Concussion Form - BrainSTEPS

Brain Injury Support Framework

Step 1 of 5

Directions for BrainSTEPS Consultants Completing the BISF:

1. Ask the student which of the following Symptom Changes they experienced during the past week.

2. Emphasize that you are looking for Symptoms since their brain injury occurred.

3. Choose the correct Symptom from the lists below based on the student’s self-report.

4. Discuss the various Academic Support Options listed below each chosen Symptom with the school team.

5. Choose one or more Academic Support Options by clicking on the box next to each option. These Academic Support Options should be determined by the BrainSTEPS consultant, in conjunction with the student’s teachers.

6. The BrainSTEPS Consultant should review all current Symptoms and complete the remaining sections of the BrainSTEPS BISF with the school team.

7. The BrainSTEPS BISF can be saved and made available for immediate download as a pdf document. The BrainSTEPS Consultant can also email the BrainSTEPS BISF to school staff and parents directly from this application at the conclusion of the school meeting.

8. The student’s teachers should refer to the BrainSTEPS BISF document and implement the recommended Academic Support Options during the school day to help alleviate the student’s brain injury-related symptoms to promote learning.

9. BrainSTEPS Consultant should follow up with the student, parent, and school team within 30 days to review and update the BISF.

Physical Symptoms / Changes
Thinking/Learning (Cognitive) Changes
Behavioral / Social Changes
General Brain Injury Considerations

Physical Changes

Headache / Pressure in the Head
Vision Issues
Dizzy or Balance Issues
Light sensitivity
Noise sensitivity
Vomiting/Numbness/Ringing in Ears
Fatigue and Sleep Issues
Other Physical Changes Not Listed
Currently Not Experiencing Physical Symptoms / Changes

Contact physician immediately with any new physical symptom or increase in existing physical symptoms

Other Physical Change Not Listed Above:

Headaches

Mindfulness has been shown to help headache pain. A common exercise is to have the student place one hand on stomach and inhale slowly through the nose to the count of four. Student should be taught to feel their stomach expand with their breath. After the count of four, student should exhale through their mouth slowly to the count of four. Student should feel their stomach deflate with the release of their breath. Repeat this cycle three times

Environmental Considerations:

Monitor triggers that may increase headache ie bright lights, noise, movement in visual field, computer work, note taking, reading, hunger/thirst
Adjust room lighting or use alternate light source such as lamp versus fluorescent lighting

Student Considerations:

Allow student to wear a hat with a brim or sunglasses indoors to reduce light sensitivity / glare
Cue student to take short “eye breaks” from computer screen (e.g., focus on something across the room to give eyes a rest, close eyes for a short period of time).
Schedule longer “brain breaks” from the computer throughout day if needed.
Limit ‘screen time’ especially on small screens such as phones, SmartWatch even during non-school hours if this activity increases headache.
Discourage student from doing online learning on a smart phone – the screen is too small and can cause eye fatigue and cognitive fatigue. Encourage use of laptop or computer screen (use largest screen available)

Computer Considerations:

Immersive Reader.
Safari Reader on the Safari browser.
Mercury Reader extension on Chrome browser.

Instructional Considerations:

Have teacher read exams to the student via Zoom or other online platform (Zoom is currently offering free subscriptions for all K-12 public schools)
Dictate answers instead of writing
Provide student with teacher notes prior to class. This allows the student to ‘listen’ and avoid near/far vision changes that may spike headache. Student may highlight key concepts
Provide recordings of live lessons to allow student to review for missed content
Listen to reading material – CDs, Digital, or Internet access to textbooks and reading material to listen to reading material instead of reading it, &/or to have the ability to adjust font size and background (black with white text) or dim the screen as well
Have student use word prediction software that predicts words while the student is typing such as:

Co:Writer.
TypeIt4Me (Macs only).

Text-to-speech – for a student who may find reading too taxing they can have books or documents read aloud. Examples include:

Snap and Read
Audio Books: Audible, Scribd
Reads other types of documents- NaturalReader, Voice Dream Reader

Speech-to-text – Speech recognition software that will turn a student’s speech into text on the computer screen

Siri’s dictation feature offers real-time speech-to-text conversion, recording the words you say as typed text on Apple products.
Mac Speech to Text (Apple products).
Dragon. Google Docs Speech to Text/Voice Typing on Chrome browser

Use a filter (pastel colored report covers or index dividers – blue, purple, or green) over paper to read text to give eyes a break
Use dark paper along with the colored filter above to block of parts of pages when reading to reduce “visual clutter”
Provide concrete clues on student’s desk – taped 100’s charts, math number lines, alphabet, vocabulary lists, word bank lists
Use headings for any content changes on the screen or in notes.
Provide student page numbers or web links to help student find answers

Testing Considerations:

