Return to School: Children with Brain Injury

1. Return to School: Children with Brain Injury Susan Caputo M.A., CCC-SLP Elisa Green M.A., CCC-SLP

2. Definitions Acquired Brain Injury Internal insult to the brain occurring after birth and is not hereditary, congenital, or degenerative. Often resulting in change in neuronal activity effecting physical, metabolic, and functional ability of the cell. Not referring to injuries induced by birth trauma. • Causes: tumors, blood clots, strokes, seizures, toxic exposure, infections, metabolic disorders, neurotoxin poisoning and lack of oxygen to the brain

3. Definitions (Cont’d) Traumatic Brain Injury Insult to the brain not caused by degenerative or congenital means, but external physical force, that may produce a decrease or altered state of consciousness, resulting in an impairment of cognitive, physical, emotional, or behavioral functioning. • Causes: motor vehicle accidents, falls, gunshot wounds, sports injuries, workplace injuries, shaken baby syndrome, child abuse, domestic abuse, military actions, and other injuries caused by trauma

4. Pediatric BI Incidence & Prevalence • Leading causes: motor vehicle accidents, bicycle accidents, falls, sports injury, abuse • In 2004 brain injury results: 7,000 deaths; 150,000 hospitalizations; 1,000,000 emergency room visits • Age is strong predictor of the cause of BI • Nonaccidental trauma is the cause of 80% of deaths from head trauma in children under 2 years of age • 2/3 of children under 3 years old who are physically abused, have BI’s • Preschool age children are the second highest risk group for BI • Children between 6-12 are involved in twice as many pedestrian vs. vehicles as younger children • 220 out of 100,000 youths under age 15 will sustain a BI, yearly • 14-19 year olds are most susceptible to sports and auto accidents

5. Anatomy

6. Anatomy (Cont’d) • Cerebrum • 4 lobes: Frontal, Temporal, Parietal, Occipital • Largest and most developmentally advanced portion of the brain • Controls higher functions, including speech, emotion, the integration of sensory stimuli, initiation of the final common pathways for movement, and fine control of movement • Left and right hemisphere - controls the majority of functions on the opposite side of the body

7. Anatomy (Cont’d) 2. Cerebellum • Second largest area of the brain • Controls reflexes, balance and certain aspects of movement and coordination 3. Brain Stem • Critical life automatic life functions: breathing, digestion and heart beat – as well as alertness and arousal (the state of being awake)

8. Brain Growth and Maturity

9. Classifications Mild BI • Loss of consciousness for less than 30 minutes (possibly no loss of consciousness) • Posttraumatic amnesia for less than 24 hours • Temporary or permanent altered mental or neurological state • Glascow Coma Scale 13-15 • Postconcussion symptoms may include: headaches, dizziness, vomiting, sleep disturbance, irritability, changes in personality, memory problems, depression, difficulty problem solving, diminished attention span

10. Classifications (Cont’d) Moderate BI • Coma more than 20-30 minutes, but less than 24 hours • Possible skull fracture with bruising and bleeding • Signs on EEG, CAT, or MRI • Glascow Coma Scale of 9-12 • Some long term problems in one or more areas of life Severe BI • Coma longer than 24 hours, often lasting days or weeks • Bruising, bleeding in brain • Signs on EEG, CAT, or MRI • Glascow Coma Scale of 8 or less • Long term impairments in one or more areas of life

11. Preparation of School for Student’s Return Referral from rehabilitation program, staff can work with school to advise them on student’s: • Brain Injury • Therapies • Strengths and abilities • Difficulties and weaknesses • Expectations for recovery • Planned discharge date • Needs for special help

12. Preparation of School for Student’s Return (Cont’d) Rehabilitation staff should: • Identify someone responsible for coordinating & planning with school • Contact school • Determine if child needs to be referred for evaluation for special education • Meet with child’s teacher(s), school nurse, special ed. Director • Visit the child’s school to plan ahead • Possibly conduct an in-service program for school staff – School SLP can also play a role in educating school staff • Be available for follow up questions and planning • Written reports should be made available for school personnel

13. BI Effects in Classroom Cognitive Communication Effects • Memory • Unable to recall previously learned information that serves as foundation for new learning • Can not remember a series of 2-3 step directions • Unable to grasp new concepts without repeated exposures • Difficulty recalling the day’s schedule, what was assigned for homework, or what materials to bring to class

14. BI Effects in Classroom (Cont’d) Cognitive Communication Effects (Cont’d) • Attention and Concentration • Distracted by normal classroom activity • Difficulty staying on topic during class discussion • Unable to complete a task without prompting • Blurts out answers • Fatigued by mid-afternoon and appears uninterested in activities

