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Centers for Disease Control and Prevention

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Current treatments for autism spectrum disorder (ASD) seek to reduce symptoms that interfere with daily functioning and quality of life. ASD affects each person differently, meaning that people with ASD have unique strengths and challenges and different treatment needs. Therefore, treatment plans usually involve multiple professionals and are catered toward the individual.

Treatments can be given in education, health, community, or home settings, or a combination of settings. It is important that providers communicate with each other and the person with ASD and their family to ensure that treatment goals and progress are meeting expectations.

As individuals with ASD exit from high school and grow into adulthood, additional services can help improve health and daily functioning, and facilitate social and community engagement. For some, supports to continue education, complete job training, find employment, and secure housing and transportation may be needed.

Types of Treatments

There are many types of treatments available. These treatments generally can be broken down into the following categories, although some treatments involve more than one approach:

Behavioral Approaches

Behavioral approaches focus on changing behaviors by understanding what happens before and after the behavior. Behavioral approaches have the most evidence for treating symptoms of ASD. They have become widely accepted among educators and healthcare professionals and are used in many schools and treatment clinics. A notable behavioral treatment for people with ASD is called Applied Behavior Analysis (ABA). ABA encourages desired behaviors and discourages undesired behaviors to improve a variety of skills. Progress is tracked and measured.

Two ABA teaching styles are Discrete Trial Training (DTT) and Pivotal Response Training (PRT).

DTT uses step-by-step instructions to teach a desired behavior or response. Lessons are broken down into their simplest parts, and desired answers and behaviors are rewarded. Undesired answers and behaviors are ignored.

PRT takes place in a natural setting rather than clinic setting. The goal of PRT is to improve a few "pivotal skills" that will help the person learn many other skills. One example of a pivotal skill is to initiate communication with others.

Developmental Approaches

Developmental approaches focus on improving specific developmental skills, such as language skills or physical skills, or a broader range of interconnected developmental abilities. Developmental approaches are often combined with behavioral approaches.

The most common developmental therapy for people with ASD is Speech and Language Therapy. Speech and Language Therapy helps to improve the person's understanding and use of speech and language. Some people with ASD communicate verbally. Others may communicate through the use of signs, gestures, pictures, or an electronic communication device.

Occupational Therapy teaches skills that help the person live as independently as possible. Skills may include dressing, eating, bathing, and relating to people. Occupational therapy can also include:

Sensory Integration Therapy to help improve responses to sensory input that may be restrictive or overwhelming.

Physical Therapy can help improve physical skills, such as fine movements of the fingers or larger movements of the trunk and body.

The Early Start Denver Model (ESDM) is a broad developmental approach based on the principles of Applied Behavior Analysis. It is used with children 12-48 months of age. Parents and therapists use play, social exchanges, and shared attention in natural settings to improve language, social, and learning skills.

Educational Approaches

Educational treatments are given in a classroom setting. One type of educational approach is the Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH) approach. TEACCH is based on the idea that people with autism thrive on consistency and visual learning. It provides teachers with ways to adjust the classroom structure and improve academic and other outcomes. For example, daily routines can be written or drawn and placed in clear sight. Boundaries can be set around learning stations. Verbal instructions can be complimented with visual instructions or physical demonstrations.

Social-Relational Approaches

Social-relational treatments focus on improving social skills and building emotional bonds. Some social-relational approaches involve parents or peer mentors.

The Developmental, Individual Differences, Relationship-Based model (also called "Floor time") encourages parents and therapists to follow the interests of the individual to expand opportunities for communication.

The Relationship Development Intervention (RDI) model involves activities that increase motivation, interest, and abilities to participate in shared social interactions.

Social Stories provide simple descriptions of what to expect in a social situation.

Social Skills Groups provide opportunities for people with ASD to practice social skills in a structured environment.

Pharmacological Approaches

There are no medications that treat the core symptoms of ASD. Some medications treat co-occurring symptoms that can help people with ASD function better. For example, medication might help manage high energy levels, inability to focus, or self-harming behavior, such as head banging or hand biting. Medication can also help manage co-occurring psychological conditions, such as anxiety or depression, in addition to medical conditions such as seizures, sleep problems, or stomach or other gastrointestinal problems.

It is important to work with a doctor who has experience in treating people with ASD when considering the use of medication. This applies to both prescription medication and over-the-counter medication. Individuals, families, and doctors must work together to monitor progress and reactions to be sure that negative side effects of the medication do not outweigh the benefits.

Psychological Approaches

Psychological approaches can help people with ASD cope with anxiety, depression, and other mental health issues. Cognitive-Behavior Therapy (CBT) is one psychological approach that focuses on learning the connections between thoughts, feelings, and behaviors. During CBT, a therapist and the individual work together to identify goals and then change how the person thinks about a situation to change how they react to the situation.

Complementary and Alternative Treatments

Some individuals and parents use treatments that do not fit into any of the other categories. These treatments are known as Complementary and Alternative treatments. Complementary and alternative treatments are often used to supplement more traditional approaches. They might include special diets, herbal supplements, chiropractic care, animal therapy, arts therapy, mindfulness, or relaxation therapies. Individuals and families should always talk to their doctor before starting a complementary and alternative treatment.

There may be other treatments available for individuals with ASD. Talk to a doctor or healthcare provider to learn more.

For more information you can visit:

American Academy of Pediatrics Council on Children with Disabilities: https://pediatrics.aappublications.org/content/145/1/e20193447external icon

Autism Society: https://www.autism-society.org/living-with-autism/treatment-options/external icon

Autism Speaks: https://www.autismspeaks.org/treatments-autismexternal icon

Interagency Autism Coordinating Committee: https://iacc.hhs.gov/publications/publications-analysis/2012/treatments.shtmlexternal icon

National Institute on Child Health and Human Development: https://www.nichd.nih.gov/health/topics/autism/conditioninfo/treatmentsexternal icon

References

Hyman, S.L., Levy, S.E., Myers, S.M., & AAP Council on Children with Disabilities, Section on developmental and behavioral pediatrics. (2020). Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics, 145(1), e20193447.

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Treatment and Intervention Services for Autism Spectrum Disorder

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Autism Spectrum Disorders (ASDs) are a group of developmental disabilities that can cause significant social, communication and behavioral challenges. CDC is working to find out how many children have ASDs, discover the risk factors, and raise awareness of the signs.

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Sensory Products for Autism, ADHD, Aspergers

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Special Needs equipment including Bubble Tubes, FiberOptics, Interactive Floors and Panels, and incredible Tactile Wall Tiles and Murals

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Check knowledge through verbal responses.

Modify assignments only as needed.

Arrange room to accommodate students' equipment.

Look at alternatives for excessive writing.

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-Review with learner after lesson to see if lesson needs to be modified to their needs.

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Extra Practice
Modified reading/writing assignment

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-Review sessions 1:1 can help those needing more time to understand a concept in a lesson.

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How can it affect a child at school and at home?

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How can it affect a child at school and at home?

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Classroom Accommodations:

Allow additional time to complete in-class assignments

Allow for extra or extended breaks

Provide student with instructor’s notes or help student obtain quality notes from other students

Provide both oral and written instructions; clarify instructions

For lectures, provide student with an outline or study guide when available

Reduce quantity of work required, in favor of quality.

Test Accommodations:

Allow additional time to complete tests.

Provide for completion of tests in a quiet, individual environment with the goal of minimizing distractions.

Assess knowledge using multiple-choice instead of open-ended questions.

Permit student’s use of a calculator.

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Some adaptations may include the use of an interpreter to be sure a student receives the information being presented. Also large print or Braille copies of overhead materials or a transcript of videotapes/slides may be needed for the learner.

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The use of videotapes in the class, class lecture using an overhead projector, and slides. Provide optimal lighting conditions to capitalize on students residual vision. Reduce glare, increase contrast between materials and print are appropriate for the students vision. Consider close proximity to the activity during instruction.

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Setting Accommodation:

A “quiet spot” in the classroom may be useful for students with an emotional disturbance.   The child may use this quiet spot to remove himself from a stressful situation to diffuse any negative emotions that could cause the situation to escalate.

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Amanda Zezima, MS, CAS, NCSP

Research on the impact of poverty and trauma in urban school settings highlights the challenges faced by students in the Schenectady community. Specifically, research shows that children exposed to trauma are more likely to be referred for special education, have higher rates of school discipline referrals and suspensions, have lower test scores and grades, and are less likely to graduate from high school (Martin, 2015; Owen, et al, 2015). In addition to their academic challenges, victims of childhood trauma face difficulties with communication, expressing emotion, and tend to have higher rates of hostility, aggression, and interpersonal violence. Moreover, research on intergenerational trauma and urban poverty has demonstrated that adults with histories of childhood abuse and exposure to family violence have challenges with emotional regulation, aggression, social competence, and interpersonal relationships, leading to functional impairments in parenting that they then transmit to the next generation (Collins, et. al, 2010).
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Classrooms are the primary space for students to learn and can be a stable environment to promote and protect students from extraneous factors that may impact their ability to learn, particularly for students facing risk (e.g., poverty, homelessness, trauma & related stressors). Tier 1 strategies for a calm classroom can positively benefit all students despite their degree of exposure to trauma. Tier 1 strategies are strategies or opportunities available for use by all students or by entire classrooms.

Some basic environmental strategies to promote a calm classroom are to: reduce lighting (ceiling fluorescent light covers or lamps), play calming music, post a visual schedule, diffuse aromatherapy, use nonverbal signals and use mindful jars or other calming tools. Mindful jars can be made from empty soda bottles with wrappers removed, filled with one large portion water and one small portion glitter glue, then sealed with crazy glue.

Specific strategies that will be further discussed are:

1. Calm corners

2. GoNoodle relaxing videos

3. Mindfulness Practices

4. Time keeping

5. Weighted toys ​

A classroom calming corner is a quiet area of the room equipped with soft furnishings and soothing materials to help a student de-escalate when upset. The purpose of a calming corner is for students to briefly get away from the frustrating task or over-stimulating activity to de-escalate. When students are in the calming corner space, the goal is to give the student "time away" so that the behavior does not escalate any further. The calming corner is a positive place that rewards students for noticing that they are feeling emotionally dysregulated and using strategies to calm themselves so that learning can occur (The Watson Institute, 2017).

A classroom management plan should reinforce the use of preventative strategies, including limit setting, rules and routines for us of the calming corner to promote appropriate use of the space and prevent students from using the calming corner as an avoidance tactic (Porter, 2003). The calming corner should be a safe place where a student can go to calm down using pre-taught strategies for a short amount of time (The Watson Institute, 2017). Generally, the maximum amount of time spent in a calming corner should be around 10 minutes; consider developmental needs when setting up the expectations for your classroom's calm corner.

Teach when and how to use the calming corner:

1. Incorporate rules and routines around the calming corner in your classroom management plan

2. Discuss with the class about some specific reasons why someone might use the calming corner, and how these reasons could be different for different students

3. Talk with the class about how to go to the calming corner (walk, hands to self, quiet voice), how to be in it (show materials that are in your calming corner and how to use them) and how to come back without disturbing others in the class. Depending on students' age, decide whether or not to require permission for calm corner use and whether students will start timer independently or not.

4. Role play and model with students

5. Be specific on what you will and won't allow in the calming corner space.

6. Let students know that they are responsible for completing work they may have missed while being in the calming corner. Let the student know what time, place or determined structure on how the student will complete the work that they have missed.

7. Have a plan in place for when students are too upset to use the calming corner. Refer to Domain 5 of your Comprehensive Classroom Management Plan.

Materials used in the calming corner may include:

bean bag chair, floor cushion, large pillow

soft rug

relaxation music

headphones

books, magazines

low partition/divider

visual calming strategies

visual timer

Process for implementing a classroom calming corner:

1. Select a low traffic area

2. Furnish the area

3. Set up the partitions

4. Post a set of simple visual calming strategies in the area to provide self-managing reminders and promote independent use of the space

5. Talk with students privately and explain how and when to use the area. Let them know they are allowed to use the area at the first sign of becoming upset. Tell them that you'll meet them back there and together quietly agree on a time limit to use the area, set the visual timer for the agreed upon amount of time.