Additional symptom-based supports not listed above:

Vision Issues

(Blurry vision, double vision, difficulty reading, visual field cuts)

Parent should inform child’s physician of symptom

Environmental Considerations:

Monitor triggers that may increase vision disturbances ie bright lights, movement in visual field, computer work, note taking, reading, hunger/thirst
Discourage student from doing online learning on a smart phone – the screen is too small and can cause eye fatigue and cognitive fatigue. Encourage use of laptop or computer screen (use largest screen available)

Student Considerations:

Cue student to take short “eye breaks” from computer screen (e.g., focus on something across the room to give eyes a rest, close eyes for a short period of time)
Schedule longer “brain breaks” from activities that require reading and computer work throughout day
Limit ‘screen time’ especially on small screens such as phones, SmartWatch even during non-school hours if vision is impacted
Discourage student from doing online learning on a smart phone – the screen is too small and can cause eye fatigue and cognitive fatigue. Encourage use of laptop or computer screen (use largest screen available)
Students with vision problems may benefit from prism glasses, eye patching and/or vision therapy. Parent may wish to discuss these options with treating physician

Computer Considerations:

Use computer blue light blocking glasses to help reduce eye fatigue or use attachable blue light screens
Increase font size (large print is defined as 16 -to 18-point bold type, depending on the typeface used); fewer words on page
Adjust screen settings to enlarge entire screen
Reduce screen glare (encourage student to sit away from windows, bright lights)
Dim/ adjust screen brightness
Try alternative screen colors
Contrast desktop screen from light to dark
Use “high contrast” (white print on black background) to assist with reading documents on the computer or e-reader (iPad, Kindle, Nook) to read text to give eyes a break
Reduce visual clutter on the screen pages to reduce visual overload

Immersive Reader
Safari Reader on the Safari browser.
Mercury Reader extension on Chrome browser.

Text-to-speech -for a student who may find reading too taxing they can have books or documents read aloud. Examples include:

Snap and Read.
Audio Books: Audible, Scribd.
Reads other types of documents- NaturalReader, Voice Dream Reader.

Speech-to-text – Speech recognition software that will turn a student’s speech into text on the computer screen

Mac Speech to Text (Apple products).
Dragon.
Google Docs Speech to Text/Voice Typing on Chrome browser.

Scanners with Optical Character Recognition (OCR) software which converts print-to-speech output
Have student use word prediction software that predicts words while the student is typing such as:

Co:Writer
TypeIt4Me (Macs only)

Instructional Considerations:

Have teacher read exams to the student via Zoom or other online platform (Zoom is currently offering free subscriptions for all K-12 public schools)
Dictate answers instead of writing
Provide student with teacher notes prior to class. This allows the student to ‘listen’ and avoid near/far vision changes that may spike vision issues. Student may highlight key concepts
Provide recordings of live lessons to allow student to review for missed content
Listen to reading material – CDs, Digital, or Internet access to textbooks and reading material to listen to reading material instead of reading it, &/or to have the ability to adjust font size and background (black with white text) or dim the screen as well
Have student use word prediction software that predicts words while the student is typing such as:

Co:Writer
TypeIt4Me (Macs only)

Text-to-speech – for a student who may find reading too taxing they can have books or documents read aloud. Examples include:

Snap and Read
Audio Books: Audible, Scribd
Reads other types of documents- NaturalReader, Voice Dream Reader

Speech-to-text – Speech recognition software that will turn a student’s speech into text on the computer screen

Siri’s dictation feature offers real-time speech-to-text conversion, recording the words you say as typed text on Apple products.
Mac Speech to Text (Apple products)
Dragon.
Google Docs Speech to Text/Voice Typing on Chrome browser

Additional symptom-based supports not listed above:

Dizzy or Balance Issues

Parent should inform physician of student’s symptoms. Physician may want to consider vestibular issues/vestibular therapy
Poor sleep the night before is the most important contributor after a brain injury to dizziness the next day. Parents should help to ensure the student is maintaining a consistent sleep schedule at home in the evenings, avoiding naps during the day. Naps can disrupt the student’s regular sleep schedule at night

Student Considerations:

Avoid environments that trigger dizziness such as assemblies, cafeteria, crowded hallways, school bus if necessary
Avoid walking in busy hallways. Allow student to leave class a few minutes early or arrive late to next class to avoid crowded hallways. Allow student to eat in a quiet room if necessary
Have student use a buddy system for hallways/carrying books
If traveling to or from second floor, use handrail at all times or provide student with elevator key
Transition slowly from sitting to standing position
Sit and close eyes at desk/table until symptoms pass
Provide student pass to go to a quiet room to rest for 5-10 minutes until symptoms pass

Instructional Considerations:

