Traumatic Brain Injury in Ohio

1. Traumatic Brain Injury inOhio Program provided by: Ohio Brain Injury Program and Advisory Committee Rehabilitation Services Commission Checklist for presentation: Plan well in advance of your presentation. Have the PowerPoint disk and computer projection system ready Handouts run off for participants - take more than you think you will need Add any additional materials this specific audience should receive Trainer�s Manual for reference notes as needed Rehearse for running time with your personalized comments - plan to stay comfortably within the time limit. Decide whether or not to show the hidden slides Take blank paper and pens for questions and requestsChecklist for presentation: Plan well in advance of your presentation. Have the PowerPoint disk and computer projection system ready Handouts run off for participants - take more than you think you will need Add any additional materials this specific audience should receive Trainer�s Manual for reference notes as needed Rehearse for running time with your personalized comments - plan to stay comfortably within the time limit. Decide whether or not to show the hidden slides Take blank paper and pens for questions and requests

2. THIS PROGRAM MAY BE COPIED AND DOWNLOADED IN ANY FORMAT. HOWEVER, THE CONTENT OF THIS PRESENTATION MAY NOT BE ALTERED. 

3. Objectives Define brain injury Give epidemiological data Summarize neuropathology of TBI Describe functional impacts commonly associated with TBI Physical Behavioral Communicative Impact on family Outline programs available in Ohio Introduction Ask a few questions at the beginning to see who�s present, and then take what you hear into account as you conduct your session. Remember to involve the participants to keep interest level high. Begin by stating the goals of this presentation: To describe Traumatic Brain Injury (TBI), and how the brain and behavior are affected by TBI. Define brain injury Give epidemiological data Summarize neuropathology of TBI Describe functional impacts commonly associated with TBI Physical Behavioral Communicative Impact on Family Outline programs available in Ohio: HRSA Implementation Grant OBA, HIAC Introduction Ask a few questions at the beginning to see who�s present, and then take what you hear into account as you conduct your session. Remember to involve the participants to keep interest level high. Begin by stating the goals of this presentation: To describe Traumatic Brain Injury (TBI), and how the brain and behavior are affected by TBI. Define brain injury Give epidemiological data Summarize neuropathology of TBI Describe functional impacts commonly associated with TBI Physical Behavioral Communicative Impact on Family Outline programs available in Ohio: HRSA Implementation Grant OBA, HIAC

4. Explain the diagram as follows: Brain injury: Is a generic term that encompasses many disabilities. Congenital Injuries are injuries that occur either while the mother is carrying the child or at the time of birth. Acquired Brain Injury: This type of injury occurs to a normally developing individual after birth. It can be of two types: Non-traumatic & Traumatic Non-traumatic: Includes problems such as tumor, stroke, meningitis, encephalitis, toxic problems such as lead or mercury. Traumatic: Injury occurs as a blow to the head from an outside source such as a car crash, lead pipe, gunshot, fall. There are two types: Closed & Open Closed: Implies the skull did not fracture and remained intact. Open: Implies there was a skull fracture.Explain the diagram as follows: Brain injury: Is a generic term that encompasses many disabilities. Congenital Injuries are injuries that occur either while the mother is carrying the child or at the time of birth. Acquired Brain Injury: This type of injury occurs to a normally developing individual after birth. It can be of two types: Non-traumatic & Traumatic Non-traumatic: Includes problems such as tumor, stroke, meningitis, encephalitis, toxic problems such as lead or mercury. Traumatic: Injury occurs as a blow to the head from an outside source such as a car crash, lead pipe, gunshot, fall. There are two types: Closed & Open Closed: Implies the skull did not fracture and remained intact. Open: Implies there was a skull fracture.

5. This is the federal definition from the department of education. There are multiple legal or medical definitions that apply to all populations. No uniformly accepted definitions exist in Ohio. This is the federal definition from the department of education. There are multiple legal or medical definitions that apply to all populations. No uniformly accepted definitions exist in Ohio.

