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Traumatic Brain Injury (TBI)
Children Birth to 4 Years
1
Introduction
Brain injury is the most frequent cause of disability and
death among children in the United States
This training will help early childhood professionals
identify young children who may have had a previous
brain injury and give them tools to support community
early childhood programs in making programmatic
adaptations
The Birth-4 TBI training is based on an in-depth
assessment of needs of Utah early intervention services
providers
2
3
This course is intended for:
Part C Early Intervention providers
Part B Preschool Special Education Teachers
Early Head Start Providers
School Psychologists
Educational Consultants
Social Workers
Guidance Counselors
Program Administrators
Speech and Language Pathologists
Occupational and Physical Therapists
EI and School Nurses
Successful completion of the course
provides Utah Early Childhood providers
with four professional development hours
Course will meet Baby Watch EI
recertification hours, teacher licensure
and PT, OT, SLP recertification licensure
4
Certificate of Completion
Section 1: TBI Overview
Definitions of TBI
Eligibility under IDEA
Incidence of Pediatric TBI
5
What is a TBI?
Insult/Injury to the Brain
External force = cause
Involves diminished/altered consciousness
Results in changes in cognitive, physical,
behavioral functioning
Changes may be temporary or permanent
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7
“An 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 child’s educational
performance.”
Def: Individuals with Disabilities Act
(IDEA): Sec. 300.8(c)(12)
Def: Individuals with Disabilities Act
(IDEA): Sec. 300.8(c)(12) cont.
Traumatic brain injury applies to open or closed
head injuries resulting in impairments in one or
more areas, such as cognition; language;
memory; attention; reasoning; abstract thinking;
judgment; problem-solving; sensory, perceptual,
and motor abilities; psychosocial behavior;
physical functions; information processing; and
speech.
Traumatic brain injury does not apply to brain
injuries that are congenital or degenerative, or
to brain injuries induced by birth trauma.”
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Incidence of Pediatric TBI
Approximately 475,000 traumatic brain
injuries (TBIs) occur in children <14 years
old annually
TBI in children is associated with $1 billion
in total hospital charges annually
Gender: Boys twice as likely as girls
Source: Surveillance for Traumatic Brain Injury--Related Deaths --- United States, 1997--2007
9
Age Factor (Donders, 2006)
TBI from child abuse primarily below age
3
Younger children more likely due to falls
Older children more likely due to motor
vehicle accidents
Transportation and falls account for more
than 50% of pediatric TBI
Highest risk 0-4 years, 15-24, and 75
years and older
10
Estimated Average Annual Numbers of Traumatic
Brain Injury-Related Emergency Department
Visits, Hospitalizations, and Deaths by Age Group,
United States, 2002-2006
Age Group
Emergency Dept.
Visits
Hospitalizations Deaths Total
Children (0-14
years)
473,947 35,136 2,174 511,257
Older Adults (>
65 years)
141,998 81,499 14,347 237,844
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Quiz, True or False
A mild brain injury (concussion) is mild
and less damaging than other brain
injuries
12
Section 2: Developmental Stages
and TBI in Children
Gain knowledge of TBI specific to early
childhood
Recognize the effects of TBI at each
developmental stage
13
Quiz: True or False
Younger children with TBI heal better
than adults with TBI.
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The Child’s Brain
More vulnerable to the effects of a brain injury and takes longer to recover
Undeveloped Unlike heart or kidney, the brain needs time and
experience to mature
The amount of time depends on the activity or function
Not well organized undifferentiated
New abilities build on established skills over time
Easily injured & greater diffuse swelling
15
Effects of Early Childhood TBI
No two are alike
TBI can cause injury all over the brain
Depend on the age of the child when injury occurred: younger shows greater impact
Younger age (<7yrs) = increased risk of long term difficulties
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Effects of Early Childhood TBI
continued…
TBI may not show up on scans
Even a mild brain injury can seriously disrupt higher order thinking, executive functions and social behavior
Previously developed skills may be preserved after brain injury, but new learning may be difficult
Latent effects: may not be apparent until more advanced skills develop
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Effects of Early Childhood TBI
continued…
More extreme discrepancies among
skills
More uneven and unpredictable
progress
The condition could improve to pre-
injury state
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Parent Story:
Two days before her first birthday she was
in a head on collision. We didn’t realize
anything was wrong until she started
kindergarten and had a horrible time
concentrating and learning…”
Kansas parent
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Video: Recognizing a Child’s early TBI
Later in the Classroom
20
How does TBI impact
development?
