1. Changes in the classroom.
In general, schools are arranged to decrease excess stimulation for the
students to encourage learning new material. Thus, schools tend to be quiet places where play activities
are discouraged and calm behavior reinforced. To the extent that this is true for the average student,
it is even more necessary for the child/adolescent with TBI. Changes in the physical setting in the
school need to be considered in order to further promote a decrease in stimulation and encourage a
focus on learning.
- Many children/adolescents with TBI do not function adequately in a regular classroom, in part, due
to the size of the class. When there are 20 or 30 other children /adolescents in the class, that
represents 20 or 30 sources of excess stimulation which are distracting to the child/adolescent with
TBI. Decreasing the size of the class decreases the excess stimulation by simply removing those
other bodies. A class size of 10 is the upper limit for a child/adolescent returning to school after TBI
who is exhibiting attentional difficulties. Optimally, a class size of five would be even better with
as much individualized attention provided as possible.
- Individual work stations would be helpful at school for children/adolescents with TBI. Setting up
study carrels that serve to block extraneous stimulation would be appropriate. If these are not
available, arranging work stations or centers would be appropriate where one or two students
work at a time.
- Avoid placing children/adolescents with TBI in classrooms in close proximity to a great deal of
activity. For instance, having a classroom right by the front entrance of the school where people are
coming and going all day and thus creating auditory and visual distraction would not be appropriate.
Also having a class with many windows facing out on a playground would not be helpful. If there
are windows with some degree of distraction, using window blinds could be considered.
- Seating a child/adolescent with TBI close to the teacher would be appropriate for several reasons.
First of all, to the extent that the child/adolescent responds to more structure and prompting than
the average student, this can be accomplished more easily with the teacher in close proximity.
Second, whatever intervention initiated by the teacher can be done in an unobtrusive fashion so that
it does not become a topic for class discussion. Third, if the student is sitting near the teacher it
usually means they are near the front of the class. This puts the other students, who are a potential
source of distraction, behind the child/adolescent with TBI.
- It is often beneficial for the child/adolescent with TBI to stay in the same classroom as much as
possible. The teacher may change, but the physical setting of the classroom should remain the same.
Anytime a child/adolescent moves to a new class it is a source of distraction due to the new stimuli
involved. When attempting to minimize excess stimulation, it makes sense to stay in the same
2. General Teaching Ideas
Every teacher has methods that have been developed through practice in
dealing with students. One teacher may be more directive than another. One uses time-out as a
disciplinary measure while another uses extra work. These practices should not be forsaken simply
because there is a TBI child/adolescent in the classroom. However, the teacher should be flexible in
the use of such strategies since they may not work as effectively after TBI. The following suggestions
are obvious in many cases and are already utilized with average students. In the case of the
child/adolescent with TBI, however, most likely these need to be more clearly identified and stressed.
- Children/adolescents with TBI benefit from as much individualized attention as possible. In
any group activity they have the chance of being lost due to their attentional difficulties,
behavioral problems, or over-stimulation leading to withdrawal. Realistically, the classroom
teacher may not be able to provide one-on-one attention on a consistent basis. For this reason
classrooms with a TBI child/adolescent should be provided with an aide or volunteer help on a
- The teacher should anticipate having to repeat directions/comments and review past materials
more often than with the average student. At the beginning of the day, it would be beneficial to
briefly review the materials which were covered the previous day, then introduce new
material with repetition of that material several times during the day. This repetition can be
provided in one-on-one sessions or through extra work which does not necessarily have to be
given to other students. The goal is to provide a framework for the student based on what has
been learned in the past, then add to that framework with the new material and strengthen the
framework with repetition.
- When a child/adolescent is struggling to provide a particular answer or generate a correct word,
it is appropriate to provide cues before the teacher provides the answer. Oftentimes, the student
knows the answer but cannot generate the actual wording. If the teacher can provide cues, with
the student then actually remembering the item, it provides a source of self-esteem and
acknowledgment that the student is still learning. For instance, in trying to recall a specific fact,
it might be helpful for the teacher to provide background information about what is to be recalled
and, if that is not sufficient, then the first sound of the word. Of course, if the child/adolescent
is becoming frustrated and has made attempts after cueing and still cannot derive the correct
information, then the teacher should provide that information with reassurance that next time it
will be easier.
- It is often more effective to redirect inappropriate behavior on the part of children/adolescents
with TBI than to discuss it with them, particularly within the context of a classroom situation.
