Presentation on theme: "Supporting Students with Brain Injury In the Classroom"— Presentation transcript:
1 Supporting Students with Brain Injury In the Classroom INTRODUCTIONPOINT OUT SIGN IN SHEET AND EVALUATION FORMSEXPLAIN THAT PROJECT BRAIN IS FUNDED BY A FEDERAL GRANT FROM THE MATERNAL AND CHILD HEALTH BUREAU (MCHB) OF THE HEALTH RESOURCES AND SERVICES ADMINISTRATIONTHIS 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 PROGRAM5 minutes
2 OBJECTIVESReview federal and state definitions of traumatic brain injury (TBI)Learn about the discrepancy between:Incidence rates of TBI amongchildren and youthvs.Number of students counted in the TBI category of Special Education
3 OBJECTIVESDevelop an understanding of the causes and effects of TBI on children, their families, and communitiesLearn about normal brain development and the effects of brain injury on a developing brainREAD OVER OBJECTIVES (continued)
4 OBJECTIVESDevelop an awareness of the potential physical, cognitive, behavioral, and psychosocial effects of a TBIAn overview of successful strategies and resources for supporting students with TBI in the classroomREAD 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 InjuryAfter birth processTraumatic Brain Injury(external physical force)THIS SLIDE SHOWSHOW DIFFERENT TYPES OF BRAIN INJURIES ARE CLASSIFIEDTHE TYPE OF INJURY WE WILL FOCUS ON TODAY IS TRAUMATIC BRAIN INJURYNon-traumatic Brain InjuryClosed Head InjuryOpen HeadInjurySavage, 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 INCLUDESFOR 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 IDEATHE 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:cognitionlanguagememoryattentionreasoningabstract thinkingjudgementproblem-solvingsensory, perceptual and motor abilitiespsychosocial behaviorphysical functionsinformation processingspeech*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:StrokeBrain InfectionTumorAnoxiaExposure to Toxic SubstancesTRAINER:*READ THESE COMMENTSIMPORTANT TO NOTE: FOR A STUDENT WHO HAS AN ACQUIRED BRAIN INJURY SUCH AS THESE, BY DEFINITION THEY COULD BE CLASSIFIED WITHIN ANOTHER DISABILITY GROUPSUCH AS: OTHER HEALTH IMPAIRED, PHYSICAL DISABILITY, ETC.
11 that result from either an may have similar effects. Important note:Brain injuriesthat result from either anexternalor internal forcemay 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 TIMEIN 1999, THE CENTER FOR DISEASE CONTROL RELEASED A STUDY ON TRAUMATIC BRAIN INJURY.
14 National prevalence rates of various disabilities 400,000 with Spinal Cord Injuries500,000 with Cerebral Palsy2.3 million with Epilepsy3.0 million with Stroke-related Disabilities4.0 million with Alzheimer’s Disease5.3 million with Traumatic Brain Injury5.4 million with persistent Mental Illness7.2 million with Mental RetardationTRAINER:IT IS SURPRISING TO CONSIDER THE PREVALENCE RATES OF OTHER DISABILITY GROUPS AS COMPARED TO TBIWE 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 injury2004006008001000120014001600TBIRegistryDOEReportThe number of people, ages 3 to 21, who were recorded in the TBI Registry for the school year: 1547TRAINER: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 : 306What is happening with the 1,241 students?
16 Reasons for the discrepancy Not all children who sustain a brain injury experience lasting effectsThe etiology of a student’s disability may be unidentified or misunderstoodThe student may be served under a 504 planThe effects of the brain injury in children can be latent, surfacing as more advanced skills are required of the student at schoolWhen the effects of the injury do surface, they may resemble other disabilities, such as a learning disability or emotional disorder*READ REASONS FOR DISCREPANCYTRAINER COMMENTS:RESEARCH ON INCIDENCES OF TBI SAYS:OF THOSE WHO SUSTAIN MILD TBI’S, 10% HAVE LIFELONG IMPAIRMENTSOF THOSE WHO SUSTAIN MODERATE TBI’S, 70% HAVE LIFELONG IMPAIRMENTSOF THOSE WHO SUSTAIN SEVERE TBI’S, 90% HAVE LIFELONG IMPAIRMENTSAN 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 TBIWHEN 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 AGESOTHER TYPICAL CAUSES INCLUDE: FALLS, BICYCLE ACCIDENTS, VIOLENCE OR ABUSE, AND PEDESTRIAN INJURYCERTAIN CAUSES ARE PREVALENT AMONG CERTAIN AGE GROUPSEXAMPLE: FOR ELDERLY PERSONS, FALLS ARE PREVALENTFOR INFANTS, ABUSE IS MOST PREVALENTMALES, 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.”
