Brain

Understanding and Teaching Students with Traumatic Brain Injury What Families and Teachers Need to Know

Florida Department of Education Bureau of Exceptional Education and Student Services 2005

This is one of many publications available through the Bureau of Exceptional Education and Student Services, Florida Department of Education, designed to assist school districts, state agencies which support educational programs, and parents in the provision of special programs. For additional information on this publication, or for a list of available publications, contact the Clearinghouse Information Center, Bureau of Exceptional Education and Student Services, Florida Department of Education, Room 628 Turlington Bldg., Tallahassee, Florida 32399-0400. telephone: (850) 245-0477 or Suncom: 205-0477 FAX: (850) 245-0987 or Suncom: 205-0987 e-mail: [email protected] website: http://www.myfloridaeducation.com/commhome/

Understanding and Teaching Students with Traumatic Brain Injury What Families and Teachers Need to Know

Florida Department of Education Bureau of Exceptional Education and Student Services 2005

Copyright State of Florida Department of State 2004 Authorization for reproduction is hereby granted to the state system of public education consistent with Section 1006.39(2), Florida Statutes. No authorization is granted for distribution or reproduction outside the state system of public education without prior approval in writing.

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Table of Contents

Preface ...................................................................................................... v

Understanding Students with Traumatic Brain Injury ......................... 1

Background .......................................................................................................... 1

What is a traumatic brain injury? ...................................................................... 1

What is the national prevalence of traumatic brain injury among our youth?..... 1

What do we know about traumatic brain injury? ............................................... 1

What does it mean to have a traumatic brain injury? ......................................... 2

Area Injury and Effects ....................................................................................... 2

What are the effects of brain injury? ................................................................. 2

Brainstem Injuries....................................................................................... 3

Frontal Lobe Injuries .................................................................................. 3

Parietal Lobe Injuries.................................................................................. 4

Temporal Lobe Injuries............................................................................... 5

Occipital Lobe Injuries ............................................................................... 5

Emotional, Psychological, and Behavioral Problems .......................................... 5

What are typical behavioral reactions of children with a TBI? .......................... 6

What kinds of mental health problems can be caused by a traumatic

brain injury? ................................................................................................... 6

What kinds of social behavior problems are symptoms of traumatic

brain injury? ................................................................................................... 7

Is counseling or psychotherapy useful?............................................................. 7

Cognitive Impairments......................................................................................... 8

What are typical cognitive effects of a traumatic brain injury in children? ........ 8

Can the brain be fixed? ..................................................................................... 8

What strategies can be used to address cognitive impairments?......................... 9

The Family Situation .......................................................................................... 10

What characterizes the family after the child is injured? ................................. 10

What are some practical recommendations for the family of a child with a

traumatic brain injury?.................................................................................. 11

What can schools do to form alliances with families? ..................................... 12

Teaching Students with Traumatic Brain Injury .................................. 13

What happens when a student who experienced a traumatic brain injury

re-enters school?................................................................................................. 13

What can the teacher do as soon as a student with a traumatic brain injury

re-enters school?................................................................................................. 13

What services are available for students with TBI?............................................... 14

What classroom strategies can be implemented for a student with TBI?................ 14

Should teachers consider anything else when instructing students with

traumatic brain injury?........................................................................................ 15

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What are some best practices for addressing psychological issues in the classroom? ......................................................................................................... 16

Are there suggested classroom strategies that will accommodate students

with TBI? ........................................................................................................... 16

Summary Thoughts................................................................................. 16

Appendix 1: Student Checklist ........................................................... 17

Appendix 2: Summary of Best Practices for the Classroom ............. 19

Appendix 3: Summary of Best Practices for Addressing

Psychological Issues in the Classroom......................... 21

Appendix 4: Suggested Classroom Strategies to Accommodate

Students with Traumatic Brain Injury ....................... 23

References................................................................................................ 25

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Preface

A significant number of students are reported to sustain a traumatic brain injury every year. A traumatic brain injury can bring new and often harsh challenges to its victim, family members, teachers, and friends. It is of great benefit to all concerned to understand such traumatic brain injuries and how to address the effects. The development of this document, Understanding and Teaching Students with Traumatic Brain Injury: What Families and Teachers Need to Know, was contracted by the Florida Department of Education so that families and school-based personnel would obtain a greater understanding of traumatic brain injuries and their effects on students. The document is written using a question and answer format that is easily followed by the reader. The document is divided into two sections. The first section, “Understanding Students with Traumatic Brain Injury,” presents background information on the various types of brain injuries, resulting effects or deficit areas, and the impact on the family situation. The impact of a traumatic brain injury on the student’s social and academic performance and on family members and friends is discussed fully. The second section, “Teaching Students with Traumatic Brain Injury,” provides practical classroom strategies to use when dealing with the student’s academic and social needs. The focus of this section is on the student’s readjustment to daily school routines. Classroom strategies, concise checklists, and a pocket summary are included to aid busy teachers.