Provide a second set of books at home so that student does not have to carry books or a backpack which can impact balance
Provide student book in each physical classroom, so student does not have to carry books to and from class
Provide student with teacher notes prior to class. This allows the student to ‘listen’ and avoid near/far vision changes that may spike balance/dizziness issues. Student may highlight key concepts
Cue student to take short “eye breaks” from computer screen (e.g., focus on something across the room to give eyes a rest, close eyes for a short period of time)
Schedule longer “brain breaks” from the computer throughout day
Provide student page numbers (or web-links) to help the student find answers in book

Additional symptom-based supports not listed above:

Light Sensitivity

Mindfulness has been shown to help light sensitivity. A common exercise is to have the student place one hand on stomach and inhale slowly through the nose to the count of four. Student should be taught to feel their stomach expand with their breath. After the count of four, student should exhale through their mouth slowly to the count of four. Student should feel their stomach deflate with the release of their breath. Repeat this cycle three times

Student Considerations:

Allow student to wear a hat with a brim or sunglasses indoors to reduce light sensitivity / glare
Work in a room with natural lighting, if possible. Adjust/dim room lighting. Avoid fluorescent lights. Sit away from windows where light and sun filter through
Fluorescent overhead light filter covers helps to dim direct bright lights (Amazon)
A table lamp may be preferred to overhead lighting

Instructional Considerations:

Additional symptom-based supports not listed above:

Noise Sensitivity

Mindfulness has been shown to help noise sensitivity. A common exercise is to have the student place one hand on stomach and inhale slowly through the nose to the count of four. Student should be taught to feel their stomach expand with their breath. After the count of four, student should exhale through their mouth slowly to the count of four. Student should feel their stomach deflate with the release of their breath. Repeat this cycle three times

Student Considerations:

Monitor student for triggers such as noisy environments ie cafeteria, assemblies, music/band/orchestra/ chorus/shop class
Be aware that a metal roof on house could cause noise sensitivity during a hard rain or thunderstorm
Warn before any siren tests (tornado, fire, carbon monoxide)
Fluorescent lights may cause noise sensitivity issues if there is a low humming sound. Try switching to a floor lamp or desk lamp
Allow use of ear plugs, noise cancelling earbuds/headphones
Adjust computer volume to student’s comfort level

Instructional Considerations:

Allow preferential seating in classroom away from noisy areas such as open doors/windows, hallway noise, center type activities, seating next to HVAC/fish tank/chatty peers
Working in a quiet room away from distractions. If there is not a quiet room available, try creating a quiet corner in the room
Establish eye contact with the student before speaking to them. Gain visual attention prior to giving instructions
Ask student to repeat directions back to you before they start their work to ensure they understand
Break directions down into steps and allow extra time for student to process them if needed
Teach student to ask for help and make yourself available to them if they are having difficulty

Additional symptom-based supports not listed above:

Vomiting/Numbness/Ringing in Ears

Contact physician immediately if you are experiencing numbness or tingling.
Contact physician immediately if you are experiencing ringing in your ears.
Contact physician immediately if you are experiencing vomiting or consistent nausea.
Contact physician with any new physical symptoms or increase in existing physical symptoms.

Additional symptom-based supports not listed above:

Fatigue and/or Sleep Issues

Additional supports the student’s teachers should explore

Poor sleep is the most important contributor after brain injury to daytime sleepiness. Parents should help to ensure the student is maintaining a consistent sleep schedule at home in the evenings, avoiding naps during the day. Naps can disrupt the student’s regular sleep schedule at night
Be aware! Attention, concentration, new learning, retrieval, processing speed, behaviors and headaches often worsen when a student’s sleep has been disrupted after a brain injury
Parents should inform physician of ongoing sleep disturbances. Physician may consider possible use of over the counter sleep aid such as Melatonin

Student Considerations:

Limit caffeine during day (no caffeine after noon)
Limit screen time before bed
Do not exercise before bed

If student is having difficulty falling asleep, have the student try one or more of the following:

Get out of bed and do something relaxing, once student feels sleepy, go back to bed
Soothing music
White noise (fan or noise machine)
Warm milk before bed
Relaxation techniques
Avoid looking at the clock which can cause anxiety and make sleeping even more difficult

Instructional Considerations:

Student does every 2nd or 3rd problem
Student does 50% of the problems/questions,

Student does every 2nd or 3rd problem

Use a timer and draw a line across their homework page at the end of 10 or 15 minutes of sustained work
Student can demonstrate that they understand the main learning concept(s) taught that day, rather than having them complete full worksheets

Additional symptom-based supports not listed above:

Thinking & Learning (Cognitive) Changes

Memory Issues
Attention and Concentration
Cognitive Fatigue/Slow Processing/Fogginess/Confusion
Difficulty Planning/Organizing
Difficulty Expressing Thoughts
Difficulty Making Decisions
School Work Takes Longer
Other Cognitive Changes Not Listed
Not Experiencing Any Cognitive Issues

