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Advances in Neurodevelopmental Disorders

, Volume 2, Issue 3, pp 310–321 | Cite as

Traumatic Brain Injury (TBI) in School-Based Populations: Common Sequelae and Assistive Technology Interventions

  • Amy Pacos Martinez
  • Marcia J. Scherer
  • Timea Tozser
ORIGINAL PAPER
  • 76 Downloads

Abstract

Traumatic brain injury is the leading source of injury and death among children within the USA and worldwide. According to the World Health Organization, traumatic brain injury will surpass many diseases as the primary cause of death and disability in children within the next few years. A traumatic brain injury is the result of an outside force striking the head in any manner causing the brain to become structurally damaged. Dependent on the severity of the injury, there are persistent lifelong deficits a child may endure. The present article reviews the symptomology of children who sustain a traumatic brain injury and demonstrates the significant impact on future academic achievement. Thus, emphasizing the value of neuropsychological evaluations in aiding children, parents, providers, and educators to select tools such as assistive technology to help children achieve developmental milestones, perform at appropriate age levels in academic contexts, and build compensatory strategies. The vast array of AT options can provide much-needed support to children with varying cognitive needs. Further, the implementation of assistive technology for children is critical in breaking down barriers in academia and allowing for additional research in the field of assistive technology.

Keywords

Traumatic brain injury Assistive technology School-based population School-based populations 

The World Health Organization indicates that by the year 2020, traumatic brain injury will surpass many diseases that typically lead to the major causes of death and disability worldwide (Hyder et al. 2007). Traumatic brain injury affects over 10 million people annually worldwide (Hyder et al. 2007). Globally, consistent findings provide evidence of traumatic brain injuries (TBIs) to be the result of car accidents or road traffic accidents, falls, and violence (Hyder et al. 2007). Roughly half a million children from ages 0–14 years are admitted to the emergency room for TBI-related injury every year (McKinlay and Hawley 2013). The rates of traumatic brain injury-related emergency room and hospitalizations for children have increased since 2007. Reports indicate that roughly 1591.5 per 100,000 children 0–4 years of age are affected by a traumatic brain injury and children ages 15–24 traumatic brain injury rates are 1080.7 per 100,000 in the USA (Taylor 2017).

Hyder et al. (2007) explains that low- and middle-income countries face a much higher burden and risk for increased TBI frequency among these populations (2007) due to both higher risk for a traumatic brain injury and inadequately prepared health systems. Annual rates of brain injury are highest among very young children ages 0–4 and adolescents 15–19 years old (Faul et al. 2010). Many countries that are at higher risk of traumatic brain injury include Latin American countries and countries in sub-Saharan Africa (Hyder et al. 2007). These global findings are also consistent in the literature of children in the USA (McKinlay and Hawley 2013). Traumatic brain injury (TBI) is a leading cause of death and disability among children and adolescents in the USA as well as a critical health problem worldwide. A particular challenge persists for children and teens as they return to school following a TBI. A wide array of physical, cognitive, and psychological symptoms exist that can impact school performance, attendance, and emotional stability when in a school-based setting. The importance of educational support for children and the use of assistive technology in schools for children with traumatic brain injury is critical.

Traumatic brain injury is the result of the brain enduring a powerful acceleration or deceleration of movement caused by an external mechanical force leading to brain trauma (Mistry and Murray 2017). Traumatic brain injuries may result from many causes such as a car accident, the head struck by an object, or a sports-related injury (Mistry and Murray 2017). TBI causes the brain to become structurally damaged. However, cognitive insufficiencies will often not become present until much later after the initial trauma. Individuals who have a traumatic brain injury (TBI) suffer short-term and long-term impairments including those in the physical, behavioral, emotional, and cognitive domains (Centers for Disease Control and Prevention 1999). Typically, individuals who experience TBI or concussion can experience loss of consciousness, alterations of mental state, and loss of memory before the injury, among other neurological insufficiencies (Wood 2004).

Individuals may report headaches, dizziness, nausea, and deficiencies in balance or vision. Their symptoms typically subside within a short time frame following the trauma. However, there is always a degree of variability depending on the severity of the trauma. Initial cognitive issues and complaints are often resolved within 1 to 4 weeks. While long-term deficits of TBI are not as well documented as short-term ones, some research suggests that there are persistent long-term deficits of TBI past acute recovery in children (Mangeot et al. 2002). A traumatic brain injury can significantly impact a youth’s ability to lead a productive and independent life, resulting in significant societal costs and permanent sustained cognitive alterations (Leopold et al. 2015).

While there is a significant degree of variability, the acute treatment phase of TBI involves relatively standard protocols for emergency department treatment, possible hospitalization, or possible outpatient treatment (Laatsch et al. 2007). Post-acute recovery, the “brain injury” aspect of a TBI is often misunderstood, which may lead to interference of cognitive development in many domains in life later on such as education, social, personal, and behavioral (Laatsch et al. 2007). Individuals who have traumatic brain injury do not necessarily show cognitive impairments following the first hospital or doctor visit (Faul et al. 2010). Therefore, the long-term impact of TBI may not be noted or recognized immediately after the brain trauma or after initial diagnosis. The complications that result from TBI, for instance, impaired cognition and memory, are often not initially “visible;” therefore, public awareness is limited about cognitive impairments (Faul et al. 2010). While education regarding traumatic brain injuries for parents and support systems are adequate at best, traumatic brain injuries continue to be a widespread worldwide epidemic (Moore et al. 2006).

