Chapter 3

The Challenges of Working with ABI

3.1 Case Study
3.2 Functional/Behavioural Expectations in the Classroom
3.3 General Challenges in the Classroom Following ABI
3.4 Cognitive Challenges Following ABI
3.5 Behavioural/Emotional Challenges Following ABI
3.6 Physical Challenges Following ABI
3.7 Other Important Considerations Regarding Challenges in the Classroom

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3.1 - Case Study, Classroom Behaviour

At 15, Chris was described by her teachers as a troublemaker. She refused to participate in any positive way for the nearly 2 years of her high school career. Persistently disruptive and oppositional behaviour, along with frequent truancy and fights with peers, had resulted in a school career made up mostly of suspensions. All of this later behaviour was in sharp contrast to the report cards from primary school, which described her as bright, co-operative, and popular.

Chris’s first 2 weeks in a new school proved to be the full horror show that the previous school had predicted. Chris had no intention of engaging in any classroom work. Her attitude when she went to class, which wasn’t often, was one of total defiance. Any attempt to ease her into the activities of the class was met with an outburst of screaming and profanity, followed by a rapid exit from the classroom. Chris’s aggressive behaviour with her peers in the hallways and lunchrooms was making it very difficult to keep her in school.

A meeting with Chris’s grandmother revealed that she was just as out of control in her new home as she was in her new school. It was in the midst of this discussion that the grandmother reminisced about what a sweet little girl Chris had been in her early years and what a “complete devil she had turned out to be.” “In fact,” she said, “she’s never been the same since she was hit by the truck.” The collision had left her unconscious for an unspecified period of time with a broken arm and a lot of scrapes and bruises. Chris seemed to make a full recovery. However, she was not quite the same bubbly, inquisitive student that she had been before the accident. She was less active and frequently whiny. By the time she was in Grade 7, the moodiness had evolved into frequent outbursts, which only got worse with time.

The real tragedy for Chris was that her brain injury and the potential for impairment was never recognized. Once the broken arm and the scrapes and bruises were healed, the incident with the truck and the period of unconsciousness were forgotten. Certainly they were never recorded in any school record. The disability was not a factor in anyone’s planning for Chris because it was never recorded.

What Schools Value Most in Students	Potential Difficulties for Students with ABI
1. Attention	1. Attention
2. Motivation	2. Motivation
3. Initiation	3. Initiation
4. Processing Speed	4. Processing Speed
5. Abstract Thinking	5. Abstract Thinking
6. Expressive & Receptive Language	6. Expressive & Receptive Language
7. Memory	7. Memory
8. Reasoning	8. Reasoning
9. Strategic Thinking	9. Strategic Thinking
10. Self-Monitoring	10. Self-Monitoring

3.2 - Functional/ Behavioural Expectations in the Classroom

There are certain modes of interactions and/or behaviour that we attempt to nurture in students in order to enhance learning in a group setting. The most common behavioural tasks from a developmental and functional school perspective that students need to succeed are listed below.

1. Ability to listen appropriately to other speakers without interruptions.
2. Ability to share materials.
3. Displays appropriate restraint regarding self-stimulation.
4. Uses non-aggressive words or actions.
5. Accepts unexpected changes in routine.
6. Refrains from provoking others.
7. Hears constructive criticism without losing temper.
8. Uses words rather than physical actions to respond when provoked or angry at others.
9. Seeks adult assistance, if necessary, when experiencing peer conflict, especially conflicts involving violence.
10. Responds to/handles teasing in a constructive way.
11. Handles frustration when experiencing difficulties with school tasks/activities.
12. Shows common sense in words and actions around bullies, gangs, or strangers.
13. Maintains behavioural control in large groups of children (e.g., cafeteria, assemblies).
14. Resolves ordinary peer conflicts or problems adequately on his/her own without requesting educator assistance.

3.3 - General Challenges in the Classroom Following ABI

Challenges that students with ABI may face in the classroom occur on many different levels including:

• Cognitive - e.g., limited attention, changes in perception, learning, remembering, reasoning, understanding.
  
  
• Behavioural/Emotional - e.g., self-esteem (sense of competency/adequacy), inability to control response reactions, unaware of consequences/outcomes/predictions of actions on others, agitation, distractedness, impatience, lowered frustration tolerance, trauma responses/ behaviour; social interaction - e.g., reintegration with family and peers, inability to readily/smoothly manage transitions between the home and school (change in rules, schedules, people, comforts/ supports, acceptance).
  
  
• Physical - e.g., pain/discomfort, lack of access or restrictions to classroom involvement, fatigue, seizures, sleep disruption.