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Understanding Students with Traumatic

Brain Injury

Background What is a traumatic brain injury? A traumatic brain injury (TBI) is caused by a blow to the head or violent head movement similar to what happens in a high-impact motor vehicle accident. Such an occurrence is after and not during birth. The term “TBI” is only applied when there is evidence of total or partial functional disability or psychological impairment, or both, that adversely affects a child’s education performance. It is not applied to individuals who have developmental brain disorders such as a learning disability, attention deficit disorder, or mental disability. TBI is not the result of a tumor, infection, stroke, or loss of oxygen to the brain. However, each of these conditions can cause serious problems. Injuries resulting from a blow to the head or an object striking the head can destroy brain cells. This can happen in several ways, such as the following: • A blow to the head can cause blood vessels to tear, resulting in a hematoma (collection of blood) putting pressure on a specific part of the brain or causing a blood clot. • An object striking the head can break through the skull and penetrate the brain or push bone fragments into the brain. • A blow to the head can actually bruise the brain, damaging tissue located under the point of impact (contusion). Brain injuries can range from mild to severe. The location and extent of the injury to the brain determines the types of problems an individual will face and the severity of those problems. The severity of the brain injury has implications not only for the physical and emotional recovery of the person, but also for his/her educational needs. What is the national prevalence of traumatic brain injury among our youth? It is estimated that three percent of children have had a significant head injury by the time they enter high school (Savage & Woolcott, 1994). With this high incidence, schools are likely to have one or more students with TBI at most grade levels. What do we know about traumatic brain injury? Although individuals with a TBI exhibit characteristics reflecting varying degrees of severity, there are certain general principles that can be applied to all, or at least, most cases. They are as follows: • A traumatic brain injury produces a condition that is unstable at the beginning or immediately following the injury.

• The level of impairment is greatest at the time of the injury or soon afterwards. • The depth of a coma and/or length of traumatic amnesia can indicate the severity of the brain injury. • The true effects of the impairment will be seen once the person with a brain injury returns home and attempts to resume normal daily living activities. • A brain injury will affect the entire family. • The more severe the injury, the more personality changes can be expected. • Mild head injuries are often ignored until problems materialize later through challenges posed by everyday living. • TBI can be a condition requiring lifelong accommodations. What does it mean to have a traumatic brain injury? Members of the general public simply do not understand that a traumatic brain injury is a distinctive and complex matter. The survivor of a head injury may even have difficulty making sense of the situation. Imagine you are the person waking up in a hospital bed with no memory of any injury or accident (post-traumatic amnesia). It takes days for your dulled mind to begin to remember bits of information. Gradually, the cold, hard facts about your injury begin to take shape. You understand that you were in an accident, were taken to the hospital, and have had a brain injury. However, you feel normal and you don’t see any need to stay in the hospital. You are released from the hospital. You find the home situation to be more frustrating than the hospital. You are told that you cannot stay alone or drive a car. Family members say that you keep on asking the same questions over and over again. You begin to realize that you forget a lot. You have trouble organizing your thoughts during the day and when you see an old friend, you don’t know what to say. You drop things, blurt out rude remarks, do impulsive things, and have an excuse for every one of your behaviors. Family members also have difficulties making sense of what happened. Most family members have the opportunity to observe the survivor immediately following the head injury and are eager to see improvement.

Area of Injury and Effects What are the effects of brain injury? The effects of brain injuries are well understood and highly predictable based on the part of the brain that was injured. The brain is comprised of the brainstem and frontal, parietal, temporal, and occipital lobes. Although all these areas interact, each one is responsible for influencing particular types of functioning.

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Brainstem Injuries Individuals with brainstem injuries may experience both physical and cognitive effects. The brainstem, although small compared to the rest of the brain, regulates major lifesupport functions. Injury to the brainstem produces slow thinking, easy fatigue, sleep disturbance, diminished awareness, impaired balance and coordination, and/or losses of sensation and movement. The controls for movement and sensation pass through the brainstem and are partially regulated by it. Injury can produce impaired balance and coordination; uneven cadence of speech; flaccid or spastic paralysis of limbs (usually on one side of the body); or body-sense disturbances including numbness, insensitivity, or odd sensations. Victims of high-speed automobile or motorcycle crashes sometimes have local brainstem injuries. Brainstem injuries may produce extreme weakness or even total inability to use muscles on one side of the body. These injuries can also produce a dramatic softness of voice because of reduced breath control, unusual cadences and tones in speech that may sound abnormal, and/or spastic contortions of the muscles of the face. Consequences of these injuries may also include slow reflexes, fatigue, disorganization of thought, and poor awareness of changes or new occurrences. Frontal Lobe Injuries Frontal lobe injuries most often affect executive functions like impulse control, initiation planning, organization, mental flexibility, and monitoring for errors. Such injuries also produce a susceptibility to mental overload. Although frontal lobe injuries can have different effects depending upon exactly where they are situated, most injuries due to TBI are found in a limited band of brain tissue located directly across from the bony ridges on the inside of the skull. Almost any kind of head trauma brings these brain areas up against the bony points and produces at least some degree of damage. Hence, damage to the systems that travel through this specific location produces the most common symptoms of TBI (Jennett & Teasdale, 1981). Injury to the frontal lobe can cause impulsive responses that result in a tendency to break rules of proper conduct (e.g., getting into fights). This type of injury tends to affect a person’s monitoring or alertness to his or her own mistakes and inappropriate interpersonal behaviors. The part of the brain that extends back toward the ears on the sides of the frontal lobes contains the “behavioral sparkplug” that produces initiation. Damage here tends to make a person passive and unresponsive. Individuals who experience this type of injury can smell smoke without putting into action any fire-safety behaviors or will be late in responding to a shift in conversation or a direction. Decisions may seem to take forever and speech may be infrequent and employ a limited number of words. The control systems of the frontal lobes are relatively inactive at birth and continue to be limited in function during early and middle childhood. Children of this age range depend

