Students with Brain Injury in Oregon

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Students with Brain Injury in Oregon

• Jay Gense, Pat Sublette, Ann Glang
• Oregon Department of Education
• Teaching Research Institute-Eugene

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David

• The teachers say David is fantastic, such a joy.
  A little slow. But thats David now. They
  dont know David as any way else.
• -Davids mother

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David

• I dont know if the information about his brain
  injury got passed along to the 2nd grade teacher.
  Its in his cumulative file, but I dont know if
  anyone reads those.
• -Davids mother

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David

• I had no training in TBI. It was toughI wanted
  to push him, but I didnt want him to get
  frustrated and shut down.
• -Davids teacher

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Educational 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, that adversely affects a
  childs educational performance. The term
  applies to open or closed head injuries resulting
  in impairments in one or more areas, such as
  cognition language memory attention
  reasoning abstract thinking judgment
  problem-solving sensory, perceptual, and motor
  abilities psychosocial behavior physical
  functions information processing and speech.
  The term does not apply to brain injuries that
  are congenital or degenerative, or to brain
  injuries induced by birth trauma.

U.S. Department of Education, Office of Special
Education and Rehabilitative Services. (1999)
Rules and Regulations Part II. Federal
Register, 64 (48), p. 12422.
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Incidence of TBI in Oregon

• Where are the students?

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National Incidence of TBI

• For children and adolescents, annual estimates of
  head injuries are about 1.4 million
• About 165,000 children will be hospitalized, with
  16,000-20,000 serious enough to cause lasting
  effects
• Almost twice as many males as females
• Head injuries are the leading cause of death and
  disability in children

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Sports TBI

• Amateur Boxing
• Decrease in mental functioning consistent with
  acute TBI or post-concussive syndrome
• Football
• 20 of high school players sustain brain
  injury/season
• Soccer
• 5 due to head-to-head contact or heading the
  ball
• Horseback Riding
• 17 of all equestrian injuries are brain injuries
• (Brain Injury Association of America)

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Under-identification for Special Education

• 30,000 annually with persisting disabilities
  from brain injury
• 10,000 annually (1/3) need SPED support
• 130,000 cumulative total (K-12)
• 23,509 on Federal Sped. 2005 census (ideadata.org)

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National Statistics/100,000

• 180/100,000 infants children and adolescents are
  hospitalized for TBI annually
• Krause 1995

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SPED Incidence of TBI in Oregon

• 269 Oregon students id with TBI in 2006
  http//www.ode.state.or.us/policy/federal/idea/par
  tb/2006_2007/table1.xls
• 562,828 school children in Oregon in 2006
• At the 180/100,000 rate
• 1008 students hospitalized for TBI annually in
  Oregon

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Estimate of Students In Need of Special Education
in Oregon

• If only 1/3 of the 1000 or 333 hospitalized
  students need special education
• An extremely conservative cumulative estimate
  ages 0-21
• 4000 students in Oregon alone

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Disability Distribution Birth-21
ODE - 2004
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Where are the Students with TBI in Oregon?
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Back to School Project Identification for
Special Education at Discharge

• N 75 (Oregon Washington)
• 28 report no problems
• 21 are served under TBI category
• 5 are served under another category
• 20 are experiencing challenges and are not
  identified for special education

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Back to School ProjectGeographic Distribution
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Back to School ProjectSeverity of Injury
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Back to School Project School placement at
re-entry
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Why are Students with TBI Under-Identified and
Under-Served?
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Lack of Awareness of TBI

• Plasticity myth
• kids bounce back
• Child will be fine
• medical field and community
• Successful medical outcomes differ
• from successful educational outcomes

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Need of Knowledge

• Need pre-service training in TBI
• Increase knowledge of the impact of TBI on school
  performance
• Increase feelings of competence for teachers

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TBI the Forgotten Injury

• Early injuries
• impact may not be seen until years later
• Families unaware of injury significance
• school not informed
• As student transitions through grades
• Information of injury and its impact is lost in
  file purges

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Todays School Context

• Shrinking school and community resources
• Schools serving more students with more severe
  needs?large caseloads

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Program Development is Challenging

• Learning and behavioral characteristics are
  unlike students with other disabilities
• The extreme diversity within the population
• The extreme diversity within each child

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TBI Other Disabilities

• Students with ADHD
• 1.8x more likely to have a concussion
• 1.7x more likely to have intercranial injury
• 30 students with vision impairments have TBI as a
  secondary disability

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Students Brain Injury Often Invisible

• Student looks fine
• Student appears to be recovered
• Student is no longer being followed by medical
  personnel

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Under-identification Cycle
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• Learning Issues Commonly Associated with TBI

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Children with Moderate to Severe TBI

• 50-90 limitations in bathing, dressing, and
  walking
• Children with 4 or more functional deficits
• 75 impairments in self-feeding, cognition, and
  behavior
• 67 speech
• 29 vision
• 16 hearing
• Supplement. Rehabilitation for Traumatic
• Brain Injury in Children and Adolescents
• http//www.ncbi.nlm.nih.gov/books/bv.fcgi?ridhsta
  t1.chapter.2633

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Executive Function Other Cognitive Impairments

• Children with pre-frontal injury may have
  language skills and other cognitive abilities and
  severe self-regulation deficits
• (Ylvisaker Feeney, 2002)

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Executive Functions Symptoms

• ineffective planning
• decreased flexibility/ shifting
• slowed processing
• diminished divergent thinking
• concrete thinking
• immature problem solving
• weak self-monitoring
• inefficient responses to feedback/ consequences
• reduced initiation
• dulled emotional responses

• impulsiveness
• poor social judgment
• social disinhibition
• egocentrism
• difficulty interpreting the behavior of others
• perseveration
• poorly regulated attention
• disorganization (in thinking, talking, and
  acting)
• weak goal formulation

