TBI training full day - Redmond School District

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					      TBI 101,
Eligibility & IEPs for
 Students with TBI

 Bathrooms
 Breaks
 Agenda
 Write a problem associated with TBI
  and children
    put it in the basket sometime this

 Overview
 Break
 Assessment
 Lunch
 Eligibility
 Break
 IEP Writing for students with TBI
   Teaching Research
20 years of researching brain injury
Developed model of TBI Teams &
 service delivery for TBI adopted by
 several states
Ongoing dedication to serving who
 have brain injuries and school
   See handout in packet of current projects
Oregon’s Response

Leading the way to serving the
 needs of students with TBI
  TBI Team-What is it?

 Teaching Research
 Regional Programs for Low Incidence
ODE, TRI & Regional Services
 an evolving service model
 One Part-time liaison per region who works to:
  Refer consultations to trained team
  Design and refine the model of TBI
   Services for Oregon
  Make presentations on TBI in region for
   building capacity
  Give input on website and TAP paper
  Serve as STEP contact from Legacy-
   Emanuel for students who have had a TBI
 New TBI team members

 Training open to educators throughout
  Oregon at no charge with permission
  of supervisor who covers substitutes
 2-year commitment
    6, 2-day trainings throughout year with
     nationally known speakers
   TBI Consulting Team
 Trained TBI Consultants
    Many volunteer time outside of work on
     evenings, weekends and over the summer
 Available to:
    Present in-services
    Consult with teachers, schools & families
    TBI Educational Consulting Team
 Contact us:
    TBITeam@wou.edu
    541-346-0593 877-872-7246
Other Supports for students
    with TBI in Oregon
Oregon Brain Injury Resource Network
    Email http://www.tr.wou.edu/tbi
    Resource librarian (Laura) available to
     find specific information for your
     particular request regarding TBI
              Coming soon:
Website for Oregon educators of students
 with TBI www.TBIED.org
    Evaluation/Eligibility, IEP, SDI, Related Services,
     Accommodations, Capacity Building, Access,
     Safety, and Transition
    Each content area has tabs for:
      •   General information
      •   Links
      •   Best Practices-articles and research-based advice
      •   Tools
Technical Assistance Paper on TBI
  Creating writing team next month for
   producing TAP this year
Brain Trivia…….
              The Brain
 About 3.5 pounds
 3 day Jello
 Bony case surrounded by less than ¼ cup of
  spinal fluid
 10 billion neurons
    Each neuron connects with others
      • average of 10,000 synapses
    Parallel processing saves the day
Simplified Brain Behavior Relationships
 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
The Injured Brain…
 Acquired Brain Injuries

                  Cerebral Vascular Accidents
Internal Causes

                  Ingestion of Toxic Substances
   Acquired Brain Injuries

                  Open Head Injuries
External Causes

                                Closed Head Injuries
Other Types of Injuries

  Contusion
     Bruising
  Crushing
  Shearing & rotation
  Coup-contra coup
Types of        Compression
                fracture                   Subdural veins
Damage                                     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 v. 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
       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 be unconscious
    Special Education

SPED Services and Children with TBI
   1994-1995
     • 7,188 students 6-21 yrs of age received sped
       services under TBI nationwide
   1999
     • 11,914 children served under TBI

                        Rehabilitation for Traumatic Brain Injury in Children and
                        Adolescents: Summary of Evidence-based Practice
                        Program Oregon Health Sciences University
National Statistics/100,000

  180/100,000 infants, children and
   adolescents hospitalized for TBI

                                       Krause, 1995
TBI in Oregon Special Ed

   269 Oregon students id with TBI in 2006

562,828 school children in Oregon in 2006
      At the 180/100,000 rate
      1008 students hospitalized for TBI annually in
Epidemiological Estimates

  If 1/3 of the 1000 (333) hospitalized
   for TBI need special education
  Conservative cumulative estimate
     ages 0-21
     4000 students in Oregon
       • ½ or 1500-2000 ages 16-21
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
   20% high school players
   5%
Horseback Riding
   17% of all equestrian injuries are brain injuries
     (Brain Injury Association of America)
Levels of Severity

 Does not always predict outcome
           Mild TBI ?