Distinguishable differences between mild traumatic brain injury and moderate/severe traumatic brain injury are based on the duration a person is unconscious and the length of post-traumatic amnesia. Typically, children with mild TBI experience at most 30 min of loss of consciousness and no post-traumatic amnesia to a day after the accident (Rabinowitz and Levin 2014). Children with moderate to severe TBI, on the other hand, may lose consciousness for over 30 min and experience over 24 h of post-traumatic amnesia (Rabinowitz and Levin 2014). The relationship between TBI severity and the effect of long-term cognitive impairment has been shown to be linear, based on the duration of loss of consciousness (Rabinowitz and Levin 2014). About 80–90% of the children who have had a head injury sustain at least a mild TBI (Taylor et al. 2008).

The neuropsychological assessment of psychological and behavioral functions of the brain uses objective measures to determine true cognitive and behavioral abilities based on standardized norms (Vanderploeg 2014). The assessment process raises some questions that should be addressed. Assessment is beneficial in understanding the brain-behavior functionality, yet; in some cases, the currently available short screening instruments are not necessarily sensitive to brain impairment as much as a comprehensive neuropsychological battery (Vanderploeg 2014). Threats to validity of some of the assessments also come into question. First, participant effort level is always a factor that may contribute to the patient’s test performance. Secondly, an inconsistency among score on measures of similar abilities should be taken with caution due to the multitude of variables such as motivation and innate skills before the injury. Premorbid intelligence and cognitive strengths and weakness are typically not extensively assessed before a TBI. Therefore, it becomes another variable that needs to be considered when evaluating post-TBI. Nevertheless, traditional neuropsychological testing, time and time again, has been shown to be largely dependable and accurate when assessing concussions (Echemendia et al. 2013). Neuropsychological assessment allows neuropsychologists, parents, and educators to understand and establish specific information regarding neurocognitive and neurobehavioral deficits and, in turn, help tailor intervention to assist a student’s educational needs (Vanderploeg 2014).

A clinical interview is an essential aspect of neuropsychological assessment and is vital to creating a detailed holistic approach to evaluating a child with a traumatic brain injury (Prince and Bruhns 2017). As noted in Table 1, clinical interviews review the presenting condition, associated symptoms, premorbid functioning, and relevant patient history (Prince and Bruhns 2017). History may include psychosocial history, school, developmental and behavioral observations, and cultural variables (Johnson et al. 2011). The interview may also include additional information about the child from the parents and educators (Prince and Bruhns 2017). Clinical interviews coupled with neuropsychological assessment allow an integrated evaluation and comprehensive view of the etiology of the child’s TBI at the present moment and help create recommendations for treatment (Prince and Bruhns 2017). This holistic approach for evaluating children with traumatic brain injury allows for a unique profile for each child to be created and enables one to develop to specific treatments or suggestions to assist the child for future success (Prince and Bruhns 2017). The value of neuropsychological assessment provides knowledge and insight into present and likely long-term neurocognitive deficits in children with traumatic brain injury (Table 1).
Table 1

Areas evaluated in clinical interviews and domains evaluated in assessment

Areas assessed in clinical interview for children

Testing battery assessment domains for children

Presenting condition and associated symptoms

Intellectual functioning

Premorbid functioning

Memory and learning

Social history

Information processing

Educational history

Attention

Behavioral changes

Executive functioning

Behavioral observations

Premorbid abilities

insight from parents and educators

Emotional and behavioral symptoms

Cultural variables

Adaptive functioning

 

Academic functioning

 

Processing speed

Assistive technology devices are designed to improve the functional capabilities of individuals whose disabilities can limit their active participation in daily activities and education. Devices for children with various disabilities vary from simple tools and adaptations such as pencil grips and slant boards to sophisticated apps and computerized devices. Broadly defined, AT could refer to very familiar, basic devices such as graphic organizers, visual schedules, and highlighted notes to assist individuals with memory, organization, and cognitive needs. Simple and low-cost devices such as magnifying lenses and talking wristwatches can promote independence and improve the individual’s quality of life. Technologies requiring or supporting interaction with a person or information, such as voice output communication devices, telecommunication technologies, and adapted software are also essential resources (Lancioni et al. 2007) as are modified keyboards and switches for access to computers, toys, and everyday appliance use.

Assistive technology is a tool that is used to enhance an individual’s strengths and use those strengths as compensatory strategies to assist in overcoming numerous types of disabilities (Johnson et al. 1997). The goal of assistive technology is to increase, maintain, or improve functional capabilities for individuals with sustained traumatic brain injury deficits (Leopold et al. 2015). By incorporating assistive technologies as a tool into a child’s daily routine, one can positively affect the way a child interacts with their environment and help improve task effectiveness (Federici and Scherer 2012). Many assistive technologies are geared towards cognitive domain-specific deficits a child with traumatic brain injury may struggle with (Liea and Paaske 2013). Neuropsychological testing, which can be used for determining an individuals’ unique cognitive profile and then pairing that with the appropriate assistive technology, will be instrumentally beneficial for the academic success of children in the short term and long term.

