Introduction to Traumatic Brain Injury TBI for Educators
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)
Outline ___________________________ • Brain injury definition • Brain Function • Common Problems • Steps to evaluation and programming success • Resources
WHAT IS A BRAIN INJURY?
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.
Types of Brain Injury ___________________________ Brain Injury Congenital and Perinatal (no period of normal development) Perinatal (e. g. , birth stroke) Congenital (e. g. , PKU) Acquired (following a period of normal development) Non-traumatic (internal occurrence e. g. , tumor) Traumatic (external physical force) Open (e. g. , gunshot) Closed (e. g. , fall)
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
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
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)
What Happens When the Brain is Injured? ___________________________ • Brain injuries are either: 1. Closed head – Skull not penetrated (car accident, falls) 2. Open Head – Skull and meninges are penetrated (gunshot, nail) • Both of these result in: ü A disruption of communication within the brain due to torn or stretched neurons ü Lack of oxygen to the brain resulting in cell death.
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
Mechanism of injury: Coup/Contracoup ___________________________ Reprinted with permission from the North Carolina Department of Public Instruction
Shearing & Tearing of Neurons • When an injury occurs the neurons stretch, twist or tear.
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)
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.
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)
Severity of Brain Injury: Moderate ___________________________ • Coma less than 24 hours • Unable to form new memories following the injury (less than 24 hours)
Severity of Brain Injury: Severe ____________________________ • Coma more than 24 hours • Unable to form new memories following the injury (longer than 24 hours)
Proportion of Mild, Moderate, and Severe Brain Injuries ____________________________ • The vast majority of students with brain injuries returning to school have mild injuries.
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.
The Brainstem ____________________________ • 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 Cerebellum ___________________________ • Primarily helps modulate motor responses • Regulates direction, rate, force, and steadiness • Injury disrupts coordination and muscle tone
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)
The Lobes of the Cerebral Cortex ___________________________ • Each hemisphere of the brain is divided into four lobes: ü ü Frontal Temporal Parietal Occipital Reprinted with permission from the North Carolina Department of Public Instruction
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.
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)
The Temporal Lobes ___________________________ • Receives, analyzes, and integrates auditory information • Center for language If Injured you may see impaired: -ability to listen, understand generalize auditory input -expressive and receptive language -memory formation
The Occipital Lobes ___________________________ • Receives, analyzes. integrates visual information If Injured you may see impaired: -ability to understand 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
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.
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
Common Motor Problems ___________________________ • Apraxia • Ataxia • Coordination problems • Paresis or paralysis • Orthopedic problems • Spasticity • Balance problems • Impaired speed of movement • Fatigue
Sensory/Perceptual Problems ___________________________ • Visual deficits – field cuts – tracking (moving and stationary objects) – spatial relationships – double vision (diplopia) • Neglect • Auditory deficits • Tactile deficits
Cognitive/Communication Problems ____________________________ • Executive functions • Memory • Attention • Concentration • Information processing • Sequencing • Problem solving • Comprehension of abstract language • Word retrieval • Expressive language organization • Pragmatics
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
Behavioral Problems ___________________________ • Deficits (all types) may lead to challenging behaviors – non-compliance – aggression – confrontational behavior – lack of initiative – withdrawal
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
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.
