Return to School:
Children with Brain
Injury
Susan Caputo M.A., CCC-SLP
Elisa Green M.A., CCC-SLP
Definitions
Acquired Brain Injury
Internal insult to the brain occurring after birth
and is not hereditary, congenital, or degenerative.
Often resulting in change in neuronal activity
effecting physical, metabolic, and functional
ability of the cell. Not referring to injuries
induced by birth trauma.
– Causes: tumors, blood clots, strokes, seizures, toxic exposure,
infections, metabolic disorders, neurotoxin poisoning and lack
of oxygen to the brain
Definitions (Cont’d)
Traumatic Brain Injury
Insult to the brain not caused by degenerative or
congenital means, but external physical force,
that may produce a decrease or altered state of
consciousness, resulting in an impairment of
cognitive, physical, emotional, or behavioral
functioning.
– Causes: motor vehicle accidents, falls, gunshot wounds,
sports injuries, workplace injuries, shaken baby
syndrome, child abuse, domestic abuse, military actions,
and other injuries caused by trauma
Pediatric BI Incidence & Prevalence
• Leading causes: motor vehicle accidents, bicycle accidents,
falls, sports injury, abuse
• In 2004 brain injury results: 7,000 deaths; 150,000
hospitalizations; 1,000,000 emergency room visits
• Age is strong predictor of the cause of BI
– Nonaccidental trauma is the cause of 80% of deaths from head
trauma in children under 2 years of age
– 2/3 of children under 3 years old who are physically abused,
have BI’s
– Preschool age children are the second highest risk group for
BI
– Children between 6-12 are involved in twice as many pedestrian
vs. vehicles as younger children
– 220 out of 100,000 youths under age 15 will sustain a BI,
yearly
– 14-19 year olds are most susceptible to sports and auto
accidents
Anatomy
Anatomy (Cont’d)
1. Cerebrum
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4 lobes: Frontal, Temporal, Parietal,
Occipital
Largest and most developmentally
advanced portion of the brain
Controls higher functions, including
speech, emotion, the integration of
sensory stimuli, initiation of the final
common pathways for movement, and fine
control of movement
Left and right hemisphere - controls the
majority of functions on the opposite side
of the body
Anatomy (Cont’d)
2. Cerebellum
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Second largest area of the brain
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Controls reflexes, balance and certain
aspects of movement and coordination
3. Brain Stem
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Critical life automatic life functions:
breathing, digestion and heart beat
– as well as alertness and arousal
(the state of being awake)
Brain Growth and Maturity
Ages 1-6
Ages 7-10
Ages 11-13
Ages 14-17
Ages 18-21
•Rapid brain
growth in all
areas
•Frontal
executive,
visuospatial,
somatic, and
visuoauditory
functions
•Skills: form
images, use
words, serial
order
•Begin tactics
for solving
problems
•Sensory &
motor systems
continue to
mature and peak
at about age 6
•Executive
system rapid
development
•Determining
weight and
simple logicalmathematical
reasoning
•Elaboration of
visuospatial
functions
•Maturing of
visuoauditory
regions
•Age 10 visual
and auditory
regions fully
mature
•Skills: formal
operations,
calculations,
apply new
meanings to
familiar objects
•Visuoauditory,
visuospatial,
somatic peak
and continue to
develop
•Skills: Review
formal
operations, find
flaws in them,
create new ones
•Region
controlling
executive
functions
matures
•Skills:
questions
information,
reconsider it,
form new
hypothesis
Classifications
Mild BI
• Loss of consciousness for less than 30 minutes
(possibly no loss of consciousness)
• Posttraumatic amnesia for less than 24 hours
• Temporary or permanent altered mental or
neurological state
• Glascow Coma Scale 13-15
• Postconcussion symptoms may include: headaches,
dizziness, vomiting, sleep disturbance, irritability,
changes in personality, memory problems,
depression, difficulty problem solving, diminished
attention span
Classifications (Cont’d)
Moderate BI
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Coma more than 20-30 minutes, but less than 24 hours
Possible skull fracture with bruising and bleeding
Signs on EEG, CAT, or MRI
Glascow Coma Scale of 9-12
Some long term problems in one or more areas of life
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Coma longer than 24 hours, often lasting days or weeks
Bruising, bleeding in brain
Signs on EEG, CAT, or MRI
Glascow Coma Scale of 8 or less
Long term impairments in one or more areas of life
Severe BI
Preparation of School for
Student’s Return
Referral from rehabilitation program,
staff can work with school to advise
them on student’s:
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Brain Injury
Therapies
Strengths and abilities
Difficulties and weaknesses
Expectations for recovery
Planned discharge date
Needs for special help
Preparation of School for
Student’s Return (Cont’d)
Rehabilitation staff should:
• Identify someone responsible for coordinating & planning
with school
• Contact school
• Determine if child needs to be referred for evaluation for
special education
• Meet with child’s teacher(s), school nurse, special ed.