6. When the time is up, privately reinforce the student for returning to the work area

7. If you feel the student is beginning to use the area frequently and suspect possible work avoidance, you may decide to start providing a limited number of break tickets to be specifically used in am or pm

2. RELAXING VIDEOS FROM GoNoodle.com

GoNoodle is an online tool used to help manage energy in a classroom designed for K-5 through the use of short interactive activities. Videos on GoNoodle are free, research based, fast and designed for long-term engagement. Structured movement breaks are designed to empower a student's body, heart and mind. Various videos focus on helping students think, reflect and set positive intentions for their day. Throughout the day, GoNoodle has videos for fun stretching, mindfulness, self-regulation and deep breathing to explore self-awareness of attitude, stress, behavior and emotions (GoNoodle, 2017).
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Categories of videos to choose from on GoNoodle that help with calming a classroom, ranging from 1 to 10 minutes long, that can be used at your classroom's neediest times of day:

The literature on mindfulness reveals the following positive impacts of incorporating mindfulness practice in schools:

Positive development of cognitive performance skills and executive function (e.g., the ability to attend, focus, think creatively, use existing knowledge more effectively, improve working memory, and enhance planning, problem solving, and reasoning skills)

Improvement of the mental, emotional, social, and physical health and wellbeing of young people (e.g., reducing worries, anxiety, distress, reactivity and bad behavior, improve sleep self-esteem, and bring about greater calmness, relaxation, self-regulation, and awareness).

Significant decreases in both test anxiety and ADHD behaviors and also an increase in the ability to sustain attention (Weare, 2012).

One way schools can promote the trauma-informed values of safety, choice, trust, empowerment and collaboration is through planful approaches to mindfulness practice for teachers and students. Schenectady Schools are promoting the mindfulness practices using a variety of approaches, including the following. To get involved, contact the Behavioral Health Consultant assigned to your building.
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1. Discover Mindfulness through Professional Development: Learn about varying mindfulness practices that can used with students, and which types of practices will have energizing or calming effects on classrooms. Explore varying practices experientially, learn about best practices sources of similar practices, and discuss practical tips for application with students.

2. Mindful Meet-ups with/for Adults: Cultivating our own mindfulness practice will enable us to self-monitor, model being mindful, increase attunement to student needs, become more responsive and less reactive, and sustain ourselves through self-care. See below for examples of free Mindfulness Smart Phone Apps.

3. Pilot a Validated Mindfulness Curriculum: Select a research based curriculum that meets the classrooms needs and demographics. Complete pre and post measures about students to help determine the impact of the curriculum on social, academic, emotional, and behavioral outcomes. Set a schedule/routine to follow while implementing the curriculum.

​Time keeping throughout the day and during activities can be used to reduce stress and anxiety. Some students can feel distant or confused throughout the day because they can feel lost in time. Clocks, clock print outs and time keepers can help individuals understand when the transitions and events of the day need to happen. The predictability of time keeping can help reduce stress and anxiety in students (Trauma Informed Positive Behaviour Support, 2017).

Weighted materials can provide therapeutic relief to some individuals who are stressed, anxious or need to calm down. The weight of the instruments helps individuals feel safe and secure, similar to a hug. The sensory input from a weighted instrument can realign an individual's senses to help soothe (Trauma Informed Positive Behaviour Support, 2017). Types of weighted instruments are:

Blankets

Plush toys

Ball

Stuffed animal filled with rice

Neck wrap filled with rice to provide weight on the shoulders

Collins, K., Connors, K., Davis, S., Donohue, A., Gardner, S., Goldblatt, E., Hayward, A., Kiser, L., Strieder, F. Thompson, E. (2010). Understanding the impact of trauma and urban poverty on family systems: Risks, resilience, and interventions. Baltimore, MD: Family Informed Trauma Treatment Center. http://nctsn.org/nccts/nav.do?pid=ctr_rsch_prod_ar
GoNoodle. (2017). www.gonoodle.com.
Martin, K. (2015, December 11). Trauma in the American Urban Classroom. Retrieved March 30, 2017, from http://edwp.educ.msu.edu/green-and-write/2015/trauma-in-the-american-urban-classroom/.
Owen. J., Wettach, J., & Hoffman, K.C. (2015). Instead of suspension: alternative strategies for effective school discipline. Duke Center for Child and Family Policy and Duke Law School. Retrieved March 30, 2017 from https://law.duke.edu/childedlaw/schooldiscipline/downloads/instead_of_suspension.pdf.
Porter, D. (2003). A Quiet Place for Rough Moments. Retrieved from Responsive Classroom: https://www.responsiveclassroom.org/a-quiet-place-for-rough-moments/
Trauma Informed Positive Behaviour Support. (2017). Child Trauma Toolkit. A free cuide of practical strategies, tools and resources for educators. Trauma Informed PBS.
The Watson Institute. (2017). The Classroom Calming Corner. Retrieved from Watson Life Resources: http://www.thewatsoninstitute.org/watson-life-resources/situation/classroom-calming-corner/
Weare, K. (2012) Evidence for the Impact of Mindfulness on Children and Young People.

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Amanda Zezima, MS, CAS, NCSP Research on the impact of poverty and trauma in urban school settings highlights the challenges faced by students in the Schenectady community.

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MODIFICATIONS:
*Set up goals aimed at social interactions
*Use role-playing situations
*Use seating arrangement to encourage social interaction.
*Set up personalized goals and strategies, so that the child can find success.
*Early detection and intervention is the best strategy
Children with Emotional Behavior Disorders may present extra challenges to caregiver in forms of outbursts and disobedience.
ACCOMMODATIONS:
*Teachers should accommodate students to encourage other students to slowly interact with those who are affected by EBD. *Have your non-EBD students understand not to pressure EBD students to talk or interact with them; only encouragement should be allowed within that classroom.
*Teacher should accommodate EBD students by asking the entire class to answer questions as a group. Encourage different opinion and different problem solving skills/methods.
*Accommodate EBD students by setting up small groups. Have each student come up with a question, pair an EBD student with a non-EBD student and have them share their answers to their questions. It is important for teacher to accommodate the student by allowing him/her to have extra time to lower the level of anxiety.

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Emotional issues

Students ability to properly communicate with family members

Students abiity to express their feelings

Social withdraws

Frustration

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-Term experts use to describe any kind of vision loss, whether it's someone who cannot see at all or someone who has partial vision loss.
-Some people are completely blind, but many others have what's called legal blindness.

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-Visual impairment can be caused at birth, from other injuries later in life, and conditions that can develop later in life
-Ophthalmologists can determine if a person has visual impairment through a variety of tests

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-Loss of vision can affect all areas of development, especially when they are born with a visual impairment
-Social development is affected as children are not able to pick up on non-verbal cues or if they are unable to make eye contact they may appear disinterested and can reduce sustained social interactions

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-although visually impaired children may be more aware of the presence of auditory clues in conversations, this does not necessarily mean that they have correctly identified the implied meaning
-may rely on more help from parents at home that they cannot always receive when interacting with others at school
http://www.intellectualdisability.info/physical-health/articles/visual-impairment-its-effect-on-cognitive-development-and-behaviour

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This Course Video Transcript

In the education of children with visual impairment, there is at present a global movement away from segregated special schooling, and towards inclusive neighbourhood schools. Inclusion provides an opportunity for everyone, teachers as well as learners, to become more acquainted about life with visual impairment and to overcome some of the barriers of difference which have existed in the past. But if it is to be successful, teachers and others require key skills and insights in order to create classroom environments which fully accommodate the learning needs of children with visual impairment. In this course, you will discover the visually impaired child by recognizing that there are many different eye conditions and that each affects learning and behavior differently. During the course, we will explore the Expanded Core Curriculum, which is a collection of content areas that teachers integrate into the core curriculum to give visually impaired learners access to knowledge that sighted learners gain through observation. You will also learn how to make your classroom, the content, your teaching, and the assessments accessible through curriculum differentiation strategies. By the end of the course you will have the necessary tools to create empowering classrooms where you can teach children with visual impairment in an inclusive, accessible, and attuned space. You will be able to purchase a Verified Certificate if you wish to show evidence of your achievements, but this is optional, and you may apply for Financial Aid if you are unable to pay the certificate fee.

View Syllabus

Discover the visually impaired child

Welcome to the first week of the course! In this week, we take you on a journey to explore visual impairment and in doing so, help you discover the visually impaired child in your classroom. We consider the different educational settings in which visually impaired children may find themselves as well as different eye conditions and how these circumstances may affect the child's learning and behaviour in the classroom. You will also start with the important task of creating an empowering classroom by learning how to create an inclusive space. At the end of the week, I have invited a group of visually impaired professionals to discuss some of the issues based on their experience. You will also have the opportunity to share your thoughts in the discussion forum and look through the list of further resources we provide. This week's assessment is a quiz. May you have a rich and empowering first week.

Taught By

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How Visual Impairment Affects Learning - Discover the visually impaired child | Coursera

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Video created by University of Cape Town for the course "Teaching Children with Visual Impairment: Creating Empowering Classrooms". Welcome to the first week of the course! In this week, we take you on a journey to explore visual impairment and ...

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-Work directly with the learner.
-Finding an  area in the LE that supports their learning.
-Visuals for the assignments.
(This all depends on the disabilities).

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If there is an assighnment that is requiring listening, allow them to not do this portion of the task, or modify it to where they are able to do it another way completly.

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-Articulation Flash Cards: Picture cards to help with articulation of specific sounds
-Comfortable pacing in the classroom: Read slowly and easily, Allow time for response, Avoid time pressures, Allow time for students to finish thoughts.
-Communication Boards: Allows students with speech and language difficulties to communicate needs
-Flexible Grouping: To allow students the chance to talk in small groups and pairings

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- Special seating arrangements for movement
- Instruction on developing fine motor skills
-Using assistive devices such as

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Autism, or autism spectrum disorder (ASD), refers to a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech, and nonverbal communication.

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What behaviors and characteristics would you see?

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What behaviors and characteristics would you see?

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Visual support materials
Allowing extra time on tests
Or closed captioning on videos

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Allowing closed captioning, or visuals for their assigned tasks.

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IDEA states that:

Other health impairment means having limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment

- Ashema
-ADHA
-Epilepsy
- Heart conditions
-Diabetes
-Leukemia
-Tourettes
-and more
https://www.parentcenterhub.org/ohi/

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This will affect a child in school because learner will have limited access. This limited access will cause isolation that will affect the learners development and learning. The more severe a child's deaf blindness is the more narrower the world from which they can learn is. For example communicating with other students and teachers, capability of functioning in a classroom, causing learning difficulties, and motor skills.

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An individual can be diagnosed with deaf blindness with tests that show an individual’s hearing and vision. Most of these tests are done during newborn screening. These screenings are carried out to see if baby has any issues from birth. This includes problems with eyes and hearing.  During the screening if there are no issues picked up during this stage, deaf blindness is detected during routine checks as the child becomes older. There are many cases where deafblindness happens gradually as an individual becomes older.

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eye pain.

blurred vision.

halos around light sources.

reduced night vision.

difficulty seeing in bright sunlight or well-lit rooms

needing to turn up the volume on the television or radio

difficulty following a conversation

not hearing noises such as a knock at the door

asking others to speak loudly, slowly and more clearly

needing to hold books or newspapers very close, or sitting close to the television

difficulty moving around unfamiliar places

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Deaf blindness is a combination of hearing loss and vision loss. The term describes an individual who has some degree of loss in both vision and hearing. The amount of loss in either vision or hearing depends form individual to individual.

They can have both hearing and vision loss from birth or early childhood.

They are blind from birth or early childhood and lose hearing later on.

They are deaf from birth or early childhood and lose sight later on.

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Depends on the home situation...

Affects communication skills and can have some social emotional difficulties.

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Tips to support Learners who are Deaf/HH

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Tips to support Learners who are Deaf/HH

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Here's a statistic that might surprise you: according to the CDC, as many as 15% of school age children have significant hearing loss in at least one ear. Hearing loss in children can vary from mild, where a child might have difficulty hearing over background noise, to severe, rendering a child completely deaf. Students who are deaf/hard of hearing (DHH) face special challenges in the classroom, but given the right accommodations, they can succeed academically. Here's what teachers need to know.

Know the signs of potential hearing loss in kids.

Severe hearing loss is usually identified before a child enters school. However, mild to moderate hearing loss may not be recognized until a child is older. Hearing loss due to injury, illness, or disease can begin later in life too. Teachers should know what signs of hearing loss to look for in their classroom and recommend a hearing screening as needed.

