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Supporting Students with Brain Injury In the Classroom

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1 Supporting Students with Brain Injury In the Classroom
INTRODUCTION POINT OUT SIGN IN SHEET AND EVALUATION FORMS EXPLAIN THAT PROJECT BRAIN IS FUNDED BY A FEDERAL GRANT FROM THE MATERNAL AND CHILD HEALTH BUREAU (MCHB) OF THE HEALTH RESOURCES AND SERVICES ADMINISTRATION THIS GRANT WAS AWARDED TO THE TBI PROGRAM OF THE TN HEALTH DEPARTMENT. THE TENNESSEE DISABILITY COALITION IS IMPLEMENTING THE PROJECT THROUGH A CONTRACT WITH THE TN TBI PROGRAM 5 minutes

2 OBJECTIVES Review federal and state definitions of traumatic brain injury (TBI) Learn about the discrepancy between: Incidence rates of TBI among children and youth vs. Number of students counted in the TBI category of Special Education

3 OBJECTIVES Develop an understanding of the causes and effects of TBI on children, their families, and communities Learn about normal brain development and the effects of brain injury on a developing brain READ OVER OBJECTIVES (continued)

4 OBJECTIVES Develop an awareness of the potential physical, cognitive, behavioral, and psychosocial effects of a TBI An overview of successful strategies and resources for supporting students with TBI in the classroom READ OVER OBJECTIVES (continued)

5 WHAT IS THE DEFINITION OF A TRAUMATIC BRAIN INJURY (TBI)?

6 BRAIN INJURY Congenital brain injury Pre-birth During birth
Acquired Brain Injury After birth process Traumatic Brain Injury (external physical force) THIS SLIDE SHOWSHOW DIFFERENT TYPES OF BRAIN INJURIES ARE CLASSIFIED THE TYPE OF INJURY WE WILL FOCUS ON TODAY IS TRAUMATIC BRAIN INJURY Non-traumatic Brain Injury Closed Head Injury Open Head Injury Savage, 1991

7 IDEA 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. TRAINER: DEFINITIONS OF TRAUMATIC BRAIN INJURY CAN VARY IN TERMS OF THE TYPES OF INJURIES THE DEFINITION INCLUDES FOR PURPOSES OF THIS TRAINING, WE WILL LOOK AT THE DEFINITION OF TBI AS DEFINED IN SPECIAL EDUCATION LAW OR IDEA(INDIVIDUALS WITH DISABILITIES EDUCATION ACT) TBI WAS ADDED AS AN ELIGIBILTY CATEGORY IN 1990 TO IDEA THE IDEA DEFINITION IS: *READ DEFINITION

8 TBI Definition (IDEA) 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 judgement problem-solving sensory, perceptual and motor abilities psychosocial behavior physical functions information processing speech *READ DEFINITION

9 TBI Definition (IDEA) The term does not apply to brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma. Federal Public Law *READ DEFINITION

10 Exposure to Toxic Substances
Neither definition includes “acquired” brain injuries caused by internal conditions, such as: Stroke Brain Infection Tumor Anoxia Exposure to Toxic Substances TRAINER: *READ THESE COMMENTS IMPORTANT TO NOTE: FOR A STUDENT WHO HAS AN ACQUIRED BRAIN INJURY SUCH AS THESE, BY DEFINITION THEY COULD BE CLASSIFIED WITHIN ANOTHER DISABILITY GROUP SUCH AS: OTHER HEALTH IMPAIRED, PHYSICAL DISABILITY, ETC.

11 that result from either an may have similar effects.
Important note: Brain injuries that result from either an external or internal force may have similar effects. THIS IS IMPORTANT TO NOTE BECAUSE YOU MAY BE SUPPORTING STUDENTS WHO HAVE HAD A STROKE OR TUMOR, OR A BRAIN INJURY FROM NEAR DROWNING- THESE CASES DON’T QUALIFY AS A “TRAUMATIC BRAIN INJURY” BY IDEA’S DEFINITION, BUT THE SAME STRATEGIES CAN BE HELPFUL.

12 WHO SUSTAINS A BRAIN INJURY?
TRAINER: WE KNOW THAT ANYONE CAN SUSTAIN A BRAIN INJURY AT ANY TIME IN 1999, THE CENTER FOR DISEASE CONTROL RELEASED A STUDY ON TRAUMATIC BRAIN INJURY.