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upon adults to modulate and control their emotions, to make plans for them, and to set limits for behavioral acceptability. At puberty, the last major maturational change in the brain is the full wiring-up of the frontal systems. Hormonal changes of puberty intensify the child’s desires and emotions and the frontal lobes become fully functional to take control of them. This fact about development has an important implication for the education of students with TBI at the middle school level. It is during that age when greater controls are expected. However, a child with this type of brain injury that was previously undetected may now suddenly appear to be disorganized, impulsive, and out of control. Parietal Lobe Injuries Parietal injury produces perceptual impairment, language comprehension deficits, safety issues, judgment disorder, and difficulty making sense of self and others. The parietal lobes are situated toward the back of the brain, where three jobs are performed. • First, the parietal lobe processes the input of sensations from the body to the brain. Damage to this area may cause individuals to have difficulty recognizing changes in their body state. Hence they tend to stay too cold or too hot, remain seated in an uncomfortable position, or be hungry or thirsty without realizing the problem or doing anything about it. Adults with this type of injury may not recognize a problem for many months. A child experiencing this type of injury may be locked in the past and not realize there is any damage and may, therefore, reject instruction. • Additionally, the parietal lobe contains the “locator” circuits of the brain that tell where things are found and where they are situated in respect to the body. Mental maps are made and used here. The routes taken to drive to a certain location or where on the street the car is parked are imprinted in the mind. Individuals with injury to this area are at great risk of losing their way in the community and in buildings. They also tend to leave things everywhere. • The third and most important function of the parietal lobe is its high-level processing of all the brain’s input data. The parietal lobe brings together all kinds of information to produce understanding. The left parietal lobe generates understanding of ideas expressed in words, including stories, articles, explanations, and requests. Damage to this area has serious scholastic consequences in that individuals are unable to extract complex meaning from words and sentences. The right parietal lobe gives the “big picture” both in visual images and in forming ideas. Since judgment depends upon the ability to visualize the negative consequences of an action (Walker, 1997), right parietal injuries produce impairment of judgment (Damasio, 1994). This area also accesses data files containing information already learned about specific people. When it is damaged, social intelligence may suffer (Schutz, 2003). The reading of emotions and nonverbal communications (including implied messages) may be diminished. The processing system that generates intuition, the lightning-quick understanding

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that goes beyond what you can explain in words, is also based here. This is the part of the brain that takes over in emergencies (Damasio, 1994). It also guides response to novel situations, including the early stages of learning any new skill (Goldberg & Costa, 1981; Goldberg, 2001). Depth perception, perception of shapes and contours, and whole-part relationships are part of this system. Temporal Lobe Injuries Injury to the temporal lobe often impairs the ability to interpret sounds. It can also affect the brain’s ability to automatically turn down sounds that are too loud, so hearing can become too sensitive and noises that others can tolerate may be extremely disturbing. Injury to the back of the left temporal lobe can produce aphasia or loss of the ability to understand speech. Injury to the right hemisphere compromises a person’s ability to perceive the emotions or emphasis in another’s voice. The temporal lobes contain much of the circuitry of the system that produces memory and emotional responses. Individuals with this type of injury may show excessive emotions (e.g., crying and tearing up a test paper with one mistake) or inappropriate laughter in place of other more appropriate emotions. The temporal lobe is also responsible for new learning. Depending on the severity of the injury, individuals may be able to learn only one fact at a time or a few facts in a few minutes. Thus, while a person with this type of injury can learn, he/she may not be able to learn in usual ways like reading a chapter, listening to an explanation, observing a demonstration, engaging in hands-on activities, or looking at a picture. Occipital Lobe Injuries The occipital lobes are a small region at the rear of the brain where sensory input from the eyes is processed. Among both adults and children, cases of occipital damage from head injury are relatively rare. Occipital injury produces problems in recognizing and identifying visual stimuli. Each of the above brain areas interacts with one or more other area(s). Thus, the brain can be thought of as a grouping of networks. Disturbing any one of these areas (lobes) affects other areas. This is especially true in TBI, where broad-spectrum damage is the norm.

Emotional, Psychological, and Behavioral Problems Children with TBI are noted to have a high incidence of emotional, psychological, and behavioral problems for several reasons. First, there is the sudden nightmare of the actual brain injury and then the gradual discovery that one’s previous self was changed, quite possibly forever. The adjustment process could take many years, with false starts and much grieving. The myriad of emotional responses is normal. It is important, however, not to confuse natural reactions like distress, irritation, resentment, confusion, self-doubt, and worry with a mental health disorder. Inappropriate emotional and social behaviors that are a direct result of the injury to a particular area of the brain may be exhibited. For 5

those children with pre-existing mental health disorders, those disorders may worsen after a traumatic brain injury. What are typical behavioral reactions of children with a TBI? Life after a brain injury that includes hospitalization, physical disability, supervision, loss of mental powers and self control, proneness to excessive mistakes, stigmatization, social rejection, and loss of valued personal traits and future potential is almost always psychologically traumatic, even for those with the most robust mental health. Reacting with grief, rage, guilt, self-doubt, resentment, and rebellion is a normal response. Brain injuries challenge every survivor’s sense of personal security, reason for living, spiritual beliefs, trust, and self-esteem. These are strong emotional reactions and can cause other people to over-react. Only reactions that are excessive or inappropriate to the circumstances are symptoms of a psychological disorder (Millon, 1968). The most universal effect of TBI is to rob the child of valued parts of the self – the rewarding social interactions of daily life. Friends may react differently to this child who doesn’t seem to be the same. The child loses inclusion in that he or she is left out of group activities, parties, and conversation. The child may be teased, taunted, and bullied. Children with additional facial and physical deformities, motor impairments, scarring, and speech problems have a particularly difficult time. Those with more subtle cognitive and behavior changes face rejection on a delayed basis after enough time has passed to become fully aware of the behavioral changes. Some children with TBI are no longer considered viable friends. These losses are indescribably painful for older children and adolescents who are seeking to establish a personal identity through their social niche. Children who previously developed special talents often lose their skill level and no longer excel or stand out. Some children feel ashamed and embarrassed by their cognitive deficits and try to avoid situations in which they are expected to perform. Children who have experienced a TBI need time to recognize and cope with their losses. What kinds of mental health problems can be caused by a traumatic brain injury? While all brain injuries are inherently traumatic, it is important to realize that the TBI population includes many individuals who had psychological disorders prior to the injury (Lehr, 1990). The added stress produced by hospitalization, convalescence, and the impairment may cause the person to become psychologically unstable. Unlike cognitive and physical symptoms, which routinely take an improving course, psychological reactions often grow worse over time (Kraemer & Blacher, 1997; Rosen & Gerring, 1986). Emotionally unstable children usually take longer to understand what they have lost, which in turn ignites psychological reactions to the loss on a delayed basis (Lishman, 1968). Children who have experienced a TBI are at increased risk for depression. Screening for and diagnosis of depression is difficult. Grief responses and emotional symptoms caused by the actual injury must be ruled out. Anxiety prone children who become aware of their