Method

With this in mind, the purpose of this paper is to explore and review current research on the school-based needs of TBI youth and the application and use of assistive technology as a supportive strategy. Specifically, the impact of assistive technology on school performance and learning will be discussed in several domains including medical and neurological symptoms, cognitive symptoms, attention, language, emotional and behavioral symptoms, anxiety, depression, executive functioning, and academic achievement and issues regarding assessment and the instruction of students with traumatic brain injury. The article will address relevant assistive technology-based interventions as compensatory strategies for long-term cognitive difficulties that may arise after sustaining a mild traumatic brain injury and how objective neuropsychological testing can be influential in documenting these long-standing cognitive impairments and aid in the determination of what assistive technology will best help. Our objective is to provide cognitive domain-specific assistive technologies that are currently available to aid in the school-based population and explore future research into the benefits of assistive technologies.

The aim of this manuscript is not an exhaustive literature review of traumatic brain injury in school-based populations; instead, it is an overview of recent and relevant literature in these domains to aid in identifying assistive technologies for a school-based population. Our objective is to identify several cognitive-based functional consequences of traumatic brain injury and their effects on school performance and learning with the additional recent literature of assistive technologies of devices used and the outcomes of that device use. Relevant articles include those that explained the cognitive and functional changes children experience when sustaining a mild traumatic brain injury, the multiple approaches to evaluating children with traumatic brain injury, how traumatic brain injury effects students from an educational standpoint, how neuropsychological testing can be involved in determining domain-specific deficits, and assistive technologies used with individuals with complex cognitive deficits.

Results

As mentioned previously, symptoms associated with a traumatic brain injury are varied depending on the severity of the trauma, length of unconsciousness, and degree of post-traumatic amnesia (Centers for Disease Control and Prevention 1999). Observable characteristics of a TBI after the incident may include complaints of a headache, acute and persistent dizziness, changes in sleep patterns, notable fatigue, auditory processing deficits, and deficits in visual tracking and visual attention (Arciniegas et al. 2005). Many of these somatic symptoms will subside after a few weeks or days after the accident. However, not all of these symptoms will diminish, and they may result in long-term cognitive impairments (Arciniegas et al. 2005). Over half of children with a TBI or a concussion from sports injuries struggle with impairment of oculomotor control and impairments of the vestibular system (Broglio et al. 2015). Impairments in oculomotor control may contribute to blurred vision, diplopia, difficulty reading, and issues with visual scanning (Broglio et al. 2015). Impairments to the vestibular system also play a role in hindering visual and spatial clear functioning, balance, and muscle reactions of the head and body for balance. Prolonged feelings of dizziness have been shown to be a precursor to impairments of the vestibular system (Broglio et al. 2015).

Brains of children and adolescents are incredibly malleable and are continually developing at an exponential rate throughout their young lives. Children are much more neurologically vulnerable if they have a TBI; even mild forms of traumatic brain injuries will produce long-term cognitive consequences (Ylvisaker et al. 2001). Years after a traumatic brain injury, many children will often display cognitive impairments and difficulties achieving developmental milestones (Savage 2012). While highly varied, some common cognitive problems for children with TBI include memory impairment, attention deficit, slowed processing speed, impaired executive function, word-finding slowness, behavioral disinhibition, and emotional lability (Wozniak et al. 2007) (see Tables 1 and 2).
Table 2

Difficulties that may be experienced by children and adolescents with TBI and examples of relevant supports from everyday specialized technologies

ICF mental functions—specific

Examples of behavioral observations

Examples of what may be difficult

Examples of assistive technologies (simple to complex) including apps*

(Note: many fits into multiple categories)

Attention (b140)

Specific mental functions of focusing on an external stimulus or internal experience for the required period.

Will not focus or concentrate, distractible, cannot easily shift attention or continually shifts attention

Organizing step-by-step, performing a task to completion

General alarms, white noise machines, personal FM systems (to amplify and focus sound), noise-canceling headsets, ChatterBlocker [http://chatterblocker.com], The Listening Program [http://www.thelisteningprogram.com], Endeavor 3 [https://www.ablelinktech.com/index.php?id=19]

Memory (b144)

Specific mental functions of registering and storing information and retrieving it as needed.

Misses appointments, cannot locate items, forgets to take medication

Remembering things presented visually (right hemisphere injury) or verbally (left hemisphere injury)

Voice recorders; voice recorder software for iPod Touch, Windows mobile, or Android; cue cards; colored index cards and Post-it notes; Google Calendar with SMS reminders sent to a cell phone; calvetica calendar for iPhone [calvetica.com], vibrating and talking alarm watches [ForgettingThePill.com], WatchMinder 2 [http://watchminder.com]; cueing devices such as Voice Cue [https://www.enablemart.com/attainment-voicecue], Invisible Clock [http://www.invisibleclock.com]; Endeavor 3 [https://www.ablelinktech.com/index.php?id=19], Best Intentions and Memory Works for Names & Faces [http://TheMemoryWorks.com], Personal planning apps to help build and manage schedules, [www.cognitopia.com]. See also technologies for “Higher-level cognitive functions (b164)”

Psychomotor (b147)

Specific mental functions of control over both motor and psychological events at the body level.