Director
• Visit the child’s school to plan ahead
• Possibly conduct an in-service program for school staff –
School SLP can also play a role in educating school staff
• Be available for follow up questions and planning
• Written reports should be made available for school
personnel
BI Effects in Classroom
Cognitive Communication Effects
• Memory
– Unable to recall previously learned information
that serves as foundation for new learning
– Can not remember a series of 2-3 step
directions
– Unable to grasp new concepts without repeated
exposures
– Difficulty recalling the day’s schedule, what
was assigned for homework, or what materials
to bring to class
BI Effects in Classroom
(Cont’d)
Cognitive Communication Effects (Cont’d)
• Attention and Concentration
– Distracted by normal classroom activity
– Difficulty staying on topic during class
discussion
– Unable to complete a task without prompting
– Blurts out answers
– Fatigued by mid-afternoon and appears
uninterested in activities
BI Effects in Classroom (Cont’d)
Cognitive Communication Effects (Cont’d)
• Higher Level Problem Solving
– Difficulty organizing and completing long-term
projects
– Lacks ability to sequence steps necessary to
plan activity
– Unable to generate solutions to situations (e.g.,
lost lunch money)
– Difficulty drawing conclusions from facts
presented
BI Effects in Classroom (Cont’d)
Cognitive Communication Effects (Cont’d)
• Language Skills
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Difficulty taking turns in conversation
Unable to summarize and verbalize thoughts
Circumlocution or uses empty speech
Does not understand the meaning of a
conversation when idioms or metaphors are
used
BI Effects in Classroom (Cont’d)
Sensorimotor Effects
• Max increase in time to complete written material
• Unable to take notes and listen to lecture
• Difficulty copying from board or overhead
projector
• Difficulty completing sheet of math problems
when given a sheet of them
• Completes only one half of paper secondary to
visual field deficits
• Becomes disoriented in hallway and difficulty
finding way around
BI Effects in Classroom (Cont’d)
Social/Behavioral Effects
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Says and/or does inappropriate things
Difficulty fitting in with peers
Easily mislead by peers into making poor choices
Unable to start or stop a task without assistance
Leaves seat or classroom secondary to impulsivity
Easily frustrated
Denies or is unaware of deficits
Qualifying for Services
IDEA - “Traumatic Brain Injury” category
• Allows needs of students with TBI to be addressed
specifically
• Avoids misclassifying students
• Some states expanded to include acquired brain injury
– If not, they can qualify for special services under
“Other Health Impairment”
• IL has the words “acquired” in the definition, however
further defines as external physical force
504 Accommodation Plan
• To qualify a student is only required to have a “presumed
disability”
• Examples: extended testing time, alternate formats for
exams, note takers, preferential seating, assistance with
project planning, provision of audio-taped books
Purposes
Evaluation
1. Evaluate current function
2. Develop profile of strengths and needs
3. Determine ability to benefit from
intervention
4. Acquire information necessary for
treatment planning
5. Educate student, family, and caregiver
regarding findings
Process
Evaluation (Cont’d)
1. Review of records
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Past school, medical, and rehab records (Premorbid/postmorbid
function)
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Family/student questionnaire
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Guides selection of appropriate evaluation tools, pacing, and
scheduling
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Determine special sensory, motor, or medical concerns
2. Interview of student, family, rehab specialists, educational
specialist, etc.
