Tyler, 18, looks like an average high-school senior—but spend a few minutes talking with him, and you may notice he has trouble sustaining the discussion. When Tyler was 14, he was the front-seat passenger in a car that hit a tree. Although wearing a seat belt, Tyler sustained several broken bones, lacerations, and a traumatic brain injury, which temporarily affected his ability to speak. After many surgeries, a 20-day hospital stay, and several weeks in rehabilitation, Tyler is now fully recovered physically and has returned home—and to school.
Previously a strong student, Tyler qualified for school speech-language pathology services to help him increase verbal output. As he progressed through high school, his status for speech-language pathology services was changed to "consultative"—meaning that he received no services, but a speech-language pathologist attended Tyler's Individualized Education Program (IEP) meetings.
His English and social studies grades were Bs and Cs, and at an IEP meeting at the end of Tyler's junior year, his parents and English teacher expressed concerns about his ability to complete the written portion of college entrance exams. The SLP's comprehensive assessment revealed difficulties with the teen's ability to compose complex sentences and provide supporting evidence for main ideas. Amending his IEP, the SLP worked with Tyler to compose complex sentences with cues, then—in conjunction with his English teacher—devised a strategy for classroom carryover for strategy practice during class assignments. Although the strategies helped to raise his English grade during junior and senior years, he did not pass the written portion of the SAT. Tyler recently graduated and plans to attend a small college that does not require SAT scores for admission.
Tyler is one of the estimated half a million children ages 0–14 who receive medical treatment for traumatic brain injury (TBI) each year (Langlois, Rutland-Brown, & Thomas, 2006). Although approximately 145,000 children live with a persistent disability following TBI (Zaloshnja, Miller, Langlois, & Selassie, 2008), the number of students enrolled each year in special education services in the TBI category is 24,602 (U.S. Department of Education, 2007).
What is happening to these students when they return to school—or, in the case of very young children, when they begin school?
Typically, treatment for TBI begins with a medical model, with overall coordination by a physician; length and amount of services are dictated by insurance coverage. Hospital stays are typically short—three weeks—and insurance often limits children's access to rehabilitation services.
The school system, therefore, becomes the de facto provider of most long-term services for children with TBI. But as many as 60% of children with TBI fail to receive those school-based services because of factors such as delayed effects of the injury or adults' failure to realize the need for ongoing TBI monitoring, according to data from a federally funded study (Todis, 2007).
Such monitoring is critical, however, because many children with TBI experience cognitive changes—many within the SLP's scope of practice—that affect new learning, development, educational placement, and participation in social activities for many years following the injury. Cognitive symptoms range from reduced general intellectual functioning to more specific deficits in attention, memory, speed of processing, executive functioning, language processing and expression, and visual-perceptual skills (Arroyos-Jurado, Paulsen, & Lindgren, 2000; Catroppa & Anderson, 2009; Yeates et al., 2002).
These consequences have a direct effect on learning; in particular, children with TBI are vulnerable to disruption of new and emerging skills, namely language and reading, that can impede academic performance, vocational outcomes, and life quality (Catroppa & Anderson, 2009). With their training in helping children develop such language and reading skills, school-based SLPs are uniquely positioned to provide these services to children with TBI—and to raise awareness of the need for them.
Rehabilitation in Schools
One compelling reason for more TBI awareness-raising is that children under age 5 who sustain an injury may not demonstrate academic or behavioral difficulties until they begin elementary school, a phenomenon known as a "neurocognitive stall" (e.g., Anderson et al., 2006; Chapman, 2007).
Even when the injury is reported, medical information about the event may not travel with the child as he or she progresses from elementary to middle to high school—perhaps because as families move between schools, the schools may transfer educational rather than medical records, or because parents request not to have the injury information follow their child.
For those injured during high school, families and school systems may allow students to graduate with their class rather than stay in school longer to take advantage of services that could advance the teens' long-term career development after high school. This practice may boost the teen's self-esteem at the time; it is more beneficial, however, for students to stay in school for services and supports that can contribute to career development after high school.
Transition plans for students enrolled in special education usually include connection to vocational rehabilitation services after high school; graduating students without a transition plan are unlikely to be similarly connected.
Among the key developmental and functional areas potentially affected by TBI-and addressed
Cognitive communication. SLPs assess and treat cognitive communication disorders and also provide counseling about cognitive-communication impairments and case management services. In medical rehabilitation, SLPs often work on memory and attention skills. Knowledge of pragmatics and social communication contributes to assessment and program planning for children with TBI. Our background and roles in cognition can facilitate goal development for learning and communication skills in the classroom (ASHA, 2005).
Language. School-age children with TBI are more likely to show deficits in discourse and narrative performance, according to research. Children with TBI:
- Produce shorter narratives with less information compared to typically developing children (Chapman, Watkins, Gustafson, Moore, & Levin, 1997; Ewing-Cobbs & Barnes, 2002).
- Have difficulty linking information across sentences, recalling propositions to convey story content, and sequencing verbal information (Chapman et al., 1997; Ewing-Cobbs & Barnes, 2002).
- Exhibit greater deficits if they are younger than 5 at the time of the injury (Chapman, Levin, Wanek, Weyrauch, & Kulfera, 1998).
