5A. Return to Learning

Schooling and education: Return to learning

TBI affects students

ƒThe effects of TBI vary greatly from student to student; no two will be alike.ƒSometimes the effects of a brain injury are not obvious at first but become more noticeable later when thinking and social activities increase at school.

Planning to return to school

Much of the frustration and confusion related to returning to school can be avoided with proper planning.

Rehabilitation professionals should communicate with family members and school personnel to help find the most effective ways to help the student return.

The Tabbed sections include a model for brain development and for deficits for each area of brain functioning (attention, language, executive, etc) behavioural impacts cognitive and academic impacts and suggested environmental supports and accommodations.

School personnel should be contacted as soon as possible after the injury to plan for the student’s return to school.

Parental Involvement

Parental involvement is critical when a young person is returning to school after a traumatic brain injury (TBI).

Parents have the most knowledge about their child and are deeply invested in their daughter’s or son’s well-being and future. Often parents become advocates to ensure that all essential supports are in place to enhance their child’s successful return to school. Parents may also be a go-between to make sure all the necessary medical information has been provided so the school can design the best plan for the student. If the student is close to exiting school, vocational rehabilitation professionals may also be involved.

Schools' supports for students with TBI

It is important to obtain information about the student’s pre-injury cognitive abilities from current or former teachers, and from the student’s rehabilitation professionals such as neuropsychologists.

Educators and family members need to understand the nature and severity of the injury. A neuropsychologist and other rehabilitation professionals can evaluate the student’s current strengths and abilities and recommend possible supports both in and out of the classroom. This information can be used to determine what classes the student should be placed in and any changes needed within the classroom.

 

 

 

 

Building Blocks of Brain Development

The graphic below represents the Building Blocks of Brain Development. Our brains develop each and every “building block” or brain function in a progressive manner. They build upon each other to become more complex (i.e., higher order thinking). The building blocks included here represent typical areas of processing/learning and those that are commonly affected by brain injury.

  • There may be other areas affected by brain injury, as this is not an exhaustive list.
  • The graphic depicts the building blocks at the fundamental, intermediate, and higher order levels.
  • Each level is color-coded – the fundamental or foundational building blocks are at the base (orange level). These fundamental building blocks are very sensitive to brain injury and are essential for all learning and behavior.
  • The intermediate level (green) building blocks denotes all learning and language and visual-spatial processing.
  • The higher order thinking skills – executive function and social emotional competency are represented at the blue level.
  • Overall functioning and achievement (purple level) requires the fundamental, intermediate and higher order building blocks to be solidly in place and work in concert with one another. A brain injury may cause gaps in the functioning of these areas which can impact learning and/or behavior.

The Building Blocks of Brain Development framework is provided as a general guideline for educators and professionals. It was developed as a beginning “reference point” for professionals working with students where a brain injury is suspected or known to be present.

 

Note:

This framework is used in Brain Injury in Children and Youth: A Manual for Educators which also offers a wide range of suggested assessment tools and intervention strategies for students with brain injury (as well as other conditions impacting neurocognitive functioning).

It is available for free on the CDE website: http://www.cde.state.co.us/cdesped/sd-tbi and the homepage: https://cokidswithbraininjury.com/). The manual provides a detailed explanation of how each building block may be effected in the school setting if a brain injury occurs. In addition, an extensive list of accommodations, strategies, and interventions for each building block are provided in the manual.

A very helpful tool for data collection in each of the Building Block areas is the Neurocognitive Evaluation Form.  For more resources, please refer to the additional resources at the end of this guide.

 

 

 

 

Fundamental processes (attention, inhibition, etc)

This TAB includes for deficits for each aspect of fundamental brain processes (attention, inhibition, processing speed, etc) behavioural impacts, cognitive and academic impacts and suggested environmental supports and accommodations for students return to learning.