Kids are often reluctant to speak up when they can't hear well, so watch for patterns of behavior including the signs shown above. If a student regularly asks you to repeat instructions, misunderstands questions, or doesn't hear when you call their name, check in privately to ask if they're having trouble hearing. Even if they say they're not, continue to watch for signs and don't hesitate to talk with their parents.

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Recognize the challenges children who are deaf/hard of hearing face in the classroom.

Most teachers no longer use a traditional teaching style, facing the class while they lecture from the front. This is terrific for accommodating a variety of learning styles, but makes life in the classroom much harder for children who are deaf/hard of hearing, as they often cannot see the teacher's lips or hear them well when they move around the classroom. Here are some other ways hearing loss causes challenges in school.

Background Noise. For kids with mild to moderate hearing loss, background noise can be their biggest enemy. Since many classrooms are now a hum of busy activity all day long, it's much more likely these kids will miss or have difficulty hearing instructions or feedback.

Acoustics. When a teacher stays in one place, children who are deaf/hard of hearing can be placed close to them. But they still may not hear other students across the room, or pinpoint where a sound is coming from.

Back-lighting. For students who lip-read or work with a sign language interpreter, sitting facing a window or other strong light source makes it hard or impossible to see what's being said.

Note-taking. Taking notes while a teacher talks is a nearly futile task for children who are deaf/hard of hearing.

Difficulty Collaborating. Group work is common and helpful in most classrooms. But students who are deaf/hard of hearing find this difficult, as they often can't understand others. If they aren't comfortable asking for help, they're likely to be left out.

Social Concerns. Those same problems apply to social situations like lunch or recess. Kids with hearing loss can become isolated and have difficulty making friends.

Find more information about challenges facing students who are deaf/hard of hearing here.
Adjust your classroom and teaching style to help lip readers.

Children with any level of hearing loss may use lip-reading to get by. But lip-reading is not only a difficult skill to acquire; it also relies heavily on guesswork. In fact, it's estimated that only about 30-60% of words are seen clearly by lip readers. For the rest, it's like putting together a puzzle without having all the pieces. But teachers can make it easier for lip readers in the classroom.

Make eye contact, speak clearly and normally, but don't shout.

Always be sure you have the lip readers' attention. Ask if it's okay to touch their arm if you need them to look at you. Form your words clearly, and if you're a fast talker, make an effort to slow down just a bit. (All your students will benefit from this.) Talk in a normal tone of voice; shouting can actually distort your mouth.

Arrange seats in a horseshoe or circle.

Lip readers should be able to see all the faces in the classroom during discussions. When possible, a circle or horseshoe is ideal. If not possible, place them close to the front of the room in a seat of their choice, and always repeat any questions or comments from students they may not be able to see.

Reduce back-lighting concerns.

When a teacher or other students are lit from behind, their faces are much harder to see. Close curtains and use overhead lights to ensure everyone is equally well-lit during class.

Give hearing-impaired students a moment to identify who is speaking.

During discussions, new speakers should allow a moment for those who are deaf/hard of hearing to turn their way before talking. Avoid talking over one another so they can focus on one person at a time.

Learn to work with a sign language interpreter.

One way to accommodate kids who are deaf/hard of hearing is the use of a sign language interpreter during class. These interpreters are skilled experts who can make things better for both teacher and student, but you'll need to work closely with them to get the most benefit.

Seat the student close to and facing both the teacher and the interpreter.

Make sure the student can see both of you, and that you're both properly lit. (See concerns about back-lighting above.)

Speak clearly and use specifics.

Sign language interpreters can keep pace with most speakers, but they'll appreciate it if you talk clearly and at a regular pace. Make sure to use specifics when giving directions (for instance, say "put your name in the top left corner" instead of "put your name here".)

Provide vocabulary lists in advance when possible.

In classes like science, kids are always learning new vocabulary words. Sign language interpreters might have to learn them too, if the subject isn't one that's familiar to them. Provide them a list in advance of words relevant to the current topic, so they can see if corresponding signs exist and teach them to their student. When signs don't exist, interpreters will need to use fingerspelling, and they may need assistance with more complicated terms and subject jargon.

Talk directly to the student during class, not the interpreter.

Always interact directly with the student when asking or responding to questions or comments. You don't need to acknowledge the interpreter each time they speak for the student. Let them do their job while you do yours.

Make additional accommodations for children who are deaf/hard of hearing.

Along with lip-reading and interpreters, students may use technology like hearing aids, assistive listening devices, and captioning or transcription. With or without this technology, teachers can also make a variety of accommodations to help these students learn. In many cases, an IEP will detail the adaptations needed.

Face students when speaking, and be sure you have their attention.

This is a good tip for all teachers, in every class. Make eye contact with students so you know you have their attention. Avoid giving instructions while passing out papers or moving around the room. Speak clearly and at a normal speed. For students who are deaf/hard of hearing, ask how they'd like you to get their attention before speaking.

Provide study guides and pre-written notes.

Taking notes while listening to a lecture isn't an ideal way to learn for kids who are deaf/hard of hearing, even if they lip read or have an interpreter. Providing a general outline or pre-written notes, preferably in advance, is better. This allows them to pay attention and interact in class.

Allow time for students to review slides or handouts before speaking.

Slideshows are a great way to help all students follow along in a lecture. When you flip to a new slide, allow a minute for everyone to read what's there before talking. Students who are deaf/hard of hearing can't read a whiteboard at the same time they're trying to lip-read or look at their interpreter. The same goes for handouts or other visual aids.

Check frequently for understanding and questions.

Students who are deaf/hard of hearing might be unwilling to interrupt when they don't understand. Give them more opportunities by pausing more frequently to check for understanding (something else your whole class can benefit from). Additionally, make it very clear when you're about to change topics and move on to something else, and allow some time for final notes or processing.

Use technology to help you out.

We live in a brave new world! Take advantage of speech-to-text technology. Use detailed slideshows and chat/messaging programs. Show streaming movies with closed captioning turned on. Always be on the lookout for new ways technology can improve learning.

Teach other students to communicate with those who are deaf/hard of hearing.

One of the major drawbacks for children who are deaf/hard of hearing is that they can suffer socially. Open up a better, brighter world for them by encouraging your other students to learn how to best interact with them. Teach your class basics signs and fingerspelling. Help them learn the best ways to talk to a lip-reader. Seek out playground games that don't involve hearing. Pair a kid who is deaf/hard of hearing with a friendly buddy classmate who can assist them as needed. Plan field trips that all your students can enjoy. Above all, don't let a student who is deaf/hard of hearing feel isolated and avoid singling them out whenever you can. They really just want to be "normal" kids, so help them feel that way when you're able.

Resources
Books: Online: How do you help students who are deaf/hard of hearing succeed? Come share on the WeAreTeachers HELPLINE Facebook page. Vision loss can also cause students to suffer academically. Learn the 9 signs that could mean your student has a vision problem here.

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A Teacher's Guide to Hearing Impairment in Children

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Know how to recognize and accommodate children who are deaf/hard of hearing in your classroom. Learn how to work with lip readers, interpreters, and more.

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Having a speech or language impairment can affect a child in many ways in their classroom, and even on the playground with their peers. Communication is a big factor, as well as understanding.

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“Term used when there are limits to a person’s ability to learn at an expected level and function in daily life.”

An be caused by injury, disease, or a problem in the brain but for many children it is not known what caused it

Down syndrome, fetal alcohol syndrome, fragile X syndrome, genetic conditions, birth defects, and infections can cause intellectual disability

Can still be caused by a problem that starts any time before a child turns 18 years old→ might include serious head injury, stroke, or certain infections

There are six different levels that vary the severity of the case

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Frustration in their education, or even around their peers, for not being able to communicate with them the way that they may want to. Another characteristic that can be seen is depression or anxiety.

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CONTEXT: A large number of studies have shown a relationship between language disorders and problem behaviors; however, methodological differences have made it difficult to draw conclusions from this literature.

OBJECTIVE: To determine the overall impact of language disorders on problem behaviors in children and adolescents between the ages of birth and 18 years and to investigate the role of informant type, age, and type of problem behavior on this relationship.

DATA SOURCES: We searched PubMed, EBSCO, and ProQuest.

STUDY SELECTION: Studies were included when a group of children with language disorders was compared with a group of typically developing children by using at least 1 measure of problem behavior.

DATA EXTRACTION: Effect sizes were derived from all included measures of problem behaviors from each study.

RESULTS: We included 47 articles (63 153 participants). Meta-analysis of these studies revealed a difference in ratings of problem behaviors between children with language disorders and typically developing children of moderate size ( g = 0.43; 95% confidence interval 0.34 to 0.53; P < .001). Age was entered as a moderator variable, and results showed that the difference in problem behavior ratings increases with child age (increase in g for each additional year in age = 0.06; 95% confidence interval 0.02 to 0.11; P = .004).

LIMITATIONS: There was considerable heterogeneity in the measures of problem behaviors used across studies.

CONCLUSIONS: Children with language disorders display greater rates of problem behaviors compared with their typically developing peers, and this difference is more pronounced in older children.

Identification of Studies

Searches of PubMed, EBSCO, and ProQuest were performed for all dates until July 2017. The following search terms were used, restricted to the titles and/or abstracts within each database: "disruptive behavior*," "behavior problems," "problem behavior*," "challenging behavior*," "externalizing behavior*," "internalizing behavior*," "agress* behavior*," or "behave*," and "communication," "language," "vocabulary," "semantics," "syntax," or "grammar" and "delay," "disorder," "impairment," "disability," or "late talkers." In total, this search yielded 3128 unique abstracts. Additionally, reference lists of included studies were searched to identify additional studies that may have fit our inclusion criteria, and known authors of relevant unpublished data sets were contacted, resulting in an additional 43 abstracts.

During the first screening phase, abstracts were screened for inclusion on the basis of the following a priori criteria: a cross-sectional design other than single-subject design or case studies is used, is written in English, includes 1 group of children with language disorders and 1 control group, average age of participants is <18 years, language-disordered group is not solely composed of children with autism spectrum disorder, includes ˃10 participants, and includes a measure of externalizing, internalizing, or total problem behaviors. Articles that failed to meet any of the listed inclusion criteria were excluded. In the case of longitudinal studies or follow-up studies of a previously studied sample, only the first time point was used. During this first screening phase, the number of included studies decreased from 3171 to 76. During the data extraction process, an additional 29 articles were excluded from analyses. Reasons for exclusion of these articles are available in Supplemental Table 5.

Data Extraction

After digital or hard copies of each included study were obtained, data were extracted from each article by using a detailed coding protocol (this protocol can be obtained by contacting the first author). To test for bias within studies, a "quality of language assessment" variable was created to rate the rigor of the diagnostic methods used to classify children as typically developing or language disordered in each study. A 5-point scale was developed, and a code was assigned to every article (see Table 1 for a full explanation of this code). All articles were double-coded by 2 independent reviewers, and discrepancies were resolved through consensus.

Included in many studies were separate language-disordered groups. For instance, authors of some studies divided children into receptive-expressive, expressive-only, and articulation-disordered groups. Because authors of studies varied considerably in how they defined language disorder subgroups, and no consistently defined groups could be extracted across studies, for the purposes of the current analyses, all language-disordered groups were combined to form a single language-disordered group for each study. Groups comprising only participants with articulation disorder, when reported separately, were excluded. Additionally, groups comprising only participants with pragmatic language impairment were excluded. Pragmatic language impairment, also referred to as social (pragmatic) communication disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is characterized by difficulties in the social use of language that is not better explained by deficits in grammar or word structure. Although these difficulties with pragmatic language may be associated with problem behaviors, the underlying mechanisms of that association may be different than the mechanisms linking deficits in language content and structure to problem behaviors. For this reason, we feel that articles in which authors investigate pragmatic language difficulties specifically warrant a separate study and so have been excluded in the current analyses.

Behavioral Measure Characteristics

In the studies that were included in this meta-analysis, authors used a number of different measures of problem behaviors, including published standardized measures, researcher-created interviews or questionnaires, and coding of direct observations of children's behaviors by researchers. Questionnaires and interviews were completed by parents, teachers, or both.

