School Re-Entry after Traumatic Brain InjuryRoger C. Peace Rehabilitation HospitalAnne Bradley, Ph.DSarah Powell, M.Ed. CCC-SLP

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Learning ObjectivesUnderstanding TBIBrain Recovery and DevelopmentReturning to SchoolIdentification and AssessmentIntervention and Classroom AccommodationsAdvocacy and Resources

Preview of Section 1: Understanding Brain InjuryAppreciate the under-reported nature of TBILearn what a brain injury isLearn how to identify the level of severity of a brain injuryBe able to generally predict the early course after injury.

Disguised as a Low Incident DisabilityEach year, an estimated 1.7 million people sustain a TBI annually. Of them: 52,000 die, 275,000 are hospitalized, and 1.365 million, nearly 80%, are treated and released from an emergency department. The number of people with TBI who are not seen in an emergency department or who receive no care is unknown.

Incidence and PrevalenceChildren aged 0 to 4 years, older adolescents aged 15 to 19 years, and adults aged 65 years and older are most likely to sustain a TBI. Almost half a million (473,947) emergency department visits for TBI are made annually by children aged 0 to 14 years. Only 200 of every 100,000 cases go to the hospital.

Definition of TBIAcquired Brain InjuryCongenital and Perinatal Brain InjuryTraumatic Brain InjuryOpen Head InjuryClosed Head Injury

Acquired Brain InjuryBrain Injury incurred after a period of normal developmentInternal causesExternal causes

Congenital and Perinatal Brain InjuryNo period of normal developmentCongenital- a condition a child is born with such as a chromosomal abnormalityPerinatal- a condition that develops around the time of birth such as a perinatal stroke

Traumatic Brain InjuryAn acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment or both, that adversely affects a childs educational performance.

Effects of Brain InjuryInjury to brain tissues at the site of damageShearing and tearing of neurons throughout the brainBleeding, swelling, and lack of oxygen to the brainPossible coma

Severity of Brain Injury

MildModerateSevere

Mild Traumatic Brain Injury: AKA Concussion - DefinitionAny period of loss of consciousnessAny loss of memory for events immediately before or after the accidentAny alternation in mental state at the time of accidentPosttraumatic amnesia is no greater than 24 hoursSigns of concussion nausea and vomiting, headache, fatigue, dizziness

Concussion: Sports related injuriesImmediate Presentation:Delayed effects:

Mild Traumatic Brain Injury:Typical Early RecoveryCommon effectsHeadachesLethargyDizzinessSensory hypersensitivitiesPoor concentrationCourseAbout 80% uncomplicated mild TBIs fully recovery by 3 months

Mild Traumatic Brain Injury: TreatmentEstimated 80% of concussions are not treatedMost often seen in the emergency room or by pediatrician and sent homeOut of school perhaps a day or two, up to a couple weeks

Moderate Traumatic Brain Injury: DefinitionComa less than 24 hours durationPost traumatic amnesia 1-24 hoursNeurological signs of brain trauma Tissue damageBleeding

Moderate Traumatic Brain Injury Typical Early RecoveryCommon effectsThose seen in Mild TBI, but of greater severity, frequency and longer durationHigher risk of focal deficitsHigher risk of motor deficitsCourseGenerally 3 to 6 monthsGreater risk of long term deficits after initial recovery

Moderate Traumatic Brain Injury: TreatmentMost often seen in the emergency room or by pediatrician and sent homeOccasionally hospitalized on an acute care medical unit for days to a couple weeksRarely receive inpatient rehabilitationMore frequently receive outpatient therapies (most often if there is a deficit in physical functioning)

Severe Traumatic Brain Injury:DefinitionComa more than 24 hoursPost Traumatic Amnesia more than 1 day

Severe Traumatic Brain Injury Typical Early RecoveryCommon effectsAttention-executive, memory deficits are commonHigh risk of focal processing deficitsHigh risk of motor deficitsCourseGenerally 6+ monthsOver a 1/3rd classified as disabled after initial recovery period

Severe Traumatic Brain Injury: TreatmentShort to very long stays in ICU/PICU/ NeuroICUsMore likely to get inpatient rehabilitation, but more frequently seen by therapists in an acute medical care settingAverage inpatient rehabilitation stays are 2 to 4 weeksThe younger they are the less likely referred to inpatient rehabilitation and the quicker they are discharged homeMost likely to be referred to outpatient therapy

Review of Section 1: Understanding Brain InjuryAppreciate the under-reported nature of TBILearn what a brain injury isLearn how to identify the level of severity of a brain injuryBe able to generally predict the early course after injury.

Preview of Section 2:Recovery and DevelopmentUnderstand what is meant by plasticityUnderstand the role of neural networksUnderstand how plasticity contributes to brain developmentUnderstand how plasticity contributes to recovery from brain injuryBe able to identify the limitations on plasticityBe able to generally predict long-term outcome after brain injury

What is Brain Plasticity?

The Brain

Neural Networks: Neurons that Play Together, Stay Together

The Interconnected Brain: Axonal Tracts

For example: Corticospinal Tract

What is Brain Plasticity:

Brain Plasticity During DevelopmentAdult Brain1 year old2 weeks old2 years old2 weeks old1 year oldAdult Brain

Brain Plasticity During Development: Productive EventsNeuron proliferation

Prenatal Proliferative zoneAcross lifespan dentate region of the hippocampus

Brain Plasticity During Development: Productive EventsMyelinationFront to back progressionSpike in production in temporal parietal lobes between 6 and 12 years oldGrowth drops off after 12 yo

Adult brain

Brain Plasticity During Development: Subtractive EventsSynaptic PruningThose neural networks that are most frequently used are preservedThose that are used left often are destroyed

Brain Plasticity During Development: Gray MatterUCLA Laboratory of NeuroimagingBrain mapping of subjects 3 through 20 years of ageTime lapse of 2 weeks to 4 yearsFound both rapid growth as well as loss of gray matter

Brain Plasticity During Development: Gray MatterUCLA Laboratory of NeuroimagingProliferation in first 18 months and at pubertyGenerally a back to front progression of pruning across childhood and adolescenceExtreme poles front to back mature first, then association areas during middle childhood, then frontal lobes during adolescenceFrom 5 to 20 years of agewarm = more volumecool = less volume

What is Brain Plasticity?