Attention

Behavioral Impacts

  • Spacey and forgetful
  • Easily distracted
  • Difficulty with turn taking
  • Doesn’t turn in assignments
  • Fidgets/squirms in seat or doesn’t stay in seat
  • Interrupts conversations
  • Loses things
  • Low frustration tolerance
  • Off topic
  • Talks excessively

Cognitive Academic Impacts

  • Careless mistakes on school work
  • Difficulty following directions
  • Does not follow through with directions/tasks
  • Doesn’t complete assignments
  • Erratic memory
  • Fails to give close attention to school work
  • Has inconsistent performance in school
  • Can’t keep up with rest of the class

Environmental Supports and Accommodations

  • Directly teach and practice what paying attention looks like
  • Teach self-monitoring
  • Brain Breaks
  • Vigorous exercise
  • Mindfulness, meditation, relaxation techniques, yoga
  • Ensure that you have the child’s focus prior to giving instructions
  • Frequent check-ins and redirection
  • Reduce visual and auditory distractions
  • Clear desk of everything except what is needed for the lesson
  • Seat child closest to point of instruction and away from distractions
  • Verbal and visual cues (cue word, nonverbal gesture, sticky note system, stop light system)
  • Behavior Intervention Plan

Inhibition

Behavioral Impacts

  • Acts on first thing that pops into their mind
  • Blurts thoughts out and can talk excessively
  • Calling out rather than waiting with hand raised
  • Fidgety/squirmy
  • Difficulty staying in line, seat, classroom, etc.
  • Impulsive; “jumps before looks”
  • Interrupts; socially intrusive
  • Jumps into an activity rather than waiting for/reading instructions
  • Physical touch with others may be too much
  • Disregard for boundaries
  • Social Difficulties
  • Participating in unsafe behaviors or behaviors that get them into trouble

Cognitive Academic Impacts

  • Can be disruptive in the classroom
  • Difficulty following multi step directions
  • Not slowing down to process directions
  • May complete assignments incorrectly
  • May require a lot of redirection from teacher

Environmental Supports and Accommodations

  • Provide structure
  • Teach routines and expectations. Fade external support to internalization of routine and systems
  • Intentional adult movement through room
  • Brain Breaks and movement
  • Fidgets, wiggle seats, exercise balls, etc.
  • Allow standing while working
  • Verbal and visual cues (cue word, nonverbal gesture, sticky note system, stop light system)
  • Teach goal-directed problem solving process; Goal-Plan-Do-Review
  • Teach stop, relax and think
  • See Reasoning, Mental Flexibility and Social/ Emotional Competency Building Blocks

Processing Speed

Behavioral Impacts

  • Acts like he doesn’t understand
  • Appears inattentive
  • Delay in response
  • Fatigues easily
  • Frustration

Cognitive Academic Impacts

  • Delay in response
  • Difficulty following lecture
  • Difficulty multi-tasking
  • Spotty learning of new information
  • Difficulty taking timed tests
  • Does not appear to remember information
  • Incomplete work
  • Poor grades in-spite good effort
  • Slow at doing work

Environmental Supports and Accommodations

  • Establish daily routines and classroom expectations
  • Allow for delay in response
  • Copies of notes and outlines
  • Extra time
  • Give clear and concise instructions one at a time
  • Repeat instructions
  • Provide written instructions
  • Combine visual and verbal information
  • Limit number of tasks required to complete at one time

 

Memory

Behavioral Impacts

Make a differential distinction between memory problems and New Learning
  • Appears manipulative
  • Appears to have attitude issues
  • Can’t remember more than one thing at a time
  • Disorganized
  • Doesn’t remember recent events
  • Forgets to turn in assignments
  • Gets lost frequently and easily
  • Learned helplessness
  • Looks spacey
  • Repeatedly asks the same question

Cognitive Academic Impacts

  • Can’t re-tell a story
  • Difficulty retaining new skills
  • Difficulty with multi-step directions/multi-step problem
  • Difficulty with spelling
  • Fails test in spite of studying
  • Forgets assignment
  • Forgets events
  • Forgets people and names
  • Inconsistent performance
  • Splintered learning
  • State dependent learning

Environmental Supports and Accommodations

  • Encourage to develop visual picture of what have learned or read
  • Teach concept and have them teach others
  • Experiential Learning
  • Have student paraphrase directions or steps
  • Mnemonic strategies
  • New concepts – engage background knowledge
  • Errorless learning
  • Pictures or visual cues
  • Provide copies of notes
  • Practice daily routines
  • “Priming the pump” – slightly elevate emotions when teaching new concepts
  • Use memory aids e.g. visual cues, planners, PDAs or other compensatory strategies
  • Use of competitive games
  • See New Learning Building Block

