NeuroRehabilitation An InterdllClpllM" Joumal

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NeuroRehabilitation 9 (1997) 133-148

Beyond school re-entry: addressing the long-term needs of students with brain injuries Patricia L. Janus * , Lois W. Mishkin, Sue Pearson 9602 Hingston Downs, Columbia, MD 21046, USA

Abstract Educators today face the challenge of providing appropriate programs for students with a wide variety of needs. Students with acquired brain injuries may sustain permanent physical, cognitive, and psycho-social sequelae which can significantly impact their ability to function at home, in school, and in the community. After discharge from a rehabilitation facility, the educational system becomes critical in facilitating the student's ongoing progress. Addressing the long-term needs of students with brain injuries requires that educational personnel become knowledgeable about appropriate learning strategies and program modifications. This article describes the educational outcomes of students with acquired brain injuries, discusses critical features of effective programs, and suggests interventions for consideration in instructional planning. © 1997 Elsevier Science Ireland Ltd.

Keywords: Acquired brain injury; Educational planning; Educational strategies; Student outcomes

1. Introduction

Over the past 10 years, great strides have been made in facilitating a child's successful re-entry to school after an acquired brain injury. Hospitals and schools are working more efficiently, sharing pertinent information, and effectively collaborating in planning strategies to ensure a smooth reintegration. While this is encouraging, it must be recognized that re-entry is but one step in a long-term, life-long process. Long-term recovery from brain injury is different from rehabilitation. Rehabilitation is a highly structured, technical

* Corresponding author. Tel.: (W) + 1 301 6574959, (H) + 1

301 7250272; fax:

+ 1 301 6574989.

period of time where the professional's goal is to help the individual regain lost skills. Upon discharge, the hospital can provide information on current medical status and answer what skills the child has, but it cannot answer or guarantee that those skills will be applied in the real world. For a child, the real world consists of family, school and social activities, environments which are full of change and often dramatically different from a rehabilitation setting. Given the reality that improvement in rehabilitation can not necessarily be equated with longterm success, it is important to examine those elements which are critical to extending a child's success beyond the doors of the rehabilitation hospital. This article will address the long-term

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needs of children with acquired brain injuries. The implications of these needs and strategies will be discussed to assist educators in planning appropriate programs that expedite functional outcomes and promote a child's sense of control over his life. Perhaps the biggest tragedy of any disability is the loneliness and depression that can result from frustration, misunderstanding, and poor self-esteem. When educators strive to provide understanding and successful learning experiences, they are helping each child to develop into an adult with positive self-esteem who can contribute to society and establish fulfilling interpersonal relationships. 2. Long-term needs

Children recovering from brain injury may continue to exhibit a variety of physical, cognitive, and psychosocial needs for years after their injury and often for life. Therefore, educators should be knowledgeable about these needs, understand their implications and plan educational programs accordingly. One of the most challenging issues in programming for students with brain injuries is the variability of residual needs that each student presents. No two profiles are identical in types and/or intensity of problems. Additionally, needs may change over time as normal recovery occurs and interventions are implemented. The long-term effects of brain injury will vary depending upon a number of factors including the child's age, etiology, location and severity of injury. Generally, the first 6 months after an injury are frequently characterized by rapid recovery and a resolvement of physical and medical issues. However, for the majority of students with moderate to severe brain injury a variety of cognitive and psychosocial needs persist long after motor recovery and usually require educational modifications and/or support from special education services. Ewing-Cobbs et al. [1], found that 2 years after their injury, only 25% of the children were able to function in a regular education class. These children had all sustained a period of impaired consciousness for longer than 24 h. Similarly, looking at 22 students who had sustained moderate or severe brain injuries and were at

least 2 years post-trauma in a public school system in Maryland, Janus [2] found that all 22 continued to need some level of special education support. Only five of the group were in regular education classes with resource room support while 17 required more intensive services and were in special classes for the majority of their day. Fourteen of the 22 continued to require one or more related services of occupational therapy, physical therapy, or speech and language services.

2.1. Pre-school injury Considering the effect of age upon recovery, educators must be aware that contrary to what many believe, younger children do not necessarily demonstrate better recovery than older children and adolescents. In fact, the opposite is often true, especially for pre-schoolers. While performance may seem within normal range during pre-school and primary years, functional deficits may emerge later with maturation and require instructional modifications or special education services. For example, a pre-school child who has sustained damage to the frontal lobe area of the brain may appear to be fully recovered until years later, when teachers and parents begin to expect the child to demonstrate executive functions, such as planning and organizing. Pre-schoolers represent the second highest risk group for brain injury, second to youths from ages 15 to 25 [3,4]. Less is known about the long-term outcomes for pre-school children in comparison to older children and adolescents, but recent research has indicated that skills in a rapid stage of development at the time of brain injury may be more susceptible to impairment than more automatized and overlearned skills [5]. Furthermore, following brain injury, the recovery of previously learned information and skills appears to be easier than learning new information, which puts pre-school children at a distinct disadvantage, as most have not learned to read or write and, in general, have had relatively little academic experience. Allison [6] quotes Singer, 'An adult has already had significant life experiences, opportunities for learning, language development, social skills and a variety of adaptive skills that permit

