# Presentation: 700241

** **

**Identification and Appropriate Service Delivery for Children with TBI in the Schools**

**Janet Tyler, Ph.D., Director, Neurologic Disabilities Support Project/**
**University of Kansas Medical Center**
**Mail Stop 3055, 3901 Rainbow Blvd.**
**Kansas City, KS 66160-7335**
**Phone:  (913) 588-5943  Email: jtyler@kumc.edu**
**Ann Glang, Ph.D. **
**Teaching Research Institute**
**99 W. 10th, Suite 370**
**Eugene, OR  97401**
**glanga@wou.edu**

## Traumatic Brain Injury (TBI)

**Open Head Injuries**

**Closed Head Injuries**

## What Happens 

**During a **
**Closed Head Injury?**

## Types of Damage in a Closed Head Injury

**Types of Damage in a Closed Head Injury**

## Slide 5

## Slide 6

## Neurons

**Neurons**
**Shearing Plane**

**neurons**

**shearing**
**plane**

- Adapted from Pang, 1985

## Slide 8

## Effects of Trauma

**Effects of Trauma**

**Before ****	****	****  &****	****	****   After**

- From:  Swiercinsky, Price, & Leaf, 1987

## Slide 10

## Traumatic 

**Brain **
**Injury **
**Defined**

## Medical Definition of TBI

**Mild:**
**  ****Brief or no loss of**
**     ****consciousness**
-   **Shows signs of concussion**
**vomiting**
**lethargy**
**dizziness**
**lack of recall of injury**

**Moderate:**
**  ****Coma < 24 hours duration**
**  ****Neurological signs of**
**     ****brain trauma**
** ****skull fractures with**
**     ****	****contusion (tissue damage)**
** ****hemorrhage (bleeding)**
**  ****Focal Findings on EEG**
**     ****or CT scan**

**Severe:**
-   **Coma > 24 hours duration**

## Brain injury can occur even if there is no loss of consciousness!

**Brain injury can occur even if there is no loss of consciousness!**

## Brain Injuries can Range from Mild to Severe

**Even ****mild**** injuries can have an impact on a student’s school performance**
**Moderate**** brain injury can result in physical, cognitive, and/or behavioral impairments that last days, weeks, months, or even a life time.**
**Severe**** brain injury **_**almost always**_** results in some degree of permanent physical, cognitive, and/or behavioral effects.**

## Educational Definition of TBI

** ****caused by an external physical force **
** ****not of a degenerative or congenital nature **
** ****produces a diminished or altered state of consciousness**
** ****results in an impairment of cognitive abilities, physical                 **
**     ****functioning, and/or behavioral/emotional functioning**

**Educational Definition of TBI**

## Incidence

**and**
**Causes **
**of **
**TBI**

## Brain injury is the leading cause of death and disability in children and young adults

## According to the CDC, each 

**year in the United States...**

**Approximately 1.4 million individuals receive a TBI.**
**  ****Ages 0-4 years: 1 in every 90 children experiences a TBI**
**  ****Ages 5-9 years: 1 in every 152 children experiences a TBI.**
**  ****Ages 10-14 years: 1 in every 159 children experiences a TBI.**
**  ****Ages 15-19: 1 in every 123 adolescents experiences a TBI.**
**Approximately 80% of these injuries result in Emergency Department Visits, 17% in hospitalizations, and 4% in death.**

## Brain Injury Dangers for School-Aged Children

**Motor**
**Vehicle ****Crashes****50%**

**Falls****21%**

**Firearms****12%**

**Sports/Recreation****10%**

**Other (e.g., abuse. assault ) 7%**

## Numbers: Where Have All the Children with TBI Gone?

## Under-identification for Special Education

- National Pediatric Trauma Registry
- US Department of Education

- Todis & Glang, 2005

## Todis & Glang, 2005

**Under-identification Cycle**

**Todis & Glang, 2005**

## Long-Term Effects of TBI 

***Long-Term Effects of TBI****** ***

**Visual disturbances, hearing loss, headaches, seizures, **
**balance problems, reduced stamina, etc.**

***Physical***

***Cognitive***

**Memory deficits, decreased intellectual functions, language problems, reduced academic functioning, difficulty focusing & sustaining attention, delayed response time, and/ or organizational difficulties. **
**Problems with: simultaneous processing, generalizing, flexible problem solving, concept formation, perceptual/spatial functions, etc.**

