Internal Versus External Issues Impacting Biobehavioral States

Understand and address what is going on internally

Clipart image of child's brain.
Clipart image of child’s brain.

There are a number of reasons a child may have difficulty reaching and maintaining an alert state. Medications, chronic illness or pain, seizure disorders, and other physical conditions can place continual stress on the child. As educators we have the responsibility to understand, as much as possible, the impact of these internal issues and do what we can to limit their impact or target times when these have the least impact on the child’s functioning. For some children, not much can be done to eliminate these factors readily.

We do, however, have the power to adjust external factors that impact biobehavioral states. Assess the environment for external issues that challenges the child ability to attend and engage in learning. This might include unnecessary noise, visual clutter, lack of things and people to engage, pacing that startles or confuses. Additionally we can structure activities and learning environments that are rich with things, people, and actions that are highly preferred by the child.

Pinpoint and address external issues

Families and educators need to pinpoint external issues that may impact the child’s ability to learn.  We cannot always eliminate them totally, but if we are mindful we can certainly make changes in our behaviors and the environment to support better access to learning for these children who face such monumental challenges to learning.


Many times these children are in noisy and distracting environments. Because they are not  able or yet developmentally ready to process multiple sensory information and integrate that information, we have to enhance the information that is most accessible to them and dampen other sensory input. For example, if a child is able to use some vision, we may want to limit auditory information coming in at the same time, like a television or radio playing in the background, talking to him while he is engaged, or hearing environmental sounds nearby.

Likewise, if we are interacting with the child, our focus needs to be on him or her. When we are engaged in a learning activity with the child, do everything possible to establish a “do not disturb” policy. Utilize support staff as gatekeepers of your time and space with the child if at all possible, letting them deal with other students, people stopping into the classroom, and nonemergency situations.

Positioning and movement

We also can make sure the child is positioned optimally so that engagement with the environment and others is easier. If the task is visual are we positioning things in the child’s best field of vision? If it is auditory, can the child touch the object making the sound to locate the source? If a child is only able to explore with her mouth and head, are materials positioned there? If the child cannot move his arms away from his torso, are we locating interesting objects on his body or offering them under his hands?

Utilize information and support from your OT, PT, teachers of students who are visually impaired, deaf and hard of hearing or deafblind, orientation and mobility specialist, and others to understand positioning and movement needs for the child.

Anticipation and closure

To help the child feel as secure as possible when engaging in a learning activity, it may be helpful to associate a specific activity with a specific location and a specific object symbol. For example, eating happens in the kitchen and might be symbolized by a spoon. Hygiene activities and toileting take place in the bathroom or bedroom; playing with specific toys may happen in the family room, outside, or bedroom. Each activity should have a specific object symbol or signal associated with it to let the child know what is coming next.

When a child is bed-bound, using object symbols or touch cues to signal the start or transition to a new activity can be very helpful. For example, you might offer a familiar object from a Active Learning vest, Position Board or Mobile before placing it on or  near the child on the wall or hanging from above. Offering a towel or wash clothe before moving the child from the bed for bathing, helps them anticipate the activity, reduces their stress and allows them to participate more fully in the activity.

Though the learner may not be ready for a formal calendar system, use of an object symbol, signal, and/or touch cue before you begin an activity can help to develop anticipation of an activity and thereby reduce stress. Likewise having some type of “finished” container to signal the end of an activity may allow a child to communicate his desire to end an activity. Even if the activity is one the child finds enjoyable most of the time, there may be times when the child prefers to do something else. 

Pace and latency in response

When interacting with a child who is congenitally deafblind, ALWAYS try to slow your pace. This allows the child time to process sensory information most efficiently.

There may be multiple reasons why it takes the learner longer to process information and respond. For example, a child with cerebral palsy may need more time to organize his system to move an arm or turn her head. A child who is visually impaired by need more time to process limited or distorted visual information before they can attend. Pay attention to delays in response time and don’t rush the child. After some observation you will begin to know an approximate latency time for a child to be able to respond.

Interest and motivation

When developing activities and selecting materials for learning environments we must focus on things that interest and motivate the child to engage. We also must minimize things that create stress, are aversive, and repulse the child. Sometimes this can take a while to figure out. To learn more about how to do this go to Assessment Procedure for Students Who Are Deafblind with Additional Significant Disabilities

These children cannot handle having demands made of them, especially to participate in an activity they find boring or frightening. When they have developed better skills and more self-confidence, we can begin to encourage them to tolerate for just a bit, something or someone that they do not feel comfortable about engaging.


We need to consider these questions during our assessment:

    • Does the child have a medical disorder that can impact his/her internal state?
    • Does the child take medication to manage any medical disorder? If so, what are the side effects?
    • Does the child suffer from chronic pain? (gastrointestinal, joint/muscle, etc.)
    • Is the child currently experiencing any health related conditions that are impacting his/her internal state?
    • What sensory information can be especially distracting?
    • What position(s) allow the child to have optimum ability to process sensory information and be active?
      • in visual activities?
      • in auditory activities?
      • in movement activities?
      • in tactual activities?
      • in activities utilizing taste and smell?
    • Does the child exhibit latency in his/her response? What is a typical response time for the child?