Interventions for School Reentry after a Traumatic Brain Injury

1. Interventions for School Reentry after a Traumatic Brain Injury Marine McDonnell

2. Presentation Outline Serving Student with TBI– IDEA Understanding TBI Pre-reentry Interventions Developing a Multi-Disciplinary Team Educating Staff Assessment for Reentry IEP Development Instructional Interventions Interventions to support the family Psychosocial interventions

3. Serving Students with TBI in Schools The Individuals with Disabilities Education Act (IDEA) included TBI as a disability category in 1990. Prior to this time, individuals were usually served under the more general category of “other health impaired.” Individuals with TBI are eligible for and require special education services in school. Because of the cost of healthcare, individuals are often returned to the school setting very early in their recovery. This implies that schools need be able to effectively develop interventions for short term and long term recovery.

4. Definition and Diagnosis TBI is an injury caused by external physical force that results in a total or partial functional disability and / or psychosocial impairment that adversely affects a child’s educational performance. TBI typically occurs as a result of deceleration or penetration injuries. TBI is usually qualified as mild, moderate, or severe.

5. Prevalence TBI is the leading cause cause of morbidity and mortality in children and adolescents. Approximately 3% of the school-aged population is, or has been, affected by TBI. Males and members of low SES groups are more likely to sustain a TBI. There is a higher prevalence of TBI in males and in low SES groups. TBI is most likely to occur between the ages of 0-4 and 15 – 19. Common causes include falls, sport injuries, motor vehicle accidents, and violence.

6. Characteristics of TBI Frontal lobe injury is associated with delayed consequences.

7. Age of Injury Earlier Age of TBI Better Long Term Outcome

8. Delayed Consequences of Injury

9. A Note on Identification Do not assume that a TBI will be identified or disclosed. Students may experience a head injury and have seemingly no ill effects – these students will likely not be flagged for monitoring or assessment. Students with mild TBI are sometimes later diagnosed with ADHD, learning, emotional, or behavioural disorders.

10. Considering Reentry after TBI Reasons to plan intervention for reentry to school: Returning to school and other life routines promotes recovery from TBI. Reentry without intervention is likely to have negative consequences for the child. Early intervention enhances long term outcomes. Documenting interventions in the short term validates the need for future interventions.

11. Pre-Reentry Interventions Plan for reentry as soon as knowledge of the TBI is provided to the school. Designate a ‘point person’ as soon as possible. Consider placement options, gradual reentry, and necessary environmental adaptations at the school. Consider the whole child including planning for academic, cognitive, and social – emotional wellbeing. As much as possible, anticipate the needs of the student prior to the first day back at school and understand that the demands of school are very different than the demands of the home or hospital.

12. Establish a Multidisciplinary Team Focus on collaborative decision making and a multidisciplinary response. Members of the Team Student Family School staff (teacher, administrator, special education teacher, counsellor) School psychologist Medical Personnel (pediatric neurologist, hospital psychologist, etc.) Speech / language support Physical / occupational therapist Other (hospital teacher, hospital social worker, community care providers, etc.)

13. Educate Staff about TBI and Recovery Recovery from TBI is varied and inconsistent and depends on many of the factors that contribute to the characteristics of a TBI. After the TBI, there is often a period of rapid recovery. Students with TBI often progress adequately for a year or two after their injury and after which time they have difficulty keeping up with grade level expectations due to deficits associated with their injury. Frame behaviours within the context of the disability. Remember that behaviours may have more to do with neurological insult than environmental triggers. Provide and seek ongoing feedback and assessment data to staff at case management meetings.

14. Comprehensive Assessment for Reentry Use academic, cognitive, and neuropsychological measures that include assessments of executive function and memory. Compare pre- and post-injury levels of function. Conduct observations in multiple settings. Conduct functional behavioural assessments. Consider the ecological validity of results from standardized tests – students may over-perform in the 1:1 test setting. Test the limits to identify effective interventions (consider the WISC-IV integrated). Reassess at regular intervals. Does your school district have a protocol for prioritizing students waiting for evaluation that includes reentry following a TBI? Is anyone in your school district trained in neuropsychological assessment?

15. And… if Standardized Assessment is not Feasible Current medical status and injury specific information. Compare pre-injury function to post-injury function. For placement, assess the academic level that the child was at, then test backwards to find the best point for re-entry if the child can no longer perform the tasks she or he could once perform.

16. Pre- and Post-Injury Status Questionnaire(Glang, Singer, & Todis, 1997)

17. Develop an Individual Education Plan (IEP) Design an IEP as soon as possible upon reentry. Best practice in developing and implementing an IEP for students with TBI is to allow for flexibility and regular reevaluation. Plan interventions for the academic, cognitive, behavioural, and social – emotional needs of the student. Plan for the provision of support as well as for the reduction of support as recovery of function is achieved.

18. Instructional Interventions Because of the varied range of deficits associated with TBI, a set of specific “TBI interventions” does not exist. Best practice: draw from evidence based interventions for specific academic, cognitive, and executive function deficits. General strategies include implementing a process oriented instructional approach, teaching meta-cognitive and self-regulation strategies, providing structure and routine, and supporting organization and memory. Interventions are most successful when integrated into daily routines – do not assume that interventions will be generalized or transferred. Focus on environmental adaptations rather than adaptations that utilize an internal locus of control.

19. Interventions to Support Family Family function is a predictor for short term and long term recovery from TBI. Family focused interventions include establishing clear lines of communication, providing support and advocacy, respecting family wisdom, demonstrating a willingness to work through interpersonal problems, having realistic expectations of family members, and respecting the family’s wishes.

20. Psychosocial Interventions Educate students at school about the nature of the injury sustained by their classmate prior to reentry if possible. Initiate connection between peers and the injured student as soon as possible the student will be absent from the school setting for a period of time. At reentry, provide additional support and supervision to support social interaction. Recognize that students with TBI may be experiencing grief, loss, and personal identity issues. Provide support.

21. Remember… Inconsistency in learning and behaviour is predictably unpredictable in students with TBI. Work smarter, not harder… AND keep your sense of humour.

22. Conclusion Reentry to school after a TBI requires careful intervention planning. Interventions should include pre-reentry planning, using multidisciplinary supports, educating school staff, conducting comprehensive student assessment, IEP development, being creative and persistent in finding effective interventions, supporting family and peer relationships, and keeping it all in a healthy perspective.

23. QUESTIONS??

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