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									   Traumatic Brain Injury:
Eligibility, Special Education
  and Classroom Practices

 Josh Zola MA, Ed.S, CBIS
 Sarah Powell M.Ed, CCC-SLP, CBIS
        Disguised as a Low Incident
   Each year, an estimated 1.7 million people
    sustain a TBI annually. Of them:
       52,000 die
       275,000 are hospitalized,
       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. Only 200 of every
        100,000 cases go to the hospital.
      SC Special Education Law

   Traumatic Brain Injury means 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 student’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
                       Types of Brain Injury

                                          Brain Injury
      Congenital and Perinatal                                    Acquired
     (no period of normal development)            (following a period of normal development)

   Perinatal               Congenital            Non-traumatic                  Traumatic
(e.g., birth stroke)        (e.g., PKU)          (internal occurrence      (external physical force)
                                                      e.g., tumor)

                                                                           Open            Closed
                                                                        (e.g., gunshot)   (e.g., fall)
    Short term effects of Brain Injury

   Injury to brain tissues at the site of
   Shearing and tearing of neurons
    throughout the brain
   Bleeding, swelling, and lack of oxygen to
    the brain
   Possible coma, loss of consciousness
   Described as mild, moderate and severe
      Long Term Consequences

   A student’s decreased functioning may be
    noted immediately upon return to school
    OR it may be several years after the
   If not aware, teachers may see changes
    but do not know why they have suddenly
    Typical Medical Course for a Student
        with a Moderate/Severe TBI

   Emergency room
   Regional trauma center if necessary
   Surgery if necessary
   Acute care setting (hospital)
   Rehabilitation unit or center
   School
   (So there should be tons of paperwork)
A student with a TBI has landed in
          your school…
    Meeting the Challenge of TBI

   To address the educational needs of
    students who have experienced a TBI,
    educators need to clear 4 hurdles…
       Identification
       Assessment
       Qualifying for Services
       Classroom Accommodations
      4 Facts about Identification
   Each student will vary greatly, no 2 will be alike
   Changes are unlikely to disappear fully over time
   Negative consequences may not be seen
    immediately but emerge when developmental
    demands reveal problems
   An injured brain is less likely to meet the
    increasingly complex tasks all children face as
    they get older
    Common Problems Teachers look
   Physical/Medical Problems
   Motor Problems
   Sensory/Perceptual Problems
   Cognitive-Communication Problems
   Emotional and Behavioral Problems
        Physical/Medical Problems

   Problems
       Seizures
       Fatigue
       Headaches
       Swallowing/Eating
       Self-care activities
   Medication issues
              Motor Problems
   Apraxia                   Spasticity
   Ataxia                    Balance problems
   Coordination              Impaired speed of
    problems                   movement
   Paresis or paralysis
   Orthopedic problems
    Sensory/Perceptual Problems

   Visual deficits
       field cuts
       tracking (moving and stationary objects)
       spatial relationships
       double vision (diplopia)
   Neglect / Inattention
   Auditory sensory changes
   Tactile sensory changes
Cognitive-Communication Problems

   Executive functions      Problem solving
   Memory                   Comprehension of
   Attention                 abstract language
   Concentration            Word retrieval
   Information              Expressive language
    processing                organization
   Sequencing               Pragmatics
    Emotional & Behavioral Problems