What Does Brain Injury Do?

What Does Brain Injury Do: Disruption of Neural NetworksDTI of someone with Multiple Sclerosis

What is Brain Plasticity?

Plasticity after Brain Injury:Synaptogenesis

Plasticity after Brain Injury:Reorganization

Brain Development after Pediatric Brain Injury1 year old2 weeks old2 years old2 weeks old1 year oldAdult Brain

Brain Development after Pediatric Brain InjuryCost toFuturePlasticity

Brain Development after Pediatric Brain Injury

Pediatric Brain Injury:Injury+Plasticity+Development=OutcomeCognitive Reserve CapacityBrain Reserve CapacityHow long since injury?Where in development?What parts were affected?PLASTICITYOUTCOME

Pediatric Brain Injury:Injury+Plasticity+Development=OutcomeCognitive Reserve CapacityBrain Reserve CapacityHow long since injury?Where in development?What parts were affected?PLASTICITYOUTCOME

Cognitive Reserve CapacityBrain Reserve CapacityHow long since injury?Where in development?What parts were affected?PLASTICITYOUTCOMEPediatric Brain Injury:Injury+Plasticity+Development=Outcome

Cognitive Reserve CapacityBrain Reserve CapacityHow long since injury?Where in development?What parts were affected?PLASTICITYOUTCOMEPediatric Brain Injury:Injury+Plasticity+Development=Outcome

Cognitive Reserve CapacityBrain Reserve CapacityPediatric Brain Injury:Injury+Plasticity+Development=OutcomeHow long since injury?Where in development?

Cognitive Reserve CapacityBrain Reserve CapacityPediatric Brain Injury:Injury+Plasticity+Development=OutcomeHow long since injury?Where in development?What parts were affected?

Cognitive Reserve CapacityBrain Reserve CapacityHow long since injury?Where in development?What parts were affected?PLASTICITYOUTCOMEPediatric Brain Injury:Injury+Plasticity+Development=Outcome

Cognitive Reserve CapacityBrain Reserve CapacityHow long since injury?Where in development?What parts were affected?PLASTICITYOUTCOMEPediatric Brain Injury:Injury+Plasticity+Development=Outcome

Review of Section 2:Recovery and DevelopmentUnderstand what is meant by plasticityUnderstand the role of neural networksUnderstand how plasticity contributes to brain developmentUnderstand how plasticity contributes to recovery from brain injuryBe able to identify the limitations on plasticityBe able to generally predict long-term outcome after brain injury

Case Example: Jerry

Preview of Section 3: Returning to SchoolIdentify what actions need to be take to facilitate school re-entry after brain injuryIdentify common physical and cognitive sequelae of brain injury.Assess issues that distinguish TBI from other diagnoses.Identify means by which the students needs can be assessed.

The Process of School Re-entry:Who, When and How?

The Process of School Re-entry:Who

The Process of School Re-entry:When

The Process of School Re-entry:Moderate to Severe Brain Injury - HowMedical StaffFamiliesIdentify a family and medical contact person to receive and provide informationFocus on the provision of medical careIntegrate the family into the patients careEducational StaffParticipate in their childs medical careMake their wishes known regarding visits and other contacts

The Process of School Re-entry:Moderate to Severe Brain InjuryMedical StaffIdentify a school contact personProvide updates on progress and needsProvide information needed for the school to evaluate the students needs and form a reasonable school re-entry planEducate family and school staff

The Process of School Re-entry:Moderate to Severe Brain InjuryEducational StaffRequest updates from medical contact personIdentify appropriate members of school re-entry teamShare information about students prior achievement and behavior with medical contact personEducate medical staff regarding local education resources and proceduresUpdate others as needed

The Process of School Re-entry:Moderate to Severe Brain InjuryFamilyConsent to allow communication between school and medical staffFacilitate contact between appropriate staff membersParticipate in education provided by medical staffMake wishes known regarding support needs

The Process of School Re-entry:Moderate to Severe Brain InjuryMedical StaffInform family and school of discharge dateProvide discharge summariesProvide summaries of treatment and recommendationsComplete appropriate paperwork to support recommendations (e.g., homebound, therapies at school, Early Childhood referral)Maintain ongoing collaboration with schools as proceeds through outpatient therapies

The Process of School Re-entry:Moderate to Severe Brain InjuryEducational StaffEducate family about homebound, Section 504, and/or special education processRefer for special education services if appropriateObtain medical recordsArrange for staff education (dont forget homebound teachers)Meet to determine if more evaluation is needed, and/or what is the appropriate immediate school plan for re-entryMaintain ongoing collaboration with outpatient therapies

The Process of School Re-entry:Moderate to Severe Brain InjuryFamilyParticipate in the school re-entry planning process on the medical and educational system sidesMake needs known regarding tolerance of riskMake preferences known regarding priorities for the current school yearMaintain close communication with outpatient therapies and school regarding their childs functioning

The Process of School Re-entry:Mild Brain InjuryMedical StaffFamiliesIdentify a family and medical contact person to receive and provide information?Educational StaffPursue appropriate medical care for their child

