Traumatic Brain Injury: Eligibility, Special

Education and Classroom Practices

Josh Zola MA, Ed.S, CBISSarah Powell M.Ed, CCC-SLP, CBIS

Disguised as a Low Incident Disability…

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 LawSC Special Education Law (Definition) (Definition)

Traumatic Brain Injury means an Traumatic Brain Injury means an acquired injuryacquired injury to the to the brain caused by an brain caused by an external physical forceexternal physical force, resulting in , resulting in total or partialtotal or partial functional disability or psychosocial functional disability or psychosocial impairment, or both, that impairment, or both, that adversely affectsadversely affects a student’s a student’s educational performanceeducational performance. The term applies to . The term applies to open or open or closed head injuriesclosed head injuries resulting in impairments in resulting in impairments in one or one or moremore areas, such as cognition; language; memory; areas, such as cognition; language; memory; attention; reasoning; abstract thinking; judgment; attention; reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motor problem-solving; sensory, perceptual, and motor abilities; psychosocial behavior; physical functions; abilities; psychosocial behavior; physical functions; information processing; and speech. The term does information processing; and speech. The term does not not apply to brain injuries that are congenital or apply to brain injuries that are congenital or degenerative, or to brain injuries induced by birth degenerative, or to brain injuries induced by birth trauma.trauma.

Types of Brain InjuryTypes of Brain Injury

P erinatal(e .g ., b irth s troke)

C ongenital(e .g ., P KU)

C ongenita l and Perinatal(no period of norm al developm ent)

N on-traum atic(in terna l occurrence

e.g., tumor)

O pen(e .g., gunshot)

C losed(e.g., fa ll)

Traum atic (externa l physica l force)

A cquired(fo llow ing a period of normal development)

B rain In jury

Short term effects of Brain Injury

Injury to brain tissues at the site of damage

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 injury!

If not aware, teachers may see changes but do not know why they have suddenly emerged.

Typical Medical Course for a Typical Medical Course for a Student with a Moderate/Severe Student with a Moderate/Severe

TBITBI

Emergency roomEmergency room Regional trauma center if necessaryRegional trauma center if necessary Surgery if necessarySurgery if necessary Acute care setting (hospital)Acute care setting (hospital) Rehabilitation unit or centerRehabilitation unit or center School School (So there should be tons of (So there should be tons of

paperwork)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 for:

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 Ataxia Coordination

problems Paresis or paralysis Orthopedic

problems

Spasticity Balance problems Impaired speed of

movement

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 Memory Attention Concentration Information

processing Sequencing

Problem solving Comprehension of

abstract language Word retrieval Expressive

language organization

Pragmatics

Emotional & Behavioral Problems

Irritability Impulsivity Disinhibition Perseveration Emotional Lability Insensitivity to

social cues Low frustration

tolerance

Anxiety Withdrawal Egocentricity Denial of deficit/lack

of insight Depression Peer conflict Sexuality concerns High risk behavior

So you begin to think about assessment and will

this student qualify for services…and qualify for

what services???

Assessment… Traditional

Assessment Focuses on

intellectual, emotional and academic functioning

Example: an IQ score that declines over time

Cognitive Assessment Focuses on

the underlying reasons for academic failure such as problems with attention, memory, and executive skills

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 important

The impairments are different, as are the implications for educators

TBI: How is it Different?TBI LD ED

Onset and Cause

Sudden with blow to head and loss of consciousness

Early/ unclear Slow/ unclear

FunctionalChange

Marked contrast between pre and post onset

No before-after contrasts

Changes emerge slowly

Physical Disabilities

Loss of balance, weakness, paralysis

Poor coordination

Unlikely

Behavior Agitation, impulsive, restlessness, disinhibited

Restlessness, impulsive

Variable

Emotions Labile, depression, anxious

Prone to outbursts

Reactions due to distortions of reality

Academic Deficits

Based on disrupted cognition

Based on type of learning disability

Not based on impaired cognition

Difficulties with Learning

Old info easier to recall than new info

New learning can be linked with old learning

New learning can be linked with old 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 done…

What services are out there? Qualifying for Special Ed

Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)

Title of Regulation:Title of Regulation: Regulation No.:Regulation No.: R43-243.1R43-243.1

  CRITERIA FOR ENTRY INTOCRITERIA FOR ENTRY INTO

PROGRAMS OF SPECIAL EDUCATIONPROGRAMS OF SPECIAL EDUCATION

FOR STUDENTS WITH DISABILITIESFOR STUDENTS WITH DISABILITIES

Vs.Vs.

Medical Definition of TBIMedical Definition of TBI  

  

SC TBI Eligibility CriteriaSC TBI Eligibility Criteria A multidisciplinary evaluation team shall include A multidisciplinary evaluation team shall include

a certified school psychologist, a licensed school a certified school psychologist, a licensed school psychologist, or a licensed psycho-educational psychologist, or a licensed psycho-educational specialistspecialist in addition to a speech-language in addition to a speech-language therapist therapist knowledgeable in the education of knowledgeable in the education of students with traumatic brain injurystudents with traumatic brain injury..