7. A Typical Day in the USA During a three hour period today: 684 Americans will experience a TBI (5479/day) 17 Americans will die from a TBI (137/day) Most of these newly injured Americans will be: young children young adults ages 18�25 elderly adults over age 65 Vehicle crashes will account for nearly 50% of all these TBIs Describe the incidence of TBI (from Closed Head Injuries) from BIA (Brain Injury Association) Falls are the most common cause for children under 5 years of age Physical abuse (64% of infant head injuries attributed to abuse) Motor vehicle crashes (which are the leading overall cause) and children in the 5-14 year age range frequently sustain TBI following pedestrian-motor vehicle or bicycle crashes. Recreational activities such as football, skateboarding and tubing are responsible for many injuries.Describe the incidence of TBI (from Closed Head Injuries) from BIA (Brain Injury Association) Falls are the most common cause for children under 5 years of age Physical abuse (64% of infant head injuries attributed to abuse) Motor vehicle crashes (which are the leading overall cause) and children in the 5-14 year age range frequently sustain TBI following pedestrian-motor vehicle or bicycle crashes. Recreational activities such as football, skateboarding and tubing are responsible for many injuries.

8. In Ohio by Midnight Tonight No one will be able to accurately report the number of persons who experienced a TBI today due to a lack of a TBI registry. However, based on national incidence and prevalence statistics, it is estimated that: 30 Ohioans will have suffered a TBI today and will be counted as one of the 196,047 other Ohioans who are living with long term disabilities as a result of a TBI Review Ohio data on TBI incidenceReview Ohio data on TBI incidence

9. 5 Ohioans will have died today due to a TBI 11 Ohioans injured today will be under 22 years old Statistics compiled by Ohio Legal Rights Service

10. National Facts and Figures 100/100,000 Annual national rate of TBI 272,000 Americans who experience a TBI each year 52,000 Americans who die due to TBI 5,300,000 People in US with long-term disabilities as a result of a TBI 25% Percent of TBIs classified as moderate or severe Review national statistics. Also note the following figures if time: 271,896,950 population of U.S. 11,200,000 population of Ohio 4% Ohio�s percent of total USA population Many injuries not classified as severe may also cause permanent effects on a child�s functioning. Even those that are considered �completely recovered� may have problems later on.Review national statistics. Also note the following figures if time: 271,896,950 population of U.S. 11,200,000 population of Ohio 4% Ohio�s percent of total USA population Many injuries not classified as severe may also cause permanent effects on a child�s functioning. Even those that are considered �completely recovered� may have problems later on.

11. 30% Percent of individuals with TBI eligible for Medicaid 18�25 Ages when most TBIs occur 20% Mortality rate for TBI in USA 50% Percent of TBIs related to vehicle crashes 34% Percent of all injury deaths in USA due to TBI 10% Percent of all individuals with disabilities in USA who have a TBI 20% Percent of individuals with TBI resulting from violence-related incidents

12. Ohio Information About TBI 11,174 Estimated number of new incidences of TBI /year in Ohio 17.7% Mortality rate for TBI in Ohio in 1996 1982 Number of Ohioans who die of TBI each year 7768 Number of Ohioans who are hospitalized each year due to TBI 2590�3330 Number of Ohioans who are disabled each year due to TBI

13. 74 Number of Ohioans each year who persist in vegetative state due to TBI 196,047 Number of people living in Ohio with long term disabilities as a result of TBI 38% Percentage of individuals who receive a TBI prior to age 22 Statistics compiled by Ohio Legal Rights Service

