Teaching the Student with Brain Injury: Information for Teachers

QUESTION:

I have a student who is returning to elementary school after rehabilitation for a severe brain injury. She still needs speech and physical therapies, which will be coordinated by the school. As her teacher, I am wondering how to work with this student at this point. Should my focus be on coordinating rehabilitation therapies or on academics? Would it be feasible to integrate the therapies into an academic program, or would this overwhelm the student during her recovery?

ANSWER:

You sound like a perfect teacher for this child! You are thinking through both rehabilitation and academic areas. However, there is no reason that therapy should be considered apart from academic work for they are one and the same in many cases. What is important for this child is that she reintegrate into her job--which is going to school. Neither therapy or academics should be thought of as separate entities for her. Here are some ideas for you.

Before specific goals are considered, she should first fit into the routine of the day. Consider what she is capable of doing to make her a part of the school routine. Does she need to move throughout the building? There is where physical therapy comes into play. Does she have a need to communicate in your classroom? That is where speech-language therapy should be integrated.
Consider curriculum and therapy goals; see how to merge the goals into activities that will accomplish both. For example, what is the math vocabulary that can be learned while working with a tutor or the speech-language pathologist?
Consider teaching the process of an activity rather than insisting on performance of the activity. For example, can the child tell you how to subtract -- what is the idea behind the procedure? Then, rather than requiring many repetitions of the same activity (do 25 homework problems), can the activity be modified to show she understands what she is doing (do 10 homework problems and verbally describe what the process was to get the answer)? Can the child tell what the idea for writing a sentence might be? Can she write the main parts of that sentence? These activities get at executive functioning -- knowing what you can do well and where you need assistance, as well as developing organizational skills.

If you think about the underlying problems that the child is demonstrating (see the reports from the hospital and therapists), you can create lots of teaching opportunities that will address both the therapeutic needs as well as the academic ones. Remember to start slowly and build the skills as the child demonstrates stamina and ability. Bring in the therapists and have them brainstorm with you about how to incorporate therapy into the classroom whenever possible.

Literature you may find helpful:

Bowen, J. M. (2005). Classroom interventions for students with traumatic brain injuries. Preventing School Failure, 49(3), 34–41.
Bullock, L. M., Gable, R. A., & Mohr, J. D. (2005). Traumatic brain injury: A challenge for educators. Preventing School Failure, 49(3), 6–10.
Deidrick, K. K. M., & Farmer, J. E. (2005). School reentry following traumatic brain injury Preventing School Failure, 49(3), 23–33.
Lash, M., Wolcott, G., & Pearson, S. (2000). Signs and strategies for educating students with brain injuries: A practical guide for teachers and schools (2nd ed.). Wake Forest, NC: Lash & Associates.
Ylvisaker, M., Todis, B., Glang, A., Urbanczyk, B., Franklin, C., DePompei, R., & et al. (2001). Educating students with TBI: Themes and recommendations. Journal of Head Trauma Rehabilitation, 16, 76–93.

QUESTION:

I am a teacher seeking advice on how to help a high school student with traumatic brain injury and behavior problems. The student is capable of at least average school work, but he cannot seem to stay out of trouble. He is easily distracted and has a difficult time controlling his anger. At times he is too aggressive for the classroom. How can his teachers help this student achieve academically? What are some behavior management techniques that are appropriate for the classroom?

ANSWER:

You are on the right track when you are looking at behavior as a reason for lack of progress in school. However, perhaps you may want to view these behaviors a little differently. I wonder if they are behaviors that he is choosing to demonstrate or whether these behaviors are telling you something about the underlying processes that have been affected after the brain injury. If the choice is his, then behavioral management may be appropriate. If they are underlying processes that are affecting behavior, then modification of your expectations and the daily routines may be the most beneficial to him.

If he is easily distracted, have you considered that his attention span may not be adequate for the situation in which he has been placed? What are the typical environmental distractions? Is he seated in the quiet part of the room (away from teacher’s desk, windows, busy traffic patterns)? What else is going on in the classroom? Is it easy to pay attention to the teacher or are there other simultaneous activities taking place? Can he be moved about the classroom for different parts of the class? For example, sit in front of the teacher when lecturing is taking place, move to a "work station" to complete written work, move to another seat to work on a two-person project? All of these activities will aid with the underlying problems of a short attention span which leads to being distractible.

