The Ultimate Guide to SLCN

Acquired Brain Injury

The umbrella term ‘Acquired Brain Injury’ (ABI) describes an injury to the brain which happens sometime after birth and following a period of normal development. There are many causes of ABI, including Traumatic Brain Injury (TBI) which is commonly the result of a fall or road traffic accident; illnesses and infections, e.g. stroke, epilepsy, or meningitis; and medical procedures, e.g. surgery or radiation treatments. The brain can be damaged by deprivation of oxygen as well as by direct trauma. The site of the injury can be small or widespread and any part of the brain can be affected.

All aspects of human functioning are ultimately controlled by the brain, and therefore any function can be affected by a brain injury. ABI can lead to changes in the way a person thinks, feels, and interacts with their environment. Typically, ABI will result in a diverse set of difficulties and these difficulties can mask one another, so it can be difficult to identify the root cause of specific behaviours. The symptoms experienced can be direct or indirect, and difficulties do not necessarily appear straight away: some immediate difficulties resolve quickly, other difficulties persist long-term or are permanent, and other difficulties may emerge weeks, months, or years after the injury occurs as the brain develops and the demands faced by the child evolve. Any difficulties associated with ABI may not be immediately obvious, as most children with ABI have no physical signs of their disability. No two injuries are the same, just as no two children are the same, and therefore the consequences and impact of an ABI cannot be predicted.

It’s important to be aware that many children who have impairments associated with ABI may not have any formal diagnosis. ABI can easily be overlooked or misidentified. It is thought that some children may later be inaccurately diagnosed with different conditions, as the difficulties associated with ABI can appear similar to ASD or ADHD, for example.

Top Tip

During conversations or when providing spoken information, summarise what you have said at regular intervals.

Prevalence

Every year an estimated 1.4 million people attend hospital in England and Wales with a head injury, of which 33-50% are children less than 15 years old. Exact figures are unknown, but it is estimated that 24-31.6% of young people have suffered a TBI. A larger number of children and young people would be expected to be living with ABI.

What to look for

The changes and difficulties surrounding ABI are hard to spot, therefore, it is sometimes called ‘the hidden disability’. The type of injury a child has sustained will be unique to them and the impact that the injury has will also be unique. Cognition, communication, behaviour, motor skills and emotional regulation may all be affected. Many children function physically as before, making it difficult to appreciate the damage that has been done to their developing brain. Some difficulties will only emerge as the demands of the curriculum or social and emotional demands increase. Difficulties which impact on thinking and learning are common and it is likely that a child with ABI will have a range of cognitive and executive function impairments. Behaviour difficulties which might be seen in school or at home can either be a direct result of the injury or they may arise indirectly, indicating that the child is struggling to cope with physical, cognitive, social or emotional challenges.

Difficulties specific to SaLT or education

• Slow processing speed.
• Difficulties maintaining concentration and high distractibility by visual and auditory information are very common. However, it is important to recognise that apparent attention and listening difficulties may actually arise from other needs, e.g. poor understanding of the task and processing difficulties can lead to low motivation and result in inattentive behaviour.
• Memory difficulties.
• Difficulties with articulation of speech sounds might occur due to motor function impairments.
• Conversation skills can be impaired because holding a conversation relies on skills such as memory, attention, and processing speed. Sustaining a conversation is even more challenging when there is more than one other person taking part, which can, for example, impact on the child’s ability to take part in classroom discussions.
• Social awareness and social communication skills can be impaired, e.g. difficulty understanding the ‘unspoken rules’ of communication, increased impulsivity and ability to make appropriate judgements about how to respond.
• Behavioural changes, which can sometimes include increased aggression.
• Emotional changes, including intense and rapid ‘mood swings’, increased anxiety and depression, which can lead to mental health difficulties in the longer-term. The child may appear to be more ‘sensitive’ or emotionally reactive. Confidence and self-esteem can also be impacted.
• Personality changes are common, which can put a significant strain on friendships and family relationships.
• Difficulties understanding and using language.
• Specific difficulties with word-finding.
• Difficulties with reasoning skills such as predicting and inferencing. This can impact on the development of literacy skills – particularly comprehension – and also problem-solving.
• Difficulties with planning and organisation.
• Physical effects of ABI can include fatigue, impaired mobility and limb weaknesses.

