1. Tammara Thomas, ABD, MS, VRC
Traumatic Brain Injuries (TBI) Coping With Grief and Loss Experienced By Caregivers
Tammara Thomas, ABD, MS, VRC
University of Iowa - Instructor
Veterans Administration- Vocational Rehabilitation Counselor
July 30, 2012
Throughout this webinar, attendees will be allowed to ask questions. Note that presenters will provide a response based on limited and unverified information. These responses should not be construed as direct advice regarding the issue raised, nor should they be construed as a formal opinion issued by CRCC.

2. Objectives Review of Traumatic Brain Injury and Symptoms
Veteran and TBI
Gain understanding of the impact of TBI on Caregivers and Family Systems
Attending from the perspective of grief and loss
Introduction of Conceptual Model of Health-related Quality of Life
Strategies for families and rehabilitation professionals to assist individuals with TBI
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

3. Traumatic Brain Injury (TBI) defined
Department of Defense and the Department of Veteran Affairs (2007)
“Any traumatically induced structural injury and/or physiological disruption of the brain function as a result of an external force that is indicated by a new onset or worsening of at least on of the following clinical signs, immediately following the event.”
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

4. 5 TBI Diagnosis Criteria
Any period of loss of or a decreased level of consciousness;
Any loss of memory for events immediately before or after the injury;
Any alteration in mental state at the time of the injury;
Neurological deficits;
Intercranial lesions
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

5. Types of TBI injuries Focal Injury (Open):
This is an injury that results from a direct blow to the head (penetrating). The skull is fractured with a blow. The injury can be to a specific area of the brain.
Closed Injury:
The injury results from a blow or a violent shifting of the brain. The skull isn’t broken, but the brain tissue can be damaged through tearing or shearing.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

6. Epidemiology of TBI Facts:
TBI is a leading cause of death and disability in the U.S. (CDC, 2007)
5.3 million people have enduring disabilities as a direct result of TBI. (CDC, 2007)
Estimated costs such as hospital care, lost of productivity (indirect), extended care, and other medical are services were estimated at $60 billion. (Finkelstein, et al., 2006)
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

7. Military TBI
The military is calling TBI the “signature injury” of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). Active Duty timeline is from September 11, 2001-Present.
In there were 1,313 veterans who received VA Inpatient hospital care for TBI.
33% of all patients with combat related injuries and
60% of patients with blast-related injuries seen at Walter Reed Army Medical Center have sustained a TBI.
These numbers are not true estimates because individuals with mild TBI may not seek medical care. Additionally, these figures don’t include physical, emotional, and social costs to the injured person and their family from TBI-related injuries. Mild TBI is one of the most common forms of combat-related injury.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 7

8. Severity of Traumatic Brain Injury (TBI)
The severity of TBI is a continuum, and the classification used to designate if a patient has mild, moderate, or severe TBI. The classification is arbitrary because the level of the TBI is not able to predict the patient’s likelihood of functional recovery.
This benefit of classification is that it does provide a baseline in which to measure the initial onset and to monitor further development.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 8

9. Severity Grades Severity Grades are defined by using four indexes:
The Glasgow Coma Scale (GCS)
The length of coma (duration of unconsciousness).
Length of period of altered consciousness (mental status) and,
Length of posttraumatic amnesia (PTA)
Post Traumatic Amnesia (PTA) is the time interval from when the person regains consciousness until he or she is able to consistently form memories for ongoing events (Whyte, Rosenthal & Zuccarelli, 200)
TACE Center: Region IV, a project of the Burton Blatt Institute.
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10. Types of TBI Closed Head Injury: Open Head Injury:
The blow to the head to leave the skull intact, but the brain shifts within the skull resulting in damage.
Open Head Injury:
Penetration or fracture of the skull, which may cause more localized damage.
In a closed head injury, the result of the forceful shifting can cause extensive damage like shearing, tearing, swelling (edema), and hemorrhaging.
Open head Injuries run the risk of the same symptoms but additionally, there is risk of fragments
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 10

