UKABIF - Acquired brain injury: A guide for schools

Over 40,000 children and young people (CYP) experience an acquired brain injury (ABI) every year (NHS England, 2018). The majority return to school, and most need school to play a core role in supporting their rehabilitation. Despite this, many teachers and SENCOs know little about ABI, and schools frequently feel unprepared and ill-informed.

What is an ABI and how does it impact on education?

An ABI is an injury to the brain acquired after birth. It is a leading cause of death and disability and can follow accident/trauma, infection, illness, stroke, tumour or hypoxia. ABIs range from mild to severe, so the need for support ranges from simple adaptations to long-term support or a change in school. Outcomes can impact across all domains; from behaviour and emotions to cognitive, physical and sensory difficulties. Many CYP also experience extreme fatigue; and changes in their social skills and communication.

After an ABI, families need to adjust to a ‘new normal’ and returning to education is frequently very difficult. School is both familiar, yet completely different. Childhood ABI can have a significant impact on attendance (Leo et al., 2017), integration, engagement and achievement (Sariaslan et al, 2016). It is also reported that fewer CYP with ABI go on to further study or employment and many report to feeling socially isolated.

The nature of ABI means difficulties may be hidden, cumulative and evolving (e.g. Anderson et al., 2011). New needs can emerge as the brain develops; an 8-year-old in primary school might present very differently to the same child aged 12 in a busy secondary. Emerging difficulties in executive function, attention and behaviour are common, but also represent changes frequently misinterpreted by school, which may not be linked back to the earlier injury.

So presumably teachers know all about childhood ABI?

Research suggests UK teachers rarely receive training about ABI and indicates the understanding of brain injury amongst educators is poor (Linden et al., 2013; Ettel et al., 2016). SENCOs report to have little knowledge, often holding misconceptions about ABI, and claiming to have had little training (Howe and Ball, 2017; Bennett, Woolf & Thomas, 2019). A recent study of SENCOs in Nottinghamshire found a significant gap in training for the majority of participants. Those involved suggested a training programme on childhood ABI to cover; Causes and effects; How ABI impacts on development, classroom strategies, and signposting to resources.

What is the impact of this knowledge gap?

ABI is not mentioned within the Special Educational Needs Code of Practice or addressed in teacher training programmes. Where ABI is not identified or is misinterpreted, CYP are at increased risk of exclusion, disengagement, and failure to meet their potential. YP with a history of ABI are over-represented in alternative provision, as well as the criminal justice system (Williams et al., 2010, Hughes et al., 2015).

As people leave hospital/treatment settings and return to their everyday activities they start to understand how changes in their abilities affects their functioning (Turner, Fleming, Ownsworth & Cornwell, 2011). Because so much of a CYP’s rehabilitation after brain injury effectively happens at school, a lack of understanding of ABI has a significant impact on outcomes.

Teachers also report that information about a CYP’s ABI is “often not transferred between classes and schools” (Hawley et al., 2002). Therefore, the CYP may get lost in the system without support. SENCOs in Nottinghamshire (Bennett et al., 2019) reported they found it hard to obtain funding for a child with ABI due to their limited understanding of the impact and ongoing needs, and the lack of awareness of ABI in education and Local Education Authority systems. Families and CYP often highlight the importance of school staff and peers in understanding their needs and being able to respond to them. This is a challenge to an education system that isn’t always resourced to meet a sudden change in needs.

Schools as rehab settings

Despite the challenges, school is arguably the primary provider of rehabilitation. A review of YP’s goals in community-based rehabilitation highlighted the importance of activity and participation, with the majority of YP giving the return, reintegration and sense of belonging to school, as their primary focus (McCarron et al., 2019).  

Schools provide the optimal environment for supporting everyday rehabilitation goals and there is a lot they can do to help. Firstly supporting the CYP to be held in mind during any hospital admission or time away from school can reassure them and help maintain their sense of belonging.

Effective transition to school has been linked to an increased likelihood of young people staying in education (Todis & Glang, 2008) which, in turn, is likely to positively influence future outcomes and quality of life.  An effective transition can be facilitated through attending hospital discharge planning meetings; liaising with professionals and the family and YP, who will be able to answer any questions about ongoing needs.

The impact of cognitive fatigue on learning and engagement, can be profound if not managed effectively. It is crucial schools develop a transition plan/timetable that considers the cognitive demands of activities and allows for periods of rest. Processing information can be an issue and giving extra time is particularly important. It can be helpful to reduce non-essential tasks to allow a focus on core information. 

When developing intervention plans effectiveness must be monitored over time and handovers managed to ensure needs and goals are supported as they change or emerge over time.

Teachers and SENCOs can learn more about ABI via these resources:

• The Child Brain Injury Trust: www.childbraininjurytrust.org.uk/ resources and training for teachers including a joint publication with NASEN for teaching professionals:  https://childbraininjurytrust.org.uk/wp-content/uploads/2018/11/ABI-Mini-Guide.pdf
• The Children’s Trust: https://www.braininjuryhub.co.uk/information-library/return-to-education 
• The Stroke Association: https://www.stroke.org.uk/resources/supporting-children-after-stroke-toolkit-teachers-and-childcare-professionals
• The Brain Tumour Charity: https://www.thebraintumourcharity.org/get-support/children-and-families-service/education-resources/
• A teacher’s guide for CYPs with brain tumours: https://www.cerebra.org.uk/wp-content/uploads/delightful-downloads/2018/09/Returning-to-school-2015-revised-InDesign.pdf 
• The Encephalitis Society: https://www.encephalitis.info/Pages/Category/encephalitis-in-children

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