Students with Brain Injury: Implementing Curriculum-Based Assessment and Intervention

Editor's Note: This text is an edited transcript of the course Students with Brain Injury: Implementing Curriculum-Based Assessment and Intervention, presented by Jennifer Lundine, PhD, CCC-SLP, BC-ANCDS.

Learning Outcomes

After this course, participants will be able to:

• Describe common cognitive-communication and executive function difficulties experienced after pediatric brain injury, and their impact on school performance.
• Identify at least three practical methods for assessment and intervention that school personnel can use to address students’ cognitive-communication & executive function difficulties following brain injury.
• Explain how to encourage professional and family collaboration to assist students with brain injury across the educational continuum.

Brain Injuries

Today, I will discuss implementing curriculum-based assessment and intervention for students with brain injury. By the end of this course, I hope you will have some practical tools to use or enhance your existing clinical practice. Before we start, let's ensure everyone understands the topic of today's discussion. We will cover traumatic brain injuries with specific data on the slides. However, we should also consider non-traumatic brain injuries.

When we talk about traumatic brain injuries, we refer to bumps, blows, or jolts to the brain inside the skull. This is the typical scenario we envision with brain injuries, such as someone falling off a bike and hitting the pavement, being struck by a car, or being involved in a high-speed motor vehicle crash. We must also consider concussions or mild brain injuries that fall into this category. For instance, athletes hit on the football field, or soccer players whose heads hit the ground or collide with another player during a play. These are also traumatic brain injuries, and while most students will recover without significant intervention, they can still impact students' lives.

“Other” Brain Injuries -> Non-Traumatic

But we also need to consider acquired brain injuries that are not traumatic in nature. These include anoxia, which occurs when the brain is deprived of oxygen. This can result from strangulation, a near-drowning event, or cardiac arrest. Infections like meningitis or encephalitis can also lead to brain injuries. Other examples include tumors or tumor resections, strokes, and metabolic or chemical injuries to the brain, such as from a drug overdose.

Additionally, COVID-19 is worth mentioning. There is growing evidence suggesting that a small number of individuals who had a COVID-19 infection may experience chronic neurological difficulties. This is an area we will likely learn more about in the coming years.

Pediatric TBI: Facts & Statistics

So, we've discussed the differentiation between traumatic and non-traumatic brain injuries. It's important to note that most statistics about brain injuries are based on traumatic brain injuries, which involve a bump, blow, or jolt to the brain. The CDC indicates that in the US, the four age groups at highest risk for TBI include all young people with developing brains, spanning from birth up to 24 years old, as well as individuals over 75.

Today, we'll focus on the young people whose brains are still developing and who are at higher risk for sustaining a traumatic brain injury. Annually, approximately 700,000 children between 0 and 14 years old sustain a traumatic brain injury. When we include older adolescents, ages 15 to 24, the number exceeds one million.

It's worth noting that these statistics are somewhat outdated due to changes in how the CDC tracks this data. While these are the best statistics available, they likely represent a significant undercount of young people with brain injuries. This undercounting occurs because these statistics only include children who report to an Emergency Department, are hospitalized, or die as a result of their injury. In reality, most children who sustain a traumatic brain injury do not go to the Emergency Department and thus are not counted in these numbers.

What Happens to These Students?

What happens to these students? Since we are talking about young people, the majority of them will return to our public or private school systems. Estimates suggest that each year, over 2 million students in our school systems have experienced a traumatic brain injury and may be dealing with its consequences. A more recent study estimated that over 60% of children who sustain a moderate to severe traumatic brain injury are not appropriately identified under the TBI/IDEA designation in our special education system.

This is a very alarming statistic that should raise concern among all of us. It's important to understand that not every student who experiences a traumatic brain injury will need special education. However, if less than 40% of kids with moderate to severe traumatic brain injuries are identified as TBI in our schools, this likely represents a significant undercounting.

Why is There Such a Huge Discrepancy?

How do we explain this huge discrepancy? Where are all of these kids going, and why aren't we identifying them in our schools? One problem is that our standardized language and cognitive testing often fails to show the deficits these young people are experiencing. These kids may do well enough on developmental language tests or even neuropsychological assessments conducted by school psychologists or neuropsychologists, but these controlled testing situations don't reveal substantial deficits. Yet, when these kids return to the classroom or social situations, they do not flourish.

Part of the reason is what we consider the "invisibility" of a traumatic brain injury. Even with more moderate to severe injuries, physical recovery often happens faster than cognitive communication or language recovery. So, you have young people who look "fine"—they appear okay, can talk, and move around on their own—but something is off. They struggle in classrooms and with maintaining or establishing new friendships. It's easy to forget they've undergone a traumatic event that has potentially changed how their brain functions.

Unfortunately, when young people experience a brain injury, their brains are still developing. As a result, these deficits can grow even many years after the injury. Someone may recover their previous skills, but new difficulties can arise as they get older, and more is expected of them cognitively, academically, and communicatively.

What About Children Injured Before Entering School?

The age group at the highest risk for traumatic brain injury includes children from zero to four years old. These children are not yet in structured school systems. If they sustain a traumatic brain injury, they will be entering school systems in kindergarten already having had an injury to their brain.

