School Re-Entry after Traumatic Brain Injury:

For Educators

Anne Bradley, Ph.D

Sarah Powell, M.Ed. CCC-SLP

Roger C. Peace Rehabilitation Hospital

Traumatic Brain Injury Program

Goals

• Understanding Traumatic Brain Injury• Returning to School• Identification and Assessment• Intervention and Classroom

Accommodations• Advocacy and Resources

Preview of Section 1: Understanding Brain Injury

• Appreciate the under-reported nature of TBI

• Learn what a brain injury is• Learn how to identify the

level of severity of a brain injury

• Be able to generally predict the early course after injury

Disguised as a Low Incident Disability…

• Each year, an estimated 1.7 million people sustain a TBI annually. Of them: – 52,000 die, – 275,000 are hospitalized, and – 1.365 million, nearly 80%, are treated and

released from an emergency department.

– The number of people with TBI who are not seen in an emergency department or who receive no care is unknown.

Incidence and Prevalence

• Children aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI. 

• Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years.

• Only 200 of every 100,000 cases go to the hospital.

Parts of the Brain

Definition of TBI

• Acquired Brain Injury• Congenital and Perinatal Brain Injury• Traumatic Brain Injury

– Open Head Injury– Closed Head Injury

Acquired Brain Injury

• Brain Injury incurred after a period of normal development– Internal causes– External causes

Congenital and Perinatal Brain Injury

• No period of normal development• Congenital- a condition a child is born with

such as a chromosomal abnormality• Perinatal- a condition that develops

around the time of birth such as a perinatal stroke

Traumatic Brain Injury

• An acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment or both, that adversely affects a child’s educational performance.

Effects of Brain Injury

• Injury to brain tissues at the site of damage

• Shearing and tearing of neurons throughout the brain

• Bleeding, swelling, and lack of oxygen to the brain

• Possible coma

Severity of Brain Injury

• Mild• Moderate• Severe

Mild Traumatic Brain Injury: AKA Concussion - Definition

• Any period of loss of consciousness• Any loss of memory for events

immediately before or after the accident• Any alternation in mental state at the time

of accident• Posttraumatic amnesia is no greater than

24 hours• Signs of concussion nausea and

vomiting, headache, fatigue, dizziness

Concussion: Sports related injuries

Immediate Presentation: Delayed effects:

Mild Traumatic Brain Injury:Typical Early Recovery

• Common effects– Headaches– Lethargy– Dizziness– Sensory

hypersensitivities– Poor concentration

• Course– About 80%

uncomplicated mild TBI’s fully recovery by 3 months

Mild Traumatic Brain Injury: Treatment

• Estimated 80% of concussions are not treated

• Most often seen in the emergency room or by pediatrician and sent home

• Out of school perhaps a day or two, up to a couple weeks

Moderate Traumatic Brain Injury: Definition

• Coma less than 24 hours duration• Post traumatic amnesia 1-24 hours• Neurological signs of brain trauma

– Tissue damage– Bleeding

Moderate Traumatic Brain Injury Typical Early Recovery

• Common effects– Those seen in Mild TBI,

but of greater severity, frequency and longer duration

– Higher risk of focal deficits

– Higher risk of motor deficits

• Course– Generally 3 to 6 months– Greater risk of long term

deficits after initial recovery

Moderate Traumatic Brain Injury: Treatment

• Most often seen in the emergency room or by pediatrician and sent home

• Occasionally hospitalized on an acute care medical unit for days to a couple weeks

• Rarely receive inpatient rehabilitation• More frequently receive outpatient

therapies (most often if there is a deficit in physical functioning)

Severe Traumatic Brain Injury:Definition

• Coma more than 24 hours• Post Traumatic Amnesia more than 1 day

Severe TBI sustained in a snowboarding accident: Recovery after a 2 month coma

Severe Traumatic Brain Injury Typical Early Recovery

• Common effects– Attention-executive,

memory deficits are common

– High risk of focal processing deficits

– High risk of motor deficits

• Course– Generally 6+ months– Over a 1/3rd classified

as disabled after initial recovery period

Severe Traumatic Brain Injury: Treatment

• Short to very long stays in ICU/PICU/ NeuroICU’s

• More likely to get inpatient rehabilitation, but more frequently seen by therapists in an acute medical care setting

• Average inpatient rehabilitation stays are 2 to 4 weeks

• The younger they are the less likely referred to inpatient rehabilitation and the quicker they are discharged home

• Most likely to be referred to outpatient therapy

Review of Section 1: Understanding Brain Injury

• Appreciate the under-reported nature of TBI

• Learn what a brain injury is• Learn how to identify the

level of severity of a brain injury

• Be able to generally predict the early course after injury.

