ec 304 589 author carter, susanne title · 2014. 7. 18. · (skull fracture, contusions, bullet...

$: EC 304 589 AUTHOR Carter, Susanne TITLE · 2014. 7. 18. · (skull fracture, contusions, bullet wound, cerebral vascular accident, etc.), suffered a slow change in cognitive abilities$
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ED 391 340 EC 304 589

AUTHOR Carter, SusanneTITLE Traumatic Brain Injury: A Guidebook for Idaho

Educators.INSTITUTION Western Regional Resource Center, Eugene, OR.SPONS AGENCY Office of Special Education and Rehabilitative

Services (ED), Washington, DC.PUB DATE Jul 95CONTRACT H028A30003NOTE 209p.PUB TYPE Guides Non-Classroom Use (055)

EDRS PRICE MFOI/PC09 Plus Postage.DESCRIPTORS Check Lists; Classroom Environment; Consciousness

Raising; Definitions; Diagnostic Teaching;Educational Legislation; *Educational Methods;Elementary Secondary Education; Federal Legis!ation;*Head Injuries; *Intervention; *NeurologicalImpairments; Peer Acceptance; *Reentry Students;Rehabilitation; Student Characteristics; *Symptoms(Individual Disorders); Transitional Programs

IDENTIFIERS Idaho

ABSTRACTThis guide is an introduction to head injury and to

educational resources in the field. An introductory section describestraumatic brain injury (TBI) as a federally recognized disabilitycategory and provides its federal and Idaho definitions. Thefollowing section introduces the unique characteristics of studentswith brain injuries. A section on "re-entry" discusses the student'stransition from a rehabilitation setting to the home school and thecomprehensive planning efforts needed to coordinate this process. Asection on interventions describes specific strategies for addressingcognitive and behavioral needs of students with TBI and givessuggestions for creating a physical, social, and psychologicalenvironment conducive to optimal learning for these students. Thefinal sections consider ideas to promote awareness and understandingof TBI among students and staff members and describe Internetresources. Appended are reprints that include the following articlesor measures: "Planning for Traumatic Brain Injury (TBI): A NewChallenge for Special Education" (Ellie Kazuk and Denise Stewart);"General Information about Traumatic Brain Injury" (also in Spanish);"Traumatic Brain Injury: What the Teacher Needs To Know" (B. Pieper,Ed.); "Physical Facilities and Planning Checklist for Schools";"Checklist for School Reentry"; "Welcome to a New World: APresentation by the Traumatic Brain Injury Re-Entry Team, TacomaPublic Schools"; "Neuropsychological Assessment Test Battery";"Traumatic Brain Injury Checklist"; "Related Services for School-AgedChildren with Disabilities"; "Health Care Plan"; "Modifying theElementary Classroom"; "Modifying the Secondary Classroom"; "Servingthe Student with TBI"; "Observable Behaviors and Strategies";"C,Impensatory Strategies"; and "Developing an Educational Program."(Contains 63 references.) (DB)

TRAUMATIC BRAIN INJURY

A GUIDEBOOK FOR IDAHOEDUCATORS

Author: Susanne Carter

Layout & Design: Myrrh SagradaEditor: Lynne Rossi

July, 1995

Western Regional Resource CenterUniversity of Oregon

U.S. DEPARIMENT OF EDUCATIONOtfrce of Educational Research and Improvement

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

Xtis document has been reproduced asreceived from tne person or organizationorigmatmg rtMinor changes nave been made to improvereproduct,on Quaid},

Forms of view or opinions stated rn this document do not necessanty represent plirC$alOE RI positn or pokcy

-PERMISSION TO REPRODUCE THISMATERIAL HAS BEEN GRANTED BY

TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)

This document was developed by the Western Regional Resource Center, Eugene, Oregon, pursuant toCooperative Agreement Number H028-A30003 with the U.S. Department of Education, Office of SpecialEducation and Rehabilitative Services. However, the opinions expressed herein do not necessarily reflectthe position or policy of the U.S. Department of Education. Nor does mention of tradenames, commercialproducts, or organizations imply endorsement by the U.S. Government. [TAA 110DISCAT]

0.0

BEST COPY AVAILABLE

Acknowledgments

We greatly appreciate the efforts of educators in Idaho who reviewed thisdocument for us during its development:

Nolene Weaver, Director, Idaho SEALynette Ferguson, Regular Education Teacher, Wallace School District

Rosanna Robbins, Psychologist, Post Falls School DistrictJames McGill, Special Education Administrator, Melba School District

Leslie Fantelli, Secondary Resource Room Teacher, Idaho Falls School DistrictMark Graham, School Psychologist, Shelley Special Education, Joint School District No. 60

Traumatic Brain injury

3

TABLE OF CONTENTS

Introduction

a) The new disability category 1b) Policy development 2c) New challenges for schools 3d) Scope of this document 5

The Student With Traumatic Brain Injury

a) Characteristics 7b) Identification 12

Re-entry

a) Rehabilitation 15b) Re-entry into school 16c) Evaluation 21d) Individualized Education Plan 23e) Health Care Plan 28f) Placement 30

Interventionsa) Cognitive needs 38b) Behavioral needs 41

Edmation and Awarenessa) State efforts 47b) District efforts 50

Internet Resources 53

References/Recommended Resources 57

Traumatic Brain injury4

iii

TABLE OF CONTENTS, continued

Appendix A 63

Appendix B 71

Appendix C 83

Appendix D 165

5

iv Traumatic 13rain Injuty

INTRODUCTION

The New Disabaty Category

Traumatic Brain Injury and autism were added as two new separate

disabilities to Public Law 101-476, the Individuals with Disabilities Education Act

(IDEA), when President George Bush signed the new law in 1990. The creation of

a separate category for students with Traumatic Brain Injury represents a

significant step toward increased awareness of the educational needs of these

students. Expanding the federal educational mandate to include traumatic brain

injury carries the anticipation of more appropriate educational assessment,

planning, and services for students with head injury. This new category also

presents educators with new challenges in identification, evaluation and

providing appropriate programs to meet the mandates of IDEA.

Most states have adopted the federal Traumatic Brain Injury definition

(Katsiyannis & Conderman, 1994):

"Traumatic brain injury" means an acquired injury to the brain causedby an external physical force, resulting in total or partial functionaldisability or psychosocial impairment, or both, that adversely affects achild's educational. performance. The term applies to open or closedhead injuries resulting in impairments in one or more areas, such ascognition; language; memory; attention; reasoning; abstract thinking;judgment; problem-solving; sensory, perceptual and motor abilities;psychosocial behavior; physical functions; information processing; andspeech. The term does not apply to brain injuries that are congenital ordegenerative, or brain injuries induced by birth trauma. §300.7(b)(12)

However, other states, including Idaho, have developed their own. The

Idaho definition of Traumatic Brain Injury reads:

6I

Traumatic brain injury refers to an injury to the brain caused by anexternal physical force and resulting in a total or partial functioningdisability or psychosocial impairment, or both, that adversely affectseducational performance. The term applies to open or closed headinjuries resulting in impairments in one or more areas, such ascognition, language, memory, attention, reasoning, abstract thinking,judgment, problem-solving, sensory perception and motor abilities,psychosocial behavior, physical functions, information processing, andspeech. The term does not apply to congenital or degenerative braininjuries or to brain injuries induced by birth trauma.

(Idaho, 1993, p. II1-27)

In the state of Idaho, for a student with Traumatic Brain Injury to be

eligible for special education and/or related services, the student must:

a. Have suffered a sudden onset of impairment due to direct brain trauma(skull fracture, contusions, bullet wound, cerebral vascular accident, etc.),suffered a slow change in cognitive abilities due to a change in medicalstatus (tumor, encephalitis, etc.), or suffered an anoxic insult to the brain(cardiac arrest, drowning, etc.) that adversely affects educationalperformance; and

b. Have documentation as having a traumatic brain injury by a licensedphysician, including diagnosis and recommendations; and

c. Be assessed as to cognitive functioning, educational strengths and needs,adaptive behavior skills, speech and language abilities, and motor skills;and

d. Require special facilities, equipment, or methods to make his or hereducational program effective; and

e. Be certified by a CST as qualifying for and needing special educafionservices. (Idaho, 1993, p. III-27)

Policy Development

The addition of Traumatic Brain Injury as a new disability category,

coupled with a continuing increase in students who have complex health care

needs being served by our schools, has challenged state and local education

agencies to establish model programs and policies to best serve the needs of these

2 Traumatic Brain injwy

students. Although students with complex health care needs have the samebasic needs of all students, they have additional health care needs that must beremembered when developing policies:

the need to be provided with a free appropriate educational program

the need to be provided with an education in the least restrictiveenvironment

the need to have a health care plan as part of their educational program

the need to be treated as a child first, then as a student, and not as apatient

the need to interact with other children with and without similarhealth care needs (Lehr, Educating, 1990)

State and local policies regarding the needs of students with complex

health care needs should treat the individual as a student with special needs

rather than as a medical patient (Lehr & McDaid, 1993). The special procedures

and/or technological supports required by many of these students can be thought

of as alternative methods that facilitate both good health and learning. "The

point is that we must begin with a view that the child is not sick, but utilizes

health care support, sometimes in the form of technology, to maintain health"

(Lehr & McDaid, p. 6).

New Challenges for Schools

Because of advances in medical technology and care, the survival rate of

individuals who experience a traumatic brain injury continues to increase. But

"survival is not without irony, however," Gerring & Carney (1992) note, as many

individuals are left with significant educational, psychosocial, communicative,

and/or health needs. Educators thus face challenges they may not have

encountered before. A student who was once healthy and self-sufficient may re-

enter the public school system as a medically fragile stranger who is unable to

walk, talk, or eat without assistance. Another once familiar student may return

Traumatic Brain injuty 3

8

to school with numerous special learning needs. Still another student with no

obvious physical or cognitive defidt may return to school with a strangelyaltered personality.

As the incidence of traumatic brain injuries continues to increase with

correspondingly higher survival rates, public school systems face a greaterresponsibility to provide a wider range of educational programs both to students

re-entering the school environment and to those who may be temporarily

homebound or hospital bound (Began, 1987; Ylvisaker, 1991). Along with

medical interventions, educational interventions are among the most

influential factors in the recovery of patients with Traumatic Brain Injury. And

schools have the distinction of being "the most appropriate place for children to

gain reassurance that achievement is possible againeven while being

confronted with enormous new difficulties in thinking, remembering, speaking,

reading or concentrating" (Gerring & Carney, 1992, Preface, p. ix).

Because recovery from a traumatic brain injury may take months or evenyears, the student returns to school while his or her recovery is still ongoing.

Therefore, the program and support provided by the school greatly influence

how well the student recovers. Educational programs can offer features that

contribute to recovery such as "a regular schedule, commitment to training, and

systematic building on previous skills" (Mira & Tyler, 1991). The availability of

trained specialists in schools to provide motor, language, and educational

therapies can also enhance recovery. "School work is a central activity for

children, and the routine, structure, and demand for mental activity made upon

students is a critical component of recovery. Support is essential so that there

may be success at-some level . . . . Allowances need to be tempered with

expectations and demands in order to maintain a balance between expecting too

much and not expecting enough" (Rosen & Gerring, 1986).

It is critical that schools assist students with Traumatic Brain Injury by:

1) "evaluating and determining whether they need regular or special classroom

4 Traumatic Brain injury

instruction, 2) helping them attain the greatest possible degree of independence,

3) facilitating the establishment of positive social relationships, and

4) monitoring progress and changes in the student's needs over time and theeffectiveness of the IEP" (Arizona, 1993).

Planning for students with Traumatic Brain Injury, write Kazuk & Stewart

(1993), "may be no different than planning for all students as the world becomes

more complex in general and teachers move from being information givers to

facilitators and managers of resources which meet individual needs" (p. 5).

These authors further state: "When a commitment is made to meet the

individual needs of each student and to draw on every available resource from a

variety of disciplines to meet those needs, then planning for TBI will not be a

question of setting up unique procedures for a unique category of special

education, but the model for meeting the unique educational needs of all

students, regardless of disability" (p. 5). This article has been reprinted on pages67 - 70 of Appendix A.

Scope of This Document

This document is intended as both an introduction for educators and a

guide to educational resources published in this field. It is our hope that the

information included in this document will increase awareness and aid

educators as they prepare to serve students with Tratunatic Brain Injury.

The following section, "The Student With Traumatic Brain Injury,"

introduces the unique characteristics of students with brain injuries that

educators must be sensitive to when planning and implementing an appronriate

educational program. The "Re-entry" section of this document discusses the

student's transition from a rehabilitation setting to the home school and the

comprehensive planning efforts that must take place to coordinate this process.

Evaluation, development of an Individualized Education Plan and Health Care

Plan, and placement decisions are all part of insuring that the recovering student

Traumatic Brain Injury 10 5

makes a smooth re-eniry back into school. "Interventions" describes specific

strategies for addressing cognitive and behavioral needs of students with

Traumatic Brain Injury and gives suggestions for educators to create a physical,

social, and psychological environment that is most conducive to optimallearning for students with Traumatic Brain Injury. Finally, the "Education andAwareness" section considers ideas to promote awareness and understanding ofTraumatic Brain Injury among students and staff members, including

prevention curricula.

Supplemental information for each of these sections has been appended atthe end of the document.

REFERENCES

Arizona Department of Education. (1993). AZ-TAS Themes & Issues: Traumaticbrain injury. Phoenix: Author.

Begali, V. (1987). Head injury in children and adolescents: A resource aridreview for school and allied professionals. Brandon, VT: ClinicalPsychology Publishing.

Idaho Department of Education. (1993). Idaho Special EducationImplementation Manual. Boise: Author.

Lehr, D. H. (1990). Educating students with special health care needs. In E. L.Meyen (Ed.), Exceptional children in today's schools (pp. 107 - 130).Denver: Love Publishing.

Lehr, D. H., & McDaid, P. (1993, February). Opening the door further: Integratingstudents with complex health care needs. Focus on Exceptional Children,pp. 1 - 8.

Ylvisaker, M., Ed. (1985). Head injury rehabilitation: Children and adolescents.San Diego: College-Hill Press.

11 Traumatic Brain Injury

THE STUDENT WITH TRAUMATIC BRAININJURY

Traumatic Brain Injury is the leading killer and cause of disability in

children and young adults, a,:cording to the National Head Injury Foundation.

Every 15 seconds someone in the United States sustains a head injury; every fiveminutes, one of these people dies and another becomes permanently disabled.

A minimum of one of every 550 school-aged children each year will experience a

traumatic brain injury that will result in a long-term disability (Savage &

Wolcott, 1994, p. 9).

Head injury accidents vary in nature with different age groups. The majorhazards for each population are listed in Table 1 below. Twice as many boys as

girls experience traumatic brain injuries, and the greatest number of injuries

occur in middle to late adolescence (Savage & Wolcott, 1994, p. 9). General

characteristics of head injuries sustained during different age periods are

described in Table 2 on page 8 (Mira, Tucker & Tyler, 1992; Oregon, 1991, p. 7).

TABLE 1. Major Hazards for Head Injury to Different Age Groups

INFANTSTODDLERS &

PRESCHOOLERSSCHOOL-AGED

CHILDRENADOLESCENTS &YOUNG ADULTS

accidental droppingintentional abuse

fallingmotor vehicleaccidents,especially if notproperly restrainedby seat belts

recreational andsports activitiesautomobile-bicycleaccidents

motor vehicleaccidentsassaultrecreational andsports activities

12Traumatic I ain Injuly 7

Table 2.General Characteristics of head Injuries as SustainedDuring Different Age Periods

Preschool

Children who are injured during the preschool years, even those with severe injuries, mayappear to recover fully after the injury. They recover motor and speech skills, and oftenteachers and parents expect that they will develop and function normally in subsequentyears. However, these children often develop academic problems when higher order skillsand functions are needed. An IQ may be normal, but the child still has significant academicdifficulties.

Early Elementary School

Early elementary school-age children have developing brains, and injuries producinga comaof 24 hours or more are likely to produce persistent intellectual difficulties.

While they respond well to school resumption, these children are likely ,to have difficultyas they progress through the grades. They are able to store and recall facts fairly well, butobstacles arise as they encounter demands for high level cognitive functioning. Evenintelligence test scores may decline.

Early Adolescence

Head injury in early adolescence presents special problems for children and schools.Although a head injury at this age may not have such profound effects on intelligence as itdoes in younger children, the behavioral and emotional effects may be greater. At this age,students are very concerned about physical appearance and social skills. Head injuryinterferes with the developing sense of self. Loss of confidence and feelings of depression maylead to isolation from peers. Issues related to sexual development and impact of the injury onfuture psychosocial functions become important. Psychological counseling is generally neededfor children in the older elementary and early adolescent years. Such counseling may berequired for 2 to 3 years to help the child deal with the multiple psychosocial effects of thehead injury.

If a child sustaining a TBI had behavioral or emotional impairment prior to the injury it ismore likely that subsequent psychosocial adjustment will be significantly impaired.

Adolescence

Sustaining a TBI at adolescence has a significant effect on academic functioning. High schoolclass work requires complex cognitive and reasoning skills that range from difficult toimpossible for the student with TBI. Another problem may arise because adolescents areplanning their future. The student is looking forward to finishing high school and getting onwith the next step of life, which may mean higher education or a job. The student has beenanticipating leaving high school and gaining independence from family. It is difficult forthe student to accept the need to take time from school to recover from the head injury, or todelay graduation because of a reduced course load or a shortened day. When there aresufficient residual deficits to indicate special services within the school, it is better that thestudent delay high school graduation to use school services that would not be available aftergraduation. This, however, can be a very difficult step for a high school student to consider.


When students with Traumatic Brain Injury are compared to studentswhose disabilities are caused by congenital complications, clear differences are

apparent, as explained by Savage and Wolcott (1994):

The primary difference is the sudden onset of the injury, which often

disrupts nearly all aspects of the student's and his or her family's life.

Although much of the student's life experience, academic achievement, and

personality often survive such an injury, this sudden intrusion into the

individual's life leaves the student significantly altered, possibly for the long

term. In many cases, the student is aware of these changes and some of

their implications. The surviving skills and abilities are, in a sense, both a

blessing and a curse. They serve as the basis for rebuilding the student's life.

At the same time, the sense of "who I used to be" serves as a constant

reminder of the loss that has occurred. In contrast, the student (and parents)

who have "grown up" with impairments that occurred at or before birthhave experienced the limitations of those impairments gradually at eachdevelopmental milestone (p. 9).

Other unique characteristics of Traumatic Brain Injury include the

following:

1) The severity of the injury is not necessarily equal to the severity of the

disability. What appears to be a minor injury involving a very small pai

of the brain can result in a severe disability.

2) A wide range of disabilities can result from a traumatic brain injury.

These can range from mild to severe and affect cognitive, social, and/or

physical functioning. Common deficit areas for students who have

sustained brain injuries include the following:

14

Traumatic Brain Injury 9

Cognitive Social and Behavioral Neuromotor-Physical

Communication and Self-esteem Vision and hearinglanguage Self-control Speed andMemory, especially for Awareness of self and coordination oflearning new others movementinformation Interest and social Stamina andPerception involvement enduranceAttention and Sexuality Balance, strength, andconcentration Appearance and equilibriumJudgment, planning,and decision making

groomingFamily relationships

Motor functionSpeech

Ability to adjust to Age-appropriate Eye-hand coordinationchange (flexibility) behavior Spatial orientation

3) Post-injury recovery is dynamic and unpredictable. Whereas many

individuals experience rapid recovery during the first few months until

they are back to preinjury status, for others primary tissue damage persists

and continues to affect future functioning. Since recovery from a

traumatic brain injury may never be complete, recovery should be

thought of "as a continuum rather than an endpoint" (Mira, Tucker, &

Tyler, 1992, p. 17; Savage & Wolcott, 1994, p. 9 - 10).

15


Other characteristics of students with Traumatic Brain Injuries that areunique to this population compared to students with other disabilities include:

/ a previous successful experience in academic and social settings;

/ a self-concept of being normal prior to the injury;

/ variability and fluctuation in the recovery process resulting inunpredictable and unexpected spurts of progress;

/ more extreme problems with generalizing, integrating, or structuringinformation;

poor judgment and loss of emotional control, which makes the studentappear to be emotionally disturbed at times;

/ cognitive deficits that are present with other disabilities but are unevenin terms of the extent of damage and rate of recovery;

/ combinations of conditions resulting from the injury that are uniqueand do not fall into usual categories of disabilities;

inappropriate behaviors that may be more exaggerated (moreimpulsive, more distractible, more emotional, and more difficulty withmemory, information processing, organization, and flexibility);

se learning styles that require a variety of compensatory and adaptivestrategies;

more extreme discrepancies in ability levels; some high level skillsmay be intact, making it difficult to understand why the student willhave problems performing lower level tasks;

difficulty becoming independent thinkers;

/ more severe problems with cause/effect relationships and problemsolving;

It reliance on pre-injury learning strategies that are no longer effective;

increased vulnerability to head injuries, particularly during the firstyear following the initial injury;

a previously learned base of information which assists rapidrelearning.

(DePompei & Blosser, 1987; Mira, Tucker, &Tyler, 1992; Ylvisaker, 1985)

Traumatic Brain kiln)/ 1

tqFqT (WV AVAILARLF

Additional problems that may be experienced by students with Traumatic

Brain Injury are outlined in the NICHCY Fact Sheet reproduced on pages 75 -78of Appendix B.

This wide range of configurations of cognitive, social, behavioral,

neuromotor, and physical problems that students with Traumatic Brain Injury

may experience requires a highly individualized education program for each

student. However, while each brain injury creates a different profiler there are

several significant characteristics generally associated with brain injuries which

should be considered when developing educational programming for recoveringstudents (Colorado, 1991). These include:

Brain injuries almost always result in slow processingstudents willneed more time to accomplish everything.

The injury will probably affect memory and organizational abilities.St-4dents may have difficulty with short and/or long-term memoryand memory may be intact at one time but gone at another. Inaddition, memory for newly learned material may be more affectedthan memory for previously learned material or for recent events.Students will need compensatory strategies to help them accommodatesuccessfully.

Problems caused by a brain injury may be hidden to casual observers ifthe student looks "normal." Therefore, it may be difficult for others inthe student's environment to understand the need foraccommodations.

The effects of a traumatic brain injury will result in rapid, erraticchanges in behavior. For instance, a student may have appropriateclassroom behavior one day and inappropriate behavior (which may becompletely beyond his or her control) the next day.

Effects of a brain injury are long lasting. Although progress is to beexpected, especially during the first five years, the effects of brain

12 17 Traumatic Brain Injwy

damage do not go away completely, and it is important to providecontinued support, education and training in compensatory strategies.

The student's problems are acquired, not developmental. Therefore,students with TBI will remember how things were before theiraccident. This causes feelings of frustration, sadness, depression, andanger. Ironically, often a brain-injured student may lack the self-awareness to see the need for compensatory strategies.

(Colorado, 1991, pp. 4 - 5)

Identification

For students who have sustained a severe head injury, the ,--liagnosis is

usually clear. If the recommended procedure for re-entering these students is

followed, they will make a smooth transition from a rehabilitative setting to theschool setting with the guidance of a team of professional representatives from

both disciplines. Teachers will be aware of these students' individual needs and

will be prepared to provide an appropriate educational program and classroomenvironment.

But for students who have sustained mild or moderate injuries,

identification may be more difficult. These students may return to school with

or without receiving medical attention and without notification to the school of

the injury. Classroom teachers may be the first to recognize changes in these

students' learning and behavior patterns (Utah, 1992). "Even a minor injury

may result in both short and long-term disruption to behavior, learning, and

development, so it is critical that professionals be sensitive to possible change

and/or disruption in order to identify the specific needs of the student" (Utah,

1992, p. 4). Since the human brain controls so much activity, there are numerous

ways a head injury may effect a student. Teachers should be aware of possible

symptoms or signs (see Teacher Alert on page 81 of Appendix B) and refer

students for appropriate assessment if a traumatic brain injury is suspected.

Traumatic Brain Injuty 13

8

REFERENCES

Arizona Department of Education. (1993). AZ-TAS Themes & Issues: Traumaticbrain injurif. Phoenix: Author.

Cohen, S., Joyce C., Rhodes, K., & Welks, D. (1985). Educational programming forhead injured students. In M. Ylvisaker (Ed.), Head injunj rehabilitation:Children and adolescents (pp. 383 - 411). San Diego: College-Hill Press.

Colorado State Department of Education. (1991). Traumatic Brain Injuries.Guidelines paper. Denver: Special Education Services Unit.

DePompei, R., & Blosser, J. L. (1987). Strategies for helping head injured childrensuccessfully return to school. Language, Speech and Hearing Services inSchools, 18, 292 - 300.

Lehr, E. (1990). Psychological management of Traumatic Brain Injuries inchildren and adolescents. Rockville, MD: Aspen Publishers, Inc.

Mira, M., Tucker, B. F., & Tyler, J. S. (1992). Traumatic brain injury in childrenand adolescents. Austin: PRO-ED.

Mira, M. P., & Tyler, J. W. (1991, January). Students with traumatic brain injury:Making the transition from hospital to school. Focus on ExceptionalChildren, pp. 1 - 12.

Oregon Department oi. Education and Portland Public Schools. (1991). Traumaticbrain injury: An educator's manual. Salem: Oregon Department ofEducation.

Pieper, B. (1991). Traumatic brain injury: What the teacher needs to know. NewYork: New York State Head Injury Association, Inc.

Savage, R. C., & Wolcott, G. (1994). Overview of an acquired brain injury. In R.C. Savage and G. F. Wolcott (Eds.), Educational dimensions of acquiredbrain injury (pp. 3 12). Austin, TX: PRO-ED.

Utah State Office of Education. (1992). Guidelines fur serving students withtraumatic brain injuries. Salt Lake City: Utah Department of Education.


RE-ENTRY

Rehabilitation

Rehabilitation begins while the individtial who has sustained a headinjury is still hospitalized. Early intervention by a hospital rehabilitation team

increases the patient's chances of maximum recovery medically, physically,

cognitively, and psychologically (Oregon, 1991, p. 8). Communication and

coordination between local school districts and the hospital rehabilitation team

can contribute to recovery and a smooth transition back to the student's home

school. This transition is a process that takes place over a period of time rather

than a one-time event.

For the student to successfully return to school, staff members from both

the education and rehabilitation systems need to share and interpret information

about the student (Savage, 1991). A designated school representative who

assumes the role of case manager can facilitate this process by coordinating clinic-

based with school-based services (Tucker & Colson, 1992).

The hospital environment is a sheltered environment in which services

are often brought to the patient. The school environment, by contrast, is less

sheltered, more confusing, and is focused on education rather than

rehabilitation. For some students, the hospital and education systems may

overlap (Tacoma, 1994). Education staff members may visit the student in the

hospital while he or she is still an inpatient to provide educational services.

After returning to school, the student may still receive medical services as an

outpatient.

20


Re-entry into School

The student's transition from the rehabilitation setting to the home schoolrequires comprehensive planning, structure, and consistency (Oregon, 1991). Amultidisciplinary school team, which may include several school staff membersas well as the student's parent(s), needs to work closely with the hospital

rehabilitation team in planning this transition so that continuity inprogramming is maintained and the home school becomes a natural extensionof the rehabilitation process.

Blosser & DePompei (1994) recommend a variation of the Map ActionPlanning System (MAPS) to help the multidisciplinary school team plan anappropriate education program for the returning student. The MAPS approachfocuses the team's planning discussion on seven key questions:

O What is the student's history?

0 What are the family's dreams for the student?

O What are their nightmares?

O Who is the student? (Characterize him or her.)

O What are the student's strengths, gifts, and talents?

O What are his or her needs?

O What is the ideal school plan for the student? (Include discussions ofenvironments, goals, objectives, and activities.) (p. 420)

Planning a student's re-entry needs to be a four-way process that considers

the health care setting, educational setting, rehabilitation setting, and the home

setting (Utah, 1992). Rehabilitation and school-based professions s.hould work

together to ensure that:

Er' the student's strengths and needs are properly understood;

Er' flexibility and creativity are brought to decisions about classification,placement, service mix, and modifications in service over time;


* the student has academic as well as social support;

* significant people in the student's environment are properly orientedand trained; and

* the student's program is effectively monitored and modified as thestudent changes and responds to the academic and social challengesthat lie ahead. (Ylvisaker, Hartwick, & Stevens, 1991)

To effectively coordinate all the people and procedures involved in a re-

entry plan, it is helpful to have a case manager who a) serves as a liaison among

school, family, and rehabilitation professionals; b) assures that all are informed

about the student's progress and needs; c) performs many tasks that assure a

coordinated transition from hospital to school for the student; d) translates

medical information for educators; e) provides information about Traumatic

Brain Injury to family and educators; and f) coordinates school inservice

programs (Mira, Tucker, & Tyler, 1992).

Although their injuries and resulting disabilities may vary considerably,

all brain-injured students re-entering the school environment have several

common needs. These include strurture to provide organization and

reinforcement to the recovering student; flexibility to "strike the best balance"

between academic requirements and necessary accommodations; reduced

demands to match the abilities of the recovering student; supervision to

correspond appropriately with the degree of independent functioning of the

student; and interventions that meet the individual needs of the student

(Gerring & Carney, 1992).

Mira, Tucker, and Tyler (1992) list eight "critical elements" that should be

in place before a student re-enters the school system. These include:

* Provisions for the student's safety* A well-informed staff* Staff and facilities to provide a program of the necessary intensity* An environment that is sufficiently controlled* Provision of special equipment

c)ArlepTraumatic Brain injury 17

* Ability to design and implement a behavioral management program todeal with interfering behavioral deficits

* Knowledge of TBI resources available* Planned provisions for frequent communication among staff (pp. 45 - 46)

Similarly, these authors list six barriers that can impede successful school

reintegration, including:

lo* Lack of staff training

*, Addition of new staff without training** Lack of flexibility in program planning

*, Lack of understanding of the diagnosis of Traumatic Brain Injury** Resistance to outside sources of informationP Unwillingness to begin planning prior to re-entry (pp. 46 - 47)

Staff training should include all school employees who will be involved

in educating the returning student (Mira, Tucker, & Tyler, 1992). This training

should include the following:

* General information about the effects of Traumatic Brain Injury* The differences between students with Traumatic Brain Injury and

other disabilities* Specific information about the returning student's unique medical and

educ ltional needs (The staff may view videotapes of hospital therapysessions to examine the student's recovery progress.)

* Expected long-term problems the student may have* Related services the student may need* Transition techniques for school re-entry* Instructional strategies for students with Traumatic Brain Injury* Scheduling modifications that may be needed (p. 49)

The school re-entry procedure includes five major phases: preplanning,

planning, implementation, evaluation, and reevaluation and adjustment. The

steps involved in each phase are described below.


PHASES OF SCHOOL RE-ENTRY FOR STUDENTSWITH TRAUMATIC BRAIN INJURY

Preplan

Collaborate with medical facilityPrepare school staff with general information on TBIObtain medical and educational historiesObserve student in various contextsAssess student's performanceDetermine what modifications are neededAssess school's capabilities and staff availabilityPrepare staff with specific training on TBIForm networks of support

Plan

Obtain input horn parents, teachers, rehabilitation professionals, specialists,and administrators

Discuss expectations and fearsDiscuss student's strengths, gifts, talents as well as needsBrainstorm a plan

Implement

Take action on the planTrain non-disabled peersObserve student's behaviors, performance, and responsesAssociate these with assessment resultsHelp teachers self-evaluate their own teaching behaviors, strategies, and

proceduresProvide support needed by student with TBI, other students, and staffSet schedule for evaluating progress

Evaluate

Maintain ongoing evaluationObtain data from a variety of sourcesBring in outside resources to assist staff and students where neededMaintain close contact with fa rnily, involving them in all decisionsAdjust plan to accommodate student's changing needsReevaluate and adjust

Reprinted from Traumatic Brain Injury: An Educator's Manual(Oregon Department of Education, 1991, p. 10)

24Traumatic Brain Injury 19

The multidisciplinary school team needs to consider a number of factorswhich may affect the student's readjustment to school. These include:

Medical Conditions

Fatigue levelMedication information andproceduresEmergency informationBowel and bladder issuesDietSkin careOther

Academic Issues

Test data, schedule for frequentneuropsychological testing (every6 months recommended)Inservice for staff on TBI learningstylesReview of educational program inrehabilitation settingFlexible placement that can readilybe changedPlan to decrease academic loadwithout sacrificing learningOther

Social and Emotional Concerns

Counseling: individual, family,sexual, support groupsPlan to modify behavior verbaland nonverbal cuesEducation of peers and staffBuddy systemPeer activities planningVideotape to see themselves asothers doManagement of impulsive,unpredictable, aggressive behaviorOther

Organizational Details

Time schedule for transition, teammeeting scheduleIndividual Education Plan (IEP)Initial attendance long-termattendance goals, collapsedscheduleLength of school dayTransportation to and from schoolMovement within school buildingPlacement in area of the classroomChoice of "check-in" person(coordinator of daily activities)Safety concernsBathroom needsLunch, recess, and assembly plansCompensatory tools, organizationsystems, student helpers, studyguides, calculators, computers,adaptive equipmentPersonal aideOther

(Oregon, 1991, p. 9)

25

20^IIIIMIIM1111.4

Traumatic i3rain Injury

The skills necessary to form and maintain adult social relationships are

developed during adolescence (Papalia & Olds, 1981). Friendships are extremely

important to adolescents striving for independence and status. Adolescents

judge their quality of life and success in terms of social acceptance. Because of

importance of maintaining social relationships during this time in their lives,

Abbot & Wilkinson (1993) recommend that peer inservice and ongoing peer

support be a major component of school reintegration programs for adolescent

students with Traumatic Brain Injury. They write:

With all survivors, but especially adolescents, the focus of rehabilitationmust go beyond its traditional boundaries and address the issues ofnormal development in social relationships. Effective rehabilitation foradolescents must include programming around social relationshipsthrough the continuum of recovery: inpatient programs, outpatienttreatment, and return to school. Specific interventions must be designedfor each therapy to avoid the potential of social isolation as an adolescentor as an adult. (p. 242)

A Physical Facilities and Planning Checklist for Schools and a Checklist for

School Reentry (Mira, Tucker, & Tyler, 1992) have been reprinted on pages 87 -89; 93 -95 of Appendix C.

