Supporting Students with TBI in the Classroom

955 Woodland Street
Nashville, TN 37206
Phone (615) 383-9442
FAX (615) 383-1176
TTY (615) 292-7790

Supporting Students With TBI In The Classroom

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BRAIN INJURY 101:
An Overview

"Brain Injury 101" provides a brief overview of brain injury and the implications for students who sustain such injuries. Topics covered during this session include:

Demographic information about brain injury (definition, causes, and incidence)
What happens during a brain injury and common after-effects
The process of school re-entry and strategies for supporting the student with TBI

Local and national resources for professionals & families who support students with TBI
Tailored to meet busy school schedules, this free 75-minute or two-hour training provides a PowerPoint® presentation with illustrative handouts, a question and answer session, short video, and a current listing of local resources. This course was designed for individuals who provide personal and professional support to students with brain injuries. Target audiences include but are not limited to: general education teachers, special education teachers, school administrators, school nurses, psychologists, guidance counselors, related therapists, families and health care professionals.

BRAIN Resource Teams

After attending Brain Injury 101, interested individuals may apply to serve on BRAIN Resource Teams for their school district. BRAIN Resource Team members receive intensive training on pediatric brain injury and learn how to consult on TBI issues in the classroom. Team members act as a local resource to students, schools, families, and health professionals within their school system.

Contact Us

Project BRAIN is a joint effort of the Tennessee Disability Coalition and the Department of Health's Traumatic Brain Injury Program. To obtain further information about becoming a BRAIN Resource Team member or to schedule a "Brain Injury 101" session for your school system or group, contact the BRAIN Project Coordinator at the Tennessee Disability Coalition:
(615) 383-9442 or email at paula_d@tndisability.org.

Interventions for Problems with Attention

Following an injury to the brain, your student may have difficulty with one or more aspects of attention. Selective attention allows us to pay attention to something within a noisy, distracting school environment as compared to attending in a nice, quiet setting. Alternating attention allows us to switch our focus between two separate tasks; for example, you must alternate attention when correcting a sheet of math problems (e.g., you must check your own answer against an answer key, paying attention to two different sources of information). Divided attention allows us to complete two activities at the same time, such as listening to a lecture and taking notes. It is important to determine which aspect of attention has been affected, as this will impact which supports are effective.

Listed below are some supports that are often helpful for children with attentional difficulties. The use of ongoing, collaborative, contextualized hypothesis-testing assessment will help to ensure that attention is indeed the source of the student's difficulty. Train the student to use each strategy within the context it will be used, and provide adequate assistance at the outset. Cues should be faded, as the student becomes more independent in selecting and implementing strategies throughout the school day.

Teach Attention: It is more important to teach a student with attention difficulties to attend than it is to teach him isolated academic tasks. As his ability to attend to task improves, then the focus should shift to teaching him specific academic or work materials.

Signal for Attention: Agree on a signal that will alert the student that it is time to pay attention. How overt the cue is will depend on the level of support needed. Ideas include:

Touch the student on the shoulder, say "Scott, time to listen. I am going to give the directions now." Immediately state the directions in simple, concrete terms.
For younger students, teach the entire class a strategy for getting ready to listen and learn, such as:

"Give me 5" - 1. eyes on the speaker; 2. listening ears on; 3. close your mouth; 4. hands on top of the desk; 5. body still.

All students will benefit from knowing what it looks and feels like to listen and learn. Gradually fade the cues from going through each of the five components, to a simple verbal cue of "Give me 5," to a simple visual cue of holding up five fingers.

Turn on music; clap a rhythm, etc., as a signal that learning time is about to begin.

Script/Routine for Paying Attention - less support necessary: Assist the student in developing a script for "Paying Attention, " and teach her to use it.

For example: "To pay attention, I need to:

Look at the teacher when she talks
Listen
Say or read the directions to myself
Ask for help if I need help.