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Verify, clarify, expand information from record review
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Question student’s learning style
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Determine: Presenting problem, Severity of injury, Motor and
Sensory Deficits, Cognitive-Communication changes,
Medications, Medical status, Premorbid medical history, Rehab
history, Developmental history, Psychosocial history,
Criminal/legal activity, Guardianship
Evaluation (Cont’d)
Process (Cont’d)
3. Behavioral observations
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View functional abilities and frontal lobe dysfunction: CognitiveCommunication, Communication abilities, & Environmental
influences on communication
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Assess: Attention, Memory, Executive/Metacognitive Function,
Response Patterns, Affect, Drive/Motivation
4. Formal testing (standardized/non-standardized)
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Tests with proven reliability and validity & adequate
normative data
Tests typically used with students or adults with brain
injury (also may use tests addressing specific area of
need)
Tests addressing each area of communication/educational
functioning
Tests with relevance to real-life functioning
Evaluation (Cont’d)
Process (Cont’d)
4. Formal testing (standardized/non-standardized) (Cont’d)
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Informally address skills in a hierarchy
1.
Auditory and reading comprehension (Single words,
questions, directions, and paragraphs)
2. Verbal memory and learning (Orientation, personal
information)
3. Verbal expression (of words [e.g., naming and rapid word
association], sentence generation, picture description)
4. Written expression (words, sentences, paragraphs also,
spelling, mechanics, grammar, punctuation, capitalization and
legibility)
5. Verbal and semantic organization (Word meanings,
associations and categorization, Sequencing of steps,
Similarities/Differences, analogies, Scripts, story
generations)
6. Abstract Language (humor, proverbs, idioms, slang)
7. Reasoning and problem solving
Evaluation (Cont’d)
Process (Cont’d)
5. Needs assessment/future planning
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Identify contexts in which functional abilities
should be evaluated
Assess activities important in student’s life to
determine disability and impact of environment
on student
6. Evaluation of everyday performance
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Determine actual abilities in everyday situations
(e.g., playground, hallway, lunch)
IEP Considerations
1.
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Cognitive and Communication
Attend and concentrate
Initiate activities and work
Organize and plan ahead
Reason and solve problems
Learn new information
Recall previously learned information
Communicate clearly and effectively in speech and writing
Make good and safe decisions
Be flexible and adjust to change
IEP Considerations
(Cont’d)
2. Social/Behavioral
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Self esteem and self control
Awareness of how actions effect others & feelings of others
Knowing what to expect in social situations
Awareness of appropriate dress and grooming
Ability to control sexual comments, gestures, and actions
Control anger and handle frustration
IEP Considerations
(Cont’d)
3. Sensorimotor
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Compensate for visual and hearing changes
Detect changes in sound, height, distance, and touch
Adjust to changes in body coordination
Slow down or speed up movements
Increase balance and steadiness
Recognize and handle fatigue
Improve hand/eye coordination
Cognitive Communication
Accommodations
Processing Delays
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Increased time to complete assignments/tests
Extra time to answer questions verbally
Breakdown complex directions into steps
Repeat pertinent information
Decrease length of assignments
Use precise concrete language
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Frequent breaks
Assignments divided into small increments
Preferential seating
Verbal prompts to check work
Attention
Cognitive Communication
Accommodations (Cont’d)
Memory Deficits
• Written & verbal directions for tasks
• Check student’s understanding of directions by having
student provide oral summary
• Frequent review of information
• Strategy for notetaking during long reading assignments
• Set timelines of completing work
• Have student repeat instructions to check for
comprehension
• Using a watch alarm to remind student to look at memory
aides
• Use planner and have teacher check to ensure all
assignments written
Cognitive Communication
Accommodations (Cont’d)
Organizational Skills
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Study guide and/or timeline
Daily calendar for assignments and tasks
Instruction in using a planner
Highlight materials to emphasize important or urgent information
Planning activities in routine sequences
Use a schedule
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Peer tutor
Small group discussion
One on one instruction
Assign person to monitor student’s progress
Contact person (home/school)
Weekly progress report between home and school
Academic Process
Sensorimotor
Accommodations
Fine Motor Difficulties
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Notetaker for lectures
Oral examinations
Taped lectures
Textbooks on tape
Assistance with daily living skills
Gross Motor Difficulties
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Adaptive physical education
Modify activity level for recess
Special transportation
Use or ramps and elevators
Restroom adaptations
Sensorimotor
Accommodations (Cont’d)
Mobility
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Early release from class
Extra set of books for home
Assistance with carrying lunch tray, books, etc.
