1. Traumatic Brain Injury School Re-entry Program Renée Lavelle, MS CCC/SLP Lindsay Wilson, MS CCC/SLP

2. This overview will feature assessments, case studies, and family interviews of children returning to school following TBI. Attendees will be able to assess, set goals, develop treatment and educate staff regarding management of Cognitive/Language abilities of the school-age child with TBI.

3. TOPICS COVERED TODAY TBI Recovery and Long Term Needs Areas of Deficit Assessment and Screening Therapy and Justification Teaching and Training

4. TBI Recovery & Long Term Needs Define the Population – Mild TBI “They look great,” no outward signs of disability Deficits- Short-term memory, attention, following directions and social behaviors – Severe TBI Ongoing moderate to severe physical/cognitive disability Complicated to manage transition from school to possible vocational training – Younger TBI Previous learning ability typical Acquired/previous learning is typically limited; therefore new learning may become more challenging

5. TBI Recovery & Long Term Needs Common Changes – Fatigue – Irritability, anger outbursts, impulsivity – Aggressive acting out, or misbehaving – Passive behavior – Depression – Social immaturity – Sexually inappropriate behavior – Forgetfulness – Distractibility – Difficulty following directions – Poor organizational skills – Poor or lower grades – Initiation

6. TBI Recovery & Long Term Needs Anatomy – Frontal Lobe Most common Executive function impacted in this area, which in turn affects overall ability of brain to recognize, organize, plan and react – Shearing Injury Based on the nature of head injury, the brain is forcefully moved around in the skull and makes contact with bony processes, swelling, etc. which creates scattered and diffuse injury – “Swiss Cheese” Effect Areas of completely intact brain function are sharing space with areas that no longer demonstrate typical function

7. Assessment and Screening Standardized Language Assessment – NOT appropriate for these children Test protocols we have found helpful: – Test of Problem Solving – Rivermead Memory Assessment – Language Processing Test – Assessment of Pragmatic/Social Language

8. Informal assessments – Pragmatic test protocols and the Test of Problem Solving can offer insight into therapy needs – Listening skills (literal, interpretive, critical and metacognitive) – Speaking/conversational skills through discourse analysis Observation – classroom setting to identify social skills, initiation, attention to task, problem solving, organization of task, following directions, etc. – Playing a game Assessment and Screening

9. Areas of deficit Attention to task Memory Executive Function: Organizing/Planning/Sequencing Impulsivity Lack of insight Pragmatics Sensory overload Language Written Communication

10. Therapy and Justification Approaches for therapy: – Attention process training – Use of strategies and environmental support – Use of external aids – Psychosocial support

11. Areas of deficit Attention to task – Focus on ways to compensate for specific classroom needs – Therapeutic techniques Select strategy and use consistently Focus on short/concise directions and assignments Organize schedule for rest or medication breaks Develop cuing systems (verbal, gesture, visual cues to use to redirect student) Remove distractions/select best seating placement in classroom Therapy sessions-use more structured tasks (maze learning tasks, number cancellation) Pre-teach and repeat directions verbally/visually and check for comprehension

12. Areas of Deficit Memory – Develop external and overt procedures to make tasks easier to remember – Therapeutic techniques Memory Book Electronic devices for schedules and events Log of activity Buddy system for consistent use Use multisensory presentations of information Teach note-taking techniques Make information relevant and meaningful to the student Help develop a consistent class schedule and routine Be mindful of changes and their effect on student

13. Areas of Deficit Executive Function (organizing, planning, sequencing) – Typically have difficulty with initiation, organizing, and developing a plan for changing tasks – Therapeutic techniques Use consistent template that can be used for a variety of tasks Identify main idea or goal, supporting details/steps, and conclusion Limit number of tasks Provide first steps and give cues as needed to complete Use categories to focus on topics Break large tasks into sequences of smaller tasks Sequence routines that are meaningful and provide positive outcomes (ex: check-off lists for routines)

14. Areas of Deficit Impulsivity – Manifests in behaviors that result in incomplete assignments, incomplete directions, verbal outburst, aggressive behaviors – Therapeutic techniques Identify behaviors that interfere with classroom (input from 2-3 professionals to gain complete story) Pre-teach expectations/sequences Provide written plan Verbally discuss/repeat expectations prior to starting assignment Role-play situations to provide choices Discuss positive/negative of situations and develop ongoing plans Develop plan for answering in class

15. Areas of Deficit Lack of insight – TBI patients frequently are not able to predict the effect of their appropriate/inappropriate actions on situations or people – Most behaviors are very egocentric; little regard for others – Therapeutic techniques Identify the behavior, sort through actions while understanding the effect of behavior, and identify appropriate changes Predict long term outcomes: Why we do things the way we do Group interaction with peers to talk through emotions Ongoing opportunity for “debriefing” where situation, actions and outcomes are outlined, discussed and new plans developed