Also called post-concussive syndrome
    Brief or no loss of consciousness
    90% of concussions resolve in a few
    10% have symptoms that last a lifetime
    Symptoms are not “mild”
          Moderate TBI

 Loss of consciousness for < 24hrs
    Skull fracture, contusions, hemorrhage,
     or focal damage
    In children may result in
      •   Physical weakness
      •   Cognitive-communication impairments
      •   Difficulty learning new information
      •   Psycho-social problems
          Severe TBI

 Loss of consciousness > 24 hours
 Multiple cognitive, communicative,
  physical, social, emotional &
  behavioral problems
 20% return with minimal changes
    Approx 80% have life long changes
Medical Complications
 Resulting from TBI
 Post traumatic Seizures
     5% of People with TBI
 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
Neurogenic Heterotopic Ossification
   10-20% joint pain and decreased range of
Heterotopic Ossification
   hips, knees, elbows, shoulders, hands &
   Risk factors for HO are post traumatic
    coma >2weeks, limb spasticity and
    decreased mobility
   Greatest risk is 2-3 months post injury
  Medical Complications
   Resulting from TBI

 Spasticity
    25 %
 GI and GU complications
      stress ulcers
      dysphagia
      bowel and bladder incontinence
      elevated liver function
  Medical Complications
   Resulting from TBI
       Even more
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
Sensory & Endocrine
 Vision
    may have field cuts
    field neglect
 Feeling and Sensation
    loss of smell & taste or touch
 Hearing
 Endocrine Disorders
    hormonal
    pituitary
    thyroid
TBI & Mental Health Issues

  Depression is a common outcome
     In children can look like
       •   Agitation
       •   Anger
       •   Poor short term memory
       •   Lessened focus
       •   Irritability
 Early rapid recovery is not an
  indication that long-term recovery will
  continue rapidly and be complete
      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)
     Children and TBI

 Effects of TBI may not be evident until
  later in childhood when higher
  executive functions are required for
Recovery Sequence of Skills

   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)
  Recovery Sequence

 Speech Communication skills
    expressive speech may resolve within a
     few months,
    subtle language problems may persist
     indefinitely and go unrecognized
   Recovery Sequence

 Measured IQ changes
    mild head injuries may be relatively
     modest appear to recover around two
     months after injury-may not recover
    not as rapid as motor, sensory and
     speech functions
 Memory, Attention, Processing speed
    may persist for many months or
     permanently be reduced
  Recovery Sequence

 Higher Level Cognition
    information processing
    learning under complex or difficult situations
    ability to function effectively and efficiently in
     new situations.
    Children tend to be negatively affected by
     stress more easily than before.
    May be impacted for years or permanently

 “Everything will be normal within a
 Physical recovery is fast so cognitive
  will be the same
 Don’t know how to get help from
  school or community
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 of young man with TBI who was
              hiding from teachers as a 12th grader
TBI Assessment
  in Schools
Educational Difficulties
   Reading Comprehension
   Abstract Reasoning
   Literal & Factual Comprehension
   Interpretive & Evaluative
   Generalizing Information
   Organizing Material
   Performing Mental Computation

     Recovery to pre-traumatic
 achievement levels following head
injury does not guarantee continued
  achievement at pre-injury rate. A
  head injury has major impact on
           new learning!
   Executive Functioning
 poor social judgment          PROBLEM SOLVING:
 social disinhibition           decreased flexibility/
 Egocentrism
                                 slowed processing
 difficulty interpreting the
   behavior of others            diminished divergent
                                 concrete thinking
                                 immature problem solving
 Perseveration
                                 weak self-monitoring
 impulsiveness
                                 inefficient responses to
 poorly regulated attention       feedback/ consequences
 disorganization (in            reduced initiation
   thinking, talking, and
   acting)                       weak goal formulation
 dulled emotional responses     ineffective planning

                                               (Feeney, 2005)
Information Processing &
  Attention Impairments
   Slowed rate of processing
   Difficulty concentrating; fatigue
   Difficulty screening out distractions
    (external and internal)
   Difficulty concentrating; fatigue
   Difficulty disengaging and
                            (Sohlberg & Mateer, 2001)
 Memory & Learning
 Recent memories usually more affected
 Prospective memory (i.e., ability to carry out
  intended actions)
 Working memory (i.e., what’s on one’s mind)
 Orientation problems
 Motor/procedural learning systems may be
  relatively spared
 Implicit learning may be spared