Other Cognitive Changes Not Listed

Memory Issues

(forgetful, misunderstands, difficulty learning new material, difficulty recalling previously learned information, difficulty remembering future events/assignments)

Student Considerations:

Instructional Considerations:

Testing:

Utilize cueing strategies for TESTS & QUIZZES such as:

Multiple Choice Tests
Word Banks
Reference Cards
Open-Notebook or Open Book

Memory Issues – Trouble Remembering to do Things on Time

Additional symptom-based supports not listed above:

Attention and Concentration

Poor sleep is the most important contributor after a brain injury to attention and concentration. Parents should help to ensure the student is maintaining a consistent sleep schedule at home in the evenings, avoiding naps during the day. Naps can disrupt the student’s regular sleep schedule at night.

Student Considerations:

Reduce distractions in the student’s work area:

Preferential seating away from noise sources (fans, open doors, talkative peers
Use of noise cancelling headphones or ear plugs
Use of study carrels
Minimize clutter on desk and in classroom
To reduce distractions for the student, computers and other equipment with audio functions that are used in the classroom by other students should be used with earphones to eliminate the sound being broadcast into the classroom

Provide scheduled “brain breaks.” Use a timer (phone, computer, stand-alone) to cue the student when break starts and stops.
Establish a verbal cue word the teacher can say to remind the student to pay attention (e.g., One, two, three…eyes on me; Listen, look, etc.).
Provide student with fidget sensory tools to stay focused while teacher is speaking. Provide student with fidget seat, rubber ball seat, or standing desk to wiggle while working

Instructional Considerations:

Testing:

Provide this student with a quiet, distraction free area for quiet study time and test taking. It is the responsibility of the teacher to take the initiative to privately and discretely (do not draw peer attention to the student) “send” this student to a quiet, distraction free room/area for each testing session. It is important to assure that once the student begins a task requiring a quiet, distraction free environment that no interruptions be permitted until the student is finished.
Allow student to respond verbally to test questions.
Alternate ways to evaluate (projects or oral presentations instead of written tests).
Provide sample test (not the same problems, but same format as test) prior to exam as a study guide.
Testing in separate room. Allow tests to be taken in an environment with fewer distractions.
Provide student extended time on tests.
Provide student a word bank of choices for answers to test questions.
Permit student to explain wrong answers on assessments.
Allow student to take short breaks as needed during testing.

Additional symptom-based supports not listed above:

Cognitive Fatigue, Slow Processing, Fogginess, Confusion

Student Considerations:

Eliminate naps
Maintain consistent sleep patterns at night, with an early bedtime when possible.
Rest when needed, but do not take naps during day
Turn off phone notifications during scheduled sleep hours.
Limit screen time before bed.
Limit caffeine.
Physical activity increases activity in the areas of the brain where processing happens. Low impact walking is an activity that can increase activity safely for a student.

Instructional Considerations:

Modify classroom and homework assignments.

Testing:

Additional symptom-based supports not listed above:

Additional supports the student’s teachers should explore

Slow Processing Speed
Slow to respond, react, takes longer to think through things

Difficulty Planning, Organizing

Poor sleep the night before contributes to organization problems the next day. Parents should try to keep the student on a regular sleep schedule at night. Avoid napping as it can throw off the student’s regular circadian rhythm for sleep.

Student considerations:

Use of paper or electronic calendar
Set reminder e-notifications
Use of daily to do lists or e-lists
Use an alarm to help with time management
Daily sign in / sign out system to help track assignments and due dates

Instructional Considerations:

Explicit instruction and reminders to use the following:

Reminder e-notifications
Electronic calendars
To do e-lists
Goal, Plan, Do, Review strategy

Additional symptom-based supports not listed above:

School Work Takes Longer

Instructional Considerations:

Create chart for all missing work ie what must be completed and what work will be excused. Provide written copy to student and parent for each class.

What will be graded
What will not be graded but needs to be completed to show understanding of the new process learned
If student is signficantly behind in work may have conversation about dropping class and/or leveling down in class (e.g., Advanced Placement (AP) to honors to academic)
Discuss the possibility of taking a medical exception for the marking period and the other 3 marking periods will be averaged together
Student will need to know the content but won’t be graded.