Children/adolescents with TBI may not fully understand brief comments made by teachers
concerning their behavior, and a lengthy discussion in the midst of class is often impossible. It
is also important not to draw attention to misbehavior since this may prove reinforcing or may
prove embarrassing to the child/adolescent with TBI. Simply reminding the child/adolescent in
a gentle way about what he is supposed to be doing is the best initial approach. Sometimes this
can be accomplished with a visual cue known only to the student and teacher.
- As a teacher, do not underestimate the impact of positive reinforcement. We all like
encouragement ourselves and as a general rule none of us believe we can get enough of it.
However, we forget to encourage others. Even the simplest of comments, such as "Good job"
or "I like your effort" can have tremendous impact on motivation and self-esteem. For younger
children it may also be possible to use physical reinforcements, such as stickers or a check mark
system with great impact. One must remember that children/adolescents with TBI are often
having significant difficulties with self-esteem. They can often remember how well they used
to perform and now cannot perform as well. So any means the teacher can use to improve self-
esteem through positive reinforcement will likely pay dividends in the future.
- Working with computers is appropriate but likely requires greater attention on the part of the
teacher than with the average student. A child/adolescent with TBI generally cannot direct
his/her own computer program even when prompted by the computer. Someone is needed to
give instruction. Thus, it would be inappropriate to expect a TBI child/adolescent to initiate
interaction with the computer in a center without supervision.
- Children/adolescents with TBI require more frequent rest breaks than the average student due
to rapid fatigue. Taking a break of five to 10 minutes every hour or so may be necessary. This
does not necessarily involve lying down but simply focusing on non-academic activities, such
as coloring, putting together a puzzle, or reading a magazine. This serves as a rejuvenation
period for the injured child/adolescent and also serves as a demarcation between subject areas.
This minimizes the chance for perseveration of responses when shifting to new areas of study.
- On a daily basis, the child/adolescent with TBI should write down homework assignments in a
designated notebook. All assignments should be written in the same notebook used on a daily
basis. The teacher should check each day to ensure that the assignments were written correctly
and also at the end of the day check to make sure the student is taking home the necessary texts
to accomplish the homework assignments. Wherever the student goes, the assignment notebook
should be with him.
- If class changes are involved, it would be appropriate to write down the student's schedule and
post it on the front of the homework assignment notebook. Due to the memory problems often
encountered following TBI, the child/adolescent may require prompting in order to get to the
proper class. By glancing at the schedule, the student may need less help from others in this
- Due to motor slowness, the TBI child/adolescent may have difficulty getting to classes on time
if there are class changes. It is not unreasonable to let him/her go a minute or two before the bell
rings so they might get a "head start." If there is any concern about memory for direction and
the student potentially getting lost, sending a friend along would be appropriate. To prevent
confusion, it would likely be best if it is the same person who accompanies the student each time.
- Many TBI individuals cannot write fast enough to keep up with notes in class. They are at
double jeopardy since, due to memory problems, they often cannot remember what is said in
class adequately. Under such circumstances it is fair to designate a notetaker for the TBI student,
who will then offer his notes on a daily basis for copying. This should be a formal relationship
in which a person is asked to serve as notetaker on a consistent basis. It would not be
appropriate for the notetaker to vary a great deal since this will lead to confusion.
- It is often beneficial when teachers give instructions one step at a time. The next instruction
should be provided only after the preceding one is completed. As a corollary to this, it is often
very helpful to divide large tasks into smaller components for the TBI student. Thus, giving an
assignment of writing a report may be appropriate to the average student but may leave the TBI
student overwhelmed. The teacher may want to break up that assignment into selecting a topic,
seeking reference materials, outlining a report, and finally writing the report.
- To avoid sloppiness on papers turned in, the teacher could provide a specific format that is to be
followed by the TBI student and others as well. This may involve having the name, date, and
any other important information in a specific and set location. It would also be beneficial for the
teacher to specify spacing. Sometimes, for instance, it is helpful to have TBI students write on
every other line of the paper or to use larger ruled paper. In doing math assignments, the teacher
should specify that only a certain number of problems be done on a single page. Giving the
student an example of the format would be helpful, which can then be kept in the homework
- Because of the frustration experienced by many students with TBI, it would be helpful if the
teacher would learn to recognize early signs of irritability and intervene at that point. It may be
possible for the student and teacher to develop a cueing system such that the student can
unobtrusively signal when he/she is feeling overwhelmed and thus subject to distress. A subtle
hand signal or placement of a specific object on the desk may be all that is required. The teacher
will then know to give that student some space and time to regain his composure without the
necessity of temper outbursts.
