Exploring Teaching and Learning Strategies for

Mainstream Post Primary Students who have

Suffered an Acquired Brain Injury and are
Currently in Rehabilitation

Paul Connaughton G00326742

Submitted for the Award of

Bachelor of Science (Hons) in Education

(Design Graphics and Construction)

to
Galway-Mayo Institute of Technology, Letterfrack

Research Supervisor: Pauline Logue Collins

Readers: Pauline Logue Collins & Susan Rogers

Programme: Bachelor of Science (Hons) in Education (Design Graphics and Construction)

Module Title: Dissertation

Date Submitted: 24/11/2017

PLAGIARISM DISCLAIMER

Student Name: Paul Connaughton

Student Number: G00326742

Programme: Bachelor of Science (Hons) in Education (Design

Graphics and Construction)

Year: 4th

Module: Dissertation

Assignment Title: Exploring teaching and learning strategies for mainstream post
primary students who have suffered an acquired brain injury and are
currently in rehabilitation.

Due Date: 23/03/2018

Additional Information:

I understand that plagiarism is a serious academic offence, and that GMIT deals with it in
accordance with the GMIT Policy on Plagiarism.

I have read and understood the GMIT Policy on Plagiarism and I agree to the requirements set out
therein in relation to plagiarism and referencing. I confirm that I have referenced and
acknowledged properly all sources used in preparation of this assignment. I understand that if I
plagiarise, or if I assist others in doing so, that I will be subject to investigation as outlined in the
GMIT Policy on Plagiarism.

I understand and agree that plagiarism detection software may be used on my assignment. I declare
that, except where appropriately referenced, this assignment is entirely my own work based on my
personal study and/or research. I further declare that I have not engaged the services of another to
either assist in, or complete this assignment.

Signed:______________________________________

Date:_____15/03/2018__________________________
TITLE
Exploring Teaching and Learning Strategies for Mainstream Post
Primary Students who have Suffered an Acquired Brain Injury and are
Currently in Rehabilitation

ABSTRACT
Acquired brain injury (ABI) is an umbrella term which includes a wide range of disabilities
which affect the brain, such as: traumatic brain injury, mild traumatic brain injury, concussion
and post-concussion syndrome. ABI impacts significantly on learning. Post primary children
who have sustained an ABI are at risk of suffering from physical, cognitive or behavioural
impairments post-injury. The transition from the hospitalisation to rehabilitation to school re-
integration impacts significantly on learning. Learners recovering from ABI, who are still
undergoing rehabilitation and are re-integrating into school, require specific learning
supports. The primary aim of this research is to explore teaching and learning strategies for
mainstream post primary students who have suffered ABI and who are currently reintegrating
into school, while continuing rehabilitation. The research methodology is a critical analysis of
current literature on ABI, with particular focus on the key sources: Journal of Neurology,
Neurosurgery & Psychiatry, Journal of Learning Disabilities and the Journal of
NeuroRehabilitation. The author examines such areas as: concussion, neuroplasticity,
memory, cognitive rehabilitation, learning implications, and school re-integration. The main
findings of this research are that: recovery from AIB is possible with the aid of neuroplasticty
and rehibilitation stratigies, time plays a significant role in the healing process, fluctuating
engagement and performance from the learner is to be expected and planned for, and
preferred learning styles post-injury require particular attention. The research recommends
two follow-on primary research studies: 1) a study on second level learners with ABI, who are
re-integrated into school, including perspectives of ABI affected students, their classroom
teachers and their Special Needs Assistants (SNAs), and 2) a study on the effectiveness of
preferred learning styles on second level learners with ABI. The intended output of both
studies would be a comprehensive training package on ABI teaching and learning strategies
for second level educators.

KEY WORDS
Acquired Brain Injury, Concussion, Neuroplasticity, Cognitive Rehabilitation and Development,
Teaching and Learning Strategies.

iii
INTRODUCTION

The World Health Organisation’s (WHO) definition of an acquired brain injury (ABI) is:

“(d)amage to the brain, which occurs after birth and is not related to a congenital or a
degenerative disease. These impairments may be temporary or permanent and cause
partial or functional disability or psychosocial maladjustment” (cited in Brian Injury
Society, 2017).

School going children who have sustained an ABI are at risk of suffering from physical,

cognitive or behavioural impairments post injury (Anderson, Brown, Newitt, & Hoile, 2011,

p. 176). Once discharged, families want to know what lies ahead for their child; some of their

main concerns tend to be: the transition from the hospital to home, social and sporting

implications, and the return to the school environment (Aitken, Mele, & Barrett, 2004).

Schooling is an important part of one’s life, not just in terms of its educational benefits, but

also in terms of the social aspects it offers, through sports, clubs, societies and general social

interaction (Catalano, Oesterle, Fleming, & Hawkins, 2004, pp. 252-261). So, how and when

should students return to school following such an injury? How is the transition managed? Do

they require specific learning supports? Can they go directly into a mainstream classroom with

an expectation of learning success? Leo, Macey & Barzi (2017, p. 1) suggest that “(i)nterviews

with children returning to school after ABI raise many issues, including social isolation, missed

schoolwork, difficulties adjusting to physical and cognitive changes, and the support provided

by schools”.

ABI’s are becoming more and more common and yet they appear to be an overlooked learning

disability during teacher education programmes. This would suggest that specific teaching and

learning strategies are needed for an ABI child re-integrating into post primary education.

1
Annually 1.7 million people experience a traumatic brain injury (TBI) (Faul, Xu, Wald, &

Coronado, 2010) and over 795,000 people sustained a stroke in the United States alone (Roger,

et al., 2012). Together that’s nearly 2.5 million people who obtain an ABI annually in the US.

The yearly incident rate of TBI between 2002 and 2006 was 579 people per 100,000 (Faul, Xu,

Wald, & Coronado, 2010). During the same timeframe the yearly incident rate for stroke was

189 people per 100,000 based on a standardised sampling schema (Kleindorfer, et al., 2010).

To put that into perspective, the annual incident rate for Acquired brain injury (TBI and stroke,

not taking into consideration undiagnosed mTBI’s and Concussions) is 768 persons per

100,000 compared to all forms of cancer combined at 463 persons per 100,000 (Howlader, et

al., 2012). That is a frightening figure but it could be much higher if all injuries were diagnosed.

