Best Practice

Supporting students who experience brain injuries

Pastoral issues Pupil wellbeing
Thousands of children experience brain injuries every year and the impact on their education and wellbeing can be severe. Emily Morley, Dr Emily Bennett, and Dr Gemma Costello advise schools and teaching staff while signposting to a range of useful resources

 

Around 40,000 children and young people experience a brain injury every year according to the Children’s Trust. This suggests that one child in every classroom will be affected by acquired brain injury (ABI) by the end of their compulsory schooling. As children with ABI are at risk of exclusion from school and social isolation from peers, it is always a good time to consider whether illness or injury could be contributing to current needs and how best to support them.

However, those working in education frequently report that they know little about ABI and how to practically support children in their care (Linden et al, 2013).

 

What is an acquired brain injury?

ABI is an injury to the brain that occurs after birth and a period of typical development. They may be traumatic (e.g. fall, accident, assault) or non-traumatic (relating to medical condition or illness, such as stroke or meningitis) and can be classified as mild, moderate or severe.

As children often make good physical recoveries from ABI, it often becomes a “hidden disability”, with the behavioural, emotional, social and cognitive symptoms going unrecognised.

As time moves on, any emerging difficulties may be less likely to be connected back to the original injury when trying to understand the child’s presentation. This in turn can lead to more complex needs if the child is unable to keep up with the school curriculum or communicate with peers and teachers.

Research shows that students with ABIs can have lower “intellectual functioning”, more difficulties with school work (Hawley, 2004) and are more likely to perform below the average than their peers (Hawley et al, 2004). Concerningly, those with ABIs are more likely to develop mental health difficulties and even suffer premature mortality (Sariaslan et al, 2016).

 

A need for change

In November 2017, headed by Chris Bryant MP, the All-Party Parliamentary Group on Acquired Brain Injury (APPG) was formed. It aims to raise ABI-related issues in a number of settings, improve governmental support and services, and give a voice to those affected.

In 2018, the APPG published its Time for Change report, focused on the importance of rehabilitation in four areas – criminal justice, sports-related concussion, the welfare benefits system, and education (APPG, 2018).

The education section of the report acknowledges that schools become a “default” rehabilitation centre for children after ABI (Bate et al, 2021), and that all educational professionals should have a “minimal level of awareness and understanding about ABI and the educational requirements of children and young people with this condition”.

Despite this recommendation, it highlights that there is a substantial lack of training and understanding of ABI in schools. Research shows that teachers and SENCOs do not feel they have adequate training or education around ABI (Hartman et al, 2015) which can lead to not understanding a pupil and their difficulties (Andersson et al, 2016) and using “trial and error” strategies (Bate et al, 2021).

Howe and Ball (2017) found that only 23.6% of their SENCO sample received training on ABI, despite a much higher proportion having regular contact with children with ABI, a finding that has been mirrored in a Nottingham SENCO sample (Bennett et al, 2022).

Communication between parents, healthcare professionals and schools is another common difficulty. Schools are often reliant on parents to tell them when a brain injury has occurred (Todis et al, 2018) and this can lead to large numbers of teachers (Hawley et al, 2004) and headteachers (Bennett et al, 2022) being unaware that a child has an ABI.

Parents may also under-report difficulties after ABI if they have become accepting of challenging behaviour or have no other children to compare behaviour to (Hawley, 2004).

One suggestion to combat this is that educational professionals can take a “proactive” rather than “reactive” role in questioning parents about any accidents or incidents that may have caused ABI (Linden et al, 2013). For example, a questionnaire at the start of school or after the summer holidays which may ask about any potential head injuries. Other questions that may be important for schools to ask are:

  • Is there a school policy for ABI?
  • Has the SENCO in your school received training on ABI?
  • Are you aware of free online training and resources for teachers around ABI (see later)?
  • Do you ask about possible ABI on point of entry to school?
  • Do all school staff have a shared understanding of the needs of a child with ABI?
  • Do you ask families to notify you of any illnesses/injuries that occur over school holidays so that you can monitor them?
  • How are children and young people supported in their return to school after an ABI?

 

Spotting potential symptoms of ABI

It is important for those in education to be aware of possible symptoms of ABI in the classroom. We should note that the symptoms of ABI differ from child-to-child and can also be influenced by how severe the injury is, and when in the child’s development it occurred.

Things to look for after ABI include the following (taken from the N-ABLES Return to Education booklet – see further information).

Behavioural: The child may struggle with impulsivity, disinhibition, risk-taking or behaviours that are challenging. At school this may look like irritability, “acting out”, difficulties attending to instructions or following an adult’s lead, or clumsiness.

