ABSTRACT: Students who have sustained a traumatic brain injury (TBI) return to the school setting with a range of cognitive, psychosocial, and physical deficits that can significantly affect their academic functioning. Successful educational reintegration for students with TBI requires careful assessment of each child’s unique needs and abilities and the selection of classroom interventions designed to meet those needs. In this article, the author presents information about the range of services that are available in the school setting and discusses typical environmental and classroom accommodations that have proven effective. The author discusses a variety of specific research-based learning strategies, behavioral interventions, and instructional interventions available to educators who work with TBI students.
Most children who have sustained a traumatic brain injury (TBI), even a severe brain injury, will eventually return to a school or classroom setting following discharge from acute hospitalization (Klonoff & Paris, 1974; Rosen & Gerring, 1986). Some will return after only a brief hospitalization and others after a lengthy hospitalization and rehabilitation program. Because the recovery process can take several months or even years, many of these children continue to have rehabilitation needs and cognitive impairments and will return to school while still in the recovery stages. It often becomes the responsibility of the educational system to facilitate ongoing recovery and to provide needed services to help these children progress in their academic and social functioning. My purpose in this article is to review intervention strategies from recent research that are available to educators as they assist children with TBI when they return to the school environment. An intervention is defined as the systematic application of research-validated procedures to change behaviors through manipulation of antecedents and consequences or by teaching new skills (Bowen, Jenson, & Clark, 2004). Successful readjustment to school may require adaptation of the learning environment, acquisition or reacquisition of skills, provision of compensatory aids and strategies, as well as support services from special education providers.
Setting the Stage
Regardless of the severity of the injury and length of rehabilitation services, advance communication and coordination between the hospital, therapists, family, and the school system is a critical first step in student’s returning to school. The goal of this communication should be to gather medical and functional information to assist the school in developing an appropriate and individualized plan for the student’s reentry into school, whether it is a few accommodations in a regular class setting or an intensive special education program. This communication should be ongoing and the reentry plan determined prior to the student’s return to school. Specific classroom interventions and accommodations required to optimize a successful school reintegration should be developed after careful assessment of students’ needs, including medical, physical, cognitive, and social-emotional problems. Thus, the educational program and classroom interventions designed to benefit students with TBI must be based on the unique needs of each individual. Because of the rapidly changing needs and recovery of children with TBI, initial evaluations conducted while in the hospital may not be accurate descriptions of the students at the time of their reentry into school. Therefore, ongoing observation and assessment of students after their return to school is usually required to develop appropriate interventions and to evaluate the effectiveness of interventions.
The range of neurologic sequelae following TBI is too diverse to prescribe specific intervention strategies that work for all students, and there are few empirical studies that validate specific interventions for students with TBI. However, validated approaches that are effective for students with other disabilities similar to those of students with brain injury offer practical intervention choices for teachers working with students with TBI. Ylvisaker and colleagues (2001) suggest that students with TBI be identified by functional need and that teachers may then select from proven instructional interventions for a particular need. Although serving students based on functional needs is important, it is also critical for educators to have an understanding of TBI as a disability and of the commonly associated features of an acquired brain injury.
Common Sequelae of TBI
Children who have sustained a TBI may exhibit a wide range of newly acquired deficits or alterations in cognition, physical mobility, self-care skills, and communication skills as well as changes in emotional and behavioral regulation, which may significantly affect school functioning (Fletcher & Levin, 1988). The nature and severity of the injury, acute medical complications, age of the child, preinjury characteristics, and the interaction of these factors with the family system and environment will affect the course of recovery and school outcome (Wilkening, 1997). Each child will present a unique pattern of sequelae ranging from mild to severe.