11. Brain Injury Measurement of Severity and Classifications
MEASUREMENT: GLASCOW COMA SCALE (GCS) Source: White and Likavec (1992)
An instrument that has become widely accepted as a classification system for measuring the seriousness of brain injury. (Jenner, Snoek, Bond, & Brooks, 1981).
The longer the person is unconscious the more severe the injury to the brain and the greater the residual effects (Hodge, 2004).
Mild TBI: Because there are few objective signs of brain damage in mild cases individuals may be accused of malingering (making up symptoms). However, these symptoms can effect emotional wellbeing and social and occupational functioning.
TACE Center: Region IV, a project of the Burton Blatt Institute.
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12. The Glascow Coma Scale Category Score Eyes Open Never 1 To pain 2
To verbal Stimuli 3
Spontaneously 4
Best Verbal Responses
None
Incomprehensible sounds
Inappropriate Words
Disoriented/Converses
Oriented/Converses 5
Best Motor Responses
Extension (rigidity)
Flexion abnormal (rigidity)
Flexion withdrawal
Individual Localized Pain
Individual obeys 6
Total
3 - 15
Explanation of Scale: The scale is used to assess the level of consciousness along a continuum ranging from alert to coma. Scores are assigned according to the level of response in each of the three areas: Eyes opening, Verbal Responses and Motor Responses. The range of scores are from The lower the score the deeper the level of unconsciousness and the greater the functional consequences. The scale can be used to establish a baseline and then changes in neurological functioning can be tracked and measured.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 12

13. Classification of TBI - Mild
Mild: A Glascow Score of 13 or higher
Occurs post-concussion (months/years later after injury) Characterized by subtle but disruptive symptoms.
Disruptive Symptoms
Headache, vertigo (dizziness), sleep disturbance tinnitus, depression, irritability, reduced attention span, and memory impairment. There is at least one symptom that result from disruption of brain functioning.
70% of all TBI’s are considered mild. These symptoms can be undetectable and may not be diagnosed.
Brief explanation of symptoms: a brief loss of consciousness, period of time after the injury when the person will be disoriented, loss of memory of events that last no longer than 24 hours, temporary neurological deficits.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 13

14. Classification of TBI - Moderate
Moderate: A Glascow Score of 9-12
Characterized by a loss of consciousness for a few
minutes or several hours. There may disorientation
and confusion that can lasts for a few days or
several hours.
Disruptive Symptoms
Physical Deficits
Cognitive Deficits
Psychosocial Deficits
Symptoms may resolve in a few weeks, months, or remain permanent.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

15. Classification of TBI - Severe
Severe: A Glascow Scale of 8 or less
Characterized by a loss of consciousness (COMA) for an extended period of time.
Disruptive Symptoms include:
A vegetative state
May open their eyes in response to painful stimuli but the response isn’t meaningful
The more severe the injury and depending on the location, the deficits can be permanent.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

16. Points to Remember! TBI is the “signature injury” of our last war.
TBI may resolve quickly, but may be permanent
Symptoms of TBI usually fall into three categories:
Physical
Cognitive
Emotional/Behavioral
Physical includes headaches, nausea, sleep disturbances, weakness, balance and coordination disorder and seizure
Cognitive: difficulties or impairment in attention, concentration, new learning, memory, speed of mental processing, planning, reasoning, judgement, , self-awareness, language and abstract thinking.
Emotional/Behavioral depression, anxiety, agitation irritability, impulsivity and aggression
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 16

17. More Points!
Brain injury severity is classified by signs and symptoms at the time of the original injury.
The majority of TBI’s are mild.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

18. Who is This Person?!
The presence of emotional and behavioral, and personality change after a head injury has been long recognized (Goldstein, 1942; Harlow, 1968).
The changes in personality that result from a head injury can be the most distress after effects for families (Lishman, 1978)
Changes of personal implies the alteration in the veteran’s habitual attitudes and patterns of behavior, so that their reactions to events and to people are different! Often times the changes can be very obvious and sometimes only apparent to those close to the veteran. The veteran may even be oblivious to the changes
TACE Center: Region IV, a project of the Burton Blatt Institute.
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19. The Veteran and TBI
Poly Trauma is a word used to describe multiple or a combination of wounds that impact more than one physical region or organ system.
Open wounds, eye injuries
Traumatic amputations,
TBI
Spinal cord injuries
Mental health issues
Musculoskeletal
Due to the increased likelihood of exposure to high energy blasts and explosions more veterans are returning with multiple combinations of injuries.
The same combat exposure that causes TBI may also result in other comorbidities or post-deployment issues like PTSD, pain, amputations, acute stress, and substance abuse. These issues can overlap with TBI
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 19