13

14 National prevalence rates of various disabilities
400,000 with Spinal Cord Injuries 500,000 with Cerebral Palsy 2.3 million with Epilepsy 3.0 million with Stroke-related Disabilities 4.0 million with Alzheimer’s Disease 5.3 million with Traumatic Brain Injury 5.4 million with persistent Mental Illness 7.2 million with Mental Retardation TRAINER: IT IS SURPRISING TO CONSIDER THE PREVALENCE RATES OF OTHER DISABILITY GROUPS AS COMPARED TO TBI WE MAY HEAR MORE ABOUT THE OTHER DISABILITY GROUPS LISTED HERE, YET PEOPLE WITH TBI REPRESENT A SIGNIFICANT PART OF THE POPULATION

15 IN TENNESSEE… Since 1996, the TBI registry has recorded over 7,000 persons, ages 3 to 21, who have been hospitalized for treatment of a brain injury 200 400 600 800 1000 1200 1400 1600 TBI Registry DOE Report The number of people, ages 3 to 21, who were recorded in the TBI Registry for the school year: 1547 TRAINER: SO WHY IS BRAIN INJURY CONSIDERED A “LOW INCIDENCE DISABILITY” IN SPECIAL EDUCATION? Number of students classified as having a TBI according to the DOE report of the school year : 306 What is happening with the 1,241 students?

16 Reasons for the discrepancy
Not all children who sustain a brain injury experience lasting effects The etiology of a student’s disability may be unidentified or misunderstood The student may be served under a 504 plan The effects of the brain injury in children can be latent, surfacing as more advanced skills are required of the student at school When the effects of the injury do surface, they may resemble other disabilities, such as a learning disability or emotional disorder *READ REASONS FOR DISCREPANCY TRAINER COMMENTS: RESEARCH ON INCIDENCES OF TBI SAYS: OF THOSE WHO SUSTAIN MILD TBI’S, 10% HAVE LIFELONG IMPAIRMENTS OF THOSE WHO SUSTAIN MODERATE TBI’S, 70% HAVE LIFELONG IMPAIRMENTS OF THOSE WHO SUSTAIN SEVERE TBI’S, 90% HAVE LIFELONG IMPAIRMENTS AN EXAMPLE OF THE ETIOLOGY (I.E. UNDERLYING CAUSE) FOR A DISABILITY BEING UNIDENTIFIED OR MISUNDERSTOOD: STUDENT HAS A SPEECH IMPAIRMENT RESULTING FROM A BRAIN INJURY; CONSEQUENTLY SPEECH IMPAIRMENT IS LISTED AS THEIR PRIMARY DISABILITY INSTEAD OF TBI WHEN YOU CONSIDER THAT THE EFFECTS OF A TBI ARE NOT ALWAYS VISIBLE AND MAY RESEMBLE OTHER CONDITIONS OR DISABILITIES, IT IS EASY TO UNDERSTAND WHY TBI IS OFTEN REFERRED TO AS THE “SILENT EPIDEMIC”

17 HOW AND WHERE DOES TBI HAPPEN?
TRAINER: MOTOR VEHICLE ACCIDENTS ARE THE LEADING CAUSE OF BRAIN INJURY ACROSS ALL AGES OTHER TYPICAL CAUSES INCLUDE: FALLS, BICYCLE ACCIDENTS, VIOLENCE OR ABUSE, AND PEDESTRIAN INJURY CERTAIN CAUSES ARE PREVALENT AMONG CERTAIN AGE GROUPS EXAMPLE: FOR ELDERLY PERSONS, FALLS ARE PREVALENT FOR INFANTS, ABUSE IS MOST PREVALENT MALES, 15-21, ARE AT GREATEST RISK FOR TBI AND ARE OVER-REPRESENTED IN THE CATEGORY OF MOTOR VEHICLE ACCIDENTS

18 WHY TBI is so devastating
MYTH: Younger children are more resilient and can therefore “bounce back” easier and more quickly from a brain injury. REALITY: It may just take longer for the effects of a brain injury to show up in a growing and developing brain.

19 Why TBI is so devastating
Myth: Visible, physical recovery is a sign that the brain is healed. Reality: The cognitive and behavioral effects of a brain injury can last long after the person heals “on the outside.”