Preview of Section 2: Returning to School

• Identify what actions need to be take to facilitate school re-entry after brain injury

• Identify common physical and cognitive sequelae of brain injury

• Assess issues that distinguish TBI from other diagnoses

• Identify means by which the student’s needs can be assessed

The Process of School Re-entry:Who, When and How?

School Re-entry Who

How

When

The Process of School Re-entry:Who

Family

ChildSchool

Medical staff

The Process of School Re-entry:When

At Injury

Hospital

Stay

Discharge

Home

The Process of School Re-entry:Moderate to Severe Brain Injury - How

Medical Staff

Families

• Identify a family and medical contact person to receive and provide information

• Focus on the provision of medical care

• Integrate the family into the patient’s care

Educational Staff

• Participate in their child’s medical care

• Make their wishes known regarding visits and other contacts

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Moderate to Severe Brain Injury

Medical Staff• Identify a school contact person• Provide updates on progress and needs• Provide information needed for the school

to evaluate the student’s needs and form a reasonable school re-entry plan

• Educate family and school staff

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Moderate to Severe Brain Injury

Educational Staff• Request updates from medical contact

person• Identify appropriate members of school re-

entry team• Share information about student’s prior

achievement and behavior with medical contact person

• Educate medical staff regarding local education resources and procedures

• Update others as needed

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Moderate to Severe Brain Injury

Family

• Consent to allow communication between school and medical staff

• Facilitate contact between appropriate staff members

• Participate in education provided by medical staff

• Make wishes known regarding support needs

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Moderate to Severe Brain Injury

Medical Staff• Inform family and school of discharge date• Provide discharge summaries• Provide summaries of treatment and recommendations• Complete appropriate paperwork to support

recommendations (e.g., homebound, therapies at school, Early Childhood referral)

• Maintain ongoing collaboration with schools as proceeds through outpatient therapies

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Moderate to Severe Brain Injury

Educational Staff• Educate family about homebound, Section 504, and/or

special education process• Refer for special education services if appropriate• Obtain medical records• Arrange for staff education (don’t forget homebound

teachers)• Meet to determine if more evaluation is needed, and/or

what is the appropriate immediate school plan for re-entry

• Maintain ongoing collaboration with outpatient therapies

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Moderate to Severe Brain Injury

Family

• Participate in the school re-entry planning process on the medical and educational system sides

• Make needs known regarding tolerance of risk• Make preferences known regarding priorities for

the current school year• Maintain close communication with outpatient

therapies and school regarding their child’s functioning

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Mild Brain Injury

Medical Staff

Families

• Identify a family and medical contact person to receive and provide information

?Educational Staff

• Pursue appropriate medical care for their child

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Mild Brain Injury

Medical Staff• Provide summary of findings and recommendations• Complete the necessary paperwork for referral for

educational services• Consider referring for therapies and/or follow-up

neuropsychological evaluation• If referred for ongoing therapies, identify contact

person and maintain collaborative relationship with school

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Mild Brain Injury

Educational Staff• Obtain medical records• Educate family about homebound, Section 504, and/or

special education process• Consider homebound services versus part-time in-class

attendance• Assess for Section 504 versus Special Education services• Arrange for staff education (don’t forget homebound

teachers)• Plan to re-assess in 1-2 months• Maintain collaborative relationship with outpatient therapies if

available

At Injury

HospitalStay

Discharge Home

The Process of School Re-entry:Mild Brain Injury

Family

• Participate in the school re-entry planning process on the medical and educational system sides

• Make needs known regarding tolerance of risk• Make preferences known regarding priorities for

the current school year• Maintain close communication with outpatient

therapies and school regarding their child’s functioning

At Injury

HospitalStay

Discharge Home

TBI Students

• Identification• Assessment/Evaluation

Which student has a TBI?