(Feeney, 2005)
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Attention-information processing impairments

• Slowed rate of processing
• Difficulty concentrating fatigue
• Difficulty screening out distractions
• external and internal
• Difficulty concentrating fatigue
• Difficulty disengaging and engaging

(Sohlberg Mateer, 2001)
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Memory Learning

• Memory almost always affected in TBI
• Recent memories often more affected then
  long-term memories
• Prospective memory
• ability to carry out intended actions)
• Working memory (i.e., 2-5 minutes)
• May learn without awareness of having learned
• Motor/procedural learning systems may be intact
• Orientation may be a problem

(Sohlberg Mateer, 2001)
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Behavioral Difficulties

• Impulsivity
• Social Disinhibition
• Inappropriate behavior
• Short temper
• Easily frustrated

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Motor Sequelae Following TBI

• Hemiplegia
• Motor paralysis of one side of body.
• Hemiparesis
• Motor weakness of one side of the body.
• Ataxia
• Loss of ability to coordinate smooth movements
  or steady gait.
• Hypotonicity
• Low muscle tone of trunk or limbs.

• Rigidity
• Resistance to movement in any range.
• Spasticity
• Inappropriate sustained contraction of muscles
• Tremors
• Involuntary movements from contractions of
  opposing muscles.

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Physical Sequelae of TBI

• Fatigue
• Vision Hearing Looses
• Headaches
• Seizures
• Fatigue Reduced Stamina
• Endocrine/Hormonal changes

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Post-Concussional Symptoms

• Headache
• Fatigue
• Dizziness
• Sleep disturbance
• Memory
• Confusion

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Developmental Overlay

• Full effects of an earlier injury may not be
  evident until adolescence when children are
  expected to demonstrate increasing competence in
  executive functions and reasoning.
• Skills may not develop if the relevant areas of
  the brain have been damaged
• (Alden Taylor, 1997 Feeney Ylvisaker, 1995
  Mangeot et al, 2002 Ylvisaker Feeney, 2002)

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Secondary Problems

• Children may also develop problems in the social
  and behavioral domains secondary to cognitive
  deficits.
• deficits in executive functions
• implications for the childs behavior
• classroom
• peer relationships.
• Secondary needs may become more pronounced in a
  child injured at an earlier age.

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After the Injury

• What Schools Need

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Transition Meetings

• Pre-meeting with information from hospital
  personnel
• FERPA and Due process must be followed
• School must establish eligibility
• 504/IEP (behavioral supports likely needed)
• Have built-in review and revise plan about 4x per
  year

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Upon discharge schools need to know..
Information to Get From the Hospital

• Present Physical Condition
• Toileting needs
• Transition needs
• Motor Skills
• Physical Limitations
• Activity Limitations
• Therapy Requirements
• Required Assistive Devices

• Self-Care Abilities
• Prescribed Medication
• Communication Abilities
• Behavior Concerns
• Cognitive Recovery Pattern
• Results of Evaluations

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Recognize Potential Problems

• Medical
• Behavioral
• Social
• Cognitive

He looks so good, but. How will he function in
the classroom?
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Other Factors to Consider

• How long since the injury
• Extent of the injury
• Co-existing conditions
• Family/ home needs
• School issues
• Social/emotional
• A time of change

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What is Needed in Schools
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Back To School Study

• Interviewed 34 teachers of students with TBI
• 85 had never attended training on TBI
• 71 had no other resources to gain information

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Understanding

• For most children, rehabilitation takes place in
  school
• Identification for special education is necessary
  to access services

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Knowledge

• The parents usually bear the responsibility to
  educate school personnel about the effects of TBI
• Even when schools are aware of the TBI, many
  dont associate certain behaviors with the injury

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Information

• Students may be viewed as
• malingering
• lazy
• disorganized
• just adolescent
• Many parents are not aware of potential school
  services available to their child

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What We Are Doing
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Working to Break the Cycle
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Promising Practices

• Systematic training for educators can lead to
  increased awareness and identification for
  services

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Training Needs for Educators

• Training and Information on
• Overview of Brain Injury
• General Information
• Working with families
• Eligibility/Evaluation
• IEP Writing
• Instructional Methods
• Transition
• Access
• (Brain Injury Professional, v.4, 2007)

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Oregon Department of Education TRI

• Services for Oregon
• Students with TBI

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ODE TRIEvolving Service Model

• Regional Manager for TBI
• Paul Andrews from HDESD
• One part-time liaison per region
• Meetings throughout year to continue to refine
  the model of TBI Services for Oregon
• Work with TBI consulting team members in region
• Presentations
• Consultations for Students with TBI

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TBI Consulting Team

• Trained Consultants
• Available to
• Present in-services
• Consult with teachers, schools families
• Training open to educators throughout Oregon at
  no charge
• 2 year commitment
• 6, 2 day trainings throughout year with
  Nationally known speakers

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TBI Educational Consulting TeamContact
Information

• TBITeam_at_wou.edu
• 541-346-0593
• 877-872-7246

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WWW.
NEW www.tbied.org

• TBI Educator Website for Oregon
• Content Areas
• Eligibility, Evaluation, IEP, SDI, Related
  Services, Accommodations, Capacity Building,
  Access, Safety, and Transition
• Each content area has
• general information
• Links
• Best Practices-articles and research-based advice
  

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Oregon Brain Injury Resources

• OBIRN
• http//www.tr.wou.edu/tbi
• Resource librarian (Laura) available to find
  specific information for your particular request
  regarding TBI

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Coming Soon

• Completed Website
• Technical Assistance Paper for TBI

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Faces of Brain Injury in Oregon