The Process of School Re-entry:Mild Brain InjuryMedical StaffProvide summary of findings and recommendationsComplete the necessary paperwork for referral for educational servicesConsider referring for therapies and/or follow-up neuropsychological evaluationIf referred for ongoing therapies, identify contact person and maintain collaborative relationship with school

The Process of School Re-entry:Mild Brain InjuryEducational StaffObtain medical recordsEducate family about homebound, Section 504, and/or special education processConsider homebound services versus part-time in-class attendanceAssess for Section 504 versus Special Education servicesArrange for staff education (dont forget homebound teachers)Plan to re-assess in 1-2 monthsMaintain collaborative relationship with outpatient therapies if available

The Process of School Re-entry:Mild Brain InjuryFamilyParticipate in the school re-entry planning process on the medical and educational system sidesMake needs known regarding tolerance of riskMake preferences known regarding priorities for the current school yearMaintain close communication with outpatient therapies and school regarding their childs functioning

TBI StudentsIdentificationAssessment/EvaluationIntervention

Which student has a TBI?Can you tell?

Common Problems of Students with TBIAnticipating these difficulties can facilitate successful re-entry to school

Problems can be physical/medical, cognitive, sensory, motor, social, emotional, and behavioral

Physical/Medical ProblemsProblemsSeizuresFatigueHeadachesSwallowing/EatingSelf-care activitiesMedication issues

Most Common Physical Deficits:Physical EnduranceMental EnduranceHeadaches

Motor ProblemsApraxiaAtaxiaCoordination problemsParesis or paralysisOrthopedic problems

SpasticityBalance problemsImpaired speed of movement

Most Common Motor Problems:BalanceFine Motor DexterityMotor Speed

Sensory/Perceptual ProblemsVisual deficitsfield cutstracking (moving and stationary objects)spatial relationshipsdouble vision (diplopia)Neglect / InattentionAuditory sensory changesTactile sensory changes

Most Common Sensory/Perceptual Issues:OVERSTIMULATION!Double VisionNeglect / InattentionHypersensitivities

Cognitive-Communication ProblemsExecutive functions MemoryAttentionConcentrationInformation processingSequencing

Problem solvingComprehension of abstract languageWord retrievalExpressive language organizationPragmatics

Most Common Cognitive-Communication Deficits:Slowed Processing SpeedIntolerance of ComplexityAttentionMemory

Emotional & Behavioral ProblemsIrritabilityImpulsivityDisinhibitionPerseverationEmotional LabilityInsensitivity to social cuesLow frustration tolerance

AnxietyWithdrawalEgocentricityDenial of deficit/lack of insightDepressionPeer conflictSexuality concernsHigh risk behavior

Most Common Emotional-Behavioral Problems:Fragile Emotional ControlPoor AwarenessImpulsivityJust dont get it

4 Facts about IdentificationEach student will vary greatly, no 2 will be alikeChanges are unlikely to disappear fully over timeNegative consequences may not be seen immediately but emerge when developmental demands reveal problemsAn injured brain is less likely to meet the increasingly complex tasks all children face as they get older

Misclassified or Missed AltogetherPoor transitional services between hospitals and schoolsTiming of injuryMild TBI slips thru the cracksTraditional approaches to assessment fail to provide necessary insight into how cognitive deficits impact schoolSpecial Ed for TBI vs. LD vs. ED looks differentDeficits are not always immediately apparent

How is TBI different from LD?TBI is not just a learning disabilityStudents with TBI cannot be dealt with as if they have something similarAlthough similar, the differences are importantThe impairments are different, as are the implications for educators

TBI: How is it Different?

TBILDEDOnset and CauseSudden with blow to head and loss of consciousnessEarly/ unclearSlow/ unclearFunctionalChangeMarked contrast between pre and post onsetNo before-after contrastsChanges emerge slowlyPhysical DisabilitiesLoss of balance, weakness, paralysisPoor coordinationUnlikelyBehaviorAgitation, impulsive, restlessness, disinhibitedRestlessness, impulsiveVariableEmotionsLabile, depression, anxiousProne to outburstsReactions due to distortions of realityAcademic DeficitsBased on disrupted cognitionBased on type of learning disabilityNot based on impaired cognitionDifficulties with LearningOld info easier to recall than new infoNew learning can be linked with old learningNew learning can be linked with old learning

Information to Determine NeedsObtain all medical information you canInformation about areas of functioningCognition and memorySpeech and language; communicationSensory and perceptual abilitiesMotor abilitiesPsychosocial impairmentsPhysical functions/safetyAcademic skills

Challenges to Evaluation: Student FactorsRapidly changing skills (especially during first 6-12 months) Communication, physical, sensory, motor, emotional, and behavioral difficulties may interfere with assessmentUneven skill profile (some higher skills preserved with lower skills lost)Performance influenced by state and situationProblems may emerge later

Other Challenges to EvaluationThe family is probably in distressInitial assessment is probably conducted outside school in a setting unlike the classroomMuch assessment information is needed from other professionals (who are busy)Medical reports may be difficult to interpretAssessment requires IEP team coordination and planning

What can be done to address these challenges?Use classroom data to guide instructionUse observation, curriculum-based measures, work samples, trial teachingAssess across content, time, settingsInvite parents to provide informationAsk medical personnel for assistancePlan team evaluationsShare information

Cognitive Assessmentis the student?Processing SpeedAccurate but slow? MemoryRetaining new info from day to day?Benefiting from context?Benefiting from repetition?Executive FunctionPrioritizing? Following through? Staying organized? Using problem solving strategies?Shifting from 1 task to another?AttentionAble to concentrate? Hold onto information?Attending to more than 1 thing at a time?Accurate when carrying out complex tasks?

