The Reintegration of Recently Brain-Injured Children
Frequently, when children who have suffered a moderate or severe brain injury are discharged from hospital, they seem relatively unscathed (compared to those in wheelchairs, with arms in slings, or other visible scars or bandaging). The lack of visible evidence, combined with a sense of extreme relief, may have convinced them and their close family that everything is virtually as it was prior to the injury.
However, it is not unusual for problems resulting from the brain injury to only become apparent in the months, or years, following their initial discharge from hospital. Following a brain injury, the recovery is most rapid in the early stages but will continue more gradually in the months that follow. The following are problem areas that are invariably characteristic of children in the recovery phase:
The act of thinking for a recovering brain will be a more tiring exercise than it had been before, so the children will be generally more tired and have reduced stamina when involved in work that requires mental as well as physical agility.
Neural pathways may well be damaged or in shock. It will take a longer time than usual for a recovering brain to process information, and -therefore to understand what is being said or to make sense of situations.
SHORT TERM AND WORKING MEMORY
In the early stages of recovery from a brain injury, there are invariably difficulties with reduced short-term and working memory. Short-term memory is the ability to make usable, reliable memories of recent events. Working memory is the ability to manipulate the understanding of ongoing events in practical activities. This deficit will mean that children will have more difficulty retaining information over a short period of time. In the very early stages they may forget how a spoken or written sentence started by the time they have got to the end. This, clearly, severely affects their powers of comprehension. They will also forget exactly what they have said to whom and will, therefore, often have a tendency to perseverate- frequently repeating themselves in conversation. Over time, this situation generally improves and usually, by the time a child is discharged from hospital, they will be able to hold sensible conversations of varying degrees of complexity.
For some time following the injury, the recovering child may have great difficulty retaining information. They are likely to forget what a teacher said to them earlier in the day or lesson, to be unable to retain information to allow them to correctly answer comprehension questions, to fail to remember to bring the correct equipment to lessons, or to forget why they went upstairs in such a hurry.
Powers of concentration will also be severely affected. These children will have difficulty maintaining their concentration in environments in which other children will function very effectively. Even in a very calm and well-behaved classroom, there will be children coughing, someone tapping a pencil, cars or birds moving outside the window or noises from elsewhere, and all of these will momentarily grab the attention of a child recovering from brain injury. This momentary loss of concentration will mean the child will lose track of what may be being said by the teacher, or the gist of the information they are reading from a text-book, or what they meant in the sentence they are in the process of writing.
Organisational abilities will be reduced. They are likely to forget where they put
their keys and their schoolbooks and they will find sequencing activities difficult.
For example, despite knowing exactly what they need to do, they may go to the wrong place first, to collect something that they can't get through the next door, and anyway, they should have asked Mrs. Smith first, who is in the other room downstairs, etc. etc.
The difficulty in processing information can also result in some behavioural problems. These children will have difficulty thinking through the consequences of what they say and do. As a result, they will say things that others may find offensive and, if goaded by friends, may take risks that previously they would have thought better of. They will, -therefore, appear dis-inhibited and are at risk of offending others or placing themselves in potentially dangerous situations if encouraged by friends.
It is clear to see that, if these children are placed too quickly in an environment such as a school, or even a busy shopping centre, they are likely to become very tired, confused and, soon, downhearted.
It is very important that these children are allowed to gradually reintegrate into school, at a slow pace that is appropriate to their stage of recovery. To fail to do this may well turn school into a frustrating and frighteningenvironment for them. It is 'likely that their response to this may be to react adversely, either by developing a negative/phobic attitude or by becoming aggressive, as a result of frustration at having to work so hard to accomplish things that they know are (or were) well within their capabilities. They also may just become quiet and withdrawn, providing staff with the belief that they are coping well, resulting in the, sadly, frequent assurance of apparent success at school ('they are good as gold'), when in fact they are failing badly.
Some ways to reduce negative experiences
- Inform all members of school staff and as many of the child's peer group as appropriate that the child will find things more difficult early in their return to school.
- Don't expect quick responses to questions, and keep questions as simple as possible.
- Inform the peer group that they may have more difficulty controlling their emotions and may be at risk of causing offence or taking risks.
- It is likely these children will be less distracted if they sit at the front of a class or initially work in smaller groups.
- It will be helpful if homework, notes, and lesson requirements are written for them by a classmate or by their teacher.
- They should always carry with them a notebook to allow them or others to write down important pieces of information, because they must not be expected to rely on their memory.
- It will be a great help to always place things in the same place in their home environment, or anywhere in which they will be expected to remember where things are.
- It will be useful for them to have routines to accomplish regular activities.
- They should not be placed in potentially dangerous environments because their ability to think quickly will be reduced. Crossing a busy road alone should, initially at least, be avoided.
Further head injuries should be avoided, at a!! costs, when the brain is in recovery.
Will Gosling - BRCU Frenchay Hospital
Support for parents and schools can be obtained from Supporting Head Injured Pupils in Schools:
For more information about brain injuries, see aboutbraininjury.org.uk
Department for Children and Young People Hospital/Home Teaching Service
School Room, Barbara Russell Children's Unit
Frenchay Hospital, Frenchay, Bristol BS16 1LE
Telephone:0117 3406704 Fax:01173403776
e-mail: William, aoslind&nbt, nhs, uk