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head injuries face greater uncertainty and threat due to the world becoming less predictable and more out of control. Various medications may be prescribed to target specific symptoms. There are medications that can give greater emotional stability, improve mental energy, limit depression, and control behavior in cases of extreme psychosis. What kinds of social behavior problems are symptoms of traumatic brain injury? Impaired social behavior is a common nonacademic difficulty caused by TBI. The most common of social behavior problems is the lack of inhibitions or the tendency to do and say inappropriate things. Before the TBI, the child learned to suppress inappropriate behaviors through years of socialization and training. After the TBI, those inappropriate behaviors are exhibited because the child’s control systems are no longer adequate to hold back the impulses (Lehr, 1997). Handling such behaviors is extremely challenging in the classroom. The social world of peer relationships may be even more demanding than the academic side of school. Social status is awarded and maintained on a competitive basis requiring a youngster to navigate an intricate maze of social rules and norms (Goffman, 1967). There is little tolerance among youth for behavioral abnormalities and flaws. Observing the young survivor of a TBI in the hospital acting passive, bizarre, or unable to make conversation makes anyone, especially children, feel uncomfortable and awkward. Some children will decide to simply avoid the person. Others may try to be sympathetic and maintain contact for a period of time. However, they may discover that the old patterns of interaction, shared interests, and common activities can not be re-established. The change may be due in part to restrictions placed on the child by doctors or parents (Pollock, 1994) or by the fundamental change in the way the child with TBI acts and reacts. In other words, the child’s behavioral style may be quite different. Children with TBI may become distanced from previous friendships and unable to make new ones. The loss of friends, social status, and popularity may cause the child to experience feelings of awkwardness, rejection, stigmatization, isolation, and loneliness (Lehr, 1990). These effects undermine the child’s self-esteem, ability to handle stress, and ability to cope, and limit opportunities for further social skill learning (Cooley et. al., 1997). Is counseling or psychotherapy useful? The more severe the TBI, the greater the need for specialized treatment and programming. Individual counseling or psychotherapy offers needed help to children having a TBI. Counseling a child with a brain injury is not like other mental health undertakings. As the child becomes more involved in recovery activities, there is additional stress. It is useful to establish counseling relationships almost immediately to deal with the stress of recovery and adjusting to the new self. Therefore, early recognition of the child’s needs is crucial.

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Cognitive Impairments Cognitive impairments resulting from a traumatic brain injury may produce an academic disability by affecting learning, productivity, organization, reading and writing speed, concentration, comprehension, and behavior. Extensive cognitive difficulties may be long-term and be of significant concern to the child and family. What are typical cognitive effects of a traumatic brain injury in children? The cognitive impairments that result from injuries produce academic difficulties by making the individual unable to do the job of being a student (Cohen, 1986). The student no longer knows a way to read that will produce accurate comprehension and adequate learning. The student does not know how to take a test so that full knowledge is demonstrated. The same applies to receiving a lecture or even a homework assignment. Behavior no longer can be self-managed to satisfy teachers and get along with peers. Even elementary tasks like packing a backpack for school, traveling from one class to another, and obeying school and classroom rules are no longer accomplished properly on a consistent basis. The student needs to be taught another way to be a student, one that will be effective despite the impairments. Cognitive impairments produce accumulating academic problems. The child with a TBI who returns to school no longer learns at a normal rate. By the year’s end, it is predicted that the student’s knowledge base will drop below grade level. As the child advances through the grades, the knowledge base falls even farther and farther below normal (Walker, 1997). The incomplete knowledge also produces progressively greater disability in performing academic tasks. For example, a child injured before learning to work with fractions is at risk to fail not only at this elementary level application, but at higher level applications of fractions taught in later years, as well. Therefore, this learning deficit deprives the child of age-appropriate knowledge and future knowledge and applications (Janus et.al., 1997; Klonoff et.al., 1993), and the child falls further and further behind peers. Can the brain be fixed? There are two ways of dealing with cognitive impairments. One is to change the environment so that it demands less from the brain, lowering demands to the point that the impaired brain’s functioning is adequate. Changing the environment involves “helping” the child with a TBI. For example, criteria for a passing grade could be lowered from 65% to 50% in order to accommodate the student’s cognitive impairment. Hopefully, the time will come when the bar will be raised to accommodate the student’s progress. The second way of dealing with cognitive impairments is through instruction/training. Instruction/training is effective when the methods are highly structured, individualized, and designed to maximize both information processing and motivational impact.