   Irritability                 Anxiety
   Impulsivity                  Withdrawal
   Disinhibition                Egocentricity
   Perseveration                Denial of deficit/lack
   Emotional Lability            of insight
   Insensitivity to social      Depression
    cues                         Peer conflict
   Low frustration              Sexuality concerns
    tolerance                    High risk behavior
 So you begin to think about
   assessment and will this
      student qualify for
services…and qualify for what
   Traditional                  Cognitive
    Assessment                    Assessment
                                     Focuses on
       Focuses on
                                      the underlying
        intellectual, emotional
                                      reasons for
        and academic
        functioning                   academic
                                      failure such as
        Example: an IQ score         problems with
        that declines over            attention,
        time                          memory, and
    Cognitive Assessment…is the student?
   Processing Speed
       Accurate but slow?
   Memory
       Retaining new info from day to day?
       Benefiting from context?
       Benefiting from repetition?
   Executive Function
       Prioritizing? Following through? Staying organized?
       Using problem solving strategies?
       Shifting from 1 task to another?
   Attention
       Able to concentrate? Hold onto information?
       Attending to more than 1 thing at a time?
       Accurate when carrying out complex tasks?
    How is TBI different from LD?
   TBI is not “just a learning disability”
   Students with TBI cannot be dealt with as
    if they have something similar
   Although similar, the differences are
   The impairments are different, as are the
    implications for educators
                     TBI: How is it Different?
               TBI                             LD                  ED
Onset and      Sudden with blow to head        Early/ unclear      Slow/ unclear
Cause          and loss of consciousness
Functional     Marked contrast between         No before-after     Changes
Change         pre and post onset              contrasts           emerge slowly
Physical       Loss of balance, weakness,      Poor                Unlikely
Disabilities   paralysis                       coordination
Behavior       Agitation, impulsive,           Restlessness,       Variable
               restlessness, disinhibited      impulsive
Emotions       Labile, depression, anxious     Prone to            Reactions due to
                                               outbursts           distortions of
Academic       Based on disrupted              Based on type of Not based on
Deficits       cognition                       learning disability impaired cognition
Difficulties   Old info easier to recall than New learning can     New learning can
with           new info                       be linked with old   be linked with old
Learning                                       learning            learning
Misclassified or Missed Altogether
     Poor transitional services
      between hospitals and schools
     Mild TBI slip thru the cracks
     Traditional approaches to
      assessment fail to provide
      necessary insight into how
      cognitive deficits impact school
     Special Ed for TBI vs. LD vs. ED
      looks different
     Deficits are not always
      immediately apparent
    So, now the assessment as been
   What services are out there?
   Qualifying for Special Ed
Traumatic Brain Injury (TBI)
  Title of Regulation:   Regulation No.: R43-243.1


              Medical Definition of TBI
       SC TBI Eligibility Criteria
   A multidisciplinary evaluation team shall include a
    certified school psychologist, a licensed school
    psychologist, or a licensed psycho-educational specialist
    in addition to a speech-language therapist
    knowledgeable in the education of students with
    traumatic brain injury.

   The existence of traumatic brain injury has been
    diagnosed by a licensed physician. Or, in the absence of
    an existing medical diagnosis or a prior diagnosis of a
    traumatic brain injury, both of the following are
      a documented history that evidences trauma to the
       head resulting in impairments according to the
       definition of the term “traumatic brain injury” and
      a cognitive profile that is consistent with the head
      SC TBI Eligibility Criteria
   The injury has resulted in partial or total
    functional disability and/or psychosocial
    The student’s traumatic brain injury
    adversely affects his or her educational
         SC Special Education Law
   The following evaluation components are
    a.   Medical records, if available.
    b.   Documentation of vision, hearing, and speech-
         language screening conducted after the injury and
         within the past twelve months.
    c.   Review of the developmental history or education
         records of the student to determine effect on his or
         her educational performance and psychosocial
         functioning. Particular attention should be paid to
         the student’s progress prior to and following the
         suspected injury.
      SC Special Education Law
d.   Observations in three environments by an observer, other than
     classroom teacher, that record the nature and severity of the
     student’s learning and/or behavior difficulties. These may include
     anecdotal records from previous caregivers; a certified school
     psychologist, a licensed school psychologist, or a licensed psycho-
     educational specialist; or the parent(s).

e.   Assessment of the student’s language processing and use (not
     receptive or expressive vocabulary tests), memory, attention,
     reasoning, abstract thinking, judgment, problem-solving skills,
     auditory perception and visual perception shall be completed by
     two professionals—a speech-language therapist and either a
     certified school psychologist, a licensed school psychologist, or a
     licensed psycho-educational specialist who are knowledgeable of
     traumatic brain injury.

f.   Documentation of the student’s physical functioning that includes
     motor abilities, sensory functions, and the status of seizure activity,
     medication, and health.
      SC Special Education Law
g.   A behavior assessment shall include psychosocial, pre-injury
     functioning and adjustments to impairments.

h.   Documentation of the evidence that the student’s traumatic brain
     injury adversely affects his or her educational performance.
      SC Special Education Law
Evaluation Results:

   The school based team (which includes the parent) must determine
    if the student meets criteria to receive special education as a TBI (or
    other classification) student.