Script/Routine for Paying Attention - more support necessary: Some students need a more complete routine for giving and maintaining attention to the task. Provide routines and supports for the entirety of the assignment, allowing the student to be as independent as possible. Here is an example of a work routine that allowed one child with severe disabilities to complete work assignments:

The student was taught to go to his desk at the beginning of each day and for each transition in his day. He used a visual schedule (varying from written words to actual laminated photographs) representing all activities. School personnel (i.e., teacher, SLP, OT, PT, paraprofessional, etc.) assisted the student in identifying the activity just completed and reviewing what would happen next.
The student sat at his designated area for the assigned task (e.g., worktable for prevocational tasks, round table in kitchen area of the classroom for cooking tasks, etc.).
If he had to wait for more than a brief time for the task to begin, he was verbally and visually guided through his "Waiting Script" (1. sit in your chair; 2. hands in your lap; 3. wait).
At the beginning of each task, the student was reminded to "Look, Listen, and Wait." At times he needed to be physically prompted to put his hands in his lap; this was a reminder for him to wait and listen to the task directions.
The student would then complete a set of activities that were familiar and easily accomplished (e.g., ABC puzzle - he says the letter and puts the letter into the appropriate space in the puzzle). Such activities served as "cues" that it was time to work Throughout his day, he was asked to do at least one of these short activities prior to beginning a new or unfamiliar task during each work session. This assisted the student in learning when it was time to pay attention and work.
Once the student is provided with the work task, it is important to make sure that he understands how many/how much work must be done; help him to learn what it looks like to be "finished."

Comprehension Check: Ask the student to paraphrase the directions to check whether or not she understands.

Consistent Location for Directions: Teach the student where to look for directions on classroom tasks. For example:

"Directions will always be on the top of the worksheet," or
"Directions will always be written on the right corner of the dry erase board."
Identify a peer buddy for the student to help him identify where/what the directions are that he needs to follow.
Make sure he can demonstrate where to locate or access instructions.
Alter the Environment: Ensure that the student's immediate environment is as distraction-free as possible and that he is seated close to the teacher. Teach the student ways to set up his own environment that will better help him pay attention (e.g., remove all learning materials that are not needed for the current task; teach him to remind the teacher that the class needs to be quiet when she is providing directions).
Learning Stations: Have the student go to a designated spot to begin and finish every assignment. Teach the student that when she is sitting in the designated learning spot, it is time to work and listen to the teacher.
Peer support: Designate a classroom peer for the student to check in with if she is confused or if she missed part of the directions.
Note taker: Pair the student with a peer so that she may check notes for missed information.
Task Analysis: Teach the student a routine for identifying tasks that will place multiple demands on his attention. Assist him in developing ways to simplify task demands.

Interventions for Organization Problems

Following are some additional supports that are often helpful for children with organizational difficulties. Keep in mind that the use of collaborative, contextualized hypothesis-testing assessments will help to ensure that organization is indeed the source of the student's difficulty. Train the student to use each strategy in the context it will be used, and provide adequate assistance at the outset. Fade your cues as the student becomes more independent in selection and implementation of strategies throughout the school day.

Clean up: Have the student clean folders, desk, and locker on a weekly basis. Teach him how to identify what papers need to be kept, thrown away, or turned in.
Put it up: Teach the student to always put away materials for each class in a designated place so that they will be there the next time she needs them.
Checklist: Assist the student in developing a simple checklist that identifies the basic materials he will need for each class; provide multiple opportunities for him to use the checklist. Consider assigning a peer to help ensure that he has only the materials needed on top of his desk.
Assignment Books: Teach her to effectively use assignment books. Coordinate this effort with the student, her family and other related school personnel.
Graphic organizers: Use visual organizers, outlines, and/or note cards to assist the student in organizing thoughts and language before beginning a writing assignment.
Advanced organizers: As appropriate, teach the student to use electronic organizers, such as a Palm Pilot, watch alarms with printed messages, etc. See the Assistive Technology weblinks in the Library to get information on available systems.
Scripts/Routines: Help develop a script/routine for what to do when he finishes assignments.

Following is an example:
- My math assignment for today is Page 346, problems 1-25.
- I read my directions and see how many lines I need to do each problem.
- I number my page 1-25.
- I do those problems.
- I know I am finished when: each problem has an answer, and I double check my work with my buddy (an identified person).
- I always put my finished work in Ms. Smith's blue wire basket and we both initial in my assignment book that I finished my assignment.
Extra supplies: Have extra pencils, paper, rulers, calculators, etc., readily accessible in the classroom.
Extra books: Provide an extra set of textbooks for the student to use at home.
Social organization: Because socialization is an important aspect of educational functioning, teach the student ways to use elements of organization during social or weekend activities.