A description of the re-entry process used by Tacoma Public Schools in

Tacoma, WAincluding a description of the re-entry team, flowchart of

responsibilities, description of the phases of re-entry, and various re-entryformshas been reprinted on pages 99 -116 of Appendix C.

Evaluation

Suc essful reintegration of recovPring students into the school

environment requires a comprehensive assessment that evaluates a wide range

of behaviors and cognitive functions and carefully analyzes students' strengths

and weaknesses.

26


Assessments should use techniques and procedures in compliance with

federal and state regulations, be multidisciplinary in nature, incorporate a

neuropsychological orientation, and include both formal and informal

evaluations. The assessment should be comprehensive enough to screen forpossible deficits in all of the functional areas cited by federal regulations:

cognition; language; memory; attention; reasoning; abstract thinking; judgment;problem-solving; sensory, perceptual and motor abilities; psychosocial behavior;

physical functions; information processing; and speech.

A comprehensive list of "Issues for Consideration in Evaluation of Needsfor Students with Traumatic Brain Injury" (Virginia Department of Education,

1992, p. 19), has been reproduced on page 119 of Appendix C. The list includes

evaluation issues in 12 areas of functioning.

Students recovering from Traumatic Brain Injury require a customized

battery of appropriate assessments that identify specific strengths and weaknesses

unique to students with brain injuries. Although experts have identified

evaluative domains relevant to students with brain injuries, no assessment

instruments have been specifically validated for these students, so results mustbe interpreted with caution (Carter, 1993).

A list of tests commonly used as a part of the Neuropsychological

Assessment Test Battery (Virginia Department of Education, 1992, pp. 91 - 94) has

been reproduced on page 123 - 126 of Appendix C.

Informal evaluations, including interviews with family members and

observations in natural settings, can help create a more detailed picture of the

brain-injured student as an individual (Carter, 1993). The "Traumatic Brain

Injury Checklist" (Virginia Department of Education, 1992, pp. 60 - 65) may be

used as an informal evaluation instrument to assess a student's current

functioning in 13 areas. This checklist has been reprinted on pages 129 - 134 of

Appendix C.


A comprehensive assessment made close to the time of re-entry ensures

that recommendations for educational placement and programming accurately

reflect students' individual needs and potential for recovery. An assessment

made before the student re-enters the school environment benefits both the

student and teachers. The student returns to a program that is appropriate for

his or her individual learning needs. Similarly, teachers are aware of both the

student's strengths and potential areas of learning difficulties and can design a

program to accommodate those needs (Carter, 1993).

Subsequent assessments conducted on a periodic and ongoing basis further

monitor recovery and effectiveness of interventions as the student progresses

(Carter, 1993). Should evaluations indicate that the student is eligible for special

education, an Individualized Education Program (IEP) and, when appropriate, a

heaith care plan tailored to the individual needs and strengths of the recovering

student will be developed. If evaluations show the student is not eligible for

special education and related services under the Individuals with Disabilities

Education Act (IDEA), the student may qualify as disabled under Section 504 al,

be entitled to all of the protection and services provided under Section 504.

Individuation PlanThe content of the returning student's Individualized Education Plan (IEP)

should be developed by the student's multidisciplinary team, including the

student's parent(s), and should "reflect the outcome of a flexible, domain-based

assessment sensitive to neuropsychologic issues" (Oregon, 1991). The individual

program developed for each student should include 1) a continuum of regular

education services, 2) evaluation and determination of services required,

3) identification of appropriate education environments and services within the

public eduL .t-ion setting, 4) maintenance of suitable levels of performance

throughout the academic program, 5) development of the greatest possible

degree of independence, and 6) establishment and maintenance of positive social

Traumatic Brain Injury 232,8

relationships (Utah, 1992). The plan should reflect both the student's strengths

and weaknesses.

When developing the student's IEP, the multidisciplinary team should

address the following general questions:

1. What are the current levels of the student's cognitive functioning?2. How has the brain injury affected the student's language, motor skills, self-

concept, social development, and academic achievement?

3. Given the student's current needs, what is the most appropriate servicedelivery system?

4. What are realistic goals for the student?

5. How can the school, family, and community provide sound support foroptimum recovery?

6. What residual physical or medical problems are likely to interfere withfunctioning in the educational setting?

7. How can residual physical problems be addressed?(Mira, Tucker, & Tyler, 1992, p. 53)

The IEP must, according to federal law, identify the current level of

educational performance in all areas affected by the student's disability and must

reflect annual goals and short-term objectives. "The goals of the IEP need to be

flexible, open-ended, monitored, and reviewed to ensure appropriate reentry and

development" (Oregon, 1991, p. 27). The IEP must also state the specific service

provisions, the specific special education and related services to be provided, the

projected amount of each service instruction and duration of services, the

evaluation procedures to measure/monitor progress, the student's participation

in regular classroom programs, and the schedule to monitor progress (Oregon,

1991).

Individualized Education Plans "should be built upon an appreciation for

the multidimensional nature of TBI and a clear delineation of the specific

cognitive, behavioral, physical, psychiatric, and psychological needs of the

individual student" (Bureau of Education, 1993, p. 31). In addition to academic

24 29 Traumatic Brain Injury

and behavioral needs, students with Traumatic Brain Injury may need to include

life skills goals in the IEP to help them relearn how to independently perform

activities of daily living such as dressing, eating, and toileting.

When developing the IEP, several other considerations need to be determinedand, if necessary, modified to assure a successful re-entry of the student. Theseinclude:

CI The physical layout of the school and physical organization of theclassroom;

O Provisions for the student's safety;

O A well-informed staff and adequate facilities to provide appropriateprogramming;

O Provisions for frequent communication among staff members;

O The ability to design and implement an appropriate behaviormanagement program;

O The student's schedule, which should consider fatigue and medicationissues as well as content and timing of course load;

O An aide or peer buddy to provide the student with assistance;

O Adaptive equipment which may aid the student to become moreautonomous and successful;

O Related services identified and integrated into the student'sindividualized program. (Bureau of Education, 1993; Oregon, 1991)

For secondary students, the IEP should include goals for transition from

public education into post-secondary educational opportunities and work

experiences. The rehabilitation continuum for secondary students with

Traumatic Brain Injury should include vocational assessment, counseling, job

training, and career development planning (Bureau of Education, 1993, p. 155).

The recovery path of individuals who have sustained traumatic brain

injuries is rarely smooth and continual; rather, it is often erratic and

unpredictable. Students with traumatic brain injuries often experience rapid

recovery spurts, sudden plateaus, and phases where information once learned

Traumatic brain liutily

appears to have been forgotten. Recovery is thus a process, not an event.

Therefore, IEP reviews may need to take place more often than once a year.

"The goal always should be to assist the student with TBI to progressively movetoward a less restrictive environment as the student continues to improve"(Oregon, 1991, pp. 27 - 28). The Utah Guidelines for Serving Students with

Traumatic Brain Injuries (1992) recommends that initial IEPs for returning

students be written on a short term basis (4 - 6 weeks) and that the student be re-

evaluated frequently during the first year of recovery.

Related services such as medical services, school health services,

communication therapy, occupational therapy, physical therapy, and assistive

technology devices such as calculators, tape recorders, positioning equipment,

augmentative communication devices, and computers may be needed by

students who are recovering from traumatic brain injuries and should be

specified in the IEP (Oregon, 1991). A discussion of related services published as

a special issue of the NICHCY News Digest (1991) has been reprinted on pages

137 - 160 of Appendix C.

Virginia's Guidelines for Educational Services for Students with

Traumatic Brain Injury (1992) recommends the guidelines below when

developing Individualized Education Programs for students with Traumatic

Brain Injury.

Specific goals and objectives need to be directly related to the student'sassessed needs in the IEP. The IEP may include:

1) A statement of the student's ability to:hear, see, and feel;manipulate objects, draw and write appropriately;maintain balance and perform hand-eye coordination activities;repeat information immediately, retain information, sustainconcentration, and endure the test session; andefficiently process information of a verbal or nonverbal nature.

26 31 Traumatic Brain Injury

(continued...)

2) A statement of the student's ability to:provide appropriate expression based on articulation, syntax,phonology, pragmetaic and semantic language;understand time concepts and sequential temporal information; andunderstand visual spatial relationships and metrically integratematerial.

3) A statement of the student's present level of intellectual and educationalperformance. This statement includes intrascale and interscale test scatter.Also included is a statement of the student's applied and abstractreasoning skills, learned vs. novel information, and verbal/visual motoroutput skills vs. performance on tasks minimizing these demands.

4) A recommended practice for the development of short-term goals andinstructional objectives is frequent reviews during the first year post-injury (1-, 3-, 6- and 12-month abbreviated re-evaluations), and annualreviews thereafter.

5) Specific special education and related services for all students as needed,to include:

specific special education service schedule (i.e., type of delivery modeland amount of special education services needed);the position of the person responsible for delivery of services;classroom modifications/accommodations for students with deficitprocessing or output;date the IEP was developed, initiation date, and duration of services;andstatement of the student's (a) participation in Family Life Educationcurriculum, literacy testing, or standardized testing, and (b) need forspecial testing accommodation in situations.

6) Timely review of IEP.

7) Appropriate observations and procedures for evaluating short- and long-term goals.

8) Placement based on justification as the least restrictive environmentappropriate.

(pp. 26, 28)

A small percentage of brain-injured students remain in a coma-like

condition with multiple disabilities. These students need an IEP tailored to their

Traumatic Brain Injury3

27

unique needs. Sensory stimulation is recommended for these students in order

to prevent deterioration in information processing abilities. Because their

responses to stimulation are usually qualitative instead of quantitative, it is

important to monitor reactions of these students carefully and to keep ongoing

records of observations in order to identify optimal sensory modalities, preferred

times of the day, preferred therapists, and/or favorite activities (Gerring &

Carney, 1992). "In designing a program for these students, professionals must

consider not only what services to provide, but also how to balance the students'

activities to their specific needs in order to enhance optimal response to their

environment" (Gerring & Carney, 1992, p. 135).

Health Care Plan

Similar to the Individualized Education Plan, a health care plan specifies

the ways in which an individual's health care needs should be met (Lehr &

McDaid, 1993). Although the specifics may vary, Palfrey, Haynie, Porter, Bier le,

Cooperman, & Lowcock (1992) recommend that each health care plan include the

following:

a brief health historya specification of special health care needsa statement of the baseline health statusa description of the medications and special dietary needsthe transportation requirements of the child's special equipment needsa description of possible problems and interventions and emergencyplans for both school and transitdocumentation of contact with the local fire department, EMT services,and emergency rooms

In the development of health care plans, particular .-4,:ention should be

paid to emergency procedures relating both to the student's disability as well a:

possible school emergency situations (Lehr & McDaid, 1993).

28 33 Traumatic Brain injury

If the student requires certain health care procedures, these should be

communicated in writing. Additionally, ongoing communication regarding the

effectiveness of the plan is critical, as is the observation, recording, and

communication regarding the student's health status. Information shared

between home and school should be shared on a frequent and systematic basis.

Although professional opinions vary on who among school staff

members should be responsible for certain procedures, there is consensus that

these individuals "should be competent and that training should be provided to

a range of personnel to develop different levels of awareness and skill" (Lehr &

McDaid, 1993).

Palfrey, et al. (1992) recommend two types of staff traininggeneral and

child-specific. General training for all staff members should be designed to

demystify the student's health care needs and to provide sufficient information

for all staff members to be prepared to respond to emergencies. Child-specific

training should focus on staff members who will actually implement health care

responsibilities. Training should be provided by qualified health care

(professionals.

The Medically Fragile Child in the School Setting (American Federation of

Teachers, 1992) includes a section entitled "Guidelines for the Delineation of

Roles and Responsibilities for the Safe Delivery of Specialized Health Care in the

Educational Setting" that specifies the roles and responsibilities of various

personnel involved in the provision of specialized health care, from the

perspective of professional practice. The document also outlines several

strategies for classroom preparation for the care of a student with complex health

care needs, including accessibility, medication, appropriate equipment, classroom

furnishings, emergency procedures, and privacy.

Utah Department of Education's Guidelines for Serving Students with

Special Health Care Needs (1992) includes an appendix of sample forms that can

Traumatic Brain Injuty 29

be used to coordinate the educational programming for students with special

health care needs, including a Health Care Plan, Health Care Plan Log, and

Health Care Plan Checklist. The Health Care Plan form has been reprinted onpage 163 - 164 of Appendix C.

Placement

After the IEP has been developed, the student's placement can be

determined. The placement decision may include one or a combination ofseveral options within this continuum:

A regular classroom program with support services, modifications, andsupplemental aidsA regular classroom program with resource room support for part ofthe school dayA self-contained special education program with regular classroomparticipation for part of the school dayA totally self-contained special education classroomHome or hospital-based tutoringCommunity or state school placement (Oregon, 1991).

As the student returns to the school environment, a gradual

reintroduction may use a combination of placements. For instance, the student

may be placed in the regular classroom with support for half days, combined

with home tutoring several times weekly as an interim step toward full-day

participation at school. Many students will need extended school year

experiences to maintain continued progress.

The small percentage of individuals with Traumatic Brain Injury who

remain in a coma-like condition, with significant physical and cognitive

impairments and other sensory deficits, may be served in their homes, nursing

homes, hospitals, or in schools, depending upon their individual strengths and

needs.

35


REFERENCES

Abbot, N., & Wilkinson, L. (1993). School re-entry of the brain injured student:A case study of peer inservicing. Intervention in School and Clinic, 27 (4),242 - 249.

American Federation of Teachers, AFL-CIO. (1992). The medically fragile child inthe school setting. Port Chester, NY: National Professional Resources, Inc.


Begali, V. (1987). Head injury in children and adolescents: A resource andreview for school and allied professionals. Brandon, VT: ClinicalPsychology Publishing.

Blosser, J. L., & DePompei, R. (1989). The head-injured student returns to school:Recognizing and treating deficits. Topics in Language Disorders, 9 (2),67 - 77.

Bureau of Education for Exceptional Students (1993). What we know abouteducating students with Traumatic Brain Injury. Tallahassee: FloridaDepartment of Education, Division of Public Schools.

Carter, S. (1993). Traumatic brain injury: The role of schools in assessment.Eugene, OR: Western Regional Resource Center.

Gerring, J. & Carney, j. (1992). Head trauma: Strategies for educationalreintegration. San Diego: Singular Publishing Group, Inc.

Lehr, E. (1990). Psychological management of Traumatic Brain Injuries inchild7en and adolescents. Rockville, MD: Aspen Publishers, Inc.

McKerns, D., & Motchkavitz, L. (1993). Therapeutic education for the child withTraumatic Brain Injury: From coma to kindergarten. Tucson: TherapySkill Builders.

Mira, M. P., & Tyler, J. W. (1991, January). Students with Traumatic Brain Injury:Making the transition from hospital to school. Focus on ExceptionalChildren, pp. 1 - 12.

Mira, M. P., Tucker, B. F., & Tyler, J. S. (1992). Traumatic brain injury in childrenand adolescents. Austin: PRO-ED, Inc.

36Traumatic Btain Injury 31

Oregon Department of Education and Portland Public Schools. (1991). Traumaticbrain injury: An educator's manual. Salem: Oregon Department ofEducation.

Palfrey, J. S., Haynie, M., Porter, S., Bier le, T., Cooperman, P., & Lowcock, J. (1992).Project School Care: Integrating children assisted by medical technologyinto educational settings. Journal of School Health, 62 (2), 50 - 54.

Papalia, D. E., & Olds, S. W. (1981). Human development. New York: McGraw-Hill.

Pieper, B. (1991). Traumatic brain injury: What the teacher needs to know. NewYork: New York State Head Injury Association, Inc.

Project School Care. (1989). Children assisted by medical technology ineducational settings: Guidelines for care. Boston: Children's Hospital.

Related services for school-aged children with disabilities. (1991). NICHCY NewsDigest, 1 (2), 1 - 23.

Rosen, C. D., & Gerring, J. P. (1986). Head trauma: Educational reintegration. SanDiego, CA: College-Hill Press.

Savage, R. C. (1991). Identification, classification, and placement issues forstudents with Traumatic Brain Injuries. Journal of Head TraumaRehabilitation, 6 (1), 1 - 9.

Shaw, S. R, & Yingst, C. A. (1992). Assessing children with Traumatic BrainInjuries: Integrating educational and medical issues. Diagnostique,17,255 - 265.

Tacoma Brain Injury Re-entry Team. (1994). Welcome to a new world. Tacoma:Tacoma Public Schools.

Telzrow, C. F. (1987). Management of academic and educational problems inhead injury. Journal of Learning Disabilities 20, 536 - 545.

Tucker, B. F., & Colson, S. E. (1992). Traumatic Brain Injury: An overview ofschool re-entry. Intervention in School and Clinic, 27 (4), 198 - 206.

Utah State Office of Education. (1992). Guidelines for serving students withTraumatic Brain Injuries. Salt Lake City: Utah Department of Education.

3732 Traumatic 13rain injuly

Virginia Department of Education and the Rehabilitation Research and TrainingCenter on Severe Traumatic Brain Injury. (1992). Guidelines forEducational Services for Students with Tral..inatic Brain Injury.Richmond: Author.

Ylvisaker, M., Harwick, P., & Stevens, M. (1991). School reentry following headinjury: Managing the transition from hospital to school. Journal of HeadTrauma Rehabilitation, 6(1), 10 - 22.

3 s

Traumatic Brain quo, 33

INTERVENTIONS

The quality of the educational program offered to students who have

sustained traumatic brain injuries can be critical to their recovery potential. The

New York State Traumatic Brain Injury: Guide for Educators (1994) recommends

that four major educational approaches be considered for students with

Traumatic Brain Injury to address cognitive, behavioral, social, and academic

skills:

10 Teaching new skills and concepts;Teaching a student to use compensatory strategies)Making modifications to the environment to assist a student tocompensate for losses in physical and cognitive abilities; andMaking modifications in teaching approaches. (p. 37)

Telzrow (1987) identifies ten characteristics of a "quality educational

delivery system" for students with Traumatic Brain Injuries. These

characteristics are:

* Maximally controlled environment

Low student-teacher ratio

c> Intensive and repetitive

c> Emphasis on process

* Behavioral programming

* Integrated instructional therapies

* Simulation experiences

*. Cueing, fading, and shadowing

* Readjustment counseling

14> Home-school liaison

(pp. 542 - 544)

Gloeckler & Simpson (1988) describe three aspects of the educational

environment that interact with one another: the physical environment, the

social environment, and the psychological environment. Based upon this

description, Blosser & DePompei (1994) make the following suggestions co

Traumatic 13rain Injury 35

educators trying to create a physical, social, and psychological environment most

conducive to optimal learning for the student with Traumatic Brain Injury:

O Identify aspects of the environment that will restrict a student's learningor pose barriers (physically, auditorially, visually).

O Eliminate or modify barriers and decrease distractions.

O Convey a sense of order by structuring and manipulating the classroom

environment physically and visually to facilitate organization and

identification of learning activities and materials (e. g. post due dates andschedules, using simple directions, codes and numbers).

O Consider the student's location in relation to the teacher's usual teaching

position.

O Permit ease of movement and promote clear traffic patterns by carefully

r:anning seating and furniture arrangements.

O Make teaching resources, materials, and equipment available and

accessible. (p. 424)

Teachers can establish a positive psychological environment in the

classroom by warmly accepting students as individuals, clearly relaying

expectations and goals to students, responding fairly and consistently to student

behaviors, and engaging students in meaningful learning tasks. Teachers who

promote a warm, friendly, sharing, and accepting social environment help

students establish and maintain relationships with their peers (Blosser &

DePompei, 1994, p. 424).

Modifications and adaptations to the learning environment will need to

be made to meet the special needs of the returning student. Those modifications

may include changing the teaching mode, modifying the school setting, adapting

instructional materials, and/or using special strategies to provide additional

support to the student with special needs. Sample checklists for modifying the

elementary and secondary classroom to better meet the needs of students with


Traumatic Brain Injury have been reprinted on pages 169 & 173 of Appendix D

(Oregon, 1991, pp. 29 - 30).

Rhein & Farmer (1994) have developed eight guidelines for interventions,

which they refer to as a "developed mind set that needs to be in place before

specific strategies can be implemented." These guidelines are:

1. Choose techniques that are simple to implement.

2. Utilize to the fullest any ancillary personnel, such as occupational

therapists and speech therapists, available.

3. Request a full comprehensive evaluation of the student and information

from the rehabilitation program as to what strategies have and have not

worked.

4. Recognize the uniqueness of each student.

5. Schedule weekly review sessions with students to evaluate how well

interventions are working.6. Realize that the development of strategies and their effective use is an

ongoing process and is most successful when presented within a team

approach.

7. Acknowledge that success with higher level activities can only be achieved

through the mastery of lower level skills.

8. Encourage family involvement, so that the strategies developed for school

activities can also be incorporated into the student's home routine. (p. 1)

Specialists in the field of brain injuries recommend interventions that

address specific cognitive and behavioral needs. Rhein and Farmer (1994).

caution that each of the following deficit categories is "not an isolated area, but

rather a component of a complex learner whose educational success will only

occur through integration" (pp. 1).

A list of recommended interventions that address cognitive and

behavioral needs follows.


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tion,

198

8;13.E

ncou

rage

the

stud

ent t

o m

enta

llypi

ctur

e ev

ents

, obj

ects

, sce

nes,

or

phys

ical

layo

uts

14.U

se o

verl

appi

ng te

chni

ques

, suc

has

rep

etiti

on a

nd r

ehea

rsal

.

15. H

ave

the

stud

ent o

verl

earn

mat

eria

l.

16.C

oupl

e ne

w in

form

atio

n w

ithpr

evio

usly

lear

ned

info

rmat

ion.

17. T

each

the

stud

ent t

o or

gani

zein

form

atio

n in

to c

ateg

orie

s to

mak

ere

call

easi

er.

18. T

each

the

stud

ent t

o us

e st

udy

stra

tegi

es s

uch

as S

Q3R

(su

rvey

,qu

estio

n, r

ead,

rec

ite, a

nd r

evie

w).

19.H

ave

the

stud

ent k

eep

a da

ilyno

tebo

ok o

rgan

izer

whe

re th

est

uden

t can

cen

tral

ly lo

cate

all

impo

rtan

t inf

orm

atio

n.

20. U

se v

erba

l reh

ears

al. E

ncou

rage

the

stud

ent t

o re

peat

info

rmat

ion

alou

d an

d th

en s

ilent

ly.

21.U

nder

line

key

wor

ds in

a p

assa

gefo

r em

phas

is.

22. R

ole

play

or

pant

omim

ein

form

atio

n t

...; r

emem

bere

d.

23.W

rite

dow

n ke

y in

form

atio

n to

be

rem

embe

red,

suc

h as

who

, wha

t,w

hen.

24.P

rovi

de a

pri

nted

or

pict

ured

sche

dule

of

daily

act

iviti

es,

loca

tions

, and

mat

eria

ls n

eede

d.

25.P

rovi

de im

med

iate

and

fre

quen

tfe

edba

ck to

ena

ble

the

stud

ent t

oin

terp

ret s

ucce

ss o

r fa

ilure

.T

ucke

r, &

Tyl

er, 1

992;

Nat

iona

l Hea

d In

jury

Rhe

in &

Fax

mer

,199

4; Y

lvis

aker

, 198

5)

I. P

lace

the

stud

ent n

ear

the

chal

kboa

rd,

scre

en, a

nd te

ache

r.

2. P

lace

the

stud

ent i

n cl

assr

oom

set

tings

as f

ar r

emov

ed f

rom

ext

erna

lin

terf

eren

ces

as p

ossi

ble.

3. R

emov

e un

nece

ssai

y di

stra

cter

s an

dm

inim

ize

extr

aneo

us a

udito

ry a

ndvi

sual

stim

ulat

ion

thro

ugh

the

use

ofst

udy

carr

els

or r

oom

div

ider

s.

4. A

llow

the

stud

ent t

o w

ork

in s

mal

lgr

oup

setti

ngs.

5. E

xplo

re a

var

iety

of

cuei

ng s

yste

ms

that

rem

ind

the

stud

ent t

o st

ay o

n ta

skan

d pr

omot

e se

lf-m

onito

ring

,

6. U

se v

erba

l med

iatio

n st

rate

gies

, suc

has

inse

rtin

g qu

estio

ns w

ithin

a le

sson

and

dire

ctin

g at

tent

ion

to th

e ta

sk a

ndto

pic.

7. L

imit

the

leng

th o

r in

tens

ity o

f th

ein

stru

ctio

nal s

essi

on, g

radu

ally

incr

easi

ng d

eman

ds a

s at

tent

ion

skill

sin

crea

se.

8. U

se te

chni

ques

that

foc

us th

e st

uden

t'sat

tent

ion

on s

peci

fic

info

rmat

ion.

9. G

ain

atte

ntio

n w

ith m

eani

ngfu

lst

imul

i by

teac

hing

fro

m a

poi

nt o

ffa

mili

arity

and

then

mov

ing

to n

ew o

rle

ss f

amili

ar c

once

pts.

10. U

se c

lear

ly d

efin

ed o

bjec

tives

that

are

mea

ning

ful f

or th

e st

uden

t,

11. U

se s

hort

and

con

cise

inst

ruct

ions

and

assi

gnm

ents

.

12. R

ewar

d on

-tas

k be

havi

or.

13. U

se n

ovel

, unu

sual

, rel

evan

t and

stim

ulat

ing

activ

ities

.

14. P

rovi

de w

ell-

plac

ed r

est p

erio

ds o

rbr

eaks

to m

inim

ize

fatig

ue o

rst

amin

a pr

oble

ms

that

aff

ect

atte

ntio

n.

15. C

lose

ly m

onito

r tim

e of

day

,m

edic

atio

ns a

nd f

atig

ue f

acto

rs.

16. B

e al

ert t

o dr

ifts

in a

ttent

ion

and

redi

rect

the

stud

ent t

o ta

sk w

hen

nece

ssar

y.

(Coh

en, J

oyce

, Rho

des,

& W

elks

, 198

5; G

ettin

g &

Car

ney,

199

2; M

ira,

Tuc

ker,

& T

yler

,19

92; N

atio

nal H

ead

Inju

ry F

ound

atio

n, 1

988;

Rhe

in &

Far

mer

, 199

4).

42B

ES

T C

OP

Y A

VA

ILA

BLE

4 3

CO

GN

ITIV

E N

EE

DS

, CO

NT

INU

ED

Vis

ion

Org

aniz

atio

nF

'robl

em S

olvi

ng1.

Giv

e ca

refu

l con

side

ratio

n to

the

posi

tion

of1.

Bre

ak d

own

assi

gnm

ents

into

man

agea

ble

1. D

evel

op a

pro

blem

-sol

ving

gui

de to

hel

p th

eth

e st

uden

t rel

ativ

e to

the

chal

kboa

rd a

ndpa

rts.

stud

ent t

hrou

gh th

e st

ages

of

prob

lem

sol

ving

scre

ens.

(e.g

. ide

ntif

y th

e pr

oble

m, l

ist r

elev

ant

2. O

utlin

e an

d su

mm

ariz

e im

port

ant p

oint

sin

form

atio

n, e

valu

ate

poss

ible

sol

utio

ns, c

reat

e an

2.U

se la

rge

prin

t boo

ks a

nd/o

r bo

oks

on ta

pe.

befo

re a

nsw

erin

g qu

estio

ns,

actio

n pl

an).

3.E

ncou

rage

the

stud

ent t

o us

e ru

lers

to a

id3.

Tea

ch th

e st

uden

t to

ask

"vvh

" qu

estio

ns.

2. R

aise

que

stio

ns a

bout

alte

rnat

ives

and

visu

al s

cann

ing

and

proc

essi

ng ti

me.

cons

eque

nces

.4.

Eng

age

in d

iscu

ssio

n gr

oups

that

req

uire

4.A

ltern

ate

visu

al a

nd a

udito

ry a

ctiv

ities

,cr

itica

l thi

nkin

g.3.

Allo

w th

e st

uden

t to

talk

abo

ut r

eal-

life

prob

lem

sth

at a

re a

ppro

pria

te f

or g

roup

dis

cuss

ion,

and

5.B

uild

in f

requ

ent v

isua

l res

t bre

aks.

S. L

imit

the

num

ber

of s

teps

in a

task

.br

ains

torm

abo

ut a

ltern

ativ

e so

lutio

ns a

nd th

eir

usef

ulne

ss.

6.A

ssig

n a

seco

nd s

tude

nt to

rev

iew

not

es w

ith6.

Pro

vide

par

t of

a se

quen

ce a

nd h

ave

the

the

stud

ent t

o m

ake

sure

impo

rtan

t inf

orm

atio

nst

uden

t fin

ish

it.4.

Int

rodu

ce r

oadb

lock

s an

d co

mpl

icat

ions

toha

s be

en in

clud

ed a

nd is

acc

urat

e.en

hanc

e "d

etou

ring

" sk

ills

and

to e

ncou

rage

7. S

truc

ture

thin

king

pro

cess

es g

raph

ical

ly.

flex

ibili

ty.

7.T

each

the

stud

ent t

o pl

ace

mat

eria

ls w

ithin

his

or h

er b

est v

isua

l fie

ld.

8. U

se c

ateg

orie

s to

foc

us o

n on

e to

pic

at a

time.

5. P

rovi

de o

ngoi

ng, n

on-j

udgm

enta

l fee

dbac

k

8.Pr

ovid

e lo

nger

vie

win

g tim

es o

r re

peat

view

ings

whe

n us

ing

visu

al in

stru

ctio

nal

9. I

dent

ify

the

mai

n id

ea a

nd s

uppo

rtin

g de

tails

mat

eria

ls,

and

teac

h th

e st

uden

t to

do th

e sa

me.

10. T

each

the

stud

ent t

o pr

actic

e or

gani

zatio

nal

skill

s at

hom

e.)

(Ger

ring

& C

arne

y, 1

992;

Mir

a, T

ucke

r, &

Tyl

er, 1

992;

(Nat

iona

l Hea

d In

jury

Fou

ndat

ion,

198

8; R

hein

&(N

atio

nal H

ead

Inju

ry F

ound

atio

n, 1

988)

Nat

iona

l Hea

d In

jury

Fou

ndat

ion,

198

8; R

hein

&Fa

nner

, 199

4)Fa

rmer

, 199

4; Y

lvis

aker

, 198

5)

45

4 4

8C

OG

NM

E N

EE

DS,

CO

NT

INU

ED

Com

preh

ensi

on/F

ollo

win

g D

irect

ions

Rea

soni

ng a

ndM

enta

l Fle

xibi

lity

Acq

uirin

g N

ew L

earn

ing

1.P

rovi

de th

e st

uden

t with

bot

h vi

sual

and

aud

itory

1. W

hen

test

ing

a st

uden

t, st

ate

the

ques

tion

as1.

Det

erm

ine

proc

essi

ng s

tyle

s an

d "t

each

to"

dire

ctio

ns,

stud

ied;

rep

hras

ing

the

ques

tion

may

be

perc

eive

d as

a n

ew q

uest

ion.

stre

ngth

s.

2M

odel

task

s an

d ac

t out

dire

ctio

ns.

2. A

naly

ze th

e m

ater

ial b

eing

taug

ht in

term

s of

2. P

rovi

de in

stru

ctio

n th

at d

oes

not r

equi

re h

igh

task

s; a

naly

ze s

tude

nt's

err

or p

atte

rns.

3. B

reak

mul

tiste

p di

rect

ions

into

sm

alle

r pa

rts

and

degr

ees

of a

ssim

ilatio

n. F

ocus

on

one

topi

clis

t the

m s

o th

at th

e st

uden

t can

ref

er to

the

befo

re in

terr

elat

ing

it w

ith o

ther

s.3.

Pre

sent

info

rmat

ion

in a

str

uctu

red/

orga

nize

din

divi

dual

sth

ps.

fash

ion.

3. P

ract

ice

reas

onin

g ta

sks,

suc

h as

exe

rcis

es in

4. T

ape

reco

rd c

ompl

ex d

irect

ions

and

allo

w s

tude

ntto

list

en s

ever

al ti

mes

.an

alyz

ing

fact

s.4.

Pre

sent

new

mat

eria

l slo

wly

and

ove

r tim

e.

4. P

rovi

de a

ctiv

ities

suc

h as

cro

ssw

ord

puzz

les.

5. A

void

abs

trac

tions

suc

h as

idio

mat

ic e

xpre

ssio

ns5.

Use

mor

e co

ncre

te la

ngua

ge.

in te

achi

ng.

5. R

ole

play

cau

se-a

nd-e

ffect

sce

nario

s.6.