14. Neuropathology of TBI The brain is a gelatin-like substance vulnerable to outside trauma. The cranium protects the brain against trauma, but does not absorb impact forces. During concussion, the brain rotates and twists inside the skull, causing damage to brain tissue State the definition of OPEN HEAD INJURY: A head injury which occurs when the skull is penetrated by a sharp instrument (such as a knife) or an explosive missile (such as a bullet or shell fragments). Describe the pathology associated with open head injury. In penetrating head injuries, tissue damage will be found at the point of penetration and surrounding the path of the intruding object. Emphasize that gunshot wounds account for the majority of open head injuries. State that for TBI, the most common form of brain damage is caused by closed head injury. State the definition of a CLOSED HEAD INJURY: A type of traumatic brain injury in which the primary cause of damage is a blunt impact or blow to the head without penetrating the skull. State the definition of OPEN HEAD INJURY: A head injury which occurs when the skull is penetrated by a sharp instrument (such as a knife) or an explosive missile (such as a bullet or shell fragments). Describe the pathology associated with open head injury. In penetrating head injuries, tissue damage will be found at the point of penetration and surrounding the path of the intruding object. Emphasize that gunshot wounds account for the majority of open head injuries. State that for TBI, the most common form of brain damage is caused by closed head injury. State the definition of a CLOSED HEAD INJURY: A type of traumatic brain injury in which the primary cause of damage is a blunt impact or blow to the head without penetrating the skull.

15. Two Primary Mechanisms of TBI Acceleration/Deceleration Example: A quarterback falls to the ground and hits the back of his head. The falling motion propels the brain against the skull.

17. Rotational

19. Vulnerable Tissues Gray Matter of the Brain Neurons, residing in the gray matter, are single cells that use chemical reactions to create electrical currents to carry out activities The gray matter is the site of processing, integration and memory Children are especially vulnerable Learning is affected by problems with integration and memory The outer layer of the cortex is referred to as gray matter, the inner portions are referred to as white matter because of their coloring. The cortex can be divided into two halves called the right and left hemisphere. The right hemisphere controls the left side of the body, and the left hemisphere controls the right side of the body. Different functions are operated by different sides of the brain. Generally, the left hemisphere is associated with language functions, and the right with non-verbal skills such as visual-spatial ability. As the brain is moved against the skull, it can also be bruised (contusions). Explain: Contusions are often found in the frontal temporal regions, regardless of the site of impact. These are areas of bony projections and irregularities in the skull with a greater degree of brain-bone interface. The outer layer of the cortex is referred to as gray matter, the inner portions are referred to as white matter because of their coloring. The cortex can be divided into two halves called the right and left hemisphere. The right hemisphere controls the left side of the body, and the left hemisphere controls the right side of the body. Different functions are operated by different sides of the brain. Generally, the left hemisphere is associated with language functions, and the right with non-verbal skills such as visual-spatial ability. As the brain is moved against the skull, it can also be bruised (contusions). Explain: Contusions are often found in the frontal temporal regions, regardless of the site of impact. These are areas of bony projections and irregularities in the skull with a greater degree of brain-bone interface.

20. Vulnerable Tissues White Matter of the Brain Nerve cells are connected by axons (long projections of nerve cells resembling insulated wiring) which connect neurons to other neurons

21. Functional Impacts of TBI Impaired mobility Impaired body functions Impaired sensory experiences Impaired communication Impaired cognitive functions Review slide without detail - detail later Review slide without detail - detail later

22. Functional Impacts of TBI The experience, injury, and associated outcomes for each TBI survivor are complex and unique. Each case must be treated on an individual basis: viewing and treating the survivor and family (and other support persons) based on findings. Review slide with audienceReview slide with audience

23. Functional Impacts of TBI Impaired Mobility Paralysis (partial or full) Spasticity Balance Gait Paralysis can be described in terms of the parts of the body affected: Quadriplegia - paralysis of the whole body Paraplegia - paralysis of the lower half of the body Hemiplegia - paralysis of one side of the body Hemiparesis - weakness of one side of the body Spasticity - an inappropriate sustained contraction of muscles. Balance - may see ataxia or loss of ability to coordinate smooth movements, regain balance, or keep upright posture Gait - way of walking - may be disturbed in rate, rhythm and balanceParalysis can be described in terms of the parts of the body affected: Quadriplegia - paralysis of the whole body Paraplegia - paralysis of the lower half of the body Hemiplegia - paralysis of one side of the body Hemiparesis - weakness of one side of the body Spasticity - an inappropriate sustained contraction of muscles. Balance - may see ataxia or loss of ability to coordinate smooth movements, regain balance, or keep upright posture Gait - way of walking - may be disturbed in rate, rhythm and balance