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them to act as adults. A brain injury to a crucial region during a key stage of brain development may thus prevent the child from ever being able to acquire and store much of this type of information'. In light of potential problems, children who are injured at an early age and demonstrate good recovery should continue to be monitored for cognitive and psychosocial needs as they progress through school. Public school programs and center-based pre-school programs can provide opportunities for interdisciplinary assessments and coordinated communication between professionals. Providing information about parent groups and/or support groups may be especially critical for parents. Parents report that talking to other families provides them with much needed support and information and helps to reduce their sense of isolation. 2.2. Physical needs

Physically, a small number of students will demonstrate full or partial paralysis of a permanent nature, but in the majority of cases, independent motor functioning returns. More commonly the major complaints are fatigue and headaches, even with milder injuries. Casey et al. [7] found that 1 month after injury, the most frequent complaint reported among a group of 321 children with mild brain injury was headache. Other physical needs include spasticity, ataxia, tremors, decreased speed of movement, and hearing and visual problems, such as double vision or visual field cuts, any of which may require environmental and instructional modifications. For example, educators should strategically select a child's seat and position materials in the presence of a field cut. By using selective seating, access to the intact visual field is facilitated. If a student has a left field cut, he should be seated in the left area of the room to view visual stimuli to the right. Desk top materials should be placed right of center as well. Equally important as understanding the child's physical condition is knowing the side effects of any prescribed medication. Accommodations such as rest periods, reduced activity time, and a shortened school day may be necessary for varying

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lengths of time following brain injury. Physical education activities may need to be adapted and strategically scheduled into the child's routine. Teachers should be aware that students with brain injury may have medical instructions prohibiting active participation in contact sports due to the risk of reinjuring the brain. 2.3. Cognitive needs

Cognitively, students may have difficulty with orientation, attention and concentration, language, organization, memory, learning of new information, planning and problem-solving abilities especially in novel situations, and difficulty with speeded processing. As the rate, amount and/or complexity of information increases, the speed of processing often decreases. Students may show signs of fatigue as processing demands increase. Parents and teachers often comment that the child is 'slow moving', has a delayed response to language, or requires extra processing time [8]. Educators should be cautioned that students may demonstrate retention of academic material learned prior to their injury and not be misled in assuming that everything is back to normal. To accurately understand the impact of the child's injury, one needs to examine how the student attends, organizes, and retains new learning.

2. 4. Psychosocial needs Needs in the psychosocial domain usually result from a number of causes including damage to the brain from injury as well as recognition of and reaction to loss of normal functioning. Furthermore, educators who do not have training in brain injury may misinterpret inappropriate behaviors as deliberate actions on the part of the student and respond in a way that exacerbates the situation. Students may exhibit irritability, difficulty with inhibiting inappropriate responses, aggression, lack of motivation, loss of self-esteem, apathy, self-centeredness, poor social judgment, lack of insight or denial, mood swings, and perseveration. They may also demonstrate anger, frustration, withdrawal, and depression as a secondary reaction to their loss. When identifying

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needs in this area, it is helpful to have an understanding of the child's pre-injury behaviors as problems that existed before the injury are often intensified by the trauma to the brain. In examining a child's psychosocial needs, one must account for the role of family members and peers. Children and adolescents do not operate in a vacuum, but seek approval from their family and peers. The family's ability to cope and provide support impacts the emotional adjustment of the child and hastens progress at every stage of development. Family dysfunctio~ is often common when dealing with the long-term consequences of brain injury, given the drain on time and financial resources. Relationships between parents, siblings, and peers can become strained and may require professional intervention and support. As one parent commented 2 years after her high school son's injury, 'It's still hard for us because he's not the same. I miss him'. 3. Critical features of effective programs As discussed earlier, students with brain injury will require a variety of service options to address the variability of their long-term needs. Students with brain injury are found in all types of classrooms that range from regular classes with no or little support to special education classes in regular schools or special education schools. The current trend in education promotes including or mainstreaming students with disabilities in regular classes in their home school. While this is indeed a worthy and appropriate placement for many students, it is important that options be maintained to address the variety of needs of all students. The size and stimulation of a regular class may be overwhelming for some students, especially shortly after their injury. A structured, quiet environment is often necessary initially with more stimulation being added gradually as the student can accommodate. Whether services are provided in a regular classroom, in a special education class, or in a special school, there are a number of program features that cross all settings and contribute to the student's success. These features include: staff training, clearly defined

outcomes, flexibility, an integrated team approach, and transition planning. 3.1. Staff training

Educational professionals need both general information about brain injury and specific information regarding the student's injury and needs. General information about brain injury should include causes, residual needs, assessment, educational interventions and prevention. Specific information should address the student's unique profile of needs and training on current strategies and accommodations being used successfully. It is helpful to hold a meeting at the beginning of each school year to share current information with new staff and report on any changes or developments over the summer. 3.2. Clearly defined outcomes

Goals and objectives should be specific and reflect functional outcomes that are measurable and based on accurate assessment and interpretation. Because students with brain injury may exhibit neurologic changes for years after their injury, frequent monitoring and review of objectives should be the rule. For students receiving special education services, the Individualized Education Plan CIEP) which delineates the child's goals and services, is required by law to be reviewed annually. However, for students with brain injury, reviews need to be held more frequently and involve the student, parents, and all team members providing service. It is sometimes helpful to include peer involvement in the review process, as appropriate and desired. Promoting the student's self advocacy and independence should always be the focus of a program review. 3.3. Flexibility

School systems need to be flexible in using their resources to address the ongoing needs of students with brain injury. At re-entry, students may require reduced or modified school programs or home instruction for a period of time until

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they are able to sustain a full day. Each year the student's physical, cognitive and psychosocial needs must be considered in designing the weekly schedule. Rest periods or study halls may need to be provided once or twice per day to accommodate for fatigue and overload.

