Classroom Strategies to Support Children with Traumatic Brain Injury (TBI) Sarah Levin Allen, Ph.D. Y.A.L.E. Schools, Medford & Mansfield Pediatric & School Neuropsychologist Jessica Glass Kendorski Ph.D Philadelphia College of Osteopathic Medicine Assistant Professor Objectives of Presentation • Provide an overview of early development and brain functioning. • Describe how schools systems can support children with a traumatic brain injury • Developing a method for intervention identifying pre-requisite skills. • Discuss best practices for interventions for students with brain injury The Brain… Functional Perspective Brain Parts • Cortex, Cerebellum, Brain Stem Executive Functioning and the Brain Frontal Lobe Responsible for inhibiting, paying attention, modulating emotion, regulating activity Efficiency • Pruning Process • Brain Power Development Normal Maturation • Pre-school: Simple errands/chores (with reminders), straighten room with help, inhibit some behaviors (too hot, don’t hit, etc.) • Grade 2-3: Run errands/simple chores/ homework (20 minutes), straighten room, bring papers to and from school, decide how to spend money, inhibit behaviors (follow rules, raise hand, etc.) Normal Maturation • Grade 6: Chores (15-20 minutes long), clean room, babysit, use organization system, follow complex schedules, long term projects, plan time, inhibit rule breaking without cue • Grade 8-9: Effectively manage work day to day, establish long term goals and plan, structure leisure time, inhibit dangerous/reckless behavior Impact of Brain Injury on natural development • Executive skill support needs • Transition times • Schooling – recovery and rehabilitation plan Common Misconceptions in schools regarding TBI TBI Effects Possible misunderstandings Important information to communicate Concussion “All children fall and hit their heads.” Concussions can have long lasting effects especially if numerous Closed vs Open head injury Many feel a closed head injury is better. Communicate the effects of coupcontra coup injuries Primary vs. Secondary Damage happens only TBI effects from trauma Primary effects may not be as great as secondary effects. Common Misconceptions in schools regarding TBI TBI Effects Possible misunderstandings Important information to communicate Age at time of TBI Children not impaired as adults following TBI Some injuries may not manifest cognitively or behaviorally until developmentally appropriate. New learning and memory storage/retrieval impaired Child maintains long term memory, so memory is not impaired. Retrograde amnesia only in severe TBI, more common to have anterograde amnesia affecting new classroom learning Common misconceptions in schools regarding TBI TBI effects Common misunderstandings Important information to communicate TBI affects psychosocial and behavioral functioning TBI only affects cognitive and/or motor skills Common finding is change in personality and behavioral adjustment, even without long term cognitive effects. TBI long term or academic, and/or psychosocial consequences. Once released from the hospital and rehabilitation, no long term effects. Long term effects need to be addressed by teacher, parents, and school personnel. Common Misconceptions in schools regarding TBI TBI effects Possible misunderstandings TBI causes TBI related to significant medical problems and interference with not school difficulty academic and behavioral functioning Important information to communicate TBI is IDEA category. Child identified with disability with Individualized Education Plan and services. IDEA definition of TBI Areas to consider during Return to School • Prior learning and academic functioning may be relatively spared HOWEVER new learning an memory may be impaired. • Important to not wait for the child to fail academically before supporting the needs. Prevention and plan ahead. Interventions • Target academic areas as well as cognitive deficits that subserve them. • Think Pre-requisite skills • Remediation vs. Compensation Remediation and Compensation • Remediation target: What is the skill that you want the child to learn? • Pre-requisite deficit- What are the skills expected to be applied independently to complete the task? • Compensation Need: What support does the child need to help achieve this goal? Across Subject Example: Within Subject Example: Remediation target: Understand the Battle of Gettysburg Remediation target: Writing a paragraph Pre-Requisite Skill below grade level Pre-requisite skilldeficit: deficit-Reading Fine Motor Compensation Need: Text to Speech, modified presentation Skills Compensation Need: Keyboard/Scribe Pre-Requisite Skills Across Subjects • • • • Processing speed (timed tasks) Reading Abstract reasoning (problem solving) Sustained mental effort (attention/fatigue) • Fine motor skills (writing) • Task initiation and persistance Behavior/Psychosocial Pre-Requisites • Attention – results in poor encoding/ persistence • Inhibition • Regulation • Problem Solving • Working Memory • Organization/Planning • Flexibility Attention Remediation • • • • Self monitor – MotivAider Practice short, timed sustained attention Teach Learning checks Provide specific and contingent positive reinforcement for desired behaviors Attention Compensation • • • • Provide short breaks built in to the day Remind students to work carefully Engaging instruction Make sure any material not absolutely necessary to the task is removed from the desk • Ask the student to run errands in the classroom Inhibition • Remediation – Teach relaxation/emotional regulation/inhibition • Use the same cues! • Practice when emotion is reduced • Use cue cards • Use “change the channel” cards • Compensation – Provide short breaks when emotion level rises, shift whole class instruction – Reduce environmental triggers – Provide time and space to reduce physiologic response – Reduce expectation when appropriate Problem Solving/ Initiation Remediation PACTa –book problem solving technique Create for “how to solve problems” Include steps for how to approach a • Problem problem (e.g. fractions) do ifproblem you don’tto know to do! – What