“Furthermore, numbers of contact sport athletes diagnosed as having their first concussion

report that they have experienced similar past episodes that were not diagnosed” (Mayers,

2008).

The aim of this dissertation is to explore teaching and learning strategies for mainstream, post

primary students who have suffered an ABI and are currently in rehabilitation. Objectives

include:

 To describe in depth what is meant by the term ABI, including the elements of traumatic
brain injury (TBI), concussion and post-concussion syndrome;

 To assess rehabilitation strategies relating to neuroplasticity, memory, learning, and

cognitive rehabilitation;

 To identify effective teaching and learning methodologies that can be utilised to

accommodate an ABI student reintegrating into mainstream education.

Methodologically, this is a secondary research literature analysis study. The scope of this

dissertation is to clarify what ABI is, to analyse how students’ learning capabilities may alter

due to ABI’s and to determine best practices for teachers to use while teaching said students.

2
Limitations of this research include that it focuses on their recovery within the classroom alone,

and that it does not incorporate any original primary research.

The structure of this article is as follows: firstly, the author will clarify the term ABI, investigate

causes and types, and examine ‘concussion’ in some depth, secondly, the author will explore

established rehabilitation strategies, with particular focus on neuroplasticity, and, finally, the

author will explore effective teaching and learning strategies for the ABI student who is re-

integrating into the mainstream classroom.

ACQUIRED BRAIN INJURY: AN UMBRELLA TERM

ABI is an umbrella term which includes a wide range of disabilities which affect the brain after

birth such as; traumatic brain injury (TBI), mild traumatic brain injury (mTBI), concussion or

post-concussion syndrome, to mention a few (Ciuffreda, K.J. and Kapoor, N, 2012, p. 95). In

this section I will clarify the meaning of these four selected medical terms, from a biological

perspective, and discuss implications for learning.

While all four of these terms are very similar, they are defined differently. TBI and mTBI are

very similar with the main difference being the length of time, if any, the person losses

consciousness. A TBI can be classified as mild if the loss of “consciousness and/or confusion

and disorientation is shorter than 30 minutes. While MRI and CAT scans are often normal, the

individual has cognitive problems such as headache, difficulty thinking, memory problems,

attention deficits, mood swings and frustration” (Traumatic Brain Injury, 2001). If the loss of

consciousness and/or confusion lasts longer than 30 minutes, the injury is considered a TBI.

Concussion and post-concussion syndrome are very similar; their symptoms overlap. However,

post-concussion syndrome is a complex disorder where the symptoms of concussion last for

weeks or months after the initial concussion itself (Mayo Clinic, 2018). It is not necessary to

3
lose consciousness to ascertain a concussion or post concussive syndrome. The Mayo Clinic

(2018) states that “(i)n fact, the risk of post-concussion syndrome doesn't appear to be

associated with the severity of the initial injury”.

Such injuries may have a substantial influence on one’s emotional state (Andersson, 2000) and

on a person’s cognitive and educational function (Anderson, et al., 2012). This is because the

limbic system and frontal lobe have been altered due to the injury (Limbic system injury, 2016).

(See Fig.1). An alteration is caused by pressure being added to the brain, through swelling, this

can be compared with hitting one’s arm off a surface; the tissue swells around the area. The

same thing occurs inside the brain, but with a slight difference. Volker (2017) points out that

when the tissue in the arm swells it presses against skin, which is a soft, stretchable material.

In contrast, in the head, when the brain swells it presses against the inside of the skull which

consists of curved bony ridges. (See Fig.2). When pressure is added to the brain forcing it into

these protrusion complications can occur (Lunnon, 2017, p. 34).

A very common form of head injury for the age group I am targeting is concussion, due to the

high number of sport related incidents. I will now discuss concussion and what happens when

you sustain a concussion.

4
Fig. 1 Areas of the Brain. Fig. 2 The Inside of the Skull

Giza et al (2013) defines concussion as a “clinical syndrome of biomechanically induced

alteration of brain function, typically affecting memory and orientation, which may involve

loss of consciousness”. Concussion is the most common type of Acquired Brain Injury

particularly for children and teenagers (Jennett, 1989, pp. 23-25). The neuropsychological

evidence surrounding the duration of altered cognitive function after ABI or concussion,

however, is inconclusive (Teasdale & Engberg, 1997). Bohnen and Jolles reported that

“cognitive deficits are maximal in the first week after injury and tend to resolve spontaneously

within three to four weeks in the majority of [mild head injury] cases,” (Bohnen & Jolles,

1992). In contrast, Teasdale and Engberg found that, some studies have shown no deficits

within the first few days post injury (Bohnen & Jolles, 1992; Newcombe, Rabbitt, & Briggs,

1994) while others have found deficits lasting months after the sustained injury (Hugenholtz,

Stuss, Stethem, & Richard, 1988).

There are many reasons for the variations in these finding such as, the severity of the injury, or

limited information regarding the person’s cognitive function prior to the acquired injury

(Teasdale & Engberg, 1997). Mayers (2008), for example, writes that “numbers of contact

sport athletes diagnosed as having their first concussion report that they have experienced

similar past episodes that were not diagnosed”. This suggests that Return to Play Protocol

(RTP) should be a minimum of 4 to 6 weeks to allow a more complete recovery and to prevent

re-injury (Guskiewicz, et al., 2003).

JAMMA’s study suggests that “players with a history of previous concussions are more likely

to have future concussive injuries than those with no history; 1 in 15 players with a concussion

may have additional concussions in the same playing season; and previous concussions may

be associated with slower recovery of neurological function” (Guskiewicz, et al., 2003). The

5
timeframe of rest post injury has been proven to be incredibly important for athletes to return

to the pitch but what about the academic side of their lives. JAMMA’s study was conducted

using 2905 football players from 25 US colleges. It examined these athletes progress in relation

to physical activity, excluding the academic side of their college lifestyle. Yet we are told that

to recover fully from a concussion or ABI, the injured party must refrain from physical and

mentally straining activity for a number of weeks depending on the severity of the injury

(Mayers, 2008). So how does a person suffering from an ABI or Post Concussive Syndrome

(PCS) know when it is “safe” to return to the classroom?