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it open, then wheel through the doorway and to the counter. 2. Bill will independently take out his multiple line picture menu and point to his choices at the ordering counter. 3. When given a verbal prompt, Bill will wait for a friend before selecting where to sit.

3.4. Integrated, team approach Many students with brain injury receive services from a number of professionals including regular and special education teachers, instructional assistants, occupational and physical therapists, speech/language pathologists, vision or hearing specialists, school nurses, social workers, and psychologists. While sometimes challenging to achieve, team members should strive to deliver integrated programs in which all service providers reinforce the attainment of priority goals. To facilitate integrated programming, all service providers, the parents and student should plan, review, and problem-solve together. The vehicle for accomplishing integrated programs for students requiring special services is the individualized education plan (rEP). In many settings, each discipline involved with a child does a separate IEP section. Unfortunately, this can result in fragmented programming and different priorities per service provider. For example, therapy is useless if it can't be used outside the therapy session. Writing a team IEP involves team members agreeing to a set of priority goals. For students with multiple and complex needs, this agreement is essential as it is impossible to address every need presented by a student. Each team member does not write a separate IEP section, but collaborates in producing a plan that delineates outcomes to be addressed in particular relevant environments. In this way, input from all members is integrated in determining goals, objectives and strategies, as follows: Goal: Bill will purchase and eat a meal in a fast food restaurant. Short term objectives: 1. After the teacher opens the door, Bill will independently wheel next to the door to brace

In a discipline-specific rEP, objective 1 would be part of the physical therapy rEP and objective 2 would be found in the speech section of the rEP. Additionally, the objectives would identify the skill to be mastered but not necessarily the context in which it would be used. When team members identify outcomes that include both the elements of target skills and environment, the likelihood that students will be able to apply those skills in real life activities is greatly increased [9]. It is important that one of the team members be selected as a case manager to coordinate the many aspects of the child's program and serve as a communication link with the parent and outside providers, if involved.

3.5. Transition planning Planning ahead for transitions, both small and large, is a necessary and critical step to ensure ongoing school success. Transition planning needs to occur as students move from grade-to-grade; from school-to-school which usually occurs at grade 6 when middle school begins and at grade 9 when high school begins; and from high school to the community for post-secondary education or employment. The transition planning from high school to community is legally mandated for special education students to begin by age 16 and involves adult public agencies in many cases. This aspect is further discussed in the section on postsecondary options. Every year of school brings changes - changes in classrooms, changes in classmates, and changes in schedules and teachers. With each change, it is necessary to orient the student to his new schedule and make certain that teachers receive the information and training they need to understand brain injury. It is often helpful to keep a facesheet

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in the student's folder that summarizes the child's injury, describes whether there are any current medical issues, and provides pertinent information on specific teaching strategies, behavior management techniques, and adaptive equipment. A list of contacts and phone numbers of previous service providers is also helpful. It is not surprising that many children with brain injury may have successful experiences in elementary school, but upon entering middle or high school begin to exhibit academic and behavioral difficulties. The transitions from elementary to middle school and middle to high school are significant as they involve a move to a larger building with more students, changing classes every period, and interacting with a different teacher for each class. Recognizing the complexities involved with these moves, the student, parents, and school staff can avoid many pitfalls by anticipating problems in advance and planning accordingly. As priorities and objectives change from yearto-year, planning for the long-term needs of students with brain injuries requires that proper assessments and strategies be employed and regularly evaluated for their appropriateness. The following discussion addresses considerations in administering and interpreting assessment protocols and provides some practical strategies for the more common and pervasive needs of students with brain injury. 4. Assessment When a student returns to school following a brain injury, it is essential that staff and classmates receive accurate information that will help them understand and adapt for the changes they observe in the student. While some of these changes will be obvious; others may be more subtle [10]. Students who demonstrate good motor recovery can be puzzling to teachers who are unfamiliar with the nuances of brain injury, because physically they appear to be fine. Educators may erroneously assume that because the student has been absent for a certain period, it's just a matter of 'making up' the missed time. Additionally, students with brain injuries may do well on

testing that measures information learned prior to their injury, leaving teachers with a misperception that once the missed work is made up, everything will be back on track. It is important that individuals who conduct evaluations and interpret results be familiar with school aged children and brain injury. Since the most rapid recovery from brain injury occurs 1-2 years after injury, a student's performance may change quickly over a short period of time. The pattern of improvement may be uneven, however, with some skills returning to normal or near normal performance while others lag behind. For example, in reading, a student's word identification skills may show a good return, but reading comprehension skills may be more compromised. Carney and Schoenbrodt [11] suggest that this occurs because of the cognitive disruption of executive function and because word identification skills tend to be overlearned. Similarly, computation skills in math may seem less affected or show more rapid recovery than math reasoning skills, as needed in story problems. Setting goals and objectives for students with brain injuries requires an analysis of their skills and needs, more frequently the first year to two after injury and usually less frequently as time passes and rapid changes no longer occur. A neuropsychological evaluation can be helpful in this regard, identifying areas of strength and pinpointing learning processes disrupted by the injury. When reviewing records from rehabilitation settings and assessing academic areas such as reading, math and written expression it must be kept in mind that most students will probably perform better on standardized tests than they will in the classroom environment. Testing environments are not the same as 'real life' situations. In testing situations, fewer distractions exist, tasks are shorter, students are provided with one-to-one instruction and are given prompts when necessary and appropriate [12]. Furthermore, many standardized tests require one word responses or utilize a format of multiple choice or fill in the blank while written expression activities are often omitted as a part of formal test procedures. Standardized tests seldom provide open ended questions which require the student to identify main ideas