Research indicates that the skills most at risk for future difficulties are those that were not yet developed or were in the process of developing at the time of the child's injury. For instance, consider a three-year-old who sustains a traumatic brain injury in a severe car accident. At three, the child has basic language skills: they can put words together, make simple sentences, understand simple directions, and learn basic concepts. However, they still need to learn more complex language and academic skills, such as reading, math, and writing, along with higher-level language and cognitive skills. These are the skills most at risk for later difficulties in children who are injured early and haven't fully developed them yet.

Sandy Chapman coined the term "neurocognitive stall" to describe what potentially happens to these kids. This term means that often, after an injury, even a severe one, children can regain the skills they had prior to the injury. However, they have trouble keeping up with the developmental pace of their typically developing peers or peers who haven't experienced a brain injury. After an injury, their skills may drop during acute recovery, then catch back up to where they were before the injury. However, they struggle to maintain the previous trajectory of development they had before the injury.

What About Students with Concusion? 

I mentioned the importance of considering concussions as traumatic brain injuries. I want to share some findings from a study I completed with my colleague Katy O'Brien, where we interviewed school-based SLPs about their knowledge and confidence related to concussions. We found that nearly half of the SLPs we interviewed were currently working with students with concussions, yet they reported having no specific clinical or training experiences related to concussion. So, while they were working with these students, they lacked specific training in concussion management.

Additionally, our interviews revealed that SLPs often have limited training around concussion management and are not specifically consulted to work with these students. These students might be in their school, but they are not on their caseload. We also assessed the SLPs' confidence in working with these students. We found that those who reported concussion-related training or work experiences had increased confidence in working with students who had concussions. While this is not a groundbreaking discovery, it supports the idea that providing training to professionals can make them feel more comfortable and confident in working with students who have had a brain injury, specifically a mild traumatic brain injury or concussion.

In general, the school-based SLPs we interviewed felt confident about their general concussion knowledge—understanding the basics about concussion—but they felt less confident about providing assessment and support to students with concussions as they returned to school. They understood the potential consequences of a concussion but didn't feel confident about what to do with those students upon their return to school. They showed the lowest competency and accuracy concerning the most recent guidelines around returning to play, returning to school, and the outcomes for children following a concussion compared to adults.

This is particularly important given that concussion is an area with ongoing research and constantly updated guidelines. The SLPs appropriately felt the least confident in areas related to these newer guidelines, but they also showed lower accuracy in questions relating to those new guidelines. They weren't overconfident in an area where they lacked knowledge; instead, they recognized their knowledge gaps and felt less confident in responding appropriately to students as a result.

Outcomes in Pediatric Brain Injury: Delayed Developmental Consequences

When we consider outcomes for young people with brain injuries, it's clear that such injuries jeopardize their ability to master new skills. If these students are expected to continue learning language, academic, and social skills but have sustained a brain injury, their skill acquisition is at risk due to the slow maturation of different brain areas.

Our frontal lobes, which house executive functions, personality, impulse control, goal setting, and evaluation, continue to develop into our 20s. Unfortunately, the frontal lobes are most at risk for traumatic injuries. When kids experience concussions or more serious injuries, the frontal lobe is often affected. Since this part of the brain develops later, deficits in academic or social behaviors may not be apparent until the teen years, when executive functioning skills are expected to mature.

Additionally, brain injuries can lead to subsequent emotional and behavioral problems, partly due to isolation following the injury. If students don't feel well-supported or successful, emotional and behavioral issues can arise, along with social isolation from peers.

Despite knowing these challenges, our systems of care have not evolved to provide excellent long-term care coordination for young people with brain injuries. Very few children receive maximum services following an injury from the medical team. Only a small percentage of children are hospitalized, and less than 5% of those who sustain a traumatic brain injury are admitted to an inpatient rehabilitation unit. Inpatient rehab units typically offer comprehensive care coordination, linking families to therapies such as OT, PT, and speech, and establishing relationships between medical providers and schools.

However, most children entering the medical system or returning to school without this level of care do not receive adequate care coordination. This places the burden on families and school professionals to manage these cases, making it challenging for everyone involved.

It's also important to recognize that concussions or mild TBIs can lead to persistent difficulties if not appropriately addressed. While most individuals with a mild traumatic brain injury recover within four to six weeks without special assistance, some children will exhibit persistent symptoms. We need to be aware of these cases and provide support during early recovery to increase the likelihood of a complete recovery.

School = Rehab

What happens to these students? As mentioned, they are entering our school systems. For those of you working in schools or outpatient or medical settings, helping coordinate services for these children, schools will bear the primary responsibility. Although school services are not traditionally viewed as rehabilitative, it's important to recognize their critical role. My background is from the medical side of our field, but I've worked extensively with colleagues in the school systems to better understand how academic and support services are provided for young people with medical conditions like brain injuries.

We need to rethink how we label our services. Those of us providing services in schools—whether in academic, language, communication, or social tasks—are engaging in a type of rehabilitation. Our goal is to make the student more functional in the academic setting to help them meet their goals successfully. While it's not rehabilitative in the traditional sense of strengthening muscles like OT or PT, it is about enhancing brain function and thinking processes.

