Traumatic Brain Injury: Eligibility, Special Education and Classroom Practices Josh Zola MA, Ed.S, CBIS Sarah Powell M.Ed, CCC-SLP, CBIS

Disguised as a Low Incident Disability… Each year, an estimated 1.7 million people sustain a TBI annually. Of them: 52,000 die 275,000 are hospitalized, million, nearly 80%, are treated and released from an emergency department. The number of people with TBI who are not seen in an emergency department or who receive no care is unknown. Only 200 of every 100,000 cases go to the hospital.

SC Special Education Law (Definition) Traumatic Brain Injury means 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 student’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. Traumatic Brain Injury means 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 student’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.

Types of Brain Injury

Short term effects of Brain Injury Injury to brain tissues at the site of damage Shearing and tearing of neurons throughout the brain Bleeding, swelling, and lack of oxygen to the brain Possible coma, loss of consciousness Described as mild, moderate and severe

Long Term Consequences A student’s decreased functioning may be noted immediately upon return to school OR it may be several years after the injury! If not aware, teachers may see changes but do not know why they have suddenly emerged.

Typical Medical Course for a Student with a Moderate/Severe TBI Emergency room Emergency room Regional trauma center if necessary Regional trauma center if necessary Surgery if necessary Surgery if necessary Acute care setting (hospital) Acute care setting (hospital) Rehabilitation unit or center Rehabilitation unit or center School School (So there should be tons of paperwork) (So there should be tons of paperwork)

A student with a TBI has landed in your school…

Meeting the Challenge of TBI To address the educational needs of students who have experienced a TBI, educators need to clear 4 hurdles… Identification Assessment Qualifying for Services Classroom Accommodations

4 Facts about Identification Each student will vary greatly, no 2 will be alike Changes are unlikely to disappear fully over time Negative consequences may not be seen immediately but emerge when developmental demands reveal problems An injured brain is less likely to meet the increasingly complex tasks all children face as they get older

Common Problems Teachers look for: Physical/Medical Problems Motor Problems Sensory/Perceptual Problems Cognitive-Communication Problems Emotional and Behavioral Problems

Physical/Medical Problems Problems Seizures Fatigue Headaches Swallowing/Eating Self-care activities Medication issues

Motor Problems Apraxia Ataxia Coordination problems Paresis or paralysis Orthopedic problems Spasticity Balance problems Impaired speed of movement

Sensory/Perceptual Problems Visual deficits field cuts tracking (moving and stationary objects) spatial relationships double vision (diplopia) Neglect / Inattention Auditory sensory changes Tactile sensory changes

Cognitive-Communication Problems Executive functions Memory Attention Concentration Information processing Sequencing Problem solving Comprehension of abstract language Word retrieval Expressive language organization Pragmatics

Emotional & Behavioral 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

So you begin to think about assessment and will this student qualify for services…and qualify for what services???

Assessment… Traditional Assessment Focuses on intellectual, emotional and academic functioning Example: an IQ score that declines over time Cognitive Assessment Focuses on the underlying reasons for academic failure such as problems with attention, memory, and executive skills

Cognitive Assessment…is the student? Processing Speed Accurate but slow? Memory Retaining new info from day to day? Benefiting from context? Benefiting from repetition? Executive Function Prioritizing? Following through? Staying organized? Using problem solving strategies? Shifting from 1 task to another? Attention Able to concentrate? Hold onto information? Attending to more than 1 thing at a time? Accurate when carrying out complex tasks?

