Enhancing Services For Students With Traumatic Brain Injury

Enhancing Services For Students With Traumatic Brain Injury (TBI) D. Jay Gense, Oregon Department of Education Ann Glang / Lauren Loos, Teaching Research Topics For Today:   Present status of services SB 167 – new opportunities   TBI “foundation” Future Planning  Input and Discussion Census Data – TBI compared to Total eligible under IDEA (birth-21) Year 2000-01 2001-02 2002-03 TBI 316 325 326 310 291 279 Total 75,936 77,988 79,030 77,921 79,171 79,780 2003-04 2004-05 2005-06 TBI : - 12% Total : + 5% Serving Students with Brain Injury Faces of Brain Injury 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. U.S. Department of Education, Office of Special Education and Rehabilitative Services. (1999) Rules and Regulations: Part II. Federal Register, 64 (48), p. 12422. Disability Distribution Birth-21 Autism Deafblind Blind/VI5% 0.03% ED TBI 0.5% 6% DD 0.41% 4.5% Comm. Disorders 25% Deaf/HH 1% MR 6% OHI 8% OI 1.3% Learning Disabilities 42% ODE - 2004 Incidence, Etiology, Signs & Symptoms Incidence     For children and adolescents, annual estimates of head injuries are about 1 million About 165,000 children will be hospitalized, with 16,00020,000 serious enough to cause lasting effects Almost twice as many males as females For all ages, more than 2 million head injuries occur each year Head injuries are the leading cause of death and  disability in children Acquired Brain Injuries External Causes Open Head Injuries Closed Head Injuries Acquired Brain Injuries Internal Causes Cerebral Vascular Accidents Ingestion of Toxic Substances Types of Damage in a Closed Head Injury Compression fracture Subdural veins torn as brain rotates forward Swelling of brain stem Damage to temporal lobes from rough bones at skull base Shearing strains throughout the brain Skull Protrusions Brain Shearing Plane Protrusion Skull Adapted From: Pang, 1985 Coup Contra-coup Shearing Simplified Brain Behavior Relationships Frontal Lobe • Initiation • Problem solving • Judgment • Inhibition of behavior • Planning/anticipation • Self-monitoring • Motor planning • Personality/emotions • Awareness of abilities/limitations • Organization • Attention/concentration • Mental flexibility • Speaking (expressive language) Parietal Lobe Parietal Lobe Occipital Lobe Temporal Lobe Cerebellum Brain Stem • Sense of touch • Differentiation: size, shape, color • Spatial perception • Visual perception Frontal Lobe Occipital Lobe • Vision Cerebellum • Balance • Coordination • Skilled motor activity Temporal Lobe • Memory • Hearing • Understanding language (receptive language) • Organization and sequencing Brain Stem • Breathing • Heart rate • Arousal/consciousness • Sleep/wake functions • Attention/concentration Executive Functions Symptoms (Feeney, 2005)          impulsiveness poor social judgment social disinhibition Egocentrism difficulty interpreting the behavior of others Perseveration poorly regulated attention disorganization (in thinking, talking, and acting) weak goal formulation           ineffective planning decreased flexibility/ shifting slowed processing diminished divergent thinking concrete thinking immature problem solving weak self-monitoring inefficient responses to feedback/ consequences reduced initiation dulled emotional responses Executive Function & other Cognitive Impairments Children with pre-frontal injury may have preserved language skills and other cognitive abilities in the presence of severe self-regulation (i.e., executive function) deficits (Ylvisaker & Feeney, 2002) Attention-information processing impairments (Sohlberg & Mateer, 2001)      Slowed rate of processing Difficulty concentrating; fatigue Difficulty screening out distractions (external and internal) Difficulty concentrating; fatigue Difficulty disengaging and engaging Memory & Learning Impairments (Sohlberg & Mateer, 2001)        Memory almost always affected in TBI Recent memories usually more affected then longterm memories Prospective memory (i.e., ability to carry out intended actions) frequently impaired Working memory (i.e., what’s on one’s mind) frequently impaired Orientation problems Motor/procedural learning systems may be relatively spared May learn without awareness of having learned Behavioral Impairments      Impulsivity Social Disinhibition Inappropriate behavior Short temper Easily frustrated Motor Sequelae Following TBI