Additional symptom-based supports not listed above:

Additional supports the student’s teachers should explore

Confusion, Head Feels Foggy/Fogginess

Difficulty Expressing Thoughts

Considerations:

Allow extra time for verbal responses (up to 10 seconds). Avoid ‘filling in’ words for student or completing student sentences. Allow student time to organize thoughts and ‘find’ words when speaking
Allow student to prepare in advance for response by providing question or prompt beforehand
Avoid confrontational questions. Instead provide yes/no or multiple choice question types
Provide a word (or phrase) bank for fill in the blank test questions.
Teach compensatory strategies ie descrbing the object, providing first sound cues, visualization.
Permit student to explain wrong answers on assessments Check progress and provide feedback often in the first few minutes of each assignment.
Allow student to respond verbally to test questions.
Consider Speech therapy screening/evaluation if symptoms persist for several months

Additional symptom-based supports not listed above:

Difficulty Making Decisions

Considerations:

Give clear choices to pick from as opposed to open-ended options
Check progress and provide feedback often in the first few minutes of each assignment.
Role play with the teacher through decision making steps. Use social stories.
Use direct instruction in evaluating and choosing.
Teach student self-talk strategies using a script, to help walk themselves through their decision-making process. Example, “First, I need to think about what the two options I must choose from. Second, I need to think about the possible outcomes of each decision. Then, I will choose the option that makes the most sense to me. After, I will evaluate the final decision I made and it’s outcome either immediately afterwards or in X # of days with my teacher.“
Use verbal prompts and cues.

Additional symptom-based supports not listed above:

Chart of Schoolwork That is Incomplete

	Based on What Cannot be Excused:

What work can be excused	What work cannot be excused	What work will be graded	What work will not be graded but still can be completed

Literal Thinking

Additional supports the student’s teachers should explore

Literal Thinking

Limit joking and sarcasm or explain when not understood.
Present the student with various idioms each week and discuss the literal definition versus the actual meaning. Have the student use the idiom in several sentences. Review throughout the week.
Pre-teach the main ideas/key content before classroom instruction occurs.
Teacher should observe classroom/recess/peer communication interactions for any issues. Consult with speech and language pathologist if it does not resolve.
Don’t use sarcasm or inferences when speaking to the student.
Utilize short, concise directions. Avoid use of excessive language, figurative language. For instance, her teacher should say: “Take your math book. Turn to page 54.” Her teacher should not provide instructions the following way: “Now, close your social studies book. I want you to go get your math book from your desk- no talking- and then turn to page 54. No talking- just get the book out and turn to the page.” Short and concise directions are important. Directions can be given one at a time if needed and written down.
Teacher should explain metaphors nuances and multiple meanings when used in class and in reading material.

Organization

Activity Triggers:

What is unorganized?

Desk? Locker? Cubby? Entire desk area? Planner? Forgetting to bring things to or from school or to/from class.

Additional supports the student’s teachers should explore

Organization
Difficulty organizing materials online and/or in school

A teacher should use headings for any content changes on the screen.
Discourage the student from doing online learning on a smartphone. Encourage use of laptop or computer screen (use largest screen available).
Explicit strategy instruction in how to use graphic online or hard copy organizers, and then the teacher provided (repeated) cueing to use them throughout the school day depending on classwork.
Present information in chunks.
Provide assistance with mapping out projects when needed allowing for extra time required.
Use concept mapping software – to help the student organize thoughts, get started on a writing assignment, plan a project.
Explicit instruction and demonstration regarding how to organize their desktop folders and files for online learning.
Explicit instruction and reminders to use:

Set reminder e-notifications
Electronic calendars
To do e-lists

Additional symptom-based supports not listed above:

Organization of Thoughts & Words

Environment:

Location of the student when the symptom occurs (school, home, etc.?)
What class(es) are symptoms occurring during?
Time of Day?

Activity Triggers:

What is the student doing when symptoms occur?

Triggers?

Additional supports the student’s teachers should explore

Difficulty Organizing Thoughts or Words Uses Wrong Words When Speaking

Additional symptom-based supports not listed above:

Task Planning, Initiation, Completion

Environment:

Location of the student when the symptom occurs (school, home, etc.?)
What class(es) are symptoms occurring during?
Time of Day?

Activity Triggers:

What is the student doing when symptoms occur?

Additional supports the student’s teachers should explore

Difficulty:
1) Planning 2) Initiating 3) Finishing a Task

Reminder e-notifications
Electronic calendars
To do e-lists
Goal, Plan, Do, Review strategy

Emotional Changes

Irritable
Sad
Depressed
Anxious or Nervous
Stressed
Panic Attacks
Currently Not Experiencing Emotional Symptoms

Environment:

Location of the student when the symptom occurs (school, home, etc.?)
What class(es) are symptoms occurring during?
Time of Day?

Activity Triggers:

What is the student doing when symptoms occur?

Triggers?

Additional supports the student’s teachers should explore

Emotional / Irritable / Sad / Depressed Supports/Anxious or Nervous Stressed School Supports / Panic Attacks

Organizing materials and time.
Developing small scripts of what to do and say either externally or internally when anxiety increases, and.
learning how to relax under stressful conditions.