So, I suggest that school is a form of rehabilitation, especially for young people with brain injuries. Schools are where most of these support services are provided, as there are not enough outpatient facilities, and students spend a significant amount of their time in school.

One of the main predictors of good outcomes is recognizing potential difficulties a child with a brain injury might face in school and intervening as soon as these difficulties are identified. If students return to school and are not identified or linked to their traumatic brain injury within the first year following the injury, they are less likely to have any indication in their school records that the injury occurred. Consequently, their difficulties may be attributed to other factors rather than the brain injury, affecting the effectiveness of interventions.

This highlights the importance of timely identification and intervention to support students with brain injuries effectively.

Optimizing School Re-integration Following Brain Injury

The timing of a student's return to school is very important. As mentioned, most kids are not hospitalized or receiving intensive services, so they return to school systems relatively quickly. This situation poses challenges for school providers, who must navigate the reintegration process with the student and their family. Therefore, there is a strong need for well-coordinated and well-prepared collaboration between the school, the family, and the medical system. Effective communication should include information about the injury, the expected recovery trajectory, the potential for long-term difficulties, the child's expectations for school, and their strengths and weaknesses.

This approach relies on having a medical connection that can provide this critical information. However, in many cases, such a connection does not exist. Schools must then find alternative ways to obtain this information, adding another layer of challenge to the process of helping these students transition back to school. Without this information, schools may struggle to provide the appropriate support and interventions needed to facilitate the student's successful reintegration.

Progressive Difficulties -> Poor Progress & Disengagement

For students with brain injury, if these difficulties are allowed to persist, they often experience poor academic progress and later disengage from both their academic activities and their friends. Typical difficulties for young people with acquired brain injuries include trouble understanding and following complex verbal and written directions, as well as challenges with comprehending textbooks. These issues may stem from limitations in attention and memory rather than being purely language-based problems.

Incorporating new vocabulary can be particularly challenging because it requires building on their long-term memory to add new elements and expand their understanding of word definitions, synonyms, and antonyms, for example. Many of these difficulties arise from challenges in short-term or working memory. Common cognitive areas affected by brain injuries include memory, attention, and difficulties with organizing and initiating tasks, as well as inhibiting inappropriate behaviors. For example, students might struggle with speaking out of turn in class or making inappropriate comments to peers, leading to trouble at school.

Unfortunately, when students experience a constant cycle of failure or feel less successful than before, they begin to disengage from schoolwork, show poor academic progress, and may isolate themselves socially. This can lead to an increase in behavioral problems. This pattern is likely familiar to those working in schools who see students with learning difficulties, whether or not they have a brain injury. As these students struggle to engage appropriately in the classroom, they may exhibit behavioral challenges as they try to navigate their educational environment.

Educational Intervention Must be Proactive

As I've mentioned, the best intervention is proactive intervention. Before traumatic brain injury (TBI) was designated as a special education category in the 1990s, students with brain injuries did not fare well. They struggled academically and vocationally, and their overall quality of life was poorer. Preventing academic and social failures can likely reduce behavioral challenges. By understanding why these behavioral challenges occur and working to prevent classroom failures, we can create a positive environment for the student.

Choosing the "wait and see" approach is not the best way to support these students. If you know a student with a brain injury is returning to your school, waiting until they experience failure or begin to show challenges is not the best response from an assessment or intervention perspective. Proactive measures are necessary to avoid later disruptions in their educational or social success.

Communication is critical. Parents must understand the importance of informing schools about an injury and ensuring schools are trained to respond appropriately. Medical staff need to be knowledgeable about school systems to provide the necessary information and support.

How Can We Help These Students?

I strongly believe that we need to move towards more curriculum-based assessment, and the research supports this idea. Providing opportunities for structured observations of students in multiple settings and activities is essential. While this may seem time-consuming, assessing them in real-world contexts allows us to identify problem areas more quickly and accurately, leading to better intervention planning.

When we have a student with a brain injury or a student suddenly exhibiting difficulties in the classroom, it's important to ask if there is any history of head injury that requires medical intervention or involves a concussion. Considering whether the observed behaviors could be related to a brain injury helps us establish more effective plans.

It's essential to recognize that there is no one-size-fits-all treatment plan for students with special needs, including those with brain injuries. Each brain injury is unique and affects each student differently. While a general understanding of potential difficulties can help in planning, the approach must be tailored to each individual student. This approach might not be suitable for the next student you encounter, but elements of it can aid in problem-solving and providing support.

To achieve this, we should use specific student hypothesis testing to determine what works for each student and what doesn't. This method allows for customized strategies that address each student's unique needs, ensuring they receive the most effective support.

Curriculum-Based Assessment and Intervention

In curriculum-based assessment and intervention, we use the existing curriculum and school-day context to measure a child's specific needs. Originally, curriculum-based assessment and intervention focused on language. However, we should expand this approach to include observing language, cognitive, and pragmatic intervention needs and progress. This means considering all aspects of what a student is doing that relates to our role as SLPs.