Tea

ch th

e st

uden

ts to

ask

for

clar

ifica

tion,

repe

titio

n, o

r fo

r in

form

atio

n to

be

give

n at

a6.

Pro

vide

wha

t? w

hy?

ques

tions

to fa

cilit

ate

6. U

tiliz

e m

ultis

enso

ry a

ppro

ache

s w

hene

ver

poss

ible

.sl

ower

rat

e.re

ason

ing.

7. S

tres

s ac

tive

part

icip

atio

n by

the

stud

ent.

7. P

air

man

ual s

igns

, ges

ture

s, o

r pi

ctur

es w

ith7.

Pro

vide

exe

rcis

es in

the

com

preh

ensi

on o

fve

rbal

info

rmat

ion,

figur

ativ

e la

ngua

ge, s

uch

as id

iom

s, a

ndw

ords

with

mul

tiple

mea

ning

s th

at a

re8.

Pro

vide

opp

ortu

nitie

s fo

r on

e-on

-one

inst

ruct

ion

and

tuto

ring,

esp

ecia

lly fo

r co

nten

t sub

ject

s.8.

Use

cog

nitiv

e m

appi

ng (

Gol

d, 1

984)

: dia

gram

idea

s in

ord

er o

f im

port

ance

or

sequ

ence

to c

larif

yco

nten

t gap

hica

lly.

pote

ntia

lly c

onfu

sing

.

8. R

ole

play

med

iatin

g an

arg

umen

t. A

sk th

est

uden

t to

anal

yze

and

synt

hesi

ze th

e tw

opo

ints

of v

iew

pre

sent

ed a

nd th

en a

rriv

e at

aso

lutio

n.

9. P

rovi

de s

peec

h-la

ngua

ge th

erap

y to

impr

ove

reas

onin

g an

d m

enta

l fle

xibi

lity.

(Mira

, Tuc

ker,

& T

yler

, 199

2; Y

lvis

aker

, 198

5)(M

ira, T

ucke

r, &

Tyl

er, 1

992)

(Rhe

in &

Far

mer

, 199

4)

44.

BE

HA

VIO

RA

L N

EE

DS

Agi

tatio

n an

d Ir

rita

bilit

yA

ggre

ssio

nPo

or E

mot

iona

l Con

trol

1. T

ry to

hel

p th

e st

uden

t ide

ntif

y w

hat i

s ca

usin

gI

. Kno

w th

e st

uden

t wel

l eno

ugh

to r

edir

ect

I .

Red

irec

t beh

avio

r, c

hang

e th

e su

bjec

t or

the

agita

tion

and

irri

tabi

lity,

suc

h as

fat

igue

or

agita

ted

beha

vior

s be

fore

they

esc

alat

e.en

viro

nmen

t, an

d re

focu

s th

e st

uden

t's a

ttent

ion

frus

trat

ion,

and

then

fm

d w

ays

to c

ope.

to s

omet

hing

pos

itive

.2.

Spe

ak c

alm

ly a

nd g

ently

to a

stu

dent

who

has

2. W

hen

a st

uden

t bec

omes

agi

tate

d or

irri

tate

d an

dbe

com

e ag

gres

sive

. Be

a ca

lm, c

arin

g, a

nd2.

Be

sens

itive

to th

e st

uden

t's in

clin

atio

n to

has

an o

utbu

rst,

redi

rect

the

stud

ent a

way

fro

mco

ntro

lled

role

mod

el.

over

reac

t to

nega

tive

criti

cism

and

per

ceiv

edth

e so

urce

of

frus

trat

ion.

Do

not d

wel

l on

the

ridi

cule

.ou

tbur

st o

r w

hat t

he s

tude

nt d

id.

3. U

se k

ey p

hras

es w

hich

are

fam

iliar

to h

elp

the

3. D

urin

g se

vere

out

burs

ts, r

edir

ect a

nd r

educ

e th

est

imul

atio

n or

fru

stra

tion

by o

ffer

ing

the

stud

ent

stud

ent g

ain

cont

rol o

f th

e ag

gres

sive

beha

vior

s,3.

Hel

p th

e st

uden

t rec

ogni

ze th

at r

ecov

ery,

like

life

,is

ful

l of

ups

and

dow

ns; h

elp

the

stud

ent

reor

ient

tow

ard

posi

tive

goal

s du

ring

dow

nwar

dan

alte

rnat

ive

actio

n to

hel

p hi

m o

r he

r co

ol o

ff,

such

as

taki

ng a

wal

k.4.

If

the

stud

ent's

agg

ress

ive

beha

vior

s ca

nnot

be

cont

rolle

d an

cllo

r th

reat

ens

the

safe

ty o

f ot

hers

,em

erge

ncy

proc

edur

es s

houl

d be

fol

low

ed

moo

d sw

ings

.

4.If

the

stud

ent u

ses

ofT

ensi

ve la

ngua

ge o

r be

com

esve

ry c

ritic

al o

f ot

hers

, rem

ind

the

stud

ent o

f ho

wsu

ch la

ngua

ge a

ffec

ts o

ther

s an

d he

lp h

im o

r he

rre

stat

e fe

elin

gs in

mor

e po

sitiv

e to

nes.

(Nat

iona

l Hea

d In

jury

Fou

ndat

ion,

198

8)(N

atio

nal H

ead

Inju

ry F

ound

atio

n, 1

988)

(Nat

iona

l Hea

d In

jury

Fou

ndat

ion,

198

8)

434

t.)B

EI-

IAV

IOR

AL

NE

ED

S, C

ON

TIN

UE

D

Apa

thy

Dep

ress

ion,

With

draw

al, a

nd S

elf-

Cri

ticis

m1.

Rem

embe

r th

at d

epre

ssio

n fo

llow

ing

a he

adin

jury

is c

omm

on f

or m

any

stud

ents

who

rem

embe

r w

hat t

hey

wer

e lik

e an

d th

eir

abili

ties

befo

re th

e in

jury

.

2. H

elp

the

stud

ent r

ecog

nize

wha

t he

or s

he c

ando

rat

her

than

wha

t the

y ca

nnot

do.

Kee

p th

est

uden

t inv

olve

d in

the

"rea

l wor

ld"

and

help

them

not

to s

lip in

to th

e pa

st.

3. B

e an

act

ive

liste

ner

whe

n th

e st

uden

t nee

dsto

talk

and

foc

us o

n th

e st

uden

t's p

ositi

vefe

elin

gs.

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hart

ach

ieve

men

t of

goal

s to

bui

ld s

elf-

conf

iden

ce.

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f a

stud

ent b

ecom

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uici

dal,

cont

act t

hesc

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chol

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t or

coun

selo

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uden

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abili

ties

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ealiz

e th

at m

any

stud

ents

with

rig

ht h

emis

pher

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juri

es m

ay n

ot r

ecog

nize

thei

r pr

oble

ms

and

thus

may

den

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at th

ey h

ave

any.

2. H

elp

the

stud

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ink

of h

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lf o

r he

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f in

term

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str

engt

hs a

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its.

3. F

ind

the

stud

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str

onge

st le

arni

ng m

odal

ity(v

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l, au

dito

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actil

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nd u

se th

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ity to

help

the

stud

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ecog

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r pr

oble

m a

reas

.

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ive

the

stud

ent a

cho

ice

of a

ctiv

ities

, and

kee

pth

e st

uden

t inv

olve

d in

gro

up a

ctiv

ities

with

othe

r st

uden

ts.

2. H

elp

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stud

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xplo

re w

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e or

she

rea

llyw

ants

, pro

ceed

in s

mal

l ste

ps, a

nd s

et e

asy

goal

s;sh

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uden

t he

or s

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an s

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3. S

truc

ture

pra

ctic

e si

tuat

ions

so

the

stud

ent c

anpr

actic

e pe

rcei

ving

the

feel

ings

of

othe

rs a

ndre

spon

ding

app

ropr

iate

ly.

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iona

l Hea

d In

jury

Fou

ndat

ion,

198

8)(N

atio

nal H

ead

Inju

ry F

ound

atio

n, 1

988;

Ylv

isak

er,

1985

)(N

atio

nal H

ead

Inju

ty F

ound

atio

n, 1

988)

tt;

BE

HA

VIO

RA

L N

EE

DS,

CO

NT

INU

ED

Impu

lsiv

e B

ehav

ior/

Lack

of I

nhib

ition

Dis

orie

ntat

ion

or C

onfu

sion

Lack

of S

ocia

l Ski

llsI.

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awar

e th

at s

tude

nts

with

fro

ntal

lobe

inju

ries

ofte

n fe

el "

out o

f co

ntro

l" a

nd c

anno

t eff

ectiv

ely

inhi

bit i

mpu

lses

.

1. P

rovi

de a

n un

clut

tere

d, q

uiet

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iron

men

t.

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rovi

de p

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hart

s, s

ched

ules

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ssro

om m

aps

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all g

roup

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iviti

esto

fac

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te in

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ctio

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it pe

er2.

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p th

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ter

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or h

er w

orld

rule

s of

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ecte

d be

havi

ors.

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iew

thes

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odel

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by k

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org

aniz

ed a

nd s

truc

ture

d an

dbe

fore

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h se

ssio

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nee

ded

thro

ugho

utus

ing

aids

suc

h as

cal

enda

rs a

nd a

ssig

nmen

t log

sth

e da

y.3.

Ass

ign

a "b

uddy

" to

ass

ist w

ith tr

avel

thro

ugho

utto

org

aniz

e th

eir

lives

,

3 .

Use

key

wor

ds a

nd p

hras

es to

hel

p th

e st

uden

t3.

Mai

ntai

n co

nsis

tent

sta

ff, r

oom

arr

ange

men

t,an

d m

ater

ials

.

the

scho

ol a

nd a

cla

ssro

om w

ork

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ner

to h

elp

the

stud

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ithin

the

clas

sroo

m.

trac

k be

havi

ors

and

less

en im

puls

ivity

.4.

Pla

n ex

trac

urri

cula

r ac

tiviti

es b

ased

on

the

4. L

abel

sig

nifi

cant

obj

ects

and

are

as.

stud

ent's

phy

sica

l and

em

otio

nal c

apab

ilitie

s as

4. H

ave

the

stud

ent w

rite

dow

n hi

s or

her

pla

ns a

ndw

ell a

s in

tere

sts

to e

ncou

rage

non

-aca

dem

icfo

cus

on r

outin

es to

dec

reas

e "n

ot k

now

ing

wha

t5.

Tea

ch s

tude

nts

to lo

ok f

or p

erm

anen

tex

peri

ence

s.to

do

next

" be

havi

ors,

land

mar

ks a

nd n

ame

the

land

mar

ks w

hen

they

com

e to

them

.5.

Pla

ce u

nnec

essa

ry m

ater

ials

out

of

sigh

t and

out

of r

each

.6.

Hav

e st

uden

ts v

erba

lize

how

to g

o to

asp

ecif

ic p

lace

bef

ore

star

ting

or w

hile

mov

ing.

6. D

iscu

ss r

ules

and

thei

r im

port

ance

at t

hebe

ginn

ing

of th

e le

sson

.7.

Use

a b

uddy

sys

tem

.

7. E

xpla

in h

ow th

e st

uden

t's im

puls

ive

acts

dist

urb

othe

rs.

8. R

ole

play

app

ropr

iate

res

pons

es.

(Nat

iona

l Hea

d In

jury

Fou

ndat

ion,

198

8; Y

lvis

aker

,19

85(Y

lvis

aker

, 198

5)(B

loss

er &

DeP

ompe

i, 19

94; M

ira,

Tuc

ker,

& T

yler

,'

1992

L

A portion of Oregon's Traumatic Brain Injury: An Educator's Manual

(1991) entitled "Serving the Student with TBI" outlines possible deficits,

behaviors, and teaching strategies for students with traumatic brain injuries.

This section has been reproduced on pages xxx of Appendix D. A similar section

of Virginia's Guidelines for Educational Services for Students with Traumatic

Brain Injury (1992) outlining "Observable Behaviors and Strategies" has been

reproduced on pages 177 - 184 of Appendix D.

New York State's Traumatic Brain Injury: A Guidebook for Educators

(1994) divides intervention approaches into three areas: Compensatory

Strategies, Environmental Modifications, and Instructional Modifications.

Examples of these have been reproduced on pages 209 - 212 of Appendix D.

Waaland (1991) lists four program areasScheduling, Instructional

Strategies, Assistive Device, and Social/Behavioral Interventionsand suggests

interventions that address issues, problems, and deficits in each of these area.

This chart has been reproduced on pages 215 - 216 of Appendix D.

REFERENCES

Arizona Department of Education. (1993). AZ-TAS Themes & Issues: TraumaticBrain Injury. Phoenix: Author.

Blosser, J. L., & DePompei, R. (1994). Creating an effective classroomenvironment. In R. C. Savage & G. F. Wolcott (Eds.), Educationaldimensions of acquired brain injury (pp. 413 - 451). Austin: PRO-ED.

Cohen, S., Joyce C., Rhodes, K., & Welks, D. (1985). Educational programming forhead injured students. In M. Ylvisaker (Ed.) Head injury rehabilitation:Children and adolescents (pp. 383 - 411). San Diego: College-Hill Press.

Dunn, C. (1992, Oct/Nov). Reaching challenging kids. Headlines, p. 18.

Gerring, T. & Carney, J. (1992). Head trauma: Strategies for educationalreintegration. San Diego: Singular Publishing Group, Inc.

r44 Traumatic Brain Injuzy

Glang, A., Singer, G., & Cooley, E. (1992). Tailoring direct instruction techniquesfor use with students with brain injury. Journal of Head TraumaRehabilitation, 7 (4), 93 - 117.

Gloeckler, T., & Simpson, S. (1988). Exceptional students in regular classrooms:Challenges, services, methods. Mountain View, CA: Mayfield.

Gruen, A. K., & Gruen, L. S. (1992). Back into life! Functional narratives forbrain injured adolescents and adults. Eau Claire, WI: ThinkingPublications.

Mc Kerns, D., & Motchkavitz, L. (1993). Therapeutic education for the child withTraumatic Brain Injury: From coma to kindergarten. Tucson: TherapySkill Builders.

Mira, M. P., Tucker, B. F., & Tyler, J. S. (1992). Traumatic Brain Injury in childrenand adolescents. Austin: PRO-ED, Inc.

National Head Injury Foundation, Inc., (1988). An educator's manual: Whateducators need to know about students with Traumatic Brain Injury.Southborough, MA: Author.

New York State Education Department. (1994). Traumatic Brain Injury: AGuidebook for Educators. New York: Author.

Oregon Department of Education & Portland Public Schools. (1991). TraumaticBrain Injury: An educator's manual. Salem: Oregon Department ofEducation.

Pieper, B. (1991). Traumatic Brain Injury: What the teacher needs to know.New York: New York State Head Injury Association, Inc.


Telzrow, C. F. (1987). Management of academic and educational problems inhead injury. Journal of Learning Disabilities, 20, 536 - 545.

Tucker, B. F., & Colson, S. E. (1992). Traumatic Brain Injury: An overview ofschool re-entry. Intervention in School and Clinic, 27 (4), 198 - 206.

Tyler, J. S. (1990). Traumatic head injuny in school aged children: A trainingmanual for educational personnel. Kansas City, KS: University of KansasMedical Center, Children's Rehabilitation Unit.

Traumatic 13rain Injwy 45

Tyler, J. S., & Mira, M. P. (1993, Spring). Educational modifications for studentswith head injuries. Teaching Exceptional Children, 24 - 27.

Virginia Department of Education & the Rehabilitation Research and TrainingCenter on Severe Traumatic Brain Injury (1992). Guidelines forEducational Services for Students with Traumatic Brain Injury..Richmond: Author.

Waaland, P. (1991). Academic reentry of children and youth followingTraumatic Bra!n Injury. Special Topic Report #4. Richmond, VA:Rehabilitative Research & Training Center on Severe Traumatic BrainInjury.


5 6


EDUCATION AND AWARENESS

As the incidence of Traumatic Brain Injury continues to rise, education

and prevention efforts are ongoing across the country on both district and state

levels in order to increase student awareness of prevention of Traumatic Brain

Injury and to train educators to work more effectively with students who have

sustained brain injuries.

State Efforts

Utah's Guidelines for Serving Students With Traumatic Brain Injuries

(1992) makes a number of recommendations for State Education Agencies and

Local Education Agencies to increase awareness and understanding of Traumatic

Brain Injury among staff members as well as students. Among those

recommendations are the following:

O Developing educational materials and programs for noninjuredstudents to increase their understanding and acceptance of classmateswho have experienced Traumatic Brain Injury but also to increase theirknowledge of prevention strategies to reduce the risk of TraumaticBrain Injuries for themselves and others;

O Making an educator's guide to Traumatic Brain Injury available to allschool staff members;

O Offering training programs on Traumatic Brain injury to school staffmembers;

O Developing an awareness program to train teachers to identify studentswho may have sustained an untreated Traumatic Brain Injury andrefer those students for assistance;

O Providing inservice training to school districts regarding TraumaticBrain Injury, its consequences, prevention strategies, and educationalimplications and assisting school districts in developing procedures toprovide inservice training to all district personnel; and

57


O Maintaining a roster of qualified presenters and trainers on TraumaticBrain Injury issues;

O Making educational and support programs available to parents ofchildren who have sustained Traumatic Brain Injuries;

O Developing a parent's guide to help increase awareness and knowledgeof educational options for students with a Traumatic Brain Injury;

Informing health care providers about the educational needs ofstudents with Traumatic Brain Injuries;

O Developing and maintaining, with the assistance of public libraries, aclearinghouse of educational resources on Traumatic Brain Injury forparents, teachers, and the public;

Developing public service announcements in collaboration withparent groups and head injury associations to increase the level ofawareness in the community and provide programs to help preventTraumatic Brain Injury;

O Assembling and training a Head Injury Team in each school district toserve as a resource whenever a student with Traumatic Brain Injury isidentified in the school district;

O Disseminating updated information on Traumatic Brain Injury to allinstitutions training future educators;

O Encouraging universities to include Traumatic Brain Injuryinformation in courses about disabilities; and

O Initiating changes in teacher certification to include curriculumregarding Traumatic Brain Injury. (pp. 7 - 12)

In their survey of special education directors, Katsiyannis & Conderman

(1994) found that 37 states offer technical assistance to local education agencies

(LEAs) on Traumatic Brain Injury, and 23 states that indicated their state

departments offer training to LEAs on the same issue. The training topics most

frequently addressed are identification., assessment, programming, and full

inclusion practices. Arizona, Florida, Kentucky, Montana, Rhode Island, and

Virginia have developed technical assistance manuals. New York, Oklahoma,

and Connecticut offer primary technical assistance through regional centers.


Other states have entered collaborative agreements with other state agencies andprivate institutions and/or clinics to assist LEAs.

An in-service training project underway in Oregon is training educators tobe consultants to other educators on Traumatic Brain Injury (Training on TBI,1995). Funded by a U. S. Department of Education grant, the TBI Inservice Projectprovides training to teams throughout the state to promote effective educationalpractices for students with Traumatic Brain Injuries. The one-year trainingperiod includes information about Traumatic Brain injury; interventions forbehavioral, academic, and social outcomes; consultation skills to facilitate

collaboration among school personnel and foster positive parent/professionalinteractions. Once teams are trained, they provide consultation and inservicetraining to other school personnel in their regions. (For additional informationabout the TBI Inservice Project, contact Bonnie Todis, 99 W. 10th Ave., Suite337C, Eugene, OR 97401, (503) 345-0593).

The state of Kansas has also developed a statewide model of preservice and

inservice training for educators and parents in the area of Traumatic Brain

Injury. The primary purposes of the project are:

1. To develop and field test inservice and preservice training modules,

including diagnostic and teaching methods, curricular materials, andresource linkages;

2. To train a regional cadre of educational personnel to serve as inservice

providers and consultant/resource persons for local education agency staff

and parents; and

3. To create a system for ongoing preservice and inservice training and

dissemination of the TBI training model after the project has been

completed.

riJ


This federally funded, five-year project is a collaborative effort between the

Kansas State Department of Education and the Department of Special

Education/University of Kansas. Educational and medical staff of the Children's

Rehabilitation Unit University Affiliated Program and the University of Kansas

Medical Center are serving as staff and resources for the project.

Kansas is a large state which is predominantly rural, and implementation

of statewide inservice training requires a regional network capable of providing

human and technological resources. Regional Area Education Service Centers

have indicated their willingness and interest in participating in the provision of

training for regional and local educational personnel and parents. An

interactive video system, which will allow distant teaching, consultation, and

supervision of practica, is in operation in the Area Service Centers of the most

rural areas of the state.

For more information concerning this state project, contact the Special

Education Office, Kansas State Department of Education, 120 East Tenth Street,

Topeka, KS 66612-1103, (913) 296-3869.

District Efforts

A number of school districts are incorporating educational and prevention

programs into their curricula. These programs are designed to increase

children's perceptions of the severity of brain injuries and their own

vulnerability, to help students gain a better understanding of cause-effect

relationships and the rationale for safety principles, and to enhance the

perception that injuries can be prevented and that safe behavior is smart

(Richards, 1992).

A typical elementary curriculum entitled Preventing Injury: A Safety

Curriculum is based on principles and approaches of child development, early60


childhood education, and prevention psychology. The curriculum's operatingassumption is that if awareness of catastrophic injury can be established early inchildren's lives, as well as knowledge of ways to avoid such injury, they will ageinto the high-risk age category (15 - 24 years) with better formed attitudes, beliefs,

and appropriate behavioral strategies concerning behaviors that can lead to

injury. The curriculum includes eight units: Spinal Cord and Brain Injury

Awareness, Motor Vehicle Safety, Pedestrian Safety, Bike Safety, Playground andRecreational Sports Safety, Preventing Falls, Weapons Safety, and Water Safety

(Richards, 1992). Programs aimed at elementary school students strive to help

students develop safe habits while they are young before behavioral patternsbecome increasingly more difficult to change as children reach adolescence.

The School Injury Prevention Resource Guide (Brackett, 1992) describes

resources that may be used by educators to address injury prevention in their

classrooms. Curricula are included that are especially designed for elementary,

middle school, and high school students. These cover a broad range of

prevention issues, including skills for injury prevention (pedestrian safety,

playground safety, bicycle safety), stopping violence, and managing anger.

REFERENCES

Brackett, C. (1992). School Injury Prevention Guide. (ERIC DocumentReproduction Service No. ED 366 894).

Richards, J. S. (1992). Preventing injury: A safety curriculum. Santa Cruz, CA:ETR Associates. (ERIC Document Reproduction Service No. ED 358 076).


61


INTERNET RESOURCES

Title: Emory Center for Injury Control

Address: http://www.emory.edu/WHI/cichome.html

Description: The Emory Center for Injury Control is a collaboration of Emory'sschools of Public Health and Medicine. The center's clinical partner is the GradyHospital Trauma Center. The broad-based Center for Injury Control is involvedin research, community service, and education with emphasis on prevention.

Title: Fact Brochures

Address: http://www.sasquatch.com/tpn/brochures.html

Description: Brain Injury: Prevention IS Worth a Pound of Cure but SometimesIt Happens Anyway! is a brochure that includes brain injury statistics as well assigns/symptoms. It focuses on prevention steps that can be taken.

Title: Ohio Valley Center for Head Injury Prevention and Rehabilitation

Address: http://rmstewart.uthscsa.edu/ccmcase15.html

Description: The Ohio Valley Center is located at Ohio State University in theDepartment of Physical Medicine and Rehabilitation. The center develops anddistributes model programs of prevention, acute care, and rehabilitation forindividuals who have had Traumatic Brain Injuries.

Title: The Perspectives Network

Address: http://www.sasquatch.com/tpn/

Peacriplion: The Perspectives Network, Inc. is an international tax-exempt, non-profit organization founded by a survivor of acquired brain injury in 1990. Asevidenced by the services its offers, TPN's primary focus is communicationbetween survivors, family members/caregivers/friends, professionals and

Traumatic Brain Injuty

6 c.?

53

community members in order to create positive changes and enhance publicawareness and knowledge of acquired brain injury.

TPN services include:The TPN Magazine including Current On-Line IssueComputer ForumsSurvivor Identification CardsPeer Communication NetworksFact BrochuresLending Library & Topical File ArchivesBrain Injury Empathy Experience WorkshopsFrequently Asked Questions (FAQ)Resources: Books, Publications, Periodicals, VideosInformation/Material Request FormSupport Groups (Searchable by City)Additional Internet ABI/TBI Resources

Title: Technical Assistance Center Serving Southwest Virginia

Address:http://infoserver.etl.vtedu/coe/COE_admin/labs&centers/tac/tac_p.html

Description: The Technical Assistance Center for Students with SevereDisabilities (SD TAC) provides assistance to teachers and school personnel insouthwest Virginia serving students who have been identified as autism, dual-sensory impairments, traumatic brain injury, visual or hearing impairments,severe to profound cognitive impairments, as well as students who haveorthopedic impairments or multiple handicaps. Services include on-siteconsultations, workshops, long-term planning with school divisions, and aninformation and referral services to educators. The SD TAC has a lending librarycovering a wide range of topics of interest to individuals who teach, assist orsupport students with severe disabilities. Additionally, the library offers the useof assistive technology devices and software.

Title: ABI/TBI Information Project

Address: http:/ /ns.sasquatch.com/tbi/Welcome.html


llessaigtiQn: In conjunction with the TBI- SPRT E-Mail List and ABI/TBI Gopher,this area is dedicated to providing information on brain injury withoutpreference to any particular person, thought, theory or belief. Information isprovided about the TBI-SPRT e-mail list and how to subscribe. The site alsoincludes selected articles pertaining to Traumatic Brain Injury and topicaldiscussion archives which may be searched by keywords.

Title: Acquired Brain Injury Forum

Address: http:/ /aztec.asu.edu/abi/welcome.html

Description: This forum is for the Acquired Brain Injury (ABI/TBI) Communityof Arizona. It is being hosted by The Perspectives Network whose logo appears atthe top of the page. In this forum you will find regional infOrmation regardingthe Arizona Head Injury Foundation, the various support groups they sponsoras well as national information and resources.

Arizona resources include:Arizona Head Injury Foundation (AHIF)Support GroupsAn ABI/TBI Discussion Group can be found in the AzTeC SIG area.National ResourcesThe Perspectives Network (TPN) On-LineFrequently Asked Questions (FAQ)Resources: Books, Publications, Periodicals, VideosThe ABI/TBI Information Project GopherAn international ABI/TBI Newgroup called TBI SPRT can be found inthe AzTeC SIG area.

Title: Injury Control Resource Information Network

Address: http://www.pitt.edu/-hweiss/injury.htm

Description: ICRIN is a dynamic list of Internet accessible resources broadlyrelated to the field of injury research and control. The resources are in the formof clickable hyperlinks to other sources and documents somewhere on the Net.New users may want to look at the ICRIN slide show that presents an overviewof the structure, content, and benefits of this site. Contents of ICRIN include:


Federal Agencies (U.S.)Data and Database SourcesData StandardsJournals, Bibliographies, and Desk ReferencesEducation and TrainingConferences and Meeting AnnouncementsInjury Specific ResourceRecent ResearchInjury Prevention Research CentersGrant Opportunities and InformationProfessional and Other OrganizationsRelated Discipline LinksSafety Products (commercial)Software and Related Research Tools (available through web browsersand FTP)

Other Injury Related Internet Resources (lists, newsgroups, BBS, E-mail)Searches (places to conduct key word searches for Internet resources)Neat Stuff (innovative uses of the WEB with possible applications toInjury Control)Feedback (E-mail a comment to the author about ICRIN)

65


REFERENCES

Abbot, N., & Wilkinson, L. (1993). School re-entry of the brain injured student:A case study of peer inservicing. Intervention in School and Clinic, 27 (4),242 - 249.

American Federation of Teachers, AFL-CIO. (1992). The medically fragile child inthe school setting. Port Chester, NY: National Professional Resources, Inc.


Begali, V. (1987). Head injury in children and adolescents: A resource andreview for school and allied professionals. Brandon, VT: ClinicalPsychology Publishing.

Blosser, J. L., & DePompei, R. (1994). Creating an effective classroomenvironment. In R. C. Savage lk G. F. Wolcott (Eds.), Educationaldimensions of acquired brain injury (pp. 413 - 451). Austin: PRO-ED.

Brackett, C. (1992). School Injury Prevention Guide. (ERIC DocumentReproduction Service No. ED 366 894).

Bureau of Education for Exceptional Students. (1993). What we know abouteducating students with Traumatic Brain Injury. Tallahassee: FloridaDepartment of Education, Division of Public Schools.

Carter, S. (1993). Traumatic brain injury: The role of schools in assessment.Eugene, OR: Western Regional Resource Center.

Cohen, S., Joyce C., Rhodes, K., & Welks, D. (1985). Educational programming forhead injured students. In M. Ylvisaker (Ed.) Head injury rehabilitation:Children and adolescents (pp. 383 - 411). San Diego: College-Hill Press.

Colorado State Department of Education. (1991). Traumatic Brain Injuries.Guidelines paper. Denver: Special Education Services Unit.

DePoinpei, R., & Blosser, J. L. (1987). Strategies for helping head injured childrensuccessfully return to school. Language, Speech and Hearing Services inSchools, 18, 292 - 300.


General information about Traumatic Brain Injury. NICHCY Fact SheetNumber 18 (FS18). (1994). Washington, DC: National Information Centerfor Children and Youth with Disabilities.

Gerring, J., S- Carney, J. (1992). Head trauma: Strategies for educationalreintegration. San Diego: Singular Publishing Group, Inc.

Gloeckler, T., & Simpson, S. (1988). Exceptional students in regular classrooms:Challenges, services, methods. Mountain View, CA: Mayfield.

Gold, P. C. (1984). Cognitive mapping. Academic Therapy, 19(3), 227 - 284.

Idaho Department of Education. (1993). Idaho Special EducationImplementation Manual. Boise: Author.

Katsiyanrds, A., & Conderman, G. (1994). Serving individuals with TraumaticBrain Injury: A national survey. Remedial and Special Education, 15 (5),319 - 325.

Kazuk, E., & Stewart, D. (1993, August). Planning for Traumatic Brain Injury(TBI): A new challenge for special gducation. Plantation, FL: SouthAtlantic Regional Resource Center.

Lehr, D. H. (1990). Educating students with special health care needs. In E. L.Meyen (Ed.), Exceptional children in today's schools (pp. 107 - 130). Denver:Love Publishing.

Lehr, D. H., & McDaid, P. (1993, February). Opening the door further: Integratingstudents with complex health care needs. Focus on Exceptional Children,pp. 1 - 8.

Lehr, E. (1990). Psychological management of Traumatic Brain Injuries inchildren and adolescents. Rockville, MD: Aspen Publishers, Inc.

McKerns, D., & Motchkavitz, L. (1993). Therapeutic education for the child withTraumatic Brain Injury: From coma to kindergarten. Tucson: TherapySkill Builders.

Mira, M., Tucker, B. F., & Tyler, J. S. (1992). Traumatic Brain Injury in childrenand adolescents. Austin: PRO-ED.

Mira, M. P., & Tyler, J. W. (1991, January). Students with Traumatic Brain Injury:Making the transition from hospital to school. Focus on ExceptionalChildren, pp. 1 - 12.

67

58 Traumatic Brain Injwy

Mira, M., Tyler, J., & Tucker, B. (1988). Traumatic head injury in children: Aguide for schools. Topeka: Kansas State Department of Education.

National Head Injury Foundation, Inc. (1988). An educator's manual: Whateducators need to know about students with Traumatic Brain Injury.Southborough, MA: Author

New York State Education Department. (1994). Traumatic Brain Injury: Aguidebook for educators. New York: Author.

Oregon Department of Education & Portland Public Schools. (1991). TraumaticBrain Injury: An educator's manual. Salem: Oregon Department ofEducation.

Palfrey, J. S., Haynie, M., Porter, S., Bier le, T., Cooperman, P., & Lowcock, J. (1992).Project School Care: Integrating children assisted by medical technologyinto educational settings. Journal of School Health, 62 (2), 50 - 54.

Papalia, D. E., & Olds, S. W. (1981). Human development. New York: McGraw-Hill.

Pieper, B. (1991). Traumatic Brain Injury: What the teacher needs to know.New York: New York State Head Injury Association, Inc.

Project School Care. (1989). Children assisted by medical technology ineducational settings: Guidelines for care. Boston: Children's Hospital.

Related services for school-aged children with disabilities. (1991). NICHCY NewsDigest, 1 (2), pp. 1 - 23.

Rhein, B., & Farmer, H. (1994, April). Teaching strategies for students withTraumatic Brain Injuries. Paper presented at CEC Conference, Denver,CO.

Richards, J. S. (1992). Preventing injury: A safety curr:culum. Santa Cruz, CA:ETR Associates. (ERIC Document Reproduction Service No. ED 358 076)


Savage, R. C. (1991). Identification, classification, and placement issues forstudents with Traumatic Brain Injuries. Journal of Head TraumaRehabilitation 6 (1), 1 - 9.

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Traumatic Brain irriury 59

Savage, R. C., & Wolcott, G. (1994). Overview of an acquired brain injury. In R.C. Savage & G. F. Wolcott (Eds.), Educational dimensions of acquired braininjury (pp. 3 - 12). Austin: PRO-ED.

Tacoma Brain Injury Re-entry Team. (1994). Welcome to a ncw world. Tacoma:Tacoma Public Schools.

Telzrow, C. F. (1987). Management of academic and educational problems inhead injury. Journal of Learning Disabilities 20, 536 - 545.