• Can you tell?

Common Problems of Students with TBI

• Anticipating these difficulties can facilitate successful re-entry to school

• Problems can be physical/medical, cognitive, sensory, motor, social, emotional, and behavioral

Physical/Medical Problems

• Problems– Seizures– Fatigue– Headaches– Swallowing/Eating– Self-care activities

• Medication issues

Most Common Physical Deficits:

• Physical Endurance• Mental Endurance• Headaches

Motor Problems

• Apraxia• Ataxia• Coordination problems• Paresis or paralysis• Orthopedic problems

• Spasticity• Balance problems• Impaired speed of movement

Most Common Motor Problems:

• Balance• Fine Motor Dexterity• Motor Speed

Sensory/Perceptual Problems

• Visual deficits– field cuts– tracking (moving and stationary objects)– spatial relationships– double vision (diplopia)

• Neglect / Inattention• Auditory sensory changes• Tactile sensory changes

Most Common Sensory/Perceptual Issues:

• OVERSTIMULATION!• Double Vision• Neglect / Inattention• Hypersensitivities

Cognitive-Communication Problems

• Executive functions • Memory• Attention• Concentration• Information processing• Sequencing

• Problem solving• Comprehension of abstract language• Word retrieval• Expressive language organization• Pragmatics

Most Common Cognitive-Communication Deficits:

• Slowed Processing Speed• Intolerance of Complexity• Attention• Memory

Emotional & Behavioral Problems

• Irritability• Impulsivity• Disinhibition• Perseveration• Emotional Lability• Insensitivity to social cues• Low frustration tolerance

• Anxiety• Withdrawal• Egocentricity• Denial of deficit/lack of insight• Depression• Peer conflict• Sexuality concerns• High risk behavior

Most Common Emotional-Behavioral Problems:

• Fragile Emotional Control• Poor Awareness• Impulsivity• “Just don’t get it”

4 Facts about Identification

• Each student will vary greatly, no 2 will be alike• Changes are unlikely to disappear fully over time• Negative consequences may not be seen

immediately but emerge when developmental demands reveal problems

• An injured brain is less likely to meet the increasingly complex tasks all children face as they get older

Misclassified or Missed Altogether

• Poor transitional services between hospitals and schools

• Timing of injury• Mild TBI slips thru the cracks• Traditional approaches to assessment fail to

provide necessary insight into how cognitive deficits impact school

• Special Ed for TBI vs. LD vs. ED looks different• Deficits are not always immediately apparent

How is TBI different from LD?

• TBI is not “just a learning disability”• Students with TBI cannot be dealt with as

if they have something similar• Although similar, the differences are

important• The impairments are different, as are the

implications for educators

TBI: How is it Different?TBI LD ED

Onset and Cause

Sudden with blow to head and loss of consciousness

Early/ unclear Slow/ unclear

FunctionalChange

Marked contrast between pre and post onset

No before-after contrasts

Changes emerge slowly

Physical Disabilities

Loss of balance, weakness, paralysis

Poor coordination

Unlikely

Behavior Agitation, impulsive, restlessness, disinhibited

Restlessness, impulsive

Variable

Emotions Labile, depression, anxious Prone to outbursts

Reactions due to distortions of reality

Academic Deficits

Based on disrupted cognition

Based on type of learning disability

Not based on impaired cognition

Difficulties with Learning

Old info easier to recall than new info

New learning can be linked with old learning

New learning can be linked with old learning

Information to Determine Needs

• Obtain all medical information you can• Information about areas of functioning

– Cognition and memory– Speech and language; communication– Sensory and perceptual abilities– Motor abilities– Psychosocial impairments– Physical functions/safety– Academic skills

Challenges to Evaluation: Student Factors

• Rapidly changing skills (especially during first 6-12 months)

• Communication, physical, sensory, motor, emotional, and behavioral difficulties may interfere with assessment

• Uneven skill profile (some higher skills preserved with lower skills lost)

• Performance influenced by state and situation• Problems may emerge later

Other Challenges to Evaluation

• The family is probably in distress• Initial assessment is probably conducted

outside school in a setting unlike the classroom

• Much assessment information is needed from other professionals (who are busy)

• Medical reports may be difficult to interpret• Assessment requires IEP team

coordination and planning

What can be done to address these challenges?