One complexity in measuring problem behaviors arises from the factor structures used when creating measures. Many measures, such as the CBCL, group items into lower-order "narrow-band" factors (ie, "aggression," "anxious and/or depressed," etc), as well as higher-order factors, typically labeled as "internalizing problems," "externalizing problems," or "total problem behavior" factor, in which all behaviors are combined. When measures that used such factor structures were included in studies, there was a great deal of heterogeneity in what scores authors reported. Authors of some studies reported only higher-order factors, such as "internalizing composite" or total problem behaviors, whereas other authors reported only subscales. In the current analyses, we were interested in the following 2 broad domains: total problem behaviors and a comparison of internalizing and externalizing problems. For this reason, all reported effect sizes were captured. When it was known that an author had not reported a certain scale (for instance, he or she reported the CBCL internalizing composite but not the externalizing composite), attempts were made to contact the author and obtain these data. Out of 7 data requests sent, 3 authors were able to provide us with missing data.

Data Synthesis

Study authors reported the included effect sizes as differences in means, percentages of each group meeting a "clinical cutoff" for problem behaviors, reported t test results, and 2-group analyses of variance. Effect sizes and effect size variances were computed in the Comprehensive Meta-Analysis (version 3.3.070) software. Because some studies had small sample sizes, all effect sizes were converted to Hedges' g, which is used to correct for small sample size.

In some studies, measures were available for only subsamples of the study participants, either because of measurement issues (eg, Malay 1995) or because of missing data. When data were available, participant ages and sex ratios were calculated for each measure individually; when these data were not available, the overall ages and participant sexes for the whole study were used.

Effect sizes were classified as representing either internalizing or externalizing behaviors. Measures that were not classified by the measure itself (eg, "CBCL 1.5-5 Internalizing Composite"), the authors of the study or other publications were independently classified by 2 of the authors with 91.8% agreement. Discrepancies were resolved by consensus.

Data Analysis

Conventional meta-analytic methods require that each study is used to contribute only 1 independent effect size. Because many of the study authors included in this meta-analysis reported ˃1 effect size that need to be included in the same analysis, these traditional meta-analytic methods are not appropriate for the current study. When multiple effect sizes are derived from the same participants, these effect sizes are not independent but are instead correlated. It is possible to create synthetic effect sizes for each study by averaging effect sizes from the same study; however, the synthetic effect size's SEs are dependent on the covariance structure between the individual effect sizes from which they are computed, making this approach problematic.

To more accurately model these multiple, dependent effect sizes across studies, we employed the robust variance estimation method created by Hedges et al. This novel method of meta-analysis does not require the explicit covariance structure between effect sizes reported from the same study (which are rarely available) but instead uses the observed residuals to estimate the meta-regression coefficient estimates. A correction for small sample sizes was employed in the current analyses. These analyses allowed us to include multiple effect sizes from the same study (eg, Malay), avoiding both the problems of excluding valid estimates of problem behaviors as well as biasing our effect size estimates.

Moderator Analyses

In addition to these strengths, robust variance estimation also allows researchers to include additional variables as a means of modeling observed heterogeneity across effect sizes, what is frequently called a moderator analysis. These analyses function much like typical linear regression analyses, with the study-derived effect sizes as the dependent variables and study-level covariates, such as average age of participants or informant type, as the independent moderator variables. Full details are given in Hedges et al. The method of ordinary least squares is used to solve the linear equation predicting individual effect sizes, modeled with an intercept (the average effect size across studies and measures) and any moderators the researcher chooses to include. Each regression coefficient within the meta-regression can be interpreted as in a typical linear regression (for a 1-unit increase in the moderator variable, what is the expected change in the observed effect size?). SEs, significance levels, and confidence intervals (CIs) are provided for each parameter estimate to aid in interpretation. Statistically significant moderator variables suggest that the differences in effect sizes across studies are associated with differences in that particular moderator variable in the meta-regression. It is important to note that moderator variables entered into these meta-regressions are used to predict the effect sizes from each study. That is, moderators such as age, informant type, or type of problem behavior are used to predict the standardized difference in problem behavior scores between children with typical development and children with language delays or disorders.

Research Question 1: What Is the Difference in Rates of Problem Behaviors Between Children With Language Delays and Their Typically Developing Peers?

To address this question, we created an intercept-only model. Results are reported in Table 2, and a forest plot is available in the Supplemental Information. For this model, there were 47 studies included with a total of 128 effect sizes (minimum = 1; mean = 2.7; maximum = 18), for τ ² = 0.05. The intercept was significant (0.43; 95% CI 0.34 to 0.53; P < .001), indicating that, on the whole, children with language delays have problem behavior ratings 0.43 SDs higher than their typically developing peers. See Fig 1 for a forest plot of effect sizes included in this analysis.

Research Question 2a: Do Effect Sizes Differ on the Basis of Informant?

It is possible that ratings of problem behaviors may vary across settings (ie, home, school, or research laboratories) or that different informants may rate children's problem behaviors differently. Estimates of effect sizes are given in Table 2 for each type of informant individually. Average effect sizes from teacher report were higher than both those derived from parent report, as well as from researcher observational coding (0.63 versus 0.37 and 0.43, respectively). To test whether these differences were statistically significant, a moderator analysis was run by using a "teacher report" dummy code. This variable was coded as 0 for parent or researcher observations and 1 for teacher reports. Because there were comparatively few effect sizes derived from researcher observation (5 studies, 14 effect sizes), and the effect sizes derived from parent reports and researcher observations were similar, no variable was entered to differentiate between parent and researcher observations. Results from this model are given in Table 2. The intercept, representing the average standardized difference in problem behaviors between children with typical development and children with language delays or disorders, remained significant, indicating that children with language delays are rated by their parents and researcher observations as having significantly more problem behaviors than typically developing children. The unstandardized coefficient of the dummy code for teacher reports was statistically significant, indicating that, within the studies included in this meta-analysis, on average, teachers identified a larger difference between groups than do parents or research observations.

Research Question 2b: Does the Association Between Language Disorders and Problem Behaviors Vary on the Basis of Children's Age?

To test whether the relation between language disorders and problem behaviors varies by children's age, an additional analysis was run with the average child age from each study entered as a moderator variable. Again, the dependent variable in these models is individual effect sizes, representing the standardized difference between children with language delays or disorders and children with typical language development. The age variable was centered at the age of the youngest participants (Henrichs et al mean age = 1.5 years), so that the intercept would represent the average effect size for children 1.5 years of age, and the unstandardized regression coefficient on mean age would represent the increase in effect size predicted by a 1-year increase in children's average age. Results from this model are given in Table 3.

Results revealed that even for children as young as 1.5 years of age, language disorder status was associated with higher rates of problem behaviors (unstandardized coefficient = 0.19; 95% CI 0.07 to 0.31; P = .004). The unstandardized coefficient for the mean age variable was also statistically significant (0.07; 95% CI 0.03 to 0.11; P = .001), meaning that the association between language disorder status and problem behaviors is larger in older children than in younger children.

It could be argued that age and number of effect sizes derived by teacher report may in fact be collinear with one another, confounding the relation between age and problem behaviors and between informant type and problem behaviors. Indeed, within the current sample of studies, the average age for teacher-reported outcomes was significantly older than the average age of parent-reported outcomes (mean parent or observer-rated reported age = 5.02 years; mean teacher reported age = 6.61; t(34.18) = −2.88; P = .007). When both mean age and the teacher report dummy code were included in the same model, the unstandardized coefficient for the dummy variable for teacher report no longer approached significance (0.19; 95% CI −0.12 to 0.49; P = .21). More importantly, the estimate of the difference between parent-reported or observer-rated effect sizes and teacher-reported effect sizes dropped from 0.35 to 0.19, after controlling for mean age. This suggests that the overall higher ratings of problem behaviors by teachers within this sample are strongly related to children's age. Within this model, the unstandardized coefficient of mean age was again significant (0.06; 95% CI 0.01 to 0.10; P = .01), indicating that after controlling for informant type, each additional year in age was associated with a 0.06 SD increase in the difference in problem behavior scores between children with language disorders and their typically developing peers.

Research Question 3: Is Language Disorder Status More Strongly Associated With Either Internalizing Behaviors or Externalizing Behaviors?

Several researchers have suggested that language more strongly impacts 1 type of behavior (internalizing versus externalizing) compared with the other., To test this possibility within the current sample of studies, a "contrast variable" was created and scored as −0.5 for internalizing and +0.5 for externalizing scales. This type of coding results in the intercept signifying the overall effect size for all scales, whereas the contrast variable represents the average difference between internalizing and externalizing effect sizes. Parameter estimates for this model are given in Table 4. For this model, there were 40 studies included with a total of 122 effect sizes (minimum = 1; mean = 3.05; maximum = 14), for τ ² = 0.05. When predicting the standardized mean difference between children with language delays or disorders and children with typical language development, the intercept remained significant, indicating that children with language disorders display significantly more problem behaviors than do their typical peers. The behavior type variable, used to differentiate between internalizing and externalizing effect sizes, was not significant ( P = .50), indicating that language disorders are not significantly more associated with either internalizing or externalizing behaviors.

To test whether there may be a differential impact of language disorders on internalizing and externalizing behaviors that varies on the basis of the child's age, we created an interaction term between the following 2 moderator variables: mean age (again centered at 1.5 years) and behavior type. These variables and the interaction term were used to predict individual effect sizes, or the standardized mean difference between children with language disorders or delays, and children with typical language development. This interaction term was not significant (unstandardized coefficient = 0.003; 95% CI −0.07 to 0.07; P = .92), suggesting that, across development, the difference in rates of problem behaviors between children with language disorders or delays and children with typical language development does not differ between internalizing behaviors and externalizing behaviors, regardless of children's ages.

Sensitivity Analysis and Publication Bias

To test the extent to which the quality of the language assessment might influence the effect sizes derived from each study, we performed a sensitivity analysis. A "potentially low-quality language assessment" binary indicator was created for studies receiving a rating of 3, 4, or 5 on our language assessment quality rating (see Table 1). When this indicator was entered into a meta-regression for total problem behaviors, the resulting coefficient was nonsignificant (−0.12; P = .22). These results reveal that the quality of language assessment did not significantly impact the results of our analyses. Additionally, a "leave-1-out" analysis was performed by systematically running the total problem behaviors analysis, leaving 1 study out each time to assess each study's individual impact on the results. The exclusion of any 1 study did not significantly impact the results (minimum average effect size = 0.41; maximum average effect size = 0.45).

To test for the presence of publication bias, or the selective publication of only significant effect sizes, a publication bias analysis was performed in R by using the metafor package. This analysis was done separately for averaged total problem, internalizing, and externalizing measures from each study. For externalizing measures, there was no evidence of publication bias according to Egger's linear regression test ( z score = 1.32; P = .19). Conversely, there was evidence of publication bias for total problem behaviors and for internalizing effect sizes. Egger's linear regression test revealed significant asymmetry in the total problem behavior funnel plot ( z score = 2.62; P < .01) and the internalizing funnel plot ( z score = 2.97; P < .01) (funnel plots available in Supplemental Information), suggesting the presence of publication bias. A "trim-and-fill" analysis was conducted, wherein additional artificial effect sizes (in this case representing small or negative effect sizes) are added to balance the funnel plot. The resulting modified random effect size estimate continued to be significant for both types of analyses (total problem behaviors: unstandardized coefficient = 0.41; P < .001; internalizing behaviors: unstandardized coefficient = 0.27; P < .001), suggesting that even after accounting for publication bias, children diagnosed with language disorders have higher rates of total problem behaviors and internalizing behaviors compared with their typically developing peers.

Finally, a sensitivity analysis for the value of ρ, or the assumed within-study correlation value, was conducted as specified by Hedges et al. This value was systematically varied from 0 (no between-measure correlation) to 1 (perfect between-measure correlation), with little change to any parameter estimates, strengthening our confidence in the results of these analyses.

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Language Disorders and Problem Behaviors: A Meta-analysis

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CONTEXT: A large number of studies have shown a relationship between language disorders and problem behaviors; however, methodological differences have made it difficult to draw conclusions from this literature. OBJECTIVE: To determine the overall impact of language disorders on problem behaviors in children and adolescents between the ages of birth and 18 years and to investigate the role of informant type, age, and type of problem behavior on this relationship.

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Deaf and hearing loss affects language and communication skills and development.