Escort between classes
Visual-Spatial Deficits
• Preferential seating in classroom
• Large print materials
• Modified materials (e.g., limit amount of material
presented on page, extraneous pictures removed)
Social/Behavioral
Accommodations
Emotional Well-Being
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School Counseling
Identify an adult that the student can “check in” with daily
Quiet area for re-grouping
Public praise and private reprimands when possible
Script about accident and hospitalization
Brain injury in-service for staff and classmates
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Functional behavioral assessment
Positive behavioral management plan
Modification of nonacademic tasks (e.g., lunch, recess)
Time and place to re-group when upset
Additional structure in daily routine
Avoid criticism – Provide frequent positive feedback
When aggression occurs, act in neutral manner
Behavior
Other Accommodations
Technology
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Computer for homework
Tape recorder for class work and class lecture
Use of communication devices
Books on tape for text and leisure materials
Talking calculators for math assignments
One-handed keyboard or control switches
PDA (e.g., Palm Pilot)
Talking watch to assist with time management
Watch alarm for reminders
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Reduced Schedule
Avoid “overloading”
Limit distractions
Planned rest breaks
Schedule arranged for high cognitive demand tasks to be followed
by less stressful coursework
Fatigue
Treatment Techniques
Auditory Comprehension
• Locating picture/object named
• Listening to lectures
• Questions re: reading texts, magazines, newspaper, CD labels,
news/educational videos
• Following directions 1-2 step, multi-step, barrier, in classroom
• Listen to voicemail or announcements and report back relevant information
Reading Comprehension
• Student reads text or other reading material and answers questions
• Signs in school, crossword puzzles, word searches, charts, graphs, maps
• Accelerated reading programs
• Planner
Treatment Techniques
(Cont’d)
Verbal Expression
• Naming: Confrontational/Responsive naming of items in classroom
or school environment, synonym/antonym, similarities/differences,
analogies, word association, multiple meanings, definitions,
figurative language, vocabulary words
• Sentence to paragraph formulation to describe wants, needs,
pictures, actions, events, likes/dislikes
• Conversational discourse (e.g., homework assignments, weekend,
school activities)
• Summarize reading texts, magazines, newspaper, opinions,
news/educational videos
• Giving directions (barrier tasks for challenge)
• Make phone call or listen to voicemail and report back relevant
information
Treatment Techniques
(Cont’d)
Written Expression
• Copy designs, shapes, letter, words, phrases,
sentences
• Generate word to dictation, sentence to describe,
write letter or email, take notes in lecture
• Copy assignments into planner
• Write own flashcards to review school work
• Create outlines and reports
• Take messages from voicemail or phone call
Treatment Techniques
(Cont’d)
Memory
• Memory strategies (WRAPP - write, repeat, associate,
picture, pair)
• Visual retention (e.g, objects, pictures of objects, details of
picture, items in room)
• Recall list of items/words, or details from auditory stimuli
• Prospective memory tasks (e.g., routines, responsibilities
each day, to-do next week, month, etc)
• Mental manipulation such as ranking, recalling specific words
or concepts from sentence or paragraph, unscrambling
sentences, repeating directions or sentences
• Answer general information questions
Treatment Techniques
(Cont’d)
Reasoning
• Category naming, convergent/divergent, category
exclusion, conclusions, problem solving, verbal
absurdities, analogies, figurative language,
alternate solutions to situations, pros/cons,
consequences, inferences about other’s feelings,
inductive/deductive puzzles, inferencing,
improving product/situation, other uses for items
Sequential Thought
• Sequencing pictures, demonstrating &/or
verbalizing each step in a simple-complex
situation, unscrambling words/sentences,
sentence/story completions
Treatment Techniques
(Cont’d)
Attention/Concentration
• Visual scanning, mathematics, alternating between tasks,
crossword puzzles, word searches
Insight/Awareness
• Probing questions (i.e., What will be hard for you? What will be
easy? How long will this take you? Do you think you’ll need any
help?)