21 Geography of the Brain Midline View Surface View Hippocampus TRAINER: CORPUS CALLOSUM: 4INCH BAND OF NERVE FIBERS ALLOWING LEFT & RIGHT HEMIS.S TO COMMUNICATEPERSONS W/SEVERE DAMAGE TO CORPUS CALLOSUM : RIGHT SIDE OF BODY DOESN’T KNOW WHAT LEFT SIDE IS DOINGMAY BE OPERATED ON IN CASES OF SEVERE SEIZURE DISORDERSLIMBIC SYSTEMPLAYS A ROLE IN EMOTIONAL ACTIVITYMEDIATES INTERNAL STATES SUCH AS THIRST, HUNGER, FEAR, RAGE, PLEASURE, ETC.REGULATES MEMORY AND LEARNINGMODULATES DRIVE OR MOTIVATIONCONNECTED 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 DAMAGEHippocampus
22 can be especially devastating, TBI in childrencan 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 MaturationP-O parietal/ occipitalC central(limbic & brainstem)T temporalF-T frontal/ temporal% of maturation increments6P-OCTF-T4TRAINER:#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 LIFELEARNING 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 DEVASTATINGCHILDREN 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-OCF-TT CF-T2P-Oage increments
25 Two types of TBI CLOSED-HEAD INJURY OPEN-HEAD INJURY (penetrating) Example:Skull fracture that penetrates the brainGunshot woundCLOSED-HEAD INJURYExample:Coup-ContraCoupDiffuse axonal injuryTRAINER:WE WILL LOOK AT TWO TYPES OF TRAUMATIC BRAIN INJURIES THAT CAN OCCUR FROM AN EXTERNAL PHYSICAL FORCEOPEN-HEAD INJURIES INCLUDE THOSE WHERE THE SKULL HAS BEEN PENETRATEDINJURIES THAT INVOLVE PENETRATION OF THE SKULL AND BRAIN CAN BE MORE LOCALIZEDCLOSED 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 PRIMARYTHE INJURY IS MORE OR LESS COMPLETE AT THE TIME OF IMPACTSKULL FRACTURECONTUSION/ BRUISING OF THE BRAINHEMATOMA/BLOOD CLOT ON THE BRAINDIFFUSE AXONAL INJURYSECONDARYTHE INJURY EVOLVES OVER A PERIOD OF HOURS TO DAYS AFTER THE INITIAL TRAUMABRAIN SWELLING/EDEMAINCREASED INTRACRANIAL PRESSUREINTRACRANIAL INFECTIONEPILEPSYHYPOXEMIA (LOW BLOOD OXYGEN)HIGH OR LOW BLOOD PRESSUREANOXIA/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 INJURIESDiffuse Axonal InjuryRotational forces onthe brain cause thestretching and snappingof axonsTRAINER: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 INJURYNEURONS/BRAIN CELLS ARE NOT ABLE TO COMMUNICATE WITH EACH OTHER AS EFFICIENTLY AS BEFORETREATMENT 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 HemmorhageEpidural HematomaSubduralHematomaTRAINER: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 INJURIESEnlarged VentriclesBrain with EdemaEdema (swollen brain tissue)TRAINER:EDEMA, OR THE SWELLING OF BRAIN TISSUE, HAPPENS AS A RESULT OF A PRIMARY INJURYHYDROCEPHALUS: WHEN THE FLOW OF CEREBROSPINAL FLUID IS BLOCKED, THIS CAUSES THE OPEN SPACES, OR VENTRICLES, TO BECOME ENLARGED.CAN CAUSE INCREASED INTRACRANIAL PRESSUREOFTEN REFERRED TO AS “FLUID ON THE BRAIN”Brain with Hydrocephalus
32 TBI ENORMOUS VARIABILITY AGEAT THE TIMEOF INJURYTYPE OFINJURY&SEVERITYAVAILABLEKNOWLEDGE,RESOURCES,&SUPPORTTRAINER:THERE IS NO “TYPICAL” BRAIN INJURY OR TYPICAL STUDENT WITH TBITHE CHALLENGES A STUDENT MAY FACE FOLLOWING TBI ARE NOT SO DIFFERENT FROM THOSE EXPERIENCED BY OTHER DISABILITY GROUPSA PRIMARY DIFFERENCE IS THAT THESE CHALLENGES OR IMPAIRMENTS WERE ACQUIRED VERSUS CONGENITAL.RECOVERYPRE-EXISTINGDISABILITIESOR BEHAVIORS
33 TBI Can Affect… Physical skills Cognitive skills Behavioral / Psychosocial SkillsTRAINER:WE WILL DISCUSS THE WAYS IN WHICH A BRAIN INJURY CAN AFFECT A STUDENT IN THE FOLLOWING WAYS:PHYSICALLY;COGNITIVELYBEHAVIORALLY / SOCIALLYTHE CHILD WHO SUSTAINS A BRAIN INJURY MAY EXPERIENCE IMPAIRMENTS IN ONE OR MORE OF THESE AREAS
34 Possible Physical Effects Impairment of:SpeechVisionHearingDifficulty with:BalanceSpasticityParalysisParesisTRAINER COMMENTS:UNILATERAL HEARING LOSS TYPICALLY OCCURS WHEN A CHILD SUSTAINS A SKULL FRACTUREAS 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 MUSCLESAPPROXIMATELY 5% OF CHILDREN WHO HAVE SUSTAINED A SEVERE TBI WILL DEVELOP A SEIZURE DISORDERLess obvious physical effects:headachesfatigue
35 Possible Cognitive Effects Impairments in:attention or concentrationability to initiate, organize, or complete tasksability to sequence, generalize, or planflexibility of thinking, reasoning, or problem-solvingabstract thinkingjudgment or perceptionlong-term or short-term memoryconfabulationability to acquire or retain new informationability to process information- slowed speedTRAINER:THIS LIST INCLUDES THE MOST COMMON, BUT NOT ALL, OF THE COGNITIVE CHALLENGES A STUDENT WITH TBI MAY FACETHESE TYPES OF CHALLENGES ARE TYPICAL WITH INJURIES TO THE FRONTAL LOBE AND LIMBIC SYSTEM