3.4 - Cognitive Challenges Following ABI

Students who have experienced an injury to the head and brain may experience some or all of the following cognitive difficulties: (For more information, see Section 4.7)

Challenge to Student

What an Educator Might See

Acquisition of new knowledge

Struggles with new schoolwork despite prior history of ability. Islands of preserved high level knowledge may convey overly optimistic picture of the student's level and current learning abilities to both student and educator. Inconsistency in learning rates. Since the student is accustomed to pre-injury success, he/she may not be able to recognize or acknowledge current inferior performance. Difficulty keeping up with the class. Unable to process information at the regularly delivered rate. Inability to produce responses at the regularly expected rate (late homework, incomplete assignments).

Challenge to Student

What an Educator Might See

Memory

Difficulty comprehending new concepts or settings. Inability to learn from previous mistakes. Difficulty staying oriented to a schedule or to activities. Difficulty registering new information or words that have been learned, particularly when under stress. Failure to complete assignments because the task request, if not written or repeated several times, is not remembered. Need for extraordinarily large number of repetitions to learn simple motor sequences (e.g., tying shoes), classroom routines and rules, and textbook information.

Challenge to Student

What an Educator Might See

Organization

Difficulty generalizing information from large amounts of unstructured information. Late and/or consistently incomplete homework assignments. Difficulty analyzing a task into component parts (i.e., breaking categories down into representative member of the category). Inability to use different strategies to enhance comprehension (e.g., outlining the text, underlining key points, asking themselves questions as they read, discussing the text, objects into appropriate categories or groups and/or events into appropriate sequences) despite repeated teaching. Inability to sequence properly. Inability to gather required tools and/or information for a task. Total inability to adapt to change in routines.

Challenge to Student

What an Educator Might See

Attention and Concentration

Inability to stay on task, pay attention; easily distracted by things in the environment. Difficulty maintaining attention; fragmented understanding of tasks. Inability to filter out environmental distractions or internal feelings or thoughts. May result in the student talking out of turn, introducing irrelevant topics ofrresponding inappropriately. Difficulty shifting easily from one topic to another. Unexpected shifts from topic to topic in conversation because of an unusual set of associations; this may be interpreted as social strangeness or as a result of a lack of knowledge about the subject.

Challenge to Student	What an Educator Might See
Perception (Vision)	Difficulty seeing objects in part of the visual field. Difficulty perceiving the spatial orientation of objects. Difficulty separating the object of perception from background stimuli. Difficulty recognizing objects if too much is presented at once or too rapidly.
Perception (Auditory)	Misperceives speech sounds, leading to inability to formulate a response. Requires additional time for written or verbal responses. Unable to retrieve words. Difficulties in writing ability (e.g., exhibits messy or incomplete material).

Challenge to Student

What an Educator Might See

Reasoning

Inability to apply appropriate learning and solving strategies that have been taught. Difficulty understanding abstract levels of meaning (e.g., figures of speech, metaphors). Difficulty drawing conclusions from facts presented. Difficulty considering hypothetical explanations for events. Difficulty perceiving the exact nature of a problem (e.g., cannot connect different, but similar, types of information or recognize patterns of information). Inability to appreciate cause and effect relationship.

Challenge to Student

What an Educator Might See

Problem-solving

Inability to reason or understand different points of view. Inability to break the task into parts and decide what to do first and next, and so on. Difficulty identifying and synthesizing information into larger units (e.g., main ideas or themes), therefore, unable to grasp/infer the major concept based on detailed information. Inability to integrate the information to determine the main ideas and write a short summary. Difficulty considering information relevant to solving the problems. Difficulty weighing the relative merits of alternative solutions.

Challenge to Student	What an Educator Might See
Initiation	Will be unable to begin a task May be able to explain steps needed but unable to implement Step One. May be unclear of the expectations, but will not initiate asking for assistance. Often categorized as "lazy." Appears to be just staring off into space.

3.5 - Behavioural/ Emotional Challenges Following ABI

Students who have experienced an injury to the head and brain may experience some or all of the following behavioural/emotional difficulties: (For more information, see Section 4.9)

Challenge to Student	What an Educator Might See
Frustration	Gives up on tasks easily. Becomes angry or agitated rather than trying a new approach or asking for help. Seems unaware of sources of frustration. Easily discouraged. May be less tolerant of noise and distraction.

Challenge to Student	What an Educator Might See
Disinhibition	Inappropriate remarks or behaviour of an aggressive or sexual nature. Inability to self-monitor. Rude/hurtful remarks. Disregard for safety rules. Problems interpreting social rules. Responding too quickly, blurting out, impulsive actions and words. Mood swings, irritation, frustration, verbal or physical outbursts.

Challenge to Student	What an Educator Might See
Aggression	May hit others. Verbal/physical attacks or threatening. Difficulty self-monitoring. Swearing. Destruction of property.

Challenge to Student	What an Educator Might See
Depression	May be withdrawn/quiet. Lack of interest in appearance. May express feelings of hopelessness. May be overly focused on negative. Unable to see positive qualities in oneself.

Challenge to Student	What an Educator Might See
Initiation	Fail to begin assignments. Will be able to verbalize task but not begin. Will need prompting. Appears disinterested. Will not respond through generation of ideas, response to questions.