15. BI Effects in Classroom (Cont’d) Cognitive Communication Effects (Cont’d) • Higher Level Problem Solving • Difficulty organizing and completing long-term projects • Lacks ability to sequence steps necessary to plan activity • Unable to generate solutions to situations (e.g., lost lunch money) • Difficulty drawing conclusions from facts presented

16. BI Effects in Classroom (Cont’d) Cognitive Communication Effects (Cont’d) • Language Skills • Difficulty taking turns in conversation • Unable to summarize and verbalize thoughts • Circumlocution or uses empty speech • Does not understand the meaning of a conversation when idioms or metaphors are used

17. BI Effects in Classroom (Cont’d) Sensorimotor Effects • Max increase in time to complete written material • Unable to take notes and listen to lecture • Difficulty copying from board or overhead projector • Difficulty completing sheet of math problems when given a sheet of them • Completes only one half of paper secondary to visual field deficits • Becomes disoriented in hallway and difficulty finding way around

18. BI Effects in Classroom (Cont’d) Social/Behavioral Effects • Says and/or does inappropriate things • Difficulty fitting in with peers • Easily mislead by peers into making poor choices • Unable to start or stop a task without assistance • Leaves seat or classroom secondary to impulsivity • Easily frustrated • Denies or is unaware of deficits

19. Qualifying for Services IDEA - “Traumatic Brain Injury” category • Allows needs of students with TBI to be addressed specifically • Avoids misclassifying students • Some states expanded to include acquired brain injury • If not, they can qualify for special services under “Other Health Impairment” • IL has the words “acquired” in the definition, however further defines as external physical force 504 Accommodation Plan • To qualify a student is only required to have a “presumed disability” • Examples: extended testing time, alternate formats for exams, note takers, preferential seating, assistance with project planning, provision of audio-taped books

20. Evaluation Purposes • Evaluate current function • Develop profile of strengths and needs • Determine ability to benefit from intervention • Acquire information necessary for treatment planning • Educate student, family, and caregiver regarding findings

21. Evaluation (Cont’d) Process 1. Review of records • Past school, medical, and rehab records (Premorbid/postmorbid function) • Family/student questionnaire • Guides selection of appropriate evaluation tools, pacing, and scheduling • Determine special sensory, motor, or medical concerns 2. Interview of student, family, rehab specialists, educational specialist, etc. • Verify, clarify, expand information from record review • Question student’s learning style • Determine: Presenting problem, Severity of injury, Motor and Sensory Deficits, Cognitive-Communication changes, Medications, Medical status, Premorbid medical history, Rehab history, Developmental history, Psychosocial history, Criminal/legal activity, Guardianship

22. Evaluation (Cont’d) Process (Cont’d) 3. Behavioral observations • View functional abilities and frontal lobe dysfunction: Cognitive-Communication, Communication abilities, & Environmental influences on communication • Assess: Attention, Memory, Executive/Metacognitive Function, Response Patterns, Affect, Drive/Motivation 4. Formal testing (standardized/non-standardized) • Tests with proven reliability and validity & adequate normative data • Tests typically used with students or adults with brain injury (also may use tests addressing specific area of need) • Tests addressing each area of communication/educational functioning • Tests with relevance to real-life functioning

23. Evaluation (Cont’d) Process (Cont’d) 4.Formal testing (standardized/non-standardized) (Cont’d) • Informally address skills in a hierarchy • Auditory and reading comprehension (Single words, questions, directions, and paragraphs) • Verbal memory and learning (Orientation, personal information) • Verbal expression (of words [e.g., naming and rapid word association], sentence generation, picture description) • Written expression (words, sentences, paragraphs also, spelling, mechanics, grammar, punctuation, capitalization and legibility) • Verbal and semantic organization (Word meanings, associations and categorization, Sequencing of steps, Similarities/Differences, analogies, Scripts, story generations) • Abstract Language (humor, proverbs, idioms, slang) • Reasoning and problem solving

24. Evaluation (Cont’d) Process (Cont’d) 5. Needs assessment/future planning • Identify contexts in which functional abilities should be evaluated • Assess activities important in student’s life to determine disability and impact of environment on student 6. Evaluation of everyday performance • Determine actual abilities in everyday situations (e.g., playground, hallway, lunch)

25. IEP Considerations 1. Cognitive and Communication • Attend and concentrate • Initiate activities and work • Organize and plan ahead • Reason and solve problems • Learn new information • Recall previously learned information • Communicate clearly and effectively in speech and writing • Make good and safe decisions • Be flexible and adjust to change