REHABILITATION STRATEGIES

MedicineNet (2017) defines rehabilitation as “The process of helping a person who has

suffered an illness or injury restore lost skills and so regain maximum self-sufficiency. For

example, rehabilitation work after a stroke may help the patient walk and speak clearly again”.

In 1992, the Brain Injury-Interdisciplinary Special Interest Group (BI-ISIG) of the American

Congress of rehabilitation Medicine Published rehabilitation guidelines for patients who had

suffered an ABI or stroke (Harley, et al., 1992). Although these guidelines set out standards of

care, “they have been criticized as being based more on expert opinion than on empirically

demonstrated effectiveness that might better quantify the degree of effectiveness of different

treatments” (Rohling, Faust, Beverly, & Demakis, 2009, p. 20). There are many different forms

of rehabilitation when it comes to brain injuries. For this dissertation I am going to focus on

four: Neuroplasticity, Spontaneous Recovery, Training-induced Recovery and Cognitive

Rehabilitation and Development.

NEUROPLASTICITY
Neuroplasticity is a term used for the brain’s ability to adapt, reorganise and change, these

changes happen in response to new learning, experience or following an injury (Oxford

6
Dictionary, N/A). Neuroplasticity is also known as brain plasticity or brain malleability.

(MedicineNet, 2016). Neuroplasticity forms new pathways and connections between brain

cells. Although neuroplasticity is taking place on a daily basis as our brains adapts to learn new

skills and overcome different situations, the process itself is complex and not yet fully

understood (Lunnon, 2017). We do know however, that neuroplasticity is significant for brain

injury recovery; Dr.Swathi Kiran says that “(b)rain plasticity is particularly important after a

brain injury, as the neurons in the brain are damaged after a brain injury, and depending on the

type of brain injury, plasticity may either include, repair of damaged brain regions or

reorganisation / rewiring of different parts of the brain” (Cashin-Barbutt, 2016). Therefore, it

has become the basis of many rehabilitation programs (Lunnon, 2017).

Neuroplasticity “allows the neurons (nerve cells) in the brain to compensate for injury and

disease and to adjust their activities in response to new situations or to changes in their

environment” (MedicineNet, 2016). To form new neural pathways to complete a needed

function, brain reorganisation must take place. A mechanism called “Axonal Sprouting” refers

to the process of undamaged axons growing new nerve endings to relink neurons whose links

were damaged or detached. Undamaged Axons can also sprout nerve endings to connect with

other undamaged nerve cells to create these new neural pathways (MedicineNet, 2016). For

example, if one hemisphere of the brain is damaged, the other hemisphere will take over some

of its functions to compensate for this damage. This compensation takes place by reorganising

and forming new connections of intact neurons (MedicineNet, 2016). For these neurons to

reconnect, they need to be stimulated through activity. This is where the importance of

rehabilitation comes into play; it is vital if one is to achieve the highest possible recovery after

a brain injury. Lunnon (2017, p.36) writes that “(t)here are limits to how much our brains can

recover … Neuroplasticity enables the brain to adapt to an injury but sometimes an area is so

extensively damaged that its ability to reorganise is not sufficient to regain the lost function”.

7
Neuroplasticity can contribute to impairments also if the rehabilitation process has not been

carried out correctly. For example, tinnitus is a condition which effects people who are deaf. It

is the continual ringing in their ears and is caused by the rewiring of neurons who long for

sound. It has been demonstrated that “for neurons to form beneficial connections, they must be

correctly stimulated” (MedicineNet, 2016).

The study of human brain plasticity has been carried out using non-invasive imaging methods.

This allows us to “measure the grey matter (neurons), white matter (axons) at a somewhat

coarse level. MRI and fMRI techniques provide snapshots and video of the brain in function,

and that allows us to capture changes in the brain that are interpreted as plasticity”

(MedicineNet, 2016). There are two stages in this type of recovery: stage one is spontaneous

recovery and stage two is training-induced recovery (Chen, Epstein, & Stern, 2010). Reyst

(n.d) states that, “(d)epending on the stage of recovery, different neural mechanisms are at work

to either initiate recovery strategies or in response to changes in experience in the form of

training or rehabilitation”. This two-stage model is described below in relation to a timeframe.

Fig. 1 Two Stage Model (Reyst, N/A)

STAGE ONE: SPONTANEOUS RECOVERY

Even without rehabilitation due to spontaneous recovery, Chen, Epstein and Stern (2010)

indicate that "there is resolution of injury and functional change in close time proximity after

8
injury which plateaus within three months for focal injury and six months for diffuse injury”

(Reyst, N/A). Three processes have been conceived within that timeframe to explain this early

spontaneous recovery after injury when specific rehabilitation has not been used (Dancause &

Nudo, 2011). They are: 1) diaschisis reversal, 2) changes in Kinematics and 3) cortical

reorganization.

Diaschisis is the diminishing of the inflammatory process, blood flow changes, metabolic

changes, edema, and neuronal excitability (Warraich & Kleim, 2010). Results from Diaschisis

reversal is improved function because previously disrupted areas of the brain have been

restored. Restoration is consequently a vital neural strategy after sustaining an injury. Reyst

(n.d.) argues that “(f)rom a purely neurobiological level, this may be thought of as the only true

level of recovery in the strictest sense of the word, in that the same brain circuits are facilitating

function post injury as they were pre injury”. Restoration occurs in both cognitive (e.g.

language and attention) and physical (e.g. motor movement) domains (Kleim J. , 2007).

The second feature of spontaneous recovery is in relation to changes in kinematic or movement

patterns where compensatory patterns are applied. The individual intrinsically begins to carry

out motor movements in a diverse way, resulting in improved motor function, sometimes in

completely different manners than previous. Reyst (n.d.) comments that “(w)hile these new

movements likely contribute to functional improvement, these compensatory strategies have

the potential to be maladaptive”.