Social emotional development and support.

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One can be born deaf/HH or can have hearing loss.

Hearing loss is measured by loudness/intensity and frequency/pitch.

Loss greater than 90 decibels is considered deaf.

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Finding a setting suitable to the child’s intelligence level

A child’s ability to effectively communicate with teachers, support staff and peers

A student’s capability to function in the classroom

Assessing and compensating for visual or hearing impairments

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https://youtu.be/KcxPQ3AYpqo

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Deafness: This occurs when a person cannot understand speech through hearing, even when sound is amplified. Profound deafness: This refers to a total lack of hearing. An individual with profound deafness is unable to detect sound at all.

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Helping Your Child Adjust

Introduction

Although no two children or their brain injuries are alike, many children struggle with similar emotions and challenges after TBI. These include:

denial that the injury will have a long-term impact,

grief over their loss of function and skill,

changes in how they relate to others,

rustration with the recovery process, and

limited awareness of the differences in themselves.

Your child's ability to cope with or develop strategies for dealing with these changes will vary depending on many factors. Some of these may include your child's previous coping skills, her intellect and personality, the support available from friends and family, her emotional health, the strength of her relationships, the stage of development she was in when injured, and the extent of the injury.

As a parent, you will play a key role in helping others understand your child. Thanks to your unique experience parenting your child, you will be able to provide professionals with valuable information and insight into your child's individual traits. During the rehabilitation process, parents' involvement and commitment are often seen as pivotal to their child's recovery and return to home and school.

To help you better help your child, this chapter will examine some of the changes that children with TBI commonly face during the acute, rehabilitation, and back-at-home phases of the recovery process. It will also offer suggestions for helping your child cope with and adjust to these changes.

Your Child During the Acute Phase

Once your child's condition is stabilizing and she is beginning to emerge from coma, you feel some reassurance. There is joy, relief, and hope but still uncertainty. You try not to be overjoyed, as the road ahead is still uncertain, but you experience some slight relief, a small lift of the burden. This was the small step, the sign that everyone has been waiting for. From this moment forward, your experience of parenting your child is changed forever.

In the acute phase, as you are trying to manage your emotional roller coaster, you find yourself asking, "What should I be doing for my child?" Below are some suggestions for supporting your child as she emerges from coma.

Emerging from Coma

Emerging from a coma is a frightening experience for a child. One child recalled the experience this way: "I remember being scared and wondering where I was. I remember there were doctors and nurses and I saw my mom sitting by the side of my bed." Each child's beginning steps of recovery are unique and marked by varying memories. The environment is unfamiliar and your child's memories leading up to the injury may be unclear and uncertain. Usually, there is no memory of the actual injury. Uncertainty and unfamiliarity mark the beginning of the road ahead that your child now faces in coping with the changes in herself.

When your child is emerging from coma, there will be times when she is not alert or responsive. Providing stimulation, support, voice, and touch can be helpful to your child. Even if your child is not responsive, providing this support can help you feel connected to your child. If possible, surround your child with familiar items, including pictures of family members and friends, mementos from home, and familiar music. Try to create a familiar environment within the unfamiliar hospital room. When you are ready, encourage close family members to visit your child. You and your family members should keep talking to your child, providing those familiar voices and reassuring words of love and support.

Your Child During the Rehabilitation Phase

The work begins. Your child may be faced with many physical, cognitive, and emotional challenges. As a parent, you are constantly observing and encouraging your child, hoping for changes, slight improvements that might ultimately lead to larger accomplishments. Your child may experience difficulty walking, managing personal care, expressing wants and needs, and remembering: things that she once did without any thought or effort. Now is the time in the recovery phase where the effort to regain previously mastered skills begins. Demands are placed and goals are set, as a variety of specialists begin challenging your child to reach her potential. Your child begins making small, slow steps toward larger accomplishments.

During the rehabilitation phase, your child may have difficulties with memory, self-awareness, and problem solving. She may have sudden changes in her emotions (emotional lability) or show no emotions at all (flat affect). She may also become easily frustrated, fatigued, and irritable, and have changes in her behavior and personality. These changes often lead to poor social behavior and interactions with others.

Confronted with Changes

Recovery is a gradual and challenging process with no clear endpoint. It varies depending on the injury and the child. As your child begins to slowly emerge and progress, deficits become more apparent. Your child may be discouraged by the slowness of progress and the ups and downs that come with recovery. Seemingly simple activities may now by difficult to perform. She may also be faced with accepting changes in her physical appearance. Often there are healing wounds that are difficult for a child to accept. Hair may have been shaved immediately following the injury. Your child may not be comfortable with changes in her appearance. Additionally, she may be frustrated by her new physical limitations. For instance, a once very active 14-year-old basketball player with artistic talents was very frustrated by the difficulties he experienced in walking, and in using his dominant hand to eat, care for personal needs, and draw as he used to.

Difficulties with Insight and Awareness

Sometimes children are not aware of other emerging differences aside from the physical differences. They may not agree that their academic performance, memory, language skills, behavior, personality, or social behavior have changed. Often children lack insight into their cognitive deficits, as it is easier to see, understand, and focus on rehabilitation of the physical differences. This can be particularly challenging for family members who are able to observe both the physical and cognitive difficulties their child is facing.

Developmental Stages

During the rehabilitation phase your child is working hard to regain a multitude of lost skills. Your child has experienced a tremendous amount of change in herself in a very short period of time. How your child views those changes will likely depend on her stage of development. For instance, an infant or toddler will have little understanding of her differences. Older children and adolescents have more capacity to understand these changes in self that can affect identity, self-perception, peer relations, previously mastered skills, and goals for the future.

Often children and adolescents experience grief, anger, a decrease in self-esteem, and depression, as the loss of skills and changes in personality, social behavior, academic performance, communication, language skills, and appearance become more apparent. During adolescence, children normally struggle with the formation of their identity and have often formulated negative attitudes toward those who are different, less capable, and less "cool." The discrepancy between an adolescent's former and current self can be problematic.

What You Can Do for Your Child during the Rehabilitation Phase

During this rehabilitation phase, your family will become central to recovery and the primary support for your child. You can provide professionals with specific information that can't be gleaned by testing, serving as a window into your child. You know your child best, and have the commitment to become her lifelong advocate. Below are some suggestions that will help you and other family members support your child.

Focus on Daily Successes

During the rehabilitation phase, your child may be discouraged by the slow process of recovery, experiencing periods of ups and downs. Help her to see recovery as a long process by focusing on the daily positives and progress already made. You can compare specific challenges to other times in life when accomplishing a goal took time and was challenging. For example, you might remind her of the time when she practiced her flute every day and took private lessons to prepare for her audition for the school orchestra. Praise your child for her accomplishments since the injury. Be supportive and encouraging while maintaining realistic goals. Try not to evoke additional frustration by focusing on the negative, putting extra pressure on your child to perform, or setting goals that she is not ready for.

It may be difficult to see your child struggle with physical needs as well as cognitive demands. You can help, however, by re-instilling confidence while she is relearning and regaining skills. When appropriate, encouraging her to be independent can help your child feel a sense of self-worth.

Your child's feelings and motivation may fluctuate as she faces numerous changes during the recovery period. Family members can help by providing consistency, support, and encouragement. Focus on the positive, and minimize critical feedback. Again, you know your child best--what motivates her, her personality, her previous coping style, and her level of acceptance. Communicate this knowledge to professionals who work with your child.

Your role in supporting your child in her daily coping may seem like a high-wire balancing act, but remember that your family is her primary source of support. It is well worth your efforts to do whatever it takes to help your child regain her participation in the outside world.

Managing Changes in Appearance

How much of an emotional impact your child's physical changes have on her will depend on her age and stage of development. Your child may not like the way she now appears to others and may therefore be uncomfortable with visits by friends and family members. Helping your child understand the importance of family and friends in her life may help to ease her discomfort. In the meantime, it is fine to respect her wishes and minimize the number of visitors until she feels more comfortable.

Help your child feel as comfortable as possible with her appearance. For example, allow her to wear a baseball cap or clothing that covers her injuries if it makes her feel more secure.

If your child feels comfortable discussing her differences (for example, hair, stitches, cuts, scars, braces/splints), encourage her to talk about them and how they affect how she perceives herself. Discuss how these physical changes also take time to heal. Hair grows back and some cuts and scars will fade over time. It may help your child to see photographs of herself before the injury and during the course of recovery so that together you can observe and realistically discuss changes.

If your child does not seem comfortable discussing her appearance, take her lead. Minimizing the attention placed on physical appearance may reduce the importance of this in your child's mind. Listen to your child if she wishes to talk about her appearance, but do not keep bringing up the topic if it seems to be a sore subject for her. Once again, you know your child best.

Understanding Cognitive Changes

It is often difficult for a child to conceptualize the magnitude of a brain injury and its effects on memory, problem-solving ability, language, and personality. With the assistance of professionals, you can help your child to understand all that the brain controls, while emphasizing the importance of, and length of time for, recovery. Tell your child that just like an injured arm or leg, the brain needs time to heal and to be exercised. Be sensitive to your child's reaction to these deficits and changes. Allow her to express thoughts and feelings associated with the anger and grief surrounding the loss of skills. Seek the assistance of professionals to help your child feel that it is OK to have such difficult feelings about deficits, the recovery process, and thoughts about the future.

Your injured child's lack of insight into her actions and behaviors and recently acquired limitations will present new challenges for your family. Where you may have once felt comfortable with your child out of your sight, you may now feel just the opposite. This can be particularly difficult with teens and children with active lifestyles. Again, you are balancing on the high wire. One of the greatest challenges is for you to re-instill a sense of responsibility in your child while providing what may now be a greater level of safety and supervision than ever before.

Without insight and awareness into the reasons for heightened supervision, your child may feel mistrusted. It's best to continually discuss this issue and help her achieve a sense of responsibility in other, possibly new and creative ways. For example, find things for your child to do around the home where she can feel a sense of responsibility within a safe environment. If it was previously your child's responsibility to mow the lawn, you might change her responsibility to the equally important chore of getting the mail.

To balance your child's desire to regain her previous autonomy and freedom around the neighborhood with the need to keep her safe, you may consider asking for help from trusted friends and neighbors. Talk to adults and responsible children in the neighborhood about your child's limitations and the importance of safety while she is recovering. Ask adult neighbors and friends' parents to help supervise and monitor the safety of your child's activities. Maintain open communication throughout the recovery process and continually focus on the length of the recovery process in working toward future progress.

The Peer Network

When a friend suffers a brain injury, peers often struggle with the same emotions that parents and family members experience, including guilt, fear, anger, sorrow, and concern. Your family will need to decide which peers need to know what and who will be the one to share this information with them.

While your child is beginning the recovery process, it is important to involve peers who are responsible and close to your child. Like your family, your child's friends are wondering if your child will ever be the same and need to learn to accept some of the obvious and more subtle differences. Peers need to be educated about brain injury and recovery . . . to relearn and readjust to your child, their friend.

When it is comfortable for your family, involve peers in the rehabilitation process. How much peers are involved may vary depending on your child's age and comfort level, as well as distance/accessibility of the rehab facility. Identify a handful of responsible and devoted friends whom you know and trust, and whom you can envision being your child's eyes and ears once she returns to school. Encourage peers to contact your child in the hospital through phone calls, letters, cards, and face-to-face visits when the time is appropriate. This will help friends to cope with the changes in your child and adjust to and understand her new needs. It will also help your child begin to accept the changes in herself. Educating and exposing peers along the way will help with the inevitable transition to home and school, and with the understanding of differences, limitations, and changes in personality and behavior. If supportive peers understand your child's needs, this will hopefully lead to a positive and accepting transition back into the community.

Changes in Self-Esteem

As your child becomes more involved in the rehabilitation phase, her self-esteem can suffer. The noticeable changes in herself and her skills, as well as differences in behavior, moods, cognition, and personality can challenge your child's self-esteem. For example, this is how one parent described the changes in her child:
"Before his injury, Tom was so positive and confident. He was always the first to try something and most things came easily for him, be it school work, sports, artistic endeavors. Since his injury, he no longer has the use of his right arm and hand and requires a cane to help with walking. It takes him longer to process information, and math, which was once easy, is now a chore. He is a different person now, ashamed of what his friends might think of him, frustrated that he can no longer do things the way he used to, and unwilling to try new things. You see, Tom wanted to be an electrical engineer and play basketball in high school and college. I know that when he thinks about his future now it scares him."
The evolution of such changes, coupled with the uncertainty of recovery, is extremely frustrating for a child with TBI and can cloud a previously favorable and confident self-perception.