Teach student to practice relaxation techniques such as mindfulness meditation, progressive muscle relaxation, controlled breathing, and visualization to help reduce anxiety and stress and increase feelings of relaxation and emotional well-being.
Try thought challenging, also known as cognitive restructuring, to challenge the negative thinking patterns that contribute to his anxiety and replacing them with more positive, realistic thoughts. The student’s school counselor should help with this.
Online yoga
Relaxation techniques
Apps for deep breathing such as the following:

Headspace App.
Calm App.
Rest, deep breathing, talk to parent, counselor, about different relaxation techniques.
Cognitive-behavioral techniques such as thought stopping, visual imagery and focusing on the positive and future goals.
YouTube mediation before bed: A Walk on the Beach: Guided Mediation with Lori Granger.

Long Deep Breathing.
Relax Melodies.
Breathe2relax.
Relax and Sleep Well.
I Can Relax.
Universal Breathing by Saagra.

School psychologist should screen anxiety/depression @4wks
Rest, deep breathing, talk to parent, counselor, relaxation techniques
Concussion online support groups
Peer support
Brain injury support and training for the student to gain a better understanding of concussions
Parents should explore CBT therapy options within the community for student

Additional symptom-based supports not listed above:

Behavioral or Social Changes

Restless/Fidgety
Verbal/Physical Outbursts
Impulsive/Risky Behavior/Poor Judgement
Sad/Depressed/Anxious/Panic Attacks
Changes in Relationships with Friends/Peers
Easily Frustrated, Irritable, Overwhelmed
Other Behavioral Changes Not Listed
Currently Not Experiencing Behavioral/Social Changes

Other Behavioral Changes Not Listed

Additional supports the student’s teachers should explore

Friendship Changes & Peer Social Supports

Additional symptom-based supports not listed above:

Restless/Fidgety

Students often become increasingly restless and / or fidgety with increased cognitive demand and fatigue.

Considerations:

Easily Frustrated, Irritable, Overwhelmed

Students may become frustrated and irritable with increase cognitive demands and fatigue

Student Considerations:

Build in breaks throughout the day. Provide the student a schedule for when breaks will occur. Use a timer as needed.
Provide the student with a touch – base adult (teacher, parent) who the student knows they can connect with during the day for emotional support when overwhelmed, frustrated, and irritable.
Allow student use of a “hot pass” or “cool off card” that allows student to leave class, flash the hot pass to the teacher, and go to office, guidance counselor, nurse (designated ahead of time) to cool off, if they feel a negative behavior coming on.
Periods of relaxation (deep breathing, quiet break, visualization) built into the day, cued by teacher/adult.
Relaxation techniques should be first taught, and then used by the student when he or she feels irritable or frustrated. Relaxation times should be built into the day, just as breaks are scheduled. Relaxation techniques can occur simultaneously with breaks.
Exercise as permitted by physician (e.g., walking).

Instructional Considerations:

Be aware of the student’s signs when they are starting to lose control. Be proactive in dealing with the issues BEFORE the student has a meltdown. Encourage break; provide distraction
Use time warnings and increased transition time
Present work in manageable segments.
Provide periodic checks for understanding.

Testing Considerations:

Provide a sample test (not the same problems, but same format as test) prior to exam as a study guide
Provide testing in separate room. Allow tests to be taken in an environment with fewer distractions.
Allow student extended time on tests
Allow student to take short breaks as needed during testing

Additional symptom-based supports not listed above:

Verbal/Physical Outbursts

Testing Considerations

Be aware of the student’s signs when they are starting to lose control. Be proactive in dealing with the issues BEFORE the student has a meltdown. Encourage break; provide distraction
“Hot Pass” or “Cool Down Pass” which is a card the student gets and they can leave class, flash the hot pass to the teacher, and go to office, guidance counselor, nurse (designated ahead of time) to cool off, if they feel a negative behavior coming on
Substitute teachers: Prepare the student for substitute teachers and changes to the daily schedule in advance.
For transition difficulties, provide advanced notice prior to transitions. Use a timer or give student a verbal cue that it will be time to change activities. Increase time for transitions.
Consider need for Functional Behavior Assessment to identify triggers, antecedents and consequences of behavior; and to develop effective strategies for eliminating behaviors

Additional symptom-based supports not listed above:

Impulsive/Risky Behavior; Poor Judgement

Poor sleep the night before contributes to impulsivity the next day. Parents should try to keep the student on a regular sleep schedule at night. Avoid napping as it can throw off the student’s regular circadian rhythm for sleep.