How can I gather more info?Record review (school and medical)Direct observation (school or hospital)Student interview (if possible)Teachers/service provider interviewsCriterion-referenced assessmentCurriculum-based assessmentRating scales and checklistsNeuropsychological assessment (if available)Identify cognitive strengths and weaknesses

Review of Section 3: Returning to SchoolIdentify what actions need to be take to facilitate school re-entry after brain injuryIdentify common physical and cognitive sequelae of brain injury.Assess issues that distinguish TBI from other diagnoses.Identify means by which the students needs can be assessed.

Preview of Section 4:Interventions for Students with TBIIdentify the domains in which you can intervene.Identify how common physical, cognitive and emotional/behavioral sequelae are expressed in the classroom.Identify several avenues of intervening to address the impact of sequelae on the students ability to benefit from the educational environment.

Intervention Environment (space and time)Instruction and materialsSchool staffPeersStudentFamily

Most Common Physical Deficits:Physical EnduranceMental EnduranceHeadaches

Endurance:WhiningLow frustration toleranceConflict with peersShuts down at certain times of the dayMore likely argumentativeSlows downThe slow blink

Physical Endurance

EnvironmentReduce the distance between classes, provide extra materials, 2 lockers in different areas, adjust shelves, provide comfortable seatingInstruction/materialsOffer breaks between activities, provide rest periods, late arrival, early dismissal, adaptive PESchool staffAssign adult to assist with transitions, be sure staff understand safety issues, coordinate demands across classesPeersAssign peers to help carry materials, even pick up dropped materials/booksStudentNeeds to understand his/her limitations, stop activity when limits are reached, report to teacher when tired. FamilyEducate on importance of sleep and routine, adjust medications if need be

Mental Endurance

EnvironmentPreferential seating, fewer transitions, less core academic classes, shorten school day, part time or homebound instructionInstruction/materialsSlow the pace of instruction, reduce the components, provide repetition, provide outlines and class notes, chunk information into ideas, watch for frustrationSchool staffCheck on other class demands, identify patterns of fatigue or inattention, offer breaksPeersAssign a peer note takerStudentTake rest breaks before fatigue starts, eat healthy snacks, exercise, speak up if tiredFamilyEducate on importance of sleep and routine, adjust medications if need be

HeadachesVague complaintsMost often able to be more specific, but may under or overgeneralize effectIncrease with mental/physical exertion

Physical Signs of Severe Pain:PallorSweatingShallow breathingElevated pulseDilated pupilsSensory hypersenstivitiesPreoccupationLethargy

Headaches

EnvironmentAllow student to leave and go to comfortable place to lay down in quiet and darkness; limit noise in classroomInstruction/materialsBreak components down, slow pace of instruction,Provide rest breaks, use intermittent teaching to avoid exacerbation School staffEducate other staffPeersEducationStudentEncourage student to speak up at first sign of headacheFamilyExplore medications, consult with family or rehab doctor

Most Common Motor Problems:BalanceFine Motor DexterityMotor Speed

BalanceHigher rate of fallsClumsy, bumps into things, tripsSlow and extra careful/fearfulDynamic balance issuesMulti-tasking while walkingWorse when tiredWhen burdened

Balance

EnvironmentKeep transitions to a minimum, teachers change class rather than student, provide assistance in cafeteria or in bathroomInstruction/materialsAdapt physical education requirements, provide adaptive equipment when neededSchool staffMonitor safety in an unstructured or crowded settingPeersBe aware of students needs, no pushing or running in hallsStudentLeave plenty of time between classes to walk, do not carry too much, hold hand railsFamilyConsult with family on strategies used at home

Fine motor dexteritySlow and laboriousPropping elbow, bearing downSloppy workHard time with separating zippers and buttonsIllegible written workDifficulty completing written work in a timely mannerLecture notes sketchy, incomplete

Fine Motor Dexerity

EnvironmentAllow student to use computer, consult with OT on adaptive equipmentInstruction/materialsChunk work into manageable pieces, reduce expectations for written work, assign a scribe, utilize tap recorder; time extensions when neededSchool staffCoordinate strategies across classes; provide set up in cafeteriaPeersCan offer to take notesStudentAllow student to report verballyFamilyOT and PT referrals, medication options

Motor speedCould you be any slower?Always the last oneSlowed reaction times

Motor Speed

EnvironmentHave students leave class early to afford more time and less congestion in hallways, consider desk placement, watch for rugs, etc, clear pathwaysInstruction/materialsConsider a second set of books at homeSchool staffNotify staff of students deficits and allow for extra timePeersTeach peers no rough housing, to be careful on playgroundStudentTeach student to keep hands free in case of balance problems, take their time, FamilyAllow extra time for morning and homework routines

Most Common Sensory/Perceptual Issues:OVERSTIMULATION!Double VisionNeglect / InattentionHypersensitivities

Overstimulation:The Butterfly EffectWide-eyed apprehension0verexcitableIf escalate, leads to tantrumsQuiet disorganization, omissions, errorsShut down and shut outIRRITABILITY to argumentativeness to agitation

OVERSTIMULATION

EnvironmentLimit distractions and noise, decrease clutter, help organize students notebookInstruction/materialsUse small group instruction whenever possible, watch for signs of decreased frustration tolerance, provide routine and scheduleSchool staffRecognize early signs of overstimulation and have plan in place in case of escalationPeersEducate peers on noise level, consider other students needs/deficits, educate on signs of overstimulationStudentEncourage student to take rest breaks before getting over stimulatedFamilyExplore medications

Double VisionHolding materials up to one eyeHead hovering over materialsPoor hand-eye coordinationMay or may not wear eye patch as prescribedOverreachingWorn outlead with one eye

Double Vision

EnvironmentPreferential placement near the board / in uncovered eyes field of vision.Clear path to desk. Early dismissal to transition to next classInstruction/materialsOral presentation and demonstration of mastery until addressed. Visually simplified materials.School staffEncourage student to take rest breaks. Provide peer and/or lecture notes.PeersProvide a peer to take notes and/or review for accuracy.StudentConsult occupational therapy regarding possible use of a eye-patch.FamilyEncourage referral to neuro-ophthalmology consultation.