As a parent, watching your child struggle with the emotional impact of the injury can be very painful and difficult. Often you have shared the same hopes and aspirations for your child. You may feel as if you want to take this struggle away, since your child already has so much to manage.

Again, encouraging and rewarding progress while remaining sensitive to the length of the recovery process will help your child feel supported and recognize her accomplishments. Be patient and communicate with your child. Help her to know that it is OK to talk about her feelings and experiences, and allow frustrations to be expressed. Never try to talk your child out of her feelings. Your child's feelings are what she feels-they are neither right or wrong. The losses that your child is experiencing are real and will inevitably be accompanied by a variety of emotional expressions and reactions. The support and strength provided by your family will help your child through all stages of the recovery process.

If your child seems to need more emotional support than your family can provide, do not hesitate to seek supportive therapy for her, as well as your family, from psychologists, social workers, or counselors experienced with traumatic brain injury.

Your Child Back at Home

After weeks, possibly months, of recovery in the hospital setting, your child is now ready to transfer her recovery process to the home and community. As a parent, you may feel both positive and negative emotions about this step. On the one hand, you know that your child has made progress and that there is hope for continued success once your child returns home. You will probably become more confident as time at home increases, experiencing some relief and hope. You will also probably welcome the longed-for semblance of normalcy in your life, with your family again reunited at home.

On the other hand, you may feel ambivalent, scared, and worried about how this transition home will play itself out. You know there may need to be physical changes made to your home as well as changes in roles and expectations. You have been part of the team process, working and training closely with professionals who have provided care for your child 24 hours a day. You have come to rely on the support of professionals, and now your family is expected to carry out this lifetime mission back at home.

With practice and experience, families can learn to adjust to the changes at home and continue to support their child. This section details some of the changes to expect.

Changes in Family Roles and Responsibilities

When your child returns home, many of the physical and cognitive difficulties that she experienced during the rehabilitation phase will continue, only now these issues will play themselves out in your family's everyday life experiences. You may find that the demands and challenges increase and that roles within the family shift. For example, younger siblings may take on more of a big brother or big sister role in the family, with greater responsibilities. Siblings may assist your injured child with her homework or daily care routines. Or they may take on chores and responsibilities for their recovering brother or sister.

I'm Home, I'm OK

Depending on the injury and level of recovery, children with TBI often feel that they have returned to pre-injury life once they are home. Now, more than ever, parents will struggle to balance their instincts to overprotect their child with the need to allow for some independence within the constraints of safety and supervision. Your child may not value or understand the need and importance of safety and close supervision, particularly if she is an older child or adolescent who has previously been granted some independence and freedom. Often when children return home, they feel that this is the permission they have been waiting for to resume previously enjoyed social activities. "I'm out of the hospital, so now I'm better and I can do what I want," they may think.

For children who do not show any physical signs of a traumatic brain injury, yet have cognitive challenges, restrictions on activities may be difficult to adjust to and understand. The reaction of this sixteen-year-old who was struck by a car while crossing the street is typical: "Since I've been home from the hospital, my mom won't let me out of her sight. She won't even let me ride my bike or go swimming unless she is watching me. She says she's worried that I may injure my brain again." It is difficult for children who previously had very active lifestyles and enjoyed such activities as football, soccer, roller-blading, skateboarding, or swimming to now see these activities as risky and potentially dangerous.

In short, although the return home is a positive and significant step in recovery, it often exposes your child to more restrictions and limitations than could be imagined while hospitalized. As your child re-enters her life at home and in school, the discrepancies between what she could do before and what she can do now become more evident.

Your Child's Losses

As your child adjusts to home, losses that were beginning to be apparent during the rehabilitation phase may intensify and become more real. In addition to the previously discussed cognitive and physical losses, additional losses may begin to surface once at home. These may include the loss of roles and responsibilities within the family, changes in friendships and social groups, and adaptations to goals and dreams for the future.

Once home, the emotions associated with loss will resurface throughout your child's and your family's life cycle, depending on the specific loss and how it affects your child and family at a specific point in time. For example, as your child reaches the age when milestones often occur - learning to drive, high school graduation, college acceptance - your child and family may feel a sense of loss if those milestones aren't reached on schedule.

Peer Involvement and Response

With the early and timely involvement of close friends, these friends will hopefully become an integral piece of your child's transition back to home and school. Many times, peers are able to cope with the changes in their friend and can provide the support and understanding that your child will need. Other times, friends can become less supportive, unsure how to respond to the numerous changes they see. Often the injured child's social behavior may be inappropriate or disruptive, or seem immature and even embarrassing to friends. They may think, "Before her injury she was quieter and liked to do different things. Now she is always embarrassing me with her comments and never invites me to do anything." It is often difficult for peers to understand that these changes in their friend are the result of the brain injury and that behaviors, emotions, personality, and moods may now be very different.

Returning to School

Preparing to return to school is yet another milestone in the recovery process that evokes a variety of emotions for children with TBI and their families. Again, there may be positive feelings about this transition, yet, it can be another time of ambivalence and concern. Depending on what kinds of extra help your child will need and what is specifically provided by the school, your child may be better served at a different school. (See Chapter 9 for a thorough discussion of these issues.)

Whether your child returns to her school or transfers to another school, there will be challenges to face. If your child now requires special education services, becoming involved with the special education system may be a new experience for your family. Children often perceive that there is a stigma attached to special education services that reinforces the permanence of differences in themselves, causing a change in identity. Whether or not your child needs special education services, she may be worried about changes in academic performance and about how peers may respond to physical and cognitive changes. On the other hand, your child may not have the insight into her differences, and may view herself as unchanged, believing that everything will be the same. Regardless of your child's level of insight and understanding into the complexity of such changes, educational services and supports need to be designed for her specific needs.

Social Behavior

As your child rejoins the community, social situations that once seemed natural and appropriate to your child's development may now present challenges. For example, your once outgoing, social child may now be quiet and withdrawn and appear confused at birthday parties. Or she may be disinhibited and impulsive, blurting out comments without thinking and engaging in risky behavior. Adolescents may struggle with peer interactions, requiring the re-teaching and rehearsing of social skills. Sometimes this can result in social isolation, and a growing distance between your child and her peers.

What You Can Do for Your Child at Home

As described above, returning home presents its own set of challenges for your family and your child. Over time your family will gradually adjust its life to address these changes. This section describes things you can do for your child to help with this transition back to the home and community.

Encouraging Family Communication

One of the most critical steps you can take to help your family weather your child's transition back home is to facilitate and encourage open dialogue between family members as to how these changes are affecting each individual. Important issues to discuss include:

Feelings about changes in household roles, routines, and responsibilities;

Siblings' feelings about your injured child's new behaviors and how they are managing at school and in the neighborhood;

Feelings your injured child has about her siblings being allowed to do things that she is not.

Consider holding regular family meetings to gather feedback from family members. Set a time during the week when all family members are expected to attend and discuss what is and is not working within the home. Ongoing open communication within your family will help to establish a foundation for solving problems, alleviating stress, and strengthening relationships within the family.

Setting Limits and Encouraging Other Activities

There are ways to provide safety and supervision for your child while enabling her to have some sense of control and responsibility. First, encourage activities to take place in your home or the home of a trusted adult so that supervision can be unobtrusively provided. Second, set limits with siblings, friends, and your child regarding activities that are safe and appropriate so that your child does not feel pressured or confused in social situations. Third, schedule time together as a family to explore and encourage new activities or interests that present less of a risk for re-injury. Fourth, continue to communicate openly with your child, allowing her to express her frustrations with restrictions. Lastly, educate and inform others as you learn new ways of keeping your child safe. The more people know about the importance of providing a safe environment for your child, the less likely your child is to be put in compromising social situations.

One mother of a sixteen-year-old sat down with her son and his friends and listed activities that Jimmy was allowed to participate in, activities that would require adult supervision, and activities that were completely off limits. This particular mother developed valuable relationships with friends and neighbors early on in her son's recovery process through educating and informing. Several months following her son's return home, she felt comfortable with a handful of trusted friends who understood the importance of safety and were willing to look after her son in social situations.

Managing Losses

Helping your child to manage losses can be a challenging and difficult task, especially when you are likely experiencing and managing your own losses. Establishing a strong support network of family, neighbors, friends, members of religious and community institutions, school personnel, and other professionals is critical. When comfortable, encourage your child to express herself to you and other people in her life.

As mentioned above, there are many times when support from outside professionals can be very helpful. It is worth getting outside help whenever your family does not seem to be coping well, and the neutral, objective perspective and support from a professional might help you over a hump. Additionally, you should seek professional assistance if your child is feeling very distressed, angry, overwhelmed, stressed out, frustrated, depressed, or isolated from peers. In these instances, it is likely that your child's emotional struggles are affecting the whole family.

One way to seek out professional help is to utilize school resources, including school social workers, guidance counselors, and psychologists. Your child may also benefit from counseling services provided by a professional who is experienced with traumatic brain injury. Additionally, family counseling or support groups may help all family members, as issues of loss and change cycle throughout one's life and will likely need to be revisited.

Memory Book

Many families use memory books as a tool to help their child understand what has happened to her from the point of injury through the recovery process. Often these books include:

photographs of the child taken at different points during recovery;

significant dates, times, and events during recovery; and

pictures and comments of professionals who have helped the child and family along the way.

By providing a chronology of the events that happened, the memory book can reinforce the seriousness of the injury to your child, let your child see that she is recovering, and help her integrate this trauma into her lifetime experiences. This tool can also be used to encourage conversation with your child and help in educating others.

Some families reserve a section of the memory book or make a separate memory book to help their child remember information needed for day-to-day life. For example, as an aid to remembering, they list names, dates, times, phone numbers, school schedules, and the steps needed to complete daily living tasks or routines within the classroom or home.

Managing Social Situations

As discussed above, children with TBI often experience social isolation as a result of changes in behavior, personality, mood, and awareness. This can be extremely difficult for your child if she has previously had solid peer relationships. If your child struggled with relationships before her injury, making and keeping friends will probably be even more challenging now. In addition, difficulties with insight, good judgment, and social awareness could place your child in vulnerable situations. For example, your child might be pressured to do something that could place her at risk for another injury. If she is feeling anxious to be liked and accepted by the group, she might take the risk.

Again, help your child by educating her friends and school personnel about recovering from, and long-term effects of, a brain injury. If your child's friends seem to be backing away from her, try offering them more information about your child's condition to help them understand the changes in her. It may help to talk to the parents of your child's friends to better understand the friends' perspectives.

Listen to your child's frustrations about social situations. With the assistance of professionals specializing in traumatic brain injury, you may need to re-teach and rehearse social skills with your child by role playing or by practicing responses to scenarios that your child may be confronted with. Encourage your child to initiate social activities and conversations with her friends, serving as a role model for appropriate behavior.

Returning to School

Returning to school can be a difficult yet positive experience for you and your child. It will be very important to establish close and frequent communication between your family and school personnel (social workers, guidance counselor, teacher). Communication is the key to better understanding and helping your child. Often a communication log or notebook that travels between home and school is the easiest way for the school and family to communicate and is helpful in tracking and planning for the needs of your child. Parents can ask questions about what is happening at school and write about progress and difficulties that their child is having related to school. Likewise, teachers can use the notebook to record what they observe, respond to questions, and have an ongoing dialog with parents.

Your child may feel anxious about returning to school or beginning a new school. Anxiety could be the result of insight into changes in herself, concerns with changes in academic performance or physical appearance, concerns about peer reactions and acceptance, or worries about being placed in special education or the amount of time missed from school.

It is natural and appropriate for your child to worry about returning to school, yet there are some ways to help to ease this process for your child. First, professionals who are experienced with traumatic brain injury can help by educating peers and school personnel before your child's first day at school. Professionals can educate staff and students through in-services to help others less familiar with brain injury to better understand your child. Second, your child should have access to a school professional, such as a social worker, guidance counselor, or nurse, who is available to discuss her concerns about returning to school. Third, as a parent, you can ask to meet with school personnel to discuss your child's educational needs at any time. In fact, you will probably find that advocating for your child will be critical to your own well-being. And finally, it may help for your child to be paired with a "buddy," a trusted and responsible peer who can look out for your child and help to guide her during the school day. Your child may be able to help choose this buddy. Ultimately, however, the buddy should be a responsible student with whom both your family and school are comfortable.