Any part of communication—whether verbal, written, reading, or listening—can be impacted by a brain injury. We need to consider all these different elements as we assess a student and determine how their injury may have affected their abilities. By using the natural context of the school environment, we can obtain a more accurate understanding of a student's needs and progress.

Curriculum-Based Assessment

In curriculum-based assessment, we need to consider whether the student has the language and cognitive skills to learn the curriculum and perform the tasks we're asking of them. Viewing school as a form of rehabilitation, the services provided are directly related to helping students access the curriculum, as they require cognitive and language foundations to do so. We, as professionals, can help provide these services in a school setting. To achieve this, we can interview key players, conduct task analysis, and use dynamic assessment.

Interviewing Key Players

When interviewing key players, we want to ask about the greatest areas of concern for the student and the goals for the student, the family, and the teacher. What do we need the student to be able to do? What does the teacher need the student to be able to do? Additionally, what does the student want to be able to do? What are their goals in potentially interacting with a therapist or any kind of intervention support, which doesn't necessarily have to be provided by an SLP?

Task Analysis

To do this, we will consider task analysis. This involves breaking down tasks into several different steps, considering the skills needed to complete a task, what the student currently does, what they might learn to do differently, and what strategies we might be able to teach them. We also consider how we can modify the curriculum or environment to help the student be successful.

In this process, we ask: What is the expected response? What behavior do we want to see from the student? What are we currently seeing, and how do we bridge that gap between the expected response and current observations? What tools can we add to the student's toolbox to help bridge that gap?

Consider All Communication Contexts

When we're doing this, we need to think about all communication contexts. It's essential to understand that how a student communicates with their peers is not the same as how we expect them to communicate in a classroom or when they're talking with a teacher. We need to assess how they use communication in each of these different contexts. For example, they might sit quietly in a classroom but become impulsive and disinhibited in the lunchroom.

This is important because we may only focus on the classroom and overlook the child's communication challenges in busier settings with peers. We also need to consider other communication modalities. Verbal communication is important, but we should also evaluate how the student responds in written language, reads and comprehends information, and writes responses or essays. We must think about all communication contexts and how they might be affected by challenges following a brain injury.

To do this, we should consider our WH questions related to communication. Who is engaged in the exchange? How does communication differ when the student talks to one peer versus a group or in a classroom setting versus one-on-one with a teacher? Where is the communication taking place? For instance, in the lunchroom, classroom, recess, or gym class? What is being asked of the student? What is the expected response, and what are the observed behaviors?

For example, if we expect a student to sit quietly, raise their hand, and take notes during a lecture but observe them staring out the window, using their phone, or writing irrelevant notes, we need to understand why. These difficulties might be related to cognitive challenges like attention, memory, organization, problem-solving, inhibition, and impulsivity. Understanding why these behaviors occur helps us develop effective intervention plans.

Finally, we must consider how to modify the situation and assess further. Should we teach the students to do something differently, or can we modify the environment to help them succeed? For instance, placing a student at the front of the room to reduce distractions is an environmental modification that doesn't require the student to change their behavior.

A really important point that I want to make, and something I hope everyone takes away from this talk, is understanding how the behaviors we've discussed are often mislabeled or misinterpreted for students with brain injuries. Earlier, I mentioned that if students aren't identified within the first year after a brain injury, the observed behaviors are less likely to be linked back to that injury. This means kids in our classrooms might be labeled as having attention difficulties, being oppositional/defiant, having discipline issues, experiencing emotional disturbances, or being antisocial or apathetic.

I'm not saying that some students don't have these specific diagnoses, but for students with brain injuries, we risk misidentifying their difficulties and labeling them inappropriately. If we mislabel these characteristics, we're likely to use inappropriate and ineffective response plans. For instance, if we think a child is oppositional/defiant when they're actually struggling because they don't understand what's happening in the classroom or can't remember what the teacher just told them, they might respond by trying to escape the situation. They might act out to be removed from the classroom, which is a way to escape the discomfort they're experiencing.

Responding punitively to these behaviors doesn't address the root cause. If we misidentify the root cause, we choose interventions that are inappropriate and ineffective, which won't help our students succeed. This point is so important to consider, especially when thinking about the students you work with in your settings.

Dynamic Assessment

Another part of curriculum-based assessment is dynamically assessing what a student is doing and how we might offer intervention plans or strategies to support them in their daily tasks. Many of you are already familiar with dynamic assessment, so I won't belabor it, but it's important to think about it in the same way for a student with a brain injury.

In this context, we use the same principles of dynamic assessment, guiding the student's learning and monitoring their progress. First, as with task analysis, we observe what the student is currently doing. To bridge the gap between what we want them to do and what they are currently doing, we implement different strategies. In dynamic assessment, we try various strategies, such as moving the student to the front of the classroom or creating a secret code between the teacher and the student to redirect attention.

We then observe whether these strategies lead to the expected behavior. For instance, consider a student who does their homework but struggles to turn it in. Parents and the student say the homework is done, but it doesn't get turned in. We need to identify where the breakdown occurs. Is the homework left at home, lost in their backpack, or stuck in a locker or desk? Understanding this helps us implement a strategy to address the issue.