Inattention / NeglectLoses things /takes a long time to find thingsComplains that others move thingsRuns into things on the left Miss information when reading!! Miss information from the left side of the classroomCant follow scantronsMix up math signsLose track of organization of math problems

Neglect/Inattention

EnvironmentProvide preferential seating, position the student toward the left side of room or best visibility, audio record materialsInstruction/materialsUse cut outs or overlays, highlight margins, dark lined paper, anchor on page for student to look to, provide extra written copies of materials, use large printSchool staffInform all staff of students needs, ensure appropriate supervision for safetyPeersTeach peers to cue student to look leftStudentAdjust placement of materials, respond to cues by nodding head, monitor comprehension, read out loudFamilyAsk the family what strategies are used at home that can be generalized to the classroom

Sensory HypersensitivitiesVague complaints about aches and painsRubs eyes, covers ears, wincesLashes out at energetic peersDislikes being touchedStartles at loud noisesShuts downcomplains about too bright too loud too much

Hypersensitivites

EnvironmentConsider more natural types of lighting rather than artificial lighting, use dim lighting, quiet environmentInstruction/materialsPreferential seating, trial of colored lensesSchool staffConsider alternative placementPeersEducate peers on students deficits and needsStudentRating scales of strategy usefulnessFamilyConsider audiological evaluation

Most Common Cognitive-Communication Deficits:Slowed Processing SpeedAttentionIntolerance of ComplexityMemoryReasoning and Problem-solving

Slowed ProcessingLooks impulsive: needs more time than giving selfDazed/overwhelmed look

Huh?Misses information, you wonder about attentionDoes really well 1:1, but overwhelmed in the classroomHomework looks good, but timed tests are poorDoesnt produce information on the spot

Slow Processing Speed

EnvironmentReduce distractions, create opportunities for students to work in small groups, position student for optimal learningInstruction/materialsGive smaller segments of information, allow extra time for processing, emphasize and repeat key points, pair visual info with verbal instruction, model what your expectationsSchool staffEducate others on students deficits, get students attention first before trying to provide instructions, allow extra time for responsePeersEducate others on students deficits, get students attention first before trying to provide instructions, allow extra time for responseStudentTeach student to clarify information, monitor comprehension, ask questions or give a signal when he/she doesnt understand, watch others, examine sampleFamilyEducate others on students deficits, get students attention first before trying to provide instructions, allow extra time for response

AttentionShort attention spanDistractibleForgetful, loses thingsWatch Where Youre Going!COMPLEX ATTENTION !Managing the complexities of a day to day, and long-term scheduleThing needed at school is at home, thing needed at home is at schoolForgets things outside of routine

Attention

EnvironmentReduce factors that interfere with the students ability to attend (noise, light), provide preferential seating in the classroomInstruction/materialsMatch the students abilities to attend; Plan activities that dont exceed the students attention span; Break tasks into smaller partsSchool staffBe sure student understands instructions, identify factors that facilitate/interfere with attentionPeersEducate peers on attention types and strategies; have them limit distractions and interruptionsStudentUse a timer to focus attention for a specific period of time, monitor attention to task, complete a pre-determined amount of work and then take a break; have student clarify informationFamilyDiscover students interests, encourage good study habits

Complex attention

Intolerance of ComplexityRelies fairly heavily on routinesFocuses on the detailsDisorganized workHave more difficulty when:Out of routine (novelty)Lots of information at onceHas not mastered or is not provided over-arching organizationHigher level of abstraction/integration

Intolerance of Complexity

EnvironmentAdhering to routinesInstruction/materialsBreak material down into smaller components, provide student with outline, provide student with pre-instruction, given written materials, monitor students comprehension of materials, alternate complex lessons with more simple materialSchool staffKeep a routine, help student anticipate and know what to expectPeersConsider asking peer to take notesStudentAsk for clarification, ask for rest breaks, consider using study strategies or alternative ways to organize/study, teach time managementFamilyConsider a tutor

MemoryInconsistent performanceClingy to teacherVigilant to what peers are doingGets it in the classroom with its extra cues, but not when on ownStudies the material to mastery, then bombs the testDefensive or flippant

Memory

EnvironmentConsistent routines, sequences, and schedules; use visual aids, create environment that doesnt rely on memoryInstruction/materialsChunk work into manageable pieces, highlight important information, provide rehearsal and practice, use written instruction, provide prompts and cues, mnemonic devicesSchool staffUse repetition and consistency, create assignment sheet that all teachers can usePeersBuddy system, peer note takerStudentUse planners, external memory strategies, keep routines, generate their own memory cues, keep journals; teach compensatory strategies; awareness trainingFamilyGeneralize strategies from home to school and vice versa

Reasoning and Problem-solvingFollows scripts doggedlyTend to acquire rote academics wellStruggle with applicationAcquires the concrete facts and skills, but struggles with inferring and integrating information Tends to run into the same problems repeatedly, depending on others to generate solutions Relationships tend to wax and wane

Reasoning/Problem Solving

EnvironmentReduce unnecessary frustrations or problems, be sure there are enough materials for everyone, provide visual cuesInstruction/materialsUse clear instructions, expectations should be clear, include samples, explain format/structure, maintain consistency and routineSchool staffProvide adequate supervision, be aware of students limitations, provide cues, help student identify a problem solving approachPeersBe aware of the strengths and needs of the student, seek adult assistance when dealing with an issue, use a problem solving model/approachStudentStop and think, Seek adult assistance, be aware of environmental cues, listen FamilyWhat strategies work at home, be consistent

