Introduction to Traumatic Brain Injury (TBI) for Educators

1. Introduction to Traumatic Brain Injury (TBI) for Educators Funded by an IDEA Discretionary Grant #2007-9911-22 Wisconsin Department of Public Instruction (http://www.dpi.wi.gov)

2. Outline______________________________________________________Outline______________________________________________________ • Brain injury definition • Brain Function • Common Problems • Steps to evaluation and programming success • Resources

3. WHAT IS A BRAIN INJURY?

4. What is a brain injury?______________________________________________________ • An injury to the brain caused by a blow to the head; penetration of the skull caused by an accident. • The injury may disrupt functioning in a single area of the brain (focal damage) or impact multiple areas of brain functioning (diffuse damage). • Adverse effects could be short term or life-long.

5. Types of Brain Injury ______________________________________________________

6. Wisconsin TBI Definition______________________________________________________ • Traumatic brain injury • an acquired injury to the brain • caused by an external physical force • resulting in total or partial functional disability or psychosocial impairment, or both • adversely affects a child’s educational performance

7. Prevalence______________________________________________________Prevalence______________________________________________________ • Every 23 seconds 1 person in the U.S. sustains an acquired brain injury • 1 in 500 students sustain an acquired BI each year in the U.S. • 1 in 25 students will sustain an acquired BI before high school graduation • Overall twice as many boys as girls • Highest risk: 0-4 year olds and 15-19 year olds

8. Primary Causes of BI by Age______________________________________________________ • Infants Abuse; neglect • Toddlers Abuse; falls • Early Elementary Falls; pedestrian-motor vehicle accidents • Late elementary/Middle school Pedestrian-bicycle accidents Pedestrian-motor vehicle accidents Sports • High school Motor vehicle accidents (Savage & Wolcott, 1994)

9. What Happens When the Brain is Injured?______________________________________________________ • Brain injuries are either: • Closed head – Skull not penetrated (car accident, falls) • Open Head – Skull and meninges are penetrated (gunshot, nail) • Both of these result in: • A disruption of communication within the brain due to torn or stretched neurons • Lack of oxygen to the brain resulting in cell death.

10. Primary Effects of Brain Injury______________________________________________________ • Injury to brain tissue at the initial site of impact and at the second injury site (Coup & Contracoup) • Shearing and tearing of neurons throughout the brain disrupts communication

11. Mechanism of injury: Coup/Contracoup______________________________________________________ Reprinted with permission from the North Carolina Department of Public Instruction

12. Shearing & Tearing of Neurons • When an injury occurs the neurons stretch, twist or tear.

13. Secondary Effects of Brain Injury_______________________________________________________ • Bleeding (contributes to increased intracranial pressure) • Swelling (contributes to increased intracranial pressure) • Lack of oxygen to the brain (results in cell death)

14. Mild, Moderate, Severe______________________________________________________ • Injuries can range from “mild” (a brief change in mental functioning) to “severe” (extended period of unconsciousness) • Significant long-term disability. • Full effects of brain injury may not be apparent until later when the child is expected to perform more advanced skills and to self-regulate behavior.

15. Severity of Brain Injury: Mild______________________________________________________ • Brief or no loss of consciousness • Signs of concussion • Nausea and vomiting • Headache • Fatigue • Dizziness • Poor recent memory • Unable to form new memories following the injury (less than 1 hour)

16. Severity of Brain Injury: Moderate______________________________________________________ • Coma less than 24 hours • Unable to form new memories following the injury (less than 24 hours)

17. Severity of Brain Injury: Severe_______________________________________________________ • Coma more than 24 hours • Unable to form new memories following the injury (longer than 24 hours)

18. Proportion of Mild, Moderate, and Severe Brain Injuries_______________________________________________________ • The vast majority of students with brain injuries returning to school have mild injuries.

19. Brain Function ______________________________________________________ • The adult brain weighs about 3 pounds. • The brain is a complex organ made up of billions of neurons that all relate to each other. • Each area of the brain has primary responsibilities that contribute to our ability to function.

20. Brain Surface______________________________________________________

21. At the base of the brain above the spinal cord Comprised of the medulla, pons, and midbrain Responsible for basic life functions Severe injury causes death The Brainstem_______________________________________________________

22. The Cerebellum______________________________________________________ • Primarily helps modulate motor responses • Regulates direction, rate, force, and steadiness • Injury disrupts coordination and muscle tone

23. The Cerebral Cortex______________________________________________________ • Center of conscious brain activity • Divided into two hemispheres connected by the corpus collosum • The right side of the brain controls the left side of the body and vice versa • Dominant hemisphere represents language (usually left hemisphere)

24. The Lobes of the CerebralCortex______________________________________________________ • Each hemisphere of the brain is divided into four lobes: • Frontal • Temporal • Parietal • Occipital Reprinted with permission from the North Carolina Department of Public Instruction

25. The Frontal Lobe Functions______________________________________________________ • Control executive functions • Area of motor cortex • Deficits may become apparent over time If Injured you may see impaired: -memory -motor planning and performance -behavior control -higher level thinking skills (summarizing, inferencing) -deficits may become more apparent as child is expected to perform higher level skills.