The third feature of spontaneous recovery is in relation to the nervous system. The “nervous

system undergoes within-area and between-area reorganization or rewiring” (Reyst, N/A). For

example, Kerr, Cheng and Jones (2011) found that elements of neuroplasticity around the

infarct area after stroke, including cortical reorganization, neurogenesis, axonal sprouting,

dendritic plasticity, new blood vessel formation. Chen, Epstein and Stern (2010) outlined

9
neural shifts in allocation of brain functionalities due to injury during spontaneous recovery

timeframe. After a stroke occurs, in similar areas, the opposite side of the brain is needed to

carry out tasks so it adapts. Later during the spontaneous recovery timeframe, when the neuron

pathways have been reconnected, there is a shift back to the injured side to carry out these tasks

(Reyst, N/A). An example of this would be, if the left-side Broca’s area (language area) was

damaged, the right-sides counterpart would be required to carry out its functions for a period

of time until the injured side could finally carry out its functions again.

Another crucial alteration in brain function is the activation of learning networks in the early

stage, where plasticity occurs similarly to when the brain was developing as an infant. This

consist of motor control and task-learning networks (Chen, Epstein and Stern, 2010).

Cortical reorganization during spontaneous recovery is seen as a “compensatory as different

circuits or networks of neurons are utilized post injury than those utilized pre injury” (Reyst,

N/A). Although spontaneous recovery takes place without the need for rehabilitation, there is

definitely an opportunity for an overlap of trained induced recovery while spontaneous

recovery is also taking place, capitalizing on the rehabilitation process. It should be known that

the trained induced recovery must only begin once the patient is capable of preforming such

tasks post injury.

STAGE TWO: TRAINING-INDUCED RECOVERY

Training by means of rehabilitation can encourage plasticity after an injury, but it is not under

time constraints like spontaneous recovery processes which are (Chen, Epstein, & Stern, 2010).

Reyst (n.d.) comments that “(r)ecovery in this stage involves compensation, in that either new

brain areas or neural networks are enlisted to complete previous functions. Through the process

of training, neuroplasticity is induced”. Chen, Epstein and Stern (2010) noted that changes

which occur after an injury are the result of new patterns of activation which consist of

10
“plasticity in areas surrounding the damaged cortex, reorganization of existing networks or

recruitment of new cortical areas or networks” (Reyst, N/A).

Throughout training-induced recovery, areas which did not play a role in a particular function

pre-injury now contribute to functions post-injury (Kleim , 2011). Generally this is done by the

requitment of neural areas from the undamaged hemisphere. From a physical perspective, this

might consist of changes in motor maps where the non-injured hemispheres’ motor cortex can

be recuited to produce motor movement and function in an impaired limb which was controlled

by the injured motor cortex previouly to the head injury (Reyst, N/A). From a cognative

perspective, “neural recruitment may entail the enlistment of the right side homologue (similar)

to Broca’s area to improve language function if Broca’s area (left frontal lobe) is damaged”

(Reyst, N/A). Rehabilitation is used to encourage such changes which might include manual

therapy or completion of cognative based tasks while encorporating complex hand movements

in the opposite hemisphere which encourages a shift to the uninjured hemisphere.

Retraining consist of the training of the remaining brain areas, causing the reorganisation

within the cortex and compensation for lost function (Kleim , 2007). In the case of lost motor

function, if tissue is damaged which controlled finger movements for example, other cortical

tissue beside it can reorganise to control that lost movement.

COGNITIVE REHABILITATION AND DEVELOPMENT

Woolfolk (2008) defines the term “development in its most general psychological sense refers

to certain changes that occur in human beings between conception and death”. Development

takes place in a logical order. You must crawl before you walk and you must walk before you

can run. Woolfolk (Woolfolk, 2008)makes the point that “(t)heorists may disagree on exactly

what comes before what, but they all seem to find a relatively logical progression”. What about

the development of thinking and personality? A lot of psychologists believe that in these

11
domains of development, both maturation and interaction with the environment (nature and

nurture) are influential but disagree on the importance of each one (Woolfolk, 2008). When

going through this early developmental stage in life, if a person has been affected by an ABI,

it affects both maturation and their interaction with their environment. It can lead to isolation

in both mental and physical sense. Isolation from previous hobby’s or sports which require

physical or high levels of mental interaction which then can lead to social isolation effecting

ones’ mental wellbeing. This isolation will depend on the severity of the injury and will last as

long as the person is unable to resume normal daily activity initially. Until the possibility of

returning to more interactive interests again, once the conditions have hopefully subsided.

There are many different areas of the brain, each with its own function. For example, the

cerebellum controls ones’ coordination and also related to higher cognitive functions such as

learning. The hippocampus function is for recalling new information and recent experiences.

The thalamus is used to learn new information, in particular, verbal. The reticular formation is

associated with attention and the corpus callosum transfers information from one side of the

brain to the other (Woolfolk, 2008). Some researchers believe the brain is similar to a jungle

of layers and loops, an interconnected and complex organic system (Edelman, 1992).

The phenomenon of ‘lateralization’ is also examined in the literature. Woolfolk writes that

“(a)nother aspect of brain functioning that has implications for cognitive development is

Lateralization, or the specialization of the two hemispheres of the brain” (Woolfolk, 2008).

Each side of the brain controls the opposite side of the body, meaning if you were to damage

the left side of the brain it would affect the right side of your body and vice versa (Sousa, 2006).

Before lateralization occurs, if one part of the cortex was to be damaged, other parts of the

cortex could compensate and take over the functions of the damaged area (Woolfolk, 2008).

However once lateralization has occurred this becomes more difficult to compensate for

12
(Woolfolk, 2008). Now that we know how our brains rehabilitate, we can use that information

along with specialised teaching and learning styles to maximise the recovery process.

IMPLICATIONS OF ABI FOR THE CLASSROOM

A core objective in this study is to examine the implications of ABI for the classroom. What

can teachers expect from a student returning to their classroom after suffering from an ABI?

