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Behavioral Considerations Associated with Traumatic Brain Injury Joan Mayfield, Preventing School Failure (page 4 of 6) Page 4 of 6

Children and adolescents who did not exhibit behavioral difficulties prior to injury are sometimes less likely to develop behavioral difficulties following a trau­matic brain injury than are those children who had behavioral difficulties before the injury. However, it is important to remem­ber that behavioral problems related to brain injuries often do not appear until sev­eral months or years following an injury (Deaton & Waaland, 1994). Children and adolescents who suffer more severe head injury tend to develop behavioral difficul­ties earlier in their course of recovery than do those who suffer a mild to moderate brain injury (Guthrie et al., 1999).

Interventions

Many of the behavioral problems that are exhibited in the classroom are direct­ly related to cognitive deficits. Children with TBIs may exhibit cognitive deficits related to attention, memory, expressive and receptive language, visual and visu­al–spatial problem solving, and process­ing speed, which is directly related to new learning. Children with severe head injuries have difficulty retrieving newly learned information and have impaired capacities for control, regulation, and adaptation of complex behaviors (Lezak, 1986). Impaired executive functioning includes the inability to plan, organize, initiate a task, inhibit responses, and self-monitor behaviors. Deficits in these areas are common after a head injury, especial­ly if the frontal lobes are affected. A neu­ropsychological evaluation provides information about the extent of the cog­nitive deficits to parents and teachers, and explains cognitive strengths and weak­nesses. When teachers are provided with this information, they are able to develop strategies to optimize the child’s ability to learn and function in the classroom. An effective behavior management program provides caregivers and educators with the tools necessary to promote positive behavior in children with TBIs. Several recommendations to assist with behavior management are listed below.

In a behavior management program, being able to determine the antecedent prior to the behavior is critical. Children with severe head injuries may not be able to inhibit responses or self-monitor behaviors. Ylvisaker et al. (1998) have recommended setting up antecedent control procedures, realizing that the child may not be able to control his or her reaction to stimuli. This may include

• (a) removing triggers from the environ­ment, (b) setting up a schedule or rou­tine, (c) preparing the child in advance for any changes in the routine, (d) being aware of the child’s psychological status and his or her ability to cope with the demands, and (e) redirecting the child at the first stage of disruptive behavior.
• Some children may fail to respond appropriately in the classroom because they do not have an understanding of rules, roles, routines, or social scripts (Ylvisaker et al., 1998). Educators should provide short, concise instructions. They should explain the rules that provide spe­cific rewards and consequences for behaviors. Children with head injuries may not generalize from one situation to another. Providing verbal feedback for appropriate or inappropriate behaviors will help classify a child’s behaviors and process generalizations. In addition, pro­viding role-play social situations will help develop a script for behavior and allow the child to rehearse appropriate responses.
• Children may have difficulty self-monitoring their behavior and, therefore, may not be able to distinguish between when their behavior is appropriate or inappropriate. It is important to focus on appropriate behavior. One way to do this is to tape a 3- x 5-in. index card on the corner of the child’s desk. The teacher explains to the child that they are work­ing as a team to correct a behavior, such as talking out in class. Every time the child raises a hand, the teacher places a check on his or her card. At the end of the day, the teacher rewards the child either verbally or with a point system for talk­ing at appropriate times. The child then takes the card home, and the parents are able to reinforce the positive behavior.
• Children who have sustained a frontal lobe injury may have a lack of initiation. This means that the child may fail to do what the teacher wants him or her to do based on an impairment of activation or initiation (Ylvisaker et al., 1998). It will be important for the teacher to monitor whether a child has initiated a task. Chil­dren with TBIs may require additional explanation or demonstration to begin the task. Avoid providing too many direc­tions, as the child may have difficulty beginning the task if he or she is over­whelmed. If multiple steps or instructions are needed, provide the child with a list so that he or she may check off the steps as they are completed.
• Activities that many children may perceive as enjoyable may be overstimu­lating to the child who has sustained a TBI. The lunchroom, music class, gym­nasium during physical education, or the playground during recess may be over­whelming. As the child becomes over­stimulated, he or she may overreact to the environment and experience a fight or flight reaction. It may be difficult for the child to explain his or her response, but he or she may voice a need to be removed from the busy environment. The over-stimulation may manifest in crying, anger, or anxiety. Allowing the child to go to a quiet place away from the overstim­ulation will allow the child to become calm and relax.
• The child who has sustained a head injury may experience confusion and dis­orientation (Ylvisaker et al., 1998). Cre­ating a routine and preparing the child for any deviation in routine will be important. A buddy system may be useful to help the child maneuver between classes. Allow­ing time in the morning for the teacher or the buddy to help the child gather all required materials for morning classes might be necessary. The child will need to repeat this activity at lunch and at the end of the day. Again, a peer may help with this activity. This will help eliminate frus­tration and facilitate the learning process.
• Children may continue to experience physical complaints after they return to the classroom. It is necessary to monitor for headaches or other physical symp­toms. These problems are often exacer­bated as the child fatigues. Providing breaks during the day can help with fatigue. Children with a TBI may need to rest or nap during the school day. In addi­tion, having the schedule alternate between academic and nonacademic classes will decrease fatigue and increase productivity in the classroom.

From Preventing School Failure magazine. Heldref Publications. Reprinted with permission. www.heldref.org.

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