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

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

Brain Injury

Congenital Brain InjuryPre-birth or during birth

Acquired Brain InjuryAfter 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

Shearing strainsthroughout thebrain

Subdural veinstorn as brainrotates forward

Swelling ofbrain stem

Damage totemporal lobesfrom roughbones at skull base

Compressionfracture

Types of Damage

in a Closed Head Injury

Coup

Contra-coup

Skull Protrusions

Adapted From: Pang, 1985Skull

Shearing Plane

Brain

Protrusion

Overly Simplified Brain Behavior Relationships

Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

Brain Stem

Parietal Lobe• Sense of touch• Differentiation: size, shape, color• Spatial perception• Visual perception

Occipital Lobe• Vision

Cerebellum• Balance• Coordination• Skilled motor activity

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)

Brain Stem• Breathing• Heart rate• Arousal/consciousness• Sleep/wake functions• Attention/concentration

Temporal Lobe• Memory• Hearing• Understanding language (receptive language)• Organization and sequencing

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)

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

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

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

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

Apparent Low Incidence

Eligible Under Different Category

Lack of Awareness

Lack of Research

Money

Lack of Training

Lack of Services for

those Identified

Under–Identification Cycle

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.

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

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)

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

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

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

Observed Behaviors Underlying Problems

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 Behaviors Underlying Problems

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

INTERVENTIONS – What do they need?

0-21

Physical Challenges

EXECUTIVE FUNCTIONS

• Difficulty holding instructions/Information

• New learning is most difficult• Difficulty with multiple cognitive

demands (writing)

• Metacognition• Goal-Directed activity• Problem solving for attainment of

future goal• Inability to form Mental

representations & interpretations

• Difficulty with multi-Step tasks• Engaging in independent tasks• Organizational difficulties

• Inhibition• Rigidity/Inflexibility• Sustained Energy• Poor monitoring and awareness

of behavior• Frequent distractions

Self Regulation

Planning

MemoryStrategic Learning

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

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

Slow processing speed

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

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)

Concrete ThinkingDifficulty with abstraction, synthesis, inference etc.

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

Self-Regulation and Behavior

Goal

Obstacle

Plan

Predict

Do

Review

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?”

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

Self

Regulation

Executive

Functioning

Communication Skills

We must teach and support the underlying processes to get to self-regulationR. DePompei 2009

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

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

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

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

QUESTIONS/COMMENTS