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Brain Injury 101Supporting Students
with Brain Injury
In the Classroom
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OBJECTIVES
Review federal and state definitions oftraumatic brain injury (TBI)
Learn about the discrepancy between:
Incidence rates of TBI among
children and youthvs.
Number of students counted in the TBI
category of Special Education
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OBJECTIVES
Developan understanding of thecauses and effects of TBI on children,
their families, and communities
Learn about normal brain
development and the effects of braininjury on a developing brain
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OBJECTIVES
Develop an awareness of the
potential physical, cognitive,
behavioral, and psychosocial effectsof a TBI
An overview of successful strategiesand resources for supporting
students with TBI in the classroom
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WH TIS THE DEFINITION OF ATR UM TIC BRAININJURY(TBI)?
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BRAIN INJURY
Congenital brain injury
Pre-birth During birth
Acquired Brain Injury
After birth process
Traumatic Brain Injury
(external physical force)
Closed
Head
Injury
Open Head
Injury
Non-traumatic
Brain Injury
Savage, 1991
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IDEA Definition of TBI:
an acqu ired in jury to the brain
caused by an external phys ical
force resu l t ing in total or part ialfunc t ional d isabi l ity or
psychosoc ial impai rment o r bo th
that adversely affects a childseducat ional perfo rmance.
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TBI Definition (IDEA)
The term appl ies to open or c losed head in jur ies
resul t ing in impairments in one or m ore areas,
such as:
cogni t ion
language
memory
attent ion reasoning
abstract th inking
judgement
problem-solv ing
senso ry, perceptual and
motor abi l i t ies
psy chos ocia l behavior
phy sica l funct ions
in format ion processing
speech
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TBI Definition (IDEA)
The term does not apply to brain
injur ies that are congeni tal ordegenerat ive, or brain inju r ies
induced by b ir th trauma.
Federal Public Law 101-476
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StrokeBrain Infection
Tumor
Anoxia
Exposure to Toxic Substances
Neither definition includesacquired brain injuries caused
by internal conditions, such as:
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Important note:
Brain injuries
that result from either an
external
or internal force
may have similar effects.
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WHO
SUSTAINSABRAIN
INJURY?
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National prevalence rates ofvarious disabilities
400,000 with Spinal Cord Injuries
500,000 with Cerebral Palsy
2.3 million with Epilepsy
3.0 million with Stroke-related Disabilities
4.0 million with Alzheimers Disease
5.3 mil lion w ith Traumatic B rain Injury
5.4 million with persistent Mental Illness
7.2 million with Mental Retardation
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IN TENNESSEE
Since 1996, the TBI registry hasrecorded over 7,000 persons, ages3 to 21, who have been hospitalizedfor treatment of a brain injury
0
200
400
600
800
1000
1200
1400
1600
TBI
Registry
DOE
Report
The number of people,ages 3 to 21, who wererecorded in the TBIRegistry for the 2003 -2004 school year: 1547
Number of studentsclassified as having aTBI according to theDOE report of the 2003 -2004 school year : 306
What is happening with the 1,241students?
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Reasons for the
discrepancy Not all children who
sustain a brain injuryexperience lasting
effects
The etiology of a
students disability may
be unidentified or
misunderstood
The student may be
served under a 504 plan
The effects of the brain
injury in children can be
latent, surfacing as more
advanced skills are
required of the student at
school
When the effects of theinjury do surface, they may
resemble other disabilities,
such as a learning
disability or emotional
disorder
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HOWAND
WHEREDOES TBI HAPPEN?
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WHY
TBI is so devastating MYTH: Younger
children are more
resilient and can
therefore bounce
back easier and
more quickly from a
brain injury.
REALITY: It may just
take longer for the
effects of a brain
injury to show up in
a growing and
developing brain.
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WhyTBI is so devastating
Myth: Visible,
physical
recovery is a
sign that the
brain is healed.
Reality:The
cognitive and
behavioral effects
of a brain injury
can last long after
the person heals
on the outside.
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The
Growing Brainand
Injury
Surface View
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Geographyof the Brain
Midline View
Surface View
Hippocampus
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TBI in children
can be especially devastating,
as a childs brain is in an almost
constant state of development.