Agitation and restlessness, poor eye and hand coordination, slow speech, frequent and inappropriate gestures such as hand-wringing

Participating in social situations and conversations with peers

Snoezelen Multi-Sensory Environment [http://www.snoezeleninfo.com]; one-switch and free computer games[http://www.oneswitch.org.uk], other computer games appropriate for persons with cognitive disabilities [www.nanogames.com]

Emotional (b152)

Specific mental functions related to the feeling and affective components of the processes of the mind.

Mood swings, temper outbursts, anxiety attacks

Socially expected and appropriate behaviors have “meltdowns.”

Noise-canceling headphones, soft music players, alternative lights, and vests that apply deep pressure. Snoezelen Multi-Sensory Environment [http://www.snoezeleninfo.com]

Perceptual (b156)

Specific mental functions of recognizing and interpreting sensory stimuli.

Inability to discriminate sounds, colors, shapes, smells, tastes, textures

Identify items in a grocery store, recognizing objects, faces and words; recognizing social cues (facial expressions, a tone of voice)

Color overlays, bar magnifiers, labels on objects, multi-sensory presentation of information; reduction of sensory load (e.g., using text chat for communication); scanning pens like Quicktionary and LiveScribe pen [http://www.livescribe.com/en-us], ZoomText [https://www.zoomtext.com/zoomtext11]

Thought (b160)

Specific mental functions related to the ideational component of the mind.

Incoherent thoughts and delusions, illogical thinking

A sequence of tasks that require logic and planning, following through with a plan.

Endeavor 3 [https://www.ablelinktech.com/index.php?id=19]

Higher-level cognitive functions (b164)

Specific mental functions especially dependent on the frontal lobes of the brain, including complex goal-directed behaviors such as decision-making, abstract thinking, planning, and carrying out plans, mental flexibility, and deciding which behaviors are appropriate under what circumstances; often called executive functions.

Poor decision-making, stubbornness and fixation on an idea, poor insight into ones’ behavior, difficulty with novel situations, slow processing speed, rigid thinking, concrete interpretation, perfectionism, focus on the wrong details, difficulty with “if…then” thinking, overloaded easily

Time management, insight and judgment, cognitive flexibility, conceptual and abstract thinking

Technologies to maintain and alert user of daily schedule and routines such as BrainAid [http://www.brainaid.com], Picture Planner [http://www.cognitopia.com]

- - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Endeavor 3 [https://www.ablelinktech.com/index.php?id=19]

Language (b167)

Specific mental functions of recognizing and using signs, symbols and other components of a language.

Expression and word-finding, comprehension of written or spoken language, repetitive or perseverative in conversations, gives odd verbal responses

Producing meaningful messages and communications, correctly interpreting what others are saying

Allows users to input into a computer without using a keyboard; speech to text software (for example, Dragon Naturally Speaking); WordQ; reading assistance solutions (e-book readers, text-to-speech devices)) such as Kindle, Nook; adaptations for web accessibility such as WEBADAPT2ME, communication products such as PRIO [http://www.prentrom.com], Chat Fusion [http://www.saltillo.com]; Minspeak [http://minspeak.com/],

Proloquo2go [http://www.proloquo2go.com], DynaVox [http://www.dynavoxtech.com]

Calculation (b172)

Specific mental functions of determination, approximation, and manipulation of mathematical symbols and processes.

Problems counting money, learning math

Managing lunch money, an allowance, mastering math lessons

The Talking Checkbook [http://www.premierathome.com/products/TalkingCheckbook-features.php]

Sequencing complex movements (b176)

Specific mental functions of sequencing and coordinating complex, purposeful movements.

Cannot organize one’s grooming and dressing.

Doing things in the right order and completely

Endeavor 3 [https://www.ablelinktech.com/index.php?id=19]

Experience of self and time (b180)

Specific mental functions related to the awareness of one’s identity, body, position in the reality of one’s environment and of time.

An altered view of one’s size and weight, body schema, proprioception, kinesthesia.

Correct identification of body parts, attention to tasks, appropriate selection, and use of tools.

Children’s yoga, tai chi, balance boards, virtual reality games and Wii therapy games such as tennis or bowling [http://www.nintendo.com/games].

Many of these cognitive impairments, as mentioned previously, will impact a child with traumatic brain injury for the long term. A study by Hoofien et al. (2001) showed how children who sustain TBI performed on several cognitive assessments 10–15 years after the traumatic brain injury. Results indicated that individuals had notable deficits in dexterity, short-term memory, motor responses, psychomotor slowness, and difficulty in verbal learning, compared to individuals of the same age who had never had a traumatic brain injury (Hoofien et al. 2001). A study by Taylor et al. (2008) demonstrated that children with mild to severe traumatic brain injury had a lower general cognitive ability, which included tests in memory, spatial reasoning, and executive function. Verbal impairments and pragmatic language scores also showed significant differences between children with traumatic brain injuries and children who did not have TBI (Taylor et al. 2008). The study demonstrated that children with TBI scored lower on scales that measured early achievement or academic readiness skills for school compared to children their age without a traumatic brain injury (Taylor et al. 2008). In general, the variety of cognitive impairments children have due to a traumatic brain injury impacts spatial reasoning, short-term memory, dynamics of language, and overall intelligence (Taylor et al. 2008). Poor adaptive functioning influences social skills, as well as practical daily living skills such as personal hygiene and dressing (Rabinowitz and Levin 2014).

