Students with TBI:

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29 Νοε 2013 (πριν από 3 χρόνια και 6 μήνες)

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Students with TBI:



Who and Where are They?


What are the Effects of TBI?


What Do They Need?



The Brain


About 3.5 pounds


Consistency of 3 day
-
old Jello


Bony, bumpy case surrounded by less than ¼ cup
of spinal fluid


10 billion neurons


Each neuron connects with others


average of 10,000 synapses


Brain Injury

Congenital Brain Injury

Pre
-
birth or during birth

Acquired Brain Injury

After birth process

Traumatic Brain Injury

(TBI)

Closed Head Injury


Concussion


Swelling results in further


(secondary) injury


No loss of consciousness


Damage great or greater than


open brain injury


Open Head Injury


Skull is fractured


Blood & swelling have a


place to go





Shearing strains

throughout the

brain

Subdural veins

torn as brain

rotates forward

Swelling of

brain stem

Damage to

temporal lobes

from rough

bones at skull base

Compression

fracture

Types of
Damage
in a
Closed
Head
Injury

Coup

Contra
-
coup

Skull Protrusions

Adapted From: Pang, 1985

Skull

Shearing Plane

Brain

Protrusion

Overly Simplified Brain Behavior
Relationships

Frontal
Lobe

Parietal
Lobe

Occipital
Lobe

Temporal
Lobe

Cerebellum

Brain
Stem

Parietal Lobe

• Sense of touch

• Differentiation:


size, shape, color

• Spatial perception

• Visual perception

Occipital Lobe

• Vision

Cerebellum



Balance

• Coordination

• Skilled motor activity

Frontal Lobe

• Initiation

• Problem solving

• Judgment

• Inhibition of behavior

• Planning/anticipation

• Self
-
monitoring

• Motor planning

• Personality/emotions

• Awareness of


abilities/limitations

• Organization

• Attention/concentration

• Mental flexibility

• Speaking


(expressive language)

Brain Stem

• Breathing

• Heart rate

• Arousal/consciousness

• Sleep/wake functions

• Attention/concentration

Temporal Lobe

• Memory

• Hearing

• Understanding language


(receptive language)

• Organization and sequencing

What’s Different about TBI?


No two brain injuries are exactly the same.


Brain injury is complex and varies greatly from person to
person.


Cause, location and severity of injury determine the effects.


Long
-
term effects are not always apparent and may present
as cognitive and environmental demands increase.


Attainment of developmental milestones may be effected by
a past injury.


Commonly results in functional deficits that may be
identified in another disability category(ies)

Causes of TBI in Children


Motor Vehicle Crashes


High Risk Sports


ATVs, rodeo, skiing, snow boarding


Motorcycle incidents


Pedestrian vehicle incidents


Violence


Falls


Abuse


Shaking

TBI in Children


1.4 million children injured annually


Highest risk groups ages 0
-
4 and 15
-
19


More likely to survive than adults


Less likely to lose consciousness


1/50 kids have had a concussion

Scope of the Problem:
Oregon


Approximately 1000 children hospitalized
annually in Oregon


More than 1/3 experience persisting functional
limitations


Expected yield = approx 3,000
-
4,000 identified


Just over 300 identified for SPED under TBI in
Oregon


Just 50 in NWRESD service area

Why Don’t We Find Them?


Lack of medical training and referral


Lack of educational training and awareness


Lack of parental recognition


Many “look good” physically


Developmental bias that they will be OK

Apparent Low
Incidence


Eligible Under
Different
Category

Lack of
Awareness

Lack of
Research
Money

Lack of
Training

Lack of
Services for
those
Identified

Under

Identification

Cycle

Special Educational
Definition of TBI

…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 child’s 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.