Myth Busting

Will the long-term impact be less significant for a child who was younger at the time of their brain injury, because younger brains recover better?

It’s more complicated than this. Some experts believe that young brains are more ‘plastic’ and other parts of the brain might therefore be able to compensate for the damaged areas. However, this would still place additional demand on the healthy parts of the brain. Some experts also argue that a younger brain might be even more vulnerable to the effects of injury because development continues to happen in damaged areas of the brain, so the long-term effects are difficult to predict. The development of a young child’s brain is ‘interrupted’ by injury and they do not have as many skills to be able to compensate. On top of this, we know that brain injury makes developing new skills more difficult, so young children may have a harder time developing skills which they have not yet mastered.

Will we know the full extent of the impact of the injury within two years?

The long-term implications of brain injuries which are acquired in childhood may not become apparent for years after the injury has happened and, in fact, the majority of difficulties that will develop for a child with ABI are initially invisible. This is sometimes referred to as a ‘sleeper effect’. The human brain continues to develop until at least the mid-twenties and impaired function might not become apparent until development which is expected to occur later in life does not emerge, or until increasing and changing demands in the child’s environment highlight deficits in their capabilities.

Do mild brain injuries have any lasting effect?

Some people with mild brain injuries, including concussion for example, will make a full recovery, but this is not true in all cases. At least 10% of mild brain injuries will have a long-term impact. The implications of every brain injury will be unique.

If children are able to remember things they learnt before suffering a brain injury, will they be able to learn new material without any difficulties?

You may find that children are able to perform well on assessments which access previously learnt knowledge. Children with ABI are often able to recall learning and memories which were formed before the injury happened, but they may have difficulty forming new memories and therefore securing and integrating their new learning. Performance on assessments of previously learned material is not predictive of the child’s learning capabilities post-injury.

Could it really be a life-changing brain injury if the child is back at school so soon? Wouldn’t they have been kept in hospital for a long time?

Children often don’t have access to the same range of rehabilitation options and facilities as adults with ABI. Approximately 70% of children with ABI return to mainstream education and they are likely to still be in recovery when they return to school. Schools are thought of as the largest provider of services to children with ABI.

Strategies

The specific difficulties faced by a child with ABI will be complex and unique. General SLCN strategies will be appropriate, as will the more specific strategies below, but a child living with ABI will likely benefit from individualised professional assessments to help identify their specific strengths and needs and the strategies or interventions which will support them best.

• Colour coded resources will help support organisation and planning skills.
• Visual support strategies can reduce memory load. Include written information and instructions if this is appropriate for the child’s level of literacy.
• Allow additional processing time and consider how you can build this in to whole class teaching and discussions.
• Ensure any homework tasks are clearly explained with explicit instructions and that these are understood by the child. You may need to consider how you can help the child to record tasks and to remember when things need to be completed by.
• Reduce distractions in the classroom as much as possible.
• Keep your language simple and deliver instructions one step at a time, allowing time for the child to complete each step before delivering the next instruction.
• Encourage the child to request help, clarification or repetitions when they need to – develop strategies appropriate to the child’s level and explicitly teach the child how to use these in order to promote independence in the classroom.
• Explicitly teach a variety of memory strategies. Encourage the child to find several strategies which work for them and will be appropriate for remembering different kinds of information and in different situations. Use external memory aids (e.g. writing lists, keeping a diary or taking photos) as appropriate.
• If the child is struggling to find the words they need to explain their ideas, encourage them to talk around the word (making links or describing) or show you another way. If you know what word they are trying to say you could try giving them the first sound to see if this prompts them.

Role of SaLT

A child who is presenting with SLCN as a result of ABI may be seen by a SaLT, who can assess all areas of their communication to address the child’s individual needs. Some difficulties arising from ABI will respond to direct interventions, but other difficulties may be permanent. This will require the child to learn strategies and/or adaptations to be made to the child’s environment in order to maximise their functional skills to the child’s best potential.

Further Information

The Children’s Trust for children with brain injury – www.braininjuryhub.co.uk

Child Brain Injury Trust – childbraininjurytrust.org.uk

Headway – www.headway.org.uk/about-brain-injury

Supporting Head Injured Pupils in Schools – www.shipsproject.org.uk

Read more about Childhood ABI in The Link magazine, issue 8