Sensory & Motor - Over stimulation

Behavioral Impacts

  • Always touching people or things
  • Appears overwhelmed
  • Behavior may appear oppositional however, it may be adaptive; e.g. wearing hat to cover eyes, laying on the floor
  • Bumps into others when in line
  • Clothes are disheveled due to tugging and sucking on clothes
  • Emotionally melt down
  • Fidgety
  • Irritable, short fuse
  • Overly excited in stimulating environments such as the playground, PE, lunchroom, etc.
  • Seeks oral stimulation
  • Seeks physical feedback, e.g. leans on desk
  • Tunes out due to over stimulation

Cognitive Academic Impacts

  • Difficulty completing worksheets with too many items on them
  • Difficulty shifting from workbook/textbook to writing on answer sheet/paper
  • Difficulty transitioning
  • Difficulty with group work and group discussion
  • Difficulty with reading due to visual stimuli
  • Difficulty with seat work
  • Excessive erasing, crossing out of words
  • Gets overwhelmed in crowded environments
  • Incomplete work
  • Messy papers, school work is not well-organized
  • Poor handwriting

Environmental Supports and Accommodations

  • Occupational Therapist and/or Physical Therapist Consult
  • Allow student to dictate first draft of written assignment rather than write
  • Allow student to use a computer for written work
  • Reduce number of problems on a page
  • Break down written work into chunks
  • Deep joint pressure
  • Preferential and thoughtful seating to reduce auditory and visual stimulation
  • Preferential seating to decrease sensory input
  • Reduce visual and auditory distractions
  • Situation modification: earplugs, sunglasses, visors, moving to a new location
  • Situation selection: tune into preferential sound, mindfulness, goal orientation, diaphragmatic breathing
  • Use color overlays
  • Use line ruler to assist with visual tracking
  • Use study carrel
  • Weighted vests/ items (blankets, animals)
  • Wiggle Seat/inflatable chair cushion/ dynamic seating systems
  • Conduct assistive technology evaluation

Sensory & Motor - Under Stimulation

Behavioral Impacts

  • Motor – can appear clumsy and run into objects/people
  • Motor – constantly on the move
  • Tactile – seeks out touch or being held
  • Takes a lot of sensation to stimulate the child – so they seek out more stimulation
  • Taste – picky eaters

Cognitive Academic Impacts

  • Difficulty following verbal directions
  • Tactile – difficulty registering pain or pressure

Environmental Supports and Accommodations

  • Brain Injury in Children and Youth: A Manual for Educators (Chapter 3) (CDE)
  • Occupational Therapist and/or Physical Therapist Consult
  • Allow them to chew gum, hard candy, or crunchy foods
  • Fidget items
  • Heavy work or deep pressure activities
  • Running or jumping
  • Stretch bands on chairs
  • Therapy seats/exercise balls for sitting
  • Therapy swings or swinging
  • Trampoline
  • Wall push-ups

Motor - Fine

Behavioral Impacts

  • Difficulty with fasteners
  • Shaky hands/tremors
  • Poor coordination

Cognitive Academic Impacts

  • Avoids tasks involving writing
  • Difficulty with cutting
  • Difficulty with drawing
  • Poor handwriting
  • Takes long time to produce written work
  • Messy work

Environmental Supports and Accommodations

  • Occupational Therapist and/or Physical Therapist Consult
  • Assistive/Adaptive Technology
  • Adapted scissors
  • Allow student to use computer for written work
  • Develop pre-prepared materials so that they do not have to focus on cutting etc. but can focus on content
  • Guided notes/outline
  • Pencil grips
  • Slant boards
  • Speech to text technology
  • Typing/texting vs. writing

Motor - Gross

Behavioral Impacts

  • Avoids sports
  • Bumps into things
  • Difficulties carrying lunch tray
  • Clumsy
  • Falls/Stumbles
  • Unsteady on stairs, playground equipment or in crowds

Cognitive Academic Impacts

  • Avoids recess
  • Difficulty with or avoidance of P.E.
  • Slumps in seat

Environmental Supports and Accommodations

  • Occupational Therapist and/or Physical Therapist Consult
  • Adapted sports and physical education class
  • Adapted seating (chairs, desks)
  • Heavy work activities e.g. standing wall pushups, carrying books, stacking chairs, etc.