24. Functional Impacts of TBI Impaired Body Functions Swallowing difficulties Temperature control Changes control of body functions (bowel and bladder, sexual functioning, hunger) Swallowing problems may be seen with difficulty recognizing, manipulating, or controlling foods or liquids and swallowing them safely. Aspiration or choking may be a problem. Temperature control - due to injury to the brainstem areas, the body may chill or spike fevers Person may have difficulty controlling bowel or bladder either through physical control or cognitive awareness of need and place to relieve themselves. Sexual functioning and behaviors can be disrupted due to injury to the brainstem centers for desire and cognitive awareness of socially appropriate actions. Swallowing problems may be seen with difficulty recognizing, manipulating, or controlling foods or liquids and swallowing them safely. Aspiration or choking may be a problem. Temperature control - due to injury to the brainstem areas, the body may chill or spike fevers Person may have difficulty controlling bowel or bladder either through physical control or cognitive awareness of need and place to relieve themselves. Sexual functioning and behaviors can be disrupted due to injury to the brainstem centers for desire and cognitive awareness of socially appropriate actions.

25. Functional Impacts of TBI Impaired Sensory Experiences Vision Hearing Smell Taste Touch Vision: Person may have discrete blind spots in the visual field. May have visual distortions due to lesions in the visual association areas. Hearing: Sounds are interrupted due to injury to the areas for reception and association of sound in the temporal lobes of the brain. Smell: Sense of smell can be lost or disturbed due to pulling or shearing on the olfactory nerve during the injury. Taste: Taste can be distorted and changed due to pulling and shearing on the cranial nerves responsible for taste (C5 & C7). Touch: Decrease or change due to parasthesiasVision: Person may have discrete blind spots in the visual field. May have visual distortions due to lesions in the visual association areas. Hearing: Sounds are interrupted due to injury to the areas for reception and association of sound in the temporal lobes of the brain. Smell: Sense of smell can be lost or disturbed due to pulling or shearing on the olfactory nerve during the injury. Taste: Taste can be distorted and changed due to pulling and shearing on the cranial nerves responsible for taste (C5 & C7). Touch: Decrease or change due to parasthesias

26. Functional Impacts of TBI Impaired Communication Speaking Expressing thoughts and ideas Understanding language Decreased everyday use of language Review this slide with audience. To augment, as time constraints allow: These slides are hidden from the audience and will not be shown unless you press the H key. Speaking: A 22 year old male with severe slurring of speech and drooling. He is unable to be understood by anyone outside his immediate family. Expressing thoughts and ideas: An 18 year old female with moderate word finding and sentence structure problems. Listeners require several repeats of the message to understand what she intends. Understanding Language: A 17 year old male with injury to the temporal lobes needs many repeats, restatements and visual aids to understand simple directions and comments. Decreased Everyday Use of Language: A 19 year old college freshman has such a struggle and is so self-conscious about her speech, that she rarely attempts to express her thoughts and ideas. She is thought to be aloof. Review this slide with audience. To augment, as time constraints allow: These slides are hidden from the audience and will not be shown unless you press the H key. Speaking: A 22 year old male with severe slurring of speech and drooling. He is unable to be understood by anyone outside his immediate family. Expressing thoughts and ideas: An 18 year old female with moderate word finding and sentence structure problems. Listeners require several repeats of the message to understand what she intends. Understanding Language: A 17 year old male with injury to the temporal lobes needs many repeats, restatements and visual aids to understand simple directions and comments. Decreased Everyday Use of Language: A 19 year old college freshman has such a struggle and is so self-conscious about her speech, that she rarely attempts to express her thoughts and ideas. She is thought to be aloof.

27. Speaking Impacts A 22 year old male with severe slurring of speech and drooling. He is unable to be understood by anyone outside his immediate family. He uses a word communication book and an electronic device to be understood and to use the phone. Speaking: A 22 year old male with severe slurring of speech and drooling. He is unable to be understood by anyone outside his immediate family. He uses a word communication book and an electronic device to be understood and to use the phone.Speaking: A 22 year old male with severe slurring of speech and drooling. He is unable to be understood by anyone outside his immediate family. He uses a word communication book and an electronic device to be understood and to use the phone.