Multiply longitude studies have correlated that the severity of the injury is associated directly

with poorer physical or cognitive results (Anderson, Brown, Newitt, & Hoile, 2011; Anderson,

Catroppa, Morse, Haritou, & Rosenfeld, 2005; Anderson A, Catroppa, Haritou, Morse, &

Rosenfeld, 2005). Leo, Macey and Barzi found that, the age when the injury is sustained also

effects the outcome due to their larger head-to-body ratio, ongoing brain tissue myelination

and their thinner cranial bones (Catroppa & Anderson, 2007). Other factors which effect

rehabilitation include the type of injury, multiple injuries, socioeconomic status and provisions

of family and school support (Leo, Macey, & Barzi, 2017).

ABI’s affect students’ abilities to learn and achieve in cognitive, behavioural and social

domains in unpredictable and often confusing ways (Glang, Tyler, Pearson, Todis, & Morvant,

2004). Cognitive effects include problems in general intellectual function, memory and

attention, visual-motor abilities and significant impairments in executive functions – the ability

to organize, plan, and monitor behaviour (Glang, Tyler, Pearson, Todis, & Morvant, 2004). We

already know that it affects ones’ academic learning but how does it affect someone’s

behaviour and how will that be seen in the classroom? Students with an ABI may seem angry,

aggressive, withdrawn or apathetic (Clarke, 1996; Farmer, Clippard, Wiemann, Wright, &

Owings, 1996) These behavioural problems may be misinterpreted as learned inappropriate

behaviour when, they are merely a direct result of the acquired injury and/or frustrations related

to social or academic disappointment (Clark, Russman, & Orme, 1999).

13
In terms of a classroom this can be seen through student engagement, attention and interest,

mood swings and students’ own isolation due to results of depressive symptoms. Not only is

the student’s education effected but also their social experiences and quality of life (QOL) can

be affected. “These deficits may impact on a child’s capacity to interact with the environment,

causing lags in skill acquisition and peer interaction, and resulting in increasing gaps between

injured children and their age-matched peers” (Anderson, et al., 2012). Perhaps one of the most

challenging aspects from the teacher’s perspective is the variation in the function ability of

each student. “The performance of a student with TBI / (ABI) may fluctuate widely from week

to week or day to day, from morning to afternoon on any single day, and across settings or

various types of tasks. Tracked over time, the student may appear to take one step forward, two

back, reach a learning plateau, and then unexpectedly make a series of gains” (Glang, Tyler,

Pearson, Todis, & Morvant, 2004).

Few educators understand the complexity and unusual problems faced by students with ABI

(Frank, Redmond, Ruediger, & Scott, 1997). According to Tyler, J. (1997) most (American)

teachers don’t receive pre-service training on the effects of ABI on school performance. In

2001 NASDSE survey showed that “none of the responding states had a TBI certification

program, and only one had a teacher endorsement in TBI, and only 8% of graduate programs

in special education include TBI training (Glang, Tyler, Pearson, Todis, & Morvant, 2004).

The difficulties of working with students with ABI are added to the already demanding job

facing today’s educators. Yet teachers and SNA’s are being asked to work with more students

with more complicated needs while having fewer resources (Coleman, 2001). On top of that,

parents of students re-entering school post injury are adding pressure to the teachers. “In most

cases, these parents have had no previous experience with the special education system and are

struggling with the prospect that their child may now have a permanent disability” (Glang,

Tyler, Pearson, Todis, & Morvant, 2004). It can be difficult for parents and educators, who

14
likely will have different views on the long term educational outcome for the student, to work

together while trying to support the student in an individualized educational program (IEP)

(Glang, Robinson, & Todis, 1999).

An individualized educational program is part of the 2004 ESPEN act (Education for persons

with Special Education Needs act). It is an act brought in to help facilitate the needs of children

with disabilities or special need. Children with special educational needs have the right to free

primary education up to the age of eighteen years old (Citizens Information, 2015). The act

primarily focuses on children’s education but there is also reference to further and adult

education. The act outlines a variety of services to be provided to people with special education

needs. These include assessments for a child’s educational needs, education plans and other

support services. “The system for personal education plans is not yet in place and its

implementation is being coordinated by the NCSE” (Citizens Information, 2015). When the

personal education plans have been fully implemented, it should include a range of information

specific to the individual child’s needs. It could include everything from their rehabilitation

strategies to their preferred learning style.

Teaching and learning styles are hypothetical concepts which help explain the process of

teaching and learning (Fischer & Fischer, 1979). By understanding the different components

of styles used such as; learning styles, cognitive styles, learning strategies, teaching styles and

instructional strategies, we can create a better understanding for how students perceive and

process information (Bentham, 2002). It is important to remember that even though one

teaching style or instructional strategies works for one class grouping, it does not necessarily

mean it will work for another, but why? Lash (2000) writes that

(e)ach child is unique, there is no one teaching program that applies to all students with
brain injuries. By adapting instruction or modifying the environment, however, the
student can have greater opportunities for success in the classroom and community.

15
Imagine each class as its own living organism. How each organism develops over the course

of their education will differ due to a number of reasons. The dynamic of each group will be

different, and range anywhere from a coherent, cooperative group who rely on each other’s

strengths to grow and learn together, to a group of students who may suffer from social and

anxiety disorders and refrain from interaction with others. These factors remain outside the

control of the teacher but must be considered as the teacher makes a conscious decision on how

best to organise, structure and deliver their lessons as to encourage and help the students to the

best of their ability. To do this efficiently it is important to be aware of different teaching and

learning styles, and plan accordingly.

Bennett (1990, p.40) defines learning style as a

(c)onsistent pattern of behaviour and performance by which an individual approaches

educational experiences. It is the composite of characteristic cognitive, affective, and
physiological behaviours that serve as relatively stable indicators of how a learner
perceives, interacts with, and responds to the learning environment.