26. IEP Considerations (Cont’d) 2. Social/Behavioral • Self esteem and self control • Awareness of how actions effect others & feelings of others • Knowing what to expect in social situations • Awareness of appropriate dress and grooming • Ability to control sexual comments, gestures, and actions • Control anger and handle frustration

27. IEP Considerations (Cont’d) 3. Sensorimotor • Compensate for visual and hearing changes • Detect changes in sound, height, distance, and touch • Adjust to changes in body coordination • Slow down or speed up movements • Increase balance and steadiness • Recognize and handle fatigue • Improve hand/eye coordination

28. Cognitive Communication Accommodations Processing Delays • Increased time to complete assignments/tests • Extra time to answer questions verbally • Breakdown complex directions into steps • Repeat pertinent information • Decrease length of assignments • Use precise concrete language Attention • Frequent breaks • Assignments divided into small increments • Preferential seating • Verbal prompts to check work

29. Cognitive Communication Accommodations (Cont’d) Memory Deficits • Written & verbal directions for tasks • Check student’s understanding of directions by having student provide oral summary • Frequent review of information • Strategy for notetaking during long reading assignments • Set timelines of completing work • Have student repeat instructions to check for comprehension • Using a watch alarm to remind student to look at memory aides • Use planner and have teacher check to ensure all assignments written

30. Cognitive Communication Accommodations (Cont’d) Organizational Skills • Study guide and/or timeline • Daily calendar for assignments and tasks • Instruction in using a planner • Highlight materials to emphasize important or urgent information • Planning activities in routine sequences • Use a schedule Academic Process • Peer tutor • Small group discussion • One on one instruction • Assign person to monitor student’s progress • Contact person (home/school) • Weekly progress report between home and school

31. Sensorimotor Accommodations Fine Motor Difficulties • Notetaker for lectures • Oral examinations • Taped lectures • Textbooks on tape • Assistance with daily living skills Gross Motor Difficulties • Adaptive physical education • Modify activity level for recess • Special transportation • Use or ramps and elevators • Restroom adaptations

32. Sensorimotor Accommodations (Cont’d) Mobility • Early release from class • Extra set of books for home • Assistance with carrying lunch tray, books, etc. • Escort between classes Visual-Spatial Deficits • Preferential seating in classroom • Large print materials • Modified materials (e.g., limit amount of material presented on page, extraneous pictures removed)

33. Social/Behavioral Accommodations Emotional Well-Being • School Counseling • Identify an adult that the student can “check in” with daily • Quiet area for re-grouping • Public praise and private reprimands when possible • Script about accident and hospitalization • Brain injury in-service for staff and classmates Behavior • Functional behavioral assessment • Positive behavioral management plan • Modification of nonacademic tasks (e.g., lunch, recess) • Time and place to re-group when upset • Additional structure in daily routine • Avoid criticism – Provide frequent positive feedback • When aggression occurs, act in neutral manner

34. Other Accommodations Technology • Computer for homework • Tape recorder for class work and class lecture • Use of communication devices • Books on tape for text and leisure materials • Talking calculators for math assignments • One-handed keyboard or control switches • PDA (e.g., Palm Pilot) • Talking watch to assist with time management • Watch alarm for reminders Fatigue • Reduced Schedule • Avoid “overloading” • Limit distractions • Planned rest breaks • Schedule arranged for high cognitive demand tasks to be followed by less stressful coursework

35. Treatment Techniques Auditory Comprehension • Locating picture/object named • Listening to lectures • Questions re: reading texts, magazines, newspaper, CD labels, news/educational videos • Following directions 1-2 step, multi-step, barrier, in classroom • Listen to voicemail or announcements and report back relevant information Reading Comprehension • Student reads text or other reading material and answers questions • Signs in school, crossword puzzles, word searches, charts, graphs, maps • Accelerated reading programs • Planner

36. Treatment Techniques (Cont’d) Verbal Expression • Naming: Confrontational/Responsive naming of items in classroom or school environment, synonym/antonym, similarities/differences, analogies, word association, multiple meanings, definitions, figurative language, vocabulary words • Sentence to paragraph formulation to describe wants, needs, pictures, actions, events, likes/dislikes • Conversational discourse (e.g., homework assignments, weekend, school activities) • Summarize reading texts, magazines, newspaper, opinions, news/educational videos • Giving directions (barrier tasks for challenge) • Make phone call or listen to voicemail and report back relevant information

37. Treatment Techniques (Cont’d) Written Expression • Copy designs, shapes, letter, words, phrases, sentences • Generate word to dictation, sentence to describe, write letter or email, take notes in lecture • Copy assignments into planner • Write own flashcards to review school work • Create outlines and reports • Take messages from voicemail or phone call