28. Expressing Thoughts and Ideas An 18 year old female with moderate word finding and sentence structure problems. Listeners require several repeats of the message to understand what she intends. Expressing thoughts and ideas: An 18 year old female with moderate word finding and sentence structure problems. Listeners require several repeats of the message to understand what she intends. Expressing thoughts and ideas: An 18 year old female with moderate word finding and sentence structure problems. Listeners require several repeats of the message to understand what she intends.

29. Understanding Language A 17 year old male with injury to the temporal lobes needs many repeats, restatements and visual aids to understand simple directions and comments. Understanding Language: A 17 year old male with injury to the temporal lobes needs many repeats, restatements and visual aids to understand simple directions and comments. Understanding Language: A 17 year old male with injury to the temporal lobes needs many repeats, restatements and visual aids to understand simple directions and comments.

30. Decreased Everyday Use of Language A 19 year old college freshman has such a struggle and is so self-conscious about her speech, that she rarely attempts to express her thoughts and ideas. She is thought to be aloof. Decreased Everyday Use of Language: A 19 year old college freshman has such a struggle and is so self-conscious about her speech, that she rarely attempts to express her thoughts and ideas. She is thought to be aloof. Decreased Everyday Use of Language: A 19 year old college freshman has such a struggle and is so self-conscious about her speech, that she rarely attempts to express her thoughts and ideas. She is thought to be aloof.

31. Functional Impacts of TBI Impaired Cognitive Functions Attention/Concentration Memory Decision making Executive functioning Organization Judgment Review slide as is. To augment, as time constraints allow: Specific examples of each will remain hidden from the audience unless you press the H key. Attention/Concentration: A man is unable to complete a task at work in a reasonable amount of time. He is distracted by the activities and noises around him. Memory: A woman is unable to recall information given to her about carpooling plans for the coming week to her daughter�s school. Decision Making: When shopping at a local department store, a man is unable to weigh the pros and cons of buying one of two expensive tools - and therefore, purchases both. Executive Functioning: A woman is unable to plan and structure her day at the office and, therefore, completes nothing during the day. Organization: A student has difficulty following the class schedule of assignments and class attendance. He is unable to organize his time and efforts. Judgment: A man went out and bought two cars in the same day at different car dealerships. He bought one for himself and one for his son. He knew he bought two cars, but he was unable to determine that he could not afford them. Review slide as is. To augment, as time constraints allow: Specific examples of each will remain hidden from the audience unless you press the H key. Attention/Concentration: A man is unable to complete a task at work in a reasonable amount of time. He is distracted by the activities and noises around him. Memory: A woman is unable to recall information given to her about carpooling plans for the coming week to her daughter�s school. Decision Making: When shopping at a local department store, a man is unable to weigh the pros and cons of buying one of two expensive tools - and therefore, purchases both. Executive Functioning: A woman is unable to plan and structure her day at the office and, therefore, completes nothing during the day. Organization: A student has difficulty following the class schedule of assignments and class attendance. He is unable to organize his time and efforts. Judgment: A man went out and bought two cars in the same day at different car dealerships. He bought one for himself and one for his son. He knew he bought two cars, but he was unable to determine that he could not afford them.

32. Attention A man is unable to complete a task at work in a reasonable amount of time. He is distracted by the activities and noises around him.

33. Memory A woman is unable to recall information given to her about carpooling plans for the coming week to her daughter�s school.

34. Decision Making When shopping at a local department store, a man is unable to weigh the pros and cons of buying one of two expensive tools - and therefore, purchases both.

35. Executive Functioning A woman is unable to plan and structure her day at the office and, therefore, completes nothing during the day.

36. Organization A student has difficulty following the class schedule of assignments and class attendance. He is unable to organize his time and efforts.

37. Judgment A man went out and bought two cars in the same day at different car dealerships. He bought one for himself and one for his son. He knew he bought two cars, but he was unable to determine that he could not afford them.