The existence of traumatic brain injury has been The existence of traumatic brain injury has been diagnosed by a diagnosed by a licensed physicianlicensed physician. . OrOr, in the , in the absence of an existing medical diagnosis absence of an existing medical diagnosis oror a a prior diagnosis of a traumatic brain injury, both prior diagnosis of a traumatic brain injury, both of the following are furnished:of the following are furnished: a documented history that evidences trauma a documented history that evidences trauma

to the head resulting in impairments according to the head resulting in impairments according to the definition of the term “traumatic brain to the definition of the term “traumatic brain injury” andinjury” and

a cognitive profile that is consistent with the a cognitive profile that is consistent with the head injury.head injury.

SC TBI Eligibility CriteriaSC TBI Eligibility Criteria The injury has resulted in The injury has resulted in partial or partial or

total total functional disability and/or functional disability and/or psychosocial impairments.psychosocial impairments.

  The student’s traumatic brain injury The student’s traumatic brain injury adversely affects adversely affects his or her his or her educational performance.educational performance.

SC Special Education LawSC Special Education Law

The following evaluation components are The following evaluation components are required:required:a.a. Medical records, if available.Medical records, if available.

b.b. Documentation of vision, hearing, and speech-Documentation of vision, hearing, and speech-language screening conducted language screening conducted after the injuryafter the injury and and within the within the past twelve monthspast twelve months..

c.c. Review of the developmental history or education Review of the developmental history or education records of the student to records of the student to determine effect on his or determine effect on his or her educational performance and psychosocial her educational performance and psychosocial functioningfunctioning. Particular attention should be paid to the . Particular attention should be paid to the student’s progress prior to student’s progress prior to andand following the following the suspected injury.suspected injury.

SC Special Education LawSC Special Education Lawd.d. Observations Observations in three environments in three environments by an observer, other by an observer, other

than classroom teacher, that record the nature and than classroom teacher, that record the nature and severity of the student’s learning and/or behavior severity of the student’s learning and/or behavior difficulties. These may include anecdotal records from difficulties. These may include anecdotal records from previous caregivers; a certified school psychologist, a previous caregivers; a certified school psychologist, a licensed school psychologist, or a licensed psycho-licensed school psychologist, or a licensed psycho-educational specialist; or the parent(s).educational specialist; or the parent(s).

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

f.f. Documentation of the student’s physical functioning that Documentation of the student’s physical functioning that includes includes motor abilities, sensory functions, and the status motor abilities, sensory functions, and the status of seizure activity, medication, and healthof seizure activity, medication, and health..

SC Special Education LawSC Special Education Lawg.g. A behavior assessment shall include psychosocial, pre-A behavior assessment shall include psychosocial, pre-

injury functioning and adjustments to impairments.injury functioning and adjustments to impairments.

h.h. Documentation of the evidence that the student’s Documentation of the evidence that the student’s traumatic brain injury traumatic brain injury adversely affects his or her adversely affects his or her educational performanceeducational performance..

SC Special Education LawSC Special Education LawEvaluation Results:Evaluation Results:

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

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

general curriculum. general curriculum.

IEP = Special Education = needs for modified curriculum IEP = Special Education = needs for modified curriculum and direct or indirect services (Resource, Self-Contained, and direct or indirect services (Resource, Self-Contained, Speech, OT, PT, etc.)Speech, OT, PT, etc.)

So now, what are your interventions?

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 EnvironmentCognitive Challenge

Accommodations

Attention/Concentration

Seat the student near the teacher, Minimize distractions, use earplugs, Low stimulation environment

Information Processing Speed

Reduce Distractions, Small Group Instruction, 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 Challenge

Accommodations

Attention/Concentration

Use peer note taker and tape recorders, Provide assignments in writing, match the student’s ability to attend, break tasks into smaller parts, alternate instructions with activities

Information Processing Speed

Give the student “time to get it”, Review notes to identify missed information, smaller segments of 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 Challenge

Accommodations

Attention/Concentration

Educate on attention types, clarify information, complete a predetermined amount of work, take rest breaks BEFORE becoming tired, limit interruptions and distractions

Information Processing Speed

Monitor their own comprehension, ask questions, signal if not understanding, educate others on 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 Values

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 tests

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 What happens as a result of these deficits and of these deficits and

behaviors?behaviors? Friends leaveFriends leave Families mournFamilies mourn Teachers are frustratedTeachers are frustrated The student is at increased risk for The student is at increased risk for

isolation from peers, academic isolation from peers, academic failure, failure, depressiondepression, , substance substance abuseabuse, , sexual behaviorsexual behavior, , delinquency, further TBIdelinquency, further TBI

Provide… 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 & Traumatic Brain Injury Information & SuggestionsSuggestions

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

http://www.aasa.dshs.wa.gov/Library/http://www.aasa.dshs.wa.gov/Library/tbitoolkitpro.pdftbitoolkitpro.pdf

A TBI tool kit for families can be downloaded at:A TBI tool kit for families can be downloaded at:http://www.aasa.dshs.wa.gov/Library/tbitoolkit.pdfhttp://www.aasa.dshs.wa.gov/Library/tbitoolkit.pdf

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.htm

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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!