- Children/adolescents with TBI, due to reasoning difficulties, frustration,and disinhibition, may
behave in socially inappropriate ways. Peers are often made uncomfortable by such behavior,
and as a means of tension release will often laugh, making light of the situation. This could
either embarrass the child/adolescent or encourage the behavior further. More so than with the
average student, it is important that the teachers do not "laugh off" inappropriate behavior and
that they discourage other students from doing so. Children/adolescents with TBI are often
searching for means to regain the attention of their peers, which they perceive as having been lost
as a result of their injury. it is very easy for them to derive attention in inappropriate ways, and
at such times they need clear feedback concerning appropriate behavior.
- ) When inappropriate behavior occurs it is important that teachers not just correct the behavior by
noting its inadequacy. The student with TBI needs to be told very directly what is expected and,
if possible, the teacher and other students should model the behavior and provide on-the-spot
practice to the TBI child/adolescent. An excellent example is raising the hand in class. If the
student with TBI is not doing this the teacher needs to explain to the student that raising the hand
is expected by showing the student what that looks like and asking the student to follow their
- Children/adolescents with TBI often do not respond well to embarrassment or teasing,
particularly in group situations. Many children/adolescents can cope with teasing from the
teacher or others because their self-esteem is such that they know that even in the face of such
teasing they are still adequate persons. Unfortunately, the child/adolescent with TBI is often
confused as to his inadequacy, and teasing only serves to create further frustration. It is also
important to avoid confrontation with the student since very little is to be gained by forcing the
student into an inflexible posture which he might not otherwise take.
- Use of visual cues with a TBI student may be appropriate since they do not interfere with the
ongoing class process and do not draw attention to the TBI student, which the latter may find
embarrassing. Using a hand gesture, such as a timeout sign, to generate quiet has been helpful
in many instances, as has a pointing response if the student's attention is wandering.
- If there are to be any changes in the school routine for the child/adolescent with TBI, it is
important that, if possible, the student be notified in advance. For instance, if a teacher is going
to be out for the next several days , it might be helpful if that could be explained to the student
in advance. Also, scheduling changes, such as having to attend an assembly, need to be discussed
in advance if at all possible. If it is not possible to discuss such changes in advance, then the
child/adolescent ought to be notified and provided more time than the average student to adjust.
- Consistency in the classroom is extremely important to children/adolescents with TBI.
Maintaining a routine is often like an anchor in a storm for the student. Students with TBI may
be having difficulty figuring out things around them and rebuilding their self-esteem, but if they
can return to a routine there is a sense of structure and confidence. Teachers that tend to be
relatively unpredictable and engage in activities on the spur of the moment often have difficulty
working with TBI children/adolescents.
- Use of humor may be very important to the recovery of the TBI child/adolescent. The humor
should not extend to ridicule and should likely take place in a one-on-one setting between the
teacher and the student. Allowing the student to laugh at himself and others provides perspective
on problems and may provide an opportunity for intervention which might otherwise be very
difficult. The child/adolescent may need modeling in order to engage in this sort of behavior and
therefore the teacher in a one-on-one setting should be able to laugh at himself.
- As a general rule, teachers should plan on having more contact with the parents of the TBI
student than parents of the average student. In some cases, daily contact through notes or a
checkmark system may be necessary to implement behavioral management strategies. For
instance, a student may receive a reward at home if he/she performs well during the school day.
This requires some communication on a daily basis between the teacher and parent.
Conferences with parents at school should be planned more regularly than with the parents of
the average student. Teachers need to be aware of problems arising at home since these may
begin to surface at school as well. An excellent example is aggressive behavior towards others.
Often this is first noticed at home towards siblings and then may become evident at school.
- When it comes to behavioral or emotional problems the teacher should set realistic goals in
addressing the problem. It is unrealistic in most cases of TBI to expect a total cessation in
misbehavior. The goal, therefore, should be a decrease in the frequency or intensity of the
behavior rather than a total abolishment of the behavior. An excellent example is failure to raise
the hand in class at appropriate times. If with a reinforcement and cueing program the
child/adolescent is able to decrease the incidence of the behavior from six occurrences a day to
two, this would be considered a success.
- Children/adolescents with TBI often do not cope well with decisions due to reasoning
difficulties. They can be easily overwhelmed by what others might consider simple decisions,
such as what to get for lunch. Teachers may help with this problem by decreasing the number
of choices involved, and if necessary, making it a yes/no decision. If this is too difficult, then
the teacher can make the decision for the child/adolescent.