                              (Sohlberg & Mateer, 2001)
    Behavioral Changes
“In pediatric brain injury the first sign or
symptoms of the consequences of traumatic brain
injury can be behavioral and personality changes.
All too often the reality of pediatric brain injury is
that the consequences of that injury are
misdiagnosed as symptoms related to hyperactivity
and ADHD, Conduct Disorder or Oppositional
Defiant Disorder.”
                                    ~Barbara C. Fisher, Ph.D.
                                  Fully Licensed Psychologist
                                       and Neuropsychologist
Behavioral Difficulties

 Irritability
 Anger outbursts
 Agitation (overstimulation)
 Apathy
 Emotional lability
 Hyperactivity
 Withdrawal
Behavioral Impairments

  Impulsivity
  Social Disinhibition
  Inappropriate behavior
  Short temper
  Aggressive Behavior
  Easily frustrated
Emotional Difficulties
 Loss of inhibition
 Rapid changes in emotion
 Emotional “flooding”
 Poor self-esteem
   Irritability, low frustration tolerance
   Impulsivity
   Anger
   Depression
Insight and Self-Awareness

   May overestimate own abilities
   Challenge to caregivers and therapists
        Confrontation usually backfires
        Awareness important for growth
        Peer feedback may carry more weight
        Self-ratings (strengths vs. areas for
  Social Difficulties
 Immaturity
 Diminished conversational skills
    Poor eye contact
    Decreased awareness of non-verbal
    Difficulty taking turns in conversation
    Increased (perhaps necessary) self-
“You Must Remember This”
    A student with a brain injury is
            a person first!

    Every brain injury is unique
    Effects vary greatly
    Outcomes depend on multiple factors:
         Cause       Baseline Functioning
         Location    Intervention
School Re-entry
     Traditional Rehabilitation
       for Students with TBI
Trauma Care
 Stabilization   Re-Entry
       Ideal Rehabilitation Course
          for Students with TBI
MEDICAL             SCHOOL               FAMILY
Trauma Care
Neurological                             regarding
 Stabilization                           needs &
Rehabilitation                           services
 Services           Education
 evaluation         Plan
                 Re-evaluation      School Re-Entry
                 and Revise
Hospital School Transition

  Treatment
  Transportation
  Academics
  Physical Education
  Access and Physical Movement
  Behavioral Problems
  Counseling
 Upon discharge schools
    need to know…..
                                Self-Care Abilities
 Present Physical
  Condition                     Prescribed Medication
 Motor Skills                  Communication
    •   Physical Limitations     Abilities
    •   Activity Limitations
                                Behavior Concerns
 Therapy Requirements
 Required Assistive            Cognitive Recovery
  Devices                        Pattern
                                Results of Evaluations
Objectives for Re-Entry

 Identify the key concepts of re-entry
  for TBI students
 Describe the TBI team and its
 Identify the issues for assessing TBI
  students for re-entry
 Describe the process and issues for the
  development of the IEP
Objectives for Re-Entry

 Identify the effects of TBI on the
  family and peers
 Describe considerations and placement
 Identify important factors in the
  relationship between expectations and
  developmental stages
Re-Entry Considerations

 The needs of the student as defined by IEP
  goals & objectives
 Scheduling concerns
       Time in school
       scheduling around appointment
       Fatigue
       Hallway chaos
 Environmental & safety concerns
 Medical concerns
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 &
  Flexibility
  Rehabilitation Act, Section 504
Techniques for Transition

 Prior agreement on length of school
  day, safety & special equipment
 Prepare everyone with information
 Prepare child with a story
 Preliminary visits to school
 Second set of books at home
       Case Study #1

 Male, CA=10, GR=5
 Date of injury 3/1/02, fell 30 feet
 Right posterior frontal and temporal
 Right posterior orbital fracture
 Sphenoid fracture
 Coma for two weeks