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Cognitive experts provide three theories of correction or remediation (Diller, 1987). The first, which is widely accepted and probably the most popular, is described as “mental muscle” theory (Howard, 1997). Mental abilities are likened to physical strength and the brain is thought of as a muscle. If the brain is too weak, it needs to be exercised. Treatment consists of having the person practice the skills that are impaired using repetitive or rote drills. This approach is popular in the rehabilitation world since it echoes the work done with orthopedic and stroke patients. Consequently, there is a longstanding tradition of using this approach and much information is available about it. However, this theory does not make any sense to those who take a behavioral neuroscience perspective since it does not deal with what was “broken.” According to these theorists, exercising the most impaired cognitive abilities produces little or no benefit (Ben-Yishay & Prigatano, 1990; Cicerone et al., 2000; Diller, 1987; Gross & Schutz, 1986; Kavale & Mattison, 1983; Mann, 1979; Schachter & Gilsky, 1986). The mental muscle theory may be likened to a paraplegic patient trying to cross-country ski to exercise his weakened legs. The second theory is developmental. This theory holds that the injured person’s cognitive skills can be restored or relearned by retracing developmental learning increments and steps. Support for this theory is drawn from comparisons between impaired persons and immature persons. However, some experts believe there are fundamental problems with this theory in that brain damage does not actually mirror developmental immaturity. Revisiting the cognitive sequence of development does not repair the damage. Also, caregivers and educators often provide too much help to children with a TBI by confusing the process of maturation with adaptation to the disability. Parents and teachers alike tend to try to “retrain” the skill as it was done when the child was younger, before the injury. The brain system, however, has changed. The third theory is neurobehavioral. It seeks to restore practical abilities by rebuilding or replacing the injured brain functions. This theory focuses on the ways in which the brain combines, organizes, and structures information (Kosslyn & Koenig, 1992; Neisser, 1976; Pinker, 1997). It looks at both the automatic and the deliberate aspects of mental activities (Schwartz & Begley, 2002). Proponents of this theory believe that the child with a brain injury can be trained to correct the injured brain processes through the sequencing of instruction. Instruction begins at the child’s present level of functioning and proceeds with incremental steps toward the overall goal.

What strategies can be used to address cognitive impairments? A cognitive intervention program should help the student and family by emphasizing that the main task of relearning is manageable. Students need to be well aware of following those important elements of a cognitive training program: • understanding how his or her new brain differs from the old one • understanding that success matters and that success should be tracked • facing challenges and sounding a warning before those challenges result in frustration

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• • • • • • •

planning and writing the schedule for the day following the same routine every day following a study system that plants new memories

outlining and organizing thoughts and explanations

recording information so that it does not get forgotten or lost using planning tools and techniques to get the big jobs done implementing a self-reminder system.

The Family Situation The family may be more traumatized by the injury than the child is. A “new” child emerges from the injury. The “new” child resembles the lost one in many ways, but may be more needy, unreliable, unreasonable, uncontrollable, and provocative. The new version may not have the same charm, sensitivity, poise, maturity, and communication skills. The child’s best features may be dimmed and the worst ones accentuated. The more impaired the child is, the more clearly the family ambitions and dreams for the child may need to be changed. Many families may need to worry about the child’s ability to hold a job, get married, manage a household alone, and live outside family supervision. Whether the family gets all this bad news in one sitting, or in a gradual way, it is difficult to accept. School can be another emotional blow. The child and parents expect a triumphant return to school and a happy reunion with classmates. Instead, events at school may reveal social estrangement and learning difficulties. School is the child’s main job and the yardstick for competitive excellence. Parents now discover that their child can no longer get the job done and will have difficulty measuring up to where he or she once stood academically and socially. This situation puts demands on the family in terms of needed support, understanding, and guidance. It is helpful for the family and school to work in concert to assist the student. What characterizes the family after the child is injured? One must keep in mind that family members were also traumatized. On the day of the injury, parents might have received a telephone call from the hospital’s emergency room, rushed down to the hospital, and found their child laid out on a bed in an odd position with head swelling and hollow eyes. The child may have been unresponsive or even in a coma. Family members are emotionally and physically depleted by the hospital experience. Later hospital or rehabilitation center experiences may encourage false hope. Every day the child gets better and accomplishes new tasks. Speech and thinking keep getting longer and clearer. Parents see the child walking with therapists’ support, dressing with help, and re-mastering reading and math skills. Therapists talk only of things that are improving, and everything seems to be improving. During the hospital and rehabilitation center stays, family responsibilities pile up. Parents feel an urgency to get the crisis over with and expect ordinary life soon. At some point, usually in the middle of inpatient rehabilitation, family members run out of leave time and must go back to work. The staff encourages them to return to work. However, at the point of discharge, the child may still

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require 24- hour supervision for safety. In cases where parents work, relatives and baby sitters need to be brought in to supervise the child. In some cases, parents may have to choose whether to give up their jobs or place their child in a residential facility. When the parents meet with the school for the first time, there is a good chance that bills are piling up, other children are clamoring for attention, and the house is in disarray. Everything that was put on hold during hospitalization now has to be handled. Marriages are strained and parents may have developed health problems due to the stress. The entire family may appear over committed (Corbett & Ross-Thomson, 1996). Many parents are profoundly wounded to see their child lose his or her special gifts and talents. Some families experience a spiritual crisis and need guidance. The injury forces parents to change their lives in extreme ways as they try to cope with the demands of this new life. Some parents react in ways that are definitely not productive, including bending over backward to bring their child joy and hold off any sources of unhappiness, being extremely permissive or punitive, and feeling guilty about the circumstances of the injury. What are some practical recommendations for the family of a child with a traumatic brain injury? There are some practical recommendations for the family. • Obtain results from the assessments. Families need to learn as much about the actual brain injury as possible, including the effects of the injury on the child’s abilities. Specifically, parents need to ask about the location and extent of the damage that was identified by medical tests (CT & MRI) and findings made by all professionals (speech and language therapist, occupational therapist, and neuropsychologist). Parents should take notes. • Get educated. Parents should attend educational programs sponsored by the hospital, read books on TBI, and search the internet for information. • Ask the school to test the child. The school psychologist can administer an academic battery of tests that will provide information to help in developing an instructional plan for the child. • Find out how to help the child become an effective student again. Parents should let the school staff know their willingness to work in partnership and provide additional assistance to the child at home. Parents can serve as supportive home therapists in terms of helping with homework and reinforcing instructional strategies learned at school. • Request a child study team meeting. The child study team will work along with the parents to determine eligibility for any special services and, if needed, an individual educational plan for the student based on the results of the assessments and observations.