If your child is placed in special education, she may worry about the perceived stigma. Be available to talk with your child regarding the unfairness and unkindness of this stigma and help her to understand the purpose of special education services. In addition, make sure that school personnel are attuned to this issue and available for your child during the transition period. Maintaining frequent contact with your child's school prior to her return, at the time of re-entry, and throughout the school year will help you help your child adjust to the changes in herself and her school program.

Community Resources

Community resources can be vital in helping your family and child adjust to your new way of life. Become connected with support groups and organizations where you can share your experiences and learn from others. Become active in your local chapter of the National Brain Injury Association, groups and organizations involved with special needs, and the local educational system. Use the supports of church and community members in bringing understanding and awareness to others. Go online and get virtual support and real information from some of the Internet resources listed in the Resource Guide. Most importantly, establish connections with others who have shared similar experiences. This will open doors for extended emotional support while acquainting you with other families who have faced, problem-solved, and made it through varying phases along this lifelong process. See the Resource Guide at the back of this book for organizations that can help you get started in seeking support.

General Guidelines

Below is a collection of basic guidelines for helping your child adjust following a traumatic brain injury:

1. Encourage and praise progress.

2. Involve peers, school, and the community when the time is right for your family.

3. Listen to your child and provide support.

4. Serve as a role model for social behavior.

5. Encourage your child to have relationships with friends.

6. Explore finding a counselor experienced with traumatic brain injury for your child and the family.

7. Consider family counseling to address role changes, sibling issues, understanding of differences, and the impact of this trauma on the family life cycle and development.

8. Encourage your child to focus on one day at a time by setting small goals as steps toward accomplishing larger ones.

9. Encourage independence with supervision. Be creative with this!

10. Seek the support and services of community members (professionals, church members, support groups).

11. Communicate! (with your child, family members, neighbors, friends, professionals, and the school).

12. Help your child understand her injury and recovery. (Let her know that the brain needs time to heal like other body parts.)

13. Instill confidence in creative ways--draw on previous skills and interests, applied in new ways.

14. Create a Memory Book. (Memory difficulties are often frustrating. This will also help to document events and reinforce progress.)

15. Encourage a normal lifestyle, predictability, and routine as much as possible.

Above all, remember that this is challenging and a lifelong process!

Parent Statements

I prayed to the good Lord to bring her back to me. He didn't say how she would be. Now I've got to deal with what I've got.

We've got this huge modified, accessible bathroom and a tiny laundry room. The bathroom is like the part of my life devoted to my child's needs and the rest of my life is like the laundry room - squeezed into a very small space.

Joe has done some things that have my heart floating - like walking to our neighbor's house independently!

Tommy's friends were really supportive when he went back to school after his bicycle accident, but now they seem to have moved on. He can't understand why they don't want to spend time with him anymore.

Sometimes I wish she could just see her problems so she would accept the fact that she needs help, but most of the time I'm glad she doesn't see.

The social worker has been the constant, predictable factor in a situation where nothing is predictable. When I'm in her office, I can pause and think and be myself.

He is doing really well now. When other kids ask him why he walks that way or why he can't use his right arm, he tells them "Somebody very bad hurt me once, but he is in jail now." Then he says, "Let's play." Because he handles it so calmly, other kids handle it well too. Sometimes he still is upset or confused about it, so we talk and practice ways he can respond to other kids' questions. He really is a terrific kid and everybody loves him.

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Children with Traumatic Brain Injury: A Parents' Guide | BrainLine

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Although no two children or their brain injuries are alike, many children struggle with similar emotions and challenges after TBI. These include: denial that the injury will have a long-term impact, grief over their loss of function and skill, changes in how they relate to others, rustration with the recovery process, and limited awareness of the differences in themselves.

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The learner might have receptive language delay or disorder such as not hearing the words or not understanding meaning of words

Some expressive language delay or disorder might be not knowing the words to use, putting words together, or knowing the words but not being able to express them

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Centers for Disease Control and Prevention

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Language and Speech Disorders in Children | CDC

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Learning a language takes time, and children vary in how quickly they master milestones in language and speech development.

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Hearing impairment has a significant impact on their academic performance in school. It can affect a learner is many ways. . Hearing impairment causes delay in the development of receptive and expressive communication skills which is their speech and language. The language defeat causes learning problems that result in reduced academic achievement.

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Whether a student with traumatic brain injury is in elementary school or in college, transitioning back to school post-injury can be difficult on many levels.

Sometimes a student's traumatic brain injury goes undiagnosed or is misdiagnosed as a learning disability or behavioral problem. After all, problems from a brain injury can be similar to those related to a learning disability, so getting an accurate diagnosis can make all the difference. A correct diagnosis can lead to more a tailored - and successful treatment plan.

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Whether a student with traumatic brain injury is in elementary school or in college, transitioning back to school post-injury can be difficult on many levels. Sometimes a student's traumatic brain injury goes undiagnosed or is misdiagnosed as a learning disability or behavioral problem.

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-Social withdrawal
-Communication skills
-Emotional problems caused by a drop in self-esteem and confidence.

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What Can Cause a Hearing Loss?

Hearing loss can be a result of numerous factors or events. These include:

Genetic factors

Chromosomal differences

Anatomical differences

Syndromes

Prenatal drug or alcohol use

Medication used in serious medical situations

Prematurity

Illness or injury

Hearing loss can also be unexplained.

What Factors Influence Speech and Language Development for a Child with Hearing Loss?

All children are different in how they develop. There are developmental stages that most children follow. Hearing loss can affect how communication develops in many ways. These include:

Age at identification of the hearing loss

Family involvement and support

Type and degree of hearing loss

Age of amplification

Consistency of device use

Type of treatment (early intervention, direct therapy, school-based therapy)

Cognitive and motor skill level

Other medical conditions

What Are Speech and Language Challenges for Children with Hearing Loss?

Children with hearing loss may have difficulty with:

Hearing and understanding sounds around them

Making speech sounds

Learning new words

Putting together sentences

Using correct grammar

Effectively expressing themselves

Understanding speech from other people

Following directions in quiet and noisy places

Paying attention and controlling behavior

Following conversations with multiple people

Making friends and interacting with peers. This can be caused by difficulty understanding games, rules, and directions.

Listening and learning in the classroom

Learning to read

What Can We Do to Help the Child and Caregivers Succeed?

Treatment for a child with hearing loss starts with a partnership. Children with hearing loss make the most progress when caregivers and professionals work together. They also make progress when caregivers work with the child at home.

The child should have a speech-language evaluation to see how the hearing loss is impacting their development. Speech and language therapy may be needed. The speech-language pathologist and family will work together in therapy. The focus of therapy will be to develop communication skills.

The speech-language pathologist will likely add listening games into the session. Listening skills are important for progress in therapy. The use of strategies with your child at home will help speech, language, and listening skills develop.

Why Are Caregivers So Important in Their Child's Success?

We know that bringing your child to therapy won't "fix" their speech or language difficulties. We actively engage caregivers to partner with us in therapy. As caregivers, please:

Actively participate in therapy with your child. Parents and caregivers are the child's best supports and teachers.

Ask questions if something is unclear. The speech-language pathologist will take time to talk about your questions.

Use speech and language strategies learned in your session with your child every day.

Keep noise to a minimum. This will help your child hear important information clearly.

Make sure you have your child's attention before talking with them. Make sure they heard you by watching their actions and responses.

Read books daily to help build your child's vocabulary and language.

Online Resources

For More Information

Contact the Division of Speech-Language Pathology at 513-636-4341 or visit our website.

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Hearing loss can be a result of numerous factors or events. These include: Genetic factors Chromosomal differences Anatomical differences Syndromes Prenatal drug or alcohol use Medication used in serious medical situations Prematurity Illness or injury Hearing loss can also be unexplained. All children are different in how they develop.

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Signs and Symptoms Related to Traumatic Brain Injury

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Signs and Symptoms Related to Traumatic Brain Injury

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Allison, K. M., Byom, L. J. & Turkstra, L. S. (2017). Traumatic Brain Injury in Children and Adolescents. In A. Johnson & B. Jacobson (Eds.), Medical Speech-Language Pathology (3rd ed.). Thieme: New York.

Allison, K. M., & Turkstra, L. S. (2012). Navigating medical speech-language pathology reports for children with TBI. Perspectives on School-Based Issues, 13, 63-69.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) . Washington, DC: Author.

American Speech-Language-Hearing Association. (1997). Preferred practice patterns for the profession of speech-language pathology. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2003). Rehabilitation of children and adults with cognitive-communication disorders after brain injury [Technical Report]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2005). Knowledge and skills needed by speech-language pathologists providing services to individuals with cognitive-communication disorders [Knowledge and Skills].

American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of Practice]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of Practice]. Available from www.asha.org/policy/.

Anderson, V., Catroppa, C., Morse, S., Haritou, F., & Rosenfeld, J. V. (2005). Functional plasticity or vulnerability after early brain injury? Pediatrics, 116, 1374-1382.

Anderson, V., Godfrey, C., Rosenfeld, J. V., & Catroppa, C. (2012). Predictors of cognitive function and recovery 10 years after traumatic brain injury in young children. Pediatrics, 129, e254-e261.

Asemota, A. O., George, B. P., Bowman, S. M., Haider, A. H., & Schneider, E. B. (2013). Causes and trends in traumatic brain injury for United States adolescents. Journal of Neurotrauma, 30, 67-75.

Bazarian, J. J., McClung, J., Shah, M. N., Ting Cheng, Y., Flesher, W., & Kraus, J. (2005). Mild traumatic brain injury in the United States, 1998-2000. Brain Injury, 19, 85-91.

Blosser, J. L., & DePompei, R. (2003). Pediatric traumatic brain injury: Proactive intervention. New York, NY: Delmar.

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# data[].attributes.attachment_link.description
Allison, K. M., Byom, L. J. & Turkstra, L. S. (2017). Traumatic Brain Injury in Children and Adolescents. In A. Johnson & B. Jacobson (Eds.), Medical Speech-Language Pathology (3rd ed.). Thieme: New York. Allison, K. M., & Turkstra, L. S. (2012). Navigating medical speech-language pathology reports for children with TBI.

# data[].attributes.body
- Poor relationships with family members.
-Drugs.
-Poor communication skills.
-Frustration, misunderstood, and blaming the child's problems.

# data[].attributes.body
- May struggle to build and maintain good relationships with their LF & peers.
- May not have strategies to be successful in school, such as memorization skills and attention, which may lead to academic difficulties.
- Puts them at risk for drop out & affecting their future.

# data[].attributes.body
-Hampered speech and communication skills

-Challenges with mobility
- Other medical conditions

# data[].attributes.body
Imaging test- take images of a person’s brain
Glasgow Coma Scale- measure a person’s functioning in (Ability to speak, Ability to open eyes, Ability to move)
person’s level of consciousness, memory loss
Blood tests- detects two proteins, UCH-L1 and GFAP

# data[].attributes.body
Having more than one disability, where the cause is unknown.
Multiple disabilities refers to “concomitant [simultaneous] impairments, such as intellectual disability-blindness, intellectual disability-orthopedic impairment, etc. The combination of which causes such severe educational needs that they cannot be accommodated in a special education program solely for one of the impairments.

# data[].attributes.body
orthopedic impairments category, educational challenges will differ case by case, and the strategies used in each case should focus on a student’s unique needs. Possible academic barriers include:

Non-accessible transportation

Trouble maneuvering around the classroom

Difficulty navigating school hallways

Earning mandated physical education credit

Communicating effectively

Teaching Strategies

1. Special seating arrangements to develop useful posture and movements.

2. Instruction focused on development of gross and fine motor skills.

3. Securing suitable augmentative communication and other assistive devices.

4. Awareness of medical condition and its affect on the student (such as getting tired quickly)

# data[].attributes.body
Inattentiveness

Inappropriate responses to questions

Daydreaming

Trouble following directions

Speech problems

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During her years teaching, former Oklahoma teacher Bonnie Stone encountered several students who were flagged as having learning, language and behavioral challenges when in reality, they had hearing loss.