***Behavioral ***

**Impulsivity, irritability, low frustration tolerance, anxiety, impaired judgment, lack of initiation, depression, etc.  **

## Central Tendencies Within the Population

** ****Sudden onset of disability**
** ****Need for hospital to school transition planning**
** ****Ongoing medical/therapy needs**
** ****Cognitive, physical, and psychological impact**
** ****Prolonged and unpredictable improvement**
** ****Evolving ability profiles**
** ****Evolution of emotional consequences**

**Central Tendencies Within the Population**

## Diverse Population

**	**

**“****Students with TBI”**

## Enormous Variability Due To...

**	**

**Enormous Variability Due To...**

## Preinjury Profiles

**	**

**Varying . . .**

**Preinjury Profiles**
**(age, education, behavior)**

## Development Without Brain Injury

**Growing Up**

**Performance**

**Normal Development**

**Development Without Brain Injury**

## TBI Without Intervention

**Growing Up**

**Performance**

**Brain Injury**

**Normal Development**

**TBI Without Intervention**

## Growing Into It

- Developmental milestones are not achieved.  No one equates this lack of development to injury years earlier.
- Child’s brain continues to develop and change over time - sometimes not in a positive manner. Children have to recover at each new stage of development.

## Benefit of  Intervention in Multiple Time Frames

**Growing Up**

**Performance**

## Severity of Brain Injury

**	**

**Varying . . .**

**Severity of Brain Injury**

**Note: Medical definition of good outcome does not always correlate with level of educational supports needed.**

- Mild
- Moderate
- Severe

## Location of 

**	**

**Varying . . .**

**Location of **
**Brain Injury**

## Medical/Rehabilitation Care

**	**

**Varying . . .**

**Medical/Rehabilitation Care**

**Length of time between injury and medical care**
**Trauma/acute care**
**Availability of rehab**

## Post-Injury 

**	**

**Varying . .**** ****.**

**Post-Injury **
**Family Supports**

## Developing Educational Programs for Students with TBI

## Complexity of TBI

**Physical **
**Cognitive**
**Psychosocial**
**Challenges**

- Variability
- in
- Functioning

- Learning & Behavior
- Characteristics Different
- from Other Students

- Specialized
- Programming
- Required

## Diversity of TBI Population Precludes 

**Diversity of TBI Population Precludes **
**“****TBI Curriculum”**

**NO** **“best”** **program or  **
**teaching method**

## However ....

**Effective Educational Strategies**
**For Varied Populations of Students**
**With and Without Disabilities**

**If Students Are Identified By Functional Need **
**Educators Can Connect Needs with **
**Proven Teaching Strategies**

**However ....**

## Educational Programming

**Educational Programming**

**Identify **
**Student’s **
**Needs**

**Pair with Proven **
**(Research Based) **
**Strategies**

**Provide Ongoing **
**Functional Assessment **
**of Needs**

**Assess Effectiveness **
**of Instructional **
**Strategies**

**Program & Methods **
**Based On**
**Unique Needs **
**of Student**

## Educators’ Knowledge of TBI

**Lack of Preservice Training**
**Limited Knowledge of the Impact of TBI on School Performance**
**Lack of Feelings of Competence **
**Teacher Training in TBI Identified as National Need**

## "He's the only identified child with TBI we have...and we didn't know what to do with him."

	- Trevor’s 5th grade teacher 

- 	- Trevor’s 5th grade teacher

## Who Needs Specialized Training?

**School Social Workers**

**Cafeteria Workers**

**General Education Teachers**

**Special Education Teachers**

**School Administrators**

**School Therapists**

**School Nurses**

**School Psychologists**

**School Counselors**

**School Bus Drivers**

**Para-Educators**

**Families**

## NCLB Quality Training

**The federal No Child Left Behind Act defines high-quality professional development broadly, calling for programs that are “sustained, intensive, classroom-focused ... and are not one-day or short-term workshops or conferences.” **