Intermediate processes (new learning, language, etc c)

This TAB includes for deficits for each aspect of intermediate brain processes (new learning, language, etc ) behavioural impacts, cognitive and academic impacts and suggested environmental supports and accommodations for students return to learning.

New Learning

Behavioral Impacts

Make a differential distinction between New Learning and Memory problem
  • Easily frustrated or overwhelmed
  • Angry outbursts or meltdowns
  • Can be misclassified as lazy
  • Can seem defiant
  • Copies others’ behavior or work
  • Follower
  • Forgetful
  • Makes things up to save face
  • May not exert effort when new material is presented
  • Spacey

Cognitive Academic Impacts

  • Cannot generalize or over generalizes information
  • Does not remember information they have been taught
  • Fails to see big picture
  • Forgets people and names
  • Inconsistent performance day to day
  • May be able to memorize but cannot apply information
  • Poor result in spite of extensive effort
  • Splintered or Uneven learning

Environmental Supports and Accommodations

Language - Receptive

Behavioral Impacts

  • Acts out
  • Confused
  • Difficulty with auditory information
  • Does not understand multiple meaning words, inferential, figurative and more complicated abstract language
  • Echolalia
  • Follower
  • Inability to follow multi-step directions
  • Inattentive, distractible
  • Says “huh” frequently
  • Slow or does not respond to directions
  • Social withdrawal

Cognitive Academic Impacts

  • Difficulty understanding complex ideas or direction
  • Answers wrong question
  • Circumlocution
  • Delayed reading
  • Difficulty following instructions
  • Difficulty problem solving
  • Difficulty understanding homework assignments
  • Difficulty with math word problems
  • Poor reading comprehension
  • Reading or writing weakness
  • Slow to understand
  • Writing output is weak

Environmental Supports and Accommodations

  • Speech Language Pathologist Consult
  • Allow extra “think” time
  • Break complex directions into concrete examples
  • Give directions slowly and one at a time
  • Have child repeat back instructions
  • Provide directions, assignments, lectures in writing
  • Reduce semantic load to minimize frustration and confusion
  • Reinforce with visual cues
  • Teach the use of graphic organizers to visually represent concepts
  • Identify target vocabulary and integrate throughout lessons

Language - Expressive

Behavioral Impacts

  • Word retrieval difficulty using words and sentences to express ideas
  • Uses poor grammar or immature speech
  • Breakdown in logical sequencing of ideas
  • Circumlocution
  • Difficult to follow in conversations
  • Difficulty interpreting sarcasm
  • Dysarthric speech (slow, slurred speech, mumbling)
  • Frequently repeat the same question or make the same comment
  • Act out
  • Follower
  • Frustration
  • Ruminating on topics
  • Social withdrawal

Cognitive Academic Impacts

  • Difficulty identifying or providing salient details
  • Difficulty summarizing
  • Difficulty with problem-solving
  • Lack of specific language in academic work
  • Often repeats the same idea rather than providing more or different information about a topic
  • Responses may be short without much elaboration on topic
  • Trouble participating in class discussions
  • Trouble writing essay questions or re-telling stories

Environmental Supports and Accommodations

  • Speech Language Pathologist Consult
  • Allow child to dictate thoughts prior to writing
  • Ask open-ended questions
  • Provide choices
  • Teach attributes of concepts
  • Teach summarization skills
  • Teach the child appropriate expressions, role play
  • Allow plenty of time for responses and do not pressure the child

Language - Social Pragmatic

Behavioral Impacts

  • Difficulty building or maintaining friendships
  • Difficulty negotiating social rules
  • Difficulty staying on topic
  • Difficulty taking turns
  • Difficulty understanding humor, jokes or sarcasm
  • Difficulty with proprioception (knowing body in space)
  • Difficulty responding to facial expressions and body language
  • Frustration
  • Inappropriate use of jokes, sarcasm or humor
  • Inappropriate tone of voice

Cognitive Academic Impacts

  • Difficulty making and maintaining friendships
  • Difficulty working in groups in the classroom
  • Doesn’t seem to fit into social groups in less structured settings such as recess, lunch, etc.