26. The Parietal Lobe Functions______________________________________________________ • Receives, analyzes, and integrates sensory and motor stimuli If injured you may see impaired: -body awareness (poor judgment about space and distance) -sensations (hypo/hypersensitivity) -visual neglect (not attend to stimuli on affected side)

27. The Temporal Lobes______________________________________________________ • Receives, analyzes, and integrates auditory information • Center for language If Injured you may see impaired: -ability to listen, understand and generalize auditory input -expressive and receptive language -memory formation

28. The Occipital Lobes______________________________________________________ • Receives, analyzes. integrates visual information If Injured you may see impaired: -ability to understand and integrate visual information -visual functions (restricted vision) -ability to track moving objects (ex: catching a ball) -ability to track stationary objects (ex: reading a line of print

29. Common Problems______________________________________________________ • Difficulties with memory, attention, concentration & fatigue are common. • Anticipating & planning for these deficits increases the likelihood of student success. • May have problems with motor, sensory/perceptual, cognitive/communication, social/emotional, behavioral functioning.

30. Common Problems______________________________________________________ Certain types of difficulties are common in students with TBI Anticipating these difficulties can facilitate success in school Problems can be physical/medical, cognitive, sensory, motor, social, emotional, and behavioral

31. Common Motor Problems______________________________________________________ Apraxia Ataxia Coordination problems Paresis or paralysis Orthopedic problems Spasticity Balance problems Impaired speed of movement Fatigue

32. Sensory/Perceptual Problems______________________________________________________ Visual deficits field cuts tracking (moving and stationary objects) spatial relationships double vision (diplopia) Neglect Auditory deficits Tactile deficits

33. Cognitive/Communication Problems_______________________________________________________ Executive functions Memory Attention Concentration Information processing Sequencing Problem solving Comprehension of abstract language Word retrieval Expressive language organization Pragmatics

34. Social/Emotional 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

35. Behavioral Problems______________________________________________________ Deficits (all types) may lead to challenging behaviors non-compliance aggression confrontational behavior lack of initiative withdrawal

36. Impact on Learning______________________________________________________ Orientation and Attention to Activity Starting, Changing, and Maintaining Activities Taking in and Retaining Information Language Comprehension and Expression Visual-Perceptual Processing Visual-Motor Skills Sequential Processing Problem-Solving, Reasoning, and Generalization Organization and Planning Skills Impulse or Self-Control Social Adjustment and Awareness Emotional Adjustment Sensorimotor Skills

37. Identifying Educational Concerns______________________________________________________ The educational team needs to consider the multifaceted implications of the brain injury. It is helpful to use checklists and other tools to assist in identifying child specific concerns. Traumatic Brain Injury checklist may be used as an evaluation tool to identify specific student concerns.

38. Traumatic Brain Injury Checklist Please rate the student’s behavior (in comparison to same-age classmates) using the following rating scale: Not at all Occasionally Often Very Severe & Frequent Problem

43. Waaland and Bohannon (1992) Reprinted from Guidelines for Educational Services for Students with Traumatic Brain Injury (Virginia Department of Education, 1992)

44. WHAT ARE THE NEXT STEPS TO SUCCESSFUL EVALUATION AND PROGRAM PLANNING?

45. What are the next steps?______________________________________________________ • Once a student suspected of having a disability is referred for a special education evaluation, the next step is to gather information. • You will need two types of information • Brain Injury information (type of injury, location of injury, length of coma, etc.) 2. Information on current functioning (physical/medical, social/emotional, academic, cognition and memory, speech/language and communication, sensory/perceptual

46. What’s Next? (continued)______________________________________________________ How will you gather the information? • Review medical reports • Observe student • Interview the student and knowledgeable others (therapists, medical personnel, parents, etc.) • Use curriculum based measures and work samples

47. What’s Next? (continued)______________________________________________________ • Identify appropriate team members (If student has fine and gross motor difficulties, should an OT, PT or APE person be part of the IEP Team?) • Conduct a thorough educational evaluation of the student to: 1. Determine eligibility and need for special education and related services 2. Identify disability-related educational needs

48. What’s Next? (continued)______________________________________________________ If the student has a disability, identify major issues to address in the IEP such as: • Student health and safety issues (wheelchair transportation, medication management, etc.) • Schedule (need for a shortened day, more frequent breaks during the day, etc.) • Classroom instruction (enlarged print, preferential seating, other modifications) • Staff training (TBI, medical procedures)

49. What can be done if the IEP Team determines that the student does not have a disability? * To support the student in regular education, the team could recommend short term accommodations such as: • adjust schedule • delay high stakes tests • prioritize homework • educate parents, teachers, peers • assign case manager to monitor progress • refer to a building team

50. Resources______________________________________________________Resources______________________________________________________ • Dept. of Public Instruction (DPI): http://dpi.wi.gov/sped/tbi.html • Level I TBI Training: http://dpi.wi.gov/sped/tbi-trg-pres.html • CESA-based TBI consultants: http://dpi.wi.gov/sped/pdf/tbi-contacts.pdf • TBI Kit (available at each CESA) • Teacher tools, charts, and checklists • Level I trainings • Memory training and resources • Links and resources • Additional TBI materials (on DPI website) • Mild brain injury informational brochure • Parent Information packet • Teacher Information packet • Administrator’s information packet • Informational brochure for hospitals and clinics