How is TBI different from LD? TBI is not “just a learning disability” Students with TBI cannot be dealt with as if they have something similar Although similar, the differences are important The impairments are different, as are the implications for educators

TBI: How is it Different? TBILDED Onset and Cause Sudden with blow to head and loss of consciousness Early/ unclearSlow/ unclear Functional Change Marked contrast between pre and post onset No before-after contrasts Changes emerge slowly Physical Disabilities Loss of balance, weakness, paralysis Poor coordination Unlikely BehaviorAgitation, impulsive, restlessness, disinhibited Restlessness, impulsive Variable EmotionsLabile, depression, anxiousProne to outbursts Reactions due to distortions of reality Academic Deficits Based on disrupted cognition Based on type of learning disability Not based on impaired cognition Difficulties with Learning Old info easier to recall than new info New learning can be linked with old learning

Misclassified or Missed Altogether Poor transitional services between hospitals and schools Mild TBI slip thru the cracks Traditional approaches to assessment fail to provide necessary insight into how cognitive deficits impact school Special Ed for TBI vs. LD vs. ED looks different Deficits are not always immediately apparent

So, now the assessment as been done… What services are out there? Qualifying for Special Ed

Traumatic Brain Injury (TBI) Title of Regulation:Regulation No.:R CRITERIA FOR ENTRY INTO CRITERIA FOR ENTRY INTO PROGRAMS OF SPECIAL EDUCATION FOR STUDENTS WITH DISABILITIES Vs. Medical Definition of TBI

SC TBI Eligibility Criteria A multidisciplinary evaluation team shall include a certified school psychologist, a licensed school psychologist, or a licensed psycho-educational specialist in addition to a speech-language therapist knowledgeable in the education of students with traumatic brain injury. A multidisciplinary evaluation team shall include a certified school psychologist, a licensed school psychologist, or a licensed psycho-educational specialist in addition to a speech-language therapist knowledgeable in the education of students with traumatic brain injury. The existence of traumatic brain injury has been diagnosed by a licensed physician. Or, in the absence of an existing medical diagnosis or a prior diagnosis of a traumatic brain injury, both of the following are furnished: The existence of traumatic brain injury has been diagnosed by a licensed physician. Or, in the absence of an existing medical diagnosis or a prior diagnosis of a traumatic brain injury, both of the following are furnished: a documented history that evidences trauma to the head resulting in impairments according to the definition of the term “traumatic brain injury” and a documented history that evidences trauma to the head resulting in impairments according to the definition of the term “traumatic brain injury” and a cognitive profile that is consistent with the head injury. a cognitive profile that is consistent with the head injury.

SC TBI Eligibility Criteria The injury has resulted in partial or total functional disability and/or psychosocial impairments. The injury has resulted in partial or total functional disability and/or psychosocial impairments. The student’s traumatic brain injury adversely affects his or her educational performance. The student’s traumatic brain injury adversely affects his or her educational performance.

SC Special Education Law The following evaluation components are required: The following evaluation components are required: a. Medical records, if available. b. Documentation of vision, hearing, and speech- language screening conducted after the injury and within the past twelve months. c. Review of the developmental history or education records of the student to determine effect on his or her educational performance and psychosocial functioning. Particular attention should be paid to the student’s progress prior to and following the suspected injury.

SC Special Education Law d. Observations in three environments by an observer, other than classroom teacher, that record the nature and severity of the student’s learning and/or behavior difficulties. These may include anecdotal records from previous caregivers; a certified school psychologist, a licensed school psychologist, or a licensed psycho- educational specialist; or the parent(s). e. Assessment of the student’s language processing and use (not receptive or expressive vocabulary tests), memory, attention, reasoning, abstract thinking, judgment, problem-solving skills, auditory perception and visual perception shall be completed by two professionals—a speech-language therapist and either a certified school psychologist, a licensed school psychologist, or a licensed psycho-educational specialist who are knowledgeable of traumatic brain injury. f. Documentation of the student’s physical functioning that includes motor abilities, sensory functions, and the status of seizure activity, medication, and health.

SC Special Education Law g. A behavior assessment shall include psychosocial, pre-injury functioning and adjustments to impairments. h. Documentation of the evidence that the student’s traumatic brain injury adversely affects his or her educational performance.