Capacities in process of development, and those not yet developed, are most vulnerable to brain injury
Abilities not yet developed at time of injury are most likely to be disrupted and may never develop
Child may regain function lost as a result of the TBI but may have difficulty achieving higher level of developmental function
The earlier the TBI, the greater the impact
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Birth – 3 yrs
Development Impact of TBI Intervention
Sleep-wake patterns Disruption in regulation Consistent/predictable
routines
No cause-effect Mood lability-irritability Organized environments
Symbiotic relationship
with caregivers
Unpredictable emotional
reactions
Consistent/predictable
care providers
Physical
growth/development
Delay in physical
development
Early Intervention:
Physical therapy
Occupational Therapy
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Quiz, True or False
Infants and toddlers diagnosed with
Abusive Head Trauma (Shaken
Baby Syndrome) display clear signs
of physical abuse.
23
Abusive Head Trauma
A
New Mexico's Aging and Long-Term Services Department with funding from the State of NM and the
US Health Resources and Service Administration. Used with permission.
Dr. Nicholas Teodore and Dr. Neera Kapoor
Abusive Head Trauma (AHT)
(Shaken Baby Syndrome)
Cannot be explained by a disease
Cannot be explained by DPT or other
childhood vaccines
Cannot be explained a simple accident
Is not caused by play
Is not caused by resuscitation (CPR)
Is not SIDS (sudden infant death syndrome)
25
Higher Risk for
Abusive Head Trauma (AHT)
Children under the age of five
Premature, special needs, or difficult to soothe
babies
Males more likely than females
26
Common Triggers for AHT :
Crying is the chief “trigger”
Toilet training of children results in many instances
of physical abuse, in addition to SBS
In infants, feeding can become an issue when they
refuse to take the bottle that is offered to them
Interrupting the caregiver
27
Long Term Effects of AHT
Possible death
Those who survive may have brain and vision problems that can last forever These problems can include:
Seizures
Intellectual disability
Blindness or trouble seeing
Physical or emotional growth delays
Learning or behavior problems that may not appear until the child starts school
28
Pre-school: 3 – 6 years
Development Impact of TBI Intervention
Concrete – Black/white Self-regulating functions
impacted
Structure/organization
Caregiver/environment
Egocentric –
Cannot take others into
account
Poor acquisition of
concepts
Visual aids/cues
Beginning – think
before acting
Express feelings
without thinking
Close supervision when
aroused
Do not like change Resistant to direction.
Rigid
Concrete assistance
through transitions
Focus on self-control Anxiety Structured/predicable
routines
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Signs and Symptoms of Mild TBI
(concussion) in Preschoolers
Can show up right after the injury, or not appear until days or even weeks after
o Tiredness or listlessness
o Irritability or crankiness (will not stop crying or cannot be consoled)
o Changes in eating (will not eat or nurse)
o Changes in sleep patterns
o Changes in the way the child plays
o Changes in performance at preschool/school
o Lack of interest in favorite toys or activities
o Loss of new skills
o Loss of balance or unsteady walking
o Vomiting
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Section 3: TBI Screening and Assessment
for Early Childhood Systems
Why Screen?
SAFE Child Screening Tool
Educational TBI eligibility classification and
medical diagnosis
Criteria to provide Special ED services
Suggested Procedures for Utah Early
Childhood Programs
Evaluation and Assessment of TBI in children
0-4
31
Why Screen?
Child receives appropriate interventions
The TBI should be considered as an underlying cause of the of the developmental delays
Effects of TBI in young children may not be identified until later
Allows family/child to develop self-advocacy skills
Prevents a cycle of failure
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Challenges:
TBI is an invisible injury
Parents may not be informed by their
primary care provider about the impact
of a TBI
Parents want to think that there isn’t a
problem..everything is fine with their
child
TBI not familiar to Early Intervention and
Preschool Staff
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SAFE Child Screening Tool
Modeled after HELPS Screening Tool
Developed by Nebraska task force members
Asks questions of parents: Symptoms
Accidents
Falls
Emergency Room
Changes
Completed screens left with nurse
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Nebraska Screening procedure:
Parents receive “Brain Injury in Young
Children” Brochure with their screen
Brochure includes information on
prevention, signs/symptoms, multiple
injuries and additional resources for
more information
Was screening tool found useful?