- Display differences in other higher-level functioning language skills, namely story recall and verbal fluency (Anderson, Catroppa, Haritou, Morse, & Rosenfeld, 2001).
- Are at risk for deficits in basic language skills such as vocabulary and grammar. Those with more severe injuries display mild to moderate impairment on standardized measures of vocabulary and grammar; those with mild to moderate injuries perform in the low average range for children (Anderson et al., 1997; Anderson, Morse, Catroppa, Haritou, & Rosenfeld, 2004; Ewing-Cobbs & Barnes, 2002; Ewing-Cobbs, Fletcher, Levin, Iovino, & Miner, 1998).
Reading. Oral language as a whole forms the foundation of reading; therefore, weaknesses or disorders in developing language skills place children at risk for difficulties with reading, a linguistic skill critical for both academic and long-term vocational success. Reduced language attainment and word reading—two areas that are typically depressed following TBI—may be associated with increased risk of reading difficulties, particularly reading comprehension.
Hearing. The mechanism of a TBI also puts children at risk for hearing loss. The incidence of hearing impairment ranges from 16% (high-frequency sensorineural loss) to 32% (conductive hearing loss; Zimmerman, Ganzel, Windmill, Phillips, & Nazar, 1993). Those providing medical care to children following a TBI, especially in an emergency room or a pediatrician's office, often do not assess the child's hearing. In other cases, children are not tested for hearing loss because parents may not seek medical care for mild injuries.
Swallowing and motor speech. TBI may also cause dysphagia and oral-motor difficulties. Injury severity is a key predictor of continued motor speech and dysphagia disabilities in children and adults (Morgan, Ward, & Murdoch, 2004). In many cases, motor speech difficulties and dysphagia of severely injured children will resolve within a hospital stay of 22–30 days. Individuals with a severe injury or who are intubated are likely to have persistent disabilities following hospital discharge (Ward, Green, & Morton, 2007).
Assistive technology. Although children are more likely to recover their motor skills than adults, some children have persistent difficulties with speech production. Because of diminished length of stay in the medical model, school-based SLPs may be the first to introduce the concept of augmentative communication to families following a period of recovery. Technology can also assist with a student's memory and organization, and access to educational information.
Schools are mandated to devise individual plans to meet a child's learning needs rather than to achieve recovery to maximum potential. Modifications to educational programs are achieved through IEPs (under the Individuals With Disabilities Education Act) or 504 plans (under the Americans With Disabilities Act), crafted by a team of teachers, special educators, and other specialists (SLP, occupational and physical therapists, psychologist, audiologist, etc.) to help the student access academic content. Services—including speech-language treatment—are based on maintaining a child's academic progress.
The SLP's Role
Speech-language pathologists can help bridge the gap between the medical and educational models for children with traumatic brain injury. Although "cognitive rehabilitation" may not be a term used in IEP or 504 plans, cognitive rehabilitation treatment strategies can be incorporated into students' education plans. SLPs can contribute to an educational program in several ways:
- SLPs often devise compensatory strategies for executive functions and memory, such as notebooks and organizers.
- Training in language development and assessment and treatment of childhood language disorders is a specialty area in our field. Children and teens with TBI need a comprehensive assessment of their language and literacy skills following an injury. They are most likely to benefit from this type of assessment when they return to school. The Pediatric Test of Brain Injury is a recent measure designed to capture the cognitive-language deficits unique to TBI.
- Our background with motor speech disorders and dysphagia adds to the complement of services offered in rehabilitation. School-based SLPs can provide assessment and remediation of neurologic motor speech disorders as part of a child's educational plan.
- SLPs' knowledge of hearing screening and remediation for auditory processing disorders can help children with TBI. SLPs in rehabilitation settings often provide assessment and treatment in these areas; school-based SLPs can bridge the gap between medical and educational services in these areas.
- SLPs can be part of the team to assess and "fit" assistive technology to augment communication or increase a student's independence.
School-based SLPs can take the lead in helping to ensure that students with TBI receive appropriate assistance for their communication difficulties. They can:
- Educate teachers, administrators, and those involved with the student's return to school about SLPs' scope of practice and TBI-related symptoms and changes that can affect learning and achievement.
- Ask to be involved with children who are identified with TBI at school, regardless of their eligibility for special education. SLPs can lend expertise to student support teams and child study teams.
- Promote the need for audiological assessment after TBI. You may be the first to request this type of testing.
- Advocate for comprehensive language assessments for children with TBI. We know that language is affected by cognitive and new learning changes over time that significantly contribute to academic achievement. A comprehensive speech-language assessment provides greater detail about language functioning than educational or neuropsychological reports.
- Incorporate principles of cognitive rehabilitations in the school program. Development of compensatory strategies, along with focus on academic content, should be included in the IEP.
- Promote the use of assistive technology for memory and learning as well as communication.
SLPs play a unique role in the children's rehabilitation following a brain injury. Our knowledge of medical rehabilitation, hearing, the motor speech mechanism, language, and cognition provides a basis for serving children in both medical and school settings. Our skills bridge the gap between the models of service that children and their families navigate following a brain injury. Communication with parents, principals, student support team leaders, counselors, school nurses, and psychologists will raise awareness of the role of the SLP as well as inform the school community about the long-term effects and issues following brain injury.
The author thanks Tracey Wallace, Jason Amos, and Tisha Coggin for their review and insightful comments.