Attention

While a majority of children who have had a severe brain injury recover fundamental aspects of attentive behavior, many higher-level attention deficits will persist in the long term (Mateer et al. 1996). Attention and memory are critical cognitive functions that are needed for successful functioning in daily living and the child’s academic setting (Mateer et al. 1996). Often, children with TBI have problems with maintenance and duration of attention, which in the past has been characteristically linked to ADHD (Mateer et al. 1996). Slowed processing speed has been characteristic of limiting the capacity of attention in children as well (Mateer et al. 1996). A child with traumatic brain injury can have a difficult time sustaining attention to a directed task for as little as minutes or seconds (Mateer et al. 1996). The lack of sustained attention will dramatically alter the accuracy of performance over short periods of time (Mateer et al. 1996). Furthermore, children will also have an impaired mental control. Therefore, their ability to switch and maintain attention between multiple tasks will also be impaired (Mateer et al. 1996).

A longitudinal study by Yeates et al. (2005) examined the long-term attention problems found in children with traumatic brain injury across 10 years. They found that children with severe TBI displayed deficits in cognitive and behavioral aspects of attention compared to an individual with an orthopedic injury. Additionally, they saw that 20% of the children with TBI had behavioral and cognitive deficits that were consistent with a subtype of ADHD (Yeates et al. 2005). This is in line with previous research that found TBI in children with cognitive deficits in attention has also been linked to executive function deficits and increased behavioral symptoms of attention problems (Yeates et al. 2005).

Additionally, damage to the frontal lobes of the brain may lead to apparent disruption of cognitive functions such as top-down control of attention (Rabinowitz and Levin 2014). Notably, children with a traumatic brain injury may have the ability to recognize newly learned material, however; they have difficulty organizing that new information for successful encoding and later retrieval (Rabinowitz and Levin 2014). Therefore, learning new material in school will not bode well for children with mild and severe traumatic brain injury if they are not getting appropriate academic assistance. These attentional deficits become a substantial threat to success in academia for children.

TBI is characteristically linked to a decline in academic functioning and poor school performance, and attention, cognition, and memory have been common concerns among teachers and parents (Hawley 2004). While these cognitive deficits may be long term for children, assistive technology for cognition can be extremely beneficial in many domains in a child’s life, especially in a school-based domain where the deficits will be showcased. This has also been associated with the reduced level of early academic readiness in these children (Taylor et al. 2008). Examples of assistive technology that may be useful for children with difficulties with concentration, distractibility, or difficulty shifting attention between multiple stimuli may include general alarms, white noise machines, or personal frequency modulation (FM) systems. This and many other applications will support students in an academic setting.

Language

Language often negatively impacts students who have prolonged cognitive impairments following a traumatic brain injury. Children with a TBI have consistent language impairments that affect language ability anywhere from short sentences to pragmatic issues (Stockbridge and Newman 2017). In most cases, children with TBI have difficulty expressing and understanding language, difficulty with an auditory selection, and memory tasks involving language production (Stockbridge and Newman 2017). In a school setting, these language deficits can hinder academic performance and learning from reading and writing tasks, and impact communicating with teachers as well as classmates effectively. Assistive technology that may help in the domains of word-finding and comprehension difficulties involving applications such as Dragon Naturally Speaking with its speech to text software or reading assistance solutions such as e-book readers, or other communication products such as WEBADAPT2ME.

Executive Function

In an academic setting, executive function is an essential aspect of success in school performance. Many years after the injury, children with severe TBI have shown impairment in self-awareness, goal setting and planning, initiation, and self-monitoring (Mangeot et al. 2002). Research has shown that deficits in executive function have been demonstrated to limit a child’s ability to function psychosocially and in academic settings (Mangeot et al. 2002). Students who have impaired executive function tend to have poor academic success and have difficulties in emotional regulation and social interactions with their peers. Executive dysfunction threatens a child’s ability to engage as an independent individual with goal-oriented behavior in a successful manner (Rabinowitz and Levin 2014).

Emotional and Psychomotor Symptoms

Depending on the severity of the traumatic brain injury, there are characteristic behavioral and personality changes that should be considered as part of the post-TBI syndrome. Some of these changes may include increased anxiety, irritability, emotional lability, insomnia, depression, fatigue, and apathy (Wortzel and Arciniegas 2014). Several psychiatric conditions also have been associated with mild traumatic brain injury, including affective disorder and combat-stress spectrum disorders (Fann et al. 2004). Other behavioral issues that are linked to children with traumatic brain injury include inattention, emotional lability, and instances of disinhibition (Mangeot et al. 2002). Additionally, many children with traumatic brain injuries will sustain long-term deficits in executive functioning. This will often lead to behavioral symptoms such as a lack of social tact, impulsivities in speech and behavior, and a lack of empathy (Gioia et al. 2000). Many children in school settings have been reported as “difficult” meaning that the children will often be disruptive, show a lack of cooperation with peers, and sometimes act aggressively (Hawley 2004).