We then observe whether the strategy helps. For example, we might use a color-coded folder system where completed homework is placed on the right side of the folder and immediately put into the backpack. When the teacher asks for homework, the student knows exactly where to find it. By watching if this strategy improves the student's success in turning in homework, we can determine its effectiveness.

School, Families & Ongoing Assessment

Another thing we need to be aware of in schools is how to identify students who might have a history of brain injury. We've discussed behaviors stemming from cognitive challenges resulting in communication or academic difficulties, but we should also consider how to screen for a previous history of brain injury when students enter our school. For incoming kindergarteners, we screen for vision, hearing, and basic literacy skills. Similarly, we should include questions about any history of head injuries that required medical care. While not all injuries result in medical visits, this would help capture a larger percentage of affected students than we currently identify.

Creating strong home-school partnerships is also important. These students may need frequent adjustments to their educational plans, making family connections vital. Additionally, we need systems to track these students as they move through the educational continuum. When children move from elementary to middle school, how do we track injuries that occur while they are in our school system? How do families report them? If a school is made aware, how is that information shared with the child's educational team?

Is there a designated point person for brain injuries at the school to instruct teachers, classroom aides, or therapy providers? This proactive approach ensures that everyone involved can watch the student and implement an appropriate plan.

It's essential to focus on key periods of transition, as these times often come with increased expectations for student independence and higher cognitive and communicative demands. For example, high school students are expected to keep track of homework, monitor long-term deadlines, and manage their workload. Can the student plan for tests in two weeks or remember weekly vocabulary assessments? Ensuring they can handle these responsibilities is critical for their success.

What Interventions Appear to Be the Most Effective?

There is certainly evidence that integrating therapies into actual school-based activities is the most beneficial for later learning. I'd like to remind everyone of the principles of neuroplasticity that you may have learned in graduate school. The idea is that we have to "use it or lose it," that "practice makes perfect," and, importantly, that context is essential.

We need to integrate therapy interventions into real-life activities to ensure they translate to everyday tasks. We cannot train students for every possible scenario they may encounter, and incorporating interventions into a student's daily regimen is the most efficient and effective way to help them apply what they learn in pull-out sessions to their everyday lives.

Consider the difference between classroom therapies and isolated pull-out therapy. While pulling a student out of the classroom for an individual session to teach skills like outlining material or taking notes on complex topics can be beneficial, we should aim to quickly transition these skills into real-life, contextually relevant environments, often within the classroom. This could also extend to other settings like the lunchroom or social communication at recess.

To make this successful, collaboration from an interdisciplinary perspective is essential. We need to involve other school professionals—teachers, classroom aides, and family members—to work on these strategies at home and support their integration into the student's everyday life.

As we work on curriculum-based assessment, we must remember that the goal is to translate these skills into the student's everyday life, despite the challenges this may present.

Curriculum-Based Intervention

So this should be the goal for all of our therapies: to help the student become maximally independent and successful in whatever they choose to do in their life. We aim to increase their access to the curriculum and teach them strategies to accommodate any difficulties they may have, helping them recognize when to use these strategies to enhance their chances of success. For school kids, this primarily takes place in the school building, in the classroom. The philosophy behind curriculum-based assessment is that it is more inclusive yet still considers the unique and specific needs of each student for whom we are assessing or creating an intervention plan.

Integrating our interventions into everyday contexts makes it more likely that the student will generalize these skills than if we only taught and practiced the strategies in isolated sessions in our speech therapy rooms or reading intervention groups. Using the curriculum and curricular materials as real-life examples helps model routines and establish behaviors. Whenever possible, involving peers as models and partners in this work is beneficial. While this may not be appropriate for every intervention goal, peer relationships are critical for school-age children, and having good models can be very helpful and motivating.

Additionally, it is essential to create strong partnerships with classroom teachers so they can help extend these strategies into the students' everyday lives across their different classes.

What Does Research Say? 

Does curriculum-based intervention actually work? While there is not an abundance of evidence up to this point, the existing research suggests that classroom-based speech and language instruction is at least as effective as pull-out intervention. Moreover, classroom-based speech and language intervention may better facilitate the generalization of newly learned skills to other settings. This is important because we want our skills to translate to various settings and activities. It's impossible to teach a child every single thing they need to be independent, so we need to help them generalize those skills.

The research on brain injury interventions is less extensive than that on speech and language instruction. However, considering the principles of neuroplasticity, this approach makes perfect sense. Observing where our students experience failure also helps guide us in this direction.

When applying the principles of evidence-based practice, we incorporate external research, the beliefs and values of SLPs, students, parents, and teachers, and our own clinical experience. This makes curriculum-based intervention a sensible path to consider.

In terms of the least restrictive environment, settings where a student can learn a skill in context are less restrictive than removing them from class to practice. Our goal in all therapies should be to maximize the student's ability to participate in relevant instructional or everyday activities. This principle should extend to all aspects of our intervention planning and implementation.

SLPs – The Right Person at the Right Time

I believe that SLPs are uniquely qualified to initiate, assist, create, establish, and maintain curriculum-based interventions. We understand the importance of standardized assessments and their limitations. This is particularly important for students with brain injuries, who often perform well on developmental language tests but struggle in real-world settings like busy classrooms. We need to explain these classroom performance discrepancies and emphasize the importance of considering real-life environments.