Although there is considerable variability in outcome following TBI, there are also general features of acquired brain injury common to many children who sustain a brain injury, particularly when structural brain damage is present. These are related to vulnerable areas of the brain often affected during a closed head injury, including damage to the frontal lobes, and the anterior and medial temporal lobes. Children with frontal lobe injury typically experience greater difficulty with executive function, which includes attentional processes, self-regulation, goal setting, initiating, and inhibiting behavior. Many behavior and social problems observed in children with TBI are related to poor executive functioning. They may also have problems with organization—planning, prioritizing, analyzing tasks, and completing a sequence of activities. Cognitive impairments can include memory problems, slowed information processing, and language disturbances. Memory impairment (recalling and retaining information) is one of the most common deficits associated with pediatric TBI (Ewing-Cobbs & Fletcher, 1990). Physical functioning can also be markedly impaired following severe TBI. Loss of function in all or some extremities, spasticity, decreased motor speed, and poor coordination in fine or gross motor movements may require physical and environmental accommodations and/or assistance with self-care skills (feeding and toileting) in the school setting.
In addition to formalized assessment of cognitive skills that may be conducted, the special education team at the school (i.e., school psychologist, special educator, speech language pathologist), uses a Functional Behavioral Assessment (FBA) to examine, measure, and treat many deficits associated with TBI, particularly behavioral changes related to increased impulsiveness, inappropriate emotional outbursts, aggression, and inattention. An assessment of the environmental variables (immediate and distant) that contribute to the occurrence of a behavior that is negatively impacting school functioning will assist in developing effective strategies. The following are the four typical categories of behavioral function: (a) gaining attention from peers or adults, (b) escaping or avoiding a nonpreferred task or person, (c) gaining access to tangible reinforcement, and (d) gaining sensory stimulation or relief. An FBA includes a descriptive assessment based on observations of the student, structured interviews, and manipulation of variables to determine the function of problematic behaviors (Gardner, Bird, Maguire, Carreiro, & Abenaim, 2003). Studies involving use of FBA to develop effective intervention plans for individuals with TBI have been reported in the literature (e.g., Feeney & Ylvisaker, 1995).
An ABC (Antecendent-Behavior-Consequence) assessment is one simple means of conducting an FBA. In conducting an ABC Assessment, assessors record the events that occur immediately before and after the unwanted behavior (antecedents and consequences). They collect information such as time of day, with whom the behavior occurs, specific places, other events, and rate and type of reinforcers are collected to help select an appropriate replacement behavior and an effective intervention plan. Distant events and physiologic conditions (e.g., physical pain, cognitive limitations) that may be contributing to the behavior should also be considered (Bowen et al., 2004). Figure 1 provides a sample ABC form.
Structuring the Environment
Because a TBI involves a progressive recovery process, a student’s physical and mental endurances may be limited during their initial return to school and steadily improve over time. Therefore, consideration of different schooling options may be necessary, including homebound instruction, gradual increase in school attendance, or change in class schedules to a less demanding course load. Academic programming and scheduling must be flexible and customized to fit children’s changing needs. Class enrollment and expectations should be based on students’ current, rather than previous, academic performances. Rather than push students quickly through classes and require them to make up missed assignments, students should be allowed additional time to relearn concepts and regain skills.
Structuring the school environment is a way to manage antecedents or consequences contributing to many problem behaviors, and to prevent the behavior from occurring. Many of the environmental strategies that will optimize success for students with TBI are effective with students with other learning problems. These strategies can be employed in general or special education settings. If attention, sensitivity to overstimulation, disinhibition, and emotional lability are identified as problems, the classroom environment should be quiet and simplified. Noise and activity levels should be controlled and unnecessary distracters and sensory stimulation (including noise, light, and movement) should be minimized (Farmer & Peterson, 1995). This may require seating the student near the teacher or by an appropriate peer, providing a study carrel, removing extra materials (e.g., pencils, books, papers), and dividing work or task lengths into smaller sections. Students may use an FM unit or earplugs to reduce external noise. Students may need a designated space in which to rest or take time out from stimulation and be allowed to have “down time.”
Special attention should be given to the physical arrangement and structure of the classroom to facilitate mobility and accommodate physical needs. A student with poor mobility may need assistance to participate in typical classroom activities. The school may need to ensure the availability of accessible bathrooms and ramps. Frequently traveled areas should be sufficiently wide for smooth transition and be free of obstacles. Students may need to be specifically taught and allowed to rehearse the routines of the learning environment, including building orientation and room design. Students in secondary schools may have a particularly difficult time navigating hallways and moving from class to class. Providing extra time for transitions and leaving class a few minutes early, before other students are in the hallways, is often recommended. A peer buddy or an adult aide may be assigned to help with hallway transitions, to provide physical assistance (e.g., in the lunchroom or bathrooms), and to ensure safety.