Statetothe bewhat solved – Help frame the situation • Action – List ALL possible ways to solve the problem • Consequences – List ALL possible consequences – Rate the actions + or – • Try it! – Try one, if it doesn’t work, try another! Pulgaron personal communication (2008) Problem Solving/ Initiation Compensation • Provide rules for approaching problems (say things the same way every time) • Provide a list of class assignments or chores on a board (e.g. write the instructions for a task in order of completion) • Give new information in smaller units when possible, reviewing frequently. • Break longer tasks/instructions into smaller, discrete units. • Help students get started on tasks and check periodically to see that he or she continues to follow directions. Working Memory • Remediation – CogMed – Other working memory interventions – Drill and practice • Compensation – Key! – Reduce load on working memory – Checklist for task completion – Pull information onto paper and out of the brain! – Use formula sheet or problem solving steps Organization/Planning • Remediation – Teach students strategies for independence • Compensation – Highly structured environments where tasks are organized for them. • Periods structured similarly (similar to language arts) with different material • Bins for handing in work, routines for turning in assignments – Break down long term assignments • Due dates for pieces of project • Study guides/notes given at the beginning of the lesson and planned reviewing Flexibility/Metacognition • Remediation – Provide instruction that helps teach students how they learn best – describe this to students throughout instruction • Compensation – – – – Flex Card! Modify assignments to be closed ended Give choices Provide problem solving steps in the moment Pre-requisite skills applied to School • Each subject requires pre-requisite skills • Think of what you want to remediate • Compensate for everything else Reading • Pre-requisite skills needed – 5 Big Ideas of Reading • • • • • Phonological Processing (auditory processing) Vocabulary (crystallized ability) Comprehension (abstract thinking, working memory) Fluency (processing speed) Alphabetic Principle (visual spatial, visual memory) – Visual tracking/scanning – Language skills (syntax, articulation) – Sustaining mental effort (i.e. attention) Reading Remediation • Phonics – Wilson Reading, phonological practice • Tracking/Scanning – OT or vision therapy • Attention – MotivAider/ self monitoring system/highlight or margin notes • Abstract Thinking – practice predicting • Fluency – drill and practice daily Reading Compensation • Phonics – read material to student/ use text to speech • Tracking/Scanning – reading window/larger print/less on page • Attention – shorter lessons/high interest topics/movement breaks • Abstract thinking – limit prediction questions/make material fact based • Fluency – give extra time Reading Summary • Need to consider pre-requisite skill most likely impacted • Design academic interventions to target those skills – Scaffolding with compensatory supports • Help students compensate while attempting remediate. Writing • Pre-Requisite skills needed – Phonological Processing (spelling) – Memory Span (working memory/visual memory) – Motor Skills (visuo-motor, graphomotor) – Processing Speed – Sustaining mental effort (attention) – Executive functioning (planning, organization, monitoring). Writing Remediation • Spelling- Cover, Copy, Compare • Integrated writing instruction • Occupational therapy for graphomotor difficulty • Graphic organizers, self monitoring Writing Compensation • Shorter assignments/high interest topics • Keyboard/Scribe • Picture prompts/ word bank • Samples • Graphic organizers to assist with planning, organization of writing. Math Achievement • Pre-requisite skills needed – Abstract reasoning skills – Visual Spatial skills – Working memory – Processing Speed – Reading – Language/comprehension skills for word problems – Sustaining Mental Effort (attention) – Follow directions Math Remediation • Talk out loud, think out loud • Cover, copy, compare • Comparison of new concepts with previously learned concepts • Self monitoring and performance feedback. • Paragraph shrinking (identifying key words) • Targeted feedback Math Compensation • Read more complex math problems to student (key words) • Calculators for complex word problems. • Larger printed numbers • Shorter assignments • Visual aids (number lines, manipulatives, formulas) • Review instructions, confirm understanding Remediation and Compensation • Remediation target: What is the skill that you want the child to learn? • Pre-requisite deficit- What are the skills expected to be applied independently to complete the task? • Compensation Need: What support does the child need to help achieve this goal? Within Subject Example: Across Subject Example: Remediation target: Word problems Remediation target: Hypothesis generation & lab write-up Pre-requisite skill deficit- Reading Pre-Requisite Skill deficit: Organization Compensation Need: Text to Compensation Need: Give sample & Lab outline speech/teacher read Summary • Identify areas of strengths and weaknesses • Decide what to remediate • Determine pre-requisite skills needed • Decide which areas to compensate • Choose the best evidence based interventions • Develop plan to promote independence based on educational scaffold (e.g.fade compensatory strategies) Tips • Individualize Interventions – Ask student their interests – Ask student what works best – Ask student their perception of what is hard – Look at profile for strengths & weaknesses – Follow natural/normal routines & tendencies • Think of strategies that generalize! Questions??? References • Hale, J.B., Metro, N., Kendorski, J.G., Hain, L.A., Whitaker, J., & Moldovan, J. (2009). Facilitating school reintegration for children with Traumatic Brain Injury. In A. Dvis (ed.), Handbook for Pediatric neuropsychology.Hoboken, NJ: John Wiley & Sons. • Hale, J. B., & Fiorello, C. A. (2004). School neuropsychology: A practitioner's handbook. New York, NY: Guilford Press. • Interventioncentral.com