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Rates of Development for theFour Regions of the Brain
% of maturation increments
age increments
1 3 5 7 9 11 13 15 17 19 21
5 DistinctPeriods of
MaturationP-O parietal/
occipital
C central(limbic
& brainstem)
T temporal
F-T frontal/
temporal0
2
4
6
P-O
C
T
F-T
P-O
C
F-T
P-O
T
C
F-T
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The Anatomy
ofa Brain Injury
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Two types of TBI
OPEN-HEADINJURY (penetrating)
Example:
Skull fracture that
penetrates the
brain
Gunshot wound
CLOSED-HEAD
INJURY
Example:
Coup-ContraCoup
Diffuse axonal injury
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Two Classes ofBrain Injury
PRIMARYTHE INJURY IS MORE OR
LESS COMPLETE ATTHE TIME OF IMPACT
SKULL FRACTURE
CONTUSION/BRUISING OF THEBRAIN
HEMATOMA/BLOODCLOT ON THE BRAIN
DIFFUSE AXONAL
INJURY
SECONDARYTHE INJURY EVOLVES OVER APERIOD OF HOURS TO DAYSAFTER THE INITIAL TRAUMA
BRAIN SWELLING/EDEMA
INCREASED INTRACRANIAL
PRESSURE
INTRACRANIAL INFECTION
EPILEPSY
HYPOXEMIA (LOW BLOODOXYGEN)
HIGH OR LOW BLOOD
PRESSURE
ANOXIA/HYPOXIA (LACK OF
OXYGEN TO THE BRAIN)
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PRIMARY INJURIES
Coup-Contra Coup
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PRIMARY INJURIES
Axon
Rotational forces on
the brain cause thestretching and snapping
of axons
Diffuse Axonal Injury
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PRIMARY / SECONDARYINJURIES
Epidural
Hematoma
Subdural
Hematoma
Intracerebral
Hemmorhage
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SECONDARY INJURIES
Enlarged
Ventricles
Brain withHydrocephalus
Brain with Edema
Edema
(swollen
brain
tissue)
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ConsequencesChallenges
After
Traumatic Brain Injury
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TBI ENORMOUS
VARIABILITY
TYPE OF
INJURY&
SEVERITY
AGE
AT THE TIME
OF INJURY
PRE-EXISTING
DISABILITIES
OR BEHAVIORS
RECOVERY
AVAILABLE
KNOWLEDGE,
RESOURCES,
&
SUPPORT
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TBI Can Affect
Physical skillsCognitive skills
Behavioral /Psychosocial Skills
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Possible Physical Effects
Impairment of:
Speech
Vision
Hearing
Difficulty with:
Balance
Spasticity Paralysis
Paresis
Less obvious physical effects:headachesfatigue
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Possible Cognitive Effects
Impairments in:attention or
concentration
ability to initiate,organize, orcomplete tasks
ability to sequence,generalize, or plan
flexibility ofthinking, reasoning,or problem-solving
abstract thinking
judgment or perception
long-term or short-termmemory
confabulation
ability to acquire orretain new information
ability to processinformation- slowed
speed
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Possible Behavioral /Social Effects
VERBAL / PHYSICAL
AGGRESSION
LOW
FRUSTRATION
TOLERANCE
MOOD SWINGS
OR
EMOTIONAL LABILITY
IMPAIRED
ABILITY TO COPEWITH
OVER-STIMULATING
ENVIRONMENTS
IMPAIRED
ABILITY TO PERCEIVE,
EVALUATE,
OR USE
SOCIAL CUES/
CONTEXT
LACK OF
AWARENESS
OF DEFICITS
IMPULSIVITY
PRE-EXISTING
MALADAPTIVE
BEHAVIORS
OR
DISABILITIES
INTENSIFIED
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What the Future HoldsSupporting Students
with
TBI
at School
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Be creative in designing
services...Use the too ls you haveto work with these
students, but keep the following in mind:
Progress can be inconsistent and unpredictable
Student may experience reduced stamina and
fatigue for some time after the injury
Student may process information slower aftertheir injury
Impairment of memory may hinder new learning
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Plan for transitions
Hospital to school
Grade to Grade
School to School
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Consider Ongoing
Supports... Establishing effective means of communication
between school and home
Establishing primary contacts for the family both
at the school level and at the administrative level
Developing peer supports for the student
Updating evaluations as needed
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Initial School Re-entry
Eligibility
A physicians letter should be obtained
documenting the Traumatic Brain Injury
Interview the family of the injured student toobtain pre-injury academic and socialhistory, as well as changes they have seensince the injury
A school staff person should be designatedto visit the student before he or shereturns to school to make anecdotalobservations
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Information to obtain:
Medical
Documentation of the injury, site(s) of injury or lesion,duration of coma, services received post-injury,medications, contact information for doctors
Medical Release
Specifies the students ability to participate in physicalactivities at school
Rehabilitation Records
Initial evaluations & discharge summaries from alltherapies administered
Specific recommendations for adaptations to the schoolenvironment
Therapy recommendations
Instructions related to use of adaptive equipment
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Information to obtain:
Psychosocial
History of student pre-injury from an educational andsocial perspective
Relevant information on siblings, including ideas abouthow to address their reaction to the injury
Educate support team about possible suicidal ideationpost-injury (especially with adolescents)
Educational
Contact person for family Initial and subsequent IEPs
Records from support personnel
Attendance records
Records from other schools attended, if applicable
Specific information related to sensory issues
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Considerations forFormal Assessment
The nature of formalized testing may compensate for
cognitive weaknesses (e.g., attention, initiation,
flexibility, information processing, executive
functioning).
