Distinguishing Between Brain Injury, Attention Deficit Hyperactivity Disorder and Learning Disabilities

Sharon Grandinette, M.S., Acquired Brain Injury Specialist/Trainer
Exceptional Educational Services
www.helpingkidsbrains.com

History of Brain Injury Eligibility in Special Education

Prior to 1990, children who acquired a brain injury after a period of normal development were identified with students who were born with their disabilities. Often, they were placed into Special Education eligibility categories and classrooms of the disabling conditions that most closely resembled theirs. Typically, those categories included Learning Disabilities and Attention Deficit Hyperactivity Disorder. Additionally, brain injury survivors with more significant deficits were incorrectly associated with students with Emotional Disturbance, Orthopedic Impairments, and Mental Retardation.

While some students who acquire a brain injury may present with deficits similar to students with other disabling conditions, a brain injury is caused by a known event and these students have their own unique set of characteristics and needs. Even though Traumatic Brain Injury became an eligibility category under the Individuals with Disabilities Education Act (IDEA) in 1990, children who acquire a brain injury continue to be misidentified and misplaced in other disability categories, and thus are not receiving the appropriate treatment and educational interventions they require.

What is a Brain Injury?

A brain injury is defined as an insult to the brain that has occurred since birth, and in most cases, after a child has experienced some level of typical development. It can be caused by trauma from an external force (open and closed head injuries) or from non-traumatic, internal occurrences such as strokes and other cerebral vascular accidents, infections of the brain, toxic exposure, near drowning, tumors, metabolic disorders and loss of oxygen. Lesions, bleeding, bruising, swelling, and the tearing and shearing of neurons that can result from a brain injury are easily identified using neuroimaging diagnostic tools (x-rays, CAT scans, MRI’s, or PET scans) available in the medical field.

A brain injury can result in total or partial functional disability or impairment that adversely affects educational performance, and may result in mild, moderate or severe impairments in one or more areas including: cognition; speechlanguage communication; memory, attention and concentration; reasoning, abstract thinking, problem solving, sensory, perceptual and motor abilities; psychosocial behavior; physical functions and information processing. The nature and timing of a brain insult may cause unpredictable consequences as trauma disrupts the normal progression of cerebral development, as injury incurred during the development of the nervous system can have extensive consequences on a child’s ability to acquire new skills and knowledge.

Children who acquire their brain injury due to trauma may be eligible for special education services under the eligibility category of Traumatic Brain Injury (TBI) while those whose injury is caused by a non traumatic event typically qualify under Other Health Impaired (OHI.) With proper identification, rehabilitation and educational intervention, many students who acquire a brain injury may show marked progress over time, regaining lost skills and physical function. Depending on the severity of the injury, services can be delivered in a variety of educational settings, from general education with a 504 Plan accommodation to special education classrooms, and receive a number of therapies including Speech/Language, Physical and Occupational therapies, Counseling and Vision and Hearing support services. Since behavior is a common problem following a brain injury, many students also require the services of a behaviorist who specializes in antecedent behavior management and applied behavior analysis.

What is ADHD?

Attention Deficit Hyperactivity Disorder (ADHD) is a condition caused by genetic factors that result in neurological deficits. It is considered a neurobehavioral syndrome/developmental disorder that begins in early childhood and can affect individuals across the life span. A physician typically diagnoses children who display developmentally inappropriate levels of inattention, hyperactivity and impulsivity prior to the age of 7, with impairments in adaptive functioning at home, at school, and in social situations with this condition.

Heredity is the most common cause of ADHD, and in almost 80% of cases, siblings of children with ADHD have a five to seven times more likelihood of being diagnosed than those from unaffected families. In instances where heredity does not seem to be a factor, difficulties during pregnancy, significantly low birth weight, excessively high lead levels, brain infections, inborn errors of metabolism, and prenatal exposure to alcohol, tobacco and cocaine, have all been found to contribute to the risk for ADHD to varying degrees. Current research suggests that ADHD may stem from a lag or failure in the development of at least 3 areas of the brain, primarily on the right side.

There are three types of ADHD: inattentive, hyperactive/impulsive, and combined. While children with ADHD have often been accused of willfully displaying inattention, poor concentration, and impulsivity, it is not in their control. Specific brain chemicals responsible for adjusting the sensitivity of the brain to stimuli and regulating the degree of activity are in limited supply, causing them to have no control over the actions and behaviors they exhibit. Children with ADHD may be eligible to receive special education services under the category of OHI-Other Health Impaired in special and general classroom settings, or receive accommodations under a 504 Plan in general education classrooms. Medication prescribed by the child’s physician is a common form of treatment, and counseling is often advised.

What is a Learning Disability?

A learning disability is an impairment in some aspect of language and/or visual-perceptual development that interferes with learning. Research supports that learning disabilities are inherited (reading disabilities are the most common form) and has found that several members of a family often have a Learning Disability. Some research suggests that the disorder arises from abnormal left-hemisphere development. Since learning disabilities are difficult to diagnose, and because they are neurological disorders that affect how the brain processes information, the medical model, neuroimaging approach (using x-rays, CAT scans, MRI’s, or PET scans) cannot definitively indicate that a child has a learning disability, and a pattern of poor educational performance confirmed by psycho-educational assessment is needed to make a determination.