38. Psychological Impacts of TBI Depression (survivor, family, friends) Lower threshold for frustration Anger, tantrums, and mood swings Impulsivity and distractibility Loss of former identity �The Invisible Disability� Depression: As people become aware of the severity of the injury and recognize changes, they may suffer periods of depression Frustration Tolerance: Decrease in ability to control anger and agitation. Also reveals decreased attention/concentration abilities. Anger, tantrums and mood swings: Shows poor impulse control and frustration associated with impairments. Mood swings may be seen as the body attempts to reestablish balance. Mood changes may be quite rapid and appear unprecipitated by environmental factors. Impulsivity: When a person has difficulty controlling impulses. Impulsive people are impatient and fail to think before acting. Loss of former identity: Awareness of changes in ability may affect self-esteem; expectations and sense of self are changed by TBI.Depression: As people become aware of the severity of the injury and recognize changes, they may suffer periods of depression Frustration Tolerance: Decrease in ability to control anger and agitation. Also reveals decreased attention/concentration abilities. Anger, tantrums and mood swings: Shows poor impulse control and frustration associated with impairments. Mood swings may be seen as the body attempts to reestablish balance. Mood changes may be quite rapid and appear unprecipitated by environmental factors. Impulsivity: When a person has difficulty controlling impulses. Impulsive people are impatient and fail to think before acting. Loss of former identity: Awareness of changes in ability may affect self-esteem; expectations and sense of self are changed by TBI.

39. �Invisible Disability� Many times individuals recover physically, but continue to have cognitive problems which are not easily recognized by the general public. �The Invisible Disability�: Because so many of the impairments are not on the surface and physically visible, but interfere with behavior they may be interpreted as purposeful.�The Invisible Disability�: Because so many of the impairments are not on the surface and physically visible, but interfere with behavior they may be interpreted as purposeful.

40. Social Impacts of TBI Impact on the family members (parents, siblings, caregivers) Isolation for the child and family Loss of friends and peer support Transportation barriers Accessibility issues Review this information as time allows: Discuss the social losses that can occur after a TBI: Parents can lose the support of friends who can no longer understand what is happening with their child. Persons with the TBI can lose friends because their behaviors (acting out, speaking out, not using social graces they used to employ) are unable to be self-monitored. Adolescents are particularly susceptible to loss of social supports. Children with a parent who has a TBI often become isolated because they don�t want friends to see how their parent is behaving. Other family members often can�t supply the time or understanding to aid in the social integration of the person with TBI. Social aspects are often responsible for inability of the individual to fit into work, family, or community activities even when they are capable of the �work�. The inability to perform adequately socially stops them from being actively accepted in these environments. Review this information as time allows: Discuss the social losses that can occur after a TBI: Parents can lose the support of friends who can no longer understand what is happening with their child. Persons with the TBI can lose friends because their behaviors (acting out, speaking out, not using social graces they used to employ) are unable to be self-monitored. Adolescents are particularly susceptible to loss of social supports. Children with a parent who has a TBI often become isolated because they don�t want friends to see how their parent is behaving. Other family members often can�t supply the time or understanding to aid in the social integration of the person with TBI. Social aspects are often responsible for inability of the individual to fit into work, family, or community activities even when they are capable of the �work�. The inability to perform adequately socially stops them from being actively accepted in these environments.

41. Family Needs & Feelings Difficulty in processing the impact of the injury on the family member and the family as a whole Need to hear information repeatedly Need to have written information for later use Review this information as time allows: The family often needs to understand what they are experiencing emotionally is normal. It is normal to have periods of anger, joy, frustration, blaming, denial, happiness. Emotions often will be like riding a roller coaster and these emotions will be present over a lifetime. The family needs to learn advocacy techniques so that they can better work with many agencies within the system. They should know how to describe the strengths and challenges of the family member, what to do if an agency seems to be unable to provide necessary assistance, and where to turn for additional assistance.Review this information as time allows: The family often needs to understand what they are experiencing emotionally is normal. It is normal to have periods of anger, joy, frustration, blaming, denial, happiness. Emotions often will be like riding a roller coaster and these emotions will be present over a lifetime. The family needs to learn advocacy techniques so that they can better work with many agencies within the system. They should know how to describe the strengths and challenges of the family member, what to do if an agency seems to be unable to provide necessary assistance, and where to turn for additional assistance.