• Use classroom data to guide instruction• Use observation, curriculum-based

measures, work samples, trial teaching• Assess across content, time, settings• Invite parents to provide information• Ask medical personnel for assistance• Plan team evaluations• Share information

Cognitive Assessment…is the student?• Processing Speed

– Accurate but slow? • Memory

– Retaining new info from day to day?– Benefiting from context?– Benefiting from repetition?

• Executive Function– Prioritizing? Following through? Staying organized? – Using problem solving strategies?– Shifting from 1 task to another?

• Attention– Able to concentrate? Hold onto information?– Attending to more than 1 thing at a time?– Accurate when carrying out complex tasks?

How can I gather more info?

• Record review (school and medical)• Direct observation (school or hospital)• Student interview (if possible)• Teachers/service provider interviews• Criterion-referenced assessment• Curriculum-based assessment• Rating scales and checklists• Neuropsychological assessment (if available)• Identify cognitive strengths and weaknesses

Review of Section 2: Returning to School

• Identify what actions need to be take to facilitate school re-entry after brain injury

• Identify common physical and cognitive sequelae of brain injury

• Assess issues that distinguish TBI from other diagnoses

• Identify means by which the student’s needs can be assessed

Preview of Section 3:Interventions for Students with TBI• Identify the domains in which you can

intervene.• Identify how common physical, cognitive

and emotional/behavioral sequelae are expressed in the classroom.

• Identify several avenues of intervening to address the impact of sequelae on the student’s ability to benefit from the educational environment.

Intervention

• Environment (space and time)• Instruction and materials• School staff• Peers• Student• Family

Most Common Physical Deficits:

• Physical Endurance• Mental Endurance• Headaches

Endurance:

Primary

Middle School

High School

- Whining- Low frustration tolerance- Conflict with peers

- Shuts down at certain times of the day

- More likely argumentative- Slows down- The slow blink

Physical EnduranceEnvironment Reduce the distance between classes, provide extra

materials, 2 lockers in different areas, adjust shelves, provide comfortable seating

Instruction/materials

Offer breaks between activities, provide rest periods, late arrival, early dismissal, adaptive PE

School staff Assign adult to assist with transitions, be sure staff understand safety issues, coordinate demands across classes

Peers Assign peers to help carry materials, even pick up dropped materials/books

Student Needs to understand his/her limitations, stop activity when limits are reached, report to teacher when tired.

Family Educate on importance of sleep and routine, adjust medications if need be

Mental Endurance

Environment Preferential seating, fewer transitions, less core academic classes, shorten school day, part time or homebound instruction

Instruction/materials

Slow the pace of instruction, reduce the components, provide repetition, provide outlines and class notes, chunk information into ideas, watch for frustration

School staff Check on other class demands, identify patterns of fatigue or inattention, offer breaks

Peers Assign a peer note taker

Student Take rest breaks before fatigue starts, eat healthy snacks, exercise, speak up if tired

Family Educate on importance of sleep and routine, adjust medications if need be

Headaches

Primary

Middle School

High School

- Vague complaints

- Most often able to be more specific, but may under or overgeneralize effect

- Increase with mental/physical exertion

Physical Signs of Severe Pain:

• Pallor• Sweating• Shallow breathing• Elevated pulse• Dilated pupils• Sensory hypersenstivities• Preoccupation• Lethargy

Headaches

Environment Allow student to leave and go to comfortable place to lay down in quiet and darkness; limit noise in classroom

Instruction/materials

Break components down, slow pace of instruction,Provide rest breaks, use intermittent teaching to avoid exacerbation

School staff Educate other staff

Peers Education

Student Encourage student to speak up at first sign of headache

Family Explore medications, consult with family or rehab doctor

Most Common Motor Problems:

• Balance• Fine Motor Dexterity• Motor Speed

Balance

Primary

Middle School

High School

- Higher rate of falls- Clumsy, bumps into things, trips- Slow and extra careful/fearful