SLPs have extensive knowledge of communication, including reading, writing, discourse, and nonverbal communication such as body language and intonation. Understanding how students use and interpret these forms of communication is essential. SLPs also understand cognition—attention, memory, organization, inhibition—key skills that underpin effective communication and self-monitoring.

Additionally, SLPs are skilled in social communication or pragmatics, understanding how students interact with peers, adults, teachers, administrators, parents, and friends' parents. We know how to modify language and cognitive activities essential for academic success, such as note-taking, creating outlines, and organizing written essays. These skills are within the expertise of SLPs and some of our colleagues in schools.

Curriculum-Based Interventions: Role of the SLP

So, what is the potential role of an SLP in curriculum-based interventions? One role can be providing intervention to individual students or small groups within the classroom setting. Instead of pulling the student out of the classroom, you might conduct small group instruction within the classroom. For instance, during a lecture, you could help a small group of students organize their outlines or note-taking. At the end of the day, you could check in to ensure everyone has their homework written down, their planners updated, and the right materials in their backpacks. This kind of specific intervention can happen within the classroom with individuals or small groups of students.

Another role involves using team-teaching strategies with a classroom teacher to scaffold interventions into classroom activities. This would involve providing direct services alongside a classroom teacher through a team-teaching approach. Alternatively, you might consult with a classroom teacher. For example, if a teacher knows about your expertise and learns that a student in their class has experienced a brain injury or is exhibiting unfamiliar behaviors, they might come to you for advice. You can then provide strategies they might consider implementing in the classroom instead of providing direct services to the student. Suggestions could include moving the student's seat to the front of the room or using specific organizational strategies to help them manage their work.

Examples of Specific Intervention Strategies

A few specific intervention strategies that we'll touch on include:

• Directed retrospection, self-management strategies
• Use of graphic organizers
• Previewing topics & vocabulary
• Constructing meaning during reading

Certainly this is not an exhaustive list, but just some examples of things that we can think about. 

Directed Retrospection. This is a technique teachers can implement during independent work periods. For instance, after wrapping up a lesson and transitioning students to work on group projects or individual homework, directed retrospection helps students reflect on their activities during that time. It involves asking questions like, "What am I doing right now? Is this what I'm supposed to be doing?" For example, if a student realizes they've been distracted and off-task, directed retrospection prompts them to check in with themselves and redirect their focus.

Teachers can guide students to set goals to increase desired behaviors. If a student is working on a big project or paper, breaking it down into manageable chunks can help. Setting specific goals, such as writing for 10 minutes or completing two pages, helps students monitor their progress and behavior. This self-check mechanism encourages students to stay on task and manage their work more effectively.

Graphic Organizers. Graphic organizers are a very helpful tool. Many of us use written strategies, like Post-it notes, to keep track of our tasks and organization. I personally use an online calendar, a written calendar, and countless Post-it notes. I jot down new tasks on Post-its, and I love the satisfaction of crumpling and tossing them when they're done or moving them to the next week if needed. Graphic organizers work similarly by helping us write things down, organize our thinking, and plan for writing or speaking.

In schools, graphic organizers can help students engage with different types of texts. For example, they can help with understanding informational or expository texts, such as procedural texts (like steps for a chemistry experiment), cause/effect passages, or compare/contrast passages. By helping students recognize keywords and phrases specific to each type of text, graphic organizers can aid in understanding and writing tasks. For instance, identifying that an essay prompt requires a compare/contrast response and noting relevant key phrases can help students structure their writing effectively.

Graphic organizers assist students in organizing their writing, speaking, and breaking down written information for study purposes. They help manage the information students take in or need to produce, making it easier to understand and process.

Previewing Topics and Vocabulary. We can teach strategies like previewing topics and vocabulary. This is a great teaching strategy for all students, including those with brain injuries. For example, at the beginning of a lesson, outline the learning objectives. This approach, similar to what I did at the start of this course, sets a foundation for what students should expect to learn. It helps students focus on relevant information, reducing the cognitive load of constantly wondering if the content aligns with the lesson's goals.

Previewing material also aids in understanding new vocabulary. In textbooks, key vocabulary is often bolded or introduced at the beginning of a chapter. Highlighting these new words prepares students for them when they encounter them in the text, helping them understand their meanings and relevance to the topic. Additionally, previewing helps identify the structure of a text or a verbal passage. It assists students in anticipating how information is organized and how to process it.

We can also use strategies that focus on recognition instead of free recall. For example, a vocabulary recognition test can be employed. In an elementary class learning about insects, the teacher might give a pretest listing words related to insects and ask students to identify which words they recognize. This pretest can gauge their prior knowledge. After the lesson, a post-test can have students select the words they now recognize and understand. They can also sort these words into categories, such as insect body parts or places where insects live.

For students with brain injuries, this method leverages recognition rather than free recall, easing the burden on their memory. It helps those with word-finding difficulties and attention or memory challenges by providing cues. For instance, recognizing the word "antennae" as an insect body part they discussed, even if they struggle with the word "larva." This strategy also gives teachers valuable insights into which concepts need further reinforcement.