20 The Growing Brain and Injury

21 Geography of the Brain Midline View Surface View Hippocampus TRAINER:
CORPUS CALLOSUM: 4INCH BAND OF NERVE FIBERS ALLOWING LEFT & RIGHT HEMIS.S TO COMMUNICATE PERSONS W/SEVERE DAMAGE TO CORPUS CALLOSUM : RIGHT SIDE OF BODY DOESN’T KNOW WHAT LEFT SIDE IS DOING MAY BE OPERATED ON IN CASES OF SEVERE SEIZURE DISORDERS LIMBIC SYSTEM PLAYS A ROLE IN EMOTIONAL ACTIVITY MEDIATES INTERNAL STATES SUCH AS THIRST, HUNGER, FEAR, RAGE, PLEASURE, ETC. REGULATES MEMORY AND LEARNING MODULATES DRIVE OR MOTIVATION CONNECTED WITH MANY PARTS OF BRAIN (E.G. FRONTAL CORTEX) HIPPOCAMPUS DAMAGED IN 80% OF CASES OF ISCHEMIA(BRAIN NOT GETTING ENOUGH OXYGEN) MANY CLOSED HEAD TBIS INVOLVE SOME COMBINATION OF FRONTAL LOBE AND LIMBIC AREA DAMAGE Hippocampus

22 can be especially devastating,
TBI in children can be especially devastating, as a child’s brain is in an almost constant state of development.

23 Rates of Development for the Four Regions of the Brain
5 Distinct Periods of Maturation P-O parietal/ occipital C central(limbic & brainstem) T temporal F-T frontal/ temporal % of maturation increments 6 P-O C T F-T 4 TRAINER: #1: THE GREATES PERCENT OF BRAIN MATURATION OCCURS IN THE EARLY YEARS, BIRTH THRU AGE 5. WE LEARN MORE DURING THIS TIME THAN AT ANY OTHER TIME IN OUR LIFE LEARNING TO WALK/RUN (P-O), SPEAK/USE LANGUAGE(T), BONDING EMOTIONALLY WITH FAMILY, ETC. DESPITE MYTHS THAT INJURY DURING THIS TIME IS OF LITTLE CONSEQUENCE, WE NOW KNOW THATTBI DURING THIS TREMENDOUS STAGE OF BRAIN DEVELOPMENT CAN BE DEVASTATING CHILDREN WITH DAMAGE TO THEIR FRONTAL LOBES FROM TBI BEFORE AGE 5 FREQUENTLY HAVE LIFELONG CHALLENGES WITH SOCIAL AND BEHAVIORAL ISSUES #2: CAN HANDLE SEPARATION (C), WRITING(P-O),FOLLOWING DIRECTIONS & IMPULSE CONTROL (F-T) #3: BECOMING MORE COORDINATED(P-O) (ex)playing team sports #4: LEARNING 2ND LANGUAGE, COMMUNICATE SOCIALLY W/PEERS & ADULTS, REMEMBERING MORE ACADEMIC INFO(T); EMOTIONS BECOMING MORE ADULT-LIKE(C) #5: ACCEPTING MORE RESPONSIBILITY, PLANNING LIVES(F-T) P-O C F-T T C F-T 2 P-O age increments

24 The Anatomy of a Brain Injury

25 Two types of TBI CLOSED-HEAD INJURY OPEN-HEAD INJURY (penetrating)
Example: Skull fracture that penetrates the brain Gunshot wound CLOSED-HEAD INJURY Example: Coup-ContraCoup Diffuse axonal injury TRAINER: WE WILL LOOK AT TWO TYPES OF TRAUMATIC BRAIN INJURIES THAT CAN OCCUR FROM AN EXTERNAL PHYSICAL FORCE OPEN-HEAD INJURIES INCLUDE THOSE WHERE THE SKULL HAS BEEN PENETRATED INJURIES THAT INVOLVE PENETRATION OF THE SKULL AND BRAIN CAN BE MORE LOCALIZED CLOSED HEAD INJURIES AND INJURIES OF A NON-TRAUMATIC NATURE (I.E. STROKE OR ANOXIA FROM NEAR DROWNING) CAN CAUSE MORE DIFFUSE OR GLOBAL DAMAGE