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What can schools do to form alliances with families? There are a variety of practices that school staff can implement in order to form and strengthen alliances with families of a student with a traumatic brain injury. Recommended practices (Walker, 1997) are listed below. • Find out what parents want right now, what they are concerned about, and how much they can handle. • Adopt a constructive mindset by valuing and respecting parents and appreciating their contributions openly. • Regard parents as experts, particularly in terms of their child’s background, personality, and home and community life. • Show interest in the child’s life at home. • Offer to share classroom data about the child. • Value parents’ input, be open to their opinions, and accept corrections from them. • Give parents choices and let them direct discussion of topics. • Try to talk the parents’ language by staying away from technical terms and jargon. • Pace conversations with parents so they can keep up emotionally and in terms of the information. • Prepare parents for formal meetings by sharing appropriate information with them ahead of time so that they have a chance to read, digest, and understand it. • Use the word “we” liberally when it comes to making plans. • Show interest in what parents have to say through body language and checking to make sure you understand their opinions and ideas. • Summarize what parents say and verify that comments were heard correctly. • Check in with parents frequently to find out how satisfied they are with the education of their child. • Be sensitive to the parents’ and the difficulties of their situation. Give parents time to talk it out, if necessary. • Develop a shared agenda for meetings that addresses the parents’ concerns and the school’s concerns. • Create an environment that feels safe to parents. A family member can indeed serve as the school’s most important partner in educating the child with a TBI.

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Teaching Students with Traumatic

Brain Injury

What happens when a student who experienced a traumatic brain injury re-enters school? Not all the symptoms of a traumatic brain injury may be evident as the student re-enters school, especially if the injury was relatively mild (Clark, 1996). However, as the academic and social behavior requirements of school increase, other symptoms may begin to appear. This may even happen up to one or two years later. This may be the first time that the teacher has had a student with a brain injury. The teacher may not understand the specific needs of the student and the difference between how that student learns and behaves as compared to other students in the class. The teacher may relax expectations, at least for a time. At some point, the student may begin to establish a track record of failure and inappropriate behavior. At the beginning, the teacher may be prone to make excuses for the student and even write those problems off as matters of psychological and emotional adjustment to the injury. The student’s inappropriate social behavior and early difficulties relating to peers may seem to give evidence of just such an adjustment difficulty. The student may begin to recognize that he or she is unable to understand and learn information and is unclear about what went wrong. Mounting anxiety begins to cause new confusion from the overload of new situations and expectations. It is likely that school will become a place of unpredictable and negative experiences and the student may want to withdraw from it emotionally or physically. After an adjustment period, the teacher will realize that the student is experiencing problems. A teacher with limited knowledge of brain injuries may allow still more time for the student to “heal.” This, however, is not the answer. Too much time allowed as an adjustment period can be characterized as wasted opportunities. What can the teacher do as soon as a student with a traumatic brain injury re-enters school? The challenge for the teacher is to recognize the extent of the academic and social behavior problems before school failure damages the student’s confidence. The teacher needs to become sensitive to and cognizant of the student’s symptoms. Seen individually, the student’s errors may look just like the errors other children make. It is the pattern of errors that is distinctive. To assess this pattern, the teacher can complete a checklist (appendix 1.) allowing the identification of problem behaviors. The Student Checklist can be completed on a daily basis in order to establish a baseline record of the behaviors over time. The frequency of the behaviors can be calculated over a period of two to three weeks to determine the extent of the problems. The results of using the Student Checklist

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can be used in developing an instructional and/or behavior management plan for the student. What services are available for students with TBI? Students with traumatic brain injury can be provided services under Florida Rule 6A6.03015, Florida Administrative Code (FAC): Special Programs for Students Who Are Physically Impaired. The term physically impaired as used in this rule includes students with traumatic brain injury. The rule includes specific criteria for eligibility (www.firn.edu/doe/rules/6a-62.htm). The rule states that a student is eligible for a special program if the student “has acquired an external injury to the brain as documented by a medical report and has significant difficulty requiring an adaptation to the school routine, school environment, or curriculum in one (1) or more of the following areas: cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem solving; sensory; perceptual and motor abilities; psychosocial behavior; physical functions; information processing; or speech.” An individual educational plan (IEP) will be developed for a student who meets the criteria stipulated in Florida’s rule based on a medical examination report (within the previous three-month period) from a physician; observations by more than one person (including parent, guardian, or primary caregiver); screening or evaluation results in cognition and information processing, academic functioning, fine and gross motor skills, communication, behavior and emotional status, and adaptive skills; and a neurological evaluation, when requested by the administrator of exceptional student education or designee. The team approach is used in analyzing evaluation results and developing an IEP based on those results. The team will identify the student’s present level of performance and establish goals and objectives and strategies to address specific academic and behavioral needs. The IEP will also identify any necessary related services, including physical and occupational therapy and accommodations that will be provided to the student.