Students learning styles differ due to characteristic strengths and preferred avenues of retaining

and processing information (Felder R. , 1996, p. 18). To break that down even further as Felder

(2005) states, “students have different levels of motivation, different attitudes about teaching

and learning, and different responses to specific classroom environments and instructional

practices” (Felder R. , 2005). To meet the diverse learning needs a classroom presents, it is

important for a teacher to understand the differences between these learning styles. As, if a

student receives their education only through their least preferred learning style, the students

discomfort level may be enough to hamper their learning (Felder R. , 1996). However, this is

not indicating that the teacher should teach specifically to each student’s preferred learning

style. It is so they can incorporate each type of learning style as frequently as possible as too

improve the students range of learning style ability. “If professors teach exclusively in their

16
students’ preferred modes, the students may not develop the mental dexterity they need to reach

their potential for achievement in school and as professionals” (Felder R. , 1996). It is important

for educators to help build students’ skills in both their favoured and less favoured modes of

learning. The aim is to meet the learning needs of each model category as frequently as

possible. This is referred to as “teaching around the cycle” (Muro & Terry, 2007).

Dunn, Dunn and Price (1985) identified twenty-two elements related to and affecting ones
learning style. Of these twenty-two elements they can be grouped under five headings;
environmental, emotional, sociological, physical and psychological. (See Table 1).

Table 1: Key Elements Relating to and Affecting One’s Learning Style (Adapted from Dunn, Dunn & Price, 1985)

Environmental Lighting, sound (absent or present), temperature, classroom design (formal

or informal design)

Emotional Levels of persistence and motivation, responsibility as opposed to non-

conformity

Sociological; Working preferences; alone, in groups or pairs

Physical Perceptual preferences such as whether the student is an auditory, visual

or tactile learner, and time-of-day preference, morning or evening

Psychological How the learner reacts to situations, e.g. are they impulsive or reflective?
(Griggs, 1991)

Learning style awareness, is but one aspect requiring attention. Confusion between ABIs and

learning difficulties presents a further challenge. The effects of brain injury often overlap with

those of learning difficulties and until the “creation of a special category of traumatic brain

injury under the Individuals with Disabilities Education Act (IDEA), many of these students

were misidentified as having learning disabilities” (Lash, 2000). These effects include;

“difficulty with sustaining attention, memory, controlling impulses, organizational skills,

17
integrating skills, generalization, abstract reasoning and social judgment” (Lash, 2000). While

acknowledging the distinction, due to the overlap with these difficulties many of the teaching

and learning strategies teachers use to help students with learning difficulties can be used or

adapted for students with brain injuries.

The effects of ABI are varied with each student showing different and unique patterns of

behaviour and of a response to teaching and learning styles and methods, and yet there are

commonalities between students with ABI and generalities can be formed form this (Ministry

of Education, Special Programs Branch, 2000). To get the most out of education, students need

to be able to: pay attention, follow directions, organize their work and remember information.

Unfortunately, these are generally difficult tasks for students with ABI and intentional teaching

strategies are needed. Table 2 (below), adapted from Lash (2000) provides examples of

teaching strategies that can be used to aid students with ABI in the classroom, clustered around

the core elements of: attention/concentration, the capacity to follow directions, organisational

ability and the role of memory in learning.

Table 2. Teaching Strategies for ABI Students. (Adapted from Lash, 2000)

Attention /Concentration
Students with brain injuries may find it hard to focus,  Remove distractions in work area
especially over extended periods of time. (extra pens, books, equipment)
 Divide work into smaller sections while
also setting time targets
 Ask students to orally summarise
information that has just been
presented
 Use designated cue words to get
students to pay attention (“listen,”
“look,” “name”)
 Use non-verbal cueing system to
maintain student’s attention (eye
contact, touch)

18
Follow Direction
Following direction is vital for completing class
assignments and homework.
Organisation
Organisation skills are important to arrange
information, materials and activities in order to learn
Memory
Memory involves being able to mentally record and
store information and recall it when needed
 Provide both oral and written
instructions.
 Ask students to recall instructions
 Highlighting important parts of
directions
 Rewriting complex directions into
simple steps
 Give direction, ask student to preform
task, check for accuracy and provide
immediate feedback
 Slow down the pace of instruction or
give in instructions in smaller more
manageable chunks
 Give additional time for review
 Written checklist to complete tasks to
be ticked off as completing exercise
 Written schedule for daily routine
 An assigned person to review the
schedule at the start of the day and
help organise materials needed for
each class
 Written cues for organising an activity
or completing a task
 Practise sequencing material
 Outline based on class lectures
 Colour coded materials for each class
 Frequently repeat information and
summarise it
 Teach the student to use devices such
as post-it notes, calendars and
assignment books as self-reminders
 Teach the student to categorise or
chunk information to aid retention
 Demonstrate techniques such as
mental rehearsal and use of special
words or examples of reminders
 Link new information to the students’
relevant prior knowledge
 Provide experiential presentations of
instructional materials
19
Having investigated the three objectives outlined in the introduction, it is now helpful to

articulate an overarching conclusion to the study.

CONCLUSION

This study set out to investigate its objectives were to describe in depth what is meant by the

term ABI, to assess rehabilitation strategies and to identify effective teaching and learning

methodologies that can be utilised to accommodate an ABI student reintegrating into

mainstream education.

Brain injuries are becoming more and more common yet the research suggests that they are an

overlooked learning disability during teacher education programmes. In the US nearly 2.5

million people obtain an ABI annually. With numbers of people sustaining ABI drastically

high, the increased chance of sustaining additional concussions being 1:15 and in according to

JAMAS’s study, examined above these statistics outline the need for regulated return to play

protocols and lengthy absenteeism from training. From my research I would recommend, in

accordance with Guskiewicz recommendation previously discussed, of a minimum of 4-6

weeks away from any strenuous activiety both physically and mentally. To add to this point

one should only proceed to return to physical and mentally strenuous activity when they are

feeling up to the challenge. Each person will recover differently depending on the saverity or

multitude of the injury. There is no definite answer in relation to a time frame. Having said

that there are ways and means of testing how you have recovered and how far your recovery

has come.

20
Recovery from this form of injury is possible with the aid of neuroplasticty and rehibilitation

stratigies. These will help the injured person to recover to the best of their abilty. However it

is extremily important to remenber the importance of time for this type of injury. Depending

on the saverity of the injury it could take anywhere from three months to three years.