- Dynamic balance issues- Multi-tasking while walking- Worse when tired- When burdened

Balance

Environment Keep transitions to a minimum, teachers change class rather than student, provide assistance in cafeteria or in bathroom

Instruction/materials

Adapt physical education requirements, provide adaptive equipment when needed

School staff Monitor safety in an unstructured or crowded setting

Peers Be aware of students needs, no pushing or running in halls

Student Leave plenty of time between classes to walk, do not carry too much, hold hand rails

Family Consult with family on strategies used at home

Fine Motor Dexterity

Primary

Middle School

High School

- Slow and laborious- Propping elbow, bearing down- Sloppy work- Hard time with separating zippers and

buttons

- Illegible written work- Difficulty completing written work

in a timely manner- Lecture notes sketchy, incomplete

Fine Motor Dexerity

Environment Allow student to use computer, consult with OT on adaptive equipment

Instruction/materials

Chunk work into manageable pieces, reduce expectations for written work, assign a scribe, utilize tap recorder; time extensions when needed

School staff Coordinate strategies across classes; provide set up in cafeteria

Peers Can offer to take notes

Student Allow student to report verbally

Family OT and PT referrals, medication options

Motor speed

Primary

Middle School

High School

- Could you be any slower?

- Always the last one- Slowed reaction times

Motor Speed

Environment Have students leave class early to afford more time and less congestion in hallways, consider desk placement, watch for rugs, etc, clear pathways

Instruction/materials

Consider a second set of books at home

School staff Notify staff of student’s deficits and allow for extra time

Peers Teach peers no rough housing, to be careful on playground

Student Teach student to keep hands free in case of balance problems, take their time,

Family Allow extra time for morning and homework routines

Most Common Sensory/Perceptual Issues:

• OVERSTIMULATION!• Double Vision• Neglect / Inattention• Hypersensitivities

Overstimulation:

Primary

Middle School

High School

- The Butterfly Effect- Wide-eyed apprehension- 0verexcitable- If escalate, leads to tantrums

- Quiet disorganization, omissions, errors

- Shut down and shut out- IRRITABILITY to

argumentativeness to agitation

OVERSTIMULATION

Environment Limit distractions and noise, decrease clutter, help organize students notebook

Instruction/materials

Use small group instruction whenever possible, watch for signs of decreased frustration tolerance, provide routine and schedule

School staff Recognize early signs of overstimulation and have plan in place in case of escalation

Peers Educate peers on noise level, consider other students needs/deficits, educate on signs of overstimulation

Student Encourage student to take rest breaks before getting over stimulated

Family Explore medications

Double Vision

Primary

Middle School

High School

- Holding materials up to one eye- Head hovering over materials- Poor hand-eye coordination

- May or may not wear eye patch as prescribed

- Overreaching- Worn out- “lead with one eye”

Double Vision

Environment Preferential placement near the board / in uncovered eye’s field of vision.Clear path to desk. Early dismissal to transition to next class

Instruction/materials

Oral presentation and demonstration of mastery until addressed. Visually simplified materials.

School staff Encourage student to take rest breaks. Provide peer and/or lecture notes.

Peers Provide a peer to take notes and/or review for accuracy.

Student Consult occupational therapy regarding possible use of a eye-patch.

Family Encourage referral to neuro-ophthalmology consultation.

Inattention / Neglect

Primary

Middle School

High School

- Loses things /takes a long time to find things

- Complains that others move things

- Runs into things on the left

- Miss information when reading!!

- Miss information from the left side of the classroom

- Can’t follow scantrons- Mix up math signs- Lose track of organization of

math problems

Neglect/Inattention

Environment Provide preferential seating, position the student toward the left side of room or best visibility, audio record materials

Instruction/materials

Use cut outs or overlays, highlight margins, dark lined paper, anchor on page for student to look to, provide extra written copies of materials, use large print

School staff Inform all staff of students needs, ensure appropriate supervision for safety

Peers Teach peers to cue student to look left

Student Adjust placement of materials, respond to cues by nodding head, monitor comprehension, read out loud

Family Ask the family what strategies are used at home that can be generalized to the classroom