Can he tell you what creates his frustration that sets off aggressive behavior? Often, it is overload of classroom demands -- too much requested at once, too much verbal instruction, listening too long to lecture or discussion, doing too many different homework assignments for each teacher without coordinating who is assigning what each day. Have you ever been listening on the phone and had someone approach you and try to talk to you? Recall the internal frustration as you try to process two messages at the same time. That information overload often triggers a frustrated aggressive response in teens with TBI. How can you control the information overload so that the student does not become frustrated and have an outburst? Does he know his own physical symptoms of overload? Does he feel agitated, flush on the neck or face, begin to make a fist, feel an upset stomach beginning? Can he tell you this prior to having the outburst? Is there a place in school where he can walk, go to relax or talk with a guidance teacher prior to becoming aggressive? Consider allowing for break times and decreasing the work load in order to reduce frustration.

Literature you may find helpful:

Feeney, T. & Ylvisaker, M. (1995). Choice and routine: Antecedent behavioral interventions for adolescents with severe traumatic brain injury. Journal of Head Trauma Rehabilitation, 10 (3) 67 - 86.
Feeney, T. & Ylvisaker, M. (2003). Context-sensitive behavioral supports for young children with TBI: Short-term effects and long-term outcome. Journal of Head Trauma Rehabilitation, 18(1), 33-51
Gardner, R. M., Bird, F. L., Maguire, H., Carreiro, R., & Abenaim, N. (2003). Intensive positive behavior supports for adolescents with acquired brain injury: Long-term outcomes in community settings. Journal of Head Trauma Rehabilitation, 18, 52–74.
Ylvisaker. M. & Feeney, T. (2002). Executive functions, self regulation, and learned optimism in pediatric rehabilitation: A review and implications for intervention. Pediatric Rehabilitation, 5, 51–70.
Ylvisaker, M., Jacobs, H. E., & Feeney, T. (2003). Positive supports for people who experience behavioral and cognitive disability after brain injury: A review. Journal of Head Trauma Rehabilitation, 18, 7–32.
Yody, B. B., Schaub, C., Conway, J., Peters, S., Strauss, D., & Helsinger, S. (2000). Applied behavior management and acquired brain injury: Approaches and assessment. Journal of Head Trauma Rehabilitation, 15, 1041–1060.

QUESTION:

For the student with short-term memory loss, learning is complicated. Are there some special techniques that the teacher can use in the classroom to help a student with traumatic brain injury learn?

ANSWER:

Students with brain injuries often have trouble remembering, especially new information. It is important to know that helping students remember better is not just having them do the same thing over and over again. (How many of us remember what the Lincoln head side of a penny looks like even though we have seen hundreds of pennies in our lives?)
To help a student remember better, try these "Top 10" cognitive strategies:

Make sure the student is paying attention. Make direct eye contact with the student whenever you are teaching new information.
Couple and connect new information with previously learned information.
Try to make the information to be learned meaningful and functional.
Match the student's learning style (e.g., visual learner) with the teaching method.
Frequently summarize information as it is being taught, using overlapping techniques such as repetition and rehearsal.
Use pictures, diagrams, and charts to reinforce what is being learned.
Control the amount of new information that is being presented.
Give multisensory presentations of new information.
Teach the student how to organize new information for better memory retention.
Teach the student to use a datebook for notes, assignments, appointments.

QUESTION:

I have a student who recently sustained a traumatic brain injury. I understand that she was having academic problems before the injury. Is there a way for the psychologist who tests her to determine whether her current deficits are due to the brain injury or possible mental retardation prior to the accident? Is the actual diagnosis unimportant if we provide her with the services she needs?

ANSWER:

It is very important that this student be evaluated by a neuropsychologist to answer this first question. This is a psychologist who has special additional training in brain injury and the relationships between the brain and behavior. Testing can help determine her ability to learn new information, not simply what was learned prior to the injury. The standard tests usually given by psychologists, especially those in the school, often focus on measuring intelligence and can be misleading after a brain injury since they do not give a complete picture of how the brain is functioning.

The neuropsychologist can determine the effects of the brain injury upon this student’s ability to learn, communicate, plan, organize and relate to classmates and teachers. It is very important that the neuropsychologist chosen have experience with students of similar age and be familiar with schools. The test results will be most helpful if the neuropsychologist interprets them in understandable language for school staff and provides practical strategies and suggestions that teachers can use in the classroom.

The diagnosis of traumatic brain injury is very important. First of all, it indicates that this student’s development was interrupted by the injury. It is even more important given the question about prior mental retardation. Some of the changes that often result from a brain injury, such as a flat or dull tone of voice, slower thinking, and difficulty with memory may give the impression of retardation but are a consequence of the brain injury and not necessarily due to lowered intelligence. A student with a brain injury will also have different educational strengths and difficulties than a student who is mentally retarded. It is very important to provide this student with instructional strategies that consider both the brain injury and possible retardation.