Physical and sensory: Difficulty with fine and gross motor skills, coordination, sensory regulation, hearing and vision. At school this may look like bumping into objects, requiring support with skills such as fastenings, threading, pencil control, physical activity, balance, hearing in busy environments, or seeking sensory feedback.

Emotional: Anxiety, low mood, low self-esteem, mental health difficulties. At school, this may look like tearfulness, physical behaviours, emotional “outbursts”, distress, tiredness due to difficulties with sleep and/or fatigue.

Social: Difficulties with communication (peers or teachers), social awareness and competence, expressive and receptive language. At school, this may look like difficulties finding the words to express themselves, understanding information, or making friends.

Cognitive: Difficulty remembering, concentrating or paying attention, or slowed processing speed. At school, this may look like “zoning out”, difficulty remembering lesson content, being easily distracted, requiring frequent prompting, taking longer than peers to complete tasks, or fatigue.


N-ABLES

The National Acquired Brain Injury Learning and Education Syndicate (N-ABLES) was formed as a response to the APPG’s Time for change report to support the implementation of the report’s recommendations and to help those in education understand ABI.

One key recommendation was the concept of an individual “return to education” plan for a child re-entering education after experiencing an ABI. This should be led by one named professional and provide individually tailored, consistent support for the child.

N-ABLES has worked alongside educational professionals and government officials to produce a collection of “ABI return” resources to help educational professionals identify, understand and support those with ABI in their classrooms, and address some of the difficulties educational professionals can face.

With ever-increasing pressure on SENCOs, teachers and headteachers, these free resources were made to be pragmatic and straightforward to implement. They include:

  • ABI return booklet: Aimed to assist professionals involved in helping children with an ABI prepare for and achieve a successful return to education and to help progress their recovery. It includes an introduction to ABI, symptoms to look for, and signposting to other helpful resources to learn more about ABI.
  • ABI return poster: Displays the guiding principles of helping a child return to education, including remembering who the child was (their likes and dislikes) before the injury, and enabling participation (i.e. being flexible with pre-existing resources and skills to help the child access the curriculum to the best of their ability).
  • SENCO/keyworker checklist: A practical resource to ensure vital steps have been carried out before a student returns to school, for example considering interim funding applications and accessing free training on ABI for staff.
  • Supporting information-sharing within school document: A practical resource for healthcare professionals to share useful and individual information about a child’s ABI with educational colleagues. Includes basic information about the nature of the injury, what works and what doesn’t work for the child in the classroom.
  • The main author of this article is Emily Morley, an assistant psychologist at N-ABLES. She has worked with children and young people with brain tumours, carrying out neuropsychology assessments for transitions to new schools and colleges.
  • Contributing author Dr Emily Bennett is a consultant clinical psychologist specialising in paediatric neuropsychology and neurorehabilitation. She has been involved in N-ABLES since its conception.
  • Contributing author Dr Gemma Costello is a specialist educational psychologist in paediatric neuropsychology. She has been a member of N-ABLES since it was formed and is committed to promoting the role of educational psychology in paediatric acquired brain injury.

 

Resources

Further information & references

  • Andersson, Bellon & Walker: Parents’ experiences of their child’s return to school following acquired brain injury, Brain injury, (30,7), 2016.
  • APPG on Acquired Brain Injury: Time for change, 2018: https://bit.ly/3zwkS9V
  • Bate, Turner & Fricke: Return to school after acquired brain injury in the UK: The educators' perspectives, Journal of Research in Special Educational Needs (21,3), 2021.
  • Bennett, Thomas & Woolf: Childhood acquired brain injury: The knowledge and training needs of SENCOs, Support for Learning (37,2), 2022.
    Hartman et al: Clinician and educator experiences of facilitating students’ transition back to school following acquired brain injury, Brain injury, (29,12), 2015.
  • Hawley: Behaviour and school performance after brain injury, Brain Injury (18,7), 2004.
  • Hawley et al: Return to school after brain injury, Archives of Disease in Childhood (89, 2), 2004.
  • Howe & Ball: An exploratory study of SENCOs’ knowledge and experience of working with children who have sustained a brain injury, Support for Learning (32,1), 2017.
  • Linden, Braiden & Miller: Educational professionals’ understanding of childhood traumatic brain injury, Brain injury (27,1), 2013.
  • Sariaslan et al: Long-term outcomes associated with traumatic brain injury in childhood and adolescence: A nationwide Swedish cohort study of a wide range of medical and social outcomes, PLoS Medicine (13,8), 2016.
  • Todis, McCart & Glang: Hospital to school transition following traumatic brain injury: A qualitative longitudinal study, NeuroRehabilitation (42,3), 2018.