Environmental Supports and Accommodations

  • Develop friendship groups
  • Consider students place with for partner/group work
  • Model and role play social interactions
  • Social narratives
  • Teach social problem solving skills
  • See Social/Emotional Competency Building Block

Visual Spatial

Behavioral Impacts

  • Can experience behavior issues due to frustration of not understanding visual materials and expectations
  • Appears overwhelmed
  • Struggles reading social cues or facial expressions
  • Complains that “it all blends together”
  • Difficulty organizing materials
  • Difficulty with proprioception (knowing body in space)
  • Gets lost
  • Increased headaches during visual tasks
  • Sensitivity to light

Cognitive Academic Impacts

  • Depth perception issues
  • Difficulty organizing written work
  • Difficulty using charts, maps, and graphs
  • Difficulty with Mathematics/Geometry
  • Distance perception difficulty
  • Handwriting issues
  • Struggles with mental rotation and object construction
  • Reading difficulty
  • Spatial perception and orientation difficulty
  • Issues visualizing mental maps

Environmental Supports and Accommodations

  • Consider if visual presentation of worksheets needs to be modified
  • Enlarge written materials
  • Provide directions verbally
  • Frequent checks for understanding
  • Provide support in aligning math problems (graph paper)
  • Provide support in organizing writing from left to right and organizing/expressing thoughts
  • Reduce visual “clutter” at student’s desk
  • Use a ruler/straight edge to track reading
  • Verbal focus on learning
  • Visual planners (webs, diagrams) may be too confusing

Higher Order Intermediate processes (initiation, planning, etc)

This TAB includes for deficits for each aspect of intermediate brain processes (initiation, planning, etc behavioural impacts, cognitive and academic impacts and suggested environmental supports and accommodations for students return to learning.

Executive Function - Initiation

Behavioral Impacts

  • Difficulty starting tasks independently
  • Can state what they are supposed to do but does not get started
  • Slow to shift at same time as peers
  • Requires constant cueing
  • Does not make plans academically or socially
  • Appears aloof or disinterested in peers
  • Follower
  • Lagging in independent living skills
  • May appear lazy, unmotivated or spacey
  • Often gets overlooked because they are not trouble in the classroom
  • Seeks out adults for social interaction

Cognitive Academic Impacts

  • Appears passive/resistant
  • Difficulty knowing how to get started
  • Difficulty managing long-range projects
  • Does not complete homework or seat work
  • Turns in poor quality work
  • Woefully incomplete work

Environmental Supports and Accommodations

  • Provide a written routine to assist/help student begin work
  • Provide assistance with getting started with school work
  • Provide more frequent check-ins to ensure student is completing work
  • Teach students how to observe others to identify what to do next
  • Use visual imagery to practice the activity steps prior to initiation
  • May need friendship groups or support initiating social interactions
  • See Planning and Organization Building Blocks

Executive Function - Planning

Behavioral Impacts

  • Difficulty with problem solving
  • Doesn’t make plans with friends
  • Rigidity of thinking
  • Often late for class
  • Often unprepared for class

Cognitive Academic Impacts

  • Difficulty organizing thoughts
  • Difficulty with long term assignments
  • Difficulty with sequential tasks
  • Difficulty with time management
  • Difficulty writing papers
  • Doesn’t brainstorm

Environmental Supports and Accommodations

  • Develop, teach and reinforce schedules and routines
  • Directly teach and model step by step problem solving
  • Anticipate and prepare for transitions
  • Report and Talk Aloud
  • Check In/Check Out
  • Block & Box (Sara Ward)
  • The Working Clock – Time Management Strategy (Sarah Ward)
  • Get Ready, Do, Done (Sarah Ward)
  • Provide student with “Planning Sheet” (see Executive Skills in Children and Adolescent resource book)
  • Use a smartphone and set reminders and alarms
  • Teach goal-directed problem solving process; Goal-Plan-Do-Review
  • See Initiation and Organization Building Blocks

Executive Function: Organisational Skills

Behavioral Impacts

  • Seems confused
  • Copies behaviors of others
  • Difficulty with transitions
  • Easily frustrated
  • Resistant
  • Follower
  • Is disorganized
  • Loses things easily
  • Spacey
  • Conversations may be disjointed

Cognitive Academic Impacts

  • Difficulty with long range projects
  • Unable to do more than one step on a task
  • Doesn’t turn in homework
  • Homework is incomplete
  • Not independent learner
  • Often forgetful
  • Work is messy
  • Difficulties answering open-ended questions

