Bullying, detention and trips to the head’s office could all be signs that a school pupil has a brain injury. Others include falling grades, poor concentration and messing around in class.

By spotting these red flags and taking action, teachers can avert a downward spiral that all too often ends in the criminal justice system.

Rates of traumatic brain injury (TBI) in young people in custody range from 65 to 76%, compared to the general population of between 5 to 24%.

A 2010 study of incarcerated young offenders in the UK aged between 16 and 18, meanwhile, found that 65.1% reported a TBI that left them feeling ‘dazed and confused’.

As well as the lobby for criminal justice reforms to better handle brain injuries, campaigning of the education system is also underway.

Schools are being urged to improve their ability to identify brain injuries in children and make valuable interventions.

By doing so, they could positively change the outlook of young people on track for a life of limited opportunities or even behind bars.

Spreading the word among teachers is an uphill struggle, however, according to Louise Wilkinson, of the Child Brain Injury Trust (CBIT).

As the trust’s information and learning manager, she is charged with switching educators on to the signs of childhood brain injuries.

But apathy, misconceptions and overly officious school gatekeepers are common barriers in her quest.

The trust offers free workshops to educational professionals, showing them how to better recognise and support children with acquired brain injury (ABI).

Yet the response rate is extremely low. She recently sent a request to about 4,000 schools for attendees at an upcoming course, for example. Ten schools replied.

“You don’t know what you don’t know,” she says. 
“The frontline person who gets our email may delete it, assuming it’s irrelevant as they don’t have any kids with brain injuries. Unless they know of a child who’s had meningitis or been in an accident, they think it’s not for them.

“With the teachers that do come along, it’s like watching lightbulbs being switched on. Often they’ve worked with a child with learning difficulties that they just couldn’t put their finger on what the diagnosis should be. Sometimes they go back to work with a list of children whose backgrounds they intend to look into.”

Teachers trained to recognise brain injury signs face the challenge of distinguishing them from other conditions.

ADHD and autistic spectrum disorder (ASD) share lots of common ground with brain injuries; although TBI is around
30 times more common in young people statistically than those two conditions.

In young people in the general population, 
the rate of TBI – which excludes brain injury caused by illness (meningitis, epilepsy and measles), stroke, tumours, poisoning and lack of oxygen – is 24 to 31.6% (McKinley et al, 2008; McGuire et al, 1998).

This compares to 0.6 to 1.2% for autistic spectrum disorder and 1.7 to 9% for ADHD, CBIT says.

“There could be hundreds or even thousands of children that have been diagnosed with ADHD whose difficulties are actually as a result of an ABI,” Louise says.

“There are so many signs that are similar, 
and so many common areas of difficulties, 
but there are also some subtle differences. If professionals don’t know them, the
child is probably not going to get the correct diagnosis.

“Children on the autistic spectrum can be obsessive and compulsive – and there may be no grey areas. Everything is black or white. They might also have difficulties with social skills and be awkward around people. But equally they might be very intelligent.

“Children with a brain injury may show similar signs. If they have frontal lobe damage they too may have difficulties with social interaction, understanding things and perception. A difference is that they may also have memory problems, whereas autistic children typically have very good memories.”

Unlike brain injury, conditions like ADHD and ASD are embedded in the training teaching professionals undergo, Louise believes.

ADHD’s higher profile in education circles is perhaps due to its regular media attention and the way diagnosis levels have exploded in the modern age.

Drug controversies, discrimination cases and classification changes have helped to keep the condition in the public eye in recent decades, certainly more so than childhood TBI.

Annual prescriptions in the UK for ADHD medications such as Ritalin more than doubled from 359,100 in 2004 to 922,200 in 2014. In the US, ADHD is now the second most frequent long-term diagnosis made in children, behind asthma.

Even among educational psychologists, training on identifying the fallout from 
brain injuries is poor. “In a two or three-year course, they tend to only have an hour or two focusing on brain injuries,” says Louise.

