Students with TBI: Who and Where are They? What are the Effects of TBI? What Do They Need?

1. Students with TBI: • Who and Where are They? • What are the Effects of TBI? • What Do They Need?

2. The Brain • About 3.5 pounds • Consistency of 3 day-old Jello • Bony, bumpy case surrounded by less than ¼ cup of spinal fluid • 10 billion neurons • Each neuron connects with others • average of 10,000 synapses

3. Brain Injury Congenital Brain Injury Pre-birth or during birth Acquired Brain Injury After birth process Traumatic Brain Injury (TBI) • Closed Head Injury • Concussion • Swelling results in further • (secondary) injury • No loss of consciousness • Damage great or greater than • open brain injury • Open Head Injury • Skull is fractured • Blood & swelling have a • place to go

4. Compression fracture Subdural veins torn as brain rotates forward Swelling of brain stem Shearing strains throughout the brain Damage to temporal lobes from rough bones at skull base Types of Damage in a Closed Head Injury

5. Coup Contra-coup

6. Brain Shearing Plane Protrusion Skull Skull Protrusions Adapted From: Pang, 1985

7. Overly Simplified Brain Behavior Relationships Parietal Lobe Frontal Lobe Occipital Lobe Temporal Lobe Cerebellum Brain Stem 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• Sense of touch• Differentiation: size, shape, color• Spatial perception• Visual perception 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

8. What’s Different about TBI? • No two brain injuries are exactly the same. • Brain injury is complex and varies greatly from person to person. • Cause, location and severity of injury determine the effects. • Long-term effects are not always apparent and may present as cognitive and environmental demands increase. • Attainment of developmental milestones may be effected by a past injury. • Commonly results in functional deficits that may be identified in another disability category(ies)

9. Causes of TBI in Children • Motor Vehicle Crashes • High Risk Sports • ATVs, rodeo, skiing, snow boarding • Motorcycle incidents • Pedestrian vehicle incidents • Violence • Falls • Abuse • Shaking

10. TBI in Children 1.4 million children injured annually Highest risk groups ages 0-4 and 15-19 More likely to survive than adults Less likely to lose consciousness 1/50 kids have had a concussion

11. Scope of the Problem: Oregon • Approximately 1000 children hospitalized annually in Oregon • More than 1/3 experience persisting functional limitations • Expected yield = approx 3,000-4,000 identified • Just over 300 identified for SPED under TBI in Oregon • Just 50 in NWRESD service area

12. Why Don’t We Find Them? • Lack of medical training and referral • Lack of educational training and awareness • Lack of parental recognition • Many “look good” physically • Developmental bias that they will be OK

13. Under–IdentificationCycle

14. Special Educational Definition of TBI …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.

15. Sequence of Skill Recovery • Motor • Gross motor functioning (1 to 2 months) • Sensory • Improves relatively rapidly in children (1 to 2 months) • Speech Communication skills • Expressive speech may resolve within a few months, • Subtle language problems may persist indefinitely • Measured IQ • May be small changes • Not as rapid as motor, sensory and speech functions • Memory, Attention, Processing speed • May lag for many months or be forever reduced • Higher Level Cognition • Information processing • Learning under new, complex or difficult situations • Ability to adapt to new problems or situations. • Children negatively affected by stress more easily than before. • May be impacted for years or permanently

16. 2 Years After Injury…. • 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)

17. Pet Scans – New Learning • Everything lights up with new learning • Pathways rewire • Pathways are created through repetition • Eventually, learning results in more efficiency • Tend to encode Irrelevant Information

18. Residual Cognitive Deficits • Disorders of Attention – easily fatigued, impaired shifting, impaired maintenance, impaired selection • Disorders of Memory – poor rote, short term difficulties, storage and retrieval difficulties, prospective memory problems (remembering to remember) • Disorders of Planning – slowed initiation, disinhibition, poor at abstraction, poor sequencing, doesn’t learn from mistakes, doesn’t ask for help, can’t get started

19. Residual Cognitive Deficits • Disorders of Judgment – misinterprets actions of others, can’t handle multiple bits of information at once, socially unacceptable physical and verbal behaviors, little self awareness of strengths and weaknesses • Disorders of Information Processing Speed – extreme slowness in reaction time, slowed psychomotor activities – writing, talking, etc. • Disorders of Communication – anomia, inefficient word retrieval, hyperverbal, peculiar use of words and phrases, uninhibited word choice Roberta DePompei, 2009

20. Daydreams, pesters peers, fiddles with materials Blurts out, interrupts, tangential speech Poor test-taker, inconsistent memory of information Needs multiple repetitions of directions, acts rude, doodles, bolts Misunderstands humor, puns, double meanings Impaired attention, perception, memory Inflexibility, impulsivity, disorganized thinking Inefficient storage and/or retrieval of information Inefficient processing of info: rate, amount, complexity Difficulty processing abstract information Observed BehaviorsUnderlying Problems