Training on TBI inaeases awareness. (1995, May). Inclusive EducationPrograms, p. 2.

Tucker, B. F., & Colson, S. E. (1992). Traumatic Brain Injury: An overview ofschool re-entry. Intervention in School and Clinic (27) 4, 198 - 206.


Virginia Department of Education and the Rehabilitation Research and TrainingCenter on Severe Traumatic Brain Injury (1992). Guidelines foreducational services for students with Traumatic Brain Injury.Richmond: Author.

Waaland, P. (1991). Academic reentry of children and youth followingTraumatic Brain Injury. Special Topic Report #4. Richmond, VA:Rehabilitative Research & Training Center on Severe Traumatic BrainInjury.


Ylvisaker, M., Harwick, P., & Stevens, M. (1991). School reentry following headinjury: Managing the transition from hospital to school. Journal of HeadTrauma Rehabilitation, 6 (1), 10 - 22.

OTHER RECOMMENDED RESOURCES:

American Federation of Teachers. (1992). The Medically fragile child in the3chool setting. Washington, DC: Author.

Bigler, E. (Ed.). (1990). Traumatic Brain Injury: Mechanisms of damage,assessment, intervention, and outcome. Austin: PRO-ED, Inc.


6 9

Blosser, J. L., & DePompei, R. (1989). The head-injured student returns to school:Recognizing and treating deficits. Topics in Language Disorders, 9(2), pp.67 - 77.

Bond, N. J. (1991). Serving the child with complex medical needs in school. InServing medically fragile children in our schools: A proceedings manual.Logan, UT: Mountain Plains Regional Resource Center.

Ewing-Cobbs, L., & Fletcher, J. M. (1990). Neuropsychological assessment ofTraumatic Brain Injury in children. In E. Bigler (Ed.)Traumatic BrainInjury: Mechanisms of damage, assessment, intervention, and outcome(pp. 107 - 128). Austin: PRO-ED, Inc.

Graff, J. C., Ault, M. M., Guess, D., Taylor, M., & Thompson, B. (1990). Healthcare for students with disabilities. Baltimore: Paul H. Brookes.

Graff, J., Ault, C., & Mulligan, M. (1993). Guidelines for working with studentshaving special health care needs. Journal of School Health, 63(8), 335 - 338.

Holvoet, J. F., & Helmstetter, E. (1989). Medical problems of students withspecial needs: A guide for educators. Boston: Little, Brown and Company.

Janz, J. (1993). Inclusive education for children with special health care needs.(ERIC Document Service No. 367 125)

Martin, R. (1990). Legal challenges in Traumatic Brain Injury. In Bigler, E.(Ed.),Traumatic brain injury: Mechanisms of damage, assessment,intervention, and outcome (pp. 395 - 406). Austin: PRO-ED, Inc.

National Conference of State Legislatures, (1994). What Legislators Need ToKnow About Traumatic Brain Injury. Denver: Author.

Szekeres, S. F., & Meserve, N. F. (1994). Collaborative intervention in schoolsafter Traumatic Brain Injury. Topics in Language Disorders, 15(1), 21 - 36.

Telzrow, C. F. (1991). The school psychologist's perspective on testing studentswith Traumatic Brain Injury. Journal of Head Trauma Rehabilitation. 6(1), 23 - 34.

Waaland, P. K. (1990). Pediatric Traumatic Brain Injury. Special Topic Report #3.Richmond, VA: Rehabilitative Research & Training Center on SevereTraumatic Brain Injury.

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Traurn&qc Brain Injury 61

Waaland, P. K. (1993). Returning to school following Traumatic Brain Injury: Aguide for school personnel [Film]. (Available from Dept. of PM andR/MCV, P. 0. Box 980542, Richmond, VA 23298-0542.)

Wadsworth, D. (1993). Children who are medically fragile or technologydependent: Guidelines. Intervention in School and Clinic, 29(2), 102 - 104.

SOURCES OF ADDITIONAL INFORMATION:

National Head Injury Foundation1776 Massachusetts Avenue NWSuite 100Washington, DC 20036(202) 296-6443

Idaho Head Injury Foundation76 West 100 NorthBlackfoot, ID 83204(208) 785-0685

Rehabilitation Research and Training Center on Severe Traumatic Brain InjuryMCV Box 434Richmond, VA 23298-0434(804) 828-4232

National Brain Injury Research Foundation1730 M Street NWSuite 903Washington, DC 20036

National Rehabilitation Information Center8455 Colesville Road, Suite 935Silver Spring, MD 20910-3319800-227-0216

1;11

62 Traumatic Brain injuty

Appendix A

Kazuk, E., St Stewart, D. (1993, August). Planning for Traumatic Brain Injury(TBI): A new challenge for special education. Plantation, FL: SouthAtlantic Regional Resource Center.

MATERIAL NOT COPYRIGHTED

73


SARRC REPORTSEmerging Issues and Trends in Education

South Atlantic Regional Resource Center August 1993

Planning for Traumatic Brain Injury (TBI)A New Challenge for Special Education

Ellie Kazuk, M.A., M.B.A.National Head Injury Foundation, Florida Association

Denise Stewart, Ed. D.South Atlantic Regional Resource Center

INTRODUCTION

As a result of changes in the Individuals with Disabilities Actmade by Congress in 1990 (P.L. 101.476) and 1991 (P.L. 102-119), special education systems throughout the country areformulating plans to address the newly added category of"traumatic brain injury" (TBI), also referred to as head injuryand traumatic head injury. TBI is defined in the newregulations as "an acquired injury to the brain caused by anexternal physical force, resulting in total or partial functionaldisability or psychosocial impairment, or both, that adverselyaffects a child's educational performance..."

In the past and also currently, students with TBI have beenconsidered a low-incidence population. However, because ofadvances in emergency medicine and in neurological assessmenttechniques, increasing numbers of children with TBI are beingidentified each year. It has been estimated that annually 1 childin 500 receives an injury serious enough to cause lastingproblems (Krause, Fife, & Conroy, 1987). Rivera and Mueller(1986) have estimated that 3% of students will have a headinjury by age 15. Also, it is widely noted in the literatureregarding childhood injuries that traumatic brain injury is theprimary cause of death and disability among youth in the UnitedStates today (Waaland. 1990). The injuries primarily resultfrom motor vehicle crashes, falls, abuse, violence and sports

related or pedestrian accidents.

4111

In planning for this growing population, school systems arefaced with challenges which are unique to this category ofdisability and much different from those faced with other specialeducation categories. From the definition of TBI, toidcuification, classification, placement and delivery of services,the planning process is likely to become bogged down withissues which have not been addressed with previous disabilities.The purpose of this paper is to delineate the major issues so that(a) further research can be done more expeditiously and (b)realistic expectations can be established for how quickly andeffectively special education departments can respond to thechanges in the statues.

ISSUES

The following issues underlie many of the more specificquestions and concerns which arise during the planning process.

1. Traumatic brain injury, more than any other category ofdisability, includes a tremendous range and varieW of problems.Consequently. it is difficult to describe a typical case, crt.ate astandard curriculum, or predict what outcomes are likely tooccur. When a head injury occurs, the brain bounces back andforth against the inside of the skull causing diffused damage to

767

brain tissue, brain stem, and to various cognitive, behavioral,sensorimotor and physical functions. The damage is unique inevery individual depending on whm and how hard the head isstruck. It is extremely difficult to access the amount ofpermanent damage to the brain or to predict long-term resultingdisabilities. Age, preinjury characteristic developmental stage,family reactions, assessment and treatment techniques areadditional factors adding to the problems (Waaland, 1990).

Complicating the matter even further is that individuals withbrain injury often remember how they were before the trauma,so that a number of secondary emotional and psychosocialproblems can occur in addition to the original injury. This isnot usually present in children with congenital disabilities(Tucker & Colson, 1992).

Finally, a brain injury is often classified, particularly in medicalmodels, as being mild, moderate or severe and educators mayassume this can predict the outcome of resulting disabilities.However, these categories represent various neurologicalsequelae based on information collected in the acute caresetting. They can be most inaccurate if used to indicatepotential for school-related problems since students with mildbrain injury can experience mote disabling problems in the longrun than those who were classified as having severe injures(Savage, 1991).

It is easy to see from the above factors that planning for TBI isreally planning for a complicated, interacting set ofsensorimotor, copitive, social/behavioral and family problemswhich uniquely manifest themselves in every student and cannotbe encompassed adequately in any one disability category.Establishing educational criteria for this category is anextremely difficult challenge.

2. Recovery and performance of students with TBI is asinamig_And_maadigialit_arseaua. While other specialeducation students are usually neurologically stable withstrengths and weaknesses which might be relatively predictable,students with a MI can change neurologically at a fairly rapidpace for weeks, months or even years following return(Ylvisaker, Hartwick, & Stevens, 1991). Also, in some cases,problems can arise months or years after the initial injury as thestudent goes through developmental stages and is confrontedwith more complex intellectual and social tasks (Telzrow,1991). Therefore, assessments should be made often (i.e., every6 to 12 weeks) rather than at six months or one year intervals asis the usual practice.

Educational needs of a student with TBI may cross categoricalor grade-level lines or require a combination of home-based andschool-based programs including the regular classroom andother special education settings. The requirements fornoncategorical programming may not be unusual for someschool systems. But for most educational planners, the extent,frequency, and uniqueness of individualized program formats

which must be created or adapted for students with TBI, areparticularly challenging problems.

3. Assessment of students with a TBI usually requiresprocedures which traditionally have not been used by schoolpsychologists or other educational specialists. Traditionalassessments usually consist of IQ tests and evaluation of educa-tional or academic performance and perceptual motor skills.These tests, however, are not sensitive to neuropsychologicalneeds of MI students. Therefore, many students with TBIperform adequately on school assessment measures, but havesignificant learning and adjusmient problems. Conversely,students may score exceptionally low on school assessmentmeasures and perform quite well in class (Telzrow, 1991).

Assessment for TBI programming should document anddescribe neuropsychological functioning. Neuropsychology isa specialty area of psychology which focuses on the relationshipbetween brain function and behavior. Neuropsychologists whoare experienced in evaluating children or school psychologistswho are trained in this area should be utilized to provide assess-ments which are essential for developing interventions. Theseindividuals may be located through the nearest medical schoolor rehabilitation facility or by calling the National Head InjuryAssociation in Washington D.C., which also has chapters inmost states.

As with other special education categories, evaluations ofstudents with TBI should be multidisciplinary including theexpertise of professionals such as occupational and physicaltherapists, speech-language pathologists, nurses, teachers, andsocial workers. But, perhaps more than in any other category,evaluations should include a functional analysis obtained fromnatural school environments and nonacademic settings(Telztow, 1991). Observations from classroom teachers, socialworkers, and others who interact with the student throughout theday can be as valuable as standard evaluation tools in assessingthe student's abilities. Contextual assessments should alsoinclude Wilily input, family reactions to the injury, and generalfamily characteristics which Waaland (1990) reports have astrong, direct relationship to school adjustment. However,measuring and interpreting these aspects of the student'sexperience, particularly as it changes during various stages ofrecovery, adds a dimension and challenge to the assessment andplanning process which most schools have not previously faced.

4. Programming for a student with a recent and serious TBIrequires cross-disciplinary planning between educational andmedical models. Transitioning from a biophysical environmentat a hospital to a psychodynamic environment at school is acritical step in the student's recovery that needs to be carefullycoordinated with the family, school, and rehabilitationprofessionals (Savage, 1991; Ylvisaker, Hartwick, & Stevens,1991). Most school systems do not have processes in place forthis type of planning to occur. Therefore, new models andprocedures for successful integration need to be established,

68 7

using newly formed, home-school-hospital teams. Schoolpersonnel need to be trained in serving this population and intranslating medical information into an educational context. Onthe other hand, rehabilitation therapists ne(xl to understand whateducational planning requires and how to provide informationand support services within an educational environment.

Ideally, specialized transitional classrooms would be availableto bridge the gap between hospital and school during the postacute care period when recovery is characterized by rapidchange. They would be staffed by specially trained educatorsand rehabilitation staff who would plan for and manage theneeds of children who do not need intensive medical servicesbut who are not ready to return to school. These classrooms doexist in a few school systems and private rehabilitation facilitiesin the country; however, most communities are faced with thechallenge of planning for ttansition without special TBI re-entryclassrooms. Consequently, short and long-term planning andcoordination must take place to ensure cross-disciplinalycommunication, information exchange, and the availability offollow-up and support services during the time students needcombined medical and educational programming.

5. Deteimining the number of children to be served is Aconfusing task with significant financial implications. Becauseinformation on neurological funcdoning and appropriateassessment procedures traditionally have not been utilized by oravailable to school personnel in most school systems, manystudents have been misidentified or classified incorrectly.Consequently, when numbers of students needing services arebased on the number of students currently classified with TBI,the problem may be significantly under-represented. Also, thechanging nature of TBI described above may result in studentsneeding special services long after the time when parents andschool personnel believe the child to be fully recovered. This isparticularly true of mild and moderate cases in which symptomsdid not appear to be serious at the time of the injury. Scinoolsystems must decide how and whether these individuals will besought out or included in the numbers to be served. They mustalso decide whether to include children who have acquired braininjuries which were not a result of an external blow to the head(e.g.. infections, brain tumors, strokes) but who often need thesame support and special education needs.

Determining the number of children to be served is not only achallenge for educational planners but for administrators aswell, since the financial implications can be overwhelming.While schools may be able to work with insurance companiesand other third-party payors to share the medical costs ofindividuals who are identified, the cost of both short-term andlong-term heurologically based rehabilitation programs andservices can be prohibitive for many school districts. It will benecessary for medical and education professionals andadministrators to work together creatively to assure that theneeds of the students with neurological dysfunctions are beingmet and that all parties are appropriately sharing the costs as the

3

law requires.

FUTURE

The numbers of students with TBI can be expected to increasewith continued advances in teclmology improving survival rates.At the same time, identification procedures, interventiontechniques, educational approaches, and assistive technologyservices are also expected to improve.

The Decade of the Brain, as former President Bush named the1990's, is upon us and information and knowledge about thebrain and its functions changes almost daily. The new field ofcognitive science is a growing, multidisciplinary area which isproducing an entirely new body of knowledge to be used as asource of information for education and rehabilitationprofessionais (Lucas, 1992). To the educational planner thismeans the entire field of traumatic brain injury (like the injuryitself as it affects each individually) is a "moving target" so tospeak in a state of growth and change. While this may leadto exciting breakthroughs in cognitive research andrehabilitation, to the pragmatic planner it means that the task isnot one of merely learning new information and developingapplicable curriculum and programs, but of establishingprocesses and procedures to accommodate change. This will bedone through a tremendous amount of teamwork amongrehabilitation professionals, education specialists, the family.and, where appropriate, the student. Most importantly, it willbe done through cross-disciplinary understanding and exchangeof information resulting from coordination and planning in thewider community far beyond the walls of the school buildingitself

In summazy, planning for students with TBI may be no differentthan planning for all students as the world becomes morecomplex in general and teachers move from being informationgivers to facilitators and managers of resources which meetindividual needs. Students with TBI need integrated,interdisciplinary, individualized programming which is basicallywhat all students need. When a commitment is made to meetthe individual needs of each student and to draw on everyavailable resource from a variety of disciplines to meet thoseneeds, then planning for TBI will not be a question of setting upunique procedures for a unique category of special education,but the model for meeting the unique educational needs of allstudents, regardless of disability.

REFERENCES

Blosser, J.. & DePompei. R.. (1991). Preparing educationprofessionals for meeting the needs of students with traumaticbrain injury. Journal of Head Trauma Rehabilitation, ii(1). 73-81.

76 69

Cooley, E., & Singer, G. (1991). On serving studentswith head injuries: Are we reinventing a wheel that doesn'troll? Journal of Head Trauma Rehabilitation, 6(1) 47-55.

Deboskey, D.S., Pace, G.M., Schultz, D.C., Freeman,A.W., Hooker, C.A., Preston, J .W., Oleson, T.W., & Dye,J.M. (1990). An educational challenge: Meeting the needs ofstudents with head injury. Tampa. FL: Debosky &Associates.

Krause, J., Fife, D., & Conroy. C. (1987). Pediatric braininjuries: The nature, clinical course and early outcomes in adefined United States population. Pediatrics, 79, 501-507.

Lucas. B. (17,92, May-June). Cognitive science andrehabilitation. 1-lead lines, pp. 10-11.

Rivera, F., & Mueller, B. (1986). The epidemiology andprevention of pediatric head injtuy. lournal_nthodIriumnRehabilitation, L 7-15.

Savage, R. (1991). Identification, classification andplacement issues for students with traumatic brain injuries.Journal of Head Trauma Rehabilitation, 6(1), 1-9.

Telzrow, C. (1991). The school psychologist's perspective ontesting students with traumatic brain injury. Journal of HeadTrauma Rehabilitation, ¢(1), 24-29.

Tucker, B., & Colson, S. (1992. March). Traumatic braininjury: An overview of school re-entry. Intervention in Schooland Clinic, pp. 198-201. .

Waaland. P. (1990). Response to childhood traumaticbrain injury. In J. Kreutzer & P. Wehman (Eds.). Communityintegration following traumatic brain injury (pp. 225-247).Baltimore, MD: Paul Brookes Publishing Company.

Ylvisaker, M., Hartwick, P., & Stevens, M. (1991).School re-entry following head injury: Managing the transitionfrom hospital to school. Inurnal_.oLliead_IngunaRehabilitation ¢(1), 10-22.

The South Atlantic Regional Resource Center1236 North University DrivePlantation, Florida 33322Tel: (305) 473-6106FAX: (305) 424-4309

Timothy Kelly, DirectorDenise Stewart, Associate DirectorDelia Cerpa, Technical Assistant CoordinatorDiane Davis, Technical Assistant CoordinatorIsa Joseph, Technical Assistant CoordinatorDeborah Seaman, Evaluation AssistantConnie Lewis, Office ManagerJudith Bransfield, Grant SpecialistAnn Lipsitz, SecretaryRita Sylvester, Secretary

This newsletter is a publication of the South AtlanticRegional Resource Center (SARRO. The development ofthis work was supported by the US. Department ofEducation, Office of Special Education ProgramsCooperative Agreement No. H0283005 awarded to FloridaAllan& University. The materials contained herein do notnecessarily reflect the positioa or policy of the U.S.Department of Education, Office of Special Education andno official endorsement should be inferred.

The Center provides information, technical assistance,consultation, and training, as requested, to state educationagencies and through them to local education agencies andother appropriate public agencies who provide specialeducation , related services, and early intervention servicesfor infants, toddlers, children and youth with disabilitiesand their families.

BEST COPY AVAILABLE

4

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Appendix 13

78

General information about Traumatic Brain Injury. NICHCY Fact SheetNumber 18 (FS18). (1994). Washington, DC: National InformationCenter for Children and Youth with Disabilities.



National Information Center

for ChiMren and Youth

with Disabilities

Definition

A

NICHCY

The regu!ations for Public Law 101476, the Individu-als with Disabilities Education Act (IDEA), formerly theEducation of the Handicapped Act, now include Trau-matic Brain Injury (TBI) as a separate disability category.While children with TBI have always been eligible forspecial education and related services, it should be easierfor them under this new category to receive the services towhich they are entitled.

Traumatic Brain Injury (TBI) is defined within theIDEA as an acquired injury to the brain caused by anexternal physical force, resulting in total or partial func-tional disability or psychosocial impairment, or both, thatadversely affects a child's educational performance. Theterm applies to open and closed head injuries resulting inimpairments in one or more areas, such as: cognition;language; memory; attention; reasoning; abstract thinking;judgment; problem-solving, sensory, perceptual, and mo-tor abilities; psychosocial behavior; physical functions; in-formation processing; and speech. The term does not applyto brain injuries -.hat are congenital or degenerative, or braininjuries induced by birth trauma. (U.S. Federal Register,57(189), September 29, 1992, p.44802)

Incidence

TBI is the leading cause of death and disability inchildren and adolescents in the United States. The mostfrequent causes of TBI are related tu :notor vehicle crashes,falls, sports, and abuse/assault. More than one millionchildren sustain head injuries annually; approximately165,000 require hospitalization. However, many studentswith mild brain injury may never see a health care profes-sional at the time of the accident.

Characteristics

The National Head Injury Foundation calls TBI "thesilent epidemic," because many children have no visibleimpairments after a head injury. Symptoms can vary greatlydepending upon the extent and location of the brain injuryHOwever, impairments in one or more areas (such ascognitive functioning, physical abilities, communication,or social/behavioral disruption) are common. These im-pairments may be either temporary or permanent in nature

P.O. Box 1492Waxhingion, D.C.

26013-1492

1-800-695-0285 (Voice/TT)

and may cause partial or total functional disability as well aspsychosocial maladjustment. Children who sustain TBImay experience a complex array of problems, including:

Physicalimpairments: Speech, vision, hearing, and othersensory impairment; headaches; lack of fine motorcoordination; spasticity of muscles; paresis or paralysisof one or both sides; seizure disorders; and balance andother gait impairments.Cognitive impairments: Short- and long-term memorydeficits, impaired concentration, slowness of thinking,and limited attention span, as well as impairments ofperception, communication, reading and writing skills,planning, sequencing, and judgment.Psychosocial, behavioral, or emotional impairments: Fa-tigue, mood swings, denial, self-centeredness, anxiety,depression, lowered self-esteem, sexual dysfunction,restlessness, lack of motivation, inability to self-moni-tor, difficulty with emotional control, inability to cope,agitation, excessive laughing or crying, and difficultyrelating to others.Any or all of the above impairments may occur to

different degrees. The nature of the injury and its atten-dant problems can range from mild to severe, and the courseof recovery is very difficult to predict for any given student.It is important to note that, with early and ongoing thera-peutic intervention, the severity of these symptoms maydecrease, but in varying degrees.

Educational Implications

Despite the high incidence of TBI, many medical andeducation professionals are unaware of the consequences ofchildhood head injury. Students with TBI are too ofteninappropriately classified as hav ing learning disabilities,emotional disturbance, or mental retardation. As a result,the needed educational and related services may not beprovided within the special education program. The des-ignation of TBI as a separate category of disability signalsthat schools must provide children and youth with access toand funding for evaluations in all areas related to thetraumatic brain injury, including (if appropriate) health,vision, hearing, social and emotional status, general intelli-gence, academic performance, communicative status, andmotor abilities. The information gathered through theseevaluations will assist the school and parents in developingan appropriate individualized education programa (I EP).

0 75

TRAUMATIC BRAINWhile the majority of children with TBI return to

school, their educational and emotional needs are likely tobe very different than they were prior to the injury. Al-though children with TBI may seem to function much likechildren born with other handicapping conditions, it isimportant ad recognize that the sudden onset of a severedisability resulting from trauma is very different. Childrenwith brain injuries can often remember how they werebefore the trauma, which can result in a constellation ofemotional and psychosocial problems not usually present inchildren witl, congenital disabilities. Further, the traumaimpacts family, friends, and professionals who recall whatthe child was like prior to injury and who have difficulty inshifting and adjusting goals and expectations.

Therefore, careful planning for school re-entry (includ-ing establishing linkages between the trauma center/reha-bilitation hospital and the special education team at theschool) is extremely important in meeting the needs of thechild. It will be important to determine whether the childneeds to relearn material previously known. Supervisionmay be needed (i.e., between the classroom and restroom)as the child may have difficulty with orientation. Teachersshould also be aware that, because the child's short-termmemory may be impaired, what appears to have beenlearned may be forgotten later in the day. To work con-structively with students with TBI, educators may need to:

Provide repetition and consistency;

Demonstrate new tasks, state instructions, and pro-vide examples to illustrate ideas and concepts;

Avoid figurative language;

Reinforce lengthening periods of attention to appro-priate tasks;

Probe skill acquisition frequently and provide repeatedpractice;

Teach compensatory strategies for increasing memory;

Be prepared for students' reduced stamina, and pro-vide rest breaks as needed; and

Keep the environment as distraction-free as possible.

Initially, it may be important for teachers to gaugewheth,:x the child can follow one-step instructions wellbefore challenging the child with a sequence of two or moredirections. Often attention is focused on the child's dis-abilities after the injury, which reduces self-esteem; there-fore, it is important *o provide opportunities for success andto maximize the child's strengths.

76

Resources

Begali, V. (1992). Head injury in children and adolescents: A resourceand review forschool and allied professionals (2nd ed.). Brandon,VT: Clinical Psychology Publishing Company, Inc. (Tele-phone: 1-800-433-8234.)

Cutler, B.C. (1993). You, your child, and "special" education: A guideto making systems work. Baltimore, MD: Paul H. Brookes Pub-lishing Co. (Telephone: 1-800-638-3775.)

Gerring, P.J., & Carney, J.M. (1992). Head trauma: Strategies foreducational reintegration. San Diego, CA: Singular PublishingGroup, Inc. (Telephone: 1-800-521-8545.)

Lash, M.(1992). When yourchildgoes to school afteran injuty. Boston,MA: Exceptional Parent Press.

National Rehabilitation Information Center. (1992). Traumaticbrain injury: A NARIC res6urre guide forpeople with TBI and theirfamilies. Silver Spring, MD:Author. (Telephone: 1- 800-227-0216.)

Savage, R.(1988). An educator's manual:What educators need to knowabout students with TBI. Washington, DC: National HeadInjury Foundation, Inc. (See address below.)

Tucker, B.F., & Colson, S.E. (1992). Traumatic brain injury: Anoverview of school re-entry. Intervention in School and Clinic,07(4), 198-206.

Organizations

National Head Injury Foundation1776 Massachusetts Avenue, NW, Suite 100Washington, DC 20036800-444-6443 (Family Helpline); 202-296-6443

Epilepsy Foundation of America4351 Carden City Drive, Suite 406Landover, MD 20785301-459-3700; (800) 332-1000

THINK FIRST Foundation22 South Washington St.Park Ridge, IL 60068(708) 692-2740

Update 11/94

This fact sheet is made possible through Cooperative Agree-ment#H030A30003 between the Academy for Educational Devel-opment and the Office of Special Education Programs, U.S. De-partment of Education. The contents of this publication do notnecessarily reflect the views or policies of the Department ofEducation, nor does mention of trade names, commercial productsor organizations imply endorsement by the U. S. Government.

This information is copyright free. Readers are encouraged tocopy and sharc it, but please credit the National InformationCenter for Children and Youth with Disabilities (NICHCY).

For more information, contact NICIICY.

Fact Sheet Number 18 FS18 1993

NICHCYNational Information Center for Children and Youth with Disabilities

P.O. Box 1492, Washington, D.C. 20013-1492140049S-0285 (Linea gramita, VozITT)

SpecialNet User Name: NICHCY ** Internet: nkhcytkapcon.net

Infonnacidn General Sabre

LESION CEREBRAL

Definicida

Las regulaciones de la Ley Pdblica 101-476, el Acta Farala Educacidn de los Individuos con Discapacidades (IDEA),antericemente el Acta para la Eclucacida de los Impedido(EHA), ahora incluye la Lesko Cerebral COMO ima categoria;parte. Los nine's coo Limits Ceracal siecupre bad sidoconsiderados etigibles para recibir los servicios a los cualestienen derecho, perobajo esta nueva categcsia el promo serimIs ficil.

La Lesion Cerebral se define en IDEA como una heridaadqnirida pot el cerebra, la cual es causada por alguna fuerzaMica extern& que results en una discapacidad funcional totalo parcial o un impedimenta psicoldgico, o ambos, que afectanadversamente el rendimiento academic° del nino. El tirminose aplica a las heridas abiertas y cerradas, las wales resultanen irnpedimentos en una o mis ireu, tales como la cognicidn;idiot= memoria; atenciden razonamiento; el pensamientoabstracto; criteria; la solucidn de problems; las habilidadessensoriales, matrices, y de la percepcidn; el compatamientopsicosocial; las funciones Micas; el procesamiento deinformacide; y el habla. El tirmino no se :Oka a las lesionescerebrates congthitas odegenerativas,o a las beridas cerebratesinducidas por trauma durante el porta. (Federal Register,57(189), septiembre 29, 1992, pig. 44802)

Incidencia

Las lesiones cerebrates son la principal causa de la muertey discapacidad en los nitios y adolescentes en los EstadosUnidos. Las mas frecuentes causas de las lesicres cerebratesson los accidentes automovilfsticos, las cafdas, los deportes, yel abuso o asalto. Cada afio, mils de un mill& de nificsexperimentan lesiones cerebrales; MOS 165,000 requiemhospitalizaci6n. Muchos alumnos con ICSiOlICS otrelxales noyen a un profesional cuancb ocurre el accidente.

Caracterlsticas

La organizacido National Head Injury Foundation hacalificado las lesiones cerebrates coma "ta epidemiasilenciosa," porque despues de la herida, muchos niflos quedansin impedimentos visibles. Los sintomas pueden variardependiendo de la gravedad y ubicacidn de Is herida. Sin

embargo, los impedimentos en una o Inas areas (tales co= elfuncionamiento cognoscitivo, las habilidades Micas,comunicacidn, o desorganizacido social o de la conducta) soncomunes. Est°, impedimentos pueden ser temporineos opermanentes, y pseden causar discapacidades funcionalestotales o parciales, ademis de mal ajuste psicosocial. Losdna que hayan experimemado una leside cerebral puedenexhibirunavariedadde problems& incluyendo los siguientes:

Impedimentos ftsicos - el habla, visido, audicion, uotro impedimesuo sensorial; dolores de cabeza; faitsde caccdinacide mark; espasticidad de los mdsculos;paresis o parilisis en uno o ambos lados del cuerpo;desdrdenes o ataques de apoplejia; e impedimentosen el balance o en el modo de ands:.Impedimenta cognoscitivos - &licit de la memoria;debilitaciars conceuracido; pmssmiento lento:atencidn limitada; impedimenta' en la percepcidn,comnicacidn, y destzezas para leer y escribir,planificacidn, logics, y juicio.Impedimentos psico-socioemocionales y de laconducta fatiga, mat humor, cootradiccicees, elegocentrism°, las ansiedades, depresidn, autoestima,dishmcidn sexual, inquietude& falta de motivasidn,dificaltades car el control emocional, la inhabilidadpara hacer frente a los problems, agitacionts, risa oItranos excesivos, yfalta de habilidad pararelacionarsecon loa danis.

Cualquier o todos de estos impedimentos pueden ocurrira diferentes niveles. La naturaleza de la herida y los problemasque la acompanan pueden variar de leve a sever°, y el curso dela recuperacidn es dificil de predecir. Es imports= notarque,a tray& de la intervencitin terap6utica, temprana y continua,

severidad demos sintamas puede dismimdr, pero a diftrentesniveles.

Motes en la Educscion

A pew del alto indict de lesion cerebral, muchosprofesiceales en los carnpos de la medicina y educaciOn noestin al tanto de las consecuencias de las lesiones cerebratesque ocunen durante la nillez. Los alumnos con lesi6n cerebralquedan equivocadamente calificados como nines conproblemas de aprendizaje, trastoroos emotional= o retraso

BEST COPY AVAILABLE 8 2. 77

mental. Como resultado, es posible que los servicioseducacionales o servicios relacionados no sean provistosdentro del programa de educación especial. La designaciOn delesion cerebral como categorfa aparte indica que las escuelasdeberfan proveer a los niflos y j6venes el acceso a fondos paraevaluaciones neuropsicolOgicas, educacionales, y del habla eidioma, entre orras necesarias, para clesarrollar un programaeducacional individualizado (IEP).

El Moho de que el &no se haya recuperado lo suficiente comopara regresar a la escuela no quiere decir que el Piro hayarecuperado toda su capacidad anterior a la herida Aunque losadios con lesion cerebral pueden demostrar una conduct*similar a la de los ninos que hayan nacido con oiro tipo decondicion o discapacidad, es importante reccaocer que losefectos repentinos causados par el trauma scamuy diferentes.En =hos casos el nifto con lesiOn cerebral puede recocaarcomo en antes del tnuma, lo cual puede resultar en muchosproblemas emocicoales y psicosociales, difereutes a los guttipicamente se encuentrar en los niftos cca discapacidades deorfgen congenito. Ademgs, el trauma puede impactar sobre Isfamilia., amigos, y profesionales que recuerdan COMO era elniflo antes de la herida y que pueden tener dificultad al cambiary ajustar sus metas y expectaciones.

Entonces, part satisfacer las necesidades del nilio es muyimponante planificar cuidadosamente su regreso a la escuela.Tambien sent inipcname &termini/ si el nifio necesita spreaderde nuevo la materia que estudid previamente. Es posible queel nino necesite supervisiea (pars ir desde el salon de clueshasta el buffo, por ejemplo), ya que puede tener dificultad paraorientarse. Los profeskwes deben estar al tanto de como lamemoria del nine" puede quedar impedida, todo loaparentemente haya aprendido en tm dfa puede olvidirselernás tarde. Para trabajar construclivamente con alumnae conlesion cerebral, los educadores deberin:

Dark al alurnno opactunidades pant repetir y unambiente consistente;Enseftar y demostrar nuevos trabajos, darleinstruccien, y prover' ejemplos pan ilustrar ideas yconceptos:Evitar el uso do expresiones figurativas:Animar al alumno a medida que vaya mejorando suconcentraciOn;Explorar con frecuencia la adquisicion de habilidadesy proveer oportunidades pars la viatica;Enseriar estrategias compensatorias para aumentar lamemccia;Estar preparado pus la falta de vigcc que es tipico delos alumnae cca leak% cerebral y proveer periodos dedescanso como sea necesario; yMamener el ambieme libre de tock distraccida

Para mayor Informal& coattato a NICHCY.