Anxiety and Depression

It is very common for an adolescent with TBI to have comorbidity for anxiety and depression. Adolescents are twice as likely to be diagnosed with an anxiety disorder or post-traumatic stress disorder following a traumatic brain injury compared to those who do not have a TBI (Osborn et al. 2016). Empirical evidence demonstrates that people with a mild traumatic brain injury have a higher risk of developing anxiety disorders (Moore et al. 2006). Osborne-Crowley et al. (2016) performed a longitudinal study that looked at a random population of individuals who had a self-reported traumatic brain injury. Through a series of three waves each 4 years apart, surveys were administered measuring sociodemographics, TBI presence, and ratings of anxiety and depression. When controlling for demographic variables, the results indicated that younger adults with sustained traumatic brain injuries were more likely to experience clinically high levels of anxiety compared to their non-TBI counterparts (Osborn et al. 2016). The study also found that anxiety had high comorbidity with depression. Notably, Osborn et al. demonstrated that the relationship between emotional symptoms like anxiety and depression were reduced when accounting for variables such as health and psychosocial variables.

Social/Behavioral Problems

Given the significant developmental impact of social skills in childhood, cognitive deficits from a traumatic brain injury can affect a child’s quality of life (Yeates et al. 2004). For example, impairments in executive function about social information processing may be a predictor of impaired social skills for children with TBI (Yeates et al. 2004). Executive dysfunction is prevalent in children who have sustained a traumatic brain injury and can be very environmentally sensitive (Gioia et al. 2000). Children who are not attending school or only attending part-time to promote prolonged cognitive rest may have exacerbated symptoms or negative mental health problems (Broglio et al. 2015). Not attending school can create a highly anxious environment for children for a variety of reasons. Some children may feel burdened and concerned that they will not perform as well as they would like to. Many children with traumatic brain injury will often fall further behind their peers socially as well as educationally. A study by Janusz et al. (2002) demonstrated that children who sustained a severe TBI were less developmentally advanced in their social problem-solving skills and these skills were related to social and academic adaptive functioning and outcomes. Because of these cognitive deficits, children will have a difficult time interacting and socializing with other children which may then lead to social deprivation.

Additionally, some children who sustain a traumatic brain injury cannot initiate activities or conversations (Rabinowitz and Levin 2014). The lack of initiation and apathy can also be linked to further social withdrawal from peers (Rabinowitz and Levin 2014). They may have issues with conversation initiation and verbal commands, and a poor self-awareness that may create issues with holding conversations with peers (Janusz et al. 2002). Additionally, children who have persistent disabilities from their traumatic brain injury are often subjected to further discrimination and social exclusion (Borg et al. 2015). Previous research by Hawley has shown a significant relationship between social deprivation and behavioral problems (2004). Many of those behavioral problems consistently included maladaptive behaviors in the classroom like being rude to teachers and students, disruptive in class (sometimes physically), or withdrawn altogether (Hawley 2004). These behavioral problems often led to the suspension or permanent exclusion from school (Hawley 2004).

Assistive technology that can be considered in the domain related to feelings and the practical components of the processes of the mind may include noise-canceling headphones or soft music players to help in cases of a child having an emotional “meltdown” and helping a child calm down. These examples of high- and low-tech assistive technologies will be useful and easy to integrate into the school environment.

Academic Achievement

Adolescents who have suffered a traumatic brain injury or a concussion will experience the many mental, physical, behavioral, and social changes that are associated with the injury that can threaten their ability to learn and academically succeed (Broglio et al. 2015). Children with mild traumatic brain injuries do not necessarily show signs of being incapacitated, and thus, the expectation is that these children will perform as they would have before the injury. This typically is not the case. Almost half of the children who have ever had a traumatic brain injury perform below their average grade level (Hawley 2004). In many cases, academic achievement problems do not arise until a year or more after the injury (Clark 1996). When academic concerns surface later in a child’s life, educators typically do not attribute these changes to the injury (Clark 1996). As mentioned previously, there are many academic achievement risk factors for children who have persistent post-concussion or TBI symptoms. This may include malingering, the co-occurrence of psychiatric disorders, and difficulty in school (Statements 2009). It is suggested that students may benefit from reduced academic workloads because it allows for significant symptoms to recover. If children return to school while symptomatic, it may cause these symptoms to worsen, resulting in a decline in academic performance (Broglio et al. 2015).

More often than not, adolescents who have sustained a TBI feel increased stressors when returning to school which negatively affects the way they properly engage in coping mechanisms post injury (Broglio et al. 2015). Some children may develop behavioral problems or anxiety because they have difficulties keeping up with school and assignments due to their cognitive weaknesses (Hawley 2004). School students who already place academic achievement as a high priority may experience an increased sense of anxiety and burden that they cannot return to school to their full cognitive capacity (Broglio et al. 2015). To combat these issues as well as avoid exacerbating somatic symptoms, implementation of educational management is critical for academic achievement (Broglio et al. 2015). Academic management is a valuable tool to improve academic achievement for children with traumatic brain injury through the use of assistive technology (Borg et al. 2015).