Constructing Meaning During Reading. This strategy is similar to previewing material and can be implemented by teachers to assist with comprehension and assess understanding across the whole class. It’s an effective teaching strategy that benefits all students, not just those with brain injuries.

When constructing meaning, take a passage of text, a part of a lecture, or a short segment of a documentary, and then stop to ask questions. For example, "What did we just learn? How does this relate to what we discussed last time or in the previous class or documentary segment?" Identifying appropriate stopping points to ask questions helps reinforce the material. Questions like, "What questions do you have? Does this resonate with you? How does this tie into our learning objectives?" prompt students to engage with the material actively.

Additionally, when reading a novel, you can ask questions like, "What is the author trying to tell you? Why did they choose this word and not another? How could we say this differently? Do we like the way the author presents this point?" These queries encourage deeper thinking and discussion, which enhances both learning and comprehension. This method not only helps with understanding the material but also fosters critical thinking skills.

Classroom Accommodations

I've mentioned that there are strategies to change the environment in which these students are interacting. Many of these strategies, similar to the direct intervention strategies discussed, are beneficial for all students, not just those with brain injuries. 

As we think about these strategies, remember that they can be helpful for a variety of students. For instance, I use some of these strategies myself because we know they improve attentiveness and engagement. It's important for educators to understand that these interventions can be broadly useful. Additionally, once established, these strategies are not difficult, time-intensive, or expensive to implement. Most of these strategies cost nothing and require minimal effort to incorporate into daily routines.

Changes to Classroom Macro-Environment

I've already mentioned the potential for changing where the student sits in the classroom. If a student is easily distracted by the windows, consider moving them away from the window or away from the door where they might hear hallway noise or be disturbed by the door opening and closing. You might also consider using an FM system, which provides direct input to the student and offers a clearer connection to the teacher's voice, helping them maintain their attention. Posting a classroom schedule can be very helpful. Ensuring that the student understands what their day looks like and informing them of any deviations in advance helps prevent confusion and keeps them on track.

Changes to Classroom Micro-Environment

We can also consider changes to the classroom micro-environment. These include previewing material, using structured conversations to reflect on newly learned information, and questioning the author. Additionally, utilizing peer note-takers or tape recorders can be beneficial. For example, if a student with a brain injury takes notes, they could also have access to a peer's notes to ensure they have captured key information. A peer could review their notes for critically missed material, such as important dates or test information.

Teaching students to use an organizer or memory aid, whether through Post-it notes, written notes, structured planners, or reminders in their phones, can also be effective. Using recognition as a means of assessment, like multiple-choice formats instead of free recall, can help students with attention and memory difficulties.

Classroom teachers can modify the structure and pacing of their instruction to maximize student attention. For instance, consider the scheduling challenges for students returning to school after a brain injury. Having four AP classes back-to-back could be overwhelming, so adjusting the schedule might be necessary to accommodate their needs.

Modify Structure and Pacing of Instruction

Helping the classroom teacher think about modifying the structure and pacing of their instruction is important. For example, students returning to school after a brain injury might struggle with back-to-back AP classes. They may need breaks between these classes, a study hall after intensive sessions, or the classes spread out throughout the day. A student with a concussion might struggle in band or orchestra due to sound sensitivity, so adjusting their schedule to avoid these triggers is important. If a student is more attentive in the morning and tired in the afternoon, scheduling higher academic load classes in the morning and lighter ones in the afternoon can be beneficial. They might also need breaks during the day to decompress in the nurse's office or a quiet place.

Encouraging a focus on the quality rather than the quantity of work is also essential. Instead of assigning 100 math problems that take three hours, having the student complete 10 problems to demonstrate understanding can prevent fatigue. This approach ensures that students who are slow due to their injury can show their competence without being overtaxed.

Allowing extra time for responses is another helpful strategy. Instead of calling on these students off the cuff, allow them to volunteer and provide extra time to respond. Teaching students to take their time, think about their answers, and ask for a minute to gather their thoughts can be beneficial. This approach helps students manage their cognitive load and perform better in class.

Modify Teaching Style

We can also work with teachers to help modify their teaching style. For example, using nonverbal cues to refocus attention can be very effective. A teacher and student might have a secret code where the teacher taps on the student's shoulder or desk to draw their attention back. Additionally, using reinforcement or repetition to highlight key points can help ensure that essential information is retained.

Again, these strategies are good teaching practices in general and are particularly useful for students who struggle with attention, memory, and organization.

Collaboration of Professionals

As I've already mentioned, collaboration among professionals is essential. Reintegrating students with brain injuries is not easy, but effective interventions don't have to be complicated or expensive. Using your background and knowledge to assist classroom teachers in modifying the curriculum or classroom expectations can help these students generalize strategies into their everyday lives and become more successful in the classroom.

It is vital to help teachers assess and modify the environment and collaborate for problem-solving. For example, discussing observed behaviors and considering whether they relate to a student's past brain injury can lead to valuable insights. Understanding the cognitive skills the student might be struggling with and finding ways to support them encourages meaningful staff discussions.