                  VC    PO/   FD/   PS    FSIQ
                        PR    WM
           4/02   113    79    96          95
           9/02   120   123   131   101   124
           1/05   134   123   123   100   127
Three Year Comparison

 80                      10 yr 3 mo
 60                      10 yr 8 mo

 40                      13 yr 2 mo

      VIQ   PIQ   FSIQ
       GR:5, 6 ’02        GR:8 ’05
       WISC-III           WISC-IV
       INFO SIM   ARI     VOC COM    DS
4/02    11   15      10   15   8     8
9/02    15   13      17   13   13    14
3/05         16           15   16    15
        PC   CD      PA   BD   OA    SS
4/02    8    1       6    11
9/02    16   9       9    18   12    11
3/05         9            14         11

         BROAD    BROAD   BROAD
        READING   MATH     WRIT
 4/02     9.0      5.8      5.1

          125      100     94

 9/02     14.1     8.1     6.6

          148      124     104
      NEPSY GR:8 1/05
                    DOMAIN SCORE   PERCENTILE

ATTENTION / EXEC.       119           90
   LANGUAGE             103           58
 SENSIOMOTOR            92            30
  VISIOSPATIAL          136           97
    MEMORY              107           68
          Case Study #2
 Male, CA=14, GR=10
 Date of injury 7/10/04, ATV accident
 Difuse axonal injury
 Left lambdoidal suture (where the parietal and occipital
  bones of the skull meet) diastasis (separation) fracture
  with extension to the mastoid (temporal bone behind the
  ear at the base of the skull)
 Intracranial pressures
 Hemorrhagic (bleeding) contusion (bruise) in the left
  temporoparietal region and the right frontal region
 Small subdural hemorrhage and contusion in the
  superior temporal area

Beta APP stain showing beaded axon to the left and
   accumulation in other axons and nerve cells.

       VC    PR/PO   WM   PS   FSIQ

9/04   85     69     71   53    64

1/05   106    96     94   75    92

5/07   126    91     92   86   107
       WISC-IV and WAIS-III
       SIM   VOC   COM   IN    DS   LN   ARI
9/04     1   11    10          9    1    7
1/05    11   12    11     9    8    1    10
5/07    17   15    18    12    8    6    12

        BD   PCn   MR    PCm   CD   SS   CA
9/04    4     4     7     4    2    1
1/05    8    11     9     9    6    5    3

5/07    9          12     5    6    9
School-based Intervention
  Identify strengths
  Identify several people who are willing
     natural helpers (prior relationship is best)
       • Peers
       • Counselors
       • Parents
       • Teachers
       • Mentors
  Student strengths + strength of natural
   helpers + strategies in natural context
Eligibility for
Serving Students with TBI

 The needs of the students with TBI
 are different than the needs of other
 students with disabilities
   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.
Traumatic Brain Injury
   Defined by ODE
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 includes open or closed head
injuries resulting in impairments in one
       or more areas, including:

      cognition
                            sensory, perceptual,
      language              and motor abilities
      memory               psychosocial
      attention             behavior
      reasoning            physical functions
      abstract thinking    information
      judgment              processing
    problem-solving        speech
The term does not include brain injuries
that are congenital or degenerative, or
brain injuries induced by birth trauma…
Shaken Baby Syndrome
Physical brain injury from shaking a baby excessively

    • Child abuse
    • Infanticide
    • Throwing baby in the air
    • Jogging with a baby in a backpack
Shaken Baby Syndrome
 "Shaken Baby Syndrome" (SBS) is
  identified when a child is admitted to an
  emergency room with
    subdural hematomas,
    retinal hemorrhages, and
    the history is not that of a motor vehicle accident
     or a fall from an appreciable height.
 Some have referred to this as the "Shaken
  Baby Triad."
Educational options…

1. No special needs
2. “504” type needs
3. Special education eligibility

Transition planning may be needed
   for all three.
   Section 504
Special Education?

    How to decide?
What are the differences?
            Section 504
Section 504 is a civil rights law that prohibits
discrimination against individuals with
disabilities. Section 504 ensures that the child
with a disability has equal access to an
education. The child may receive
accommodations and modifications.