Most Common Emotional-Behavioral Problems:Fragile Emotional ControlImpulsivityPoor AwarenessPoor Social Judgment and Pragmatics

Fragile Emotional ControlMore frequent tantrumsEmotional meltdownsEasily triggered temperNot responsive to reasoning and less responsive to soothing when escalatedDramatic reactions versus flat mood

Fragile Emotional Control

EnvironmentIdentify a quiet, safe place that all staff know about and use to help student de-escalate.Evaluate environmental antecedantsInstruction/materialsEnsure expectations are matched to the students instructional level.Once completes a difficult activity, allow a break. School staffKeep your voice firm, calm, low toned and SLOW.Talk as little as possible. Avoid attempts at reasoning, demands for articulate responses, or talking to soothe.Do not approach the student until de-escalates.PeersTeach early signs of agitation and appropriate response.Enforce intolerance of intentional provocation.StudentTeach routine of behaviors and consequences.Teach self-soothing strategies and reinforce use.Reward positive behavior, particularly ability to tolerate frustrations and disappointments.FamilyAssess external events that may be having an impact on well-being. Collaborate on carry through at home.

ImpulsivityResponds to every single thingImpulsive aggression and affectionBlurt out now, regret laterGets in more trouble during transitions between or during unstructured activitiesSloppy errorsProcesses it all out hereReduced control over behavior when emotional

Impulsivity

EnvironmentStructure, structure, structureUncluttered immediate area.Instruction/materialsModify materials to increase structure, completing one task before moving on to the next.School staffCollaborate on consistent responses to impulsivity, environmental modifications and expectations.PeersLimit access to peers who trigger impulses.Enforce intolerance of intentional provocation.StudentDirect instruction in delaying responses and reinforce use of this strategy across all staff. FamilyCollaborate on consistent responses to impulsivity, environmental modifications and expectations.

Poor AwarenessEverybodys so mean.Repeats the same mistakes over and over and over again

Completely misses the fact that there is a problem in what theyre doingMisattribution of the cause of difficultyDoesnt anticipate what should be doing because of the problem

Awareness

EnvironmentStructure activities so that they provide immediate feedback.Instruction/materialsProvide self monitoring tools, rating scales, point out strengths and weaknesses, consider providing direct instruction using an awareness modelSchool staffEducatethis is an issue, not an attitude. Learn what is TBI versus adolescentsPeersHelp facilitate peer feedbackStudentTeach student to use self management strategies, rating task completion/successFamilyBe consistent

Poor Social Judgment Do okay if rely on structured games and routines for social interactionsNeed to be explicitly taught the rules of social behaviorRely on social rules rigidlyBlurt out now. Regret? What regret?Cant perceive and integrate multilayered social communicationDont know where the line is

Social Judgment and Pragmatics

EnvironmentInclude structured, adult supervised social activities at lunch or recess, Provide supervision to prevent altercationsInstruction/materialsInclude direct teaching of social skills, include a social skills model, provide opportunities for practicing role playing, consider videotapingSchool staffMake sure staff are aware of students limitations, provide consistent feedbackPeersTeach peers to understand the difficulties of the student, show respect for others and be considerate, ask for adult help if neededStudentPay attention to social cues, be aware of strengths and weaknesses, identify social rules in specific environments, consider others perspectivesFamilyProvide feedback to student, generalize strategies

Review of Section 4:Interventions for Students with TBIIdentify the domains in which you can intervene.Identify how common physical, cognitive and emotional/behavioral sequelae are expressed in the classroom.Identify several avenues of intervening to address the impact of sequelae on the students ability to benefit from the educational environment.

Case example: JerryWhat are the physical, motor, sensory, cognitive, and emotional-behavioral issues likely to impede Jerrys functioning in the school environment?What are likely to be the 3 most important issues impeding functioning?What are some ideas for how to address these needs?

The Lost KidsIf so many children have brain injuries, why cant we find them in the schools?

Preview of Section 5:Advocacy and ResourcesBe able to define advocacyBe able to identify barriers to advocacyBe able to identify what you can do to advocate for the students in your class with brain injury.Be able to identify strategies to empower parents to advocate for themselves and their child.Identify resources for deepening your understanding of brain injuryIdentify resources for expanding your skills in facilitating school re-entry after brain injury.

Advocacy what is it?"Advocacy" can mean many things, but in general, it refers to taking action. Advocacy simply involves speaking and acting on behalf of yourself or others.

Barriers to AdvocacyAttitudeLimited trainingInexperienceFundingShortage of programs

What can you do?Understand and watch for signs and symptoms of brain injuryRecognize when to refer and who to refer toObtain medical/educational recordsExplore accommodations and interventions with input from other professionalsEducate school staff and auxiliary staffEducate student and his/her peers

Advocacy Cont.Consult with school psychologist or guidance counselorConsider altering your expectations of how this student can best learnConsider different teaching stylesAlternative placement, homebound servicesThink about transition services

Advocacy Cont.Follow up!Dont assume someone will do itConsider your own continuing education

TalkingHelps change peoples attitudesKeeps everyone on the same pageProvides educationFlushes out myths versus factsProvides opportunities for brainstormingAllows for sharing and giving examplesGives a chance to say thank you!