Breathing techniques can help students relax or calm down when feeling out-of-control. A simple exercise that they can do is to focus on breathing for 60 seconds. Breathe in through the nose, hold breath for 6 seconds, and then breathe out through the mouth.
Teach student to wait until others have finished talking before sharing their thought. If the student finds themself disrupting conversations, they should try silently repeating the question(s) before offering an answer. Counting to 10 prior to speaking is also an effective strategy. This can help them avoid cutting others off when they are speaking.
Use the “Stop, Think, Act strategy.” When the student or teacher notices the student acting on the first thing that pops into their mind, have the student STOP and count to 3 while they think about the possible outcomes of what they are about to do.
Consider direct instruction in social skills / problem solving / decision making. Provide real life scenarios and help student resolve the conflict with multiple solutions to build metal flexibility. Discuss consequences of choices and how to avoid negative outcomes.

Additional symptom-based supports not listed above:

Sad/Depressed/Anxious/Panic Attacks

Student Considerationss

School psychologist should screen anxiety/depression @4 weeks
School counselor/team to help student manage expectations due to the student not being able to perform academically as they did prior to the concussion.
School counselor/team to validate students’ feelings but offer solutions for support and strategies.
Assign an adult staff member as a “touch base” person who the student feels comfortable going to when emotions surge

Help student develop simple strategies to manage anxiety, such as:

Organizing materials and time.
Developing small scripts of what to do and say either externally or internally when anxiety increases, and.
learning how to relax under stressful conditions.
Teach student to practice relaxation techniques such as mindfulness meditation, progressive muscle relaxation, controlled breathing, and visualization to help reduce anxiety and stress and increase feelings of relaxation and emotional well-being.
Try thought challenging, also known as cognitive restructuring, to challenge the negative thinking patterns that contribute to anxiety and replacing them with more positive, realistic thoughts.
Exercise as permitted by physician
Brain injury support and training for the student to gain a better understanding of concussions/brain injury

Additional supports to be explored:

Online yoga
Relaxation techniques
Apps for deep breathing such as the following: Headspace, Calm.
Rest, deep breathing, talk to parent, counselor, about different relaxation techniques.
YouTube mediation before bed: A Walk on the Beach: Guided Mediation with Lori Granger.
Long Deep Breathing.
Breathe2relax.
Relax and Sleep Well.
I Can Relax.

Additional symptom-based supports not listed above:

Changes in Relationships with Friends/Peers

Student Considerations

Encourage participation in social activities that do not increase brain injury symptoms (football games, eating out, movies, sleep overs, school play, etc)
Preferential seating in cafeteria away from noise and activity – allow friends to join at this location
If student eats in a separate location than cafeteria, allow a few peers to join the student
Identify peer(s) who would be willing to walk with, eat with, sit with the student
Encourage student participation in non-contact clubs and activities offered through the school
Consider peer training offered by BrainSTEPS to educate peers regarding brain injury symptoms and recovery

Additional symptom-based supports not listed above:

General Brain Injury Considerations

All can be phased in or out fluidly based on the student’s individual needs during recovery:

School nurse should monitor student symptoms on a regular basis.
Students with brain injury often hide or ‘mask’ symptoms for a variety of reasons including denial of injury/changes in functioning; fear of ‘getting in trouble’ at school; confusion/ fear over new challenges; difficulty accepting the ‘new normal’.
Reassure student that teachers/ school personnel understand that the student has suffered a brain injury and is not ‘faking” or trying to avoid work
Show compassion and genuine concern for student’s challenges, fears and concerns

Student Considerations:

Instructional Considerations:

Testing Considerations:

Provide notes and study guides prior to testing.
Allow testing in a quiet distraction free environment ie separate room
Allow student to take short breaks during testing
Allow test to be taken in chunks. Present tests one section at a time. If student becomes symptomatic, stop testing and continue at another time.
Provide multiple choice questions, work banks versus open ended questions and fill in the blank questions to assess student’s knowledge without excess memory demands.
Allow student to respond verbally to test questions
Allow student to use scribe to answer essay type questions to reduce writing demands.
Permit open book, notes on tests/assessments.

Additional symptom-based supports not listed above:

Additional supports the student’s teachers should explore

Rigidity and inflexibility

Poor sleep the night before contributes to poor mental flexibility the next day. Parents should focus on maintaining a consistent sleep schedule for the student with no naps during the day. Naps can throw off the circadian rhythm of the student’s sleep schedule.
To improve mental flexibility, practice simple routines out of order. For example, parents can ask the student to get dressed or ready for bed in a different order. Teachers can change the order of a typical routine for the student.
Provide student teacher generated types/written classwork and homework steps for lengthy assignments. Encourage student to cross each step off as it is completed.

