1. Traumatic Brain Injury Meets Response to Intervention Dr. Jonelle Neighbor Dr. Karen McAvoy

2. Response to Intervention and TBI  TBI may be different from other challenges impacting learning and behavior  TBI is tied to a specific event (or events) which is medically documented or resulting from verifiable history of a blow to the head  As a result, intervention planning may not necessarily follow the same path as for other learning or behavior challenges

3. An RTI Authority: Jim Wright notes in RTI Toolkit: A Practical Guide for Schools (page 178) that “If there is strong evidence that the student has a type of special education disability (e.g., Speech or Language Impairment, Traumatic Brain Injury), the school should consider bypassing the RTI Team and referring the student directly for a special education evaluation.”

4. However  The school may immediately implement accommodations and reasonable interventions. This give the student time to recover from the injury, and the school time to determine what interventions will support the student at this moment and over time.

5. Rushing to a special education evaluation may be like hitting a moving target: the student’s needs may change so rapidly that it is best to wait for stabilization of TBI characteristics before assessing for an Individual Education Plan. Interventions can be adjusted quickly while IEPs cannot flex with a student’s potentially rapid changes in educationally relevant needs.

6. Principles of Response to Intervention (RTI) as applied to TBI As scientist/practitioners, educators know that “best practice” for all students is to:  Thoroughly understand and assess the problem  Apply a prescriptive intervention – early intervention is recommended  Assess whether the intervention is having it’s desired outcome – progress monitoring  Adjust: re-assess, attempt another intervention, progress-monitor: Adjust cokidswithbraininjury.com

7. If educational impact is established via appropriate assessment, intervention, progress monitoring and adjustment (of a reasonable time and intensity), the school team then has the authority to make the decision of: IDEA, 504 Plan or Not Eligible as appropriate. cokidswithbraininjury.com

8. Traumatic Brain Injury meets Section 504 Accommodation Plan

9. Section 504 Purpose Section 504 is a civil rights law that prohibits discrimination against individuals with disabilities. Section 504 ensures that the child with a disability has equal access to an education. The child may receive accommodations and modifications. http://www.wrightslaw.com/info/sec504.summ.rights.htm

10. Move Quickly to a 504 Plan  If a student receives a Traumatic Brain Injury, that individual may be immediately eligible for a Health Care Plan or a 504 Accommodation Plan  This is similar to a student needing accommodations after breaking the arm of their dominant hand  Specifics of when and how a 504 Plan is developed may depend upon your school district’s policies and guidelines

11. Who is an Individual with a Disability under Section 504?  Three ways a person is considered: 1. Has a physical or mental impairment, which substantially limits one or more major life functions. This covers a student recently receiving a TBI. 2. Has a record or history of such an impairment. The term includes children who have been misclassified (such as a non-English speaking student mistakenly classified as having mental retardation); or 3. Is regarded as having such an impairment

12. Section 504 Eligibility Criteria To be eligible for protections under Section 504, the child must have a physical or mental impairment. This impairment must substantially limit at least one major life activity. Major life activities include walking, seeing, hearing, speaking, breathing, learning, reading, writing, performing math calculations, working, caring for oneself, and performing manual tasks. The key is whether the child has an "impairment" that "substantially limits... one or more... major life activities."

13. Karen McAvoy, Psy.D.

14. How IEP was Changed  TNT  Feasibility Study  Timing

15. Focus Group/Best Practice (TNT) TWO GROUPS  School, Clinical and Rehabilitation Psychologist, Speech Language Pathologist, Special Education Teachers  Nurses, Physical and Occupational Therapist

16. Questions Asked  What are the “hallmarks” of TBI?  What formal assessments are you currently using when you suspect or know of TBI?  What informal assessment/observations are you currently using?  What would be helpful to you in terms of a protocol?  What training needs will you have to be able to implement the protocol?

17. Colorado Department of Education August 2008 (Timing) Medical Documentation of TBI or Credible History of TBI and Educational Impact

19. TNT Website www.cokidswithbraininjury.com

21. CDE recommends “Gold Standard” Medical Documentation It is still best practice to establish traumatic brain injury through medical documentation via hospital records and/or from a doctor or clinician who has knowledge of the Center for Disease Control (CDC) requirements for TBI. Severe and moderate TBI– usually (not always) lend themselves to medical documentation.

22. Credible History 1. “The gold standard for determining prior TBI is self/parent-report as determined by a structured or in-depth interview” (Corrigan & Bogner, 2007) Comprehensive Health History Interview (Health history must be an interview; it cannot be a form mailed to the parent/caregiver)

23. Credible history of TBI requires a skilled interviewer to know how to ask certain questions, to ask pointed questions multiple times and in a variety of ways, to establish the details of the TBI(s). al (Body)

24. Questions should include:  Where  When  How  Medical intervention(s) sought at the time, later, through the recovery  Are answers medically plausible?  Be aware of assumptions – for example, the report of a “scalp laceration” or “head injury” does not automatically define a “brain injury”

25. Credible History continued… 2. There needs to be a reported incident(s) as well as on-going symptoms/behaviors that persist beyond the incident (Corrigan & Bogner, 2007).  During the health interview, details of the incident should be clear and consistent. The description of the injury should not vary widely from report to report, from reporter to reporter (if there are multiple reporters of the same incident).  If there are multiple injuries, specifics about each injury should be well-detailed and consistent.

26. Interviewer must know acute and latent symptoms of TBI Acute symptoms: Physical Headache Dizziness Blurred vision Nausea/vomit Poor balance Sensitivity to light/sound Seeing “stars” Vacant/glassy look Cognitive Feeling in a “fog” Feeling “slowed down” Slowed speech Easily confused Difficulty remembering/concentrating Distracted Emotional Personality change Emotionally labile Irritable Sad Anxious Apathetic Maintenance Fatigue Drowsiness Excess sleep Sleeping less than usual Unable to initiate or maintain sleep

27. Latent symptoms that emerge or develop later, symptoms that “morph”. Assess pre versus post-injury learning, behaviors, social skills, personality.

28. Credible History continued… 3. Finally, a screen or in-depth interview is not enough to “diagnose” TBI. These tools are simply to “screen” for potential TBI. If a screen or in-depth interview suggest there has been a credible history of TBI, a thorough assessment/evaluation is suggested (Corrigan & Bogner, 2007). Confirm credible history with: CSU Brain Checklist Screen

29. 3 Primary Sections 1. Injury or Illness 2. Behaviors that Affect Learning 3. Symptoms

31. Educational Impact Medical documentation/credible history simply confirms the presence of the TBI. It does not or cannot automatically establish the “impact” of the TBI. Confirming that an injury has occurred does not shed light upon the affect of the injury on subsequent physical, educational, behavioral, emotional, social outcome. Once medical documentation has been established, CDE requires that school teams continue to proceed through the protocol to establish “educational impact”.

32. Establishing Educational Impact  Functional Assessment/Observation  Social/Developmental History  Focused Assessment (Matrix)

33. Functional Observation  Teacher, parent and student interview  Functional school setting observation Functional Community-Referenced Assessment 1. Interview 2. Observation 3. Summary

34. Formal “Focused” Assessment  Cognitive  Neuropsychological “MATRIX”  Achievement  Speech Language  Occupational Therapy/Physical Therapy  Adaptive  Emotional/Behavioral/Executive Functions

35. Eligibility Once medical documentation and Educational Impact is established OR Once Credible history is determined and Educational Impact is established…

36. The team can staff the student on an IEP for ‘specialized programming” Continue to assess need – set goals and objectives Apply appropriate interventions Monitor progress Adjust plan – (reassess need, apply new intervention, progress monitor)