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Modified Glasgow Coma Scale for
Infants and Children Measures child’s level of consciousness
Score:
○ 12 suggests a severe head injury
○ 8 suggests need for intubation and ventilation
○ 6 suggests need for intracranial pressure monitoring
If the patient is intubated, unconscious or preverbal, the most important part of this scale is motor response. This section should be carefully evaluated
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Glasgow Coma Scale (GCS)
Emergency response personnel use to
rate severity of injury at scene of
accident
Hospitals use to rate:
Progress or decline in status
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Glasgow Coma Scale (GCS)
Some formalized testing incorporate
initial score to evaluate progress
Mostly applicable in the initial recovery
state of the TBI, but may continue to
apply for severe TBI’s
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Rancho Los Amigos Levels of
Cognitive Functioning
Also Called Rancho Los Amigos
Cognitive Scales
or Rancho level
Used frequently during the recovery
period to describe current cognitive
level.
Used after the Glasgow Scale no longer
applies
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Rancho Levels
Example:
A patient who has spontaneous eye
opening, is talking (babbling/producing
sound) and spontaneously moving arms and
legs is the highest GCS score; however,
they may still be at a Ranch level IV:
Confused and agitated.
Physiatrists (Rehab Doctors) are familiar
with the levels, so it is a good way to
communicate function with them.
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Rancho Levels
Provides information for family and
friends regarding what they can do for
the patient at each cognitive level
Example:
○ Rancho Level I-III Limit visitors
○ Rancho Level IV Orient frequently, limit
distractions
○ Rancho Level V Repeat things as needed,
don’t assume they will remember
○ Etc.
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Rancho levels
Level I- No response to pain
Level II- Generalized reflex response to
pain
Level III- Localized response
Level IV- Confused/agitated
Level V- Confused/non-agitated
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Rancho Levels
Level VI- Confused/Appropriate (good
level for formalized cognitive testing).
Level VII- Automatic/Appropriate
Level VIII- Purposeful/Appropriate
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Rancho levels
Level IX- Purposeful/Appropriate-Stand-
by assistance on request
Level X: Purposeful/Appropriate-
Modified independent
Please see full explanation for more
specific details at each level
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Utah Part C Eligibility Baby Watch Early Intervention Program (BWEIP )does not currently have TBI on
Approved Diagnosis List
Child would have to
meet BWEIP
eligibility criteria
1.5 standard
deviation below the
mean / at or below
the 7th percentile
Determined eligible
through Informed
Clinical Opinion
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Educational Classification:
Criteria for Part B Preschool
Eligibility
While there must be prior
documentation by a physician that a
student has an acquired injury to the
brain caused by an external physical
force, a team of qualified
professionals and the student’s
parents determine eligibility
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Criteria continued… (1) The traumatic brain injury must adversely affect the student’s educational performance
(2) The student with the traumatic brain injury must require special education and related services
(3) The team must determine that traumatic brain injury is the student’s primary disabling condition
(4) The requirements of Rule II.I must be met
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Suggested Procedures for Utah
Early Childhood Programs Step 1: Health Assessment with specific TBI questions
(e.g. Safe Child Screener) medical records
Step 2: Administration of the check list for Children with a reported TBI
Step 3: Developmental Assessment with TBI emphasis OT evaluation for sensory processing
Physical Therapy for muscle tone and balance issues
Speech & Language: social communication and pragmatic speech; information processing/auditory processing
Behavioral assessment
Step 4: IFSP with TBI Emphasis
Step 5: Use intervention strategies recommended for children with TBI Including schedule charts, etc.
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Guidelines for Comprehensive
Evaluation
Physical Aspects: Quick recovery of
physical functioning may
mask remaining long
term concerns
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Common physical problems: • Hemiplegia • double vision • visual/perceptual difficulties • gait deviations • switched hand dominance • tactile defensiveness
Common health issues: • headaches • fatigue • seizure activity • anxiety • metabolic disorders
Guidelines for Comprehensive
Evaluation
Cognitive: a TBI
can significantly affect
and impact the ability
to use cognitive skills
in all aspects of
function and
independence
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• Attention: attention problems are extremely pervasive following a traumatic brain injury
• Perception: demonstrate good visual and hearing acuity but have problems interpreting incoming information
• Memory: Memory for new and ongoing events is challenged
Guidelines for Comprehensive
Evaluation
Communication: Children with a TBI can
often converse in a
general way and may be
completely intelligible in
terms of speech skills.