New learning is often not assessed.
The students scatter in abilities is often not
revealed (i.e., gaps below basals and strengths
above ceilings).Scores may not reveal the extent of reduced
functioning in the classroom. Alternatively, some
students may perform better in the real world with
natural cues present than testing would predict.
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Considerations forInformal Assessment
Real-life classroom performance is represented.
New learning can be assessed.
Hypotheses about breakdowns and possibleinterventions can be tested.
Current functioning can be compared with pre-
injury performance.
Environmental variables affecting performance can
be evaluated.
Work samples and classroom evaluation can
provide a direct link to intervention strategies.
Sample Strategies to
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Sample Strategies toConsider:
Scheduling Modifications Attend school part-time initially
Schedule several in-school breaks
Provide study halls with resource teacher
Schedule most difficult subjects early in the day
Keep number of classroom changes to a minimum, or
assign a buddy to assist the student in changing
classes
Begin with one-on-one/small group instruction, adding
additional students with improvement of concentration
Consider ESY, homebound services or tutoring for
summer months
Will child be supervised at all times?
From: TBI Inservice Training Module, Janet Siantz Tyler, PhD.,
Kansas Dept. of Education, TBI Project
Sample Strategies to
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Sample Strategies toConsider:
Instructional Strategies
Classroom rules & expectations should be well structuredand explicitly taught
Instruction should contain repetition & feedback
Avoid multi-step instructions if possible
Supplement verbal instructions with writing / modeling
Provide amply time to process, complete tasks, andrespond
Assist the student in keeping his/her materials andschedule organized
Teach compensatory strategies for test-taking, note-
taking, reading materials, etc. Try external aids such as lists, diaries, computers,
calculators
Videotape the students progress in class to providefeedback and show progress
From: TBI Inservice Training Module, Janet Siantz Tyler, PhD.,Kansas Dept. of Education, TBI Project
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IEP Development
TO INCLUDE: Obtain eligibility
documents, including
information aboutcurrent levels of
functioning
Include individuals in
IEP meetings who can
help to identify theadverse effects of the
brain injury on the
students performance
TO ADDRESS: Students current and past
strengths/ areas of need
Medical needs
General modifications /
accommodations
Involvement of student in
general curriculum
Extended school year
options
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Developing IEP Goals
Focus on 2 or 3 priority issues
Identify metacognitive & organizational
strategies
Write measurable goals that incorporate
the strategies
Include specific information about how the
strategy should be taught andimplemented across settings
Write short-term goals that are truly short-
term
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For More Information:
Paula Denslow, Coordinator &
Project BRAIN Resource Specialist
Tennessee Disability Coalition
480 Craighead Street, Suite 200
Nashville, TN 37204
Office: 615383.9442 x 56
Fax: 615383.1176
Cell: 615585.2998
TTY: 615292.7790
Jennifer Jones, M.S., C.R.C.
Project BRAIN Resource Specialist
Tennessee Disability Coalition
5641 Merchants Center Blvd.
Suite A102
Knoxville, TN 37912
Office: 865/689-1797 x 12
Fax: 865-689-8518
Cell: 865-803-5995
www.tndisability.org/brain