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and organize the information sequentially. This may explain why a student's test scores look normal, although anecdotal records and reports from teachers indicate that the student is failing to complete classroom work that seems to require the same skills and concepts. Individuals who have sustained a brain injury often seem unable to generalize information to activities of daily living at home or at school. In Descartes' E"or, Damasio [13] illustrates some of the problems with standardized testing as he discusses the case of Elliot, a young man who lived a successful life until radical changes in his personality lead to the discovery of a brain tumor. After successful surgery to remove the non-malignant growth, standardized psychological and neuropsychological tests revealed a superior intellect with no discernible problems. Despite his outstanding test performance, changes in his day-to-day performance left him unable to return successfully to his job. His poor judgment lead to the loss of his life savings, bankruptcy and eventually, the failure of his marriage. It was difficult for family and friends to understand how such a bright person could make such negative decisions. Given his performance on standardized tests, he was puzzling to professionals as well. In his discussion of standardized tests, Damasio states, 'the ongoing, open-ended, uncertain evolution of real-life situations was missing from the laboratory tasks ... real time processing may require holding information - representations of persons, objects or scenes, for instance - in mind for longer periods, especially if new options or consequences surface and require comparison. Furthermore, in our tasks, the situations and questions about them were presented almost entirely through language. More often than not, real life faces us with a greater mix of pictorial and linguistic material'. This example highlights the need for ongoing, interdisciplinary assessments that integrate the use of formal and informal procedures, and occur in more than one setting [14,15]. Some of the more recent changes in school assessment procedures may be helpful in providing an evaluation that meets these requirements. Curriculum Based Assessment (CBA) and increased use of 'problem-solving' approaches, can

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provide 'real life' information to school personnel, as these assessments usually occur in the everyday environment of the student and incorporate anecdotal information from both teachers and parents. Students are observed in their classrooms while they attempt to complete assignments using typical classroom materials. Assessments and observations are conducted by more than one person and in several different areas. Problem solving assessments can provide insight into how a student functions during a typical day. Curriculum modifications and educational strategies can then be tailored to meet the individual needs of the student, based on these functional observations. 5. Educational strategies and considerations Public Law 101-476, The Individuals with Disabilities Education Act (IDEA) mandates that students with educational disabilities such as learning disabilities, mental retardation, and traumatic brain injury are entitled to a free, appropriate, public education (FAPE) in the least restrictive environment (LRE). As a result, an increasing number of students with special needs are participating in regular classes, placing new and multi-faceted demands on educational staff. Students with brain injuries can represent an exceptional challenge to a teacher's intuition, creativity and flexibility given the variability and changing nature of their needs over time [16,17]. While there are many residual needs that can result from brain injury, there are several longterm problems which are seen more frequently and may have a life-long impact on the individual. Recent studies have indicated that after brain injury, individuals are likely to experience difficulty with memory, new learning and attention [18,19]. Parents and educators may also note changes in the student's social skills, behavior and personality. Keeping this information in mind, it is not surprising that students who have sustained brain injuries are often described as disorganized, impulsive, inappropriate, and uncooperative. In selecting strategies, factors such as the student's age, severity of needs, and personal recognition of needs must be considered. While some

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functions may fully recover, others will be permanently affected and require the student to learn the use of compensatory strategies. Both environmental (non-instructional) and instructional strategies should be considered in designing appropriate implementation plans. It is also important to remember that effective strategies and modifications need not be expensive or complicated [20]. Observing whether the student already employs any strategies is a good place to start. The following section will describe some of the strategies that can be used to address the longterm needs of students with brain injuries. The goal of any intervention is to help the student become as independent as possible in using a strategy in a variety of situations. Teaching any new strategy after an injury will initially require direct teaching and modeling, followed by repetition and practice in a variety of settings with fading cues from the adult and increased selfprompting from the student.

5.1. Environmental modifications and accommodations In the field of education, much attention has been focused on specific strategies that address the ongoing instructional needs of students with acquired brain injuries. For example, requiring completion of half of a page of problems that was assigned to the class is an instructional modification. Without such a modification, the student with slowed processing would have to spend an undue amount of time trying to complete the work and most likely experience behavioral reactions such as frustration and anger. In contrast, environmental or non-instructional modifications are frequently overlooked, but in reality should be the first to be considered in program planning. Environmental modifications and accommodations, also considered non-instructional barriers [21], must be reviewed each year as the student progresses through school. Environmental modifications include measures that simplify the environment to a level that the student can manage. Every year is different for the student and environmental modifications based on the child's physical condition, level of progress and flexibility

are an integral part of the school day. Changes can occur in any of the following from year-toyear: the school building, location of a.m. and p.m. bus, teachers, number and location of classes, bathroom, locker and lunchroom location, classroom set-up, seat location, organization of desk materials and involvement in extracurricular activities. Environmental strategies can effectively assist in addressing these time and physical barriers.

