Supporting Children with Traumatic Brain Injury by fanzhongqing


									Supporting Students with
  Traumatic Brain Injury
                                      Pat Sublette, Ph.D
     Oregon Traumatic Brain Injury Education Coordinator
                       The Teaching Research, Eugene

   Causes
   Incidence
   Impact
   Perspectives
   Challenges & Interventions
   Support

The Brain

   About 3.5 pounds
   3 day Jello
   10 billion neurons
       Each neuron connects with others
          average of 10,000 synapses
 Acquired Brain Injuries

                  Cerebral Vascular Accidents
Internal Causes

                  Ingestion of Toxic Substances
   Acquired Brain Injuries

                  Open Head Injuries
External Causes

                                Closed Head Injuries
Types of        Compression
                                           Subdural veins
Damage          fracture
                                           torn as brain
                                           rotates forward

   in a

                             Swelling of
                             brain stem

                                                Shearing strains
                                                throughout the
           Damage to
           temporal lobes
           from rough
           bones at skull base
               Skull Protrusions

                                        Shearing Plane


Adapted From: Pang, 1985
Open vs. Closed Brain Injury

      Open Brain Injury
          Skull is fractured
          Blood & swelling have a place to go
      Closed Brain Injury
          Concussion
          Swelling results in further (secondary) injury
            May go unidentified if no loss of consciousness

            Damage great or greater than open brain injury
 Overly Simplified Brain Behavior
Frontal Lobe                                                             Parietal Lobe
 • Initiation                                                               • Sense of touch
 • Problem solving                                                          • Differentiation:
 • Judgment                                            Parietal
                                                        Lobe                  size, shape, color
 • Inhibition of behavior        Frontal                                    • Spatial perception
 • Planning/anticipation          Lobe                                      • Visual perception
 • Self-monitoring                                        Occipital
 • Motor planning                                          Lobe
 • Personality/emotions                                                     Occipital Lobe
 • Awareness of                            Temporal                             • Vision
   abilities/limitations                     Lobe
 • Organization                                         Cerebellum
 • Attention/concentration                                                   Cerebellum
 • Mental flexibility                                     Brain                 • Balance
 • Speaking                                               Stem                  • Coordination
   (expressive language)                                                        • Skilled motor activity

                    Temporal Lobe                                     Brain Stem
                       • Memory                                        • Breathing
                       • Hearing                                       • Heart rate
                       • Understanding language                        • Arousal/consciousness
                         (receptive language)                          • Sleep/wake functions
                       • Organization and sequencing                   • Attention/concentration
Causes of TBI in Children

      Motor Vehicle Accidents
      High Risk Sports
           ATVs, rodeo, skiing, snow boarding
           Motorcycle Accidents
      Pedestrian Vehicle Accidents
      Violence
      Falls
      Abuse
           Shaking
Sports & TBI

    Amateur Boxing
        Injuries consistent with acute TBI
         Post-concussive syndrome
    Football
        20% high school players
    Soccer
        5%
    Horseback Riding
        17% of all equestrian injuries are brain injuries
         (Brain Injury Association of America)

TBI in Children

    1.4 million children injured annually
    About 1/2 between 16-21
    Highest risk groups ages 0-4 and 15-19
    More likely to survive than adults
    Less likely to loose conscious
National Statistics/100,000

   180/100,000 infants children and adolescents
    are hospitalized for TBI annually
       Krause 1995

Medical Complications
Resulting from TBI

     Post traumatic seizures
     Hydrocephalus
     Deep vein thrombosis
         Incidence as high as 54%
         First sign often sudden death
           Look for swelling in affected limb
Medical Complications
Resulting from TBI