20. The Veteran and TBI Cognitive Impairments
Denote a decline in intellectual or mental processing of information. This can occur immediate after acquiring a TBI. The ability to mediate behavior, self-monitor, problem solve, and strategically plan can be diminished.
The severity of cognitive impairments tend to correlate with the severity of the injury.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 20

21. Cognitive Impairments
Cognitive effects following TBI often co-exist with other psychological conditions such as:
adjustment difficulties
depression
interpersonal conflicts
PTSD
The overlap of both cognitive and emotional issues should be address through collaborative interventions.
As a result, the functional consequences of this interface on the individual can greatly exceed the cognitive effects of the TBI alone. The combination of emotional and cognitive symptoms, particularly unawareness of deficits, irritability, impulsivity, and emotional reactivity, can negatively affect cognitive recovery and the potential benefits of cognitive rehabilitation. The overlap of cognitive and emotional symptoms is best addressed through collaborative interventions by rehabilitation and mental health specialists.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 21

22. Common Cognitive Symptoms
Problematic Symptoms:
Attention
Memory Difficulty
Executive Functioning
Communication Problems
Common complaints from loved ones include: Difficulty completing tasks, reading longer materials, or following the plot line of a movie – may indicate problems with sustained attention .
Difficulty learning new information, retaining, and then retrieving it at a later time are the most common memory complaints. Memory
Distractibility or poor concentration when other activities are going on in the immediate environment–may be related to impaired selective attention
Decreased ability to shift from task to task .
Difficulty following directions or passing on messages–may be indicative of deficits in working memory
Difficulty retaining information about specific events that occur in the person’s life since the injury–may be related to problems with episodic memory
Difficulty remembering to go to appointments or to complete household chores.
Executive Functioning issues: Executive functions are those capacities, that guide complex behavior over time through planning, decision-making and response control. Individuals with executive dysfunction may perform well on familiar, highly structured tasks but are likely to have difficulty functioning independently.
Difficulty responding to two tasks simultaneously, which may be due to impaired divided attention
Complaints: Loss of initiative and drive
Difficulty moving flexibly from task to task
Diminished awareness of deficits
Inability to monitor performance properly.
Difficulty planning and organizing complex activities
Poor reasoning, problem-solving and conceptualizing
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 22

23. Cognitive Recovery
In the days and weeks following TBI, many aspects of cognition improve quickly.
Early education about possible cognitive symptoms and expectations for full recovery is important.
It has been shown to have a positive impact on the resolution of cognitive problems (Mittenberg, 1996).
Rapid improvement in the first few months is considered the rule. Cognitive symptoms of mild TBI typically resolve within a few weeks after the injury.
Intervention should first focus on managing the key factors that contribute to the overall picture of disability. For example, initial stabilization of pain and sleep issues may improve the individual’s ability to concentrate on cognitive interventions and facilitate successful treatment outcomes. Many patients with moderate injuries can and, for the most part do, recover cognitive skills to a level of independent function so that they can return to work or resume their usual responsibilities.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 23

24. Cognitive Recovery Outcomes
Many patients with moderate injuries can and, for the most part do, recover cognitive skills to a level of independent function so that they can return to work or resume their usual responsibilities.
Fewer patients with severe injuries return to work or independent living.
Persistent long-term cognitive
problems include cognitive slowness, poor
memory, and executive control dysfunction
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 24

25. Cognitive Recovery Outcomes
According to Brooks et al., 1986
Physical impairments may be prominent early in the recovery process; however cognitive and behavioral impairments are more persistent and make greater contribution to long-term disability.
The rate of cognitive recovery tends to slow down at 1-2 years post injury, but there is increasing evidence that functional cognitive improvements may continue 5-10 years post injury (Draper & Ponsford, 2008).
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 25

26. Points to Remember!
Concussions can generally cause mild cognitive symptoms, while more severe injuries may have more persistent and pervasive cognitive consequences
In the first few months post-TBI, rapid improvement is considered the rule
Compared to patients with mild to moderate TBI, fewer patients with severe injuries return to work or independent living
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