Challenge to Student	What an Educator Might See
Poor self-image	Inability to see positive qualities in oneself. Focus on limitations. Withdrawal from others. Inability to act due to fear of failure. Apparent lack of motivation.

Challenge to Student	What an Educator Might See
Poor social behaviour	Misinterpretation of social cues. Inappropriate sexual aggression. Becomes overwhelmed around other persons, irritable, distressed, frustrated. Lack of consideration for the feelings of others. Limited/faulty interpretation of other people's behaviour, actions, or words.

3.6 - Physical Challenges Following ABI

Students who have experienced an injury to the head and brain may experience some or all of the following physical and/or motoric difficulties: (For more information, see Section 4.10)

Challenge to Student	What an Educator Might See
Cluster Headaches: Migraine-like neurological pains of the head. Often minimally managed and treated. Tension headaches: Throbbing, tightness, pain; can be treated through muscle relaxation procedures.	Interference with ability to attend to class instruction and/or participate. Irritability, distractedness. Fatigue.

Challenge to Student	What an Educator Might See
Tinnitus: Ringing/buzzing sound in the ears.	Physical discomfort. "Antsiness," restlessness.

Challenge to Student	What an Educator Might See
Cognitive Fatigue ("Brain Drain"): The sense that no further information can be processed. Cloudy feeling in head; cognitively overwhelmed.	Daydreaming-like/dazed appearance. Eyes unable to focus; pale. Will attempt to leave the setting.

Challenge to Student	What an Educator Might See
Visual field neglect: Inability to perceive a segment of the visual environment. Usually lateralized (e.g. involves the right or left visual field). Impaired visual scanning ability: An inability to move eyes completely throughout one's visual environment (look all around).	Unable to detect information, items, objects in a part of their visual field; therefore, wait, read the whole blackboard or text, wait, use the whole page when writing on a sheet. Will not adjust movement of body to compensate for the environment, [e.g., will trip over backpack straps absent-mindedly]. Will look drunk or impaired or awkward.

Challenge to Student	What an Educator Might See
Seizures ranging from: Grand mal - clonic and/or tonic movement of skeletal muscles to petit mal/absence (mild twitching of individual muscle group(s) and/or lack of processing for brief episodes). In both cases there is spontaneous unintentional and uncontrollable synchronous firing of neurons which often times have unpredictable triggers/onsets.	Cannot process information, therefore cannot encode/learn during these episodes. Maybe emotionally disturbing for the student upon reemergence. Need for reorientation to person, place, and time.

Challenge to Student	What an Educator Might See
Physical Fatigue	Lack of physical or mental energy. Listlessness, yawning. Unalert, unaroused.

Challenge to Student	What an Educator Might See
Self-care: Toileting, eating, carrying a cafeteria tray, changing for gym class, putting on coat/boots, transferring from wheelchair, administering medications.	Unkempt appearance. Mismatched clothing. Obvious personal hygiene deficiencies.

Challenge to Student	What an Educator Might See
Mobility: Moving from class to class, maneuvering in the halls during busy times, playground equipment.	May be late for class. Problems with balance. Unable to access classrooms, washrooms, cafeteria, upper levels of school.

Challenge to Student	What an Educator Might See
Fine Motor: Use of writing implements.	Messy work. Incomplete work or late assignments. Failure to engage in some tasks.

3.7 - Other Important Considerations Regarding Challenges in the Classroom

Educators need to remember that students with ABI may have complicated medical and health needs. Many times, changes in behaviour are related to health care issues (i.e. decreased sleep, increased tantrum behaviour). Students often exhibit increased behaviours during times of illness due to infections, seizure activity, fluctuations in hormone levels, etc., in addition to other social factors such as loss of time from school and learning, reduced contact with others, and changes in schedule.

Medical and Health Issues

A student’s brain is a developing organ. As a result, occasionally as the student gets older, new symptoms appear even years after the brain injury. Other students may have chronic pain from injuries. Physical and occupational therapies or recreational activities may exacerbate chronic pain and decrease ability to maintain positive behavioural functioning. ABI students often complain of nagging headaches that could interfere with attention and concentration and lead to frustration and agitation.

Many students with ABI take medications and these medications can have side effects (e.g., drowsiness or fatigue, slow thinking, and inability to handle multiple pieces of information). Knowing what the medication is used for and its side effects can help educators plan accordingly and schedule them (meds) into the daily routine.

Developmental Considerations

Young students with ABI may have injured a part of the brain whose associated function matures later in development. These students may appear to have returned to normal soon after the injury, but later they experience substantial difficulty because the brain interferes with the development of the function that needs to mature (i.e., executive functions).

Adolescence is a difficult period of adjustment for nondisabled young adults. Most adolescents are looking forward to the future with anticipation. When a brain injury occurs during this time period, it greatly affects the person’s ability to cope with a dramatic shift in his/her life.

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