Es posible que al principio los profesores tenganque medir siel nifio puede segitir instrucciones simples antes de darkinstrucciones complicadas. A veces se enfoca toda la atenciOnen las discapacidades del niflo, lo alai puede reducir suautoestimaciOn; por lo tanto, es imponante aumentar lasoportunidades para el exito y llevar hasta el maximo laspotencialidades del nitio.

Recursos

Began, V. (1992). Head injury in children and adolescents:A resource and review for school and allied professionals(2nd ed.). Brandon, VT: Clinical Psychology Publishing.

Gerring, PJ., &Carney, J.M. (1992). Head trauma: Strategiesfor educational reintegration. San Diego, CA: SingularPublishing Group. (Telefono: 1-800-521-8545.)

liationalP lisbilitaeaninfamatinncenw (1901) TrazoneLticbrain ic rry: A NAIUC resource guide for people with TBIandtheirjamilies. Silver Spring, MD: Autoc. (Telefcao: 1-800-2214216. Se habliespallol.)

Savage, R. (1988). An educator's manual: What educatorsneed to know about students with TB!. Washington, DC:Naticeal Head Injury Foundation. (Ver direcoida mIts

Organiraciones

National Head Injury Foundation1776 Massachtsetts Avenue N.W., Suite 100Washington, DC 20036(800) 444-6443 (Ayuda para la familia); (202) 296-6443

Epilepsy Foundation of America4351 Garden City Drive, Suite 406Landover, MD 20785(800) 332-1000; (301) 459-3700

MINK FIRST Foundation22 South Washington StreetPark Ridge, IL 60068(708) 692-2740

Este document° fue desarrollado por el Academy for EducationalDevelopment a tray& del Acuerdo Cooperstivo&H030A30003 conla O&M& de Programs' de Educaci6n Especial. Deportment° deEducación de los Estados Unidos. El contenido de este documemono refleja necessriamente los puntos de vista o politica& delDepartamento de Educacidn de los Estado: Uridos. como tampocola mean do productos comerciales u orsaniracionea implicit laoFolacidn del Doportamenso de Educacidn. 7fsmWorms:Ma notisos &mhos le policatiths. S. puede Iwsr aria, is elitdocuments y mayor:We con Maas personas. Por favor di elctddito de publicacidn al National Information Center fox Childrenand Youth wish Disabilities (NICHCY).

83 UPDATE W94

78 BEST COPY AVMLABLE

Teacher alert, I. (1991). In B. Pieper (Ed.), Traumatic Brain Injury: What theteacher needs to know. Albany, NY: New York State Head InjuryAssociation.

REPRINTED WITH PERMISSION

"4


TEACHER ALERT, I

Head Injury? Difficulty at School?The Two May Be Related!

Children who have sustained even "mild" head injury, often experience learning or behavioralchanges which may last for various lengths of time. Further, there is not a great deal of researchon mild head injury as experienced by children. In general, it is assumed that the kinds ofproblems which are well documented for adults will be similar for children. In the past, someexperts had expressed opinions that children may be somewhat more likely to "recover" morecompletely or that symptoms may resolve more quickly. Others have postulated that a betteroutcome may be expected when the level of knowledge and skills is well developed. There is nodefinitive answer. There seems to be general agreement, however, that teacherscan be invaluablein identifying and supporting children who have difficulties relating to traumatic injury to thebrain.

Some Complaints Teachers Might Bear:

dizzinessheadachefeeling tiredcan't see rightcan't remember

Some Behaviors Teachers Might Notice:

attention deficiency/failure to sustain concentration and or/activitypoor short-term memory (literally not able to "remember from one minute or day to thenext")more time is needed to process information and respond to questionstiredness, especially after tasks which involve concentration snd continuous attentionexcuses to avoid such tasks or activitiesanxiety (may show up as fast, agitated speech, ie.)emotional swings and disinhibition (may include giggling, laughing, crying inappropriatelyand/or talking out of turn, etc.)an undesirable change in peer relationships (subtle behavioral changes may be noticed firstby other students; isolation or teasing often follow.)a changed attitude or performance from pre-injury levels

New York State Head Injury Association855 Central AvenueAlbany, NY 12206

(800) 228-8201

81

Appendix C

Physical Facilities and Planning Checklist for Schools. (1992). In M. Mira, B.Tucker, & J. Tyler (Eds.), Traumatic Brain Injury in children andadolescents (pp.101 - 103). Austin: PRO-ED.


8 'i

Traumatic Brain Injury as

APPENDIX BPhysical Facilities and Planning

Checklist for Schools

Classroom and Halls

Are floors of nonslip material?

Are water fountains located on each floor?

Does the student:

Have to change classes?

Have to change levels? (Specify appropriate optionselevator, ramps, stairs with handrails.)

Need to be dismissed early to avoid hall traffic?

Participate in recess?

Need a rest period at school? (Specify length and location.)

Carry and manage his or her own books? (Specify person whoassists.)

Require preferential seating?

Restroom

Does the student:

Need assistance in caring for bowel/bladder needs? (Specifyappropriate procedures and person who assists.)

Have an accessible, private place available for toileting?

Have bowel/bladder accidents? (Who assists? Where canextra clothing be kept at school?)

Need help with clothing?

Need F. lp with physical access to toilet?

Need adaptive equipment (e.g., raised toilet seat, grab bars)?

Have adequate time for attending to toileting needs?

Cafeteria

Does the student:

Have access to the cafeteria?Ff 8

87

88

102 APPENDIX B

Have a special diet or diet supplement? (Specify diet restric-tons. Specify who supplies special foods.)

Have ability to manage food tray and eat independently?(Specify person who assists and the needed adaptive eatingequipment.)

Gym

Does the student:

Have ability to participate in physical education classes?

Need adaptive physical education?

Need modified sports equipment?

School/Student Awareness

Have all appropriate school personnel been briefed or trainedregarding the student's medical condition and needs?

Have classmates arid other peers been informed or trainedabout medical or behavior needs?

Have emergency procedures been defined? Tested?

Does the student:

Have an adult advocate at school?

Exhibit behavior that might be dangerous to himself/herselfor others?

Medical

Does the student:

Take medicine at school? (Specify procedures, storage loca-

tion, person who administers dosage.)

Take medication producing side effects?

Take medication that affects school performance?

Have a history of or current episodes of seizures? (Specif)personnel and procedures trained to intervene.)

Wear braces or splints, or use assistance for walking?

Need humidifying/suction or other equipment for trartheatube care?

R 9

APPENDIX B 103

Equipment

Does the student:

_ Need other adaptive equipment at school?Computer, adaptive hardware, adaptive softwareTypewriter, braillewriterAdaptive seating: seat insert, lap tray, standing tableAugmentative communication: communication board,headstick, mouthstick, oth.-rAdjustable desktopSpecial paper: wide spaced, raised lines, colored linesSpecial pencils, penSqueeze scissors

Transportation and Parking

Are walking surfaces between bus and building of nonslipmaterial?

Are curb cuts between bus and building convenientlylocated?

Are there obstacles (manhole covers, ventilation grates)between parking lot and school building?

Has transportation facility been informed of schedule, andwhere to pick up and drop off student?

Who accompanies student on bus?

Does the student:

Use regular bus service?

Use alternative transportation? (Specify alternative.)

Need special transportation? (Specify needshydraulic chairlift, preferential parking.)

9089

Checklist for School Reentry. (1992). In M. Mira, B. Tucker, & J. Tyler (Eds.),Traumatic Brain Injury in children and adolescents (pp. 105 - 107).Austin: PRO-ED.


91

Traumatic Brain injuty 91

APPENDIX CChecklist for School Reentry

Thiugs To Do During the Acute Care Phase

Step 1

Rehabilitation medicine consultation with hospital psychology and/oreducation departments for psychological/ neuropsychological testingand education evaluation and planning assistance.

Step 2

Psychology/education personnel from the hospital, review student/patient's chart, visit patient and family, and check patient and chart

daily to determine readiness for appropriate standardized tests and

informal assessment.

Get appropriate consent forms signed by parents

Exchange information with schoolInclude school attendance, achievement, and anecdotal recordsSend hospital records that are relevant to future educationplanning and programming

Schedule first testing session if appropriate

Give family an information packet with materials to informthem of educational needs of students with TM and supportgroup contacts

Arrange to videotape student in therapy sessions (tapes maybe edited and used later by parents or teachers to facilitateschool reentry or document progress)

Step 3

Someone from the hospital should telephone or visit school after

parent signs consent forms.

Discuss student's current condition and estimated time until

hospital release

Discuss arrangements for homelound teaching, if appropriate

Discuss tentative sequence of events for school reentry, tech-

niques for managing reentry, and resources that may be needed

9293

94

.4 PPbNDIA

Schedule school representeives' hospital visit with student;also schedule time for them to meet physicians and rehabilita-tion therapistsInform school personnel of dates, times, and locations of hospi-tal team meetings and planning conferences; make arrange-ments for their attendance

Step 4

Arrange a time and date to conduct inservice for teachers andsupport personnel; explain considerations in reentry planning

Step 5

Request a written summary for the school

Summary should describe the student's injury, course of treatmentand recovery, and recommendations for meeting the student's edu-cation needs by modifying the education program and schoolenvironment.

Recommendations may include:

School-based occupational, physical, or speech therapy

Counselingpeer group, academic, behavioral, vocational

Planning for emergenciesphysical or behavioral problems

Medication and dosage schedules

Transportation

Equipmentwheelchair, oxygen, augmentative communication

Adaptive physical education

Ways to promote positive self-image and peer interaction

Ways to manage apathy, impulsivity, disinhibition, alteredjudgment

Ways to minimize family stress

Ways to capitalize on relative academic strengths

Ways to minimize or remediate relative academic weaknesses

Ways to increase attention, concentration, organization

Evaluation/assessment intervals

93

Timing for team meetings to discuss progresswhen to moni-tor, evaluate, and reprogram

School's liaison with other agenciesvocational rehabilitation,social services, hospital, rehabilitation physicians, communitysupport services

Most appropriate educational service delivery optionresource, self-contained, mainstream, homebound, shortenedschool day

Inservice program for school personnel or resources forobtaining inservice training

34

Tacoma Brain Injury Re-entry Team. (1994). Welcome to a new world.Tacoma: Tacoma Public Schools.


95Traumatic Brain injury 97

WELCOMETO R

NEW WORLD

I.Ak/AIIMUN\AMIN& *

MEM Allitiatalli&WINNI111211/3.111111211M111111111111111111111111111111/1111111104.41111111111 tWil MEW 111111N1117 IFEI u1V volvyIter

A PRESENTATION BY:

TRAUMATIC BRAIN INJURY RE-ENTRY TEAM

TACOMA PUBLIC SCHOOLS

96

139

TRAUMATIC BRAININJURY

RE-ENTRY TEAM

TACOMA PUBLIC SCHOOLS

The Tacoma Public Schools' TraumaticBrain Injury Re-Entry Team has beenestablished to focus on the unique needsof school aged youth who have hadtraumatic brain injuries. The team ismade up of school district personnelfrom the following disciplines:administration, classroom instruction,psychology, physical therapy,occupational therapy, communicationdisorders, social work and transition.Each discipline brings expertise to theteam which allows for the developmentof an educational strategy which bestfits the needs of the individual student.

The team participates in staffings withpersonnel from medical facilities,formulating plans for the student to re-enter the school system, consultingwith serving schools in developing andimplementing the IEP goals, and re-evaluating the ever-changing needs ofthe students. Techniques and strategieshave been developed to assist studentsand their families make the transitionfrom medical facilities to schools.

An intake process has been developed toassist the team in collecting pertinentinformation for the design of anappropriate program and placement for

100

the student. This information is used todetermine options for the student whichmay include: complete integration intohis/her home school with consultationservices from the team, completeintegration into the typical schoolprogram, shortened days, supportservices, or special education support.

The team serves students whoseresidual effects from their injury rangefrom mild to severe. These studentsenter the school system from hospitals,care facilities and their family homes.The individual student presents a uniqueset of issues which are addressed in avariety of ways. The kinds of servicesvary from consultation to directinstruction and therapy. To date, theteam has provided service for twenty-five students in the past six yaars.

For further information contact:

Richard C. KingProgram AdministratorSpecial EducationTacoma Public Schools(206) 596-1054

97

Tacoma Public SchoolsTraumatic Brain Injury Team

Flow ChartHOME SCHOOlj

1111MINNIIMINIHOSPITAL

MDT/PRINCIPAL I

CASE MANAGER

RICH KING

TEAM

REVIEWINFORMATION

LPARENT

C ONTACTcorsact penal chosat by tom)

HOSPITALCONFERENCE

(ram confers with hospital staff)

RECOMMENDATIONSPlacementProgramSchoolSupport Services

PARENT

HOME SCHOOL MDT

1

wairapla

101

PHASES OF RE-ENTRY INTO SCHOOLS

PHASE 1:

Hospital staffing information gathering

Development of plan to integrate into schoolsetting

PHASE 2:

Entry iato school setting

Implementation of plan- classes/therapies- re-evaluation of plan

On-going education and integration intothe educational setting

PHASE 3:

Community integrationcommunity access/leisure activities

- work experience- work training

Post-secondary schooling

- Residential options

10299

Q: Who do you contact in the schooldistrict when a student has had ahead injury and needs to return toschool?

Q: What resources are available in theschool district?

A: In most school districts, thecontact person would be theSpecial Education Administrator orhis/her designee. In someinstances the school principal orschool nurse may be the first toknow of the injury, but it isimportant that the SpecialEducation Administrator becontacted so support services canbe provided to the student at thetime of re-entry into the schools.

In the Tacoma School District, thecontact person is:

Richard C. KingProgram AdministratorSpecial Education(206) 596-1054

A: School districts should be able toprovide specially designededucational programs to fit theneeds of the student. This programmay include specific supportservices designed to help thestudent be successful in theeducational environment. Theseneeds are identified through aprocess of referral, review ofpertinent information (includingmedical, pre-injury school records,psychological reports, etc.)assessment and a decision of themultidisciplinary team (MDT).

1GIO

103

Q: What is different in theexpectations of the hospitalenvironment and the schoolenvironment?

104

A: The hospital environment is asheltered environment for theperson who has sustained a braininjury - uncrowded hallways, one toone therapy, choices are made forthe patient as to appointments, andso on. The services provided in thisenvironment are designed to berehabilitative in nature, and areoften brought to the patient.

The school environment, on the

other hand, is less sheltered, moreconfusing, and is focused oneducation rather than rehabilitationThe student is expected to function

in an environment where there aremany other students, longer days,crowded hallways, recess time, busriding, decision making andexpectations that they can change

and adapt rapidly throughout theirschedule. Accommodations such asshortened day, different classpassing times, classes with fewerstudents, etc. can make there-entry into the school setting alittle easier.

For some students, the two systems

may overlap. Education personnelmay go to the hospital while thestudent is still an inpatient andprovide educational services, and

after the student returns to school,they may receive medical servicesas an outpatient.

101

Q: What kind of community resourcesare available for students andfamilies?

A: There are many supports availablefor persons who have sustained abrain injury and their families. The

most common are Division ofDevelopmental Disabilities (DDD),Division of VocationalRehabilitation (DVR), andSupplemental Security Income (SSI).

Some of these agencies (DDD andDVR) are limited in their servicesby funding, and therefore, must be

pursued as soon as possible after

the injury.

Support groups for the person whohas sustained the brain injury, aswell as their families, are availablein many communities.

Washington State Head InjuryFoundation and the National HeadInjury Foundation are excellentresources for information.

Parents Are Vital in Education(PAVE) is an excellent resource forsupports in working with andunderstanding the school system.

105

Q: Who are the most important peoplein helping the student be successfulin the school environment?

106

A: The people who are the mostimportant in making the transitionfrom the hospital to the school, thenfrom the schools into thecommunity are the student andtheir family. Others can playimportant roles in helping theperson with the brain injury, but theconstants in the person's life aretheir families and themselves. It isimportant for support people toremember this and to assist in thedevelopment of advocacy skills forboth the families and the individual.

MATTERS TO CONSIDER

- Letter to parents from the District coordinator offering directservices and/or consultation upon notification of student's injury.

- Assign team member to follow up on intake information, parentcontacts, hospital contacts, etc.

- Assure that when scheduling is done with the student, socializationopportunities are taken into account. (i.e. peer tutors, non-academiccourses, etc.)

- Develop a notebook for the student and their family which wouldinclude:

community resourcesrecord of therapy services and treatmentstypes of classes takenopportunities offered for integrationopportunities offered for community accessetc.

- Help the student and their family structure their entire day, not justthe time in which the student is in school.

- Be prepared to help the families adjust to the differences in theirchild, and accommodate for these differences in the home andcommunity

- Ensure parent involvement throughout the process

- Help the families understand the Special Education worlddue processservicestermsetc.

- Train students and parents in advocacy skills

- Have frequent reality checks with students, parents, and staff

104 107

Tacoma Public Schools Traumatic Brain Injury Team

To:Date:

, a student in your periodclass has recently suffered a traumatic brain injury. She/he isappropriate to be back in school, but may exhibit some of thefollowing symptoms:

drowsinesspoor attention spanconfusionmemory lossdifficulty with interpersonal skillspoor coordinationdifficulty with listening to and following directionsemotional outburstsinappropriate languagevision problemsextreme headacheshandwriting difficulties

Please contact if any of thesebehaviors are of concern to you, or if you would like moreinformation about head injuries or this students.

Thank You!!!

1081115

Tacoma Public SchoolsTraumatic Brain Injury Team

Intake Data

Student name Respondent

Parent name Phone

Address

Person administering survey Date of survey

Accident Information:

Date of accident

Nature of accident

Nature of Injuries

Medical Information:

Care Source

Doctor Phone

Treatment

Medication:

Dosage Frequency

Dosage Frequency

Dosage Frequency

109

Medical Information (cont'd):

Significant Medical History:

Illnesses

Injuries

110

Attention Span:

What is the student's attention span like in the following:

directed activities minutes

chosen activities minutes

Memory:

Does the student have difficulty in recall? (i.e. names, events, etc.)

short term

long term

Can the student follow directions? (check the following):

one step three step

two step four step

Communication:

Does the student speak name clearly? (please comment)

How is the volume?

Is speech production slow? (please describe)

11)7

Communication (cont'd):

Is the student having difficulty recalling specific words or phrases? (please list)

Self Help:

Does the student initiate self care tasks? (please list)

Does the student identify when it is time to bathe?

Eating:

Can the student feed self independently?

Are there any adaptations which are needed? (i.e. cutting meat, special diets, cravings, etc.)

(please list)

Does the student have any definite likes and dislikes? (please list)

Dressing:

Can the student dress independently?

Can the student do fastenings? (buttons, zippers, etc.)

Does the student choose appropriate clothing? (ie. matching, weather appropriate, etc.)

Bathing:

Can the student prepare for bathing ?(ie. water temperature ok, organize clothing, etc.)

Bathe independently Brush teeth wash hair shave

Other(please describe)

Vs 111

Self Help (Cont'd)

Toileting:

Can student toilet independently?

What kind of assistance is necessary?

How does the student move around your home?

Leisure Time:

How does student spend time at home? (ie. computer games, TV, etc.)

How much time in each area?

What are the student's favorite things to do at home or in the community?

Sleep Patterns:

How many hours per day does the student sleep?

Which hours of the day does this sleep occur?

Any sleeping problems? (ie. nightmare, awake at night, etc.)

Physical Limitations/Abilities:

112ma

Adjustment:

Pleas circle each of the behaviors listed below which have been observed at any time since thisstudent received a traumatic brain injury:

denial of limitations nightmares leaving assigned area without permission

refusal to comply with requests excessive eating shortened attention

heightened distractability dizziness swearing or vulgarity

inappropriate sexual behaviors lack of interest in activities

temper outbursts changes in sleep patterns large mood swings

fearful reactions to normal conditions compulsive use of tobacco

misreprentations of facts misappropriation of money or other things

Please describe the approaches you have taken with this student to help him with the behavioralconcerns identified above and winch have been most effective.

Goals:

What goals do you envision this student accomplishing over the next few months?

Social:

Academic:

110 113

Goals (Cont'd)

Self help:

Mobility:

Current/ Stated Prognosis:

Support Services:

If any support services are currently being provided please state the service and list thetherapist's name(s) and phone number if available:

Support service Therapist Phone

e

Resources/Reports are available from:

Agana Address Key person

Additional information/comments:

1 11JL ." A.

115

116

TRAUMATIC BRAIN INJURY RE-ENTRY TEAM

Tacoma Public Schools

Members:

RICHARD C. KINGProgram Administrator

CAROL BARNEWCase Manager

CAROL COARPsychologist

SALLY KELLYCommunication Disorder Specialist

LIZ SCHROEDELOccupational Therapist

SHARON FULTZPhysical Therapist

AL SORENSONPhysical Therapist

KRIS HIRSCHMANNTransition Specialist

v 3

Issues for consideration in evaluation of needs for students with TraumaticBrain Injury. (1992). In Virginia Department of Education and theRehabilitation Research and Training Center on Severe TraumaticBrain Injury (p. 19). Guidelines for Educational Services for Studentswith Traumatic Brain Injury. Richmond: Author.



Table 4Issues for Consideration in Evaluation of Needs for

Students with Traumatic Brain Injury

Medical (Physiatrist or Neurologist)Neurologic Status (EEG, CT, and neurologic exam)Physical limitations (e.g., restrictions from physical

education; fatigue)Medical Problems (Seizures, motor spasticity,

headaches, pain, dizziness or "vertigo")Medication needs (e.g., Anticonvulsant, antidepres-

sant, psychostirnulant medications)Needed Assistive Devices (Augmentative communi-

cation, wheelchair, positioning tools,writing board, computer software)

Hearing (Audiologist)Partial or total hearing loss in one or both earsDiscrimination of language in a noisy environmentDevelopment of a "ringing s Dund" called tinnitus

Vision (Ophthalmologist)Partial or total loss of visionvisual "cuts" causing "blind spots' in eyesImpaired visual tracking (affecting reading,writing, driving, etc.)Visual blurring ("diplopia')

Gross Motor (Physical Therapist)Extreme weakness ("paresis") or total paralysis of

one or both sidesReduced muscle tone ("hypotonia") or rigidityMuscle contractions or spasticityPoor balance or ataxia

Fine Motor (Occupational Thi rapist)Reduced motor dexterity and tremors impairing

cutting, drawing, and writingProblems with motor planning ( "dyspraxia")

impairing dressing or assembly skillsProblems with written output ( "elysgraphia")

affecting written communicationSocial and Academic History (Social Worker)

Preinjury student educational attainment, behavior,and family adjustment

Preinjury student interests, talents, extracurricularparticipation, and friendships

Family beliefs and attitudes about student, theinjury, and educational needs

Family stresses, support systems, and needsFamily perception of student's abilities, adjustment,

and home management problemsPersonality and Socioemotional Adjustment(Neuropsychologist/Neuropsychiatrist)

Mood: Aagitated, depressed, anxious, or labileBehavior: Immature, insensitive, and inappropriateSelf<oncept: Poor or unrealistic perception of

physical, social, and intellectual skillEnergy level: Hyperactive, lethargic, or both

Adaptive Skills (Social Worker or Evaluator withAppropriate Assessment Training)

Problems in self-care (dressing, hygiene,feeding)Problems in community living skills (e.g., time,

money, and safety concepts)Problems in classroom or home managementProblems in socialization (social skills, coping skills,

play,leisure interest)Speech and Language (Speech Pathologist)

Oral motor dysfunction affecting articulation orswallowing

Problems understanding or efficiently processinglanguage

Dysfluent speech or problems retrieving words from

memoryPragmatic language deficits in conversation, turning-

taking, and social "rules"Neuro/psychological Status (Neuropsychologist)

Reduced intellectual skills often underestimated bystandardized IQ tests

Distractibility, poor concentration, and poor impulse

control ("disinhibition")Poor memory affecting encoding, retention, and

retrieval of informationVisual-spatial problems affecting part-whole reason-

ing, integration, and synthesisImpaired judgment, conceptual reasoning, and

organizational skillsSlow processing and output of information affecting

performance on timed testAcademic Achievement (Educational Diagnostician)

Impaired word recognition ("dyslexia') or (morefrequently) reading comprehension

Confusion with math calculations and especially

applications ("dyscalculia")Poor retention for facts in content-subjects such as

history and scienceErrors in mechanics and fluent expression of written

language ("dysgraphia")Vocational Skills (Vocational Specialist or Rehabilita-

tion Counselor)Impaired entry level work skills (limited occupational

interests, behavior or attitudes interferring withemployment, and limited job seeking or interview

skills)Physical, cognitive, and educational limitations

affecting prevocational trainingLimitations in job training or job "keeping" skills

necessitating supportive employment

119

Neuropsychological Assessment Test Battery. (1992). In Virginia Departmentof Education and the Rehabilitation Research and Training Center onSevere Traumatic Brain Injury (pp. 91 - 94). Guidelines for EducationalServices for Students with Traumatic Brain Injury. Richmond:Author.



Neuropsychological Assessment Test Battery

The following provides a list of commonly used tests. A brief description is provided for measures usedby neuropsychologists or rehabilitation specialists. This list is not exhaustive, and is included for thepurpose of education rather than endorsement for use by school personnel. Because of performancevariability in structured vs. unstructured setting. observation in the classroom and other school settingsprovides an excellent supplement to formal evaluation.

Perception/Reception/Discrimination

Halstead Reitan Sensory Perceptual Exam: Screening measure to assess basic ability toidentify tactile. auditory, and visual stimulation on left vs. right sides of body

Auditory

Speech-Sounds Perception Test: identifies verbally-presented nonsense words(primarily left temporal lobe)

Seashore Rh}-thm Test: Discriminates (same/different) rhythmic patternsWoodcock-Fristoe-Johnson Test of Auditory Discrimination:Discriminates among phonetically-similar word patterns in quiet and back

Visual Perceptual

Gardner Test of Visual Perceptual Skills: Visual discrimination, closure, and memoryHooper Visual Organization Test: Ability to recognize fragmented pictures

Tactile

Tactual Performance Test (or Sequin-Goddard Forrnboard): Assesses tactileform recognition, memory for shapes and spatial location, and psychomotorproblem-solving

Motor Functions

Fine Motor TasksDynanorneter Test: Grip strengthFinger-Oscillation Test: SpeedPurdue (Sequin) or Grooved Pegboard Task: Psychomotor dexterityMaze Test: Assesses speed and accuracy in running a stylus through a maze

Perceptual Motor TasksBender Visual Motor Gestalt TestBeery Developmental Test of Visual Motor Integration

123

117

Ray Osterrieth Complex Figure: Figure copy and memoryTarget Test: Delayed response in reproducing visual-spatial configurations of increasing

complexity.

Fine/Gross Motor TasksPeabody Developmental Motor ScalesBattalle Developmental InventoryBruininks-Oserataky Test of Motor ProficiencyRiley Motor Problems Inventory: Screening measure

Attention. Vigilance, and Impulse Control

Attention Deficit Disorders Evaluation Scale, Connors Rating Scale:Teacher or parent rated behavior

Gordon Diagnostic System: Computerized task with measures of sustained vigilance,impulsivity, and distractibility

Alternatives: Matching Familiar Figures Test, Continuous Performance Test, and variousletter cancellation-tasks

Detroit Test of Learning Aptitude (Primary and 3): Attention-enhanced scalesPaced Auditory Serial Addition Test: Serial-addition task to asses rate

of information processing and sustained attention

Memory and New Learning

Wide Range Assessment of Memory and Learning: Measures of immediateauditory and visual memory, new learning, and delayed recall

Stanford-Binet (4th Edition): Memory areaKaufman Assessment Battery for Children, McCarthy Scales of Children's Abilities, and

Wechsler Scales: Select subtestsWechsler Memory Scale (Revised): Measures of immediate auditory and visual memory,

new learning, and delayed rec2ll for late adolescents and adultsRay Auditory Verbal Learning Test: Multiple-trial list-learning taskCalifornia Verbal Learning TestSelective Reminding Test: Multiple-trial list-learning task

Cognition/Intelligence

Bayley Scales of Children's AbilitiesMcCarthy Scales of Children's AbilitiesWechsler Preschool and Primary Scale of Intelligence (Revised)Wechsler Intelligence Scale for Children (Third Edition)Wechsler Adult Intelligence Scale (Revised)Stanford-Binet Intelligence Scales (Fourth Edition)Detroit Test of Learning Aptitude (Primary and 3): Assessment of process-oriented

functions in conjunction with primary batteriesKaufman Assessment Battery for Children (in conjunction with primary batteries)

1241 8

Speech and Language

Test of Language CompetenceToken Test for ChildrenTest of Early Language DevelopmentTest of Language DevelopmentTest of Written Language (Revised)Test of Adolescent Languages (TOAL-2)Clinical Evaluation of Language Fundamentals (Revised) (CELF-R)Test of Auditory Comprehension of Language (Revised)Assessing Semantic Skills through Everyday Themes (ASSET)Let's Talk Inventory for ChildrenTest of Word FindingThe Word TestThe Word Test - AdolescentOne-word Receptive Vocabulary Test (Gardner or PTVF): Word identificationOne-word Expressive Vocabulary Test (Gardner or Boston): Confrontative namingHalstead-Wepman Aphasia Screening Exam: Brief screening measure.assessing naming

(dysnomia), spelling (spelling dyspraxia), writing (dysgraphia, enundation (dysarthria),reading (dyslexia), reproduction (constructional dyspraxia), arithmetic (dyscalculia),and comprehension (verbal dyspraxia) (cursory screening tool)

Verbal Fluency Test: Child is required to name as many words beginning with a certainletter or things from a certain category

Menyak Syntactic Measure: Assesses understanding of increasingly syntactic complexsentences/phrases

Children's Word Finding Test: The child is required to determine the 7-leaning of a non-sense word through appreciation of its verbal context

Nonverbal Problem-ScAving. Mental Flexibility. and Abstract Reasoning

Color-Form Test: Visual perceptual reasoning and flexibilityProgressive Figures Test: Visual perceptual reasoning and flexibilityCategory Test: Assesses nonverbal concept formation, abstraction, mental flexibility and

learningWisconsin Card Sortin Test: Assesses nonverbal ability to form abstract concepts and shift/

maintain setLeiter International Performance Scale: Nonverbal cognition (visual spatial, sequential,

reasoning, and concept formation)Trial-Making Test (Parts A and B): Timed measure of problem solving

(connecting numbers and number-letter sequences)Columbia Mental Maturity ScaleTest of Nonverbal Intelligence

125

AchievementBasic Achievement Skills Individual ScreenerKaufman Test of Educational AchievementPeabody Individual Achievement Test (Revised): NonverbalWoodcock-Johnson Psycho-Educational Battery (Revised): Tests of achievementGray Oral Reading TestGates-MacGinitis Reading TestStanford Diagnostic Reading TestWide Range Achieyement Test (Revised. 1 and 2)Key Math Diagnostic Arithmetic Test

Adaptive Behavior

Vineland Scales of Adaptive BehaviorFunctional Skills AssessmentAAMD Adaptive Behavior ScaleSocioemotional Adjustment

Parent Report: Child (Achenbach) Behavior Checklist, Personality Inventory for Children,and other age- or developrnentally-normed rating scales

Teacher Report: Child (Achenbach) Behavior Checklist and other age- or developmentally-norrned rating scales

Youth Self-Reported Personality/Adjustment: Clinical or psychiatric problems assessed theMillion, Minnesota Multiphasic Personality Inventory, and Youth Self-Report measures;Personality style or self-concept assessed by the Child Personality Questionnaire, HighSchool Personality Questionnaire, Piers Self-Concept Scale, and other developmentally-normed rating scales

126

1 20

Traumatic Brain Injury Checklist. (1992). In Virginia Department ofEducation and the Rehabilitation Research and Training Center onSevere Traumatic Brain Injury (pp. 60 - 65). Guidelines for EducationalServices for Students with Traumatic Brain Injury. Richmond:Author.


1 1Traumatic Brain Injury 127

Traumatic Brain Injury ChecklistPlease rate the student's behavior (in comparison to same-age classmates) using the followingrating scale:

Not at allOccasionallyOftenVery Severe & Frequent Problem

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,A. Orientation and Attention to Activity.

Confused with time (day, date); place (classroom, bathroom,schedule changes); and personal information (birth date,address, phone, schedule)

Seems "in a fog" or confused.

Stares blankly

Appears sleepy or to fatigue easily

Fails to finish things started

Cannot concentrate or pay attention

Daydreams or get.; lost in thoughts,

Inattentive, easily distracted

B. Starting, Changing, and Maintaining Activities

Confused or requires prompts about where, how or when tobegin assignment

Does not know how to initiate or maintain conversation (walksaway, etc.)