## Recommendations for Teacher Training 

**To have an impact on students, TBI training and support for educators must:**
**Relate in practical ways to their everyday interaction with students**
**Be ongoing**
**Involve specific teacher assignments and intervention experiments with concrete feedback, including collaborative problem solving**

**Ylvisaker, et al. 2001**

## Recommendations for Teacher Training 

**To have an impact on students, TBI training and support for educators must:**
**Be broadly consistent with the school’s culture and existing constraints on teachers’ time, and meet the objectives of those seeking help**
**Ultimately result in improvements in the student’s performance**

**Ylvisaker, et al. 2001**

## States Implementing TBI Resource Team Model

|  |
| --- |
| Arizona |
|      Hawaii |
|           Iowa |
|                Kansas |
|                     Nebraska |
|                          Oregon |
|                               Tennessee |

## Team Membership

- Varies according to regional needs
- All members based in schools
- Includes representatives from some or all of the following disciplines:

## Team Membership

**General educator****	****Special educator**
**School psychologist****	****Administrator**
**Paraprofessional****	****Individual with TBI**
**Physical therapist****	****Counselor**
**School nurse****	****Occupational therapist**
**Parent****	****Speech/language therapist**

## Team Membership:Expectations

- Participate in intensive training
- Once trained, provide consultation and training to others

## Training Content

- Incidence, etiology & effects of TBI
- Family-school partnership
- Behavior management
- Facilitating social integration
- Promoting academic success
- Organizational strategies
- Effective consultation and presentation techniques

## TBI Awareness & Training Activities Provided

|  | Arizona | Kansas |
| --- | --- | --- |
| Number of Trainings | 
90 | 
52 |
| Number of Participants | 
2,146 | 
1,129 |

- 2004-05

## Number Students Servedby the TBI Resource Team

|  | Arizona | Kansas |
| --- | --- | --- |
| Total number of students served | 273 | 135 |

- 2004-05

## Number of Students Served

- (Arizona 2004-05)

## Type of Support Provided

- (Arizona   2003-05)

## Frequency of Consultation Activities

- (Arizona   2003-05)

## Identification for Special Education pre/post training 								(S. Arizona)

|  | 2000 | 2003 |
| --- | --- | --- |
| Number of students served | 93 | 374 |

## Resources Needed:Start-up

- Department of Education support
- Resource Team coordinator
- Training budget
- Funds to support release time for school-based staff

## Maintaining the Model 

- Ongoing evaluation of team activities
- Department of Education support
- Consistent coordination
- Regular team trainings and meetings

## Advantages

- Easily accessed resource for educators, parents and medical personnel
- Builds local capacity
- Professional development that spans disability groups
- Raises awareness of brain injury

## Challenges

- Work-load of Team members
- Variations in “school climate”
- Geographic distribution of team members
- Fluctuations in fiscal support for Team operation

## Breaking the Cycle

**Todis & Glang, 2005**

## Materials for States to Utilize for Trainings

**Web Sites**
- Brain Injury Association of America (BIAA) 			_[www.biausa.org](http://www.biausa.org/)_
- Centre for Neuro Skills 						_[www.neuroskills.com](http://www.neuroskills.com/)_
- Kansas Neurologic Disabilities Support Project 		_[www.kstbi.org](http://www.kstbi.org/)_
- Lash and Associates Publishing/Training			_[www.lapublishing.com](http://www.lapublishing.com/)_
- National Dissemination Center for Children with Disabilities
- 		_[www.nichcy.org](http://www.nichcy.org/)_

## Materials for States to Utilize for Trainings

**Web Sites**
- Oregon Brain Injury Resource Network (OBIRN)			_[www.tr.wou.edu/tbi/index.html](http://www.tr.wou.edu/tbi/index.html)_
- Special Education Guide 					_[www.parentpals.com](http://www.parentpals.com/)_
- National Association of State Head Injury Administrators (NASHIA)
- 		_[www.nashia.org](http://www.nashia.org/)_
- Traumatic Brain Injury Technical Assistance Center at NASHIA’s
- 	Traumatic Brain Injury Collaboration Space (TBICS)
- 		_[www.tbitac.nashia.org/tbics](http://www.tbitac.nashia.org/tbics)_