5.2. Time barriers Because students with brain injuries often exhibit fatigue as the day progresses due to cognitive overload or side effects from medication, the following suggestions should be considered when planning programs. 1. Determine what length of time a student can work and what length of day the student can tolerate before showing signs of overload. Even several years after school re-entry, a student may not be able to work for an entire morning without a break. Some cannot benefit from a full day and will require a modified schedule. Some helpful suggestions include shortening the day by either starting later in the morning or ending earlier in the afternoon, providing for rest periods as needed throughout the day, and allowing cognitive breaks when needed. 2. Schedule classes that are more difficult at a time when the student is most alert. Avoid scheduling heavy content classes at the end of the day, if possible. 3. Schedule a resource room period at the beginning and/or end of the day. This can be used to make sure the student is organized prior to first period and to check for understanding of homework at the end of the day. 4. Extended time on tests and projects may need to be provided. This may be even more necessary to keep up with the demands as the student progresses through school and the work load increases. 5. A student with a disability may be eligible for extended school year services over the

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summer if information learned preceding vacation would be lost over the break and require a significant period of time to recoup those skills in the fall.

5.3. Physical barriers Physical needs and difficulties in orientation and memory can be helped by the following. 1. When possible, arrange for classes to be near each other to avoid excessive walking which can lead to fatigue and getting lost. When this is not possible, allow the student to leave class a few minutes early. This requires planning for a 'buddy' to communicate what happened during those last few minutes or for the teacher to be flexible and assign homework, announce quizzes, tests, projects, etc., prior to the time the student leaves. 2. Arrange for the student's locker to be easily accessible to classes. Sometimes students who are in large buildings benefit from having two lockers. If students cannot remember a locker combination provide a lock with a key instead. Providing the student with an extra set of books at home is also helpful. 3. With a change to a new building, often occurring in the transition from elementary to middle and middle to high school, the student needs to become familiar with the location of classrooms, main office, health room, bathrooms, guidance office and other key places prior to the start of school. This should be planned and arranged when the building is quiet and then practiced and monitored with normal distractions when school begins. It cannot be assumed that the student who demonstrates the skill in an uncrowded hall will generalize that skill to a crowded situation. 4. The locations of the last class of the day and locker may need to be in close proximity to where the student gets the bus. This can help to avoid unnecessary physical and emotional stress in the rush to make the bus. If the student has a resource period or study hall at the end of the day, there will be time to prepare for dismissal.

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5. Following a brain injury and for years beyond, many students cannot process information in an overly stimulating environment. Their desks should be away from doors, windows, computers and other distracting objects. Study carrels can be helpful in blocking visual and auditory distractions that can exacerbate confusion and decrease attention and concentration. A classroom that is next to a noisy music room or gym is not a conducive learning environment. 6. Cafeteria accommodations may be needed when considering the physical demands and agility required to pay for lunch, make selections, and carry a lunch tray when students are moving about quickly. 7. For students who are non-ambulatory or have orientation difficulties, plans and protocols for field trips and emergencies such as fire drills should be developed and shared with all staff.

5.4. Instructional strategies Instructional strategies generally involve making alterations in assignments, modifying instructional materials, and modifying the delivery of instruction. For those functions which do not fully recover, compensatory strategies can be taught.

5.5. Attention Focused and sustained attention can be problematic for many students following a brain injury. Preferential seating that minimizes distractions within the classroom, auditorium, lunchroom, etc., should be considered. Some students may find it helpful to listen to music on headphones to help screen out unwanted distractions. When possible, it will help to reduce the length of assignments so that the student is not fatigued by having to sustain attention for long periods of time. When this is not possible, longer assignments should be broken down into smaller sections with short breaks in between. Some students like the challenge of setting a timer to see how many exercises or problems they can complete before it rings. An assigned buddy sitting nearby

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can also provide quiet and frequent prompts to redirect the student's attention back to the assigned task. With guided practice, students can be taught to use self-monitoring strategies or checklists to direct and maintain their attention through a lengthy or multi-step task.

5.6. Organization and memory Following a brain injury, students may have difficulty getting organized and remembering essential information. One of the most helpful 'allpurpose' memory strategies that can be used into adulthood is an organization notebook or calendar. This book can be used to keep a daily schedule, record homework assignments and appointments, and provide communication between parents and school personnel. The student should be encouraged to have this notebook available at all times and will hopefully learn to refer to it when unable to remember specifics. Initially, many students will not be able to independently utilize the notebook and will need ongoing assistance and prompts. Parents should check to see that the notebook is with the child in the morning before leaving for school. It is also advisable that a contact person at school be identified to ensure that the notebook is with the student at the beginning and end of the school day and that assignments are written down legibly and accurately. Individual classroom teachers will also need to check that the student understands homework requirements and has the appropriate materials when moving from class-to-class. Other strategies include keeping an extra set of books at home, highlighting important information in textbooks, and using a backpack for carrying items to and from school instead of loosely in the arms. Teachers should use advanced organizers which are verbal or written prompts that point out to the students what they should be looking for before beginning the lesson. Teaching students to read the sub-headings within a text and to review the questions at the end of the chapter before reading are examples of advanced organizers. When giving directions, especially those that are multi-step, professionals should repeat or

rephrase as needed and slow down to accommodate for a decreased processing rate. An assigned buddy or peer secretary may be able to take notes for students who have difficulty synthesizing information into written form. Many teachers choose to assign several individuals to take on this role to share the responsibility. Some teachers routinely use cooperative learning strategies and have the entire class work in pairs or small groups.