Discussion

Traumatic brain injury can manifest in numerous ways and will result in structural brain damage. The variability of the damage affects recovery in the short term and long term. The body of research presents that while short-term deficits may subside, in many cases, there are long-term cognitive consequences from a traumatic brain injury that affects the trajectory of an adolescent’s life and academic achievement in the long term. Several cognitive impairments may impact a child who sustained a TBI, such as attention, memory, psychomotor skills, language, executive function, and emotions and behavior. The articles discussed demonstrated these numerous cognitive impacts in several comparable populations to those children with mild traumatic brain injuries.

The lack of public education and knowledge regarding prevalence rates of traumatic brain injury worldwide should steer future research for additional exploration of the long-term cognitive deficits children have when sustaining a traumatic brain injury. The literature and suggestions used for this review should propose future research on the long-term cognitive deficits for children with mild traumatic brain injury. As mentioned previously, there is much more research about the short-term cognitive deficits of a TBI than for the long term. This will allow the conversation to continue and provide education to the general public as well as educators of the effects mild traumatic brain injuries have on academic achievement. The current research demonstrates the importance of neuropsychological evaluations in determining what cognitive domains are affected and how the appropriate assistive technology can be used in each case.

According to Pisano (2002), a practicing school psychologist and AT coordinator, and Zapf et al. (2016), the primary reasons for a poor match of student and technology are (1) lack of knowledge of use on the part of the student, teachers, and parent and (2) the student experiencing the AT as frustrating and not helpful. As a solution, Pisano recommends an assistive technology and education model that includes student identification, assessment, training, implementation, monitoring, and integration of services. Fundamental questions he lists are as follows: how were the student’s strengths, weaknesses, and affinities determined—based on what assessments? How were the student, teacher, and parent involvement in the process? What had been tried in the past—worked and not worked?

Other researchers have written about similar findings (e.g., Korukonda 2005). Thus, a key factor contributing to the abandonment or discontinued use of AT for both adults and children is an inadequate assessment of the user’s preferences, needs, and predisposition to use the AT. Hence, the importance and involvement of neuropsychological assessment in assisting students with determining what cognitive deficits they may be experiencing and exploring appropriate technologies to assist them.

Prevalence rates of educational disabilities for children who have a TBI typically are much higher than what is assumed by educational professionals and the general public (Ylvisaker et al. 2001). Roughly 20,000 children a year enter school with new persisting disabilities (Ylvisaker et al. 2001). Ylvisaker et al. addressed common themes that relate to identifying and educating students with a traumatic brain injury including knowing the incidence and prevalence of persistent disability, the importance of TBI assessment, educational disability, and finally, determining available interventions and supports for students with TBI (2001). There is a lack of educator preparation and knowledge about children with disabilities resulting from traumatic brain injuries, and the educational needs of students are not served as well as they could be (Ylvisaker et al. 2001). It is essential to consider the role that educators have in helping students to academically achieve their goals, these children. If educators lack the knowledge as to how traumatic brain injury can affect a student’s academic abilities, it will be challenging to help children be successful (Clark 1996).

New policy implementation regarding the safety and educational outreach of children with sports-related traumatic brain injuries has improved (Echemendia et al. 2013). The availability of technologies and support services for children with a traumatic brain injury in educational settings are a strong step forward in helping children achieve developmental milestones and perform at appropriate age levels in academic contexts. As mentioned previously, there are many cognitive obstacles that children with traumatic brain injury have to overcome because of their adverse impact on the school. A traumatic brain injury can significantly affect a child’s ability to live a productive life because of the long-term cognitive deficits (Leopold et al. 2015), especially if left undiagnosed or treated. Therefore, applying a variety of different assistive technologies can be used as compensatory strategies to help children perform at their appropriate developmental milestones (Lancioni and Singh 2014, Lancioni et al. 2017).

The application of assistive technologies to provide aid for students in a school setting has been implemented by the Assistive Technology Act of 2004 in the USA (Leopold et al. 2015). A study by Hendricks et al. addresses Project Career, an early intervention program geared towards students with any degree of traumatic brain injury, that helped college students graduate. The goal of Project Career is to develop, implement, and test technology to support cognitive and vocational rehabilitation for the long term. After a comprehensive matching person and technology (MPT) assessment, they can create a unique profile allowing Project Career to provide iPads to their clients and have specific applications installed to help each student with their unique cognitive and vocational needs—which can decrease the barriers students with a traumatic brain injury typically come across (Hendricks et al. 2015). The study demonstrated that over a 6-month period, students who were encouraged to engage in assistive technology strategies were more positive, independent, and social than those not participating in Project Career (Hendricks et al. 2015). Students stated that their overall experiences had improved with the use of technology and they obtained increased positive attitudes towards technology as a whole (Hendricks et al. 2015). Assistive technology is clearly shown to be beneficial for students who are transitioning from school to the workforce. This study demonstrates that unique cognitive needs were met for each student through the use of technology, and further, allowed for career enhancement following graduation (Nardone et al. 2015).