Send a PDF of this report to the following email(s): *

Emails should be comma separated. ([email protected], [email protected])

Additional Notes from Meeting

For Student/Family to Do:

For School to Do:

Review with School Team, Parent, & Student

Pediatric Brain Injury- Points to Remember

1. All brain injuries are serious. A concussion is also a brain injury. All concussions are serious, too.

2. Most brain injuries (90%) occur without loss of consciousness.

3. Chemical and metabolic changes occur in the brain during injury, interfering with normal brain activity.

4. The majority of concussions (70%) typically resolve within 4 weeks, but in some students, effects may last a lifetime.
Moderate to severe acquired brain injuries may result in lifelong deficits.

5. Pre-existing or underlying conditions such as prior concussions or other severities of brain injury, attention deficits,
learning disabilities, and emotional/mental health disorders can be exacerbated by concussion. These can also extend concussion recovery time.

MOVING FORWARD

1.School staff should not rely on the student to ask for the academic supports listed in this document. Often, the student will not know to ask for the academic support until they are symptomatic. The purpose of this document is to alleviate symptoms during the school day, so they do not interfere with learning.
2. Designate one teacher as the advisor/supervisor/coordinator/liaison for the student and the implementation of this BrainSTEPS plan at the school-level. This individual should review the student’s progress in using the academic supports recommended in this document in one month (or sooner). This individual should be the direct link for communication between BrainSTEPS, and the student, the parent, and the school team.
3. Teachers should report to the school team and parent if the interventions and/or accommodations listed within this report are ineffective so the team in conjunction with BrainSTEPS can re¬convene and modify the plan as needed.
4. For high school students only, if the student’s signs and symptoms of brain injury do not resolve, the student should be referred to their local county Vocational Rehabilitation office by their school team or parent. This is an important part of transition for students with disabilities, whether the student receives special education or not.
5. For high school students planning to attend college, the school counselor should apply for the College Board ACT and SAT formal academic accommodations prior to testing. This must be done well in advance of the test. The application must be completed and turned in, in time for a decision to be made by the College Board. The school should provide adequate documentation of the student’s current deficits as well as current accommodations that are in place at the high school.

For high school students only, if the student’s signs and symptoms of brain injury do not resolve, the student should be referred to their local county Vocational Rehabilitation office by their school team or parent. This is an important part of transition for students with disabilities, whether the student receives special education or not.

For high school students planning to attend college, the school counselor should apply for the College Board ACT and SAT formal academic accommodations prior to testing. This must be done well in advance of the test. The application must be completed and turned in, in time for a decision to be made by the College Board. The school should provide adequate documentation of the student’s current deficits as well as current accommodations that are in place at the high school.

Your BrainSTEPS consultant can be contacted at any point in time until your student graduates to provide brain injury-related school staff consultation and training to support your student’s needs. BrainSTEPS is here to support this student until graduation.

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Additional symptom-based supports not listed above:

Comment

Brain Injury Support Framework

Directions for BrainSTEPS Consultants Completing the BISF:

TEACHERS

Physical Changes

Headaches

Vision Issues

Dizzy or Balance Issues

Light Sensitivity

Noise Sensitivity

Vomiting/Numbness/Ringing in Ears

Fatigue and/or Sleep Issues

Thinking & Learning (Cognitive) Changes

Memory Issues

Attention and Concentration

Cognitive Fatigue, Slow Processing, Fogginess, Confusion

Slow Processing Speed Slow to respond, react, takes longer to think through things

Difficulty Planning, Organizing

School Work Takes Longer

Confusion, Head Feels Foggy/Fogginess

Difficulty Expressing Thoughts

Difficulty Making Decisions

Literal Thinking

Literal Thinking

Organization

Organization Difficulty organizing materials online and/or in school

Organization of Thoughts & Words

Difficulty Organizing Thoughts or Words Uses Wrong Words When Speaking

Task Planning, Initiation, Completion

Difficulty: 1) Planning 2) Initiating 3) Finishing a Task

Emotional Changes

Emotional / Irritable / Sad / Depressed Supports/Anxious or Nervous Stressed School Supports / Panic Attacks

Behavioral or Social Changes

Friendship Changes & Peer Social Supports

Restless/Fidgety

Easily Frustrated, Irritable, Overwhelmed

Verbal/Physical Outbursts

Impulsive/Risky Behavior; Poor Judgement

Sad/Depressed/Anxious/Panic Attacks

Changes in Relationships with Friends/Peers

General Brain Injury Considerations

Rigidity and inflexibility

Additional Notes from Meeting

Review with School Team, Parent, & Student

Pediatric Brain Injury- Points to Remember

MOVING FORWARD

Your BrainSTEPS consultant can be contacted at any point in time until your student graduates to provide brain injury-related school staff consultation and training to support your student’s needs. BrainSTEPS is here to support this student until graduation.

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Slow Processing Speed
Slow to respond, react, takes longer to think through things

Organization
Difficulty organizing materials online and/or in school

Difficulty:
1) Planning 2) Initiating 3) Finishing a Task