Classroom structure should also include a predictable and consistent routine. Consideration should also be given to the length of school day that students can tolerate, their nutritional needs, and their fatigue levels and need for rest breaks; classes should be scheduled to capitalize on optimal attention periods. For students who are easily fatigued, a schedule consisting of alternating instruction, activity, and rest periods may be needed. Students with challenging behaviors are more likely to engage in appropriate, on-task behaviors when presented with a positive, well-understood daily routine. Providing a written schedule or posting a visual chart of the daily routine will help reduce confusion. Students may need simplified instructions, written or picture checklists of task steps, maps, or strategically placed signs to carry out tasks. It is important to involve the student in reviewing the schedule at the beginning of the day or period and verbally review the steps. Transition times and out-of-classroom activities should be preplanned and structured to reduce stimulation and emotional distress. Using auditory or visual cues to signal changes in the routine and giving the student advance warning is also helpful. Teachers of the same student should agree on environmental strategies and apply them consistently throughout the school day.
Typical Classroom Accommodations
Another way of altering the environment is to provide external devices and cues that the student can use to compensate for organization, memory, and motor deficits (Mateer, Kerns, & Eso, 1997). Assistive devices can include technical equipment and materials such as tape recorders, calculators, electronic spellers, computers or word processors, augmentative communication devices, timers, alarms, and beepers or equipment for mobility (e.g., wheelchair, walker, electric scooter). Other external cues used to remind students include labels, maps checklists, pictures or icons, photograph cues, post-it-notes, calendars, planners, and journals. A memory notebook is one such compensatory aid that has been used to assist in memory and organization following TBI. The memory notebook can be very flexible and may contain maps, checklists, feelings log, and other information (e.g., telephone numbers, names of contact people). Students should be trained to use the notebook (Tate, 1997).
Modifications to existing materials can assist students with TBI to learn and function in the classroom setting. Typical alterations that allow students to participate at their level include providing carbon paper notes, large print books, books on tape, and graphic organizers (visual displays to organize information). A similar approach involves altering the expectations for student participation. For example, allow more time on tests, reduce the amount of written work required, provide exams in multiple-choice format rather than recall format, and give pass–fail grades rather than letter grades (Mateer et al., 1997). It is important that students are not simply given aids or devices to use without adequate training to recognize when and where appropriate aids are useful, and how to use the strategy properly. Table 1 provides a sampling of external aids and interventions that can be used to assist students with attention, memory, organization, and processing speed deficits.
Available Resources and Services
School districts have a variety of options and resources to accommodate the particular learning needs of students returning to school following a TBI. Because of the extreme variability in outcome following brain injury, a wide range of services and accommodations may be needed and highly individualized planning is required. Many students with mild to moderate TBI can be integrated into existing school programs in regular education with some adaptations and modifications. Students with TBI who attend mainstream classes may also receive accommodations or related services under the Rehabilitation Act of 1973, Section 504. Section 504 covers all students who have a physical or mental impairment that substantially limits one or more major life activities, including learning. For students who do not require special education, but need some accommodations to participate in the regular school program, it is important to complete a 504 Plan and formalize suggested accommodations with parents and teachers. The 504 Plan documents the accommodations and designates persons involved. It must be reviewed annually and should be revised as students’ needs change.
Students with significant impairments should be referred for special education evaluation to determine if specialized services are necessary to address any cognitive, communication, physical, or social limitations. Since 1990, students with TBI are eligible for services under the Individuals With Disabilities Education Act (IDEA) under the category of Traumatic Brain Injury (IDEA, 2005). To receive services, the brain injury must adversely affect students’ educational performances and students must require specialized instruction. Special education programs are frequently selected as an intervention of choice for students with TBI because they can provide a lower adult–pupil ratio, individually designed curriculum and specialized instruction, and necessary therapies. In one follow-up study of children with head injuries, 30% required special education intervention at 1 year postinjury, and 78% of those with severe injuries were placed in special education (Greenspan & MacKenzie, 1994).