Sensory Hypersensitivities

Primary

Middle School

High School

- Vague complaints about aches and pains

- Rubs eyes, covers ears, winces

- Lashes out at energetic peers

- Dislikes being touched

- Startles at loud noises- Shuts down- complains about “too bright” “too

loud” “too much”

Hypersensitivites

Environment Consider more natural types of lighting rather than artificial lighting, use dim lighting, quiet environment

Instruction/materials

Preferential seating, trial of colored lenses

School staff Consider alternative placement

Peers Educate peers on student’s deficits and needs

Student Rating scales of strategy usefulness

Family Consider audiological evaluation

Most Common Cognitive-Communication Deficits:

• Slowed Processing Speed• Attention• Intolerance of Complexity• Memory• Reasoning and Problem-solving

Slowed Processing

Primary

Middle School

High School

- Looks impulsive: needs more time than giving self

- Dazed/overwhelmed look

- “Huh?”- Misses information, you wonder

about attention- Does really well 1:1, but

overwhelmed in the classroom- Homework looks good, but timed

tests are poor- Doesn’t produce information “on

the spot”

Slow Processing Speed

Environment Reduce distractions, create opportunities for student’s to work in small groups, position student for optimal learning

Instruction/materials

Give smaller segments of information, allow extra time for processing, emphasize and repeat key points, pair visual info with verbal instruction, model what your expectations

School staff Educate others on student’s deficits, get student’s attention first before trying to provide instructions, allow extra time for response

Peers Educate others on student’s deficits, get student’s attention first before trying to provide instructions, allow extra time for response

Student Teach student to clarify information, monitor comprehension, ask questions or give a signal when he/she doesn’t understand, watch others, examine sample

Family Educate others on student’s deficits, get student’s attention first before trying to provide instructions, allow extra time for response

Attention

Primary

Middle School

High School

- Short attention span- Distractible- Forgetful, loses things- “Watch Where You’re

Going!”

- COMPLEX ATTENTION !- Managing the complexities of a

day to day, and long-term schedule

- Thing needed at school is at home, thing needed at home is at school

- Forgets things outside of routine

Attention

Environment Reduce factors that interfere with the student’s ability to attend (noise, light), provide preferential seating in the classroom

Instruction/materials

Match the student’s abilities to attend; Plan activities that don’t exceed the student’s attention span; Break tasks into smaller parts

School staff Be sure student understands instructions, identify factors that facilitate/interfere with attention

Peers Educate peers on attention types and strategies; have them limit distractions and interruptions

Student Use a timer to focus attention for a specific period of time, monitor attention to task, complete a pre-determined amount of work and then take a break; have student clarify information

Family Discover student’s interests, encourage good study habits

Complex attention

Intolerance of Complexity

Primary

Middle School

High School

- Relies fairly heavily on routines

- Focuses on the details- Disorganized work

Have more difficulty when:- Out of routine (novelty)- Lots of information at once- Has not mastered or is not

provided over-arching organization

- Higher level of abstraction/integration

Intolerance of Complexity

Environment Adhering to routines

Instruction/materials

Break material down into smaller components, provide student with outline, provide student with pre-instruction, given written materials, monitor student’s comprehension of materials, alternate complex lessons with more simple material

School staff

Peers Consider asking peer to take notes

Student Ask for clarification, ask for rest breaks, consider using study strategies or alternative ways to organize/study, teach time management

Family Consider a tutor

Memory

Primary

Middle School

High School

- Inconsistent performance- Clingy to teacher- Vigilant to what peers are

doing

- Gets it in the classroom with its extra cues, but not when on own

- Studies the material to mastery, then bombs the test

- Defensive or flippant

Memory

Environment Consistent routines, sequences, and schedules; use visual aids, create environment that doesn’t rely on memory

Instruction/materials

Chunk work into manageable pieces, highlight important information, provide rehearsal and practice, use written instruction, provide prompts and cues, mnemonic devices

School staff Use repetition and consistency, create assignment sheet that all teachers can use

Peers Buddy system, peer note taker

Student Use planners, external memory strategies, keep routines, generate their own memory cues, keep journals; teach compensatory strategies; awareness training