5.7. Behavior After a brain injury, a student may exhibit personality changes, lack of emotional control, and display inappropriate behavior. Appropriate work expectations and assignments can significantly decrease negative responses. Modifying the curriculum to meet specific needs is critical to any student's success in school. If expectations are too high or too low, students may begin to exhibit behavior problems to avoid doing work. Likewise, preparing students for changes in their routine or transitions throughout the day is helpful in minimizing anxiety, confusion, and outbursts. Staff need to be flexible and learn to anticipate those situations that may cause problems. It is also important that students are clearly told what is expected and to reinforce appropriate responses. Opportunities to practice social skills in real life situations such as the lunchroom, playground, or extracurricular activities should be provided. Peers, also, need to be informed about what to expect and how to respond. The use of a buddy system as a natural support can be helpful to the student, particularly in unstructured activities such as recess, lunch, and changing classes. Another student can provide less obtrusive prompts and assistance as needed throughout the school day. Interaction with a 'buddy' might also help improve social relationships with other students because appropriate behavior will be modeled, providing subtle reminders in social situations. Although it is sometimes necessary to assign an adult para-professional to the student, this needs to be done judiciously as the constant presence of

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an adult may hinder the development of social interactions with other students, particularly when the students are adolescents. Students should be able to go to a counselor or case manager when they need to talk or calm down if they feel they are losing control. Educators should not take outbursts personally, but remember that they are often neurologically based. By giving students appropriate ways to deal with their feelings or a safe place to go and vent, educational professionals can be instrumental in supporting behavioral change.

5.B. Other educational considerations Flexibility, understanding, and a background in learning strategies are important traits for professionals who work with students with brain injuries. Teachers who have a difficult time individualizing and adapting the curriculum will find themselves and the students they teach in a frustrating position. Likewise, educators who feel personally inadequate if students are not taught everything will also feel frustrated. Because of these reasons, it is important that administrators provide their staff with the training, resources, and emotional support to accommodate all learning needs in their classrooms. 2. The amount of homework should always be carefully monitored. This can be a source of great frustration to many students and their families. If a student's brain injury occurred a few years ago, it is often assumed that it has 'gone away' and things are back to normal. Close communication between teachers and parents is the best way to determine whether homework demands are appropriate or not. Teachers must be aware if students are continuing in outpatient therapy after school which limits the amount of time available for homework. 3. Many students will not be permitted to actively play contact sports which can affect their participation in physical education class. The nature and severity of the brain injury, the presence of seizure activity, and visual 1.

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and vestibular needs are considered by the neurologist or neurosurgeon when determining the extent of participation in physical education. Accommodations need to be discussed that would allow involvement, even if not directly engaged in the activity. This might include designating the student as an assistant or a scorekeeper. When students cannot participate as a player they can be taught the rules of the sport so they can enjoy it as a spectator activity. Some students will participate in adaptive physical education or alternative units such as weight lifting when contact sports are being done. In some cases, students are completely exempt from physical education and an alternative class is planned such as music or resource to work on homework and study skills. 4. A modified grading system that uses a Pass/Fail grade is appropriate when one is first placed in a mainstreamed class. This reduces the pressure of grades, thereby often increasing motivation. Students who are on a reduced work load should not be penalized for completing less work than their peers if mastery of concepts is demonstrated. For example, a student who can correctly complete eight out of 10 problems has demonstrated mastery and does not need to complete 15 or 20 problems. 5. Teachers should avoid giving the student all of the missed work at one time to make up upon returning to school. This applies at reentry and to any other extended absence that may occur due to medical conditions. The following case study exemplifies the difficulties a student can encounter in school unless appropriate strategies and accommodations are identified and implemented.

5.9 Case study Jessica suffered a traumatic brain injury near the end of her ninth grade year due to a motor vehicle collision in which there was a loss of consciousness of 10-12 min. The admitting diagnoses to the hospital included a cerebral concus-

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sion and numerous physical injuries. Neuropsychological findings listed a decrease in the following: attention and concentration, cognitive endurance, executive functioning, processing speed, and short-term memory. Additionally, impulsivity, frustration, fatigue and inappropriate behaviors had increased. Jessica had been a B/C student prior to her injury and although she had not been receiving any special education services, she did exhibit weak grades in spelling, language mechanics and math concepts. She returned to school after a few weeks but did not take final exams. The following year, 10th grade, was a very difficult one as Jessica cut classes, left school without permission, talked back to school authority figures who confronted her for cutting, and ultimately had excessive absences. Decreased judgment led to staying up late at night talking on the phone and then being unable to get up for school. She appeared to have no motivation to attend school as she was failing many of her classes. There had been no modifications made in Jessica's classes and she was expected to process at a rate that she was not capable of at that time. By the end of the year, Jessica had failed English and had been identified for special education services. In lieu of summer school which would not have been successful without modifications and instructional strategies, Jessica was given a substantial packet to work on during the summer at home. The packet included a variety of tasks that had not been completed during the year. Through very hard work and a determined attitude to show her teacher that she could do it (despite the teacher saying to Jessica that she would never finish it), she completed it and passed. What made such a difference was a tutor teaching Jessica to break the information down into smaller chunks. This decreased her immediate feelings of being overwhelmed and gave her a greater sense of control. Jessica's 11th grade schedule included some special education classes in resource rooms and mainstreamed math. Jessica's attitude was most positive and her teachers thought she was a terrific student. She readily completed all work, never cut school and has begun to prepare to take the college entrance exam. While she continues to