For educators it is important to remember how an ABI can effect a student’s behavours and

abilty to learn. Gang et. al (2004) point out that “(t)he performance of a student with TBI /

(ABI) may fluctuate widely from week to week or day to day, from morning to afternoon on

any single day, and across settings or various types of tasks”. They may now seem

uninterested or distraced where previously they did not. It is important for educators to

understand these side effects and not to misinturperate them for bad behavour. How they

percieve information may now also be changed as they are forced to try to adapt to new

learning styles as previous preferred learning styles may no longer be as effective for them.

This is a very important factor for teachers to be aware of when planning their lessons. By

understanding the student’s preferred learning style, teachers can adapt their teaching style

when exploring information that is difficult to process. Having said that, it is very important

to develop all of a students’ learning styles as it better prepares them for the real world where

they will be subjected to people who will usually communiate only through their own

preferred learning styles or modes. By carrying out a more inclusive approach to learning style

in education in terms of using learning styles and teaching methadologies, teachers provide

the student with a better chance of readapting to the real world post education, which is the

key to all education itself: preparing students for their future.

With the above conclusions in mind, this research recommends two follow-on primary

research studies: 1) a study on second level learners with ABI, who are re-integrated into

21
school, including perspectives of ABI affected students, their classroom teachers and their

Special Needs Assistants (SNAs), and 2) a study on the effectivness of prefered learning styles

on second level learners with ABI. The intended output of both studies would be a

comprehensive training package on ABI teaching and learning strategies for second level

educators.

22
REFERENCES
Aitken, M., Mele, N., & Barrett, K. (2004). Recovery of injured children: parent perspectives on family needs.
Archives of physical medicine and rehabilitation, 567-573.

Anderson, A., Catroppa, C., Haritou, F., Morse, S., & Rosenfeld, J. (2005). Identifying factors contributing to child
and family outcome 30 months after traumatic brain injury in children. Journal of Neurology,
Neurosurgery & Psychiatry, 401-408.

Anderson, V., Brown, S., Newitt, H., & Hoile, H. (2011). Long-term outcome from childhood traumatic brain
injury: intellectual ability, personality, and quality of life. Neuropsychology, 176.

Anderson, V., Catroppa, C., Morse, S., Haritou, F., & Rosenfeld, J. (2005). Functional plasticity or vulnerability
after early brain injury? Pediatrics, 1374-1382.

Anderson, V., Le Brocque, R., Iselin, G., Eren, S., Dob, R., Davern, T., . . . Kenardy, J. (2012). Adaptive ability,
behavior and quality of life pre and posttraumatic brain injury in childhood. Disability and rehabilitation,
1639-1647.

Andersson, A. (2000). Coping strategies in patients with acquired brain injury: relationships between coping,
apathy, depression and lesion location. Brain injury, pp.887-905.

Author, C. (2016). Limbic system injury. MEDIGOO.

Bennett, S. (1990). Comprehensive multicultural education: Theory and practice. Boston: allyn &Bacon.

Bentham, S. (2002). Psychology and Education. Sussex: Routledge.

Bohnen, N., & Jolles, J. (1992). Neurobehavioral aspects of postconcussive symptoms after mild head injury. The
Journal of nervous and mental disease, 683-692.

Brian Injury Society. (2017). What is Aquired Brian Injury. Retrieved March 6, 2018, from Brian Injury Society, life
beyond Aquired Brian Injury: http://braininjurysociety.com/information/acquired-brain-injury/what-
is-abi/

Cashin-Barbutt, A. (2016). Brain plasticity after injury: an interview with Dr Swathi Kiran. News Medical Life
Science.

Catalano, R., Oesterle, S., Fleming, C., & Hawkins, J. (2004). The importance of bonding to school for healthy
development: Findings from the Social Development Research Group. Journal of School Health, 252-
261.

Catroppa, C., & Anderson, V. (2007). Recovery in memory function, and its relationship to academic success, at
24 months following pediatric TBI. Child Neuropsychology, 240-261.

Chen, H., Epstein, J., & Stern, E. (2010). Neural plasticity after acquired brain injury: Evidence from functional
imaging. PM & R, supplement 2, 306-312.

Citizens Information. (2015, February 12). Special needs education. Retrieved from Citizens Information:
http://www.citizensinformation.ie/en/education/the_irish_education_system/special_education.htm
l

Ciuffreda, K.J. and Kapoor, N. (2012). Acquired brain injury. Visual diagnosis and care of the patient with special
needs. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

23
Clark, E., Russman, S., & Orme, S. (1999). Traumatic brain injury: Effects on school functioning and intervention
strategies. School Psychology Review, 28(2), 242.

Clarke, E. (1996). Children and adolescents with traumatic brain injury: Reintegration challenges in educational
settings. Journal of learning disabilities, 5, 549-560.

Coleman, M. (2001). Conditions of Teaching Children with Exceptional Learning Needs: The Bright Futures
Report. ERIC Digest E613.

Constant Therapy. (2016). Brain plasticity is the key to recovery after brain injury or stroke. Retrieved November
21, 2017, from Constant Therapy: http://constanttherapy.com/blog/brain-plasticity-is-the-key-to-
recovery-after-brain-injury-or-stroke/

Dancause, N., & Nudo, J. (2011). Shaping plasticity to enhance recovery after injury. Prog. Brain Res. 192, 273-
295.

Edelman, G. M. (1992). Bright air, brilliant fire: On the matter of the mind. Ney York: Basic Books.

Farmer, J., Clippard, D., Wiemann, V., Wright, E., & Owings, S. (1996). Assessing children with traumatic brain
injury during rehabilitation: Promoting school and community reentry. Journal of learning disabilities,
29(5), 532-548.

Faul, M., Xu, L., Wald, M., & Coronado, G. (2010). Traumatic Brain Injury in the United States: Emergency
Department Visits, Hospitalizations and Deaths 2002–2006. Atlanta. (GA): Centers for Disease Control
and Prevention, National Center for Injury Prevention and Control.

Felder, R. (1996). Matter of style. ASEE prism, 6(4), 18-23.

Felder, R. (2005). Understanding student differences. Journal of engineering education, 94(1), 57-72.

Fischer, B., & Fischer, L. (1979). Styles in teaching and learning. Educational leadership, 36(4), 245-254.

Frank, E., Redmond, K., Ruediger, T., & Scott, W. (1997). Preparedness of educational speech-language
pathologists to provide services to students with traumatic brain injury. Journal of Children's
Communication Development, 18(2), 49-63.