Family Generalize strategies from home to school and vice versa

Reasoning and Problem-solving

Primary

Middle School

High School

- Follows scripts doggedly- Tend to acquire rote

academics well- Struggle with application

- Acquires the concrete facts and skills, but struggles with inferring and integrating information

- Tends to run into the same problems repeatedly, depending on others to generate solutions

- Relationships tend to wax and wane

Reasoning/Problem Solving

Environment Reduce unnecessary frustrations or problems, be sure there are enough materials for everyone, provide visual cues

Instruction/materials

Use clear instructions, expectations should be clear, include samples, explain format/structure, maintain consistency and routine

School staff Provide adequate supervision, be aware of student’s limitations, provide cues, help student identify a problem solving approach

Peers Be aware of the strengths and needs of the student, seek adult assistance when dealing with an issue, use a problem solving model/approach

Student “Stop and think,” Seek adult assistance, be aware of environmental cues, listen

Family What strategies work at home, be consistent

Most Common Emotional-Behavioral Problems:

• Fragile Emotional Control• Impulsivity• Poor Awareness• Poor Social Judgment and Pragmatics

Fragile Emotional Control

Primary

Middle School

High School

- More frequent tantrums- Emotional meltdowns

- Easily triggered temper- Not responsive to reasoning and

less responsive to soothing when escalated

- Dramatic reactions versus flat mood

Fragile Emotional ControlEnvironment Identify a quiet, safe place that all staff know about and

use to help student de-escalate.Evaluate environmental antecedants

Instruction/materials

Ensure expectations are matched to the student’s instructional level.Once completes a difficult activity, allow a break.

School staff Keep your voice firm, calm, low toned and SLOW.Talk as little as possible. Avoid attempts at reasoning, demands for articulate responses, or talking to soothe.Do not approach the student until de-escalates.

Peers Teach early signs of agitation and appropriate response.Enforce intolerance of intentional provocation.

Student Teach routine of behaviors and consequences.Teach self-soothing strategies and reinforce use.Reward positive behavior, particularly ability to tolerate frustrations and disappointments.

Family Assess external events that may be having an impact on well-being. Collaborate on carry through at home.

Impulsivity

Primary

Middle School

High School

- Responds to every single thing

- Impulsive aggression and affection

- Blurt out now, regret later- Gets in more trouble during

transitions between or during unstructured activities

- Sloppy errors- Processes it all “out here”- Reduced control over behavior

when emotional

Impulsivity

Environment Structure, structure, structureUncluttered immediate area.

Instruction/materials

Modify materials to increase structure, completing one task before moving on to the next.

School staff Collaborate on consistent responses to impulsivity, environmental modifications and expectations.

Peers Limit access to peers who trigger impulses.Enforce intolerance of intentional provocation.

Student Direct instruction in delaying responses and reinforce use of this strategy across all staff.

Family Collaborate on consistent responses to impulsivity, environmental modifications and expectations.

Poor Awareness

Primary

Middle School

High School

- Everybody’s so mean.- Repeats the same

mistakes over and over and over again

- Completely misses the fact that there is a problem in what they’re doing

- Misattribution of the cause of difficulty

- Doesn’t anticipate what should be doing because of the problem

Awareness

Environment Structure activities so that they provide immediate feedback.

Instruction/materials

Provide self monitoring tools, rating scales, point out strengths and weaknesses, consider providing direct instruction using an awareness model

School staff Educate…”this is an issue, not an attitude.” Learn what is TBI versus adolescents

Peers Help facilitate peer feedback

Student Teach student to use self management strategies, rating task completion/success

Family Be consistent

Poor Social Judgment and Pragmatics

Primary

Middle School

High School

- Do okay if rely on structured games and routines for social interactions

- Need to be explicitly taught the rules of social behavior

- Rely on social rules rigidly

- Blurt out now. Regret? What regret?