36 Possible Behavioral / Social Effects VERBAL / PHYSICAL AGGRESSIONMOOD SWINGSOREMOTIONAL LABILITYIMPAIREDABILITY TO COPEWITHOVER-STIMULATINGENVIRONMENTSPRE-EXISTING MALADAPTIVEBEHAVIORSOR DISABILITIES INTENSIFIEDIMPULSIVITYIMPAIREDABILITY TO PERCEIVE,EVALUATE,OR USESOCIAL CUES/CONTEXTLOW FRUSTRATION TOLERANCELACK OF AWARENESS OF DEFICITS
37 Supporting Students with TBI at School What the Future HoldsSupporting StudentswithTBIat 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 unpredictableStudent may experience reduced stamina and fatigue for some time after the injuryStudent may process information slower after their injuryImpairment 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 FACESchool to School
40 Consider Ongoing Supports... Establishing effective means of communication between school and homeEstablishing primary contacts for the family both at the school level and at the administrative levelDeveloping peer supports for the studentUpdating evaluations as needed
41 Initial School Re-entry EligibilityA physician’s letter should be obtained documenting the Traumatic Brain InjuryInterview the family of the injured student to obtain pre-injury academic and social history, as well as changes they have seen since the injuryA 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: MedicalDocumentation of the injury, site(s) of injury or lesion, duration of coma, services received post-injury, medications, contact information for doctorsMedical ReleaseSpecifies the student’s ability to participate in physical activities at schoolRehabilitation RecordsInitial evaluations & discharge summaries from all therapies administeredSpecific recommendations for adaptations to the school environmentTherapy recommendationsInstructions related to use of adaptive equipment
43 Information to obtain: PsychosocialHistory of student pre-injury from an educational and social perspectiveRelevant information on siblings, including ideas about how to address their reaction to the injuryEducate support team about possible suicidal ideation post-injury (especially with adolescents)EducationalContact person for familyInitial and subsequent IEP’sRecords from support personnelAttendance recordsRecords from other schools attended, if applicableSpecific 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 ModificationsAttend school part-time initiallySchedule several in-school breaksProvide “study halls” with resource teacherSchedule most difficult subjects early in the dayKeep number of classroom changes to a minimum, or assign a “buddy” to assist the student in changing classesBegin with one-on-one/small group instruction, adding additional students with improvement of concentrationConsider ESY, homebound services or tutoring for summer monthsWill 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 StrategiesClassroom rules & expectations should be well structured and explicitly taughtInstruction should contain repetition & feedbackAvoid multi-step instructions if possibleSupplement verbal instructions with writing / modelingProvide amply time to process, complete tasks, and respondAssist the student in keeping his/her materials and schedule organizedTeach compensatory strategies for test-taking, note-taking, reading materials, etc.Try external aids such as lists, diaries, computers, calculatorsVideotape the student’s progress in class to provide feedback and show progressFrom: 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 functioningInclude individuals in IEP meetings who can help to identify the adverse effects of the brain injury on the student’s performanceTO ADDRESS:Student’s current and past strengths/ areas of needMedical needsGeneral modifications / accommodationsInvolvement of student in general curriculumExtended school year optionsREFER TO HANDOUT BY URBANCZYK AND FRANKLIN
49 Developing IEP Goals Focus on 2 or 3 priority issues Identify metacognitive & organizational strategiesWrite measurable goals that incorporate the strategiesInclude specific information about how the strategy should be taught and implemented across settingsWrite short-term goals that are truly short-termTRAINER: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 ENVIRONMENTRE: SHORT TERM GOALSIT IS NOT UNCOMMON FOR STUDENTS WITH TBI TO NEED SEVERAL IEP REVISIONS WITHIN A YEAR- ESPECIALLY WHEN RECOVERY IS ONGOINGSTUDENTS 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 Coalition5641 Merchants Center Blvd.Suite A102Knoxville, TNOffice: / x 12Fax:Cell:Paula Denslow, Coordinator &Project BRAIN Resource SpecialistTennessee Disability Coalition480 Craighead Street, Suite 200Nashville, TNOffice: x 56Fax:Cell:TTY: