progress through school.11 Glang and colleagues 11 also noted a significant discrepancy between the incidence of TBI and the number of children referred for special educational services. This suggests that there are many children with TBI who are not receiving the support they need.
Martin and colleagues 12 reported that children who underachieve at school are often those who are easily distractible. Children are more likely to be distracted when they cannot concentrate, especially in unstructured environments. In a survey of teacher impressions of one child who had sustained a moderate TBI, it was found that the same child was perceived differently depending on the subject being taught.13 For more structured subjects, such as Science and Mathematics, the child performed quite well. However, in less structured subjects such as Art, the child was seen as disruptive, loud and badly behaved.
Although childhood TBI is one of the most significant causes of disability among children and adolescents 6, 14, 15 for individual mainstream school teachers it is a rare occurrence to find a child with TBI in their classroom. Consequently, teachers in mainstream schools have little or limited experience of teaching a child with TBI and most are unaware of the long-term nature of the sequelae.16 The majority of teachers do not receive any training to prepare them for teaching a child with TBI.17 It is thus clearly important to consider the education of teachers about TBI. A UK charity, The Child Brain Injury Trust offers training to school teachers, however because many schools do not see TBI as a major issue and are working within limited financial resources, they may be unwilling to release teachers for such training. Whilst conditions such as Attention Deficit Hyperactivity Disorder (ADHD) and Dyslexia are seen as common and requiring special attention and training for teachers, TBI is perceived as relatively rare.
To date, little research has been conducted on the understanding teachers hold in regard to TBI. In 1997 Farmer and Johnson-Gerard,18 working in Missouri USA, explored the knowledge teachers held when compared to rehabilitation staff from a local hospital. Findings from a 40-item questionnaire 19 showed that teachers held more misconceptions compared to rehabilitation staff who clearly had more contact with survivors of TBI. However, teachers exhibited greater awareness, compared to previous studies in the general public (e.g. Gouvier et al., 20), on questions such as a second blow to the head would not help with recall and that sometimes complete recovery was not possible. The majority of teachers in Farmer and Johnson-Gerard’s study were employed in special education (124 out of 184), 34% (n = 60) of whom had some experience with TBI. The authors suggest the use of established protocols to ensure effective communication between medical and educational staff, thus promoting a successful return to school.
A recent study, conducted in the UK, sought to determine the level of knowledge held by teachers on paediatric TBI.16 Utilising an altered version of the common misconceptions about TBI questionnaire, the authors showed that teachers held many misconceptions, or demonstrated a lack of awareness, around paediatric TBI. 57% of teachers surveyed stated that they did not know that a TBI would cause a child to feel depressed while 55% reported not knowing whether recovery was dependent on the child’s desire. However, 95% of teachers correctly disagreed with the statement that children with brain injuries looked different from other children and 54% agreed that children may not be aware of their behaviour following injury. Out of 388 responses to the questionnaire 25.8% (n = 100) reported that they had some experience of teaching a child with TBI. Considering 248 educators stated that they had more than 21 years of experience in the profession this figure seems low. Linden et al 16 suggest that this may be attributable to a lack of information on the child’s condition being adequately communicated to the school or that information being lost as the child progresses through different year groups or schools. Another possibility may be the perceived stigma associated with the child being seen as different. According to this perspective, parents may not wish their child to be singled out and suffer the ridicule and possible bullying which is associated with membership of the out-group.21
In the UK educators have a statutory obligation to assess and identify those children who have special educational needs. If teachers are ill informed about the consequences and presentation of TBI they may misattribute a child’s lack of progress in class to some other cause. For example, interventions suitable for Attention Deficit Hyperactivity Disorder (ADHD) would fail to address specific attentional or behavioural control issues which may be associated with TBI. It is therefore vital that teachers are made aware of how to screen for indications of TBI and are given appropriate support to access services and interventions to help with the child’s education. A short screening tool (e.g. the HELPS tool 22) could be made available to teachers which would make them aware of what to look out for. It would seem sensible to provide information to educators as they undergo training to enter the teaching profession with top-up courses provided for those who are already qualified. Improving communication between healthcare and education providers would ensure that schools are made aware of the child’s needs in a timely and well informed manner. Furthermore, it is important to ensure that educators are aware of the changing and long-term difficulties associated with TBI. Children with TBI should be continually monitored to ensure that their needs are being met throughout their education, and especially during the transition between school and college. Making this happen continues to be a challenge for those working with young people with TBI.
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