  Section 504 &
Special Education

 Criteria for eligibility differs
 Services differ
 Protections differ
 Legal safeguards differ
 Funding differs
        Section 504
     Eligibility Criteria
To be eligible for protections under Section 504, the
child must have a physical or mental impairment.
This impairment must substantially limit at least one
major life activity. Major life activities include
walking, seeing, hearing, speaking, breathing,
learning, reading, writing, performing math
calculations, working, caring for oneself, and
performing manual tasks. The key is whether the
child has an "impairment" that "substantially limits .
. . one or more . . . major life activities."
Eligibility has Two Prongs

  1. The presence of a diagnosed disability.

  2. The need for special education services.
   TBI Eligibility Form

The team has obtained the following
assessments (attach evaluation
report that describes and explains
the results of the evaluation
The team has obtained all of
the following assessments:
1. The team has reviewed existing
   information, including information from
   the parent(s), the student’s cumulative
   records, and previous individualized
   education programs or individualized
   family service plans. Evaluation
   documentation includes relevant
   information from these sources used in the
   eligibility determination.
   Date Reviewed
    Medical Statement

2. A medical statement or a health
   assessment statement indicating
   that an event may have resulted in a
   traumatic brain injury:
   Physician, Nurse Practitioner, or Physician's
   Date Conducted
   Date Reviewed
Psychological Assessment

 3. A comprehensive psychological
    assessment using a battery of
    instruments intended to identify deficits
    associated with traumatic brain injury:
    Examiner
    Assessment
    Date Conducted
    Date Reviewed
TBI Eligibility Requirement

  A comprehensive psychological assessment
  using a battery of instruments intended to
  identify deficits associated with traumatic
  brain injury:
   Broadly or completely covering; including a large
    proportion of something.
   So large in scope and content as to include much
   thorough, exhaustive
According to Jerome Sattler:
   comprehensive tests contain more than one
   includes at least 2 subtests for each area
Psychological Assessment
“Psychological testing is not the same as psychological
assessment. Psychological assessment is a process that
involves the integration of information from multiple
sources, such as psychological tests, and other
information such as personal and medical history,
description of current symptoms and problems by either
self or others, and collateral information (interviews with
other persons about the person being assessed). A
psychological test is one of the sources of data used
within the process of assessment; usually more than one
test is used.” (Wikipedia)
Battery of Instruments

…intended to identify deficits associated
 with traumatic brain injury:
     NEPSY-II
     WISC-IV
     Children’s Memory Scale
     Wechsler Memory Scale
     Wisconsin Card Sort
     UNIT
 cognition            sensory, perceptual,
 language              and motor abilities
 memory               psychosocial behavior
 attention            physical functions
 reasoning            information
 abstract thinking     processing
 judgment             speech

 problem-solving
    Other Assessments

4. Other assessments including, but
   not limited to, motor,
   communication, and psychosocial
   assessments as indicated by the
   student’s functioning in those areas:
   Examiner
   Assessments
   Date Conducted
   Date Reviewed
  Other Assessments
Other assessments including, but not limited to,
motor assessments if the child exhibits motor
impairments; communication assessments if the
child exhibits communication disorders; and
psychosocial assessments if the child exhibits
changed behavior. These assessments must be
completed by educators knowledgeable in the
specific area being assessed;
    Pre-Injury, Adaptive
5. Other information relating to the
   student’s suspected disability,
   including pre-injury performance
   and a current measure of adaptive
   Examiner
   Date Conducted
   Date Reviewed

6. An observation in the classroom
   and at least one other setting:
   Examiner
   Date Conducted
   Date Reviewed
    Impact of Disability

7. Assessments to determine the
   impact of the disability:
   Examiner
   Assessments
   Date Conducted
   Date Reviewed
    Educational Needs

8. Additional assessments necessary to
   identify the student’s educational
   Examiner
   Assessments
   Date Conducted
   Date Reviewed
The student meets all of the
     following criteria:

1. The student has an acquired injury to
   the brain caused by an external
   physical force

2. The student’s condition is permanent or
    expected to last for more than 60
    calendar days
3. The student’s injury results in an impairment
   of one or more of the following areas:
    Communication;
    Behavior;
    Cognition, memory, attention, abstract thinking,
    judgment, problem solving, reasoning, and/or
    information processing;
    Sensory, perceptual, motor and/or physical
Commonly Categorized
Students with TBI frequently receive SPED
services under another qualifying category
   It’s easier!
   It’s faster!
   It doesn’t matter what category a student
    receives services under ????? Hmmm….
The Right Category Matters!