Impact on communication
is dependent on sight of
injury.
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• Impaired Discourse: The organization of language (both spoken & written)
• discourse plays a central role in everyday communication
• Fluency: The smoothness or flow of sounds, syllables, words and phrases
• Decreased flow of speech contributes to awkward and incomplete expression of ideas.
Guidelines for Comprehensive
Evaluation
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Problem-solving: impact of attention,
memory and language
deficits
Reasoning: requires
the integration of
information
Executive functions: generally exhibited in a
frontal lobe injury
Problem solving: e.g. inability to generate
more than one possible solution, inability
to draw from previous experiences in
choosing the best alternative
Reasoning: requires the integration of
information with rules of logic and the
experience base
Executive functions: unable to organize,
plan and execute activities and benefit
from feedback from self-monitoring and
self-regulation
Guidelines for Comprehensive
Evaluation
Emotional &
Behavioral: A TBI
(especially a frontal
lobe injury) are likely
to exhibit behavioral
difficulties
○ May not demonstrate
social/emotional &/or
behavioral concerns
for years
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• Disinhibited, socially inappropriate and possible aggressive behavior
• Impaired initiation • Inefficient learning from
consequences • Perseverative behavior • Impaired social perception
and interpretation
Observation Checklists
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Standardized Tests
Majority of standardized measures are
appropriate for children 5 years and older
Behavior Rating Inventory of Executive Function- Preschool Version (2.0 years- 5.11 years)
The BRIEF-P is a single form used by parents, teachers, and day care providers to rate a child's executive functions within the context of his or her everyday environments--both home and preschool. Completed in just 10 to 15 minutes
Woodcock-Johnson III (2.0 years- 90+ years)
general intellectual ability, specific cognitive abilities, oral language, and academic achievement
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Section 4: Strategies
Working as a team
ISFP
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Working as a Team
Professionals and parents monitor:
Growth and nutrition
Evaluation of oral-motor skills (drooling) and
aspiration
Speech pathologist, physical and
occupational therapists and a nurse may be
needed on team
Monitor vision and hearing
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After a TBI Diagnosis: Transition
Responsibilities
Family Collect all medical
records
Provide contact
names for EI /
school (if
previously
enrolled)
Participate in
discharge team
meeting with EI
/school team
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Medical Identify EI/School
transition contact
Support for on-site
services from EI
/preschool (if
previously
enrolled)
Develop discharge
plan
Request a
discharge team
meeting with EI
/school team
EI / School Identify primary
medical contact
Provide on-site
services to child in
medical setting (if
previously enrolled)
Participate in
discharge team
meeting with medical
team
Collaborate with
medical facility to
determine services
needed
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Increase communication
Guided IFSP http://www.cbirt.org/media/dynamic/medialibrary/2010/09/IFSP_Guide_for_Children_with_TBI.pdf
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Service Coordination
Case Management
• At least 1 team member with
knowledge/ training about
TBI and impact to learning
• Coordinate service with
medical and private service
providers
• Ongoing communication
across service agencies
• Decrease confusion to
parents & child due to
multiple approaches by
different service providers &
agency requirements
Consider & Modify • Temperature
• Lighting- Highly reflective
surfaces, bright or dim
lighting
• Time of day
• Loud noises
• Period of calm allow for best
learning, over-stimulations
decrease learning
opportunities
• Significant behavior
problems need to be
addressed by behavior
specialists, Functional
Behavior Analysis
• Vision difficulties: visual
field cuts, visual tracking,
light sensitivity
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IFSP/IEP Considerations
Frequency of Services
Due to fatigue, chronic pain,
medication side effects or
sensory sensitivities
IFSP IEP
• Co-visits
• Shorter &
more frequent
visits
• Adapt
classroom
schedule to
allow for
breaks
• Shorten or
lengthen-
minutes per
days / days
per week
• ESY –
regression
recoupment
Location of Services
Over-stimulation
Under-stimulation
IFSP IEP
• Quiet
environment
• Stimulating
environment
• Sensory
equipment
• 1-1 teaching
• Small group
• Quiet
environment
• Stimulating
activities
IFSP / IEP
Describe how the child has changed due to a TBI: Communication
Remember/ use reasoning
Process information
Tolerate change / behavior
Attention
Perceptual motor sills
Abstract thinking
Use of touch, vision, hearing, smell, & taste
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Levels of
Development
Treatment – IFSP / IEP
Outcomes/ Goals
63 MCHB TBI Grant 1H21MC01691-01-00
• Keep goals functionally oriented and outcome‐based
• Base goals on the strengths paired need
• Dynamic document- rewritten to meet changing needs
The goals were modified from examples in the website to reflect learning levels for younger children in setting other than school. Center on Brain Injury Research and Training http://www.tbied.org/tbi‐support/iep‐main/sample‐iep‐goals/
Examples: Communication
• Given a topic, Steven will take 4 turns in a conversation before changing the topic 3 out of 4 trials across 3 settings: in speech therapy, in the classroom and in the hallway. • Sam will choose an activity and show a picture of that activity to another child as an invitation to play. Anna (Jenny’s mom) will identify Jenny’s body cues to increase response for feeding, comfort.