Sequence of Skill Recovery


Motor


Gross motor functioning (1 to 2 months)


Sensory


Improves relatively rapidly in children (1 to 2 months)


Speech Communication skills


Expressive speech may resolve within a few months,


Subtle language problems may persist indefinitely


Measured IQ


May be small changes



Not as rapid as motor, sensory and speech functions


Memory, Attention, Processing speed


May lag for many months or be forever reduced


Higher Level Cognition


Information processing


Learning under new, complex or difficult situations


Ability to adapt to new problems or situations.


Children negatively affected by stress more easily than before.


May be impacted for years or permanently





2 Years After Injury….


Memory problems (74%)


Fatigue (72%)


Word
-
Finding difficulties (67%)


Irritability (67%)


Impaired Speed of Thinking (64%)


Impaired Concentration (62%)

(Ponsford, 1995)


Depressed Mood


40
-
50% of people with TBI

(Glenn, 2001)

Pet Scans


New Learning


Everything lights up
with new learning


Pathways rewire


Pathways are created
through repetition


Eventually, learning
results in more
efficiency


Tend to encode
Irrelevant Information

Residual Cognitive Deficits



Disorders of Attention



easily fatigued, impaired shifting,
impaired maintenance, impaired selection



Disorders of Memory



poor rote, short term difficulties,
storage and retrieval difficulties, prospective memory
problems (remembering to remember)



Disorders of Planning



slowed initiation, disinhibition,
poor at abstraction, poor sequencing, doesn’t learn from
mistakes, doesn’t ask for help, can’t get started

Residual Cognitive Deficits


Disorders of Judgment


misinterprets actions of others,
can’t handle multiple bits of information at once, socially
unacceptable physical and verbal behaviors, little self
awareness of strengths and weaknesses



Disorders of Information Processing Speed


extreme
slowness in reaction time, slowed psychomotor activities


writing, talking, etc.



Disorders of Communication


anomia, inefficient word
retrieval, hyperverbal, peculiar use of words and
phrases, uninhibited word choice


Roberta DePompei, 2009

Observed Behaviors

Underlying Problems


Daydreams, pesters
peers, fiddles with
materials


Blurts out, interrupts,
tangential speech


Poor test
-
taker,
inconsistent memory of
information


Needs multiple repetitions
of directions, acts rude,
doodles, bolts


Misunderstands humor,
puns, double meanings


Impaired attention,
perception, memory



Inflexibility, impulsivity,
disorganized thinking



Inefficient storage and/or
retrieval of information



Inefficient processing of
info: rate, amount,
complexity



Difficulty processing
abstract information





Observed Behaviors

Underlying Problems


Can’t learn new games,
decision rules, changes in
targeted task


Temper tantrums, sticks
with one solution, won’t
change mind


Poor social interactions,
foul language, hot temper


Lack of awareness, poor
task completion, trouble
with change


Inflexibility, poor working
and short term memory,
poor “shifting” (multitask)


Ineffective problem
solving and judgment,
Limbic dysregulation


Poor judgment, lack of
self
-
awareness, language
deficits


Impaired “executive”skills



INTERVENTIONS


What do they
need?

0
-
21

Physical Challenges



EXECUTIVE FUNCTIONS




Difficulty holding
instructions/Information


New learning is most difficult


Difficulty with multiple cognitive
demands (writing)




Metacognition


Goal
-
Directed activity


Problem solving for attainment of
future goal


Inability to form Mental
representations & interpretations



Difficulty with multi
-
Step tasks


Engaging in independent tasks


Organizational difficulties




Inhibition


Rigidity/Inflexibility


Sustained Energy


Poor monitoring and awareness
of behavior


Frequent distractions


Self
Regulation

Planning

Memory

Strategic
Learning

Memory Interventions


Repeat often and summarize


Have child paraphrase, doodle, condense for encoding


Carry assignment sheet for each class


Closed
-
ended tasks (fill
-
in vs. essay)


Categorize or “chunk” information


Use visualization


Link new information to prior knowledge


Give examples with instruction


Discrete task objectives (Vocabulary)