26 Two Classes of Brain Injury
PRIMARY THE INJURY IS MORE OR LESS COMPLETE AT THE TIME OF IMPACT SKULL FRACTURE CONTUSION/ BRUISING OF THE BRAIN HEMATOMA/BLOOD CLOT ON THE BRAIN DIFFUSE AXONAL INJURY SECONDARY THE INJURY EVOLVES OVER A PERIOD OF HOURS TO DAYS AFTER THE INITIAL TRAUMA BRAIN SWELLING/EDEMA INCREASED INTRACRANIAL PRESSURE INTRACRANIAL INFECTION EPILEPSY HYPOXEMIA (LOW BLOOD OXYGEN) HIGH OR LOW BLOOD PRESSURE ANOXIA/HYPOXIA (LACK OF OXYGEN TO THE BRAIN)

27 Coup-Contra Coup PRIMARY INJURIES TRAINER:
IN A CONTRA COUP INJURY, THE BRAIN IS INJURED NOT ONLY AT THE SITE OF IMPACT, BUT ALSO AT THE SITE OPPOSITE THE IMPACT. A COMMON EXAMPLE OF THIS OCCURS DURING CAR ACCIDENTS: THE CAR YOU ARE RIDING IN IS TRAVELING AT 45 M.P.H. THE DRIVER LOSES CONTROL AND HITS A TREE. AT THAT POINT, THE CAR, YOUR BODY AND HEAD HAVE STOPPED MOVING. YOUR BRAIN HOWEVER, CONTINUES TO MOVE AT GREAT SPEED INSIDE YOUR BONY SKULL- BOUNCING BACK AND FORTH, INJURING OPPOSITE SIDES OF YOUR BRAIN.

28 stretching and snapping
PRIMARY INJURIES Diffuse Axonal Injury Rotational forces on the brain cause the stretching and snapping of axons TRAINER: IN A DIFFUSE AXONAL INJURY, THE AXONS OF THE BRAIN ARE STRETCHED AND SHEARED OR TORN. THIS OCCURS WHEN THERE IS TWISTING AND TURNING OF THE BRAIN AT THE TIME OF INJURY NEURONS/BRAIN CELLS ARE NOT ABLE TO COMMUNICATE WITH EACH OTHER AS EFFICIENTLY AS BEFORE TREATMENT IS USUALLY AIMED AT MANAGING SWELLING, AS TORN AXONS ARE NOT REPAIRABLE. NO CONTACT IS NECESSARY - COMMON EXAMPLE: “SHAKEN BABY SYNDROME” Axon

29 PRIMARY / SECONDARY INJURIES
Intracerebral Hemmorhage Epidural Hematoma Subdural Hematoma TRAINER: A HEMATOMA IS A BLOOD CLOT THAT FORMS BETWEEN THE SKULL AND THE LINING OF THE BRAIN (DURA). CAN CAUSE FAST CHANGES IN THE PRESSURE INSIDE THE BRAIN. EMERGENCY SURGERY MAY BE NEEDED, DEPENDING ON THE SIZE OF THE CLOT.

30 Brain with Hydrocephalus
SECONDARY INJURIES Enlarged Ventricles Brain with Edema Edema (swollen brain tissue) TRAINER: EDEMA, OR THE SWELLING OF BRAIN TISSUE, HAPPENS AS A RESULT OF A PRIMARY INJURY HYDROCEPHALUS: WHEN THE FLOW OF CEREBROSPINAL FLUID IS BLOCKED, THIS CAUSES THE OPEN SPACES, OR VENTRICLES, TO BECOME ENLARGED. CAN CAUSE INCREASED INTRACRANIAL PRESSURE OFTEN REFERRED TO AS “FLUID ON THE BRAIN” Brain with Hydrocephalus

31 Consequences & Challenges
After Traumatic Brain Injury

32 TBI ENORMOUS VARIABILITY
AGE AT THE TIME OF INJURY TYPE OF INJURY & SEVERITY AVAILABLE KNOWLEDGE, RESOURCES, & SUPPORT TRAINER: THERE IS NO “TYPICAL” BRAIN INJURY OR TYPICAL STUDENT WITH TBI THE CHALLENGES A STUDENT MAY FACE FOLLOWING TBI ARE NOT SO DIFFERENT FROM THOSE EXPERIENCED BY OTHER DISABILITY GROUPS A PRIMARY DIFFERENCE IS THAT THESE CHALLENGES OR IMPAIRMENTS WERE ACQUIRED VERSUS CONGENITAL. RECOVERY PRE-EXISTING DISABILITIES OR BEHAVIORS