Confused or agitated when moving from one activity, place, orgroup to another

Stops midtask (math problem, worksheets, story, orconversation)

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Unable to stop (perseverates on) inappropriate strategies,topics, or behaviors

Gives up quickly on challenging tasks

C. Taking in and Retaining Information

Forgets things that happened even the same day

Problems learning new concepts, facts, or information

Cannot remember simple instmctions or rules

Forgets classroom materials, assignments, and deadlines

Forgets information learned from day to day (does well onquizzes, but fails tests covering several weeks of learning)

D. Language Comprehension and Expression

Confused with idioms ("climbing the walls") or slang

Unable to recall word meaning or altered meaning (homonymor homographs)

Unable to comprehend or breakdown instructions and request

Difficulty understanding "Wh" questions

Difficulty understanding complex or lengthy discussion

Processes information at a slow pace1

Difficulty finding specific words (may describe but not label)

Stammers or slurs words

Difficulty fluently expressing ideas (speech disjointed, stopsmidsentence)

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E. Visual-Perceptual Processing

Cannot track when reading, skips problem, or neglects aportion of a page of written material

Orients body or materials in unusual positions when reading orwriting

Gets lost in halls and cannot follow maps or graphs

Shows left-right confusion

F. Visual-Motor Skills

Difficulty copying information from board

Difficulty with notetaking

Difficulty with letter formation or spacing

Slow, inefficient motor output

Poor motor dexterity (cutting, drawing

G. Sequential Processing

Difficulty with sequential steps of task (getting out materials,turning to page, starting an assignment)

Confuses the sequence of events or other time-related concepts

H. Problem-Solving, Reasoning, and Generalization

Fails to consider alternatives when first attempt fails

Does not use compensatory strategies (outlining or underlining)

Problems understanding abstract concepts (color, emotions,math and science)

Confusion with cause-effect relationships

IUnable to categorize (size, species) .

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Problems making inferences or drawing conclusions

Can state facts, but cannot integrate or synthesize information

Difficulty applying what they know in different or new situations

I. Organization and planning Skillsi

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Difficulty breaking down complex tasks (term papers, projects )

Problems organizing materials

Problems distinguishing between important and unimportantinformation

Difficulty making plans and setting goals

Difficulty following through with and monitoring plans .

Sets unrealistic goals

J. Impulse or Self-Control

Blurts out in class

Makes unrelated statements or responses

Acts without thinking (leaves class, throws things, sets offalarms)

Displays dangerous behavior (runs into street, plays with fire,drives unsafely)

Disturbs other pupils

Makes inappropriate or offensive remarks

Shows compulsive habits (masturbation, nail biting, tapping

Hyperactive, out-of-seat behavior

K. Social Adjustment and Awareness,

Acts immature for age

Too dependent on adults

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Too bossy or submissive with peers

Peculiar manners and mannerisms (stands too close, interrupts,unusually loud, poor hygiene)

Fails to understand social humor .

Fails to correctly interpret nonverbal social cues

Difficulty understanding the feelings and perspective of others

Does not understand strengths, weaknuses and selfpresentation

Does not know when help is required or how to get assistance

Denies any problems or changes resulting from injury.

L Emotional Adjustment

Easily frustrated by tasks or if demands not immediately met

Becomes argumentative, aggressive, or destructive with littleprovocation

Cries or laughs too easily

Feels worthless or inferior,

Withdrawn, does not get involved with others

Becomes angry or defensive when confronted with changesrestfiting from injury

Apathetic and disinterested in friends or activities

Makes constant inappropriate sexual comments and gestures

Unhappy or depressed affect

Nervous, self-conscious, or anxious behavior

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M. Sensorimotor Skills

Identified problems with smell, taste, touch, hearing or vision

Problems discriminating sound or hearing against backgroundnoise

Problem with visual acuity, blurring or tracking

Problems with tactile sensitivity-(e.g., cannot type or play aninstrument without watching hands)

. ,

Identified problems with oromotor (e.g., swallowing), fine motoror gross motor skills

Poor sense of body in space (loses balance, negotiatingobstacles)

..Motor paralysis or weakness of one or both sides

Motor rigidity (limited range of motion), spasticity(contractions) and ataxia (erratic movements) circle one

Impaired dexterity (cutting, writing) or hand tremors._

_Difficulty with skilled motor activities (dressing, eating)

/24 A. Orientation/Attention

/18 B. Task Initiation, Transition, Maintenance

/15 C. Information Encoding and Retention

/27 D. Language Comprehension and Expression

/12 E. Visual-Perceptual Processing

/15 F. Visual-Motor Skills

G. Sequential Processing

/24 H. Probkm-Solving, Reasoning & Generalizing

/18 I. Organization and Planning Skills

/24.

3. Impulse or Self-Control-

/27 K. Social Adjustment and Awareness

/30 I. Emotional Adjustment

/30 M. Sensorimotor Skills

1341'17

Waaland and Bohannon, 1992

Related services for school-aged children with disabilities. (1991). NICHCYNews Digest, 1 (2), 1 - 23.


Traumatic Brain Injuiy 135

1 `.3

Related Services forSchool-AgedChildren withDisabilities

Volume 1, Number 2, 1991

The Individuals with DisabilitiesEducation Act (IDEA) mandates that "allchildren with disabilities have availableto them...afree appropriate public educa-tion which emphasizes special educationand related services designed to meettheir unique needs..." (Section 601[c]).In accordance with the IDEA and otherfederal laws, more than -1.5 million chil-dren with disabilities across the nationreceived special education and/or relatedservices in the 1989-90 school year

This issue of NEWS DIGEST fo-cuses upon the provision of related ser-vices to school-aged children with dis-abilities. As defined by federal law, re-lated services are intended to address theindividual needs ofstudents with disabili-ties, in order that they may benefit fromtheir educational program. Occupationaland physical therapy, school health ser-vices, and special transportation assis-tance are just some examples of relatedservices that can help eligible studentswith disabilities participate more fully andsuccessfully in the learning process.

This NEWS DIGEST provides anoverview of the related services enumer-ated in federal law, with a focus uponthose services provided to school-agedchildren with disabilities. The personnelassociated with delivering each .serviceare identified, and their major duties aredescribed Readers are also given anoverview of how related services are typi-cally obtained for students, as well as howschool districts deliver, coordinate, andfund the relaied services they provide.Also discussed is one serious problemconfronting school districts. namely ashortage of personnel to deliver relatedservices needed by students. Recent courtcases, due process hearings, and the spe-cifics offederal !aware mentioned through-out this NEWS DIGEST, where relevant,to help readers understand the nature of

and limits to school districts' re-sponsibilities to provide related servicesA list ofreadings, organizations, and othersources offurther information concludesthis issue.

NICHCY

National Information Center for Childrenand Youth with Disabilities

Washington, DC

Several important federal lawshave been passed in recent years

to address the rights and educationalneeds of children and youth with dis-abilities. One such law, passed in 1975,is The Education of All HandicappedChildren Act, otherwise known as EHAor Public Law (P.L.) 94-142. Recentlyreauthorized and renamed the Individu-als with Disabilities Education Act, orIDEA (P.L. 101-476), this law man-dates that special education and relatedservice programming be made avail-able to all children and youth with dis-abilities who require them. The lawalso makes available federal funds tohelp state and local governments estab-lish and maintain special education pro-grams for students with disabilities, aswell as provide the related services thesestudents need in order to benefit fromspecial education.

But what are related services? TheIDEA defmes "related services" as:

...transportation, and suchdevelopmental, corrective,and other supportive ser-vices (including speech pa-thology and audiology, psy-chological services, physi-cal and occupationaltherapy, recteation, includ-ing therapeutic recreationand social work services,and medical and counsel-ing services, including re-habilitation counseling, ex-cept that such medical ser-vices shall be for diagnosticand evaluation purposesonly) as may be required toassist a child with a disabil-ity to benefit from specialeducation. [20 U.S.C.Chapter 33, Section1401(17), 1991]

Although the IDEA has becomelaw, at the time of this writing regula-tions for the Act have only been issuedin proposed form. Final regulations,written to correspond to the changesmade to the EHA by the IDEA, will bepublished after an extensive public com-ment and review period. Until the finalregulations are available to guide imple-mentation of the IDEA, the regulationsof its predecessor, the EHA, are beingused by school districts to determinehow and to whom related services willbe delivered. The regulations of theEHA (P.L. 94-142) list thirteen relatedservices that students with disabilitiesmay require to benefit from their specialeducation programs. These are:

audiology;occupational therapy;physical therapy;psychological services;medical services for diagnostic orevaluation purposes only;school health services;transportation services;counseling services;speech-language pathology;social work services;parent counseling and training;recreation therapy; andearly identificat ion and assessmentof disabilities in children. [34 Codeof Federal Regulations (CFR) Sec-tion 300.13 (b)(1)-(13), 19881.

02arly, the regulations define awide variety of services that must beprovided to children and youth withdisabilities identified as needing suchservices to maximize the benefits oftheir special education. However, thelaw also states that this long list ofservices is not exhaustive and may in-clude other developmental, corrective,

BEST COPY AVAILABLE 1371 9, a

or support services "as may be requiredto assist a child with a disability tobenefit from special education" [TheIndividuals with Disabilities EducationAct, 20 U.S.C. Chapter 33, Section1401(17)]. It is through this provisionin the law that many school districts areproviding students with disabilities withassistive technology devices and ser-vices. Furthermore, as states respond tothe requirements of federal law, manyhave legislated their own related servicerequirements, which may include ser-vices beyond those specified in federallaw. For example, some states alsoinclude mobility training, dance therapy,and artistic and cultural programs asrelated services that should be providedas necessary to help a student with adisability benefit from his or her specialeducation program.

Because states are required to pro-vide the related services that are neces-sary for each individual student with adisability to benefit from his or herspecial education, related services canbe quite unique. An example of thisexists in the 1981 case of Espino v.Besteiro. As a result of an automobileaccident, the student in question couldno longer function in a classroom thatwas not temperature-controlled. Ini-tially, the school system met thisstudent's need by providing him with aportable cubicle that was air conditioned.However, the court ruled that, in orderfor the student to benefit from specialeducation, air conditioning qualified asa related service and ordered the schoolsystem to air condition the entire class-room. The cubicle was not satisfactory,because it did not permit the child tofully interact with the teacher and hisclassmates (Esterson & Bluth, 1987).

Although related services can bequite expensive, school districts maynot charge families of students withdisabilities for the cost of the services.Just as special and regular educationmust be provided to a student with adisability at no cost to the parent orguardian, so, too, must related services.As a result of federal law, it is the state'sresponsibility to provide a free, appro-

priate public education to all studentswith disabilities, and that includes anyrelated services necessary to ensure theybenefit from their education.

Under the IDEA, P.L. 101-476, thestudent must be enrolled in special edu-cation to be considered eligible for re-lated services. However, there is an-other federal law the RehabilitationAct of 1973 (P.L. 93-112) that, inmany cases, broadens a student's eligi-bility for related services. The implica-tions of this law will be discussed laterin this NEWS DIGEST (see the sectionentitled "Related Services under Sec-tion 504" on page 8). First, however, letus take a look at examples of relatedservices and who is typically respon-sible for providing each one.

What Are Some Examplesof Related Services andWho Provides Them?

Perhaps the best way to develop anunderstanding of what related servicesare is to take a look at the types ofpersonnel who are involved in the deliv-ery of serv ices and what responsibilitieseach of these people typically has in theprocess. Given the range and diversityof disabilities, this list is quite lengthy.Therefore, the information presentedabout each related service is intendedonly as an introduction to that serviceand the personnel associated with itsdelivery. It is not the intent of thisdocument, just as it is not the intent ofthe law, to exhaustively describe eachrelated service. Many variations inservice delivery are possible. Readersare encouraged to make use of the re-sources listed at the end of this NEWSDIGEST to find out more about therelated services of relevance to them.(Early identification and assessment ofdisabilities in children is not discussedin this NEWS DIGEST, because it fallsoutside of this document's focus onrelated services for school-aged chil-dren.) It is important to read about allthe services and personnel in order to

know what related services are mostcommonly provided to students withdisabilities and their families.

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Audiology Services are generallyprovided by audiologists who screen,assess, and identify children with hear-ing loss. Additionally, they:

determine the range, nature, anddegree of the hearing loss;make referrals for medical or otherprofessional attention for the ha-bilitation of hearing;provide language habilitation, au-ditory training, speech reading (lipreading), speech conservation, andother programs;determine the child's need for groupOr individual amplification, selectand fit an appropriate hearing aid,and evaluate the effectiveness ofamplication.

Many school systems do not havethe diagnostic facilities necessary toassess the extent of a student's hearingloss, and so they refer students in needto a clinical setting, such as a hospital.Based on the results of the hearingassessment, related services are thenprovided by school-based audiologistsor, in school systems that do not employaudiologists, by other professionals suchas speech pathologists or educators(Friedrich, 1987).

Fe-

Occupational Therapy is providedby therapists who concentrate upon as-sessing and treating children with dis-abilities that impair their daily life func-tioning. Areas of daily life functioningupon which an occupational therapistmight focus are:

activities of daily living, such aseating and dressing;school and work skills, such aswriting, using scissors, managingbooks and papers, and sitting effec-tively in class; andplay/leisure skills, such as partici-pating in art or physical educationclass or playing with children atrecess.

138

When occupational therapy is pro-vided as a related service, it is meant toenhance a student's ability to functionin an educational program. By focusingupon the skills of daily living, occupa-tional therapists can often help indi-vidual students to function in the leastrestrictive environment. Generally,occupational therapists:

provide treatment to strengthen anddevelop fine motor functions;focus on treatment of the smallmuscles, primarily those ofthe face,upper trunk, arms, and hands; andimprove the student's ability to per-form tasks necessary for indepen-dent functioning, such as chewing,swallowing, placement of thetongue and mouth for speech for-mation, eye-hand coordination, andmanual dexterity.

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Physical Therapy is provided to achild or youth with a disability follow-ing referral from a physician and, insome states, from school nurses, teach-ers, occupational therapists, and otherprofessionals. Physical therapists:

provide treatment to increasemuscle strength, mobility, and en-durance;focus on gross motor skills that relyon the large muscles of the bodyinvolved in physical movement andrange of motion;help to improve the student's pos-ture, gait, and body awareness; andmonitor the function, fit, and properuse of mobility aids and devices.

In relation to special education,physical therapists are primarily con-cerned with developing and enhancingthe physical potential of students withdisabilities, so that they can achievemaximum independence and functionin all their educational activities (S.Esterson, 1987).

Fr-

Psychological Servicesare also de-livered as a related service when neces-sary to help students with disabilitiesbenefit from their education. Often, thepotential need of a child with a disabil-ity for psychological services is raisedduring an Individualized Education Pro-gram (IEP) meeting of teachers, schoolpersonnel, and parents. Members of theIEP team may have noticed that a stu-dent has become withdrawn and that hisor her grades have dropped. Or parentsmay be concerned that their child isreading far below his grade level andwant to know if he has a learning dis-ability. School psychologists, then, be-come responsible for delivering psycho-logical services. Some of their primaryduties are to:

administer and interpret psycho-logical and educational tests andother assessment procedures to de-termine if, indeed, the student hasa disability;obtain, integrate, and interpret in-formation about a student's behav-ior and conditions for learning.Sources of information may includeobservations of the student and in-terviews with teachers, parents, andthe student;

consult with school staff and assistin planning an educational pro-gram to meet a student's specialneeds, as indicated by psychologi-cal tests, interviews, and evalua-tions of behavior; andplan and manage programs to pro-vide psychological services, includ-ing counseling for students andparents.

It is important to know that, by law,no single assessment procedure can beused as "the sole criterion for determin-ing an appropriate educational programfor a child" (Code of Federal Regula-tions [CFR]: Title 34: Education: Part300.532, 1988). The anticipated regu-lationS for the IDEA are not expected tochange this approach to student assess-ment. One of the sChool psychologist'smost challenging duties, then, is togather information about the studentfrom a variety of sources and interpretthat information, so that an educationalprogram appropriate to the needs of thestudent can be developed.

Fe-

Medical Services are considered arelated service only under specific con-ditions. By definition, medical ser-vices:

are provided by a licensed physi-cian to diagnose a child's disabil-ity, determine the need for specialeducation, and determine the typeand extent of related services thatmay be needed; andare permitted for diagnostic rea-sons, but do not include direct, on-going medical treatment by a phy-sician.

Just how far does a school system'slegal requirement to provide medically-related services go? This has becomequite an area of controversy as schoolsenroll and place students with severeand often life-threatening disabilities.Do the constant medical needs of thesestudents qualify as supportive services aschool is obligated to provide or as on-going medical treatment, which is spe-cifically excluded as a related service?

139

131

"The more medically sophisticated the decisions abouthow to treat the child, the more (the medical) service isexcluded and the school's obligation disappears."

Decisions can only be made on a case bycase, student by student basis. How-ever, the trend emerging from recentcourt cases appears to be:

If the supportive service must beperformed by a licensed physicianand is not for the purpose of evalu-ation or diagnosis, the school is notobligated to provide it.If the service can be provided by a1..y person, such as the teacher,with minimal training, the schoolmust provide it.When the service requires somedegree of medical insight, such aswhat to do when an emergencyarises, then court decisions can goeither way. "The more medicallysophisticated the decisions abouthow to treat the child, the more thatservice is excluded and the school'sobligation disappears" (McKee &Barbe, 1990, P. 199).

Fe-

School Health Services are neces-sary, because many children and youthwith disabilities would be unable toattend a day of school without support-ive health care. Health services aretypically provided by a qualified schoolnurse or a specifically trained nonmedi-cal person who is supervised by a quali-fied nurse. Some of the health servicesthat school nurses or other qualifiedpersonnel provide to students with dis-abilities include:

special feedingsclean intermittent catheterizationsuctioningadministering medicationsplanning for the safety of a studentin school, andensuring that care is given in theclassroom to prevent injury (e.g.,changing a student's position fre-quently to prevent pressure sores)(Black & Dorsett, 1987).

A joint task force of members andstaff of four associations the Ameri-can Federation of Teachers, the Coun-cil for Exceptional Children, the Na-tional Association of School Nurses,Inc., and the National Education Asso-ciation recently released detailedguidelines to help administrators, healthcare providers, and educators providehealth services to children with specialhealth care needs (The Joint Task Forcefor the Management of Children withSpecial Health Needs. 1990). The guide-lines list "66 special health care proce-dures that some children may need tohave provided in educational settings,"as well as "the persons qualified toperform each of the procedures, whoshould preferably perform the proce-dures, and the circumstances underwhich these persons would be deemedqualified" (p. 9).

The same controversy that is com-ing to light about medical services issurfacing in regard to school healthservices. How far does the school'sobligation to provide these services go?In tilt case of Bevin H. v. Wright (1987),the court decided that the school districtwas not responsible for providing anurse to monitor Bevin's condition andassist her because of the intensive na-ture of her need. Other courts had foundthat schools were responsible for pro-viding nursing care, but the studentsinvolved in those cases only requiredintermittent nursing care that could beprovided by the school nurse, leavingthe nurse free to care for other students.The "private duty" service that Bevinrequired distinguished her case fromothers previously heard. Thus, the courtstated that placing the burden of theservices Bevin required "on the schooldistrict in the guise of 'related services'does not appear to be consistent with thespirit of the Act and the regulations"

(Bevin H. v. Wright, 1987-88 Educa-tion of the Handicapped Law Report[EHLR] DEC. 559:122, as cited in "Re-lated Services: Daily Nursing Care",1987, p. 3).

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Transportation Services are pro-vided to those students who need specialassistance because of their disability orthe location of the school relative totheir home. Not all students with dis-abilities are eligible to receive special-ized transportation services. Many areable to use the same transportation thatstudents without disabilities use to getto school. However, for those who needspecial assistance, the school districtmust:

provide travel to and from schooland between schools;provide travel in and around schoolbuildings; and

. provide specialized equipment (suchas special or adapted buses, lifts,and ramps), if required to providespecial transportation for a childwith disabilities.

Most school systems have writtenguidelines to help make decisions abouttransportation services consistent fromstudent to student. To be in compliancewith the IDEA, a school district cannotrequire the families of students withdisabilities to assume any portion of thecosts of those transportation servicesdeemed necessary to permit the stu-dents to benefit from their education.

reCounseling Services are typically

provided by school counselors who workwith students to develop their careerawareness, to improve their understand-ing of self, and to improve their behav-ioral adjustment and control skills. This,in turn, makes students with disabilitiesbetter able to participate in their educa-tional program. In many schools, thecounselor may also perflrin the func-tions of school psychologists (describedabove under Psychological Services).Additionally, school counselors may:

. identify and refer students who maybe eligible for special education;

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secure parental permission for re-ferrals;provide advice concerning astudent's level of functioning, af-fective needs, and appropriatenessof the IEP;provide student guidance and coun-seling In keeping with the IEP; andprovide supportive counseling forparents.

Speech-Language Pathology is aservice provided by speech-languagepathologists to address the needs ofchildren and youth with communica-tion disabilities, such as stuttering andimpairments in speech, language, orvoice. Typically, speech-language pa-thologists:

screen, identify, assess, and diag-nose disorders offluency, language,articulation, voice, and oral-pha-ryngeal function, and cognitive/communication disorders;provide speech and language ser-vices for the habilitation or preven-tion of communication disorders,including augmentative and alter-native communication systems; andrefer the student for medical orother professional attention neces-sary for the habilitation of speechor language disorders.

It should be noted that a studentwith a speech or language impairmentdoes not necessarily have to be mani-festing academic problems in order tobe considered eligible to receive relatedservices under the IDEA. Effective oralcommunication is regarded as a skillbasic to academic performance(Applestein, 1987).

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Social Work Services are providedin order to address the whole welfare ofthe student with a disability - his or herlife at home, in school, and in the com-munity. Historically, social workershave been used in schools as early as1913. The need for their services arosefrom "recognition of the need to con-sider factors beyond the schools thatmay be affecting a child's educational

performance" (Tabb, 1987, p. 113).Problems at home or in the communitycan adversely affect a student's perfor-mance at school, as can a student'sattitudes or behaviors in school. Social

the social worker may identify culturalor language differences that need to betaken into consideration as well (Tabb,1987).

"Social Work Services are provided in order to addressthe whole welfare of the student with a disability - his orher life at home, in school, and in the community."

work services may become necessary inorder to help the student maximize ben-efit from the educational program.

In today's society, qualified schoolsocial workers have completed a two-year master's degree program in socialwork and generally have field experi-ence obtained through placement in apublic or private facility, where theyworked under supervision. Their dutieswithin schools typically include:

preparing a social or developmen-tal history of a student with a dis-ability;providing group or individual coun-seling to the student and family;working with the problems in astudent's living situation (home,school, and community) that areaffecting the student's adjustmentin school; andmobilizing school and communityresources to enable the student tobenefit from his or her educationalprogram.

To develop an insightful social ordevelopmental history of a student witha disability requires the school socialworker to interact with both the studentand the family. This allows the socialworker to assess how family dynamicsand the home environment are influ-encing the student's learning and be-havior patterns. This information isuseful for determining the student'seducational placement and program,and also serves as a check against inap-propriate labeling of a student becauseof test scores and school behavior.Through interactions with the family,

Parent Counseling and Trainingis an important related service, becauseit addresses the needs of the parents andthe vital role they play in the lives oftheir children. The family is the "mostpowerful agent of change in the life of achild" (Blumberg, 1987, p. 70). Theparents of a child or youth with a dis-ability may have great need for counsel-ing and training in order to understandtheir child's disability and how it mayaffect development. When necessary tohelp the child or youth with a disabilitybenefit from the educational program,school counselors can:

assist parents in understanding thespecial needs of their child;provide parents with informationabout child development; andprovide parents with referrals toparent support groups, financial as-sistance resources, and profession-als outside the schoc I system.

Recreation Therapy is includedas a related service, because all chil-dren, with or without disabilities, needto learn how to use their leisure andrecreation time construct vely. For thosestudents with disabilities who are judgedto require recreation therapy in order tobenefit from special education, thetherapy can serve to improve socializa-tion skills, as well as eye-hand coordi-nation and physical, cognitive, or lan-guage development. In the case ofchildren with severe disabilities, "rec-reation activities are necessary for thepurpose of initiating greater pride andindependence" (M.M. Esterson, 1987,

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p. 99). To this end, recreation thera-pists:

assess the student's leisure capaci-ties and functions;provide therapy to remediate func-tional difficulties that limit involve-ment in leisure activities;provide leisure education for learn-ing the skills, knowledge, and atti-tudes related to leisure involvement;andhelp the student to participate inrecreation, based on the student'sneed for assistance and/or adaptedrecreation equipment.

Act (P.L. 100-407), recognizing theenormous contribution that assistivetechnology can make to the lives ofindividuals with disabilities. The Of-fice of Special Education Programs(OSEP) has issued a policy ruling stat-ing that "consideration of a child's needfor assistive technology must occur on acase-by-case basis in connection withthe development of a child's individual-ized education program (IEP)"(Goodman, 16 EHLR 1317, OSEP1990). The OSEP policy letter goes onto say that "assistive technology can bea form of supplementary aid or service

"Consideration of a child's need for assistive technologymust occur on a case-by-case basis in connection withthe development of a child's . . . IEP."

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Assistive Technology Devices andServices are not specifically listed inthe law as a related service but are oftenprovided as "other corrective or supportservices" necessary to help students withdisabilities benefit from their educa-tion. The provision of assistive technol-ogy devices and services has changedover the years as technology has beendeveloped and applied to the needs ofindividuals with disabilities. The EHA(P.L. 94-142) mentions that providing"related aids and services" may be nec-essary to help a student maximize thebenefits of his or her educational pro-gram. The early interpretation of whatqualified as a permissible related aidwas controversial. "Generally, equip-ment such as glasses, wheelchairs, andhearing aids have been considered to beoutside of the school districts' responsi-bility because these were individuallyprescribed and were used at home aswell as during school" ("Districts MustProvide", 1990, p. 76).

As assistive technology has boomed,however, the scope of this related ser-vice has expanded. In 1988, Congresspassed the Technology-Related Assis-tance for Individuals with Disabilities

utilized to facilitate a child's educationin a regular educational environment.Such supplementary aids and services,or modifications to the regular educa-tion program, must be included in achild's IEP." Thus, when an IEP of astudent with a disability is being devel-oped or reviewed, the school districtmust assess his or her need for anassistive technology device, determinethose devices that will facilitate thestudent's education, list them in theIEP, and then provide them to the stu-dent.

This policy letter, coupled with thepassage of the Technology-Related As-sistance for Individuals with Disabili-ties Act of 1988 and the IDEA, is ex-pected to dramatically affect the level ofdistrict responsibility for providing re-lated aids, devices, and technology-re-lated services to students with disabili-ties.

The IDEA defines an assistive tech-nology device as.

...any item, piece of equip-ment, or product system,whether acquired commer-cially off the shelf, modified,or customized, that is used to

increase, maintain, or improvefunctional capabilities of in-dividuals with disabilities. [20U.S.C. Chapter 33, Section1401(25)]

The number of assistive technologydevices in use across the United States islengthy, and the list is growing longerby the day. A few examples of suchdevices are: electronic communicationaids, devices that enlarge printed wordson a computer screen, speech synthesiz-ers, prosthetic devices, braille writers,and keyboards adapted for fist or footuse.

As more assistive technology de-vices become available to address thespeciil needs of students with disabili-ties, districts are confronted with mul-tiple challenges in that they must: (a)identify and acquire technology devicesappropriate to the needs of their stu-dents with disabilities; (b) train staff inthe use of the devices; (c) identify appro-priate use of computers, communica-tion devices, and other technology inthe classroom; and (d) finance the costof this related service. Additionally,districts must provide "assistive tech-nology services" to eligible studentswith disabilities. Assistive technologyservices are defined by the IDEA as"...any service that directly assists anindividual with a disability in the selec-tion, acquisition, or use of an assistivetechnology device" [20 U.S.C. Chapter33, Section 1401(26)1. Thus, schooldistricts are also responsible for helpingindividuals with di abilities to selectand acquire an appropriate assistive tech-nology device and train them in its use.

Fortunately, for parents and pro-fessionals alike, there are a number oforganizations that provide informationon the latest developments in assistivetechnology devices. Some are listed inthe resources section of this NEWSDIGEST. Another useful resource isNICIICY's News Digest on AssistiveTechnology (1989), available free ofcharge from NICHCY.

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Artistic/Cultural Therapies arespecifically mentioned in federal regu-lations as other "supportive services"and include "artistic and cultural pre-grams, and art, music, and dancetherapy, if they are required to assist ahandicapped child to benefit from spe-cial education"(34 CFR Part 300.13,Comment, 1988).

Dance therapy, for example, candevelop and promote "good posture,discipline, concentration, coordination,agility, speed, balance, strength, andendurance" (Salyer& 1983). Art therapyprovides individuals with disabilitieswith a means of self-expression andopportunities to expand personal cre-ativity and control. Music therapy isused to foster similar personal growth.Its therapeutic aims are the restoration,maintenance, and improvement of men-tal and physical health (National Asso-ciation for Music Therapy, 1988). Thistype of therapy can affect changes inbehavior, social skills, perception, self-esteem, and physical mobility and skills.

Artistic and cultural therapies aredesigned by art therapists, dance thera-pists, and music therapists to addressthe individual needs of students withdisabilities. These professionals:

assess the functioning of individualstudents;design programs appropriate to theneeds and abilities of students;provide services in which move-ment or an art form is used in atherapeutic process to further thechild's emotional, physical, and/orcognitive development or integra-tion; andoften act as resource persons forclassroom teachers.

School Breakfast and Lunch Pro-gram is not a related service specifi-cally listed in the IDEA. The programis discussed in this NEWS DIGESTbecause of its importance to those stu-dents with disabilities who have specialnutritional requirements. Because manystudents with disabilities do have un iquenutritional needs, they are unable to

participate in the national meal pro-gram unless these meals are modified.

School meal programs are admin-istered at the federal level by the UnitedStates Department of Agriculture(USDA). USDA reimburses schools forevery meal served, at rates that varyaccording to family income. Childrenmay receive meals free or at a reducedpi ice if their families meet specific in-come criteria.

Under USDA's Section 504 andchild nutrition regulations, schools par-ticipating in federal school meal pro-grams are required to make a reason-able effort to provide, at no extra charge,special meals to students whose dietsare restricted due to their disabilities [7CFR Section 15b.26(d)(1)].

In order to be eligible for modifiedmeals, a student must present a state-ment signed by a physician. The state-ment should include: (a) the disabilityof the student and how the disabilityaffects the student's diet; (b) the majorlife activity affected by the disability;and (c) the food(s) to be omitted fromthe student's diet and those that may besubstituted [7 CFR Section 210.10(i)(1)and 7 CFR Section 220.80)]. Adjust-ments to meals may include changingthe texture of food, modifying the calo-ries, and substituting different foods forthose listed on the school menu (Horsley,1988).

In a recent floor statement, SenatorBob Dole of Kansas, Senate RepublicanLeader, expressed concern about theparticipation in school meal programs

by students whose disabilities restricttheir diets. Federal regulations, Sena-tor Dole said, "put the burden on par-ents to request special meals. Yet manyparents, school administrators, andteachers do not know these regulationsexist" (Dole, I 991).

Thus, parents need to be aware thatthey are responsible for: (a) requestingmodification of their child's meals, ifappropriate; and (b) providing the schoolsystem with a doctor's statement certi-fying their child's disability and de-scribing the child's special dietary needs.If officials at the school are not familiarwith these regulations, parents shouldcontact their State school food servicedirector, who is usually employed by theState education agency. If parents havefurther questions or problems, they cancontact the Child Nutrition Division ofthe Food and Nutrition Service of USDAat 3101 Park Center Drive, Alexandria,Virginia 22302 or call (703) 305-2620.

To address the special nutritionalneeds of students with disabilities, Sena-tor Dole also recommended the follow-ing:

greater coordination between teach-ers, school food service personnel,and children's health care provid-ers;more training of school staff in thearea of nutrition and meal modifi-cation;greater disseminatko. of the manyexcellent manuals on lpecial nutri-tion already available, and

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greater attention to nutritional needsin the development of individualeducation programs (IEPs). (Dole,1991)

Because the IEP serves as a com-munication tool between service pro-viders, parents, and the student with adisability, stating nutrition goals andobjectives in the IEP, when appropriate,"will facilitate instruction on dietaryneeds and compliance" (Horsley, Allen,& White, 1991, p. 56).

Related Services underSection 504

Under the IDEA, a student must beenrolled in special education to be con-sidered eligible for related services.However, as was mentioned in the firstsection of this NEWS DIGEST, there isanother federal law, Section 504 of theRehabilitation A. of 1973 (P.L. 93-112), which in many cases broadens astudent's eligibility for related services.

The Office for Civil Rights (OCR)is responsible for overseeing compli-ance with the Section 504 regulations.In order to ensure that the discussion inthis section is as accurate as possible,NICHCY asked OCR to examine indetail all information presented here inregards to Section 504. In accordancewith OCR's review, then, the followingdiscussion cites extensively from theSection 504 regulations, the basis fromwhich OCR oversees compliance withthe law and from which school districts,at times, must make decisions in re-gards to the eligibility of students toreceive related services.

According to Section 504 of theAct, State Education Agencies (SEAs)and Local Education Agencies (LEAs)receiving Federal funds cannot excludequalified individuals with disabilitiesfrom participation in or the benefits of

"Section 504 does not require a student to be enrolled inspecial education in order to receive related services."

any program or activity offered by theSEA or LEA. Regulations of the Actalso specify that a recipient of Federalfinancial assistance operating a publicelementary or secondary education pro-gram must provide a free, appropriatepublic education to each "qualifiedhandicapped person" within its juris-diction.