Hemiplegia: Motor paralysis of one side of body. Hemiparesis: Motor weakness of one side of the body. Ataxia: Loss of ability to coordinate smooth movements or steady gait. Hypotonicity: Low muscle tone of trunk or limbs. Rigidity: Resistance to movement in any range. Spasticity: Inappropriate sustained contraction of muscles Tremors: Involuntary movements from contractions of opposing muscles. Physical Sequelae of TBI Vision & Hearing Looses  Headaches  Seizures  Fatigue & Reduced Stamina  Post-Concussional Symptoms      Headache Fatigue Dizziness Sleep disturbance Memory Developmental Overlay  Effects of brain injury in children are particularly profound because the injury occurs to a developing brain (Welsh & Pennington, 1988)  Recovery is superimposed on normal developmental processes, impacting previously learned skills and the development of future skills (Ewing-Cobbs et al., 1997) Developmental Overlay  Full effects of an earlier injury may not be evident until adolescence when children are expected to demonstrate increasing competence in executive functions and reasoning. Skills may not develop if the relevant areas of the brain have been damaged (Alden & Taylor, 1997; Feeney & Ylvisaker, 1995; Mangeot et al, 2002; Ylvisaker & Feeney, 2002)  Developmental Overlay   Children may also develop deficits in the social and behavioral domains secondary to these cognitive deficits. For example, primary deficits in executive functions have implications for the child’s behavior in the classroom and peer relationships. Such secondary deficits may become more pronounced in a child injured at an earlier age. School Re-entry Transition Requires Meetings 1. Pre-meeting with hospital personnel 2. Due process must be followed 3. School must establish eligibility 4. IEP will likely have behavioral supports 5. Have built-in review and revise Upon discharge schools need to know…..     Present Physical Condition Motor Skills • Physical Limitations • Activity Limitations Therapy Requirements Required Assistive Devices     Self-Care Abilities Prescribed Medication Communication Abilities Behavior Concerns   Cognitive Recovery Pattern Results of Evaluations Recognize Potential Problems Medical  Behavioral  Social  Cognitive  He looks so good, but……….How will he function in the classroom? Some Factors to Consider        How long since the injury Extent of the injury Co-existing conditions Family/ home needs School issues Social/emotional A time of change TBI and Awareness Lack of Awareness of TBI    Believed to be a “Low Incidence” disability Plasticity myth - continued misperception that “kids bounce back” Child will be “fine” perpetuated by medical community Under-identification Cycle Apparent Low Incidence Lack of Awareness Underidentification Lack of Training Lack of Research Money Lack of Right Services for Kids who are ID Student’s Brain Injury is often “Invisible”    Student looks “fine” Student appears to be “recovered” Student is no longer being followed by medical personnel “Forgotten” Injuries  Child injured at an early age – impact not seen until years later Families not aware of significance of injury, thus do not report to school personnel   As student transitions from elementary to middle/junior high to high school history of injury and its impact is lost Scope of the Problem  Emergency room visits and hospitalizations as a result of TBI total 707,000 per year among children aged 0-19 (Langlois et al., 2004) Approximately 30,000 experience persisting disabilities as a result of changes in cognition, behavior, physical abilities (National Pediatric Trauma Registry, 1993)  Under-identification for Special Education     Annually: 30,000 with persisting disabilities from brain injury Annually: 10,000 (1/3) needing special education supports Cumulative total (K-12): 130,000 Total on federal Sped. census (2002): 14,844 Outcomes 75 children enrolled in Back to School interview study  28 report no problems  21 are served under TBI category  5 are served under another category  20 are experiencing challenges and are not identified for special education TBI Educational Consulting Team TBITeam@wou.edu 541-346-0593 877-872-7246 Who we are?  Trained multidisciplinary team What happens when you call? 1. Referral request 2. Information gathering 3. Observation 4. Student centered planning Future Plans • “Regionalizing” Access and Service Delivery • Input and Discussion