33 TBI Can Affect… Physical skills Cognitive skills Behavioral /
Psychosocial Skills TRAINER: WE WILL DISCUSS THE WAYS IN WHICH A BRAIN INJURY CAN AFFECT A STUDENT IN THE FOLLOWING WAYS: PHYSICALLY; COGNITIVELY BEHAVIORALLY / SOCIALLY THE CHILD WHO SUSTAINS A BRAIN INJURY MAY EXPERIENCE IMPAIRMENTS IN ONE OR MORE OF THESE AREAS

34 Possible Physical Effects
Impairment of: Speech Vision Hearing Difficulty with: Balance Spasticity Paralysis Paresis TRAINER COMMENTS: UNILATERAL HEARING LOSS TYPICALLY OCCURS WHEN A CHILD SUSTAINS A SKULL FRACTURE AS FOR VISUAL EFFECTS, THE PROBLEMS ARE NOT USUALLY WITH VISUAL ACUITY BUT RATHER WITH VISUAL PERCEPTUAL SKILLS. DOUBLE VISION IS COMMON. SPASTICITY IS AN ABNORMAL INCREASE IN MUSCLE TONE CAUSING THE MUSCLES TO BECOME RIGID- OR RESIST BEING STRETCHED. PARESIS IS PARTIAL PARALYSIS OR WEAKENING OF THE MUSCLES APPROXIMATELY 5% OF CHILDREN WHO HAVE SUSTAINED A SEVERE TBI WILL DEVELOP A SEIZURE DISORDER Less obvious physical effects: headaches fatigue

35 Possible Cognitive Effects
Impairments in: attention or concentration ability to initiate, organize, or complete tasks ability to sequence, generalize, or plan flexibility of thinking, reasoning, or problem-solving abstract thinking judgment or perception long-term or short-term memory confabulation ability to acquire or retain new information ability to process information- slowed speed TRAINER: THIS LIST INCLUDES THE MOST COMMON, BUT NOT ALL, OF THE COGNITIVE CHALLENGES A STUDENT WITH TBI MAY FACE THESE TYPES OF CHALLENGES ARE TYPICAL WITH INJURIES TO THE FRONTAL LOBE AND LIMBIC SYSTEM

36 Possible Behavioral / Social Effects
VERBAL / PHYSICAL AGGRESSION MOOD SWINGS OR EMOTIONAL LABILITY IMPAIRED ABILITY TO COPE WITH OVER-STIMULATING ENVIRONMENTS PRE-EXISTING MALADAPTIVEBEHAVIORS OR DISABILITIES INTENSIFIED IMPULSIVITY IMPAIRED ABILITY TO PERCEIVE, EVALUATE, OR USE SOCIAL CUES/ CONTEXT LOW FRUSTRATION TOLERANCE LACK OF AWARENESS OF DEFICITS

37 Supporting Students with TBI at School
What the Future Holds Supporting Students with TBI at School

38 Be creative in designing services...
Use the tools you have to work with these students, but keep the following in mind: Progress can be inconsistent and unpredictable Student may experience reduced stamina and fatigue for some time after the injury Student may process information slower after their injury Impairment of memory may hinder new learning

39 Plan for transitions… Hospital to school Grade to Grade
TRANSITIONS CAN BE VERY DIFFICULT FOR SOMEONE WITH A TBI- SUPPORT PLANS SHOULD INCLUDE CONSIDERATIONS FOR TRANSITIONS THE STUDENT WILL FACE School to School

40 Consider Ongoing Supports...
Establishing effective means of communication between school and home Establishing primary contacts for the family both at the school level and at the administrative level Developing peer supports for the student Updating evaluations as needed

41 Initial School Re-entry
Eligibility A physician’s letter should be obtained documenting the Traumatic Brain Injury Interview the family of the injured student to obtain pre-injury academic and social history, as well as changes they have seen since the injury A school staff person should be designated to visit the student before he or she returns to school to make anecdotal observations