The impact of adolescence on young people’s behaviour also makes it difficult for school staff to recognise signs of brain injury. In these formative teenage years, long-forgotten childhood accidents can also re-emerge in the form of ABI-related problems.

“When children have accidents when they 
are little, parents are often told they’ve made a full recovery. However, maturation of the brain isn’t complete until a person is in their early to mid-20s. So sometimes things that are supposed to start working in adolescence suddenly don’t and issues are flagged up only then, years after the initial brain injury.

“If you bought a brand-new computer, but didn’t use a certain programme until six months later, you wouldn’t know whether or not that programme worked until then.

“We see particular problems when kids make the transition from key stages two to three [at age 11]. They’ve been going to the same classroom, sitting in the same chair, being taught by the same teacher every day.

“They know where the scrap paper is kept, and so on. Suddenly, at key stage three, they have lots of different teachers and lessons and have to navigate their way around school. They also have to remember what to take to school each day.

“The child who was fantastic in primary school and coped really well, suddenly has a high possibility of struggling with their organisational and planning skills, if they have a known or unknown brain injury.”

This change in circumstance can quickly develop into a downward slide in their performance at school.

“They end up wandering the corridors aimlessly. They can’t get their homework in on time. They get sent to detention and get admonished, but it’s not their fault. They are trying just as hard as they’ve always tried but everyone’s on their case.

“Then they start thinking ‘I might as well not bother’ and start playing up as no-one’s supporting them and it’s easier to get thrown out of the classroom. Eventually the school says they can’t cope with their behaviour and they get excluded.”

One young person quoted in a 2012 
Children’s Commissioner’s report on neurodisability and young offenders, explained this frustrating experience: “I wasn’t able to concentrate…I got distracted easily…Then they just send you out and keep sending you out and sending you out and then you end up being sent home and then you get suspended.”

A fellow member of the same focus group said: “I went to junior school, I couldn’t read or write and they just gave me work I couldn’t do, telling me to do it, and I couldn’t do it, so instead of doing it I would just mess about.”

Another said: “My mum tried to get help but everyone said no. That left her with just me, not in school.”

From there, life can sink even deeper for some teenagers, with an inevitable slip towards petty crime and then more
serious criminality.
And whether they are in education or institutional rehabilitation the same problems can persist, plunging them into more trouble.

According to the Prison Reform Trust, a person with learning difficulties and disabilities can struggle to understand and adjust to rules and can become deemed a disruptive force.

Stopping this sad school-to-prison scenario from playing out up and down the country is an important part of CBIT’s work. As well as its continual programme of education 
for teachers, the group supports parents in getting children with brain injuries the extra help they may need at school.

Louise is motivated by personal experience. Her own son, now grown up, had difficulties at school and was initially dismissed as a naughty child.

He was eventually diagnosed with ADHD but it wasn’t until Louise was immersed in the world of childhood brain injuries with CBIT that she remembered
her son’s accident.

He fell off a wall onto a concrete path at
age two, throwing up afterwards, indicating concussion. He was observed for 24 hours and then it was assumed he had recovered.

Louise is unsure that his difficulties
were connected to this rather than ADHD, but is certain that such experiences show the need for more transparency around children’s medical histories.

“We have a red book here in the UK that details a child’s medical history for the parents. But, unlike in other parts of the world such as Canada, the book is not used 
by the school system. It should be passed right the way through from primary to secondary education.”

Another systematic problem in the UK is the importance weighted on results, sometimes to the detriment of individual children.

“When you have a school that is very pupil-focused, they will move heaven and earth to support that child. We get very good results in those schools.

“Where you have a school that’s more concerned about their report from [government watchdog] Ofsted, they don’t want a failing pupil. They will not necessarily be as accommodating as other schools with requests for support and the child may end up changing schools.”

Tackling issues so ingrained in the education system is a tough ask for CBIT and its team of around 30. It hopes that 
by engaging more closely this year with local government, it will be able to exert more influence. It plans to carry out some “structured work” in one particular region of the country, working with a handful of education authorities.

See future issues of NR Times for an update on its success or otherwise.