    Spasticity
        25 %
    GI and GU complications
        stress ulcers
        dysphagia
        bowel and bladder incontinence
        elevated liver function
Sensory &
Endocrine Impairments
       Vision
           may have field cuts
           field neglect
       Feeling and Sensation
           loss of smell & taste or touch
       Hearing
       Endocrine disorders
           hormonal
           pituitary
           thyroid
    Medical Complications
    Resulting from TBI
   Post Traumatic Agitation
       1/3 of TBI patients experience
           Considered a subtype of delirium
           Excesses of behavior including combinations of
               aggression,
               dis-inhibition
               emotional ups and downs

                                              Management & Staging of
                                              Traumatic Brain Injury by
                                              David E. Smith, MD
    TBI & Mental Health Issues

   Depression
       In children can look like
           Agitation
           Anger
           Poor short term memory
           Lessened focus
           Irritability
           Outbursts
Cognitive Issues
   Executive Functions
       Pragmatic language
       Planning
       Initiation
   Memory
   Processing Speed
   Learning new information
   Language
2 Years After….

     Memory Problems (74%)
     Fatigue (72%)
     Word-Finding Difficulties (67%)
     Irritability (67%)
     Impaired Speed of Thinking (64%)
     Impaired Concentration (62%)
             (Ponsford, 1995)
     Depressed Mood
          40-50% of people with TBI
             (Glenn, 2001)
Sequence of Skills in Healing

       Motor
           gross motor functioning e.g., walking
            improves more rapidly than other
            functions (1 to 2 months)
       Sensory
           improves relatively rapidly in children (1
            to 2 months)
Healing Sequence

    Speech Communication skills
        Expressive speech may resolve within a
         few months
        Subtle language problems may persist
         indefinitely and go unrecognized
Healing Sequence
      Measured IQ
          May be small changes
              appear to recover two months post injury
              may not recover
           not as rapid as motor, sensory and speech
      Memory, Attention, Processing Speed
          may persist for many months or
           permanently be reduced
Healing Sequence

    Higher Level Cognition
        Information processing
        Learning under new, complex or difficult
        Ability to adapt to new problems or situations.
        Children negatively affected by stress more
         easily than before.
        May be impacted for years or permanently
    Children and TBI

   Effects of TBI may not be evident until later in
       higher executive functions are required for
Impact on Community

    Adults who have sustained TBI tend to
         Have higher incidence of
             mental health problems
             behavioral problems
             medical complications
       Be underemployed
       Have higher likelihood of violence & criminal activity if
        high risk taking prior to TBI
             In 2 separate studies 41 & 61% of inmates reported
                 previous, untreated TBI
Community Costs of TBI

     Mortality rate is higher
     Less likely to have social connections
     Higher likelihood of subsequent TBI
     Tend to graduate, go home and sit….
Costs to Education

   Students with TBI often tend to:
       Drop out of school
         11% of students with identified TBI drop out (nationally)
       Be socially isolated
       Be misunderstood based on their disability
   Out of 8 students with TBI at one Oregon High
           3 did not return to school after TBI
           2 attended alternative programs dropping in and out of
            school over 3 years
           3 continued in High School on IEPs
               1 attended college
               2 are at home
Impact on Family

   Challenged with
       huge debt
       insurance companies
           may not identify a brain injury to save money
       learning medical & educational systems
   Family loses the child they knew
       can’t grieve openly
           because the child lived
           child is working hard to regain and heal
Family Perspectives

   “Everything will be normal within a year”
   Physical recovery is fast so cognitive will
    be the same
   Don’t know how to get help from school
    or community
Family Recovery Patterns
Following TBI
    Overwhelming shock
        focused student survival
    Disbelief regarding injury impact
        believe with enough effort the student can ”recover”
        mixed with euphoria as a student makes rapid
         physical recovery
        may refuse needed services
    Sorrow and despondency
        anger as families begin to realize that their student is
         changed permanently.
Family Recovery Patterns

   Adaptation
       after the family has reorganized around the new
        needs of the student

   Stress
       higher for families who have an adolescent with
        moderate to severe TBI compared to students with an
        orthopedic injury