• Follow-up questions (i.e., Where you able to complete the task?
Was it completed on time? What problems did you have? What
help did you need from others? What strategies did you use?)
• Teach a student to “coach” him/herself using strategies
Pragmatics
• Role-playing, check-lists, assignments to socialize and reflect,
watch tv show and comment on the interactions, social situations
Community Resources
Brain Injury Association of America
8201 Greensboro Dr. Ste 611
McLean, VA 22102
(703) 761-0750
Family Helpline: (800) 444-6443
Fax: (703) 761-0755
E-Mail: FamilyHelpLine@biausa.org
http://www.biausa.org
Brain Injury Association of Illinois
P.O. Box 64420
Chicago, IL 60664-0420
(312) 726-5699
Nationwide: (800) 699-6443
Fax: (312) 630-4011
Web Site: http://www.biail.org
Midwest Brain Injury Clubhouse
1010 N. Hooker St.
Suite 302
Chicago, IL 60622
Telephone: 312-932-1120
Fax: 312-932-1140
www.braininjuryclubhouse.org
Rehabilitation Institute of Chicago
345 East Superior St.
Chicago, IL 60611
(312) 238-1000
Fax: (312) 238-1369
http://www.ric.org
Questions and Answers
Case Study #1
• J.D. 9 year old
• Diagnosis: Encephalitis
• Speech Diagnosis: Apraxia of
Speech, Aphasia
• Premorbid status: IEP developed to
assist with attention deficits in class,
tutor only special service
Case Study #2
• A.G. 14 year old
• Diagnosis: Traumatic Brain Injury
• Speech Diagnosis: CognitiveCommunication Disorders
• Premorbid status: Diagnosed with
learning disability, resource room
with regular education class
“It is important to keep
your feet on the ground
but not always in the
same spot” – Laura
Murphy
References
An educator's manual: National Head Injury Foundations, In Southborough, MA, 1988.
Antoinette, T., Bruanling-McMorrow, D., Lash, M. (Ed.). (2004). Training Manual for Certified Brain
Injury Specialists. American Academy for the Certification of Brain Injury Specialists.
De Pompei, R., Blosser, J., Savage, R., Lash, M., (1998). Special Education IEP Checklist. Lash &
Associates Publishing.
Fleischner, J.E., et.al., (1993). The consequences of head injury: what every teacher of the learning
disabled students needs to know. Presented at the CEC Annual Convention, San Antonio, TX.
Hartley, L.L., (1995). Cognitive-Communicative Abilities Following Brain Injury: A Functional Approach.
San Diego CA: Singular Thomson Learning.
Retrieved August 9, 2006, from http://www.biausa.org/aboutbi.htm
Retrieved September 10, 2006 from http://www.cdc.gov.ncipc/factsheets/tbi.htm
Retrieved August 21, 2006, from http://ericec.org/faq/medicalx.html
Retrieved September 12, 2006 from http://www.isbe.net/spec-ed/html/categories.htm
Retrieved August 21, 2006,from www.sesa.org/sesa/agency/docs/incltbi.html
Tyler, J., Wilkerson, L., (2002). Section 504 Plan Checklist Lash & Associates Publishing.
Ylvisaker, M. et.al. School reentry following head injury: Managing the transiton from hospital to
school. In Journal of Head Trauma Rehabilitation 1991, 6(1): 10-22.