Within the special education program there are a variety of services available, ranging from least restrictive (i.e., one resource period per day) to more restrictive (i.e., self-contained program). In addition to resource services for academic or adaptive needs, students may receive services with a speech or language pathologist, occupational or physical therapist, psychologist, or other related services (i.e., adaptive physical education, vision specialist). As with a 504 Plan, an Individualized Educational Program (IEP) must be written, reviewed, and revised annually. However, because levels of functioning may change rapidly with TBI, it is recommended that IEP reviews occur more frequently. Although there may be one or several students with TBI attending a specialized program or class, a designated “TBI classroom” is not typically offered. Students with TBI may be placed in a noncategorical program, in which students are grouped by functional skills and ability levels, and provided appropriate curriculum content and teaching strategies based on these abilities (Cohen, 1991).
Specialized Teaching Strategies
Empirically supported teaching strategies that are effective with students with different types of learning difficulties also may prove useful for students with brain injury. Although teachers must find what works best with a particular student, these techniques are effective antecedent-based interventions that can prevent or significantly reduce challenging behaviors and teach students the active use of compensatory strategies.
The Direct Instruction (DI) model is based on the principles of applied behavior analysis (Engelmann & Carnine, 1982) that include pacing, frequent opportunity to respond, feedback, and reinforcement to maintain student engagement and ensure learning. These principles can be applied in designing an instructional program with students with a TBI (Glang, Singer, Cooley, & Tish, 1992). Some recommended steps in using a DI method include the following:
- Select a meaningful goal or skill the student will need to learn and present it at the level of the student;
- Provide a simple rationale to help the student understand the relevance of the skill;
- Give clearly stated task directions (limit the number of steps) and ask the student to repeat or paraphrase the directions to ensure understanding;
- Break tasks into small steps and demonstrate each step;
- Provide opportunities for student response and practice at an appropriate pace;
- Provide immediate feedback and error correction when necessary—feedback should be positive and systematic; and
- Use verbal praise and encouragement frequently.
There are a variety of commercially produced DI materials available that include sequenced curricula and scripted wording; however, teachers may need to tailor these materials for students with TBI.
Another proactive teaching strategy that will facilitate compliance is use of effectively stated requests or precision commands (Rhode, Jenson, & Reavis, 1993). Precision commands consist of steps teachers can use to prevent escalation of behavior problems by giving clear instructions, allowing the student a chance to comply without interrupting, and reinforcing students who follow the request promptly. All teachers of students with TBI should consistently follow the same format for making requests. Some suggestions for giving effective requests include the following:
- Use a direct statement telling the student to start (rather than stop) a behavior;
- Look directly at the student as you give the request, move close, and use a soft, calm voice.; speak clearly, slowly and concisely—do not shout.
- Limit requests to only two or three at a time and give requests that the student is capable of following;
- Allow enough time for the student to follow through; and
- Recognize their effort with verbal praise and encouragement.
Students with severe cognitive and memory problems may benefit from a teaching approach referred to as errorless learning (Wilson & Evans, 1996). Errorless learning is based on a model of behavioral rehabilitation that involves discrimination training with early prompting and support that is systematically faded to ensure successful responding. In errorless learning, individuals are not allowed to guess on recall tasks, but are immediately provided with the correct response, instructed to read the response, and write it down (Mateer et al., 1997). If errors do occur they are followed by nonjudgmental corrective feedback (Ylvisaker et al., 2001).
Successful positive support for students with TBI must include interventions designed to teach functionally equivalent skills or behaviors to replace problematic ones. The primary goal is to teach students new skills that will help them achieve their needs (e.g., skills to verbally express needs and emotions). Skills training in communication, coping and relaxation, pragmatic social, problem-solving, study, and task-specific skills will help students obtain access to desired outcomes, rendering problem behaviors irrelevant. Functional communication training, for example, is a validated approach that can be used to reduce maladaptive behaviors in individuals with brain injury (Ducharme, 1999). It involves identifying the communication function of a challenging behavior, teaching a communication skill that serves the same function, and providing ready access to the outcome or reinforcer that was previously obtained by the problem behavior.