          Semrud-Clikeman, M., Kutz, A., & Strassner, E., (2004). Providing
          Neuropsychological Services to Learners with Traumatic Brain Injuries.
          In Handbook of School Neuropsychology. D’Amato, R., Fletcher, Janzen,
          E., & Reynolds C.R., John Wiley & Sons : Hoboken, NJ.
What Impacts Healing?
Healing improved by:             Children we are discussing
     Strong abilities                Tyler, Gloria, & Joshua
     Age at or above                 Tyler, Gloria & Joshua > 13
      adolescence at injury               Gary was an infant

     Socio economic status           Tyler, Gloria & Joshua
                                       solidly middle class, Gary’s
                                       mother was 19 & on welfare
     Family support following        Extremely strong for Gloria
      injury                           & Joshua
                                          Tyler’s family was unable
                                           to locate resources
                                          Gary’s was variable


            Long term
            Short term
            Prospective
            Working memory
Memory Interventions
   Planner
   PDA
   Cell phone alarm
   Notes
   Visual reminders
       Picture schedules
   Coaching
Concrete Thinking
Difficulty with abstraction, synthesis,
inference etc.
Concrete Thinking Strategies
   Prompts and reminders
       Coaching
           Goal Plan Predict Do Review
   Structured teaching
   Social settings
       Comic strip conversations
       Social stories
Slow Processing Speed
Processing Speed Strategies
   Give more time to complete requested tasks
       Continue to request school & household tasks
   In school
       Note-taker
       Books on MP3 or CD
           Audio-assisted reading
           Assistive technology programs to help with production
            of written language
Planning Challenges

   Impacts
       Behavior
       Goal setting
       Ability to complete tasks
           Homework
           Getting to places on time
Planning Interventions
   State the obvious
       it may not be as clear to the student
   Picture schedules
   Calendar to plan long-range projects with student
       Coach through every step
   Checklists or cue cards
       steps for completing a task
       organize the checklists into a small notebook for easy
   Goal-setting and planning sheets
       With number of steps in a task
       Number of items to be completed
Difficulty Initiating (starting)
   Conversations
       Appropriate
       Social nuances
   Tasks
       Jobs
       Getting out of bed
Initiation Interventions
   Goal
   Plan
   Do
   Review
   Coach the student to do tasks appropriately
    in multiple settings
   Tantrums
   Outbursts
   Inappropriate language
   Violence
   Withdrawal
       Coaching to assist with misperceptions
        Effective will all 4 students
       Give clear guidelines
        Big 5
        1.   When to start
        2.   What to do
        3.   How much to do
        4.   What finished looks like
        5.   What to do next
After the Injury
       What to do?
     Transition Meetings
1. Pre-meeting with information from hospital
2. FERPA and due process must be followed
3. School must establish eligibility
4. 504/IEP (behavioral supports likely needed)
5. Have built-in review and revise plan
    about 4x per year
Recognize Potential Problems
    Medical
    Behavioral
    Social
    Cognitive
  He looks so good,
  but……….How will he function
  in the classroom?
    Other Factors to Consider

    Time since the injury
    Extent of the injury
    Co-existing conditions
    Family/ home needs
    School issues
    Social/emotional
    A time of change

   “Everything will be normal within a year”
   Physical recovery is fast so cognitive will
    be the same
   Don’t know how to get help from school or
Reaction from School and