           IEP v. Section 504 Plan
   Section 504 Plan = Accommodations needed to access the general

   IEP = Special Education = needs for modified curriculum and direct
    or indirect services (Resource, Self-Contained, Speech, OT, PT, etc.)
         So now, what are your
   What are your IEP goals?
   504 accommodations
   What can you do in your classroom?
   Who can you ask for help?
                  Helpful Hint!

   Accommodations useful to a child with a
    TBI often benefit most or all the other
    students in the classroom!!

   Consistency!!!
       Agree on a strategy and apply it throughout
        the day and week
         Classroom Environment
Cognitive       Accommodations
Attention/      Seat  the student near the teacher, Minimize
Concentration   distractions, use earplugs, Low stimulation

Information     Reduce   Distractions, Small Group Instruction,
Processing      Position student for optimal learning
Memory          Provide written materials, consistent routines,
                schedules, visual aids, create an environment that
                doesn’t rely on memory
Reasoning       Designate  a specific location to return homework,
                Display classroom schedule and activities, Reduce
                unnecessary frustrations/problems
Classroom Instructions/Materials
Cognitive       Accommodations
Attention/      Use  peer note taker and tape recorders, Provide
Concentration   assignments in writing, match the student’s ability
                to attend, break tasks into smaller parts, alternate
                instructions with activities
Information     Give  the student “time to get it”, Review notes to
Processing      identify missed information, smaller segments of
Speed           info, emphasize key points
Memory          Use  tape recorders and highlighters, Use external
                memory management system, Test using multiple
                choice, chunk work into manageable pieces, written
                instruction, mnemonics, identify learning style
Reasoning       Use binders to keep materials and notes organized,
                Develop systems/use maps, use clear instructions,
                provide samples, keep routines
   Educating Students with TBI
            and Peers
Cognitive       Accommodations
Attention/      Educate  on attention types, clarify information,
Concentration   complete a predetermined amount of work, take
                rest breaks BEFORE becoming tired, limit
                interruptions and distractions
Information     Monitor   their own comprehension, ask questions,
Processing      signal if not understanding, educate others on
Speed           strengths and limitations, extra time to respond
Memory          Buddy system, peer note taker, external memory
                systems, routines, generate their own memory cues

Reasoning       “Stop and Think,” seek adult assistance, know your
                strengths and limitations, use a problem solving
                model, listen
    Modify your Expectations and

The teacher’s shift in his/hers expectations
 of what compromises competence
   For example:
       A teacher may feel the only test of “true”
        learning is to ask the student under time-
        limited conditions to recall ideas and facts.
       Try testing their learning through recognition
    Other things to keep in mind…

   Physical and Cognitive Endurance/Fatigue
   Low Frustration Tolerance
   Poor Awareness
   Rapid Classroom Pacing
   Lack of Predictability
   Negative Social Input
   Pragmatic Deficits
      What happens as a result of
     these deficits and behaviors?

   Friends leave
   Families mourn
   Teachers are frustrated
   The student is at increased risk for
    isolation from peers, academic failure,
    depression, substance abuse, sexual
    behavior, delinquency, further TBI
   An ear to listen
   A safe environment
   Clear structure and routine
   Consistency
   Immediate feedback and praise
   Reinforcement
   Cueing and modeling
   Advocacy
         Accessible Resources
   The Family
   School Psychologist
   Resource Teacher
   Guidance Counselor
   Speech Therapist
   Neuropsychologist
   Hospital Case Manager
   Peers and Friends
    Traumatic Brain Injury Information &

  A TBI tool kit for school staff can be downloaded at :

  A TBI tool kit for families can be downloaded at:
         Additional Resources

   www.brainline.org
   www.binav.org
   www.abieducation.com
   www.neuroskills.com
   www.projectlearnet.org
   www.dpi.wi.gov/sped/tbi-trg-pres.html
               In Summary
   Students must be identified, appropriately
    assessed, and then taught in ways that
    address both their strengths and
    weaknesses. Disguised as a low incidence
    disability, brain injury is occurring and
    students need our help at being successful
    in SC classrooms!

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