3. Curriculum issues
Placement of a TBI student in a curriculum is often one of the more difficult
decisions that has to be made. The classroom teacher can consult with a rehabilitation team, including a
speech therapist and neuropsychologist, as well as specialists in the school system. It is often beneficial for
individuals who are familiar with head injury and the child/adolescent's particular performance at the time
of school entry to talk with representatives from the school and, if possible, the classroom teacher.
Improved communication can only help. It should also be recognized that placement in a particular
curriculum or program may be short lived for the TBI student since progress is evident over time. A
common progression for the child/adolescent with TBI is to start with a homebound education program
while still receiving intensive outpatient therapies at a rehabilitation center. In many cases, rehabilitation
centers now have homebound teachers on site. This may be followed by reintroduction into a classroom
setting on a half-day basis, necessitated by the fairly rapid fatigue experienced by the child/adolescent. An
initial placement in special education services, such as for children/adolescents with learning disabilities,
provides a smaller class size and the attention of teachers who are accustomed to learning difficulties.
For those students who might need a review of material from previous school years, it is often uncertain
as to where to start. As a general rule, it is logical to start approximately two grade levels below the level
of ability existing prior to the injury and then review material in a sequential fashion. In many cases it is
possible to review and move on quickly since with some basic reminding the skills may return. On the other
hand, the teacher needs to be sensitive to the presence of gaps in recall which will require more review and
study time. For instance, a younger student may be able to perform addition and subtraction quite well after
a quick review but then struggle with multiplication. The closer one gets to skills which existed at the time
of injury the more likely these gaps are to occur.
Testing of children/adolescents with TBI is often a very difficult experience due to their slowness,
memory difficulties, and problems in expressing themselves. Teachers should anticipate that
children/adolescents with TBI will require more time than the average student to complete assignments and
tests. For instance, it may be possible to have the student complete part of the test in class and take the rest
of the test during a study hall or at home that evening. Sometimes it is also beneficial to alter the
presentation of the test or the response required. For instance, if a student has significant problems with
handwriting slowness, it may be possible to allow verbal responses. Also, if there is significant difficulty
with reading slowness, having the test read to the child/adolescent might be beneficial. In most cases it is
advisable to avoid comprehensive tests for children/adolescents with TBI, although this becomes
increasingly difficult as they progress in their education. Comprehensive tests place a great deal of emphasis
on memory and "cramming" skills. The amount of time it takes a TBI child/adolescent to study for a
comprehensive test can be phenomenal and the results marginal.
It is important not to overload children/adolescents with TBI with homework. Recall that the level of
fatigue is greater among these children/adolescents and their slowness in completing tasks must be
considered. Homework assignments for these children/adolescents might be the same as for other students
but less demanding. For instance, assigning half the number of problems in math or answering two instead
of four questions. Because of the child/adolescent's difficulty in completing homework assignments,
teachers should be wary of parents helping the children/adolescents too much and actually completing the
homework assignments. This is a tempting situation when one sees a child/adolescent struggling, becoming
fatigues, and increasingly frustrated. It might be helpful for the teacher to provide some guidelines for the
parents as to how much help they can give the student. It might be appropriate, for instance, for the parents
to cue the student without providing specific answers. Because of the difficulty in completing assignments,
it is often beneficial for children/adolescents with TBI to be allowed extra credit that might not be available
to the average student. For instance, completing a simple project reflecting some understanding of what has
gone on in class or doing some extra work that is not under time constraint could be considered.
Placement of children/adolescents with TBI in a special education curriculum is often a necessity since
they may not function well in a standard curriculum. However, difficulties often occur due to the
designation of the TBI child/adolescent based on special education criteria. It is not uncommon for TBI
children/adolescents to not fit the criteria for EMR, LD, or EC. A relatively popular designation over the
past several years has been Other health Impaired (OHI), which places children/adolescents with TBI with
students who have persistent health problems, such as diabetes or muscular dystrophy. Unfortunately, there
is no specific training program for OHI teachers in most areas of the country. These classrooms are often
not large enough to stand on their own and therefore these students are blended with the other existing
special education programs. Most likely, the number of children/adolescents with TBI identified in schools
will increase since federal law now recognizes TBI as a special education designation. Unfortunately,
guidelines for teachers dealing with TBI students are still lacking. This manual, part, is intended to address
those gaps in understanding.
Table of Contents
From: Educating the Traumatically Brain-Injured Student
By: Tom Novack, PhD and Sandy Caldwell, MA
© 1999 Board of Trustees of the University of Alabama
Published by: The UAB Traumatic Brain Injury Care System, Birmingham, AL 35233-7330.