have difficulty with problem-solving skills, she is better at identifying the issues and talking about them before getting angry. By modifying the amount of work expected of her and increasing her self-esteem, Jessica was able to succeed socially and academically. Nearly 3 years after the injury, Jessica continues to be carefully monitored by her teachers, the special education Child Study Team, parents and an outside cognitive therapist. Once the school system became more amenable to reducing Jessica's workload and changed their view of her as a 'problem teenager', Jessica encountered many positive experiences and success. 6. Impact on social functioning When a child is injured, the entire family structure is rocked. Initial hope that things will return to normal is often replaced by despair and sadness as the permanent nature of the child's needs becomes apparent. Families may require counseling and support to get through this period of time and move onto acceptance. It is also important that families be given adequate and accurate information regarding the long-term effects of their child's injury. Mauss-CIum and Ryan [22] state that family priorities include the need for a clear and kind explanation of the individual's condition and treatment, discussion of realistic expectations, and emotional support. Throughout the child's life, there will be many decisions and transitions to be made, each one requiring support and information. Frequently families comment that the intensive support network disappears shortly after the acute stage of recovery. This is unfortunate as both the student and his family require 'anchoring relationships' throughout life to see them through these transitions. Families will need to address questions that consider not only what is needed for the individual, but for the health of the family unit as well. In one instance, for example, a family decided to stop private therapy services for their child over the summer in order to be able to pay for a family vacation. As with parents, providing siblings with information about brain injury will help them to cope with the changes in their family. Siblings should

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be encouraged to ask questions and talk about their feelings. They need to be prepared to deal with the long-term issues of their sibling and corresponding effects on family interactions. Several years after a student's brain injury there may be an assumption that the attention and support that was given to the student in the re-entry stage is no longer necessary. In fact as time goes on, teachers and peers may forget about the injury or because of moving to a new building, may never be aware of the student's needs. However, as students enter new developmental stages, they will be faced with different challenges that can affect social and emotional growth and require continued support. Teachers and parents have ample opportunities to observe the student in a variety of social situations such as lunch, on the playground, after school, at their lockers, on the phone and team activities. Unfortunately, what is often observed is loneliness and social isolation. This is usually related to the student's physical, cognitive and communication limitations that make the following narrative discourse a difficult task. The speed of conversations together with slowed processing and diminished awareness of non-verbal communication often result in frustration, poor social judgment and immature behavior which can alienate peers. Behaviors noted by LaGreca and Mesibov [23] that contribute to healthy social interactions include: joining ongoing peer activities, showing enjoyment in social situations, greeting others, inviting peers to join activities, sharing and cooperating, complimenting peers, playing effectively, and maintaining hygiene and physical appearance. Brain injury may disrupt executive functioning skills that impact upon the social behaviors just noted. One avenue to effect social change in a school-aged population is through a group process that adapts to the ages involved. The group can include students with and without disabilities. One such group process is the Circle of Support, begun in Canada by Dr. Patrick Mackan and Lynn Cormier for students from pre-school age through grade 12 who have developmental disabilities. The purpose of the group is not focused on the disability but on ways to become a part of someone's life. This approach

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can be adapted to brain injury as exemplified by Melissa Fox, a social worker in New Jersey. Assigned to Josh, an eighth grader with a brain tumor who had been back in school for 1 year after a 2-year absence, Ms. Fox was instrumental in educating the staff and family about his educational needs, their impact on his functioning, and appropriate modifications. Josh had no interaction with peers and was known as the kid who was sick. He exhibited deficits in information processing, memory, sustained attention, balance and speech /hearing. After Josh was asked to identify peers that were friendly and that he liked, the guidance counselor discussed the Circle of Support with them to gauge their interest in participating. Six of the seven peers agreed to be involved. Mutual feelings were expressed in that they all liked each other but were afraid of one another. Concerns identified by the group included: if they talked to Josh, he could lose his balance; Josh was loud and embarrassed some of them; and they did not understand why, if he was cured, he didn't act the same as before the tumor. Following several weeks of bi-weekly lunch meetings with Josh and the group that centered around themes, many positive changes occurred. These included increased group interaction as well as voluntarily including Josh in activities during and after school. During these lunch sessions, the group was able to communicate their concerns that included Josh's aide who they believed to be a negative impact on him and interfered with peer interactions. There are other social skills programs that can be integrated into a school curriculum, including Skillstreaming [24], The Waksman Social Skills Curriculum and The Walker Social Skills Curriculum [25,26]' While programs such as these can potentially improve one's life significantly, much more needs to be done in this area. According to Pollack [27], social isolation and subsequent loneliness are considered to be the most frequent long-term effects of acquired brain injury. Educators and parents must work together in assisting the student in the development of healthy social relationships. Having the student and/or parent talk to classmates about the injury and subsequent issues can be helpful in fostering un-