42. Family Needs & Feelings Fatigue May require respite care Isolation May benefit from support groups, information sources Frustration May need time alone May need the opportunity to vent Review this information as time allowsReview this information as time allows

43. Family Needs & Feelings Specific service needs for the family and survivor Refer to Ohio Brain Injury Association, local social service agencies, local school district Review this information as time allowsReview this information as time allows

44. Domains of Assessment Intellectual Attention/Concentration Memory Language Motor Behavior Family State that these areas are evaluated by rehabilitation teams, neuropsychologists, and at the return to education, by school psychologists.State that these areas are evaluated by rehabilitation teams, neuropsychologists, and at the return to education, by school psychologists.

45. Community Reintegration Impacts School Vocational Leisure Friends School - school reintegration is complex and learning can be affected for many years after the injury Explain vocational - return to work and keeping a job is often difficult due to the impact of the injury (you have previously reviewed functional impacts of TBI) Leisure - because of transportation and accessibility issues, access to leisure activities is often decreased. Behaviors of the person with TBI may also interfere with social acceptance in leisure activities. Friends - who do not understand the functional nature of the injury are often embarrassed do not know what to do and so leave the friendship.School - school reintegration is complex and learning can be affected for many years after the injury Explain vocational - return to work and keeping a job is often difficult due to the impact of the injury (you have previously reviewed functional impacts of TBI) Leisure - because of transportation and accessibility issues, access to leisure activities is often decreased. Behaviors of the person with TBI may also interfere with social acceptance in leisure activities. Friends - who do not understand the functional nature of the injury are often embarrassed do not know what to do and so leave the friendship.

46. SchoolWhen a Child is Injured In the hospital: Keep local school district informed Contact hospital social service for assistance with insurance, Social Security Disability, Medicaid Develop a plan for school reintegration while in the hospital Children and adolescents present special challenges for rehabilitation and transition. Early communication among hospital and school to assure clear flow of information is critical to successful reintegration to school and community.Children and adolescents present special challenges for rehabilitation and transition. Early communication among hospital and school to assure clear flow of information is critical to successful reintegration to school and community.

47. SchoolWhen a Child is Injured Reintegration to the community (home and school): Developmental issues The brain is still developing, therefore, brain pathways and connections may or may not occur Problems in learning can emerge years later as developmental milestones are missed Child on achievement tests performs at age level after injury but may not demonstrate new learning It is important to remember that a child is not a little adult. Persons who are trained in developmental issues of children should be those providing services to children and adolescents.It is important to remember that a child is not a little adult. Persons who are trained in developmental issues of children should be those providing services to children and adolescents.

48. SchoolWhen a Child is Injured Academic challenges Learning; memory, language, integration of information, problem solving, organization Behavior; frustration, intolerance, distractibility, impulsivity, attention

49. SchoolWhen a Child is Injured Reintegration to school: Establish hospital to school communication Contact early Contact often Transfer records among all facilities Include parents in all communication Parental participation is essential to good carryover of planning for the child. Assist families to become good advocates for their children by teaching them problem solving techniques.Parental participation is essential to good carryover of planning for the child. Assist families to become good advocates for their children by teaching them problem solving techniques.

50. SchoolWhen a Child is Injured When there are concerns about school planning: Contact the director of special education in your local school district Contact one of the 16 Ohio Special Education Regional Resource Centers (SERRC) for additional information and assistance Contact Ohio Resource Center for Low Incidence and Severe Handicaps (ORCLISH) for special assistance with a severely injured child Locate your SERRC by calling the local school district or the Ohio Department of Special Education, 933 High St., Columbus OH 43085-4087, 614-466-2650. Ask for the TBI Consultant for the state. ORCLISH, 470 Glenmont Ave., Columbus OH 43214, 614-262-6131Locate your SERRC by calling the local school district or the Ohio Department of Special Education, 933 High St., Columbus OH 43085-4087, 614-466-2650. Ask for the TBI Consultant for the state. ORCLISH, 470 Glenmont Ave., Columbus OH 43214, 614-262-6131