"I taught first grade and discovered six children in three years with hearing loss," Stone said. "One was a Spanish-speaking boy who was profoundly deaf, but his lack of oral speech was dismissed because 'he doesn't know English.'"

Another student was about to undergo testing for learning disabilities when Stone suggested to the mom that her daughter get her hearing checked first.

"The next day, the mom comes in and tells me her daughter had impacted earwax in both ears and had them cleaned. By the end of the year, the girl tested in the top quartile for first grade," Stone said.

Misdiagnosis leads to real learning problems

When treated with pediatric hearing aids or cochlear implants, kids with hearing loss are just as capable as their peers. However, if childhood hearing loss is left undiagnosed and untreated, it can have an impact that's similar to a learning or behavioral disorder.

A child who can't hear well will struggle to keep up, may get restless and act out in class, or disengage from lessons. Unfortunately, this may lead to getting screened for other conditions, such as learning disabilities or ADD and ADHD. Eventually, this can affect their self-esteem, too, leading to behavioral problems.

"Hearing loss is a real and possible cause of behavioral and learning problems," she explained in a blog post about her experience. "ALWAYS assume hearing loss first and have the child screened."

Even a mild hearing loss can affect
academic performance.

How common is childhood hearing loss?

According to the CDC, about 15% of children ages 6 to 19 have hearing loss of at least 16 decibels in one or both ears. Around .1% have severe hearing loss.

Even hearing loss in only one ear has a tremendous impact on school performance; research shows anywhere from 25 to 35% of children with unilateral hearing loss are at risk of failing at least one grade level.

Hearing and learning are connected

Untreated hearing loss causes delays in the development of speech and language, and those delays then lead to learning problems, often resulting in poor school performance.

Even mild hearing loss can make it hard to keep up-yet mild hearing loss is the hardest to detect and diagnose, because kids learn quite early how to compensate for their hearing loss, and the milder it is, the easier it is to compensate. And parents may not realize that their child can hear but not understand. Over time, though, this catches up to them in school.

Untreated hearing loss leads to a very real learning gap

According to the American Speech-Language Hearing Association ( ASHA), children who have mild to moderate hearing loss but do not get help are very likely to be behind their hearing peers by anywhere from one to four grade levels.

And for those with more severe hearing loss, intervention services are even more crucial; those who do not receive intervention usually do not progress beyond the third-grade level.

What are the reasons behind this education gap? It's certainly not a question of intelligence; just because a child has hearing loss doesn't mean he is any less capable of doing well in school than his hearing peers. Sometimes the classroom environment itself doesn't support a child with hearing loss. A busy teacher who has many students to tend to, or a teacher with a poor understanding of hearing loss, often is unable to alter his teaching style or keep a student's hearing loss in mind while teaching a lesson or assigning homework.

Speech, language and vocabulary development

For example, if a teacher turns his back on the students while teaching, his voice will be directed toward the blackboard, causing a student with hearing loss to miss part of the lesson. Oral changes to homework assignments, an unfamiliar accent or a teacher who talks too rapidly can all hinder the learning progress of a student with hearing loss.

In addition to the classroom environment, certain subjects are just intrinsically more difficult for a child with hearing loss. While the ability to hear affects all aspects of academic achievement, perhaps the areas most affected are those involving language concepts. Vocabulary, language arts, sentence structure and idiomatic expressions are extremely difficult for a child affected by hearing loss to grasp.

New vocabulary, language arts, sentence structure and idiomatic expressions are extremely difficult for a child affected by hearing loss to grasp.

Frustration and confusion can also play a big part in poor academic performance. Though he might have perfectly normal speech, a child with only mild hearing loss can still have trouble hearing a teacher from a distance or amid background noise. Imagine the difficulty and confusion of not being able to hear the high-frequency consonants that impart meaning in the English language (ch, f, k, p, s, sh, t and th) and you can begin to understand some of the academic struggles a child with hearing loss faces on a daily basis. "Chick" and "thick" may sound identical to a child with hearing loss, for example.

Social struggles due to communication challenges

In addition to academic struggles in school, children with hearing loss can also experience trouble socially. Communication is vital to social interactions and healthy peer relationships; without the ability to communicate effectively they often experience feelings of isolation and unhappiness.

If a child with hearing loss is excluded from social interactions or is unwilling to participate in group activities due to fear of embarrassment, the result is that she can become socially withdrawn, leading to further unhappiness. Children with hearing loss are also slower to mature socially, which hinders peer relationships.

Hearing aids and other interventions make all the difference

The good news? Hearing aids help language development in kids with hearing loss.

Children who receive hearing aids or devices like cochlear implants can make great strides and perform just as well as their peers, according to research.

How to help hearing-impaired students in the classroom

Teachers are in a unique position to help learners with hearing impairments by arming themselves with the knowledge as to how a student with a hearing loss receives and understands information, as well as comprehensive knowledge of an individual student's capabilities and level of comprehension. Since early intervention is key, signs teachers can watch for in the classroom include:

Inattentiveness

Inappropriate responses to questions

Daydreaming

Trouble following directions

Speech problems

A child who is struggling in school, especially if she has a family history of hearing loss or has had r ecurring ear infections, should be seen by a hearing care professional for an evaluation.

Depending on the results a proper course of intervention and hearing loss student accommodations can then be recommended. Intervention is crucial because a child who is supported both at school and at home has the best chance of success, academic and otherwise.

If you believe your child is suffering from hearing loss, take her to a pediatrician or your local hearing healthcare professional today. Check out our hearing care directory for one near you.

Hearing loss is invisible and kids may not know they have it

Hearing loss in kids can be mistaken for many different problems, but is easily diagnosed with a hearing evaluation, either at school or with a doctor. Stone, the retired first grade teacher, can't stress doing this enough.

"Unlike vision, it cannot be recognized by a student who squints or tells you they can't see the board. Children with hearing loss may not even realize they aren't hearing properly," Stone, the former teacher, said. "So it is up to us, as their teachers and parents and caregivers, to be observant, educated, and aware of the signs. And to offer support and help."

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Hearing loss can mimic learning disorder in kids, leading to school problems

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During her years teaching, former Oklahoma teacher Bonnie Stone encountered several students who were flagged as having learning, language and behavioral challenges when in reality, they had hearing loss. "I taught first grade and discovered six children in three years with hearing loss," Stone said.

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Hearing impairment happens when there is a problem or damaged to one or more areas of the ear. The individual has trouble hearing clearly, understanding speech and interpreting various sounds.

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Levels vary among children

Hard time letting others know their wants and need

Children may learn much slower than other children their age→ will take longer to learn to speak, walk, dress, or eat without help

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How can it affect a child in school and home?

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How can it affect a child in school and home?

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It causes learning difficulties, social problems, motor skills which affects the ability to preform successfully in a daily life. Ex. task talking, basic social understanding.

Children with this disability have a low IQ score of 70, which result with childish behavior that is inconsistent with the Childs age.

Tip for teachers: learn as much as you can about the disability. Recognize that you can make an enormous difference in a students life. Be as concrete as possible. Demonstrate what you mean rather than giving verbal direction. Ex. show of pictures, hands on material.

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Brain dysfunction caused by an outside force, usually a violent blow to the head.

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-The referral characteristics for the student with an orthopedic impairment (OI) fall more into the area of physical characteristics. These may include paralysis, unsteady gait, poor muscle control, loss of limb, etc.

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According to the federal Individuals With Disabilities Education Act (IDEA), an orthopedic impairment is defined as a bone-, joint-, or muscle-related disability that is so severe that it negatively affects a child's educational performance. Causes of orthopedic impairment range from genetic abnormalities (such as those that cause a missing arm or leg) to disorders like cerebral palsy, as well as other issues.

Students are typically evaluated by a healthcare professional to determine if they have an orthopedic impairment that will interfere with their academic progress. Medical professionals may also observe the child in the classroom to get a sense of potential problems the student will face.

Orthopedic Impairment Disability Category

Children may be born with an orthopedic impairment or they may acquire it at some point in life.﻿﻿ Hereditary, congenital, and environmental factors can play a role in causing orthopedic impairments that affect the normal functioning of the bones, joints, or muscles.

For example, a child may be born with joint deformities, spina bifida, or muscular dystrophy. Acquired causes can include disease, injury, or surgery. (Injury or surgery may lead to the loss of a limb, muscle contractures, or bone loss that can make movement difficult.) The orthopedic impairment disability category, per IDEA, includes all orthopedic impairments, regardless of cause.﻿﻿

Potential Causes of Orthopedic Impairment

Sometimes orthopedic impairments are called physical disabilities or included in the category of " other health impairments."

Impact on Education

Students with orthopedic impairments typically have the same cognitive abilities as their peers without disabilities. Because of this, school staff should try to include these students in mainstream classes as much as possible. The IDEA law states that students should be educated in the least restrictive environment when appropriate.﻿﻿

For example, impairments such as amputations and fractures can impact attendance, making it harder for kids to keep up academically. Other impairments that have accompanying brain involvement such as birth trauma and cerebral palsy may lead to learning difficulties resulting from sensory and cognitive issues.

Accommodations

Students with orthopedic impairments will have different physical challenges and therefore require different accommodations.

Some specific concerns and challenges that children with orthopedic impairments may face include:

Behavioral: Teachers in all subject areas should be aware of the impact of an orthopedic disability on a student's behavior in class. Students with these impairments, for example, might get tired more quickly than their peers without orthopedic disabilities.

Participation: Physical education classes, in particular, may pose difficulties. Some students with orthopedic impairments will need to be excused from gym class. Other students with mild orthopedic impairments may be able to participate.

Seating: A student may need special seating arrangements to help him with posture and mobility, as moving around the classroom or moving around school hallways may be difficult. Schools may also need to arrange the schedules of these students in a way that prevents them from having to travel long distances from one class to another. Providing elevator access can also help.

Technology: They may also need assistive technology devices to help them communicate or lessons that address their disability, such as those that will help them improve their gross and fine motor skills. Devices and technologies that might be utilized may include wheelchairs, specialized desks, canes, crutches, communication software, or speech recognition software.

Travel: Children with orthopedic impairments may also face challenges accessing transportation to get to and from school. Federal law, however, requires school districts to provide the transportation necessary to help children with disabilities travel to and from school.

A Word From Verywell

Collectively, parents, medical professionals, teachers, counselors, and other school staff can work to provide children with orthopedic disabilities the support they need in the classroom. The child's needs may change over time, and the officials involved in their individualized education plan can make amendments to the plan to accommodate new needs.

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How Orthopedic Impairments Affect Special Needs Students' Education

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According to the federal Individuals With Disabilities Education Act (IDEA), an orthopedic impairment is defined as a bone-, joint-, or muscle-related disability that is so severe that it negatively affects a child's educational performance. Causes of orthopedic impairment range from genetic abnormalities (such as those that cause a missing arm or leg) to disorders like cerebral palsy, as well as other issues.

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Centers for Disease Control and Prevention. CDC twenty four seven. Saving Lives, Protecting People

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-Physically may need accommodations to move, (assistive tech, wheelchair, railing in the home)
-emotionally needs patience & understanding.
-A person to communicate with regularly to support those needs.
-A person to help physically support the child.
OI can affect how the learner  moves, communicates, and learns.

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What behaviors and Characteristics would you see?

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What behaviors and Characteristics would you see?

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Orthopedic Impairment Definition

Orthopedic impairment is defined as a severe orthopedic impairment that adversely affects a child's educational performance.

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How can it be identified in a learner?What behaviors/characteristics would you see?

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How can it be identified in a learner?What behaviors/characteristics would you see?

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- Aggression (acting out, fighting)
- Withdrawal (social isolation)
- Immaturity (temper tantrums & poor coping skills)
-Learning difficulties (academically performing below grade level)

https://www.parentcenterhub.org/emotionaldisturbance/

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Speech or language impairments is when learner has a problem with saying sounds clearly or stuttering. If someone has this disability they might not be able to understand, talk, read, or write.

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Speech is how we say sounds and words. Language is the words we use to share ideas and get what we want.

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insufficiency to learn. This cannot be diagnosed by intellectual, sensory, or health factors. ED cannot maintain a relationship with peers or teachers. Poor behavior, and depression in association with school or personal problems.