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derstanding. To the fullest extent possible, the student should be involved in decisions regarding his life. Nickerson [28] states that giving the child choices and opportunities for involvement in problem-solving and goal setting, both educationally and socially will contribute to a sense of self-worth. 7. Post-secondary options Tailoring an educational program requires working with the student and the family in order to determine what goals and skills will be critical to ensure success after graduation. Post-secondary options include 4-year college, community college, college preparatory classes, vocational or trade schools, vocational rehabilitation and independent living, competitive employment, supported employment and sheltered employment. For students who choose to attend a 2 or 4-year college program, they should be advised to check out what accommodations are available to support them. College support services are provided through an office for students with disabilities. This office can also help with peer support on campus and assist the student in locating resources for funding special equipment, transportation to and from campus and educational specialists. The Americans with Disabilities Act ensures services at the college level. However, the type and frequency of such services varies greatly. Many schools offer limited services in the form of accommodations such as a notetaker, oral testing, extended time on tests, and books on tape. Other schools offer more comprehensive services that include tutoring, weekly meetings with an educational specialist for organization and study skills support, modifications in the length and amount of assignments, math and writing labs, reduced credit loads each semester and greater flexibility in course selection. Careful selection should be made in the location of the student's dorm, room and roommate. Some students may elect not to have a roommate in light of distractions. On the other hand, a roommate can provide natural supports and diminish a sense of isolation.

There are many variables that impact upon success in college with any student but those with brain injuries are met with greater challenges. Skills that have been typically altered and result in slowed processing, less flexibility in both cognitive and social environments, decreased abstract reasoning, difficulties in executive functioning, organization, self-monitoring and new learning acquisition present a myriad of hurdles. Given such, many students choose to attend a trade or vocational school after graduation based on experiences they had in high school. During high school they may have participated in vocational assessments, community based job exploration, and community based job training which helped in their decision-making. They may have attended a vocational-technical school in the school system or had unpaid or paid work experience facilitated by school staff. In some cases students may be employed part-time in a chosen field prior to graduation. Vocational technical schools, technical institutes and trade schools are all structured to prepare students for employment in certain fields. Vocational-technical schools offer training in a number of fields and are usually publicly supported. Technical institutions are generally 2-year programs with a more demanding curriculum than trade schools and in technologically related fields as industrial technology. Trade schools provide training in one trade such as truck driving. No matter what option is selected, the office that works with students with disabilities must be an active team participant in the student's program. The need for ongoing communication between the student and those responsible for the delivery of services will continue to be critical to one's success throughout the entire course of the program, be it college or a vocational program. Prior to high school graduation, students with disabilities are entitled under the IDEA, the Individuals with Disabilities Education Act, to transition services. Transition services are provided to help students receiving special education move successfully from school into community life. IDEA specifies that beginning at age 14, and no later than age 16, IEP planning must consider the transition needs of students as they prepare for

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the eventual move to adulthood. Goals reflecting an emphasis on work-related and independent living skills are documented in the transition plan which becomes part of the IEP. The transition process also includes linking students and their families to adult service agencies. Janus [2] states that this process needs to begin early as receiving services from adult agencies is based on eligibility and not entitlement. There are generally long waiting lists of individuals for adult services.

[3]

[4] [S]

[6] [7]

8. Conclusion [8]

While the large majority of students who experience a mild brain injury recover fully, those with more serious injuries will often exhibit long-term cognitive and psycho-social needs that persist years after school re-entry. These residual needs impact on every aspect of the student's life in school, in choosing a post-secondary option, in social relationships, and in the development of self-esteem. While the permanence of these needs cannot be eliminated, their presence can be addressed with understanding, knowledge, and cooperation among all individuals involved with the child. Children spend many hours a week with educational staff who can assist them with adjustments to learning difficulties and social interactions. It takes a significant amount of time to emotionally and intellectually accept that a child's life is altered forever. Both regular and special educators are in a unique position to take an active role in fostering a fulfilling, satisfying life for these students, beginning with re-entry and extending beyond graduation.

[9]

[10]

[11] [12]

[13] [14]

[IS]

[16] [17]

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Ewing-Cobbs L, Iovino I, Fletcher 1M, Miner ME, Levin HS. Academic achievement following traumatic brain injury in children and adolescents. Paper presented at the 19th Annual Meeting of the International Neuropsychological Society, San Diego, 1991. [2] 1anus P. Advocacy and the parent-professional partnership. In: Goldberg A, editor. Acquired brain injury in childhood and adolescence: a team and family guide to educational program development and implementation. Springfield: Charles C. Thomas, 1996:211.

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Gerring J, Carney J. Head trauma: strategies for educational reintegration. Singular, 1992. [22] Mauss-Clum N, Ryan M. Brain injury and the family. J Neurosurg Nurs 1981;13:165-169. [23] La Greca AM, Mesibov GB. Social skills intervention with learning disabled children: selecting skills and implementing training. J Clin Child Psychol 8:234-241. [24] Goldstein A, Sprafkin R, Gershaw N, Klein P. Skillstreaming the adolescent. A.D.D. Warehouse, Plantation FL, 1980. [25] Waksman S, Messmer CL, Waksman DD. The Wak-

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