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

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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.

ii
 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

iii
 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

iv
 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.

v
 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.

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 life-
support 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

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

 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

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

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.

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.

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 long-
standing 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

 • 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

10

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.

11

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.

12

 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

13

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 6A-
6.03015, 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

14

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 programmed-
instructional 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

15

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.

16

√ 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)

17
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

18

√ 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 note-
taking 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.

19
 Use behavior management techniques, particularly positive reinforcement of
appropriate/desirable behaviors.

20

√ 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.

21
 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.

22

√ 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.

23
 • 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.

24
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29
John L. Winn, Commissioner

ESE 312636