51. Service Providers Within the Continuum Community Integration: Psychological service providers OT, PT, and Speech Pathologist Assistive technology specialist Special educators

52. Service Providers Within the Continuum Respite providers Transitional housing providers Independent Living Center advisors Vocational Rehabilitation assessors and counselors

53. Ohio Resources Ohio Brain Injury Association (OBIA)1335 Dublin Rd Ste 217DColumbus OH 43215-1000614-481-7100Helpline: 800-686-9563 OBIA is a volunteer organization that supplies information, referral, and support regarding brain injuryOBIA is a volunteer organization that supplies information, referral, and support regarding brain injury

54. Ohio Resources Ohio Brain Injury Program and Advisory CommitteeRehabilitation Services Commission400 E Campus View Blvd SW4Columbus OH 43235-4604614-438-1340 The Brain Injury Program was created by Ohio law in 1990. It is housed in the Rehabilitation Services Commission of Ohio. The Advisory Committee and Brain Injury Program provide some funding for research into concerns for persons and their families after brain injury. The committee provides information from a number of service providers, state agencies, and individuals with TBI and their families regarding the challenges facing persons with TBI with in the State of Ohio.The Brain Injury Program was created by Ohio law in 1990. It is housed in the Rehabilitation Services Commission of Ohio. The Advisory Committee and Brain Injury Program provide some funding for research into concerns for persons and their families after brain injury. The committee provides information from a number of service providers, state agencies, and individuals with TBI and their families regarding the challenges facing persons with TBI with in the State of Ohio.

55. There are numerous governmental Ohio State Departments that can help. Contact the appropriate ones as needed. A list of departments and phone numbers is in the handout Ohio Resources Review and briefly summarize the programs available in Ohio HRSA Implementation Grant: Health and Human Resources has been given a portion of the 25 million dollars awarded for research through the TBI ACT of 1996. They are awarding Planning and Implementation grants (one per state) to state agencies who will change the manner in which they are responding to individuals with TBI and their families. Ohio was awarded a three year implementation grant in 1998. For information, contact OBIA who is the subcontractor for the grant.Review and briefly summarize the programs available in Ohio HRSA Implementation Grant: Health and Human Resources has been given a portion of the 25 million dollars awarded for research through the TBI ACT of 1996. They are awarding Planning and Implementation grants (one per state) to state agencies who will change the manner in which they are responding to individuals with TBI and their families. Ohio was awarded a three year implementation grant in 1998. For information, contact OBIA who is the subcontractor for the grant.

56. National Resources Brain Injury Association (BIA)105 N Alfred StAlexandria VA 22314703-236-6000 Website: http://www.biausa.org

57. National Resources Brain Injury Resource Center8737 Colesville Rd Ste 950Silver Spring MD 20910301-650-8080 Website: www.tbigrants.com Through TBI Grants, a resource and information center has been established. For access to their information contact: Through TBI Grants, a resource and information center has been established. For access to their information contact:

58. National Resources National Information Center for Children and Youth with Disabilities (NICHCY)PO Box 1492Washington DC 20013-1492800-695-0285 Website: http://www.nichcy.org

59. Websites of Interest http://www.tr.wou.edu/tbi/index.html Oregon Teaching Research will provide articles and information regarding specific topics in TBI http://www.sasquatch.com/tpn/AZHIF.html Arizona BIA provides information and referral for families

60. Websites continued http://www.sped.ukans.edu.spedprojects/tbi/TBIHOMEPAGE.html The TBI project is funded by the Kansas State Board of Education and provides inservice and preservice to educators and related service personnel

61. Websites continued http://www.tbi.pmr.vcr.edu This NIDRR TBI model system provides lists of experts, answers to frequently asked questions and several links to other sites on TBI, including one to Virtual Assistive Technology Center (free or inexpensive software for people with disabilities)