What classroom strategies can be implemented for a student with TBI? In classroom situations, structured activities and a predictable routine are key. Students with TBI perform best under conditions of high structure, regardless of their particular deficits. The more routine the classroom procedures are, the better the student will do academically and socially. Deviations from the routine are less disturbing if the student is informed about them in advance. For example, the student should be told of planned teacher absences by the teacher and not by the substitute. The student can be greatly aided by a syllabus of topics to be covered in class and a schedule of events, testing dates, and due dates of pending assignments. Field trips and other special events destroy the normal routine and produce confusion for students with TBI. Field trips to unfamiliar settings are particularly problematic since they add to the student’s disorientation. A maximum effort to provide structure for these events would include a detailed schedule

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given out at least a day in advance, maps, and pictures of the setting. The student with TBI could be assigned a partner or chaperone to help facilitate participation in the field trip. New material can be presented in several ways. First, the student with a TBI can be prepared ahead of time with a summary of what is about to be discussed. In addition to a summary, a topical outline can be provided a day in advance of the scheduled new learning. This gives the student the opportunity to review the information at home with his or her family. The summary can also be presented orally at the start of the lecture. It may also be helpful to put the outline on the chalkboard before beginning the lecture (DeBoskey, 1996). Important points should be explicitly identified as being important. Transparencies can be color-coded for importance (Russell & Sharratt, 1992). Key points can be stressed by changing voice tone and repeating comments. The organizational structure of speech is strengthened by numbering multiple points as they are explained or by transitioning from one idea to another with an announcement such as “next.” Groups of related ideas should be summarized frequently. Second, learning is enhanced by depth of processing that involves integrating new information with information already known. In other words, connections between new material and that which was discussed earlier must be made. Presenting information that is personally important to the student will help to enhance learning and recall. Linking lecture material with material in the textbook is similarly helpful (DeBoskey, 1996). Main points can be repeated in the introduction, main body, and summary parts of a lecture. Many teachers include this strategy in all their teaching, particularly in the early grades. In this vein, the student with TBI requires preparation, organization, and linkage much like that needed by a younger child. Third, the teacher may present directions by listing and numbering the steps involved in the task, rather than by a running narration. The most organized method of presenting extended information is used in programmed-instructional texts. Such texts, when available, may facilitate the learning process for students with TBI. When programmedinstructional texts are not available, the teacher can adapt other texts and materials using the same approach. Lastly, the teacher should consider presenting information in the student’s preferred mode of learning (written, auditory, kinesthetic, or a combination) to increase comprehension. Some students with TBI are quite sensitive to the mode of presentation. For example, a student whose preferred mode is visual may have great difficulty understanding the content if the teacher presents the material verbally. Should teachers consider anything else when instructing students with traumatic brain injury? Teachers need to avoid pressuring a student with TBI to respond quickly. Instruction needs to be paced slowly and presented in a low-key manner. Due to slow processing, students are often unable to articulate their points and thoughts before the other person

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has gone on to new ones. This can frustrate the student to such a degree that he or she no longer wants to participate in the conversation or becomes overly agitated. If the student continues to experience this inability to hold his or her own in a classroom discussion or debate, a more explosive outburst will result. The student needs to be accommodated in order to be able to participate effectively. Appendix 2: Summary of Best Practices for the Classroom is a list of helpful suggestions that can be used for all students, including students with TBI. It is not expected that implementing these practices in the classroom will call undo attention to the student with TBI. Instead, the practices can easily be integrated into the regular scheme of classroom events. The list provides only a few suggestions. Many others related specifically to the needs of each individual student may be generated. What are some best practices for addressing psychological issues in the classroom? There are a variety of practices that teachers should consider when addressing the psychological needs of students with traumatic brain injury. Figure 3: Pocket Summary of Best Practices for Addressing Psychological Issues in the Classroom identifies many of these helpful practices, including ways to de-escalate angry behavior, strategies to train students to use systematic self-control steps, and considerations when making a mental health referral. Are there suggested classroom strategies that will accommodate students with TBI? Appendix 4: Suggested Classroom Strategies to Accommodate Students with Traumatic Brain Injury provides a listing of instructional strategies for problematic areas including speech and communication, verbal and written comprehension, organization, information processing and memory, behavior, physical, and academic. This is not an exhaustive list, but rather a good place to start. This list of suggested strategies can be particularly helpful after a student’s problem areas are identified through the Student Checklist.

Summary Thoughts Communication and cooperation between parents and teachers are key ingredients in furthering the progress of students with a traumatic brain injury. The re-adjustment process and the ultimate success of the injured student in school and in the community are vital for future achievement and personal satisfaction. It is the responsibility of all those involved to search out every available means to further these ends.

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√ Observe

Appendix 1

Student Checklist

Check if the student exhibits the following behaviors and characteristics. Speech & Communication Uneven cadence of speech Reduced breath control Dramatic softness/loudness of voice (difficulty modulating volume) Slurred speech Unusual tones of speech Impaired ability to interpret sounds Way of expressing self is confusing (not sure what he/she is trying to say) Starts to talk before figuring out what to say Talks excessively, utterances are too long, monopolizes or goes off on tangents Verbal & Written Comprehension Unable to extract meaning from words and sentences Unable to read nonverbal communications Confused by lecture format Misunderstands verbal instructions Makes errors when given verbal instructions Organization Diminished awareness Lack of awareness when activities are changed Difficulty moving between classes Not in seat for start of class Materials (e.g., notebook, pencil, glasses) are not out and ready when assignments are given Needs to have assignments repeated Does not attempt to write down assignments Assignments are not turned in on time Needs special cueing to turn assignments in on time Homework not submitted Excuses for not turning in homework Unable to take notes Fails to complete in-class assignments Puts papers in wrong sections in notebook Leaves personal belongings in the classroom Late in leaving the class (or needs special cueing to leave)

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Information Processing Disorganization of thought Leaving things behind Losing one’s way Decision-making is slow Excessive asking for teacher’s guidance, directions, and approval Working very slowly Behavior Talks out of turn or at inappropriate times Violates classroom rules Out-of-control behavior Emotional outbursts Stands up or leaves desk or room at inappropriate times Off-task behavior during reading or testing Passive and unresponsive Shows excessive emotions Depression Loss of friends Argumentative with teacher Argumentative with peers Uncooperative Disobedient Name calling Refuses to attempt tasks or makes only half-hearted attempt Withdrawn from peers/isolated Physical Impaired balance and coordination Sloppy writing Fatigues easily Headaches Academic Retains less content than peers Requires more time to learn Needs cues to recall information Exhibits difficulty comprehending information he or she knew previously Has difficulty completing tasks Exhibits difficulty copying from the chalkboard Has difficulty finding way around the school