Environmental Supports and Accommodations

  • Establish daily routine
  • Check in/Check out system
  • Color code subjects
  • Provide student with step-by-step instructions
  • Report and Talk Aloud strategy
  • Smartphone apps: clock/timer, calendar with reminders, Evernote recordings/pictures/detailed instruction
  • Use of classroom websites with posted notes and assignments
  • Multiple small storage bins; label storage area contents – create routines for use
  • Support between home and school to implement an organization system
  • Teach/support organization skills/systems (folders, planners, etc.)
  • Use of graphic organizers
  • Use a “zipper” folder containing sections for each subject and sections for work “to do”, “completed” etc.
  • Teach goal-directed problem solving process; Goal-Plan-Do-Review
  • See Initiation and Planning Building Blocks

Executive Function : Mental Flexibility

Behavioral Impacts

  • Argumentative
  • Concrete thinker
  • Rigid thinker
  • Perseveration
  • Difficulty making friends
  • Difficulty taking feedback
  • Difficulty with transitions
  • Doesn’t like to try new things
  • Lacks empathy
  • Stubborn
  • Issues with understanding the perspective of others

Cognitive Academic Impacts

  • Difficulty coming up with solutions
  • Difficulty deviating from schedule
  • Difficulty shifting between tasks or ideas
  • Difficulty with abstract thinking
  • Doesn’t do what asked
  • Doesn’t learn from mistakes
  • Doesn’t think well on his/her feet

Environmental Supports and Accommodations

  • Develop, teach and reinforce routines
  • Block & Box (Sarah Ward)
  • Explicitly teach flexible thinking skills (i.e., warnings, counting down time, timers, practice changing schedule)
  • Guided Self-Reflection
  • Plan for situations that require mental flexibility
  • Teach Stop, Relax and Think
  • Teach coping strategies, belly breathing, mindfulness, meditation, relaxation techniques
  • Social skills groups. Teach perspective taking
  • Use of social narratives
  • See Reasoning and Social/Emotional Competency Building Blocks

Executive Function: Reasoning

Behavioral Impacts

  • Acts without thinking of the consequences
  • Does not follow through with request to complete tasks
  • Doesn’t think well on his/her feet
  • Followers
  • Lacks common sense
  • Makes poor behavioral and social choices
  • May appear depressed
  • Oppositional
  • Poor social judgment and risk taking behaviors e.g. promiscuity, school suspension
  • Argumentative
  • Stubborn
  • Does not learn from mistakes

Cognitive Academic Impacts

  • Can do rote learning but does not get broader concepts
  • Concrete thinker
  • Difficulty responding to open-ended or essay questions
  • Difficulty with comprehension, e.g. reading, math, written expression
  • Difficulty with math word problems
  • Does better on multiple choice tests
  • Does not generalize information appropriately (over or under generalizes)
  • Does not get the big picture
  • Lacks insight

Environmental Supports and Accommodations

  • Present information in concrete and concise manner
  • Asking “why” questions
  • Avoid sarcasm
  • Scaffolding
  • Inquiry-based/Cooperative Learning
  • Teaching into meaningful concepts
  • Use multiple choice instead of essay test formats
  • Provide choices of activities or more support during unstructured times
  • Teach problem-solving strategies
  • Explore pros and cons of real-life situations
  • Social skills groups
  • Be clear and consistent on consequences of risk-taking behaviors
  • See Reasoning and Social/Emotional Competency Building Blocks

Social Emotional Competency

Behavioral Impacts

  • Difficulty keeping and making friends
  • Difficulty reading social cues
  • Difficulty with anger management
  • Emotionally labile
  • Meltdowns
  • Over/under reaction

Cognitive Academic Impacts

  • Cognitive distortions (exaggerated or irrational thought patterns)
  • Difficulty with group learning
  • Emotional pre-occupation that interferes with academics
  • Trouble focusing

Environmental Supports and Accommodations

  • Give clear and simple directions
  • Provide, teach and reinforce routines and clear expectations
  • Provide calm down area
  • Discuss and practice age-appropriate behaviors in real life situations
  • Social skills groups
  • Social narratives
  • Teach coping strategies, belly breathing, mindfulness, meditation, relaxation techniques
  • Behavior Intervention Plans
  • See Inhibition, Mental Flexibility and Reasoning Building Blocks