Behavior • Jenny will (with prompt) leave a confrontation with a classmate by going to her quiet time area and choosing an activity from her cool down box: 2 out of 3 occasions. • Jenny will learn 5 games to play at home, park, neighbor’s house.
Center on Brain Injury Research and Training http://www.tbied.org/tbi‐support/iep‐main/sample‐iep‐goals/
The following goals were modified from examples in the website to reflect
learning levels for younger children in setting other than school.
Problem Solving
• Sandy will be presented with simple
games requiring problem solving (simple
to increasingly difficult puzzles, playful
obstruction activities). She will be able to
resolve the problem or ask for help in an
appropriate manner.
Reasoning
• Bentley will be presented with an activity
without all the needed items for play (e.g.
bubbles without the wand, train track
without trains) he will independently
determine what is missing and request the
missing item.
Information Processing
• Given a prompt or cue, Kyle will say his
name in less than 30 seconds
•While participating in circle time, Sandy
will say the next word of the song when
the teacher pauses in less than 30
seconds, 3 times.
Sensory
• Suzy will stop crying and comfort herself while
being rocked, swung, or swaddled.
• Brandon will tolerate increasing levels of noise in
various environments.
Cognition
• Sarah will take breaks during playtime (every 30
minutes) to help keep her alert.
Memory
• Jim will successfully play increasing difficult
games requiring memory recall (items hidden while
watching, hidden while not watching, looking for
item in known place etc.)
Attention
• Sandy will attend for increasing lengths of time
during home and church activities.
Abstract Thinking
• Given a toy or items with connecting parts, Suzy
will connect the pieces (Legos, paper chains, train
tracks).
• After listening to a story Harold will tell parts of the
story.
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Center on Brain Injury Research and Training http://www.tbied.org/tbi‐support/iep‐main/sample‐iep‐goals/
The following goals were modified from examples in the website to reflect
learning levels for younger children in setting other than school.
65 MCHB TBI Grant 1H21MC01691-01-00
Judgment • With decreasing levels of guidance Mary will make choices beginning with 2 items increasing to 5 items. • Mary will identify safe and unsafe household/ community items (scissors, knifes, hammers, unfamiliar dogs)
Perceptual Motor
• Taylor will use visual cues to transition from activities independently 4 out of 5 opportunities
Physical Abilities
• Given a tangible cue, Dakota will navigate his home, yard and friend’s yard independently using his walker to the destination indicated by the cue. • Karla will spend 30 minutes each day in her stander
TBI service considerations
IFSP / IEP
Often requires 1:1 assistance or small group experience of 1-2 children
Special equipment often including sensory motor experience
Frequent experiences with children with typical development
Placement with typical developing peers as much as possible for modeling and appropriate social development
Offer services in an environment that is neither over nor under stimulating
Plan for a continuum of possible placements
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Treatment-
IFSP
IEP
Instructional Strategies for Preschoolers
See handout
Reading: Sound Boxes
Learning Facts: Incremental Rehearsal
Teaching Planning
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Suggestions for Family Support
Family education regarding TBI
Strategies to organize critical paperwork
and records
Community resources:
Developmental disability services
SSI resources
Counseling services
State & National TBI websites, networks,
parent support groups
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Looking to the Future…
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What does this mean for families
and schools?