The interaction of several cognitive impairments is complex. Therefore, the use of neuropsychological testing to identify specific cognitive deficits will promote a determination of how technology can be used to assist children in schools. This reflects the idea of matching person and technology (MPT) and the assessment process needed to pair individuals to a form of assistive technology based on their unique needs (Scherer 2012; Zapf et al. 2016). This three-factor process includes determining personal characteristics of the child, the various environmental and contextual influences that include identifying specific cognitive needs, and the descriptions of the functions and particular features for the appropriate technology (Scherer 2012; Zapf et al. 2016). MPT allows for the use of assistive technologies to meet the functional needs of each traumatic brain injury (Leopold et al. 2015). MPT can easily fit with the neuropsychological testing and clinical interviewing. The examples of technologies range from simple to complex computerized devices and can be specialized or every day/mainstream products such as a wristwatch, iPad, or smartphone. Technologies supporting interaction with people or information (telecommunication technologies) are also valuable resources for individuals with cognitive disabilities, and they include telephones, pagers, and the Internet.

As shown in Table 2, low- and high-tech assistive devices and applications can assist children in a variety of different ways. One example is the program Livescribe which uses a pen to auto-record and sync handwritten notes for children who have difficulty with divided attention. ChatterBlocker is a software program that can also be used to support attention by minimizing the intelligibility of nearby social conversations and classroom auditory distractions. Other assistive devices to aid attention include voice-canceling headsets and white noise machines. Memory-specific aids that can be accessed on smartphones and tablets include Google Calendar, alarms, emails, and voice recorders. These aids can serve as reminders and prompts to assist with daily memory recall for students. For individuals with language difficulties, using voice command software built into writing programs such as Word has also aided students in writing assignments (Johnson and Harniss 2016). Dragon Naturally Speaking and WordQ are two specific software programs that assist with written language production. Dragon allows students to dictate documents through voice recognition, while WordQ provides focused spelling and grammar support. Additionally, for those students who have vision difficulties, assistance can be provided by software packages like ZoomText, which enlarges images on a screen (Johnson and Harniss 2016). Color overlays and tinted lenses are possible visual aids to assist students in minimizing the burden of glare and vision challenges. To support the emotional needs of students with TBI, several devices to consider include alternative lights, soft music players, noise-canceling headphones, deep pressure vests, and the Snoezelen Multi-Sensory Environments, which range from portable sensory devices to custom rooms and space designs. For students who require support with higher-level cognitive functions, parents and educators may consider different mobile apps to support the TBI students’ daily functioning. Several apps to consider include Brainaid, Picture Planner, and Endeavor 3. Collectively, these three apps provide support with daily scheduling and general reminders for common activities of daily living.

Technological aids can provide necessary support for students with TBI. Through new research, we now have robotic-assisted gait training (Schmartz et al. 2011) and play (Cruz et al. 2017; Lindsey and Lam 2017) and the use of smartphones to aid memory in children (Plackett et al. 2017). Assistive technologies are also used to help adolescents participate in integrated social and academic activities. To maximize the effectiveness of AT in the classroom setting, it is imperative that students be appropriately assessed and matched for relevant devices. This is best done through a thorough and comprehensive process that meets the child’s educational needs and does not limit the child’s potential to succeed due to limited awareness in educators, parents, and the general public about AT-specific devices and their value.

Future Directions

The use of assistive technology is a key resource for children with traumatic brain injury to help build compensatory strategies and increase the likelihood of living independent lives. It is important to realize that a simple device has as much value as a complex one for users who find the device has enhanced their functioning, independence, and quality of life. Strategies for optimizing the strengths and accommodating the needs of an individual with a cognitive disability are also essential supports. The growth of assistive technology as a discipline speaks to the need for increased and integrated multidisciplinary collaboration to allow AT to become more integral and central in how providers develop care plans and reports for children with traumatic brain injuries. While the involvement of assistive technologies in clinical practice and everyday life is not currently ubiquitous, it is essential to consider the value of assistive technologies by integrating them into neuropsychological assessment and in medical care. Assistive technology is quickly heading towards the direction of more downloadable applications and new specialized applications for accessible use. This, in turn, calls for more research on the effectiveness of these applications. While the efficacy of assistive technology continues to gain research interest, clinicians and possible users of AT maintain their optimistic expectations (De Joode et al. 2010).

As researchers continue to develop and understand the importance of the utilization of assistive technology, the current research anticipates that the use of assistive technology will become a significant benefit for children with traumatic brain injuries. As the integration of assistive technologies develops with medical care and research, the expansion of education around assistive technologies for providers, educators, and in schools needs to be encouraged. Further, as providers, educators, and parents become more educated about AT, their knowledge will serve to increase the accessibility of particular applications to aid in the successful treatment and support of children with traumatic brain injuries.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Amy Pacos Martinez
    • 1
  • Marcia J. Scherer
    • 2
  • Timea Tozser
    • 1
  1. 1.Department of Physical Medicine and RehabilitationUniversity of Rochester Medical CenterRochesterUSA
  2. 2.Institute for Matching Person and TechnologyWebsterUSA

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