Collaboration promotes the best development and generalization of skills and strategies. Isolating students in a speech therapy room is far less likely to help them generalize these skills to everyday activities compared to integrating strategies into their daily routines.

Implications for Success

If implemented, all of these ideas will help these students be more successful in the classroom, creating positive downstream ripple effects. Ideally, this will reduce behavioral challenges associated with brain injury, improve the students' self-worth, and make them feel more successful and connected to their peers. This increased success in the classroom is likely to extend outside the classroom as well, improving long-term outcomes in education, employment, and overall quality of life.

We strive for this with all students or clients: identifying them early and providing appropriate interventions that can significantly impact their success in life. Small changes in our approach can make a big difference, ensuring that students not only achieve academic success but also thrive in their larger lives.

Questions and Answers

Please consider that it's not that therapists don't want to do rehab-type services; it's that funding requires that the services address access to education and academic success.

I 100% agree with that comment. I hope that what I said earlier wasn't interpreted as a way of throwing shade on therapists because I'm certainly not. I do think this is a top-down issue. We need to advocate for the need for our services to support education and academic success. Helping a child with a memory impairment or an attention impairment is going to be essential for them to have access to the curriculum.

Many times, the SLP is not even aware that a student has had a concussion. The nurse is often included, but we are not seen as part of the solution.

That is a great point and 100% correct. And I think this is probably a good topic for an entire course - how do we create better teams? How do we help educate folks so that school nurses understand who they can reach out to within the system? And making sure that nurses understand, but also athletic trainers and administrators or teachers if they're the ones that find out about a student's concussion, to understand how that student could be supported. This is something that certainly does not exist in all schools. Some schools or school districts do have concussion programs, but many do not. So I would say we need to be advocating for these students and how that can happen in our schools.

In some places, it doesn't involve the SLP, and that's okay as long as the student is being supported appropriately. I think the SLP is a great person to be on these teams, but I think the school nurse could be an appropriate person as well, as long as they understand how to get these kids back into learning and sports activities because both of those are important.

In the past, for a child to participate in special ed services, it has to be demonstrated that the child cannot successfully access the curriculum first, then classroom modifications are attempted to better support the student. Only when those fail can evaluations commence. Being proactive is not typical.

That is correct, as you are sharing from your own experience. I believe - though I am open to folks correcting me - that with the Response-to-Intervention (RTI) plans, we should be able to implement accommodations first, because those work and are sufficient for these students.  So again, putting an SLP on those teams to say, "If this child had a brain injury, being proactive is actually a better way to deal with this. Can we put accommodations into place? If we can't, then we need to at least be monitoring them closely so that when we start to see challenges, we are ready to step in." And again, most of these students are not going to need the support of something like an IEP. For most of them, if we can provide the right supports in their classroom initially, they won't need to go to that extra step. So, there is a challenge in knowing that we should be proactive but also being hampered by the systems in which we're working.

To do in-class therapy, the school administration and regular education teachers have to be on board. It's very effective when there is support and collaboration. Do you have any suggestions on how to get administrators and teachers on board? 

This is something that has to be a school-based discussion. So, thinking about how we can best support students, how could we consider doing in-class interventions? If you have a teacher who is a good partner, then you could demonstrate how this works to get buy-in from administrators or other teachers. Again, I absolutely recognize that no one has time for extra. But, if we work together, we can actually make it better for students and it requires less work in the big picture. It's obviously going to take some building and infrastructure to get there, but in the long term, it should save all of us time.

Do you have any go-to resources for a medical history questionnaire that we can use in schools or to find more executive function strategies across ages? How do we ask these questions appropriately?

I would start by trying to get a question on kindergarten screeners about head injury. Colorado and Oregon have recently passed laws stating that a guided, credible history interview is sufficient to initiate services for kids with brain injury. To my knowledge, those are the only two states that have that written into their law. In Ohio, for example, we don't have to have medical documentation of a brain injury. It is not written into our law; however, most school districts actually still require it. 

There are many layers to this and some top-down work that needs to be done. For now, I would say the place to start is getting a question on your kindergarten screeners about head injury. So, I wouldn't call it traumatic brain injury; I would call it an "injury to the head." You can even use the word "concussion." This is a way to flag students. It will be in their records at school where you could go back and look if you started to have questions about the student, for example.

How do we convince them that spending money as soon as we are aware of the injury is ultimately less expensive than waiting until there are behavior and academic issues?

This is a great question, and I think this brings in the research. We need to have documentation. This is the whole premise of early intervention, right? If we prevent a problem from happening or getting worse, we have better outcomes and spend less money. This is why preschool is a hot topic. The more kids we can get into our educational system earlier, the better we're supporting them, especially those who are at risk.

Helpful Websites

• Curriculum based assessments for Speech & Language Support (Pennsylvania Training & Technical Assistance Network): https://www.pattan.net/Disabilities/Speech-Language-1/Comprehensive-Evaluation-(1)/Parts-of-a-Comprehensive-Evaluation
• Living Guideline for Pediatric Concussion Care (Canada): https://pedsconcussion.com/
• International Paediatric Brain Injury Society (IPBIS) Toolbox: https://toolbox.ipbis.org/

References

*See Handout for full list of references