The Section 504 regulation definesa "handicapped person" as follows:

(1) "Handicapped persons"means any person who (i) hasa physical or mental impair-ment which substantially lim-its one or more major life ac-tivities; (ii) has a record ofsuch an impairment, or (iii) isregarded as having such animpairment...(2)(ii) "Major life activitiesmeans functions such as car-ing for one's self, performingmanual tasks, walking, see-ing, hearing, speaking, breath-ing, learning, and working.[34 Code of Federal Regula-tions (CFR) Section 104.3(j),1988]

Under the Section 504 regulation:

"Qualified handicapped per-son" means: ...[w]ith respectto ... elementary [and] sec-ondary ... education services,a handicapped person (i) of anage during which non-handi-capped persons are providedsuch services, (ii) of any ageduring which it is mandatory

under state law to provide suchservices to handicapped per-sons, or (iii) to whom a state isrequired to provide a free ap-propriate public educationunder Section 612 of the Edu-cation ofthe Handicapped Act.[34 CFR Section 104.3(k)(2),1988]

The free appropriate public educa-tion must meet the individual needs ofstudents who are "qualified handicappedpersons" as adequately as the needs ofstudents without disabilities are met.Such an education, according to theSection 504 regulation, can consist ofeither regular or special education andmust include any related aids or servicesnecessary to provide a free appropriatepublic education designed to meet theindividual student's needs. The lawalso requires that recipients of Federalfunds operating public elementary orsecondary education programs evaluateany person who needs or is believed toneed special education or related ser-vices because of disability. Thus, Sec-tion 504 does not require a student to beenrolled in special education in orderto receive related services.

The fact that the IDEA and Section504 of the Rehabilitation Act defineeligibility for, and entitlement to, re-lated services in different ways can com-plicate how a school district decides if astudent is eligible for and/or must beprovided with services or not. Schooldistricts can fulfill the requirements ofcertain sections of the Section 504 regu-lation by complying with the EHA (nowIDEA) (Daniels, 1988).' However, it is

'A school district can satisfy the Section 504 regulation's "free appropriate public education" requirement by implementing an 1EP developedin accordance with the El IA [34 CFR Section 104.35(b)(2)]. Establishing a procedure consistent with the EHA for periodically reevaluatingstudents who have beers provided with special education and related services is onc way of complying with the Section 504 regulation's periodicreevaluation requirement 134 CFR Section 104.35(d)1. A school district can comply with the Section 504 regulation's procedural safeguardsrequirement by complying with Section 615 of thc EHA (34 CFR Scction 104.36).

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possible for a school district to be inviolation of the Section 504 regulationwhile still being in compliance with theIDEA. This can happen when a schooldistrict denies services to an individualwho has a disability not specified underthf; IDEA but who is considered "handi-capped" under Section 504. For ex-ample, there are school districts thathave failed to administer medication tostudents with Attention Deficit Disor-der (ADD), because ADD is not listed asa handicapping condition under theIDEA. However, such students may beentitled to have the school district ad-minister medication as a related serviceunder Section 504, if the student meetsthe Section 504 definition of "handi-capped person."

An individualized evaluation wouldneed to be made by a multidisciplinaryteam to determine whether the studentis "handicapped" within the meaning ofSection 504; that is, wheth.: the studenthas an impairment which substantiallylimits one or more major life activities(e.g., learning). Once it is determinedthat a student is handicapped within themeaning of Section 504 and meets otherapplicable eligibility requirements (suchis age requirements), public elemen-tary or secondary education programsreceiving Federal financial assistanceare required by Section 504 to provide atree appropriate public education to thatstudent, without regard to the nature or

severity of the individual's disability.The free appropriate public educationmust include any related aids or ser-vices, such as administering medica-tion, that are necessary to meet the

. individual student's needs.Because the definition of disability

is broader under Section 504 of theRehabilitation Actthan underthe IDEA,many parents whose children are ineli-gible for related services under the IDEAare filing complaints with OCR, alleg-ing that denial of related services deniedtheir children a free appropriate publiceducation. It should be noted that whenOCR investigates a complaint, it doesso solely on the basis of compliance withthe rules and regulations of Section 504.OCR does not make findings of a schooldistrict's compliance or noncompliancewith the IDEA (Daniels, 1988). Inaddition, an OCR investigation focusesprimarily on the process used to iden-tify, evaluate, and place students withdisabilities, rather than on whether theprogram ultimately chosen by the dis-trict was appropriate. As the Appendixto the Section 504 regulation states:

It is notthe intention of [OCR],except in extraordinary cir-cumstances, to review the re-sult of individual placementand other educational deci-sions, so long as the schooldistrict complies with the "pro-

cess" requirements of this sub-part (concerning identificationand location, evaluation, anddue process procedures). How-ever, [OCR] will place a highpriority on investigating caseswhich may involve exclusionof a child from the educationsystem or a pattern or practiceof discriminatory placementsor education.

An example of a pattern or practiceof discriminatory placements or educa-tion is a school district's refusal to pro-vide related services to any studentswho are ineligible for such service.,under the IDEA, even if those studentsare "qualified handicapped persons"under the Section 504 regulation.

Recent investigations have resultedin OCR rulings that individuals whohave disabilities not specified in theIDEA are often eligible for related ser-vices under Section 504. In addition toADD, other examples that may be handi-capping conditions under Section 504are: alcohol and drug addiction (al-though, under 1990 amendments to theRehabilitation Act, a student who iscurrently using alcohol or illegal drugsis no longer protected by Section 504when the school district acts on the basisof such use); communicable diseasessuch as AIDS, and obesity (Cernosia,1991; "Georgia Challenges", 1990).

Notice From the Office of Civil Rights:Applicability of Section 504 of the Rehabilitation Act of 1973

to Homeless and Drug-Exposed Children

The Office of Civil Rights (OCR) is concerned about twowidespread national problems that may seriously affect ourschools. One is the predicament of children whose families arehomeless. The other is the plight of children who are born tomothers who have been exposed to drugs. Children who arehandicapped in these groups arc covered under Section 504 of theRehabilitation Act of 1973.

Under the Section 504 implementing regulation, recipients ofFederal aid operating public elementary or secondary educationprograms must annually undertake to identify and locate everyqualified handicapped person residing in the recipient's jurisdic-tion who is not recei ing a public education. Annually the schoolsystem must also take appropriate steps to notify handicapped

persons and their parents or guardiaus of its duty under theSection 504 regulation to provide a free appropriate publiceducation to each qualified handicapped person in its jurisdic-tion.

Because of its importance, OCR included iemtification ofhomeless and drug-exposed student populations for specialeducation and related services as one of the priority educa-tional equity issues in the FY 1991 National EnforcementStrategy. OCR has planned compliance and technical assis-tance outreach activities in this area during the current fiscalyear. Persons needing additbnal information or technicalassistance are urged to contact any of OCR's ten regionaloffices.

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Consistent with these rulings, schooldistricts must determine whether theeducational needs of students with suchdisabilities are being met to the extentthat the needs of students without dis-abilities are met (Daniels, 1988, p. 3).

The IDEA and Section 504 differ inanother, important aspect besides theirdefinitions of "disability." The IDEA:

...is a federal grant program.authorizing federal funds tostates to assist them in theprovision of special educationand related services to "eli-gible" students. Section 504is a civil rights statute, pro-hibiting discrimination on thebasis of handicap. ("GeorgiaChallenges", 1990, p. 208)

Therefore, although school districtsmust comply with the regulations ofSection 504 if they want to retain Fed-eral financial assistance, they do notreceive Federal funds to pay for servicesprovided to students with disabilitiesunder Section 504.

Parents and professionals who areinterested in more information abouthow Section 504 regulations affect theprovision of related services should con-tact any of OCR's regional offices. Ifyou need assistance identifying the re-gional office nearest you, please contactNICHCY.

How Are Related ServicesObtained for Students?

Usually, the need for related ser-vices is identified during the process ofevaluating a student for special educa-tion. Because far-reaching decisionsare made based upon the evaluation of astudent with a suspected disability, it isuseful to know that both the IDEA andSection 504 of the Rehabilitation Actstate that decisions about the educa-tional program of a student may not bebased solely on the findings of a singleevaluation instrument. Rather, data

must come from a variety of sources,including "aptitude and achievementtests, teacher recommendations, physi-cal condition, social or cultural back-ground, and adaptive behavior" [34 CFRSection 104.35(c), 1988]. Furthermore,data must be collected in all areas re-lated to the student's suspected disabil-ity. This may include, where appropri-ate, "health, vision, hearing, social andemotional status, general intelligence,academic performance, communicativestatus, and motor abilities" (Arena,1989, p. 23). Federal law also requiresthat the evaluation must be conductedby a multidisciplinary team, includingat least one teacher who is knowledge-able in the area of the suspected disabil-ity.

not what the school district (local edu-cational agency) can provide" (Arena,1989, p. 15). Thus, the related servicesneeded by the student must be listed inthe IEP, regardless of whether the dis-trict currently makes the services avail-able. The IEP establishes the genuineneed to be met and must describe relatedservices according to:

the servicc,$) needed (e.g., occupa-tional therapy)the type of servicr direct ser-vice to the consulting ser-vices to teachers or others)the type of service provider(s) (e.g.,occupational therapist)the frequency and duration of theservice (e.g., two 45-minute peri-dds per week).

"The IEP details the educational goals and objectivesfor the student and lists she related services that arenecessary to help the student attain those goals andobjectives."

The extensive nature of the evalua-tion process should provide decision-makers with the information they needto determine an appropriate educationalprogram for the student. It also allowsthem to identify the related services astudent will need. At this point, deci-sion-makers including the parentsand, where appropriate, the studentsit down and write an IndividualizedEducation Program (IEP) for the stu-dent. The IEP details the educationalgoals and objectives for the student andlists the related services that are neces-sary to help the student attain thosegoals and objectives. It is useful to notethat related services personnel are notrequired to participate in the IEP meet-ing. However, it is appropriate for themto participate or otherwise take part inIEP development. The written findingsand recommendations of related ser-vices personnel should become part ofthe child's evaluation report.

"The IEP...is formulated as a teameffort, based on what the child needs -

The IEP then serves as a writtencommitment for delivery of services tomeet a student's educational needs. Theschool district must provide all of theservices specified in the IEP, in theamount and degree specified. Changesin the amount of services listed in theIEP cannot be made without holdinganother lEP meeting. However, if thereis no change in the overall amount ofservice, some adjustments in schedul-ing of services should be possible with-out the necessity of another IEP meet-ing.

The above description of the evalu-ation process, IEP development, andthe specification of related services to bedelivered to a student with a disabilityassumes that the student was foundeligible for special education and re-lated services. What happens whenthings don't go so smoothly? For ex-ample, the school district may deter-mine, via its evaluation, that the studentdoes not require special education and,thus, is ineligible under the IDEA for

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related services. Or perhaps the parentsare dissatisfied with the way that relatedservices are being provided to their childor believe that their child needs relatedservices that the school district does notprovide or feels are unnecessary. Whathappens then?

Here are some points parents maywant to bear in mind in such situations(Education Law Center, 1985; U.S.Department of Education, 1986):

I. The IDEA enumerates proce-dural safeguards that school districtsmust adhere to in the delivery of educa-tional services (see Gerry, 1987). Thesesafeguards establish due process proce-dures through which parents and chil-dren with disabilities can resolve differ-ences with the school district (34 CFR§300.500 - §300.514, 1988). Amongthe procedures are: the right to an inde-pendent evaluation at public expense,the right to an impartial due processhearing, the right to an administrativeappeal and impartial review of the evi-dence, and the right to take civil action.

2. Therefore, if the school districtdetermines that a student with a disabil-ity does not require special educationand denies that student related services,parents may request that the district payfor an independent evaluation. If thedistrict should refilse this request, par-ents may ask for a hearing before animpartial hearing officer to resolve thisdifference.

3. The parents can also decide topay for the independent evaluation pri-vately. In this case, they should receivea written evaluation report specifying(a) the problem the child has; (b) pre-cisely how that problem affects thechild's ability to make progress towardthe goals of his or her IEP; (c) recom-mendations on the type of serv ice needed,the way it should be provided, how oftenand for how long, and the type of per-sonnel who should deliver the services;and (d) a description of the goals of therelated service program that is recom-mended. The school district must takethe results of the private evaluation intoaccount when making a decision about

a student's eligibility for related ser-vices.

4. Parents may also wish to nego-tiate with the school district to see if thestudent is eligible for related servicesunder Section 504 criteria. If parents donot agree with the district's decision,again, they can ask that a hearing of-ficer review the evidence. As a finalstep, parents can also file a complaintwith the regional office of the Office ofCivil Rights (OCR). An OCR hearingofficer will also review the evidence anddecide if the district is obligated toprovide the related services.

5. When a student's need for re-lated services is not linked to his or herability to benefit from special educationand is, therefore, not part of the IEP,parents have other options apart fromthe school system. For example, par-ents may seek services from rehabilita-tion organizations, private therapists,medical organizations, clinics, and otheragencies.

This latter point may be importantfor parents to consider when trying toobtain related services for their childwith a disability. Although parents dohave due process rights which they caninvoke when differences with the schooldistrict arise, they should be aware theproblems can often be worked out infor-mally. "Due process can be expensive,

time-consuming, and frustrating"(Callanan, 1990, p. 286), so it is cer-tainly worthwhile for parents to try firstto resolve problems with the district ina less confrontational way. Many stateshave alternatives to the formal appealprocess, including conciliatory confer-ences, administrative reviews, and me-diation. Flexibility and reasonablenessare key factors in working out differ-ences, and compromise on the parts ofboth the parents and the school districtmay be necessary. There are manybenefits to resolving differences throughcompromise and mediation. Not only istime saved and the cost of litigationavoided, but the relationship betweenparents and the school district will re-main a working one, where communi-cation is still open, people are still talk-ing, and future decisions are not madeimpossible by past differences.

How Are Related ServicesDelivered?

The district decides how the ser-vices enumerated in the lEP will bedelivered to the student. The districtmay provide these services through itsown personnel resources, but if this isnot possible, they may contract withanother public or private agency, whichthen provides the services.

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"There must be communication between the IEP teamand the related service provider(s) to ensure that servicesare being delivered as specified and that the student ismaking progress."

There are two kinds of related ser-vices interventions offered by schools tomeet the range of student needs. Thesecan be defined as follows (Associationfor Retarded Citizens/Minnesota, 1989,pp. 3-4):

. Direct Therapy refers to hands-oninteractions between the therapistand the student. These interactionscan take place in a variety of set-tings. The therapist analyzes stu-dent responses and uses specifictechniques to develop or improveparticular skills. The therapistshould also monitor the student'sperformance within the educationalenvironment and consult withteachers and parents on an ongoingbasis, so that some strategies can becarried out through indirect meansat other times.

. Indirect Therapv refers to teach-ing, consulting with, and directlysupervising other team members(including paraprofessionals andparents) so that they can carry outtherapeutically-appropriate activi-ties. Trained assistants, such as acertified Occupational TherapyAssistant, are sometimes employedto share in the delivery of relatedservices. Three essentials of indi-rect intervention are: (a) the inter-vention procedure is designed bythe therapist for an individual stu-dent; (b) the therapist has regularopportunities to interact with thestudent; and (c) the therapist pro-vides ongoing training, follow-up,and support to staff members andparents.One type of service intervention is

not necessarily better than the other.The type of service provided dependsupon the student's needs and educa-tional goals, and the skills and avail-

ability of school staff. Ellen Siciliano, aParent Involvement Coordinator for thePennsylvania Department ofEducation,Bureau of Special Education, sees atrend toward indirect therapy interven-tions for some related services. Shesays:

Some parents object to this,feeling that their childrenshould have the direct atten-tion of a therapist for all con-tact hours. My own opinion isthat indirect or consultativeforms of therapy are useful.When my daughter was inschool, a therapist workedwith me, so that I could workwith my daughter, and thiswas beneficial. In ruralschools, this kind of servicemay be very important in en-suring that children receivethese services. (Siciliano,personal communication, Sep-tember 20, 1990)In small and rural districts, often

there are not sufficient numbers of eli-gible students to justify employing afull-time therapist, or requirementsacross schools in a district may add upto the need for one related service pro-vider. In such cases, the district mayemploy one specialist to move fromschool to school, or several districts mayuse a cooperative approach, pool ing theirresources to hire personnel who travelamong districts to provide services. Theterm itinerant services is used to de-scribe this type of service provision, butit refers to the deployment of personnel,not to a specific type of service interven-tion.

How Are Related ServicesCoordinated?

The IDEA requires that amultidisciplinary team perform anevaluation of a student to determine hisor her eligibility for special educationand related services. Likewise, amultidisciplinary team must be involvedin any placement decisions. This teamgenerally consists of a representative ofthe public agency who is qualified toprovide or supervise the provision ofspecial education and/or related ser-vices, the student's teacher, one or bothof the student's parents, the student(where appropriate), individuals whoseinput 'is requested by either the parentsor the public agency, and a member ofthe evaluation team who is knowledge-able about how the evaluation was con-ducted and its findings (Arena, 1989).The student's IEP is developed throughthe joint efforts of these individuals. andnecessary related services are specified.

Obviously, the process of develop-ing an IEP can be complicated, requir-ing many people to interact and coordi-nate their efforts. Many school districtsappoint a school staff member (such asa teacher, psychologist, or counselor) toact as coordinator or case manager ofthe IEP process for an individual stu-dent or for all children with disabilitiesin a school. This is not required by law,but it helps the school district managethe complicated task of evaluating stu-dents and developing IEPs. The kindsof activities that a coordinator or casemanager might do include:

coordinating the multidisciplinaryevaluation;collecting and synthesizing evalu-ation reports and other relevantinformation that might be neededto the IEP meeting;communicating with parents; andconducting the IEP meeting (U.S.Department of Education, 1986).Beyond development, however,

there is implementation of the IEP.Depending on the nature of the relatedservices to be provided, many other

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professionals may become involved onbehalf of the student with a disability.This may include one or more thera-pists, a special educator, classroomteachers, counselors, the school princi-pal, paraprofessionals, and others. Theseindividuals work not only with the child,but also with the family and communityresources. Furthermore, there must becommunication between the IEP teamand the related service provider(s) toensure that services are being deliveredas specified and that the student is mak-ing progress. If the student is not pro-gressing as expected, adjustments in hisor her program must be made. The IEPteam would need to be involved in anysuch decisions, and the new plan wouldneed to be communicated to the relatedservices personnel.

Thus, it is highly desirable thatrelated services be delivered in educa-tional settings through a team approach.Related services are not to be isolatedfrom the educational program. Rather,they are to be related to the educationalneeds of students (Association for Re-tarded Citizens/Minnesota, 1989). Theinteractions of professional staff, con-sultants, community, and family,brought together in the delivery of re-lated services for a student, underscorethe usefulness of a case managementapproach in which a team leader coordi-nates and orchestrates services on be-half of the student.

How Are Related ServicesFunded?

Under P.L. 94-142 and its amend-ments, including the recently passedIDEA, students with disabilities areentitled to a free appropriate public edu-cation. State education agencies areresponsible for assuming the costs ofthat public education, and no costs ofimplementing the IEP for school-agedstudents can be passed on to parents orguardians. This includes the provisionof related services. Students and theirfamilies are entitled to receive theseservices at no cost to themselves.

Funding of related services, ofcourse, presents schools with an enor-mous fiscal obligation. While districtsreceive federal funds through the IDEAto assist them in providing special edu-cation programs and related services forstudents with disabilities, the costs can

the IDEA, to pay the costs of specialeducation and related services? Sincethe enactment of the original EHA (P.L.94-142), several new sources of fundinghave emerged. The Medicare Cata-strophic Coverage Act became PublicLaw 100-360 on July 1, 1988. Although

"(Eligible) students and their families are entitled toreceive (related) services at no cost to themselves."

nonetheless become quite staggering.However, "nowhere in the law is there aprovision that could be construed asrelieving a school system of its respon-sibility to provide a free appropriatepublic education even if sufficientfunds...are not available" ("Related Ser-vices: Funding and Personnel", 1988,p. 3). Even before the passage of theEHA, the landmark case of Mills v.Board of Education of the District ofColumbia (1972) affirmed that schooldistricts are responsible for meeting theeducational needs of students with dis-abilities. The school board in Millsargued that it could not afford to off anappropriate education to all its studentswith disabilities. The court respondedthat whatever inadequacies existed inthe school system could not be allowedto impact more heavily on the excep-tional child than on a child withoutdisabilities.

Although courts appear to becom-ing more aware of the costs involved inproviding related services, the tendencyis to consider the appropriateness ofdifferent educational options and thecosts of each, as in the Clevenger v. OakRidge School Board(1984)case. There,the 6th U.S. Circuit Court of Appealssaid, "Cost considerations are only rel-evant when choosing between severaloptions, all of which are for an "appro-priate" education. When only one isappropriate, then there is no choice."

Clearly, a school district's respon-sibility to students with disabilities isextensive and expensive. What otherfunding sources are available, besides

this legislation primarily concernedMedicare and has been repealed, it alsocontained an amendment to the SocialSecurity Act that affects Medicaid(which is a joint federal-state programproviding health care services for low-income persons). The 1988 amend-ments authorize Medicaid reimburse-ments for Medicaid-covered related ser-vices in the IEPs of Medicare-eligiblestudents with disabilities. The Omni-bus Budget Reconciliation Act of 1989,which further amended the federal Med-icaid statute, also provides that treat-ment needs recommended throughMedicaid's Early and Periodic Screen-ing Diagnosis and Treatment process(EPSDT) "must include any servicesthat are available under Medicaid, re-gardless of whether the state has optedto include such service as part of itsMedicaid state plan" ("Can Medicaid",1990, p. 161). As a result, some schooldistricts are now receiving funds throughMedicaid for certain related servicesthat are provided in the public schools.An example of this can be drawn fromthe case of Melissa, an eleven year oldwhose disabilities were so severe sherequired the services of a trained nursetwenty-four hours a day. She attendedpublic school wider district funding and,by all accounts,. lot on ly benefited greatlyherself but also provided a very positiveexample to her classmates by her enthu-siasm and her determination to learnand succeed. Melissa's parent sought afederal court ruling to require the U.S.Department of Health and Human Ser-vices (HHS) to use Medicaid funds to

1 4 1 149

"Another potential funding source that has come intouse in the last decade is third-party billing."

pay for the nursing services needed byMelissa while she was in school. 1-IHSdenied responsibility on the basis thatMedicaid regulations stipulate that pri-vate nursing care was not covered byMedicaid for locations outside of a hos-pital, a nursing facility, or a recipient'shome. However, the appellate courtfound in favor of Melissa, saying thatwhen Medicaid legislation was enactedtwo and a half decades ago, the assump-tion may have been widely accepted thata person needing a private duty nursewould be confined to the locations men-tioned in the regulations. Fortunately,that assumption is no longer true intoday's society. "Rather, private dutynursing is today understood as "settingindependent," referring to a level ofcare rather than to specific locationswhere the care can be provided" ("CanMedicaid", 1990, p. 161). Thus, thecost of the private duty nurse needed byMelissa while attending school was bill-able to Medicaid (Detsel v. Sullivan,1990).

Another potential funding sourcethat has come into use in the last decadeis third-party billing. Third-party bill-ing means that parents of students with

disabilities use their private health in-surance to pay for the individual evalu-ations or related services that their childreceives. The idea of third-party billingarose out of somewhat ambiguous regu-lations under both EHA and Section504 that state that insurers are not re-lieved of their obligation to "provide orpay for services provided to a handi-capped child" [34 CFR § 300.301(b),19881. Third-party billing has beenseen as a promising way for schooldistricts to pay for related services, butit has also become controversial. Asearly as 1980, the U.S. Department ofEducation released a policy interpreta-tion stating that educational agenciescould not compel parents of a child witha disability to file an insurance claimthat would pose a realistic threat to theparents in terms of fmancial loss. Ex-amples of fmancial loss include, but arenot limited to: (1) decreases in availablelifetime coverage or other insurancebenefits; (2) increases in insurance pre-miums; (3) discontinuation of the insur-ance policy; or (4) out-of-pocket ex-penses such as deductibles. However,the Department of Education did statethat districts may require parents to file

an insurance claim when: (a) doing sowould not result in cost to the parents;and (b) the district ensures that parentsdo not have to bear even a short-termfinancial loss, such as paying a deduct-ible. In the latter case, the school dis-trict "may insist that the parents file aclaim if it [the school district] pays forthe services and the deductible in ad-vance" (U.S. Department of Education,1980, p. 86390).

Many of the same points were reit-erated in a 1990 OSEP letter. Thisletter adds a point concerning the finan-cial loss to parents that -results whenfiling an insurance claim leads to in-creased insurance premiums. The OSEPletter states that:

...if a public agency offers topay the increased premiums,the parent would incur no fi-nancial loss and, therefore,could be required by the pub-lic agency to file an insuranceclaim. A parent's refusal tofile an insurance claim, evenwhere doing so would resultin no financial loss, does notrelieve the obligations of thepublic agency to provideFAPE [free appropriate pub-lic education] to the parent'schild who is handicapped.(Newby, 16 EHLR 549)

The Office of Civil Rights (OCR)has also become involved in the contro-versy over third-party billing. OCRinvestigations into how some schooldistricts were using third-party billingto pay for diagnostic and evaluativeservices revealed that parents were notadequately informed as to (a) the poten-tial consequences and costs of billingtheir insurance companies, or (b) theirright to refuse taking such action. BothOCR and OSEP and recently theOffice of Special Education and Reha-bilitation Services (OSERS) haveconfirmed the original Department ofEducation's policy that "without par-ents' voluntary consent to bill their in-surance, districts cannot obtain reim-

150

bursement through private insurancecarriers" ("Third-party Benefits", 1990,p. 5). Moreover, parents should beaware that a district may not terminateservices to a student with a disability ifparents refuse to file an insurance claim.

The policy interpretation issued bythe U.S. Department of Education in1980 does allow parents to voluntarilyuse their insurance benefits to pay forrelated services for their child. Thedistrict, however, must be able to provethat parents truly are cooperating vol-untarily, rather than because they feartheir child will otherwise not receiveneeded services.

Even where parents allow third-party billing, the district may still not beable to get reimbursed by insurancecompanies for providing related ser-vices. Some insurance policies specifi-cally exclude coverage of services thatthe insured can obtain free under fed-eral, state, or local laws. In a 1990 courtcase (Chester County Intermediate Unitv. Pennsylvania Blue Shield), parentsseeking reimbursement from their in-surance company claimed that the EHAforbids insurers from excluding cover-age for related services. The Court,however, found that the regulations ofthe EHA (now IDEA) do not bind pri-vate insurers (16 Education ofthe Handi-capped Law Report [EHLR] 925). Thus,insurance companies are within theirrights to exclude from coverage relatedservices that should be provided free ofcost to students with disabilities underthe IDEA. Needless to say, this repre-sents another obstacle to school districtsseeking to pay for related servicesthrough third-party billing.

Are There Shortages ofPersonnel for RelatedServices?

The answer is: Yes. The shortageof related services personnel is a recur-ring theme in state data on special edu-cation programs and related services.For example, in a survey conducted by

the University of Maryland (Smith-Davis, Burke, & Noel, 1984), 36 statesreported major shortages of physicaltherapists. In 1986, the number ofstates reporting shortages in this areahad risen to 47 (McLaughlin, Smith-Davis, & Burke, 1986). These resultsare not unusual. Personnel reported tobe in the shortest supply are occupa-tional therapists, physical therapists,psychologists, counselors, social work-ers, and speech/language pathologists(Office of Special Education Programs,Division of Innovation and Develop-ment, 1990). The results of these andseveral other recent studies (NationalEaster Seals Society, 1988; Nicholas,1990; Smith, 1990) attest to the prob-lems that school districts face in find-ing, hiring, and keeping personnel inthese important related services areas.

Salaries, of course, are a factor inthese shortages, inasmuch as hospitalsand private agencies can often offergreater compensation than can schools.But other factors include the lack oftrained applicants for school positionsand competition with other agencieswho provide related serviceS to the eld-erly population, infants at risk, andaccident trauma victims. Mr. Reynaud,Director of Special Education for thePark Hill School District and Presidentof the Council for ExceptionalChildren's Council of Administrators

of Special Education (CASE), describeshow this very problem is affecting hisdistrict's ability to provide related ser-vices.

Over the years, our district hashad an arrangement with St.Luke's Hospital in Kansas Cityto obtain OT and PT serviceson contract from its commu-nity-based program. This sum-mer, St. Luke's called to saythat they could no longer con-tract with us, because they wereexperiencing difficulty find-ing OTs and PTs to meet justthe demands of their hospitalservices, not to mention theircommunity programs. Whena big organization like St.Luke's says something likethat, you listen. (Reynaud,personal communication, Au-gust 3, 1990)Not only are vacancies difficult to

fill in many districts, but the scarcity ofpersonnel leads to heavier case loads forthose who are employed. To improveassessment and treatment, increase stu-dent contact hours, and allow more ser-vices for students who need them most,additional personnel time is certainlyneeded (Office of Special EducationPrograms, Division of Innovation andDevelopment, 1990). There is also apressing need to hire school-employed

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1 3

". . . Personnel shortages impact greatly on the schooldistrict's ability to provide related services to studentswith disabilities."

related service providers, rather thanobtaining them through contractual ar-rangements with other agencies, as isoften the case at present. However,many therapists are trained predomi-nantly for clinical work and often preferclinical rather than school settings. Asdemographics in the United Stateschange, the shrinking representation ofminorities in teaching and related ser-vices is also of concern.

All of these personnel shortagesimpact greatly on the school district'sability to provide related services tostudents with disabilities. "The worstimpact," says Dr. Lowell Harris, Direc-tor, Division of Exceptional Children'sServices for the North Carolina Depart-ment of Public Instruction, "is to knowthat children need services and the verydisturbing knowledge that services can'tbe provided appropriately, even thoughthere are funds to provide them." Headds, "The most poignant problem ariseswhen a therapist leaves. Then the pro-longed difficulty of finding a therapistbegins: children have already been re-ceiving services, but the services aretaken away. That's where the hearingscome in." (Harris, personal communi-cation, August 3, 1990).

By "hearing," Dr. Lowell is refer-ring to the legal right of parents to lodgea complaint against a school districtwhen related services are not being pro-vided to their child. A hearing is con-vened to review the evidence and deter-mine if, indeed, the child is eligible tcreceive the disputed services and, if so,what has happened that they are not. It

is clear from recent court cases andinvestigations by the Office of CivilRights (OCR) that, regardless of staff-ing difficulties, school districts are re-sponsible for providing the services stu-dents need. For example, a school dis-trict on Michigan's eastern Upper Pen-

insula found itself unable to hire andretain qualified physical therapists andspeech pathologists, due in part to thedistrict's isolated location. The districtsearched for candidates through post-ing vacancy notices in newspapers andin college placement offices, and triedunsuccessfully to establish a contrac-tual agreement with a neighboringschool district and a local sports medi-cine clinic to use their physical therapistservices. A complaint was lodgedagainst the district for failing to providephysical and speech therapy to a boywith cerebral palsy and other studentswith multiple disabilities. OCR inves-tigated the complaint and held the dis-trict in violation of its requirements.OCR then ordered the school district "totake any measures available, such ascontracting for services outside the im-mediate geographic area, to provideservices to the children" ("Related Ser-vices: Funding and Personnel", 1988,p. 2).

In Conclusion:Addressing the ProblemsTogether

Without a doubt, many school dis-tricts face very real problems in meetingtheir responsibility of providing the re-lated services needed by school-agedchildren with disabilities. Chief amongthese problems are a shortage of person-nel to provide related services and a

shortage of monies to fund them. Whileschool districts are required by federallaw to provide related services, con-structive action is needed on the parts ofparents, practitioners, and school ad-ministrators in order to improve thesituation. Here are some suggestionsfor action that can ease the budget andpersonnel crunch experienced by manyschool districts, without sacrificing thewelfare of students who require relatedservices in order to benefit from theireducation.

I. Write a complete IEP. Relatedservices needed by a student should belisted in the IEP. Not listing relatedservices in the IEP leads to inaccuratereporting of needed personnel in na-tional.and state data collection efforts,which distorts the true picture of thesupply/demand problem. Therefore, thedocumentation of related services andpersonnel needs begins with the IEP. I f

that documentation is faulty, under-standing of supply/demand becomesskewed. Plans that are made based uponthis documentation are similarly skewed,and the problem of personnel shortagesis perpetuated.

2. Wa/k in each other's shoes. Theshortage of personnel and monies isreal. There are simply not enough quali-fied related services personnel to fill allvacancies. At the same time, the newsis filled with reports of school districtsthat cannot pay for the educational ser-vices they are required by law to pro-vide. Parents, understandably, find itunacceptable that difficulties may existin meeting their child's legitimate needs.The law, after all, guarantees theirchild's right to a free appropriate publiceducation. Many parents may hold theview that the difficulties faced by school

". . . Parents and school personnel need to develop amutual recognition of the facts of their own district,appreciate the frustration that all parties have in thispredicament, and work together rather than against eachother to develop services for children."

1521 4

districts in terms of personnel and fund-ing are the school district's concern,while the child's welfare is the parent'sconcern. Ultimately, however, the dif-ficulties school districts face impact mostupon those individuals who need theservices namely, eligible studentswith disabilities.

Addressing parents, Callanan(1990) cautions: "It's important to knowand safeguard your legal rights. It canbe a mistake, however, to misuse themor to view your relationship with profes-sional educators as one-way, in whichthey give and you take... Positive par-ticipation on your part will further yourchild's education much more effectivelythan a series of avoidable confronta-tions" (p. 249). Thus, parents and schoolpersonnel need to develop a mutualrecognition of the facts of their owndistrict, appreciate the frustration thatall parties have in this predicament, andwork together rather than against eachother to develop services for children.Both parties are interested in the wel-fare of the student with a disability, andso both parties need to concern them-selves with the issues of funding andpersonnel shortages.