38. Treatment Techniques (Cont’d) Memory • Memory strategies (WRAPP - write, repeat, associate, picture, pair) • Visual retention (e.g, objects, pictures of objects, details of picture, items in room) • Recall list of items/words, or details from auditory stimuli • Prospective memory tasks (e.g., routines, responsibilities each day, to-do next week, month, etc) • Mental manipulation such as ranking, recalling specific words or concepts from sentence or paragraph, unscrambling sentences, repeating directions or sentences • Answer general information questions

39. Treatment Techniques (Cont’d) Reasoning • Category naming, convergent/divergent, category exclusion, conclusions, problem solving, verbal absurdities, analogies, figurative language, alternate solutions to situations, pros/cons, consequences, inferences about other’s feelings, inductive/deductive puzzles, inferencing, improving product/situation, other uses for items Sequential Thought • Sequencing pictures, demonstrating &/or verbalizing each step in a simple-complex situation, unscrambling words/sentences, sentence/story completions

40. Treatment Techniques (Cont’d) Attention/Concentration • Visual scanning, mathematics, alternating between tasks, crossword puzzles, word searches Insight/Awareness • Probing questions (i.e., What will be hard for you? What will be easy? How long will this take you? Do you think you’ll need any help?) • Follow-up questions (i.e., Where you able to complete the task? Was it completed on time? What problems did you have? What help did you need from others? What strategies did you use?) • Teach a student to “coach” him/herself using strategies Pragmatics • Role-playing, check-lists, assignments to socialize and reflect, watch tv show and comment on the interactions, social situations

41. Community Resources Brain Injury Association of America 8201 Greensboro Dr. Ste 611 McLean, VA 22102 (703) 761-0750 Family Helpline: (800) 444-6443 Fax: (703) 761-0755 E-Mail:FamilyHelpLine@biausa.orghttp://www.biausa.org Brain Injury Association of Illinois                  P.O. Box 64420                 Chicago, IL 60664-0420 (312) 726-5699Nationwide: (800) 699-6443Fax: (312) 630-4011Web Site:http://www.biail.org Midwest Brain Injury Clubhouse1010 N. Hooker St.Suite 302Chicago, IL 60622Telephone: 312-932-1120Fax: 312-932-1140www.braininjuryclubhouse.org Rehabilitation Institute of Chicago 345 East Superior St. Chicago, IL 60611 (312) 238-1000 Fax: (312) 238-1369 http://www.ric.org

42. Questions and Answers

43. Case Study #1 • J.D. 9 year old • Diagnosis: Encephalitis • Speech Diagnosis: Apraxia of Speech, Aphasia • Premorbid status: IEP developed to assist with attention deficits in class, tutor only special service

44. Case Study #2 • A.G. 14 year old • Diagnosis: Traumatic Brain Injury • Speech Diagnosis: Cognitive-Communication Disorders • Premorbid status: Diagnosed with learning disability, resource room with regular education class

45. “It is important to keep your feet on the ground but not always in the same spot” – Laura Murphy

46. References An educator's manual: National Head Injury Foundations, In Southborough, MA, 1988. Antoinette, T., Bruanling-McMorrow, D., Lash, M. (Ed.). (2004). Training Manual for Certified Brain Injury Specialists. American Academy for the Certification of Brain Injury Specialists. De Pompei, R., Blosser, J., Savage, R., Lash, M., (1998). Special Education IEP Checklist. Lash & Associates Publishing. Fleischner, J.E., et.al., (1993). The consequences of head injury:  what every teacher of the learning disabled students needs to know. Presented at the CEC Annual Convention, San Antonio, TX. Hartley, L.L., (1995). Cognitive-Communicative Abilities Following Brain Injury: A Functional Approach. San Diego CA: Singular Thomson Learning. Retrieved August 9, 2006, from http://www.biausa.org/aboutbi.htm Retrieved September 10, 2006 from http://www.cdc.gov.ncipc/factsheets/tbi.htm Retrieved  August 21, 2006, from http://ericec.org/faq/medicalx.html  Retrieved September 12, 2006 from http://www.isbe.net/spec-ed/html/categories.htm Retrieved August 21, 2006,from www.sesa.org/sesa/agency/docs/incltbi.html Tyler, J., Wilkerson, L., (2002). Section 504 Plan Checklist Lash & Associates Publishing. Ylvisaker, M. et.al. School reentry following head injury:  Managing the transiton from hospital to school.  In Journal of Head Trauma Rehabilitation 1991, 6(1): 10-22.