Interventions for Memory Problems

Memory impairment following brain injury is common. Your student may have difficulty with one or more of the aspects of memory and learning. For example, he may have problems with working memory, the skill that allows us to hold onto information just long enough for us to decide what to do with it (e.g., dialing a new phone number). The student may also have difficulty acquiring new memories, which is essential to academic success. The ability to retrieve memories that are already stored may also be problematic. It is therefore important to determine which supports or interventions are really appropriate for the type of memory difficulty the student demonstrates.

Following are some supports that are often helpful for children with memory difficulties. It is recommended that the supports be tested using contextualized hypothesis-testing assessments to ensure that memory is indeed the source of the student's difficulty. Train the student to use each strategy in the context it will be used, and provide adequate assistance at the outset. Fade your cues as the student becomes more independent in selection and implementation of strategies.

Write it down: Teach the student to write directions in an identified area in a daily planner. Alternatively, identify a consistent place where she can readily locate written directions within the classroom (e.g., the right corner of the dry erase board, marked with a square around the written information and a star to visually remind her).

Repetition: Provide the student with multiple repetitions of the information in an organized manner to help him develop a routine for learning that concept, idea, or task.

Key Concepts: Have the student focus on key concepts rather than multiple details to reduce the demand on his memory.

Cut the "Small Talk": Provide only information necessary for completion of task. Decrease the amount of information that the student needs to remember.

Time to Teach: Teach new concepts when she is most alert. This is typically in the morning for most children with TBI.

Curriculum Selection: Utilize direct instruction programs that provide frequent repetition of information, consistent vocabulary, similar task demands, and that allow for the student to stay at a consistent level until the task is mastered (especially if the skill to be mastered is essential to basic academic skills, such as reading and math).

Associations: Use the environment efficiently. For example: math happens at the round table; calendar review happens on the carpet at the front of the room; reading happens in the bean bag chairs. Such associations will prevent further taxing of limited memory skills.

Pre-Teach: Review key concepts prior to beginning a new lesson in order to pair old learning with new facts. Additionally, have the student discuss what he remembers about the key concepts with a buddy as another way to bring potential related concepts to mind.

Visual Cues: Provide visual cues to help facilitate memory and new learning (e.g., when teaching words for colors, write red in red, green in green, etc., fading the color cues as they improve on recognition of the word).

Graphic Organizers: Provide the student with graphic organizers that allow students to organize abstract information visually, and provide opportunities to re-access information from his knowledge base (e.g., timelines to represent an historical event; using a two-column table: ask the student to compare or contrast a "known" event (i.e., their favorite team's recent football game) to new material about an historical event to be learned (i.e., the civil war))

Organization System: Teach the student to use an age-appropriate organization system to decrease the amount of information she must remember independently (i.e., assignment notebook, and simplified daily planner).

Errorless Learning: Provide adequate support and prompting to prevent the student from making mistakes. With impaired memory, mistakes are often forgotten and the incorrect responses may be reinforced.

Peer Supports: Provide a peer buddy that will review the directions to the task with the student. Additionally, the peer's notes could be copied for the student with TBI to check for missing information.

Open-Book/Note Tests: Allow the student to use textbooks and other reference materials for tests that rely on recall of large amounts of information. Teach him to efficiently locate information in the texts; make them regularly available during class to provide multiple opportunities for accessing information.

Multiple Choice Tests: The "free recall" nature of open-ended and essay questions are often difficult for students with TBI. Consider using multiple choice questions to allow for cued recall of information.

Self-Evaluation: Teach the student to evaluate which tasks will place greater demands on retrieving from long-term memory vs. tasks which have become more automatic.

Identify Breakdowns: Teach the student to recognize memory breakdown ("I can remember ABC, but then what comes next?). Help her to identify solutions to this area of challenge. Provide frequent opportunities to implement the solutions. Teach the student to ask for help!

General Routines/Scripts: Help the student develop routines to support repetitive classroom activities (e.g., preparing for class, starting to work, completing worksheets) so that energy can be focused on tasks where effortful retrieval is required.