Advocacy and ParentsCommunicate with family regularlySet expectations for family as a member of the teamRemember, when looking for an advocate, many parents overlook the most obvious place the school Keep in mind.they dont speak your languageIEP, 504, eval

ParentsI need to be careful how I say thisits almost like it wouldve been better if the injury were severe enough that we wouldve had to have gotten help. With TBI, the moderate to mild, its invisible. People dont see it and then people dont get the help they need.~Parent

Advocacy ResourcesBrain Injury Partners~Navigating the School Systemwww.freebraininjurypartners.com http://adult.braininjurypartners.comParents and Educators as Partners~Lash and AssociatesTBI toolkit for families~www.aasa.dshs.wa.gov/Library/tbitoolkit.pdf

Resources, Who can You call?FamilySchool PsychologistResource TeacherGuidance CounselorSpeech TherapistNeuropsychologistHospital Case ManagerPeers and Friends

Educator Resourcesat your fingertipsEducating Educators about ABIwww.abieducation.comBIA NY Learnetwww.projectlearnet.orgBrainlinewww.brainline.orgProject BRAINhttp://www.tndisability.orgBrain Injury Navigatorwww.binav.orgTBI Educatorwww.tbied.org

In the LibraryAn Educators Manual: What Educators Need to Know about Students with BrainRon Savage and Gary WolcottBrainSTARS: Brain Injury: Strategies for Teams and Re-Education for StudentsJeanne Dise Lewis, Margaret Lohr Calvery, and Hal LewisParents as Educators and PartnersMarilyn Lash and Bob CluettMaking the IEP Process Work for Students with TBIAnn Glang, McKay Moore Sohlberg, and Bonnis TodisSigns and Strategies for Educating Students with Brain InjuriesMarilyn Lash, Gary Wolcott, and Sue Pearson

Review of Section 5:Advocacy and ResourcesBe able to define advocacyBe able to identify barriers to advocacyBe able to identify what you can do to advocate for the students in your class with brain injury.Be able to identify strategies to empower parents to advocate for themselves and their child.Identify resources for deepening your understanding of brain injuryIdentify resources for expanding your skills in facilitating school re-entry after brain injury.

In Conclusion, ProvideAn ear to listenA safe environmentClear structure and routineConsistencyImmediate feedback and praiseReinforcementCueing and modeling

***************Typical early course****Medical contact?FamilySchoolexperience*****See the reduction in gray matter volume

Warm colors is greatest volumeCool colors less volume

More pruning over time becomes a refined system***See the reduction in gray matter volume

Warm colors is greatest volumeCool colors less volume

More pruning over time becomes a refined system

NOW we know that brain development is a process of production and refining of connections based upon genetically determined substrate that is optimally ***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

***Interdependent

And it will adapt. To whatever extreme environment it finds itself in

**NOTE1st talk about the steps that the school, medical staff and family can follow to help plan for successful reentry to school.

Late well cover the content of what information youll need to gather and share when we get into identification, assessment and intervention,

but now that you know the basics of the timeline of recovery from brain injury, lets talk about what needs to happen during that process

*NOTE2 things to note here

The family is the center. Research on brain injury rehabilitation (and expression of skills to functional deficits)In climate of dwindling state and healthcare resources (time and funding reductions = less outreach, if you cant bill it = dont do it or youre doing it on your own time, less training in specific areas and peds rehab is by no means lucrative, dwindling lengths of stay)Families are the one constant in all of these spheresThe relative contribution of each area changes drastically over the recovery periodFor example: When the student is in the hospital the medical facility takes responsibility for determining the students needs and services and for providing information.over time, as the student becomes medically stable and begins to recover, the school staff begins to plan to meet the needs of the student in school. Although it is the responsibility of the school staff and family to determine the needs and program of the student in school, this is best accomplished in partnership with the medical team that has cared for the student.The family of the student is closely involved in both the medical care and school planning throughout the students recovery and return to school. The childs ability to contribute to the process increases as gains functioning.

**Responsibilities shift over time:

There are three stages of planning for a students re-entry to school:the time of injurywhile the student is in a medical facilityprior to discharge from the medical facilityFamily, Medical staff and school staff have important roles during each of these stages.There are strategies that all three can implement to ease the students transition back to school.

**

At the time of injuryMedical staff: Primary focus is the preservation of life and then, later, the preservation of functionIf in a pediatric setting, most often the family is integrated into care (what does this mean: Patient and Family Centered Care)If in an adult setting (and this is VERY common), family is seen as more peripheral, contact is more incidental, and more often initiated by the family.

School staff:STRESS If the injury is serious, this will likely be a time of significant stress for the family. At this time, the primary role of the contact person is to be supportive of the family.

It is critical to establish a school contact person. This could be the principal, the students teacher, a social worker, a nurse, a psychologist, director of special education, or special ed coordinator. Families are overwhelmed, they may not need to have a ton of visitors, and there are going to be a lot of rumors, need one source of informationIf the student has siblings at the school, be sure their needs are being met. Siblings may have limited help with homework at this time, may be highly emotional, or may not even be attending school. The school contact person can be sure siblings teachers are informed about the injury to a family member and the need for support.Initially it may be important to the family to have the school contact person be someone with whom they are already familiar (such as the classroom teacher or principal) but It is important that school staff members who will be involved with the child upon school re-entry know who the school contact person is.The school contact person needs to keep school staff members informed on a need to know basis.

Families:Wed all like families to be involved and helpful and rational and collaborative, but most often at this stage they are primary exhausted and irrational and overwhelmed.Its helpful to give them structure and direction. heres what we need from youAt this point, going to be low demand: after the initial crisis has passed: heres what I can do for you and what do you need in order to set your mind at rest re: school for patient and for the childs siblings go and advocate for what you can.

Who in participants districts is the typical contact with medical facilities? (It will vary from district to district. Wherever possible, it is desirable to have the school nurse involved.)

**The process intensifies as the child begins to recover. The focus of medical treatment moves from survival to preservation of function what will they be able to do and what do they need to do it.