Providing specific training in self-management or self-monitoring strategies is another approach to helping children. Self-management involves teaching students to evaluate and monitor their own behavior and performance. One simple approach involves routine recording of behavior. For example, the teacher gives the students a piece of paper with 20 boxes. At random intervals, the teacher instructs the students to ask him or herself at random intervals, “Am I listening (working, behaving, etc.)?” The student then records a plus or a minus sign in the box (Rhode et al., 1993). Other forms of self-management include the use of a checklist of open-ended questions to guide students through an assignment, the use of assignment rubrics to allow students to self-evaluate their progress, and the use of emotion logs to allow students to self-monitor their emotions (e.g., rating anger levels and responses on an Anger Log; Bowen et al., 2004).
Many children who sustain severe TBI exhibit difficulty with social adjustment related to newly acquired language deficits in pragmatic (social conversation) communication (Jordan & Ashton, 1996). Programs designed for improving social skills have been successfully implemented in the school setting that include teaching specific skills (e.g., initiation, topic maintenance, turn taking, active listening), using repeated practice and constructive feedback, and granting the opportunity to practice in the natural setting with peers, staff, and parents (Wiseman-Hakes, Stewart, Wasserman, & Schuller, 1998). Self-modeling and self-monitoring procedures can be combined with skills training, by videotaping students during the practice and having students rate their performance on scoring sheets.
The use of positive reinforcement is a valuable strategy used to create a rewarding environment and successfully reintegrate children with brain injury into school settings (Gardner et al., 2003). Reinforcement can be both contingent and noncontingent and can include a combination of primary and secondary reinforcers. For students with extremely difficult behaviors, a differential reinforcement of other behaviors or alternative behaviors contingency may need to be implemented to reinforce the student for compliance and engaging in positive or alternative behaviors. Praise is an extremely effective form of positive reinforcement and should be given more frequently than reprimands or directives (at least a 4:1 ratio). Praise should describe specific behaviors that are meaningful to the student and should be delivered immediately following a behavior. It is often necessary to prompt and reinforce each attempt at a skill or behavior that successfully approximates the desired behavior to shape the appropriate behavior over time. Other forms of positive reinforcement include social reinforcement (e.g., smile, thumbs up, high five), token economies, and awarding special privileges or small tangible or edible reinforcers. Opportunity to engage in a preferred activity or gain access to more preferred activities may be offered contingent on engaging in or meeting criteria on a less preferred task (Slifer et al., 1997).
Behavioral momentum is another strategy that has been used to increase positive behaviors and compliance in brain injury rehabilitation (Slifer et al., 1997). Behavior momentum involves making requests with which the students have a high probability of compliance before making a low-probability request—similar to the momentum of objects in motion. A sequence of high-probability requests is used to establish a high rate of reinforcement for compliance that will increase the momentum and carry over to tasks that might have a lower probability of compliance. Positive reinforcement is delivered immediately after the student performs each request. Feeney and Ylvisaker (2003) used behavior momentum as part of a multicomponent intervention for students with TBI. As part of the intervention, staff included relatively easy tasks with guaranteed high rates of reinforcement before introducing difficult work and preceded undesirable tasks with preferred activities.
Although many of the antecedent-focused interventions are effective in modifying challenging behaviors, consequences are also important components of an intervention plan; however, consequences for children with TBI should be natural and related to the behavior (Ylvisaker, Jacobs, & Feeney, 2003). Individuals with frontal lobe injury often demonstrate an inefficiency of learning from aversive consequences; therefore, punishments such as school suspension or expulsion are usually ineffective (Gardner et al., 2003). Rather than delivery of negative consequences (e.g., threats, nagging) for noncompliance or failure to complete tasks, natural consequences that will help the person complete the task are more appropriate (e.g., constructive feedback, guided compliance). Extinction is an effective intervention that consists of withholding reinforcers that were previously delivered following a target behavior (Yody et al., 2000). For example, if an inappropriate behavior is maintained by teacher attention, this teacher attention should no longer follow the inappropriate behavior. Extinction strategies can include planned ignoring of an inappropriate behavior until the student demonstrates behavioral control, and then reinforcing alternative, appropriate behaviors. Educators should try to anticipate students’ difficulties and offer verbal or physical prompts or cues to redirect behavior. Time-outs may be required to remove students from environmental events contributing to the behavior. Time-out might consist of going to a quiet area and remaining calm for 10 min before rejoining the activity. Student who become angry or explosive in reaction to academic demands, for example, could be taught an impulse control procedure to calm down and take a 5-minute break. Skills training might include identifying a cue that prompts them to “stop” or “take 5.” The student is given the cue and reminded to “stop” at natural times and is reinforced for rehearsal and eventual use of the skill to deescalate before an angry outburst occurs (Clark, Russman, & Orme, 1999).