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 Often Occasionally Not At All A. Orientation and Attention to Activity Confused with time (day, date); place (classroom, bathroom, schedule changes); and personal information (birth date, address, phone, schedule) Seems “in a fog” or confused Stares blankly Appears sleepy or to fatigue easily Fails to finish things started Cannot concentrate or pay attention Daydreams or gets lost in thought Inattentive, easily distracted B. Starting, Changing, and Maintaining Activities Confused or requires prompts about where, how or when to begin assignment Does not know how to initiate or maintain conversation (walks away, etc) Confused or agitated when moving form one activity, place, or group to another Stops midtask (math problem, worksheets, story, or conversation)
Very Severe & Frequent Problem Often Occasionally Not At All Unable to stop (perseverates on) inappropriate strategies, topics, or behaviors Gives up quickly on challenging tasks C. Taking in and Retaining information Forgets things that happened even the same day Problems learning new concepts, facts, or information Cannot remember simple instructions or rules Forgets information, learned from day to day (does well on quizzes, but fails tests covering several weeks of learning) D. Language Comprehension and Expression Confused with idioms (“climbing the walls”) or slang Unable to recall word meaning or altered meaning (homonym or homographs) Unable to comprehend or breakdown instructions with request Difficulty understanding complex or lengthy discussion Processes information at a slow pace Difficulty finding specific words (may describe but not label) Stammers or slures words Difficulty fluently expressing ideas (speech disjointed, stops midsentence)
Very Severe & Frequent Problem Often Occasionally Not At All E. Visual-Perceptual processing Cannot track when reading, skips problems, or neglects a portion of a page of written material Orients body or materials in unusual positions when reading or writing Gets lost in halls and cannot follow maps or graphs Shows left-right confusion F. Visual-Motor Skills Difficulty copying information from board Difficulty with notetaking Difficulty with letter formation or spacing Slow, inefficient motor output Poor motor dixterity (cutting, drawing) G. Visual-Perceptual processing Difficulty with sequential steps of task (getting out materials, turning to page, starting an assignment) Confuses the sequence of events or other time-related concepts H. Problem-Solving, Reasoning, and Generalization Fails to consider alternatives when first attempt fails Does not use compensatory strategies (outlining or underlining) Problems understanding abstract concepts (color, emotions, math and science) Confusion with cause-effect relationshops
Very Severe & Frequent Problem Often Occasionally Not At All Unable to categorize (size, species) Problems making inferences or drawing conclusions Can state facts, but cannot integrate or synthesize information Difficulty applying what they know in different or new situations I. Organization and Planning Skills Difficulty breaking down complex tasks (term papers, projects) Problems organizing materials Problems distinguishing between important and unimportant information Difficulty making plans and setting goals Difficulty following through with and monitoring plans Sets unrealistic goals J. Impulse or Self-Control Blurts out in class Makes unrelated statements or responses Acts without thinking (leaves class, throws things, sets off alarms) Displays dangerous behavior (runs into street, plays with fire, drives unsafely) Disturbs other pupils Makes inappropriate or offensive remarks Shows compulsive habits (masturbation, nail biting, tapping) Hyperactive, out-of-seat behavior
Very Severe & Frequent Problem Often Occasionally Not At All K. Social Adjustment and Awareness Acts immature for age Too dependent on adults Too bossy or submissive with peers Peculiar manners and mannerisms (stands too close, interrupts, unusually loud, poor hygiene) Fails to understand social humor Fails to correctly interpret nonverbal social cues Difficulty understanding the feelings and perspective of others Does not understand strengths, weaknesses and self presentation Does not know when help is required or how to get assistance Denies any problems or changes resulting from injury L. Emotional Adjustment Easily frustrated by tasks or if demands not immediately met Becomes argumentative, aggressive, or destructive with little provocation Cries or laughs too easily Feels worthless or inferior Withdrawn, does not get involved with others Becomes angry or defensive when confronted with changes resulting from injury Makes constant inappropriate sexual comments and gestures Unhappy or depressed affect Nervous, self-conscious, or anxious behavior
Very Severe & Frequent Problem Often Occasionally Not At All M. Sensorimoter Skills Identified problems with smell, taste, touch, hearing or vision Problems discriminating sound or hearing against background noise Problems with visual acuity, blurring or tracking Problems with tactile sensitivity (e. g. , cannot type or play an instrument without watching hands) Identified problems with oromoter (e. g. , swallowing), fine motor or gross moter skills Poor sense of body in space (loses balance, negotiating obstacles) Motor paralysis or weakness of one or both sides Motor rigidity (limited range of motion), spasticity (contractions) and ataxia (erratic movements) circle one Impaired dexterity (cutting, writing) or hand tremors Difficulty with skilled motor activities (dressing, eating) Waaland Bohannon (1992) Reprinted from Guidelines for Educational Services for Students with Traumatic Brain Injury (Virginia Department of Education, 1992)
WHAT ARE THE NEXT STEPS TO SUCCESSFUL EVALUATION AND PROGRAM PLANNING?
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 1. 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
What’s Next? (continued) ___________________________ How will you gather the information? ü Review medical reports ü Observe student ü Interview the student and knowledgeable others (therapists, medical personnel, parents, etc. ) ü Use curriculum based measures and work samples
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
What’s Next? (continued) ___________________________ If the student has a disability, identify major issues to address in the IEP such as: ü Student health and safety issues (wheelchair transportation, medication management, etc. ) ü Schedule (need for a shortened day, more frequent breaks during the day, etc. ) ü Classroom instruction (enlarged print, preferential seating, other modifications) ü Staff training (TBI, medical procedures)
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: ü adjust schedule ü delay high stakes tests ü prioritize homework ü educate parents, teachers, peers ü assign case manager to monitor progress ü refer to a building team
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
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