Skill-Specific Routines/Scripts: Teach the student routines specific to the skill you are trying to teach (e.g., identifying the letters of the alphabet, addition statement from Touch Math, rolling silverware).

Self-Cueing with Wh- Words: Teach the student to organize retrieval of information from the knowledge base through the use of question words - who, what, when, where, why, and how.

Interventions for Behavior Problems

As with Kevin, behavior problems demonstrated by students with traumatic brain injury are sometimes due to their cognitive difficulties. However, there are numerous supports that can assist students whose impairments are psychosocial, as well as for those who demonstrate cognitive problems. Following are some ideas to try with students that demonstrate behavioral difficulties. Supports should be selected in conjunction with a contextualized hypothesis-testing assessment to determine the source of the student's difficulty. As a general rule, train the student to implement each strategy in the context it will be used, providing adequate assistance at the outset. Begin to fade your cues as the student becomes more independent in the selection and implementation of strategies.

Structured Environment: A well-structured environment is critical for controlling behavior problems. Provide consistent schedules and well-defined expectations and routines to improve a student's chances for success. A structured environment can help to eliminate confusion and disorientation; conversely, a disorganized, over-stimulating environment can exacerbate behavioral difficulties.

Self-Awareness: Some students have limited insight into their abilities following a brain injury. Awareness training should be implemented in a supportive environment. Develop a rating scale that can be used by the student and an adult (parent, teacher, therapist, or paraprofessional) following a task. Have the student rate his own performance on the task independently; compare and discuss the student's own rating with the rating given by the adult. Use videotaping when appropriate. Also, help the student identify what it feels like to be "stressed." Use observations of his behavior, asking what he feels like when he was yelling, throwing books, etc. Help him find labels for those feelings (e.g., face hot, heavy breathing). Once he can identify when he is stressed, help him learn to analyze a situation and evaluate its potential for causing stress. When he can anticipate difficulty, he can learn to avoid it rather than being surprised or feeling forced to deal with it.

Escape: Develop an avenue of "escape" for the student when she lets you know (through a pre-established gesture/phrase/visual reminder) that she is feeling "stressed." Suggest that the student "escape" if you notice elevating stress.

Example: One student, an avid fan of the cartoon "Pokemon", developed a "Pokemon Palace" in the back of a classroom within a large closet. For times when the student felt stressed, the teacher helped her learn to implement the following routine:

When I feel stressed, I can:

Raise my hand and tell Ms. Smiley "I need a break"
or "I'm feeling _________."

Or I can give her my pencil to signal that I need a break.

Then Go to my Pokemon Palace. I can

Lay down or

Listen to music or

Read a book

After I feel better, I need to

Return to my desk

Raise my hand

Ask Ms. Smiley, "What do I need to do now?"

Eliminate Triggers: Prevent aggression by determining what typically triggers an outburst, and then eliminating the trigger whenever possible.

Task Evaluation: Help the student learn how to evaluate a task (hard vs. easy); pair this strategy with his routine/plan for requesting help when he does not know what to do.

Relaxation: Teach the student how to relax. Consult a counselor if necessary.

Control: Some children exhibit behavior problems because they are trying to exert some control in their overly managed environment. Allow her to make as many choices as her cognitive abilities will allow, using visual supports as necessary.

Frustration: Some students have difficulty tolerating frustration. Present easy, previously mastered tasks before beginning difficult work to promote positive feelings of success.

Initiation: Sometimes behavior problems are not the result of acting out, but rather not acting at all. Initiation deficits will keep a student from beginning work assignments and social interaction. Develop cues (visual, auditory, and self-cueing) that signal to the student when it's time to get started. Pair the student with a highly interactive peer and help him develop scripts for interacting with others.

Social Skills: Address social skills within the context of natural social interaction (e.g., lunch, group art activities). Cue the child to initiate and respond in an appropriate manner. Develop and teach "scripts" for interacting with peers and adults.

Self-Esteem: Students often remember the way they were before their brain injury, and feelings of self-worth often decline due to decreased abilities. Consider group counseling, and provide frequent opportunities for success.

Maturity: Students with TBI may demonstrate immature behavior. Pair the student with a buddy who is demonstrating age-appropriate behavior.

Traumatic Brain Injury in Children and Teens, A National Guide for Families