A specific learning disability (SLD) as defined in IDEA 1997 is a “disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations.” For years, most states have used a significant discrepancy model between IQ and academic achievement to determine whether a child met the criteria for a learning disability, disallowing a number of students to receive special education services that would have addressed their poor academic performance. A new provision in IDEA 2004 releases schools from that requirement, and also recognizes that a learning disability can co-exist with other types of disabilities.

The revised IDEA 2004 addresses the changing view of the special education eligibility of students with learning disabilities. According to the National Joint Committee on Learning Disabilities, a learning disability is defined as a “generic term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical abilities. These disorders are intrinsic to the individual and are presumed to be due to a dysfunction of the central nervous system.” Students with learning disabilities often receive special education services under the eligibility category of SLD-Specific Learning Disability in the form of academic accommodations and remediation. Services can be provided in both the general education classroom as well as the special education class setting. Other support services may include Speech and Occupational therapy.

Why Brain Injury, ADHD and Learning Disabilities are Commonly Confused

In the early twentieth century, the cluster of symptoms now known as ADHD was hypothesized to relate to brain trauma, and although research has since determined otherwise, many still believe this finding to be true. For years, a learning disability was defined as “minimal brain dysfunction.” Additionally, there are a number of overlapping conditions between the three disabilities, giving more credence to past theories. For example, almost 20% of children with learning disabilities also exhibit the symptoms of ADHD.

A sudden onset of a medical condition such as meningitis, encephalitis, or a stroke, as well as trauma to the brain can result in the subsequent development of learning and attention problems that look like ADHD and Learning Disabilities. Traumatic Brain Injury (TBI) is the most common because more children with brain injuries are surviving today than ever before due to the increased ability of the medical community to sustain life following traumatic and non-traumatic events. As a result, brain injury is an increasingly recognized cause of learning & behavior problems in children. However, children who acquire brain injury present very differently, since, unlike children with Learning Disabilities and ADHD, not only were most typically developing prior to their injuries, but also because of the evolving nature of their recovery.

During brain injury recovery, disorders in attention, executive functions, higher language skills and behavior are common. Although the cognitive effects of Learning Disabilities and deficits in attention, concentration and impulsivity are commonly seen in brain injury survivors as they go through the healing process, they typically show signs of recovery over time. Frequently, children with attention related problems stemming from brain trauma present a checkerboard pattern of attention difficulty in which certain attention skills have been affected, while others have been significantly impaired. For many children who sustain brain trauma, problems with speed of information processing and concept formation may contribute to what can be mistaken for ADHD. Often these children have significantly high levels of over-arousal and behavioral problems.

Children with ADHD and Learning Disabilities have lifelong disabilities, and their patterns are distinctly different. Due to this distinction, Traumatic Brain Injury (TBI) was identified as a separate category of disability under Special Education/ IDEA in 1990 to distinguish it from Learning Disabilities and other types of disabling conditions, while ADHD was included under the category of Other Health Impairment (OHI). However, when brain injury recovery is complete, some children may have residual learning disabilities as well as attention and concentration problems, adding to the labeling confusion.

The child who acquires a brain injury is not a peer of other students born with a disability because students with a brain injury have experienced a period of typical development. As a result, important differences that these children will present with may include:
  • A previous successful experience in academic and social settings
  • A pre-injury self-concept of being normal
  • Discrepancies in ability levels
  • Inconsistent patterns of performance
  • Variability and fluctuation in the recovery process resulting in unpredictable and unexpected spurts of progress
  • More extreme problems with generalizing, integrating or structuring information
  • Poor judgment and loss of emotional control, which makes student appear to be ED at times
  • Cognitive deficits that are present in other disabilities but are uneven in extent of damage & rate of recovery
  • Combinations of conditions resulting from the TBI that are unique and do not fall into usual categories of disabilities
  • Inappropriate behaviors more exaggerated (more impulsive, more distractible, more emotional, more difficulty with memory, information processing organization & flexibility)
  • Learning style that requires a utilization of a variety of compensatory and adaptive strategies
  • Some high level skills, which may be intact, making it difficult to understand why the student will have problems performing lower level tasks
  • A previously learned base of information that assists with relearning more rapidly.

References:

  • Batshaw, M.L. (2002). Children with Disabilities. (5th ed.) Baltimore, MD: Paul H. Brookes Publishing Co.
  • Blosser, J.L. & DePompei, R. (2003). Pediatric Traumatic Brain Injury: Proactive Intervention(2nd ed.) Clifton Park, NY: Delmar Thompson Learning.
  • Goldstein S. & Goldstein, M. (1990). Managing Attention Disorders in Children. New York: John Wiley & Sons.
  • National Center for Learning Disabilities http://www.ld.org
  • Silver, J.M., McAllister, T.W., Yudofsky, S.C. (2005). Textbook of Traumatic Brain Injury. Washington, D.C. American Psychiatric Publishing, Inc.
  • Savage, R.C. & Wolcott, G.F. (1994). Educational Dimensions of Acquired Brain Injury. Austin, TX: PRO-ED, Inc.

For a more detailed article on this topic, and other articles on brain injury, please visit www.lapublishing.com.

This article is from the CAPHI Newsletter, Summer 2006.