Rehearsal (often doesn’t work real well)


Visual interventions such “Inspiration” Software


Auditory interventions such as tape recorder, books on
tape

Self Regulation


Reduce distractions in work area


Make tasks shorter


Behavior contract


Divide work into smaller segments


Use cues (words, sounds, tactile) to alert person to pay
attention


Build in choice


Increase joyfulness, high interest and relationship


Ignore dis
-
inhibited response


Incentive Systems


Keep tools and materials available


Keep it structured


Allow for frequent breaks

Slow processing speed

Processing Speed Strategies


The Wright Family Story!


Give more time to complete requested tasks


Slow pace of Instruction


Note taker


Condense tasks


Music


Use Scaffolding and Modeling



Strategic Learning Strategies


Prompts and reminders


Provide scoring rubric


Have child provide a written plan


Break down tasks and timelines (note cards)


Coaching


Structured teaching


Re
-
teach affect and social clues


Flexible performance options


Visual and written instructions


High degree of tactile reinforcers


Teach Note Methods


SQ3R (Survey, question, read, write, review)


Concrete Thinking

Difficulty with abstraction, synthesis,
inference etc.

Planning Interventions


Draw maps, use lists, timelines, visual schedules


Goal Setting


Color
-
code materials, information (definition vs.
main idea


Electronic organizers


Preview completed assignment


Answer


“How will I know when I am done?”


Establish Routines


Use paraphrasing, re
-
teaching, reciprocal
coaching


Meet at beginning and end of day


Post
-
activity reflection


Self
-
Regulation and Behavior

Goal

Obstacle

Plan

Predict


Do

Review

Template Prompts

Plan
-
Do
-
Review


Goal “
What do you need to do?” “What are we here for?” “What will it look like
when it’s finished?”


Obstacle
“What stands or might stand in the way of accomplishing the goal?”


Plan
“What will you do first, second, third, etc?”



Student makes prediction about success of plan
“Will it
be hard or easy?” Is it scary or not scary?”“
Will it take an hour or take 6 hours?” “Is it a
choice or not a choice?”


Do
“Let me know if you need any help.”


Review
“How did that work out?” “What would you do differently?” “Do you think
you met your goal?”


Behavioral Interventions

(Very Common)


Conduct a FBA


Give
very

clear written and verbal guidelines


Big 5


When to start


What to do


How much to do


What finished looks like


What to do next


Coach to assist with misperceptions


Implement Positive Behavior Supports


Self

Regulation


Executive

Functioning

Communication Skills

We must teach and support the underlying processes to get to
self
-
regulation

R. DePompei 2009

What Can You Do?


Remember that TBI is vastly under identified


When you see unexplained behaviors or
learning characteristics….
suspect!


Ask! “Has your child ever had a blow to the
head or a concussion?”


Add the question to medical cards


Visit some of the great websites available

NWRESD TBI Educational

Consulting Team

Laura Bekken
lbekken@nwresd.k12.or.us

503
-
614
-
1683

Cindy Hodges
chodges@nwresd.k12.or.us

503
-
614
-
1670

Kristy Young
kyoung@nwresd.k12.or.us

503
-
614
-
1672

Oregon Brain Injury Resources

http://www.tr.wou.edu/tbi


Resource librarian (Laura Beck) is available to
find specific information for your particular request
regarding TBI

http://www.tbied.org


TBI Educator website from Teaching Research
Institute is very dense with information, resources,
forms, training opportunities

Websites of Interest


http://www.bianys.org/learnet/

-

LearnNet


excellent
resource for educators and parents


http://www.schoolbehavior.com/conditions_edfovervi
ew.htm


http://www.braininjurypartners.com/login/?next=/

especially for parents
-
Username=wear your
Password=helmet


www.cde.state.co.us/cdesped

-
Enter “TBI manual”
in search for excellent educator’s manual on TBI


QUESTIONS/COMMENTS