Help Students with TBI Avoid Frustration and Failure
By Karen Long, PhD, CCC-SLP
A high school freshman had average grades in all her classes. Her teachers described her as a quiet student who turned in assignments on time. She was well liked by her peers and played on the varsity basketball team.
During Christmas break, the teenager was involved in a car accident that required six weeks of acute care hospitalization, four months of inpatient rehabilitation, and four months of daily outpatient therapy. Despite these interventions, she was left with a moderate to severe head injury that would make its presence known for the rest of her life.
During her recovery, she would say, "When I get back to school, everything will be OK."
When she returned to school, however, she became distracted in the hallway and would forget which class she was going to, tired easily and lost her temper when fatigued, and had no impulse control. Because of this, she often was sent to the principal's office.
She could not follow classroom lectures, and her reading skills fell to a fifth grade level, which made reading and comprehending the material in a high school textbook impossible. She could not complete assignments during class because she couldn't read or write as fast as her peers. She frequently did not turn in assignments because she didn't remember hearing the teacher tell the class what was due and when.
Within the first week of school, the teen and her parents, principal and teachers were all frustrated.
This is not an unusual case. Students who return to school after sustaining a traumatic brain injury (TBI) frequently look the same as they did before the accident, so teachers, peers and school officials expect them to act the same. But even youngsters with mild TBI show signs of cognitive deficits. Unless the teachers and parents devise strategies to help these students, school will be a frustrating experience in failure.
Children with TBI typically experience short attention, inability to organize, fatigue and frequent head-aches, reduced processing speed and memory deficits.
Short attention spans are present when the child jumps from topic to topic in conversation, can't follow three or more directions in sequence, and has trouble completing tasks.
Distractibility also is evident. By kindergarten most children can sit at a desk and complete a simple worksheet, tuning out minor noises. However, students with TBI can be distracted by classroom lights, wall hangings, hallway noises, and even the writing of the person next to them.
Teachers need to make sure that students with TBI sit in front of the classroom, where there are minimal distractions. Blinds should be pulled to shield the child from outdoor distractions.
For seat work the teacher may want to set up a desk in a corner where the student can face the wall. Tasks should be broken down into short, manageable segments of 10-15 minutes. The amount of work can increase as the child increases attention to the task.
An inability to organize also can characterize children with TBI. As the child gets older, for instance, the school setting requires more self-organizational skills, especially when changing classes for different subjects. Being able to sequence the items needed for a class, gather them up at the locker, get to the right class, and have the materials ready when the class starts may be an impossible challenge.
Strategies that address these problems include keeping needed materials in the classroom so the student doesn't have to remove them from a locker and listing on the chalkboard the items that a student needs for class.
Color-coordinating books, notebooks and pens also provide a visual strategy for the student. An index card can be used to list the class period and color of book, composition book and pencil needed for that class. The card can be taped to the inside of the locker.
A buddy system can help prevent problems in the hallway by having peers help the student with TBI go from one class to another.
Fatigue and frequent headaches are not uncommon symptoms of TBI. The harder it is for a student to concentrate in class, the quicker the brain and body will get tired.
Teachers can help alleviate the fatigue factor by allowing the student to stand and stretch every 15 to 30 minutes. The school schedule should include a study break of at least 10 minutes between each major subject.
If the student shows extreme fatigue by the end of the day, the child may need a 30-minute break to rest in the nurse's office. The treating physician should send a standing order to the school that the student be allowed to take medication as needed for headaches.
Students with TBI also may experience reduced processing speed, which creates problems when they answer questions in class and takes notes. Teachers should give these children extra time to answer questions and allow them to tape-record the class. Educators also must understand that it takes these students twice or three times as long to complete work as it did before the accident.
Homework should be adjusted, so the student does not become exhausted and quit trying before completing the assignment. A good rule of thumb is to assign half the amount of work as the rest of the class until the teacher gets a feel for how the child works.
Short- and long-term memory deficits also may be present after TBI, causing problems in the classroom when the teacher gives four- or five-step directions. The student may have difficulty remembering the homework assignment long enough to write it down, much less remembering to do it at home. Keeping a homework journal will help ensure that homework assignments are completed.
The student with TBI should have a notebook for writing homework assignments, and each teacher should make sure assignments are recorded at the end of every class period.
At the end of the day, one teacher should meet with the student to review the homework journal, determine the books needed to take home, and make sure the student puts those books into his or her book bag.
While students with TBI require special considerations in the classroom, they frequently are placed in a regular classroom without modifications, fail, and then are placed in classrooms for children with learning or mental disabilities. While they may need resource classes, special education classrooms are not the least restrictive environment for many of these children.
Before students with TBI return to school, their teachers must be educated about their medical condition and cognitive deficits. The school staff should agree on strategies to address these deficits, and everyone in the school should employ them consistently.
For example, if a homework journal is to be used, every teacher must make sure the student uses it. Parents also must participate in the educational program and provide school staff with feedback on how the student fares in doing homework, studying for tests, and completing assignments.
In turn, teachers should send the parents weekly notes on how the student is doing in the classroom. Through open communication, parents and teachers can set achievable goals for students with TBI and alleviate much of their frustration.
Parents also should get assistance from the rehabilitation therapists who worked with their child after the accident.
In addition, the school should contact the state department of education for assistance on dealing with children with TBI.
* Dr. Karen Long is pediatric program director and day treatment coordinator at HealthSouth Rehabilitation Hospital in Florence, SC.