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√

Self-Check

Appendix 2

Summary of Best Practices for the

Classroom

The following are best practices for all students including students, with traumatic brain injury. It is not expected that implementing these practices in the classroom will call undo attention to the student. Instead, the practices can easily be integrated into the regular scheme of events. The list provides only a few suggestions. Many others related specifically to the needs of the individual student may be generated.  Understand the student’s injury and impairments and keep track of the symptoms by using the student checklist periodically.  When transmitting information: make sure the student is ready, control the amount and rate of information, summarize frequently, organize the content, link information to facts already known, use the student’s best mode of learning, and encourage notetaking and tape recording.  When giving assignments, encourage verbatim recording, verify understanding of the tasks, and provide handouts.  Train the student to use the time available before giving a verbal response as a time to practice or prepare for that response.  Have the student make eye contact with the speaker to confirm understanding what is being said, test for comprehension.  Learn to recognize overload.  Simplify reading, writing, mathematics, and other assignments in order to accommodate the student.  Make creative use of simple visual aids.  Be vigilant for any confusion over curricular content.  Give explicit and supportive feedback, both orally and in writing.  Use assistive devices (e.g., communication boards), when necessary.

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 Use behavior management techniques, particularly positive reinforcement of appropriate/desirable behaviors.

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√

Self-Check

Appendix 3 Summary of Best Practices for Addressing Psychological Issues in the Classroom

 Consider the possibility that the student is trying to respond normally to a highly abnormal situation before assuming he or she has a psychological problem.  If the behavior is extreme, investigate the history of any mental health issues.  Solicit the help of a consultant with experience managing problem behaviors associated with TBI.  Consider the possibility of a mental health referral to a professional who is familiar with neuro-psychological issues.  Request a neuro-psychological assessment, if such data are lacking.  Remember that inappropriate behaviors are likely to be automatic and reflexive, not deliberate.  Minimize use of criticism and punishment.  Post classroom rules.  Make sure the student is aware of the rule he or she is breaking.  Make the student aware of how he or she is behaving.  Limit distractions and irritating noises.  Re-direct the angry student.  Encourage the angry student to leave the provoking situation to regain control.  Teach the student how to substitute a desirable response (like relaxation) for the undesirable one.  Use time-out procedures, when necessary.

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 Videotape appropriate behavior for self-modeling.  Train the student to use systematic self-control sequence: sound a warning, stop and think, my choices are, will that really work, and talk self through the task.  Consider any programs or activities in which the student is involved to enhance his or her social network of peers.  Consider discussing with the IEP team the need for counseling or psychotherapy to address issues that are specific to TBI in a setting suited for that purpose.

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√

Self-Check

Appendix 4 Suggested Classroom Strategies to Accommodate Students with Traumatic Brain Injury

Speech and Communication • Train students to prepare mentally when waiting for their turn to speak. • Cue students who are unable to retrieve a word to remain calm and substitute another word or phrase in its place. • Arrange for students to use assistive devices for communication (letter and word boards, picture boards, & portable computers). Verbal and Written Comprehension • Encourage student to repeat what was said back to the speaker in his or her own words and have student ask for verification that it was correct. Organization • Keep directions, staff, material, and location of objects as consistent as possible. • Identify specific fixed locations to which every item is assigned. • Give students a daily schedule. • Have the student use a watch with an alarm to remember when to do things. • Send notes home warning of any changes expected in the classroom or curriculum so that the parents can prepare their child. • Send home written directions for completing homework assignments. • Code papers with different colors for each class. • Give student a private early warning to pack up belongings. Information Processing/Memory • Use a visual cue to indicate that important information is coming. • Provide charts, tables, and maps to indicate classroom routines and important locations. • Make sure pictures, diagrams, and forms are uncluttered and free of extraneous material. • Provide lecture notes so that the student can review them at home. • Have another student take notes for the student with TBI. • Break long assignments into smaller units. • Help the student set short-term goals for completing a task. • Limit the number of steps in a task. • Minimize pauses between tasks to discourage distractions.

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• Over-articulate speech when lecturing. • Ask a peer to escort the student to the next class or location. • Have the student describe the route he or she will take before leaving the classroom. Behavior • Assign a paraprofessional or another adult as a behavior coach. • Set up a time-out or cool down procedure for acting-out behaviors. • Post classroom rules for appropriate behavior. • Repeat classroom rules aloud. • Use a quiet voice when reinforcing classroom rules. • Correct inappropriate behaviors by providing verbal feedback to the student regarding the behaviors exhibited and the correct behaviors expected. • Coach other students in the classroom about how to treat the student by using problem solving techniques and scenarios. • Develop and implement a behavior intervention plan. • Teach awareness of all disabilities including traumatic brain injury. • Teach and encourage the use of relaxation procedures. Physical • Shorten writing assignments. • Allow student to record answers on a tape recorder. • Provide assistance in physical activities. • Have a buddy help the student perform tasks. • Use a team or partner approach to accomplish tasks. • Adapt mechanical devices (e.g., key lock rather than combination lock). Academic • Underline or highlight reading material for the student. • Repeat lecture material several times and provide many examples. • Arrange for a tutor or parent to review the material presented. • Give open note tests to compensate for memory loss. • Give simplified tests (e.g., remove the second-best answer in multiple choice tests). • Limit the amount of content in an instructional session. • Pace work to eliminate brain fatigue. • Mark left and right sides of the pages.

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References

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John L. Winn, Commissioner ESE 312636