Giza, C., Kutcher, J., Ashwal, S., Barth, J., Getchius, T., Gioia, G., . . . McKeag, D. (2013). Summary of evidence-
based guideline update: Evaluation and management of concussion in sports Report of the Guideline
Development Subcommittee of the American Academy of Neurology. . Neurology, 2250-2257.

Glang, A., Robinson, L., & Todis, B. (1999). Collaboration between parents and educators: Partners or
adversaries. Brain Injury Source, 3(3), 10-13.

Glang, A., Tyler, J., Pearson, S., Todis, B., & Morvant, M. (2004). Improving educational services for students with
TBI through statewide consulting teams. NeuroRehabilitation, 19(3), 219-231.

Griggs, S. (1991). Learning styles Counselling. ERIC Digest.

Guskiewicz, K., McCrea, M., Marshall, S., Cantu, R., Randolph, C., Barr, W., . . . Kelly, J. (2003). Cumulative effects
associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. Jama,
2549-2555.

Harley, J., Allen, C., Braciszeski, T., Cicerone, K., Dahlberg, C., Evans, S., & Levin, W. (1992). Guidelines for
cognitive rehabilitation. NeuroRehabilitation, 2(3), 62-67.

24
Howlader, N., Noone, A., Krapcho, M., Garshell, J., Neyman, N., Altekruse, S., . . . Cronin, K. (2012). SEER Cancer
Statistics Review, 1975-2010. National Cancer Institute. Bethesda, MD,.

Hugenholtz, H., Stuss, D., Stethem, L., & Richard, M. (1988). How long does it take to recover from a mild
concussion? Neurosurgery, 853-858.

Jennett, B. (1989). Mild Head Injury. Toronto: Oxford University Press.

Kerr, A., Cheng, S., & Jones, T. (2011). Experience dependent neural plasticity in the adult damaged brain. Journal
of Communication Disorders, 538-548.

Kleim, J. (2007). Role of neural plasticity in motor learning and motor recovery after brain injury. Pocketbook of
Neurological Physiotherapy, 41-50.

Kleim, j. (2011). Role of neural plasticity in motor learning and motor recovery after brain injury. Pocketbook of
Neurological Physiotherapy, 41-50.

Kleindorfer, D., Khoury, J., Moomaw, C., Alwell, K., Woo, D., Flaherty, M., . . . Kissela, B. (2010). Stroke incidence
is decreasing in whites but not in blacks. Stroke, 1326-1331.

Lash, M. (2000). Teaching strategies for students with brain injuries. TBI Challenge, 4(2), 1-4.

Leo, G., Macey, J., & Barzi, F. (2017). Educational outcomes for children with moderate to severe acquired brain
injury. Australian Medical Student Journal.

Lunnon, R. (2017). The Brain and brain injury, Brain Injury Series. Headway Ireland.

Markowitz, J., & and Linehan, P. (2001). Traumatic Brain Injury. Quick Turn Around (QTA).

Mayers, L. (2008). Return-to-play criteria after athletic concussion: a need for revision. Archives of neurology,
1158-1161.

Mayo Clinic. (2018). Post-concussion syndrome. Retrieved March 21, 2018, from Mayo Clinic.org:
https://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/symptoms-causes/syc-
20353352

MedicineNet. (2016). Neuroplasticity. Retrieved November 19, 2017, from MedicineNet.com:

https://www.medicinenet.com/script/main/art.asp?articlekey=40362

MedicineNet. (2017, October 9). Rehabilitation. Retrieved from MedicineNet.com:

https://www.medicinenet.com/script/main/art.asp?articlekey=5288

Ministry of Education, Special Programs Branch. (2000). Teaching Students With Aquried Brain Injury. A Resource
Guide For Schools. British Columbia.

Muro, P., & Terry, M. (2007). A matter of style: Applying Kolb's learning style model to college mathematics
teaching practices. Journal of College Reading and Learning, 38(1), 53-60.

Newcombe, F., Rabbitt, P., & Briggs, M. (1994). Minor head injury: pathophysiological or iatrogenic sequelae?
Journal of Neurology, Neurosurgery & Psychiatry, 709-716.

Oxford Dictionary. (N/A). Neuroplasticity. Retrieved November 19, 2017, from Oxford Living Dictionaries:
https://en.oxforddictionaries.com/definition/neuroplasticity

Reyst, H. (N/A). Neuroplasticity After Aquired Brain Injury. Rainbow Rehabilitation Centres.

25
Roger, V., Go, A., Lloyd-Jones, D., Benjamin, E., Berry, J., Bordon, W., & al., …. e. (2012). Heart Disease and Stroke
Statistics—2012 Update: A Report From the American Heart Association. Circulation,. the American
Heart Association.

Rohling, M., Faust, M., Beverly, B., & Demakis, G. (2009). Effectiveness of cognitive rehabilitation following
acquired brain injury: a meta-analytic re-examination of Cicerone et al.'s (2000, 2005) systematic
reviews. Neuropsychology, 23(1), 20-35.

Sousa, D. (2006). How The Brain Works. California: Corwin Press.

Teasdale, T., & Engberg, A. (1997). Duration of cognitive dysfunction after concussion, and cognitive dysfunction
as a risk factor: a population study of young men. Bmj, 569-572.

Traumatic Brain Injury. (2001). Mild TBI Symptoms. Retrieved March 21, 2018, from Traumatic Brain Injury:
http://www.traumaticbraininjury.com/symptoms-of-tbi/mild-tbi-symptoms/

Tyler, J. (1997). Preparing educators to serve children with ABI. Students with Acquired Brain Injury: The school’s
response. Baltimore: brooks publishing.

Volker, J. (2017, July 24). SKULL. Retrieved November 19, 2017, from earthslab:
https://www.earthslab.com/anatomy/skull/

Warraich, Z., & Kleim, J. (2010). Neural plasticity: The biological substrate for neurorehabilitation. PM & R, 2(12),
S208-S219.

Woolfolk, A. (2008). Educational Psychology. Boston: Pearson Education, Inc.

26