“The challenge of addressing the latent developmental effects of childhood brain injuries is compounded by the fact that families often must assume the primary caregiving role and schools often become the sole providers of rehabilitation services. Neither families nor educators have been systematically prepared or trained for this role”.
Glang & Lash, 2006
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Importance of Research &
Training
“Advances in trauma care have directly
contributed to the higher survival rates
of children with traumatic brain injury.
However, more attention and resources
need to be directed toward school
systems and community programs to
address the long term challenges for
neuro-recovery”. Child’s Recovery After Traumatic Brain Injury Takes
Time Blog on Brain Injury By Marilyn Lash, M.S.W.
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State Programs • Brain STEPS Program:
• http://www.caiu.org/resources/schools/brain-steps.aspx
• BrainSTARS, Brain Injury: Strategies for Teams and Re-education for Students. Jeanne E. Dise-Lewis, Ph.D.; Margaret Lohr Calvery, Ph.D; Hal C. Lewis, Ph.D.
• http://orthopedics.childrenscolorado.org/what-we-do/rehab--physical-therapy/brainstars
• Center on Brain Injury Research and Training
• www.cbirt.org
• LEARNet: A resource for Teachers, Clinicians, Parents, and Students by the BIA of New York State
• http://www.projectlearnet.org/
• REAP Concussion Management Program
• http://www.rockymountainhospitalforchildren.com/sports-medicine/concussion-management/reap-guidelines.htm
• School Transition & re-Entry Program (STEP)
• http://www.tr.wou.edu/STEP/
• Early Childhood TBI
• http://www.cbirt.org/tbi-education/early-childhood-tbi/
• Traumatic Brain Injury Networking Team Resource Network:
• http://cokidswithbraininjury.com
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Publications:
The ASHA Leader http://www.asha.org/Publications/leader/2010/101102/Pediatric-
Traumatic-Brain-Injury/
Colorado Department of Education. Brain Injury: A Manual for Educators http://www.cde.state.co.us/cdesped/SD-TBI.asp
Florida Department of Education, Bureau of Exceptional Education and Student Services, 2005; Understanding and Teaching Students with Traumatic Brain Injury: What Families and Teachers Need to Know https://www.ocps.net/cs/ese/programs/tbi/Pages/default.aspx
Returning to School after Traumatic Brain Injury and other fact sheets: http://uwmsktc.washington.edu/TBIfactsheets.html
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National Resources
BrainLine www.brainline.org
BrainLine Kids http://www.brainline.org/landing_pages/features/blkids.html
Centers for Disease Control and Prevention (CDC), TBI: http://www.cdc.gov/ncipc/tbi/TBI.htm
National Dissemination Center for Children with Disabilities (NICHCY), Traumatic brain injury: http://nichcy.org/disability/specific/tbi
TBI Focus www.tbifocus.org
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Publications
Centers for Disease Control and Prevention. “Traumatic Brain Injury: Incidence and Distribution.” Publication 2003. June 2004. www.cdc.gov
Hibbard, Mary, et al. “Students with Traumatic Brain Injury: Identification, Assessment and Classroom Accommodations.” Research and Training Center on community Integration of Individuals with Traumatic Brain Injury. November 2001.
Mount Sinai School of Medicine. “RTCTBI FAQ’s About TBI.” June 2004. www.mssm.edu/tbinet/alt/faq.html.
National Dissemination Center for Children With Disabilities. “Traumatic Brain Injury: Fact Sheet 18.” June 2004. www.nichcy.org/pubs/factshe/fs18txt.htm.
Wisconsin Department of Public Instruction. “Wisconsin DPI Traumatic Brain Injury Training Presentation.” June 2004. http://www.dpi.state.wi.us/dpi/dlsea/een/tbihomepg.html
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Utah Resources:
Brain Injury Alliance of Utah www.biau.org
Medical Home Portal http://www.medicalhomeportal.org/
Phoenix Services http://www.phoenixservices.org/
Primary Children’s Medical Center
https://intermountainhealthcare.org/hospitals/primarychildrens
Utah Brain Injury Council http://www.utahbraininjurycouncil.net/
Utah Department of Health Violence and Injury Prevention
http://health.utah.gov/vipp/traumaticBrainInjury/overview.html
Utah State Office of Education
http://www.schools.utah.gov/sars/Disability-Information/Disability-
Categories/Traumatic-Brain-Injury.aspx
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