16. Areas of Deficit Pragmatics – Impaired ability to read nonverbal signs, interpret sarcasm/slang, and implied meanings – Therapeutic techniques Pair student with responsible role model Be aware of noise level in classroom Be mindful of language choices/ use of sarcasm, idioms, figurative language Pair verbal directions with written guidelines Provide concrete instructions when giving student assignments to help with classroom activity Monitor social interactions/outcomes with peers

17. Areas of Deficit Sensory overload – Noise level of typical classroom can escalate inappropriate behaviors – Therapeutic techniques Be mindful of overall noise level Outside noises (hallway, outdoors, talking) Desk Assignment Interaction/location of seat in relation to peers Avoid expecting student to multi-task (divided attention)

18. Areas of Deficit Language (Expression and comprehension) – Levels of listening Literal Interpretive Critical Metacognitive – Expression Poorly organized discourse/narratives Paraphasias Circumlocutions Word finding difficulties Dysarthria/apraxia

19. Therapy and Justification Attention – Use a timer for completion of activities – Once “mastered”, add distractions – Give a “fidget” toy to help with the stimulation Memory – Create a memory book to use in classroom – Check-off lists for routines – Repetition is key: repeating, re-teaching a game/activity – Mneumonics

20. Therapy and Justification Executive function – Plan a therapy session or classroom party – Use their homework as activity to sort, organize, and complete – Trips to the library to find information on a given topic – Path-find through school, or lead the class to gym/music Reading/writing/studying – Develop outlines for note taking: “webbing” – Multiple choices for reading comprehension – Visual guide for following along – SQ3R – “Lite scribe”

21. Therapy and Justification Listening – Use audio or video tapes from news casts, TV shows, movies – Spoken passages and recall facts or pre-taught information – Recall of information from spoken messages Social – Give compliments throughout day with check-off list – Vocal inflection for questions/comments – Scripts for social interaction – Videotape social groups – Turn taking: answering/asking questions – “Run” the school store; leading activities in class

22. Things to think about… – Pharmacological Intervention: Attention/concentration Initiation/motivation Impulsivity/behavior Regulation of blood pressure, sodium levels, etc. Seizures – Post-traumatic stress/depression: Decrease in motivation Sleepiness Anxiety Social withdrawal

23. Things to watch for… – Edema/Hydrocephalus Signs: headaches, severe fatigue, dizziness, increased sensitivity to light/noise, ringing in the ears, changes in gait, facial drooping Malfunction in medication or VP shunt could change cognitive status immediately – Post traumatic epilepsy Signs: twitching, staring spells

24. Teaching/Training Educate staff/educators/parents – Safety precautions one year post incident – Feeding precautions – Overstimulation/path finding in halls – Schedule meetings with significant personnel on regular basis to discuss, modify, and implement changes for success – In-service for all school personnel involved in routine of student

25. “ Delayed onset of symptoms is sufficiently common after TBI in children that educational planners must ensure a long- term monitoring and safety-net system for these students. An unfortunate reality is that many children receive little support when they return to school and begin to have serious academic and behavioral difficulties some years after their injury, which are subsequently attributed entirely to their laziness, oppositional nature, or emotional instability.” Ylsaviker, 370

26. Video

27. Questions? Lindsay.wilson@cookchildrens.org Renee.lavelle@cookchildrens.org

28. References Hartley, Leila L. Cognitive Communicative Abilities following Brain Injury: a Functional Approach. San Diego, Calif.: Singular Pub. Group, 1995. Print. Hartley, Leila. "Traumatic Brain Injury- Rebuilding Cognitive &Communication Abilities." San Antonio, Texas. 30 Jan. 2009. Lecture. Savage, Ronald C., and Gary F. Wolcott, eds. An Educator's Manual: What Educator's Need to Know about Students with Brain Injury. Washington, D.C.: Brain Injury Association, 1995. Print. Schoenbrodt, Lisa, ed. Children with Traumatic Brain Injury: a Parent's Guide. Bethesda, MD: Woodbine House, 2001. Print.

29. References Sharp, Nicole L., Rosalind A. Bye, Gwynnyth M. Llewwllyn, and Anne Cusick. "Fitting Back In: Adolescents Returning to School after Severe Acquired Brain Injury." Disability and Rehabilitation 28.12 (2006): 767-78. Print. Ylvisaker, Mark. Traumatic Brain Injury Rehabilitation: Children and Adolescents. Boston: Butterworth-Heinemann, 1998. Print. Youse, Kathleen M., Karen N. Le, Michael S. Cannizzano, and Carl Coelho. "Traumatic Brain Injury." The ASHA Leader June (2002): 04-07. Print.