- Can’t perceive and integrate multilayered social communication

- Don’t know where the line is

Social Judgment and Pragmatics

Environment Include structured, adult supervised social activities at lunch or recess, Provide supervision to prevent altercations

Instruction/materials

Include direct teaching of social skills, include a social skills model, provide opportunities for practicing role playing, consider videotaping

School staff Make sure staff are aware of student’s limitations, provide consistent feedback

Peers Teach peers to understand the difficulties of the student, show respect for others and be considerate, ask for adult help if needed

Student Pay attention to social cues, be aware of strengths and weaknesses, identify social rules in specific environments, consider others perspectives

Family Provide feedback to student, generalize strateiges

Review of Section 3:Interventions for Students with TBI• Identify the domains in which you can

intervene.• Identify how common physical, cognitive

and emotional/behavioral sequelae are expressed in the classroom.

• Identify several avenues of intervening to address the impact of sequelae on the student’s ability to benefit from the educational environment.

The Lost Kids

• If so many children have brain injuries, why can’t we find them in the schools?

Preview of Section 4:Advocacy and Resources

• Be able to define advocacy• Be able to identify barriers to advocacy• Be able to identify what you can do to advocate for the

students in your class with brain injury• Be able to identify strategies to empower parents to

advocate for themselves and their child• Identify resources for deepening your understanding of

brain injury• Identify resources for expanding your skills in facilitating

school re-entry after brain injury

Advocacy… what is it?

• "Advocacy" can mean many things, but in general, it refers to taking action. Advocacy simply involves speaking and acting on behalf of yourself or others.

Barriers to Advocacy

• Attitude• Limited training• Inexperience• Funding• Shortage of programs

What can you do?

• Understand and watch for signs and symptoms of brain injury

• Recognize when to refer and who to refer to• Obtain medical/educational records• Explore accommodations and interventions with

input from other professionals• Educate school staff and auxiliary staff• Educate student and his/her peers

Advocacy Cont.

• Consult with school psychologist or guidance counselor

• Consider altering your expectations of how this student can best learn

• Consider different teaching styles– Alternative placement, homebound services

• Think about transition services• Follow up and follow through• Consider your own continuing edcuation

Talking…

• Helps change people’s attitudes• Keeps everyone on the same page• Provides education• Flushes out myths versus facts• Provides opportunities for brainstorming• Allows for sharing and giving examples• Gives a chance to say thank you

Advocacy and Parents

• Communicate with family regularly• Set expectations for family as a member of

the team• Remember, when looking for an advocate,

many parents overlook the most obvious place …the school

• Keep in mind….they don’t speak your language…IEP, 504, “eval”

Parents…

“I need to be careful how I say this…it’s almost like it would’ve been better if the injury were severe enough that we would’ve had to have gotten help. With TBI, the moderate to mild, it’s invisible. People don’t see it and then people don’t get the help they need.”

~Parent

Resources, Who can You call?

• Family• School Psychologist• Resource Teacher• Guidance Counselor• Speech Therapist• Neuropsychologist• Hospital Case Manager• Peers and Friends

Educator Resources…at your fingertips

• Educating Educators about ABI– www.abieducation.com

• BIA NY Learnet– www.projectlearnet.org

• Brainline– www.brainline.org

• Project BRAIN– http://www.tndisability.org

• Brain Injury Navigator– www.binav.org

• TBI Educator– www.tbied.org

In the Library• An Educator’s Manual: What Educator’s Need to

Know about Students with Brain– Ron Savage and Gary Wolcott

• Parents as Educators and Partners– Marilyn Lash and Bob Cluett

• Making the IEP Process Work for Students with TBI– Ann Glang, McKay Moore Sohlberg, and Bonnis Todis

• Signs and Strategies for Educating Students with Brain Injuries– Marilyn Lash, Gary Wolcott, and Sue Pearson

Resources in South Carolina

• 4 counties house traveling libraries• Contact the following:

– In Charleston County– In Greenville County– In Horry County– In Richland County

Review of Section 4:Advocacy and Resources

• Be able to define advocacy• Be able to identify barriers to advocacy• Be able to identify what you can do to advocate for the

students in your class with brain injury.• Be able to identify strategies to empower parents to

advocate for themselves and their child• Identify resources for deepening your understanding of

brain injury• Identify resources for expanding your skills in facilitating

school re-entry after brain injury

Provide…

• An ear to listen• A safe environment• Clear structure and routine• Consistency• Immediate feedback and praise• Reinforcement• Cueing and modeling