    Accurately identifying the basis of the
     student’s difficulties increases understanding
    Instructional strategies and behavior
     management strategies differ
    Increased awareness of TBI and need for
    Dollars flow through special education
     eligibilities via formulas that are established
     by the state
Why not just identify with
  LD, OHI, VI, etc….?

Other eligibilities have less variability over
 time and setting
Knowledge of TBI becomes lost over time
    effects are not lost
      • Need for higher functioning may occur after student is
        no longer eligible under another eligibility
      • Consequences of TBI may not be recognized as
        disabilities-idiosyncratic quirks
      TBI is NOT a
   Learning Disability

 Look for differences in pre-injury vs.
  post-injury performance

 NOT Ability vs. Performance
 Goals go beyond academics alone
Traumatic Brain Injury (TBI)
vs. Learning Disabilities (LD)

    What these students have in common:
      • poor organization and planning
      • poor problem solving
      • some difficulty with social interaction
   So What’s Different
       About TBI?
 Problems tend to be more exaggerated.
 More extreme discrepancies among skills.
 More uneven and unpredictable progress.
 The condition could improve to pre-injury
 Previously learned material may be gone
  or need to be relearned.
 TBI is likely to cause
    problems with
 Impulse control/ Judgment
 Organization
 Skill integration
 Generalization
 Abstract reasoning
 Social judgment
 LD could demonstrate all of the above
Characteristics that Differentiate Students
  with Traumatic Brain Injury (TBI) from
   Students with Learning Disabilities

   Students with traumatic brain injury tend to:
       • Be more impulsive and distractible
       • Have more significant discrepancies in ability levels (Swiss
       • Learn more rapidly than students with LD (particularly during
         the first several years following the injury)
       • Have more severe problems with generalization of skills
       • Have more significant problems with memory
       • Have weaker organizational and problem solving abilities
       • Demonstrate more uneven and variable learning rates
       • Have more limited processing abilities
       • Be resistant at times to new strategies because of awareness of
         pre-accident skills
            TBI ~vs~ LD

 Hx of ability to perform       Skill was always difficult
 Sudden loss of ability and     Same types of problems
  variable recovery or            throughout school years
  development of skills          Trouble with specific
 Highly variable learning        academic area e.g., math,
  needs across all academic       reading or written language
  areas                          No loss of skill due to a
 Trauma caused loss of skill     traumatic event
 Identity must be               Identity always the same

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
Lack of Awareness of TBI

   Believed to be a “Low Incidence”
   Plasticity myth - continued
    misperception that “kids bounce
   Child will be “fine” perpetuated by
    medical community
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
As student transitions from elementary to
 middle/junior high to high school history
 of injury and its impact is lost
    Writing an IEP for a
     student with TBI
 What is in the IEP for students with TBI
 Notes for writing an IEP for a student with
 Program needs for students with TBI
 Measurable annual goals
 Services and supports to consider for
  students with TBI
    What is in the Individual
     Education Program?
The IEP is an agreement between the local school district
and the parents of a student who is eligible for special
education services. It summarizes the present levels of
academic and functional performance of a student, has
annual goals, indicates the amount of time a student will
attend regular classes, be away from non-disabled
students, any accommodations the student may need to
participate in classes and statewide assessments, a plan for
transition services (for students 16 and older) dates and
location of services to be offered, related services that will
be offered to the student and supports for school
Who should be at an IEP meeting
    for a student with TBI?
   parent/guardian
   student (if appropriate)
   case manager (usually the special education
   classroom teacher
   district representative
   person knowledgeable about TBI
   person able to interpret evaluation data
Other professionals to include

   school psychologist
   physical therapist
   occupational therapist
   speech pathologist
   person with expertise in TBI (consultant)
   vision specialist
   deaf hard of hearing specialist
   school nurse
Notes for writing an IEP for a
      student with TBI