Medical staffIn the best of all possible worlds, youd have a specialized brain injury pediatric rehabilitation team with sufficient knowledge of brain injury and the school system, and a willingness to reach out and give you the information and education you need.Since that is so rare, The purpose in discussing what medical facilities can do to assist in re-entry planning is to help school professionals know what to expect and/or ask for from the medical facility. (Schools cannot dictate what medical facilities do, and vice versa.) In some instances, many supports might be available from the medical setting if they are ASKED FOR.Medical facilities vary significantly in their procedures regarding school re-entry planning. Some initiate contacts with schools, facilitate information sharing, and are active participants in school re-entry planning. Other facilities have fewer resources available or less structured procedures for assisting in the school re-entry process.

Strategies that some medical facilities use to facilitate the students successful school re-entry include:designating a contact person. It is helpful for school staff to have one person in the medical facility to contact for information. This reduces confusion and misinformation. School staff should ask who the contact person is.sharing information. Most rehab hospitals have regularly scheduled (often weekly) meetings in which patient progress is reviewed. These meetings are often called case conferences or staffings. Information from these meetings can be helpful to school personnel. Many of these children will have access to therapies (most commonly PT), with a release of information, if you do not have a contact person, you can talk directly to those providing care.in-service training. Some hospitals and rehabilitation facilities do in-service training for school personnel or are willing to incorporate a school staff person in the training that they are providing to family

**At this point, the focus is on preparing for the transition out of the hospital and into the community, including into the school.

This is where the direct exchange of information becomes important.

Rehab facilities find transcripts, state testing, discipline records, Section 504 plans, IEPs and psychoeducational evals helpful. If has been involved in PT, OT, and SLP summaries of treatment are also helpful. attempting to tease apart brain injury versus premorbid contributions to current status

The contact person may want to obtain the information shared at regular hospital case conferences. Hospitals can provide history and physical, discharge summaries, therapy notes.

If hospitals are involved in providing information and recommendations, give them the tools they need to participate

Plan for discharge: identify team. Begin search for homebound teacher if that is deemed appropriate. Refer for evaluation for special education services if this is appropriate.

IN CASE SOMEONE ASKSDesignation of the school contact person is considered recommended practice, but it is not required by state or federal law. The contact persons role differs from that of the case manager, which will be discussed on slide 26 in this module.

**NOTE The school contact person can facilitate exchange of information between the hospital and school. The hospital may request school records and the school will want to obtain hospital records. Release of information forms need to be signed for such records by the students parent or guardian.

Keep encouraging the family to participate in medical care and school planning AS THEY ARE ABLE this varies widely.**The strategies listed on this slide are ones that a medical facility can implement as the student nears discharge from the hospital.Because medical facilities vary in procedures, school staff may need to initiate contact with the medical facility. The school may need to be active in seeking out information (such as the tentative discharge date) or reports (such as the discharge summary). Dont wait for the medical facility to contact the school.

Once outpatient therapies identified: repeat the above process. Hopefully, the outpatient therapists have been updated in terms of treatment and school re-entry planning, but I wouldnt count on it.

ASK What experiences have participants had with medical facilities? How did the facilities assist in planning the students transition from hospital to school?

IN CASE SOMEONE ASKSRemind participants that these strategies represent the types of activities SOME medical facilities use to ease the childs transition from the hospital to school. It is important for educators to know about what might be available to the school from the hospital.

**

Focus is on finalizing preparations.

Giving staff and the family the tools they need to participate in the school planning and carrying out the school planMake sure have all the information you need, guided by the tentative school plan: full integration? Homebound? Section 504? IEP? Need more evaluation?

It is legally required for the school to inform the parents in advance if a referral is being made and to begin educating the parents about special education services. It is also required that parents be informed of their rights and available services.

As mentioned earlier, it is critical that special education administration be informed of the students status and possible needs.

Also at this time it may be appropriate to plan staff training about TBI.

**As the family leaves the medical setting, the responsibility for coordinating care shifts primarily to them.

They need the toolsThey need to know what is going on.They need help weighing the pros and cons of the patients and family competing needs with the resources the school system can bring to bear.Informing therapy and schools regarding what they are seeing at home is crucial (youll see why when we start talking about behavior, medical issues like endurance)**Mild brain injury is a much different process:

Remember 80% of mild TBIs receive no medical care.

Which means that families and schools take on a much bigger role in identifying the issues that are impeding the childs ability to function.

Later, we will talk about what to look for, how to know when a child with a concussion needs intervention. If you see these signs, then you may e taking a bigger role in encouraging the family to seek out medical care.

Go to the pediatrician, with a list of concerns that you are seeing. YOU are more likely to see the problems in mild TBI because school is the most complex task of childhood. Day to day routines are generally much easier to perform. They may look good on the surface, but push, ask them to acquire and demonstrate new learning and you may see something completely different. **You may need to prompt the above:**Very similar steps as seen in moderate and severe TBI, but faster, more compressed over time.

Many children with uncomplicated mild TBI recovery quite quickly, will need to re-evaluate within weeks to a month or so.**As seen in moderate to severe TBI:

You may need to prompt this.***This is the frame on which hang interventions**When assessing, observation level

Anne to do**When assessing, observation level

Anne to do****When assessing, observation level

Anne to do**When assessing, observation level

Anne to do**

Name 1 thing right now that, if youre quiet, you are aware of and its irritating.

As well as signs of fatigue as discussed previously

As escalates, leads to agitation - unable to make sense or respond to reason

**When assessing, observation level

Anne to do**As well as the more obvious

The more subtle signs****When assessing, observation level

Anne to do**On the leading edge of the development of attention executive skills*So if basic attentional systems are stressed

How the heck can the kid do: ***If having trouble with speed and attention, increasing complexity only makes it worse

**If cant keep up, problems with attention, cant hande too much at once. Slowed acquisition

had it yesterday, forgot it today

Usually about unreliable access to information Seen in decreased verbal fluency****

Everythings cool, until suddenly its not

its just too much

****

Stupid ______!

**