27. Emotional Difficulties
Facts:
Emotional difficulties, adjustment issues, and behavioral problems are common following moderate to severe brain injury (Sohlberg & Mateer, 2001).
Premorbid psychiatric problems, such as impulse control difficulties, substance abuse, and family problems increase the risk for brain injury (Vassallo et al., 2007).
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

28. Emotional Difficulties Cont.
Following a brain injury, one has to deal with both pre-injury characteristics as well as the emergence of new post-injury emotional/behavioral problems.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

29. Emotional Symptoms
Difficulty tolerating frustration or higher levels of stimulation.
Impaired ability to process information or understand situations accurately.
Post-TBI behavior problems can also occur because individuals become fatigued much more easily, increasing irritability and lowering frustration tolerance.
Inability to tolerate frustration can lead to agitation, excessive use of profanity, aggression, and potentially destructive behavior.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 29

30. Impact of Emotional Impairment
As a result, emotional issues following a brain injury often include:
Increased anger
Lowered frustration tolerance
Increased anxiety
Depression
low self-esteem
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

31. Emotional/Behavioral
Additional Issues:
Social problems, difficulty appropriately reciprocating in social interactions
Excessive talking
Over-dependency
Immature behavior
Inappropriate use of humor
Inappropriate sexual behavior
Poorly controlled spending
Self-centeredness
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

32. So What?
Besides the fact that these issues are personally debilitating for the veteran.
The difficulties that result from physical, cognitive, emotional and behavioral deficits serve only cause displacement in to social group membership for the veteran, but, further resulting in long-term obstacles for a successful recovery (Wood & Yardukal, 1997).
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

33. Caregiver and Family Systems
The changes that occurs physically, emotionally an cognitively in survivors of TBI can be not only overwhelming for the veteran but caregivers and the family.
Family systems vary in their ability to cope with life in the aftermath of the injury.
The effect of TBI on family members and caregivers is well documented (Kreutzer, et al., 1993, Sander et al., 1997 Collins and Kennedy, Therefore, healthcare providers, rehabilitation professional, supports must be familiar must be able to asssess the family system and promote family wellness by offering support and assurance.
TACE Center: Region IV, a project of the Burton Blatt Institute.
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34. Factors Contributing factors to family and caregiver
adjustment include:
Pre-existing Factors (caregivers health, hx of psychiatric issues, socio-economic resources, etc.)
Relationship Factors can contribute to adjustment of caregivers (ie. Spouses who provide care report more health and psychological issues, than parents of those with TBI.
Post-injury issues (i.e. financial burden, hospital bills, loss of income, separation from military).
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

35. Lezak (1986) Stage Theory of Emotional Reaction adapted from Lezak
Lezak’s stage theory was initially meant to describe family reactions to changes following moderate to severe TBI. Through all the stages the family or caregiver will focus on providing for the veteran and may neglect their own self care. Therefore, practioners need to encourage self care, nutrition, exercise and relaxation.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 35

36. Lezak (1986) Stage Theory of Emotional Reaction
Time Since Injury
Expectation
Family Reaction I
0-1 to 3 months
Full Recovery by 1 year
Relief, shock, denial, depression, avoidance II
1-3 months to 6-9 months
Full recovery if the patient just tries harder
Bewildered, anxious, begin to realize severity, frustrated, loss, realize their lack of knowledge
III
6 to 24 months or can continue indefinitely
Patient can become independent if family knows how to help
Impatient with veteran, recognizes the person is more impaired than they thought, guilty feelings, discouraged, information seeking. IV
9 months or later, can continue indefinitely
Little or no change
Feeling “trapped”, exhausted and need respite, begin to realize the impact, experience bereavement, veteran’s disabilities may bother family immensely V
12 months or later, usually time limited
Sadness and mourning, begin to understand & begin process of accepting losses VI
18 months to 3 years post injury
Reorganization and change in family system, creative helping, $$, time, empowerment and advocacy.
Lezak (1986) Stage Theory of Emotional Reaction
Lezak’s stage theory was initially meant to describe family reactions to changes following moderate to severe TBI. Through all the stages the family or caregiver will focus on providing for the veteran and may neglect their own self care. Therefore, practioners need to encourage self care, nutrition, exercise and relaxation.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012 36