“We’ve known him all his life, he’s just the
same as he always was only more so. You
know he’s always had his own special brand
of humor”
          ~Principal when Tyler was hiding from teachers as
            a 12th grader
Key Concepts for Re-Entry
   Schools are the key service providers
   Initiate services early
   Services are ongoing & must meet the
    changing needs of the student
   Personnel must monitor, document & evaluate
   Flexibility
   Rehabilitation Act, Section 504
   IDEA
    Techniques for Transition
   Prior agreement on
       length of school day
       safety
       special equipment needed
   Prepare
       everyone with information
       child with a story
   Preliminary visits to school
Educational Definition
   Traumatic Brain Injury
   …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. The term 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. The term does not apply to
    brain injuries that are congenital or degenerative, or to brain
    injuries induced by birth trauma.
   Compare pre injury and post injury status
   Write goals that match the student’s needs
    not previous disability
   Need a medical record of an event likely to
    cause a TBI.
   The report does not need to say the words
Writing an IEP for a Student with
      What is in the IEP for students with TBI
      Notes for writing an IEP for a student with TBI
      Program needs for students with TBI
      Measurable annual goals
      Services and supports to consider for students
       with TBI
Notes for Writing an IEP

   Depending on the time since the injury
       between 4-6 IEP meetings a year due to
        changing needs.
       plan for those dates as you complete
           Planning meetings
           IEP
           504, etc.
Regular or Extended
   Consider the student’s ability to
       work without fatigue
       manage pain
       use memory
       process information
       physically manage materials
       use vision
       structure their thoughts around problems
    Assistive Technology
   Because of difficulties transferring learning
    from one setting to another and potential
    memory deficits, students with TBI may need
    SDI to learn to use assistive technology
    devices in multiple settings
    Communication Needs

   Include
       Social use of language
           turn taking in conversation
           not interrupting others
           tracking a conversation
           other practical language skills
           as well as speech production
   Students with TBI sometimes have
       low frustration tolerance
       difficulty understanding social cues
       fatigue
       impulsivity
       confabulation
           That need to be addressed in the IEP
Common Cognitive Issues

   Orientation to place and time reduced
   Overload/breakdown of comprehension
       Especially when fatigued
       Results in irritability, tears, tantrums
   Initiation/motivation
   Agitation
   Perseveration
   Reduced
       Rate of processing
       Rate of performance
    Program Needs for Students with TBI

   Students with TBI tend to have needs that cross
    several subject areas
       IEP goals must address issues across several classes or
       Teach same skills in multiple settings
   Executive functioning skills can not be taught in
Effectively Teaching Students with TBI
Typically Includes:
       Preview
       Teaching
       Practice
       Review
       Re-teaching in a new settings
       Practice in new settings
       Monitoring the student’s progress over time.
       Use of peers or mentors to assist in coaching behaviors
        and performance is also recommended
Effective Behavior Programs
   Cause and effect is often a weak area so
    avoid a punishment orientation
   Mentor or coach to help students:

       Goal
       Plan
       Do
       Review
           (Feeney, 2007)
        Thoughts on Placement Decisions

   Cautions about home tutoring
       Behavioral problems may increase because
           family members not trained to handle
           The student may fall farther behind academically
           student may become anxious about returning to
Cautions About Placement

   Temporary placement in a special
    education class can provide:
       inappropriate modeling to students who are
        trying to regain social skills
       Emotional difficulty for student and family

   Students regain skills best with
       familiarity of the classroom
       known teachers
       known peers
       routines
       behavioral and cognitive supports needed

                                      Adapted from Ylvisaker. Traumatic Brain
                                      Injury Rehabilitation: Children and
                                      Adolescents. 2nd ed. Appendix 17-1
   For most children, rehabilitation takes place
    in school

TBI Educational Consulting
       Contact Information
       TBI Educator Website for Oregon
       Content Areas
         Eligibility, Evaluation, IEP, SDI, Related Services,
          Accommodations, Capacity Building, Access, Safety,
          and Transition
       Each content area has
         General information
         Links
         Best Practices-articles and research-based advice
         Toolbox
Oregon Brain Injury Resources
     Resource librarian (Laura)
         available to find specific information for
             Requests regarding brain injury
               Families
               Service Provider
               Educators
Coming Soon……
   Completed website (
   Technical Assistance Paper for TBI
   Continue to evolve the model of service
Faces of Brain Injury in Oregon

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