  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
    how quickly the student thinks, speaks and performs tasks
 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
      confablation
 That need to be addressed in the IEP
Present Levels of Academic
 Achievement & Functional
 Include information on the student’s academic,
  social, behavioral, sensory, communication, mobility,
  and medical issues such as headaches or fatigue.
    Adaptive ability results
    Focus on student strengths and effective strategies
    Describe what helps the student learn
    What limits or interferes with the student’s
    Include objective data from evaluations
    Indicate how the disability affects ability to
     progress in the general education curriculum
Common Cognitive Issues

Orientation to place and time reduced
Overload/breakdown of comprehension
    Especially when fatigued
    Results in irritability, tears, tantrums
    Rate of processing
    Rate of performance
Measurable Annual Goals

 State goals as an increase in positive
  behaviors rather than the elimination of
  a negative behavior
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 settings
      Teach same skills in multiple settings
  Executive functioning skills can not be
   taught in isolation
 Goals that go beyond
specific academic areas
 Keep goals functionally oriented and outcome-based
 Base goals on the student strengths paired with
  student need
 Look for changes in any of the areas
 IEP may need to be rewritten every 2-4 months to
  meet changing needs of student
 State objectives as an increase in positive behaviors
  rather than the elimination of negative behavior
    Sample IEP Goals

   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 student as an invitation to play
   Jenny will remove herself from a confrontation with a
    classmate by going to the counselor’s office and choosing
    an activity from her cool down box – 2 out of 3
    opportunities during lunch/recess.
  Cognition IEP Goals

   After learning 4 memory techniques, Sarah will chose one
    and use it to recall the names of 5 friends 3 times each
   To be better prepared for homework, Sam will record class
    assignments in a planner and review it at the end of the day
    with Mr. Green

   Shelly will self-advocate by requesting the elimination of
    sources of distraction during instruction in an appropriate
    way 4 out of 5 times two consecutive days
Cognition Goals continued….

   Abstract thinking
      Given a form to complete, Suzy will make a
       reasonable inference about a paragraph she has
       read 4 out of 5 times for 6 weeks in a row.
      After listening to a paragraph from different
       content areas, Ginger will accurately predict
       what might happen next 3 out of 5 times for 5
       consecutive days.

 With guidance Mary will use a matrix of
  choices to determine the best option for
  herself when deciding between 3
 Mary will meet with Ms. Stand to discuss
  consequences of 1 choice she plans to make
  prior to lunch 3/5 days each week.
 Cognition even more

 Problem solving
      Sandy will generate 4 solutions to a problem she has had
       at recess and choose a solution to try the next recess 3 out
       of 5 days each week.
      After choosing a problem, Sid will meet with his mentor
       to determine ways to solve the problem.
 Reasoning
      Bentley will create a shopping list using the amount of
       money he has budgeted.
      With guidance, Bentley will use a shopping list he has
       created to purchase needed items for the week at the
    Perceptual Motor

 Taylor will use visual cues to find her
  way from class to class independently
  4 out of 5 classes for 3 consecutive
 Taylor will be accompanied by an
  assistant between classes
   More Sample Goals

 Information processing
    After listening to a story, Sandy will retell with
     pauses of less than 30 seconds, 3 times each
 Sensory
    When crossing the street with assistance, Steve
     will turn his head to use his right eye to scan the
     left side of his body to keep his body safe
Physical Abilities Goals

 Given a tangible cue, Dakota will
  navigate the hall independently in his
  wheel chair to the destination indicated
  by the cue.
 Karla will spend 30 minutes each day
  in her stander.
Effective programs for students
    with TBI typically include

    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
Thoughts on placement decisions

    Cautions about home tutoring
       Behavioral problems may increase
         • family members not trained to handle
         • The student may fall farther behind
         • student may become anxious about returning
           to school
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

 Students regain skills best with
      The familiarity of the classroom
      known teachers
      known peers
      routines
      behavioral and cognitive supports
                             Adapted from Ylvisaker. Traumatic Brain
                             Injury Rehabilitation: Children and
                             Adolescents. 2nd ed. Appendix 17-1
   IEP Activity Basket

 Choose a TBI problem from the basket
 Ask a random person (or your
  neighbor) to work with you
 Work together to write two goals for a
  student with TBI
 Be willing to share your favorite goal