42 Information to obtain:
Medical Documentation of the injury, site(s) of injury or lesion, duration of coma, services received post-injury, medications, contact information for doctors Medical Release Specifies the student’s ability to participate in physical activities at school Rehabilitation Records Initial evaluations & discharge summaries from all therapies administered Specific recommendations for adaptations to the school environment Therapy recommendations Instructions related to use of adaptive equipment

43 Information to obtain:
Psychosocial History of student pre-injury from an educational and social perspective Relevant information on siblings, including ideas about how to address their reaction to the injury Educate support team about possible suicidal ideation post-injury (especially with adolescents) Educational Contact person for family Initial and subsequent IEP’s Records from support personnel Attendance records Records from other schools attended, if applicable Specific information related to sensory issues

44 Considerations for Formal Assessment
The nature of formalized testing may compensate for cognitive weaknesses (e.g., attention, initiation, flexibility, information processing, executive functioning). New learning is often not assessed. The student’s “scatter” in abilities is often not revealed (i.e., gaps below basals and strengths above ceilings). Scores may not reveal the extent of reduced functioning in the classroom. Alternatively, some students may perform better in the “real world” with natural cues present than testing would predict.

45 Considerations for Informal Assessment
“Real-life” classroom performance is represented. New learning can be assessed. Hypotheses about breakdowns and possible interventions can be tested. Current functioning can be compared with pre-injury performance. Environmental variables affecting performance can be evaluated. Work samples and classroom evaluation can provide a direct link to intervention strategies.

46 Sample Strategies to Consider:
Scheduling Modifications Attend school part-time initially Schedule several in-school breaks Provide “study halls” with resource teacher Schedule most difficult subjects early in the day Keep number of classroom changes to a minimum, or assign a “buddy” to assist the student in changing classes Begin with one-on-one/small group instruction, adding additional students with improvement of concentration Consider ESY, homebound services or tutoring for summer months Will child be supervised at all times? From: TBI Inservice Training Module, Janet Siantz Tyler, PhD., Kansas Dept. of Education, TBI Project

47 Sample Strategies to Consider:
Instructional Strategies Classroom rules & expectations should be well structured and explicitly taught Instruction should contain repetition & feedback Avoid multi-step instructions if possible Supplement verbal instructions with writing / modeling Provide amply time to process, complete tasks, and respond Assist the student in keeping his/her materials and schedule organized Teach compensatory strategies for test-taking, note-taking, reading materials, etc. Try external aids such as lists, diaries, computers, calculators Videotape the student’s progress in class to provide feedback and show progress From: TBI Inservice Training Module, Janet Siantz Tyler, PhD., Kansas Dept. of Education, TBI Project

48 IEP Development TO INCLUDE: TO ADDRESS:
Obtain eligibility documents, including information about current levels of functioning Include individuals in IEP meetings who can help to identify the adverse effects of the brain injury on the student’s performance TO ADDRESS: Student’s current and past strengths/ areas of need Medical needs General modifications / accommodations Involvement of student in general curriculum Extended school year options REFER TO HANDOUT BY URBANCZYK AND FRANKLIN

49 Developing IEP Goals Focus on 2 or 3 priority issues
Identify metacognitive & organizational strategies Write measurable goals that incorporate the strategies Include specific information about how the strategy should be taught and implemented across settings Write short-term goals that are truly short-term TRAINER: A BIG FOCUS OF THE IEP MAY BE ON GOALS THAT TEACH THE STUDENT HOW TO LEARN AND HOW TO LEARN AND INTERACT IN THE SCHOOL ENVIRONMENT RE: SHORT TERM GOALS IT IS NOT UNCOMMON FOR STUDENTS WITH TBI TO NEED SEVERAL IEP REVISIONS WITHIN A YEAR- ESPECIALLY WHEN RECOVERY IS ONGOING STUDENTS WITH TBI CAN CHANGE RAPIDLY- GOALS SHOULD BE FLEXIBLE ENOUGH TO KEEP UP WITH THE CHANGES

50 For More Information: www.tndisability.org/brain
Jennifer Jones, M.S., C.R.C. Project BRAIN Resource Specialist Tennessee Disability Coalition 5641 Merchants Center Blvd. Suite A102 Knoxville, TN Office: / x 12 Fax: Cell: Paula Denslow, Coordinator & Project BRAIN Resource Specialist Tennessee Disability Coalition 480 Craighead Street, Suite 200 Nashville, TN Office: x 56 Fax: Cell: TTY:


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