Case Study: Josh
Josh, an 11-year old, sixth-grade student was severely injured in a motor vehicle accident when the car in which he was riding swerved out of control and collided with another car. Josh was found unconscious at the scene. He was intubated and transported to a local hospital where a head computer tomography scan revealed a severe TBI, with multiple areas of hemorrhage in the right frontal and temporal regions. Josh also sustained facial fractures, as well as a right humerus fracture. He remained in a coma for 2 days and, after regaining consciousness, spent an additional 3 weeks in the hospital’s rehabilitation unit. After discharge, he continued to receive outpatient physical and occupational therapies 2–3 hrs per week.
Shortly after the accident, the school principal contacted Josh’s parents and continued to communicate with them throughout the hospital stay. Prior to Josh’s return to school, his teachers, principal, and the school psychologist scheduled a meeting with the parents. The principal asked the school psychologist to serve as Josh’s case manager. Prior to his injury, Josh had been an average student in regular education, but struggled somewhat in math. He was social, had many friends, and was active in sports. At the meeting, Josh’s parents discussed his current levels of functioning and areas of impairment and the school team developed a plan to accommodate his needs. Six weeks after his injury, Josh continued to have some cognitive problems in the area of memory, information-processing speed, and executive functioning. His verbal skills and reading skills remained relatively strong. Josh had slowed motor speed and had a mild right-sided weakness. He had decreased endurance and fatigued easily.
On the basis of this information, the school team recommended and developed accommodations for his return to school at the meeting. It was decided that Josh would initially return to school on a modified basis, starting with 2 hr per day, in the mornings, gradually increasing his attendance to all day as his physical endurance improved. The team scheduled more difficult subjects during the morning to minimize fatigue. Although Josh was eligible for special education services, the parents and school team decided Josh could be successful in his regular classroom with accommodations, and formalized these accommodations by developing a 504 Plan. These accommodations included the following:
- Allowing Josh to take breaks in the counseling area as needed and to check in with the psychologist at the beginning of the day for organizing sessions and to review his schedule.
- Seating Josh near the front of the classsroom in a quiet location near a designated peer buddy who could provide carbon copy notes and assist with prompts.
- Reducing written work requirements giving additional time to complete assignments, allowing him to dictate responses, and provide him with an extra set of books for home use.
- Providing multiple-choice exams and avoiding time limits in testing.
- Posting a schedule of daily activities in a visible place and training and prompting Josh to record his assignments in a daily planner.
- Determining environmental factors and situations that caused agitation and frustration (e.g., sensory overload, changes in routine) and avoiding them as much as possible. (The teacher and Josh developed a plan for him to “take 5” [take a 5 min. break when he became frustrated], by looking at magazines, or running an office errand).
- Meeting with the middle school team: Prior to his transition to middle school in the 7th grade, the school team, parents, and Josh met with the middle school team to discuss concerns and review the plan.
Returning to school following a brain injury presents a number of new challenges for children with TBI, as well as for those who work with them. Although some children with brain injury experience persistent cognitive and behavioral changes, when provided appropriate resources and strategies, all students can reach maximum potential. Teachers and educators play a key role in helping students with TBI succeed in their adjustment and reintegration into the school environment. To develop programs that will facilitate a successful school reentry, educators must work together to develop a comprehensive plan based on each child’s individual strengths and weaknesses. With careful planning, making needed adaptations to the learning environment, and using effective instructional aids and strategies to help children acquire new skills, most children can fortunately overcome many of these challenges and can experience success in their academic and social endeavors.
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