SC Special Education Law Evaluation Results: The school based team (which includes the parent) must determine if the student meets criteria to receive special education as a TBI (or other classification) student. The school based team (which includes the parent) must determine if the student meets criteria to receive special education as a TBI (or other classification) student. IEP v. Section 504 Plan Section 504 Plan = Accommodations needed to access the general curriculum. Section 504 Plan = Accommodations needed to access the general curriculum. IEP = Special Education = needs for modified curriculum and direct or indirect services (Resource, Self-Contained, Speech, OT, PT, etc.) IEP = Special Education = needs for modified curriculum and direct or indirect services (Resource, Self-Contained, Speech, OT, PT, etc.)

So now, what are your interventions? What are your IEP goals? 504 accommodations What can you do in your classroom? Who can you ask for help?

Helpful Hint! Accommodations useful to a child with a TBI often benefit most or all the other students in the classroom!! Consistency!!! Agree on a strategy and apply it throughout the day and week

Classroom Environment Cognitive Challenge Accommodations Attention/ Concentration Seat the student near the teacher, Minimize distractions, use earplugs, Low stimulation environment Information Processing Speed Reduce Distractions, Small Group Instruction, Position student for optimal learning Memory Provide written materials, consistent routines, schedules, visual aids, create an environment that doesn’t rely on memory Reasoning Designate a specific location to return homework, Display classroom schedule and activities, Reduce unnecessary frustrations/problems

Classroom Instructions/Materials Cognitive Challenge Accommodations Attention/ Concentration Use peer note taker and tape recorders, Provide assignments in writing, match the student’s ability to attend, break tasks into smaller parts, alternate instructions with activities Information Processing Speed Give the student “time to get it”, Review notes to identify missed information, smaller segments of info, emphasize key points Memory Use tape recorders and highlighters, Use external memory management system, Test using multiple choice, chunk work into manageable pieces, written instruction, mnemonics, identify learning style Reasoning Use binders to keep materials and notes organized, Develop systems/use maps, use clear instructions, provide samples, keep routines

Educating Students with TBI and Peers Cognitive Challenge Accommodations Attention/ Concentration Educate on attention types, clarify information, complete a predetermined amount of work, take rest breaks BEFORE becoming tired, limit interruptions and distractions Information Processing Speed Monitor their own comprehension, ask questions, signal if not understanding, educate others on strengths and limitations, extra time to respond Memory Buddy system, peer note taker, external memory systems, routines, generate their own memory cues Reasoning “Stop and Think,” seek adult assistance, know your strengths and limitations, use a problem solving model, listen

Modify your Expectations and Values The teacher’s shift in his/hers expectations of what compromises competence For example: A teacher may feel the only test of “true” learning is to ask the student under time- limited conditions to recall ideas and facts. Try testing their learning through recognition tests

Other things to keep in mind… Physical and Cognitive Endurance/Fatigue Low Frustration Tolerance Poor Awareness Rapid Classroom Pacing Lack of Predictability Negative Social Input Pragmatic Deficits

What happens as a result of these deficits and behaviors? Friends leave Friends leave Families mourn Families mourn Teachers are frustrated Teachers are frustrated The student is at increased risk for isolation from peers, academic failure, depression, substance abuse, sexual behavior, delinquency, further TBI The student is at increased risk for isolation from peers, academic failure, depression, substance abuse, sexual behavior, delinquency, further TBI

Provide… An ear to listen A safe environment Clear structure and routine Consistency Immediate feedback and praise Reinforcement Cueing and modeling Advocacy

Accessible Resources The Family School Psychologist Resource Teacher Guidance Counselor Speech Therapist Neuropsychologist Hospital Case Manager Peers and Friends

Traumatic Brain Injury Information & Suggestions A TBI tool kit for school staff can be downloaded at : A TBI tool kit for school staff can be downloaded at : A TBI tool kit for families can be downloaded at: A TBI tool kit for families can be downloaded at:

Additional Resources

In Summary Students must be identified, appropriately assessed, and then taught in ways that address both their strengths and weaknesses. Disguised as a low incidence disability, brain injury is occurring and students need our help at being successful in SC classrooms!