37. Conceptual Model of Health-Related Quality of Life
(Ferrans, Zerwic, Wilbur, & Larson, 2005)
Over the last 30 years the evaluation of how to evaluate quality of life have become important in healthcare outcomes.
The HRQ0L Model considers the idea that the following must be considered when evaluating Quality of Life. Additionally, certain components can relate to how happy or satisfied someone is with life as a whole.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

38. Model Considerations The model considers:
Biological Function (ie. Diagnosis, labs. The biological function speaks to an individuals physical resiliency and vulnerabilities.
Symptoms (defined as the patient’s perception of abnormal physical, emotional and cognitive states.
Functional Status: characterized no only by what they can or cannot do, but also takes into account the environmental factor that affect functionality
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

39. HRQoL continued
General Health Perception: this component is a synthesis of all the other components in the model. The asking individuals to self report their perception of health with a single item measure is more of a contribution when assessing factors that need to be addressed.
Quality of Life: This measurement is important because differences in values, may be the difference in how one individual sees their impairment versus another.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

40. Attending to Loss and Grief
Historically, there has been the study of loss and grief in relation to understanding individuals coping when faced with disability.
Pitzele (1985) suggested that developing a chronic illness represented a major loss.
Loss of:
Health, control over body, sense of well-being, and idyllic self-image
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

41. Loss and Grief
Elberlik (1980) said that any physical change in the body will like cause reactions of acute anxiety and grief.
Scholars indicate that there is an relationship between social, psychological and cultural factors that are operative in one’s response to loss (Marris, 1974; Parks, 1975; Shontz, 1964; Worheit, 1979).
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

42. Loss and Grief
Ben-Sira (1983) suggested the better control one has in terms of resources, the more likely they will experience successful coping.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

43. Strategies for Caregiver and Family Adjustment
Successful reintegration of a person with a history of TBI into their previous family structure is essential in maximizing quality of life and independence
(Sander, et al., 2002).
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

44. Steps in helping adjustment
Caregivers and Practitioners
Step 1: Validate and Normalize
Individual benefit from someone listening to their concerns and feelings. Use of basic counseling skills are effective (attending, reflecting, etc.)
Step 2: Educate
Psychoeducation regarding the recovery process and how to adjust to changes in the survivor can reduce distress and anxiety.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

45. Steps Continued Step 3: Collaborate and Refer (Practitioner Specific)
Consultation with other healthcare professional, community resources, family, employers, etc. is necessary. Collaboration is essential in determining what other services are needed and available to the veteran. Consultation can help with adjustment, logistical needs, community re-integration and training.
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

46. Resources Brain Injury Association, Inc- www.biausa.org
Brain Injury Resource Center-
The Perspective Network-
Recovery Awareness Foundation-
Rosalyn Carter Institute for Caregiving -
Defense and Veteran’s Brain Injury Center -
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47. Comments & Questions
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48. 48
Thank You
TACE Center: Region IV, a project of the Burton Blatt Institute.
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49. Contact Information
Tammara Thomas University of Iowa – Instructor Veterans Administration - Vocational Rehabilitation Counselor
TACE Center: Region IV, a project of the Burton Blatt Institute.
Funded by RSA Grant # H264A © 2012

50. Education Credits CRCC Credit - (1.5)
Approved by Commission on Rehabilitation Counselor Certification (CRCC)
By August 10, 2012, participants must score 80% or better on a online Post Test and  submit an online CRCC Request Form via the MyTACE Portal.
My TACE Portal: TACEsoutheast.org/myportal
TACE Center: Region IV, a project of the Burton Blatt Institute.
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51. Southeast TACE Region IV51
Southeast TACE Region IV
Toll-free: (866)  [voice/tty]
Fax: (404)
Web: TACEsoutheast.org
My TACE Portal: TACEsoutheast.org/myportal
TACE Center: Region IV, a project of the Burton Blatt Institute.
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52. 52
Disclaimer
This presentation was developed by the TACE Center: Region IV ©2012 with funds from the U.S. Department of Education, Rehabilitation Services Administration (RSA) under the priority of Technical Assistance and Continuing Education Projects (TACE) – Grant #H264A However, the contents of this presentation do not necessarily represent the policy of the RSA and you should not assume endorsement by the Federal Government [34 CFR (b)].
TACE Center: Region IV, a project of the Burton Blatt Institute.
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