21. Can’t learn new games, decision rules, changes in targeted task Temper tantrums, sticks with one solution, won’t change mind Poor social interactions, foul language, hot temper Lack of awareness, poor task completion, trouble with change Inflexibility, poor working and short term memory, poor “shifting” (multitask) Ineffective problem solving and judgment, Limbic dysregulation Poor judgment, lack of self-awareness, language deficits Impaired “executive”skills Observed BehaviorsUnderlying Problems

22. INTERVENTIONS – What do they need? 0-21

23. Physical Challenges

24. Executive Functions

25. Memory Interventions • Repeat often and summarize • Have child paraphrase, doodle, condense for encoding • Carry assignment sheet for each class • Closed-ended tasks (fill-in vs. essay) • Categorize or “chunk” information • Use visualization • Link new information to prior knowledge • Give examples with instruction • Discrete task objectives (Vocabulary) • Rehearsal (often doesn’t work real well) • Visual interventions such “Inspiration” Software • Auditory interventions such as tape recorder, books on tape

26. Self Regulation • Reduce distractions in work area • Make tasks shorter • Behavior contract • Divide work into smaller segments • Use cues (words, sounds, tactile) to alert person to pay attention • Build in choice • Increase joyfulness, high interest and relationship • Ignore dis-inhibited response • Incentive Systems • Keep tools and materials available • Keep it structured • Allow for frequent breaks

27. Slow processing speed

28. Processing Speed Strategies • The Wright Family Story! • Give more time to complete requested tasks • Slow pace of Instruction • Note taker • Condense tasks • Music • Use Scaffolding and Modeling

29. Strategic Learning Strategies • Prompts and reminders • Provide scoring rubric • Have child provide a written plan • Break down tasks and timelines (note cards) • Coaching • Structured teaching • Re-teach affect and social clues • Flexible performance options • Visual and written instructions • High degree of tactile reinforcers • Teach Note Methods • SQ3R (Survey, question, read, write, review)

30. Concrete Thinking Difficulty with abstraction, synthesis, inference etc.

31. Planning Interventions • Draw maps, use lists, timelines, visual schedules • Goal Setting • Color-code materials, information (definition vs. main idea • Electronic organizers • Preview completed assignment • Answer – “How will I know when I am done?” • Establish Routines • Use paraphrasing, re-teaching, reciprocal coaching • Meet at beginning and end of day • Post-activity reflection

32. Self-Regulation and Behavior

33. Template PromptsPlan-Do-Review • Goal “What do you need to do?” “What are we here for?” “What will it look like when it’s finished?” • Obstacle “What stands or might stand in the way of accomplishing the goal?” • Plan “What will you do first, second, third, etc?” • Student makes prediction about success of plan “Will it be hard or easy?” Is it scary or not scary?”“Will it take an hour or take 6 hours?” “Is it a choice or not a choice?” • Do “Let me know if you need any help.” • Review “How did that work out?” “What would you do differently?” “Do you think you met your goal?”

34. Behavioral Interventions(Very Common) • Conduct a FBA • Give very clear written and verbal guidelines • Big 5 • When to start • What to do • How much to do • What finished looks like • What to do next • Coach to assist with misperceptions • Implement Positive Behavior Supports

35. Self Regulation Executive Functioning Communication Skills We must teach and support the underlying processes to get to self-regulation R. DePompei 2009

36. What Can You Do? • Remember that TBI is vastly under identified • When you see unexplained behaviors or learning characteristics….suspect! • Ask! “Has your child ever had a blow to the head or a concussion?” • Add the question to medical cards • Visit some of the great websites available

37. NWRESD TBI Educational Consulting Team Laura Bekken lbekken@nwresd.k12.or.us 503-614-1683 Cindy Hodges chodges@nwresd.k12.or.us 503-614-1670 Kristy Young kyoung@nwresd.k12.or.us 503-614-1672

38. Oregon Brain Injury Resources http://www.tr.wou.edu/tbi • Resource librarian (Laura Beck) is available to find specific information for your particular request regarding TBI http://www.tbied.org • TBI Educator website from Teaching Research Institute is very dense with information, resources, forms, training opportunities

39. Websites of Interest • http://www.bianys.org/learnet/ - LearnNet – excellent resource for educators and parents • http://www.schoolbehavior.com/conditions_edfoverview.htm • http://www.braininjurypartners.com/login/?next=/ especially for parents-Username=wear your Password=helmet • www.cde.state.co.us/cdesped -Enter “TBI manual” in search for excellent educator’s manual on TBI

40. QUESTIONS/COMMENTS