3. Improve coordination of ser-vices and responsibility-sharing. Nosingle agency alone can handle the in-creasingly complex needs of children.There is a major and growing need forcoordination of services, for resourceand program sharing, and for new pat-terns of interagency collaboration andcooperative services involving schools,mental health, human services, welfare,health agencies, juvenile justice, home-less centers, and other services. Often,coordination and cooperation can beachieved more effectively at the grass-roots level, with the assistance and in-volvement of concerned citizens, par-ents, and professionals. rather thanthrough state and federal mandates.

4. Become a creative networker.There are many ways of finding servicesand establishing opportunities that gobeyond what the school district offers toyour child or youth with a disabi I ity. Becreative in building a team that utilizes

the many resources available withinyour school and community. Theseresources can offer valuable learningexperiences for your child. Become anetworker. Talk to people such as read-ing specialists in the school, the chair-person of volunteer activities in theschool or community, club leaders, li-brarians, and individuals involved inschool or community sports programs.Explore what opportunities can be cre-ated for your child in recreational orafter-school activities. Many parentshave succeeded in networking withpeople within and outside of specialeducation who are willing to involvechildren and youth with disabilities inactivities offered by their club, organi-zation, or place of employment. Be-coming involved in school and commu-nity activities can give individuals withdisabilities the opportunity to grow andlearn academically, vocationally, andsocially.

5. Take constructive action. Localparents, practitioners, and principalscan activate entire communities in plansto staffthe schools with excellent people.Among the strategies that can be carriedout, both in rural and urban areas, are:

encouragement of local students toenter careers in special educationand related services;roles for high school students astutors and aides;

negotiations with higher educationinstitutions anywhere in the coun-try to place student teachers andinterns in the district;development of community-wideand school-based incentives and awelcoming atmosphere to attractnew personnel;planning with local businesses tooffer jobs to spouses of teacherswho might relocate;acquiring and/or raising scholar-ship funds for promising youngpeople who will return to the com-munity after completing profes-sional training;arrangements with higher educa-tion to deliver locally-based train-ing to increase the population ofaides and assistants in the schools,and to provide career ladderswhereby these personnel. can ac-quire professional credentials;human-centered interagency coop-eration that can extend and enrichservices to all children;planned agendas ofschool improve-ment and community pride activi-ties that will make your town abetter place to live and work.

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REFERENCES

Applestein. S. (1987). Speech pathology. In M.M. Esterson & L.F.Bluth (Eds.). Related services for handicapped children (pp.121-130). Boston: College-Hill Press. (This book has gone outof print and may be available only through your public library.)

Arena, J. (1989). How to write an IEP (rev. ed.). Novato, CA:Academic Therapy Publications. (Available from AcademicTherapy Publications. 20 Commercial Boulevard, Novato, CA94949.)

Assistive technology. (1989). NICHCY News Digest Number 13, 1-20. (Available from NICHCY. P.O. Box 1492, Washington. DC20013.)

Association for Retarded Citizens/Minnesota. (1989). A parentsguide to obtaining occupational and physical therapy servicesin the public schools. Minneapolis, MN: Author. (Availablefrom ARC Minnesota. 3225 Lyndale Avenue South, Minneapo-lis, MN 55408. Telephone: (612) 827-5641.)

Bevin H. v. Wright. 666 F. Supp. 71 (W.D. PA 1987). (See 1987-88Education of the Handicapped Law Report [EHLRJ 559:122.)(EHLR citations are available from LRP Publications, 747Dresher Road, P.O. Box 980. Horsham, PA 19044-0980. Tele-phone: 1-800-341-7874.)

Black. G., & Dorsett. T.V. (1987). School health services. In M.M.Esterson & L.F. Bluth (Eds.), Related services for handicappedchildren (pp. 69-77). Boston: College-Hill Press.

Blumberg. 1'. (1987). Parent counseling and training. In M.M.Esterson & L.F. Bluth (Eds.). Related services for handicappedchildren (pp. 69-77). Boston: College-Hill Press.

Callanan. C.R. (1990). Since Owen: A parent-to-parent guide forcare of the disabled child. Baltimore. MD: The Johns HopkinsUniversity Press. (Available from the Johns Hopkins Univer-sity Press. 701 West 40th Street. Baltimore, MD 21211.)

Can Medicaid-reimbursed nursing services be provided in school'?(1990. April 16). The Special Educator, 1(14), 159-161.(Available from LRP Publications, 747 Dresher Road. P.O. Box980. Horsham. PA 19044-0980, Telephone: 1-800-341-7874.)

Cernosia, A. (1991). Section 504 and IDEA. A comparison.Burlington. VT: Northeast Regional Resource Center. (Avail-able from Northeast Regional Resource Center, c/o TrinityCollege. Colchester Avenue. Burlington. VT 05401.)

Chester County Intermediate Unit v. Pennsylvania Blue Shield, 896F.2d 808 (3rd Cir. 1990). (See 16 Education of the Handi-capped Law Report IEHLR] 925.) (EHLR citations are avail-able from LRP Publications, 747 Dresher Road, P.O. Box 980,Horsham, PA 19044-0980. Telephone: 1-800-341-7874.)

Clevenger v. Oak Ridge School Board, 744 F.2d 514 (6th Cir. 1984).(See 1984-84 Education of the Handicapped Law Report[EHLR] Dec. 556:213.)

Code of Federal Regulations (CFR). Title 34: Education: Parts I -299, July. 1988. (Available from the Superintendent of Docu-ments, U.S. Government Printing Office, Washington. DC20402.)

Code of Federal Regulations (CFR): Title 34: Education: Parts 300-399, July, 1988. (Available from the Superintendent of Docu-ments. U.S. Government Printing Office. Washington. DC20402. New regulations were released in 1994 and are alsoavailable at this address.)

Code of Federal Regulations (CFR): Title 7: Parts 15-220, 1991.

Daniels, L.S. (1988, October, 24). Memorandum to OCR seniorstaff Guidance concerning distinctions between Section 504and the Education of the Handicapped Act. Washington. DC:U.S. Department of Education. (Available from U.S. Depart-ment of Education. Office of Civil Rights. 400 MarylandAvenue S.W., Washington, DC 20202.)

Detsel v. Sullivan. 895 F.2d 58 (2d Cir. 1990), (See 16 Educationof the Handicapped Law Report [EHLR] 427.)

Districts must provide assistive technology devices. (1990. Novem-ber 19). The Special Educator, II(6), 73, 76-77. (Availablefrom LRP Publications. 747 Dresher Road, P.O. Box 980.Horsharn, PA 19044-0980. Telephone: 1-800-341-7874. )

Dole, R. (1991, May 21). Floor statement of Senator Bob Dole:Children with disabilities and the School Lunch Program.(Available from the Office of Senator Bob Dole. 141 HartSenate Office Building, Washington, DC 20510.)

Education of All Handicapped Children Act, 20 U.S.C. Sections1400-1485.

Education Law Center, Inc. (1985, August 20). The right toeducation in Pennsylvania. Philadelphia: Author. (Availablefrom Education Law Center, Inc., 1708 Lam, and FinanceBuilding, 429 Fourth Avenue, Pittsburgh, PA 15219.)

Espino v. Besteiro, 520 F. Supp. 905 (S.D. Tex. 1981). (See 1981-82 Decisions, 3 Education of the Handicapped Law Report[EHLRI 553:124.)

Esterson, M.M. (1987). Recreation. In M.M. Esterson & L.F. Bluth(Eds.), Related services for handicapped children (pp. 97-101).Boston: College-Hill Press.

Esterson, M.M., & Bluth, L.F. (Eds.). (1987). Related services forhandicapped children. Boston: College-Hill Press. (This bookhas gone out of print and may only be available through yourpublic library.)

154

Esterson, S. (1987). Physical therap). In M.M. Esterson & L.F.Bluth (Eds.). Related services for handicapped children (pp.79-87). Boston: College-Hill Press.

Friedrich. B. (1987). Audiology. In M.M. Esterson & L.F. Bluth(Eds.). Related services for handicapped children (pp. 17-25).Boston: College-Hill Press.

Georgia challenees OCR's jurisdiction. (1990. June 25). TheSpecial Educator. V(18), 207-209.

Gem). M. (1987). Procedural safeguards insuring that handicappedchildren receive a free, appropriate, public education. N1CHCY.Vews Digest. No. 7. 1-8. (This document is no longer availablefrom NICHCY. but other documents, such as Questions andAnswers about the IDEA. are.)

Goodman. 16 Education of the Handicapped Law Report (EHLR)1317 (OSEP. 1990).

Horsley, J.W. (1988. July). Nutrition services for children withspecial needs within the public school system. Topics inClinical Nutrition. 1(3). 55-60.

Horsley. J.W., Allen. E.R.. & White, P.A. (n.d.). Nutritionmanagement of handicapped and chronically ill school agechildren: .4 resource manual for school personnel. families andhealth professionals. VA: Virginia Department of Health andVirginia Department of Education. (Available from Depart-ment of Education. Division of Pupil Personnel Services, P.O.Box 6Q. Richmond. VA 23216-2060. Telephone: (804) 225-2072.)

Individuals with Disabilities Education Act, 20 U.S.C. Chapter 33.Section 1401.

Joint Task Force for the Manaeement of Children with SpecialHealth Needs. (1990. May 1). Guidelines for the delineationof roles and responsibilities for the safe delivery of specialt.:edhealthcare in the educational setting. Reston, VA: The Councilfor Exceptional Children. (Available from the Council forExceptional Children. 1920 Association Drive. Reston, VA22091-1589.)

McKee. P.W.. & Barbe. R.H. (1990. May 28). Medical relatedservices - what are districts required to provide" The SpecialEducator. V(17), 198-200.

McLaughlin. M.. Smith-Davis. J., & Burke. P.J. (1986). Personnelto educate the handicapped in America A status report.College Park. MD: University of Maryland. Institute for theStud) of Exceptional Children and Youth.

v Board of Educatwn of the District ofColumbia. 348 F. Supp.866 (D.D.C. 1972)

National Association for Music Therapy. (1988). Music therapy as

a career. Washington, DC: Author. (This pamphlet is availablefrom the National Association for Music Therapy, 8455Colesville Road. Suite 930, SO% er Spring. MD 20910. Tele-phone: (301) 589-3300.)

National Easter Seals Society. (1988). Crisis ahead: Recruitmentand retention of rehabilitation professionals in the nineties andbeyond. Chicago. IL: Author. (Available from National EasterSeals Society. 230 W. Monroe Street. #1800. Chicago. 11.60606.)

Newby, 16 Education of the Handicapped Law Report (EHLR) 549.

Nicholas, G. (1990). ASCUS research report: Teacher supply anddemand in the UnitedStates 1990. Evanston, IL: Association forSchool. College, and University Staffing.

Office of Special Education Programs, Division of Innovation andDevelopment. (1990). Twelfth annual report to Congress onthe implementation of the Education of the Handicapped Act.Washington, DC: U.S. Department of Education.

Rehabilitation Act of 1913, 29 U.S.C. Sections 701-794.

Related services: Daily nursing care. (1987. November 17). The

Special Educator, IR(10). 1-3.

Related services: Funding and personnel. (1988. November 2). TheSpecial Educator, IY(9), 1-3.

Salyers, D. (1983, July). The use of dance for developmentallydelayed children. Down Syndrome Report. S2). 1.8.

Smith, F. (1990, May). Personnel shortages studied. NASPCommunique, 5.

Smith-Davis, J., Burke, P.J., & Noel, M. (1984). Personnel toeducate the handicapped in America: Supply and demand froma programmatic viewpoint. College Park, MD: University ofMaryland. Institute for the Study of Exceptional Children andYouth.

Tabb, S.M. (1987). Social work services in schools. In M.M.Esterson & L.F. Bluth (Eds.). Related services/or handicappedchildren (pp. 113-120). Boston: College-Hill Press.

Third-party benefits are often not available to districts. (1990.September 11). The Special Educator, 11(1). 4-5,15.

U.S. Congress. Public Law 100-407. Technologv-Related Assis-tance for Individuals with Disabilities Act of 1988.

U.S. Department of Education. (1980, December 30). Notificationof Interpretation. Federal Register. 41(251). 86390-1.

U.S Department of Education. (1986. July 11). Education Depart-ment general administrative regulations. 34 CFR. Ch Ill Pt300. Washington. DC: U.S. Government Printing Office.

155

FYI: Ififormation Resources from NICHCY S Database

The following information was selected from numerous resources abstracted in NICHCY's database.If you know of a group which provides information about related services to families, professionals, or the generalpublic or which develops materials and programs in this area, please send this information to NICHCY for ourresource collection and database We would appreciate this information and would share it with others.

You can obtain many of the documents listed below through your local library. Whenever possible, wehave included the publisher's address or some other source in case the publication is not available in your area.The organizations listed are only a few of the many that provide various services and information about relatedservices to families and professionals

Additional publications and information are also available from state and local parent groups and stateand local affiliates of many major disability organizations. Please note that these addresses are subject to changewithout prior notice If you experience difficulty in locating these documents or organizations, or if you wouldlike additional assistance, please contact NICHCY. Finally, you may find NICIICY's State Resource Sheet foryour state or territory helpful in contacting other resources of information

You may obtain copies of the laws discussed by writing to your Congressional Representative Federalregulations are available by writing to Superintendent of Documents, U S Government Printing Office,Washington, D C 20402 There is usually a charge for documents. It is Important that you include the title ofthe regulations you are seeking.

BIBLIOGRAPHY

General Interest

I3aer. M. (1990) . .Vutrition care guidelines, Region IX. LosAngeles. CA: UAP Center for Child Development and Devel-opmental Disorders. (Available from UAP Center for ChildDevelopment and Developmental Disorders, Children's Hospi-tal-Los Angeles. Los Angeles, CA 90054. Telephone: (213)660-2450.)

Center for Consumer Healthcare Information. (1991). 199/ Casemanagement resource guide. Irvine, CA: Author. (Availablefrom Center for Consumer Healthcare Information, 1821 E.Dyer Road, Santa Ana, CA 92705. Telephone: (714) 752-2335.)

Centcr for Recreation and Disability Studies. (n.d.). The parenttraining guide to recreation. Chapel Hill, NC: Author.(Available from the Center for Recreation and Disability Stud-ies. Curriculum in Leisure Studies and Recreational Adminis-tration. 730 Airport Road. Suite 204, University of NorthCarolina at Chapel Hill. CB# 8145. Chapel Hill. NC 27599-8145.)

Children's Defense Fund (1989). 94-142 and 504- Numbers thatadd up to educational rights for children with disabilities.Washington, DC: Author. (Available from Children's DefenseFund, 25 E Strect.N.W., Washington. DC 20001. Telephone:(202) 628-8787 )

Clarke, P.N., & Allen, A.S. (1985). Occupational thorapy Jc.rchildren. St. Louis: C.V. Mosby Company. (Available fromC.V. Mosby Company, 11830 Westline Industrial Drive, St.Louis, Missouri 63146. Telephone: 1-800-325-4177.)

Colorado State Pupil Transportation Association Special EducationCommittee (CSPTA-SPED). (compiler). (1991). Transport-ing the special needs student. Lakewood, CO: Author. (Avail-able from Janine Moreland, CSPTA-SPED Committee Chair,Jefferson County Schools, 809 Quail Street. Building 2. Lake-wood, CO 80215. Telephone: (303) 674-5516.)

Enders. A., & Hall, M. (Eds.). (1990). Assistive technologysourcebook. Washington. DC: Resna Press. (Available fromResna Press, 1700 N. Moore Street, Suite 15401. Arlington, VA22209. Telephone: (703) 542-6686.)

Fraser, B.A.. Hensinger. R.N., & Phelps. J.A. (1987). Physkalmanagement of multiple handicaps: A professional's guide.Baltimore: Paul H. Brookes. (Available from Paul H. BrookesCompany, P.O. Box 10624. Baltimore, MD 21285-0624. Tele-phone: 1-800-638-3775.)

Giangreco, M.F. (1986). Delivery of therapeutic services in specialeducation programs for learners with severe handicaps. Ph.t..si-

cal and Occupational Therapy in Pediatrics. 6(2), 5-15.

156

Giangreco. M.F. (1986). Effects of integrated therapy: A pilot study.Journal of the Association for Persons with Severe Handicaps.11(3). 205-208. (Available from TASH, 11201 GreenwoodAvenue North. Seattle. WA 98133.)

Giangreco. M.F., Edeleman, S.. & Dennis. R. (1991). Commonprofessional practices that interfere with the integrated deliveryof related services Remedial and Special Education. .12 (2),16-24.

Giangreco. M.F.. York. J.. & Rainforth. B. ((989). Providing relatedservices to learners ith severe handicaps in educational set-tings: Pursuing the least restrictive option. Pediatric PhysicalTherapy. 1(2), 55-63.

Gillett, E.S. (compiler). (1990. March). Nutrition educationresources for mentally handicapped, developmentally disabledstudents. Columbus. OH: Ohio State University. (Availablefrom the Nisonger Center Publications Department. Ohio StateUniversity. 1581 Dodd Drive. Columbus, OH 43210. Tele-phone: (614) 292-8365.)

Graff. J.C.. Ault. M. M.. Guess. D.. Taylor. M., & Thompson. B.(1990). Health care for students with disabilities: .4n illus-trated medical guide for the classroom. Baltimore, MD: PaulH. Brookes.

Grosse, S. ( Ed.). (1989). The best of practical pointers. Reston.VA: American Alliance for Health. Physical Education, Recre-ation and Dance. (Available from AA1IPERD, 1900 Associa-tion Drive, Reston, VA 22091. Telephone:(703) 476-3481.)

How to obtain funding for augmentative communication devices.(1989). Wooster. OH: Prentke Romich Company. (Availablefrom Prentke Romich Company, 1022 Hey! Road. Wooster, OH44691. Telephone: 1-800-262-1984.)

Kelley..1 D.. & Frieder!, L. ( Eds.). (1989). Go for it! A book on sportand recreation for persons with disabilities. Orlando: HarcourtBrace Jovanovich. ( Available from Harcourt Brace Jovanovich.Orlando, FL 32887.)

Kreb, R.A. ( I 991). Third party payment for funding specialeducation and related services. Horsham, PA: LRP Publica-tions. (Available from LRP Publications. 747 Dresher Road,P.O. Box 980, Horsham. PA 19044-0980.)

Levine. S.P.. Sharow. N.. Gaudette, C.. & Spector, S. (1983).Recreation experiences for the severely impaired or non-ambulatory child. Springfield. IL: Charles C. Thomas. (Avail-able from Charles C. Thomas. 2600 South First Street, Spring-field. IL 62717.)

Liebmann. M. (1986). Art thei apy for groups. Cambridge, MA:BRA:line. (Available from Brookline Books. P.O. Box 1046,Cambridge. MA 02238.)

Ludins-Katz. F.. & Katz. E. (1990). Art and disabilities Establish-ing the Creative Art Center for people with disabilities. Cam-bridge, MA: Brookline Books. (Available from the NationalInstitute of Art and Disabilities. 551 23rd Street. Richmond. CA94804.)

McConkey. R. (1985). Working with parents- .4 practical guide forteachers and therapists. Cambridge. MA: Brookline. (Avail-able from Brookline Books. P.O. Box 1046. Cambridge, MA02238.)

McElheron. M. (1991). I am special: Building life skills throughmusic. Redding. MA: Addison-Wesley. (Available fromAddison-Wesley Publishing Co., Order Department. One JacobWay. Redding, MA 01867. Telephone: 1-800-447-2226.)

Orelove, F., & Sobsey, R. (1991). Educating children with multipledisabilities: A transdisciplinary approach (2nd ed.). Balti-more: Paul H. Brookes. (Available from Paul H. BrookesPublishing Company, P.O. Box 10624. Baltimore, MD 21285-0624. Telephore: 1-800-638-3775.)

Polsgrove, L., & McNeil. M. (1989, January/February). Consulta-tion process: Research and practice. Remedial and SpecialEducation, 10(1), 6-13, 20.

Rainforth. B., & York, J. (1987). Integrating related services incommunity instruction. Journal of the Association for Personswith Severe Handicaps. 12(3), 190-198. (Available fromTASH, 11201 Greenwood Avenue North, Seattle, WA 98133.)

Rainforth, B.. York. J., & Macdonald. C. (1992). Collaborativeteams for students with severe disabilities: Integrating therapyand educational services. Baltimore, MD: Paul H. Brookes.

Ratzlaff, L.A. (Ed.). (1989). Special education compliance: Guid-ance from the U.S. Office of Special Education (V olumes 1 and2). Alexandria, VA: Capitol Publications.

RESNA Technical Assistance Project. (1992). Assistive technologyand the individualiud education program. Arlington. VA:Author. (Available from RESNA. 1700 N. Moore Street. Suite1540, Arlington, VA 22209. Telephone: (703) 542-6686.)

Review of most important court cases in 1990: No precedent shatter-ing decisions rendered. (1991. June). Liaison Bulletin, 11(5),1-8. (Available from National Association of State Directors ofSpecial Education. Inc., 1800 Diagonal Road, Suite 320, Alex-andria. VA 22314.)

Roberts, T. M. (1988). Encouraging expression The arts in theprimary curriculum. Baltimore. MD: Paul H. Brookes.

Rodriguez, S. (1984). The special artist's handbook. Art activitiesand adaptive aids for handicapped students. Palo Alto. CA:Dale Seymour. (Available from Dale Seymour Publications,P.O. Box 10888, Palo Alto, CA 94303.)

BEST COPY AVAILABLE

157

Rubin, M. (1990). Pathfinder .Vutrition and the handicapped.Beltsville, MD: National Agricultural Library. U.S. Depart-ment of Agriculture. (Available from the Food and NutritionInformation Center. National Agricultural Library, 10301 Bal-timore Boulevard, Beltsville. MD 20705.)

Schmidt. L. (1985). .Vutrition for children with special needs. St.Paul. MN: United Cerebral Palsy of Minnesota. Inc. (Availablefrom UCP of Minnesota. 1821 Unil, ersity Avenue. Suite 233South. St. Paul, MN 55104.)

School bus safety: Tie-downs and restraints. (1989, September).Exceptional Parent. 12(6 60-63.

Special help: Physical and occupational therapy [special issue].(1988. November'December). Special Parent/Special Child.4(6).

Striefel, S., & Cole. P. (1987). Providing psychological and relatedservices to children and adolescents: A comprehensive guidebook. Baltimore. MD: Paul H. Brookes. (Available from PaulFL Brookes Publishing Company, P.O. Box 10624. Baltimore.MD 21285-0624. Telephone: 1-800-638-3775.)

Tracy. P.B. (1983). Supportive staff and related personnel evalua-tion. Bloomington, IN: Council of Administrators of SpecialEducation (CASE) Research Committee. (Available fromCASF Research Committee. School of Education. Room 241,Indiana University. Bloomington. IN 47405. Telephone: (812)855-5362.)

Very Special Arts. (n.d.). The role of the arts in the education ofindividuals with special needs. An annotated bibliography,19-6-1986. Washington, DC: Author. [Available from VerySpecial Arts. Education Office. John F. Kennedy Center for thePerforming Arts. Washington. DC 20566. Telephone: (202)662-8899 (voice) and (202) 662-8898 (TDD).]

Warger. C.L.. & Cuskaden. E.C. (1990). The arts work: Employ-ment training through the arts Washington, DC: Very SpecialArts. (Available from Very Special Arts, Education Office, theJohn F. Kennedy Center for the Performing Arts. Washington,DC 20566.)

Willoughby, D.M., & Duffy. S.L.M. (1989). Handbookfor itinerantand resource teachers of blind and visually impaired students.Baltimore. MD: National Federation of the Blind. (Availablefrom the National Federation of the Blind, 1800 Johnson Street.Baltimore, MD 21230.)

York, J., Giangreco, M.F.. Vandercook, T., & Macdonald, C. (1992).Integrating support personnel in the inclusive classroom. In S.Stainback & W. Stainback (Eds.), Curriculum considerationsin inclusive classrooms: Facilitating learning for all students(pp. 101-116). Baltimore: Paul H. Brookes. ( Available fromPaul H. Brookes Publishing Company. P.0 Box 10624. Balti-more. MD 21285-0624. Telephone: 1-800-638-3775.)

York. J., Rainforth, B., & Giangreco, M.F. (199)). Transdisciplinaryteamwork and integrated therapy: Clarifying the misconcep-tions. Pediatric Physical Therapy, 2(2). -3-79.

Magazines

Family support bulletin. Published quarterlY by United CerebralPalsy Associations, Inc., 1522 K Street N.W., Suite 1112.Washington, DC 20005. Telephone: 1-800-USA-5UCP, or(202) 842-1266.

Rehabilitation Technology Review. Available from the Associationfor the Advancement of Rehabilitation Technology (RESNA),1700 N. Moore Street, Arlington, VA 22209. Telephone: (703)542-6686.

The Special Educator. Pubiished by LRP Publications, 747 DresherRoad. P.O. Box 980. Horsham, PA 19044-0980. (Annualsubscription: $215.00 prepaid.)

Transporting students with disabilities. Published every two weeksby Federal News Services. Inc. P.O. Box 13460. Silver Spring.MD 20911-0460. Telephone: (301) 608-9322. (Annual sub-scription: $137.00.)

In addition, many of the organizations listed below publish journalsor newsletters. Information about these publications is available bycontacting the organizations directly.

ORGANIZATIONS

CLEARINGHOUSES AND INFORMATION CENTERS

Clearinghouse on Disability Information - Office of SpecialEducation and Rehabilitative Services (OSERS), Room 3132.Switzer Building. 330 C Street S.W.. Washington, DC 20202-2524. Teiephone. (202) 205-8241.

ERIC Clearinghouse on Counseling and Personnel Services -University of North Carolina at Greensboro. 101 Park Building.School of Education. Greensboro. NC 27412-5001. Telephone:1-800-414-9769.

ERIC Clearinghouse on Disabilities and Gifted Education - TheCouncil for Exceptional Children, 1920 Association Drive.Reston, VA 22091. Telephone: 1-800-328-0272.

National Clearinghouse for Professions in Special Education -Council for Exceptional Children, 1920 Association Drive.Reston, VA 22091. Telephone: (703) 264-9474.

158

1 5 0

National Information Center on Deafness - Gallaudet University,800 Florida Avenue. N.E., Washington, DC 20002-3695.Telephone: (202) 651-5051 (Voice); (202) 651-5052 (TDD).

National Resource Center for Paraprofessionals in Educationand Related Human Services - 33 West 42nd Street. Room620N. New York, NY 10036. Telephone: (212) 642-2948.

OTHER NATIONAL INFORMATION RESOURCES

ABLENET - 1081 10th Avenue S.E.. Minneapolis, MN 55414.Telephone: (612) 379-0956.

Alliance for Technology Access - I 128 Solano Avenue. Albany, CA94706. Telephone: 1-800-992-8111.

American Alliance for Health, Physical Education, Recreationand Dance - 1900 Association Drive, Reston, VA 22091.Telephone: (703) 476-3481.

American Art Therapy Association, Inc. - 1202 Allanson Road,Mundelein, IL 60060. Telephone: (708) 949-6064.

American Counseling Association - 5999 Stevenson Avenue,Alexandria, VA 22304. Telephone: (703) 823-9800.

American Dance Therapy Association (ADTA) - Suite 108, 2000Century Plaza, Columbia, MD 21044. Telephone: (410) 997-4040.

American Dietetic Association - Division of Practice, 216 WestJackson Boulevard, Suite 800, Chicago, IL 60606-6995. Tele-phone: (312) 899-4814.

American Foundation for Technology Assistance, Inc. - Route14. Box 230, Morganton, NC 28655. Telephone: (704) 438-9697.

American Occupational Therapy Association, Inc. - 1383 PiccardDrive, P.O. Box 1725. Rockville, MD 20850-4375. Telephone:(301) 948-9626.

American Physical Therapy Association - 1111 North FairfaxStreet, Alexandria, VA 22314. Telephone: 1-800-999-2782.

American Psychological Association - 750 First Street N.E.,Washington. DC 20002-4242. Telephone: (202) 336-5500.

American School Counselor Association - 5999 Stevenson Avenue,Alexandria, Va 22304. Telephone: (703) 823-9800.

American Speech-Language-Hearing Association - 10801Rockville Pike, Rockville, MD 20852. Telephone: (301) 897-5700 (voice/TTY).

Council of Administrators of Special Education (CASE) - 61516th Street N.W., Albuquerque, NM 87104. Telephone: (505)243-7622.

Helen Keller National Center, - Technical Assistance Center(TAC) -I 1 I Middle Neck Road, Sands Point, NY 11050-1299.Telephone: (516) 944-8900.

National Association for Music Therapy, Inc. - 8455 ColesvilleRoad, Suite 930. Silver Spring, MD 20910. Telephone: (301)589-3300.

National Association of School Nurses - Lamplighter Lane. P.O.Box 1300. Scarborough, Maine 04070-1300. Telephone: (207)883-2117.

National Association of School Psychologists - 8455 ColesvilleRoad, Silver Spring, MD 20910. Telephone: (301) 608-0500.

National Association of Social Workers, Inc. - 750 First StreetN.E., Suite 700, Washington, DC 20002. Telephone: 1-800-638-8799.

National Institute of Art and Disabilities (NIAD) - 551 23rdStreet, Richmond, CA 94804. Telephone: (415) 620-0290.

National Therapeutic Recreation Society - 2775 S. Quincy Street.Arlington, VA 22206. Telephone: (703) 820-4940.

RESNA (The Association for the Advancement of RehabilitationTechnology) - RESNA Technical Assistance Project. 1700 N.Moore Street, Suite 1540, Arlington, VA 22209. Telephone:(703) 542-6686.

Trace Research and Development Center - S-151 WaismanCenter, 1500 Highland Avenue, Madison, WI 53705. Tele-phone: (608) 262-6966 (Voice); (608) 263-5408 (TDD).

Very Special Arts - Education Office, the John F. Kennedy Centerfor the Performing Arts, Washington, DC 20566. Telephone:(202) 662-8899.

BEST COPY AVAILABLE

159

NEWS DIGEST is published three times a year. Individual subscriptions in the United States are free. In addition,NICHCY disseminates other materials and can respond to individual requests. Single copies of NICHCY materialsand information services are provided free of charge. For further information and assistance, or to receive a NICHCYPublications List. contact NICIICK P.O. Box 1492, Washington. DC 20013, or call 1-800-695-0285 (Toll-free,Voice/TT) or (202) 884-8200 (Local. VoiceITT).

NICHCY thanks our Project Officer. Dr. Sara Conlon. at the Office of Special Education Programs, U.S. Departmentof Education, for her time in reading and reviewing this document. We would also like to thank Alice Wender,Technical Assistance Branch. the Office of Civil Rights, for providing her expertise in reviewing this manuscript. Theassistance of Mary von Euler at the Office of Civil Rights was also timely and valuable. We also thank the manyprofessional organizations that shared information and guidance about the services they provide to school-aged childrenwith disabilities. Finally, we thank the American Occupational Therapy Association, Inc. for permission to reprint thephotographs used in this issue.

PROJECT STAFFProject Director Carol H. Valdivieso, Ph.D.Deputy Director Suzanne RipleyInformation Resources Manager Richard HorneEditor Lisa KiipperPrinciple Authors Judy Smith-Davis, Fairfax Station, Virginia

William R. Littlejohn, Indiana State UniversityContributing Author Lisa KupperGraphics Design/Layout Joseph Buechling

(- This document was developed by Interstate Research Associates, Inc., pursuant to Cooperative Agreement #H030A00002with the Office of Special Education Programs of the United States Department of Education. The contents of this documentdo not necessarily reflect the views or policies of the Department of Education, nor does mention of trade names, commercialproducts. or organizations imply endorsement by the U.S. Government.

This information is in the public domain unless otherwise indicated. Readers are encouraged to copy and share it. butplease credit the National Information Center for Children and Youth with Disabilities. Your comments and suggestions for

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160

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PAIDMcLean, VA

Permit No. 718

Address Correction Requested

Health Care Plan. (1992). In Utah State Office of Education. Guidelines forserving students with Traumatic Brain Injuries. Salt Lake City: UtahDepartment of Education.



1 ri3

STUDENTS WITH SPECIAL HEALTH CARE NEEDS

HEALTH CARE PLAN(Please attach forms if room is insufficient)

Student IdentificationStudent Name Date of Birth

Background informationNursing Assessment (complete all necessary sections)Brief Medical History / Specific Health Care 0 (check box tf additional information is attached)

Psychosocial Concerns 0 (check box if additional information is attached).

Student and Family Strengths 0 (check box if additional information is attached)

,

Academic 1 Achievement Profile El (check box if additional information is attached)

Goals and Actions ---Skills checklist El AttachProcedures and Interventionsbffigabia

1)

physician' s order and

(student specific)Asklinigergstja

other standards for

Egliipment

care.

Maintained by Auth I trained by

2)

3)

Medications 0 Attach medication guideline and administration log.

Diet El (check box if additional information is attached)

NORY-1992163

Goals and Actions (continued)Transportation 0 (check box if additional information is attached)

Classroom School Modifications (including adapted PE) El (check box if additional information is attached)

Equipment and Supplies: Ej Provided by Parent provided by School District C3 (not necessary)

List Equipment:

Training, Education (staff, CPR, skills checklist), (peers, students)

Student Participation in Procedures (student skills checklist) 0 (check box if additional information is attached)

Safety Measures 0 (check box if additional information is attached)

ContingenciesEmergency Plan El Attached Transportation Plan Attached TraininePlan El Attached

Substitute / Backup Staff (when primary staff not available) .

Possible Problems to be Expected

AuthorizationsI have participated in the development of tbe Health Care

Date

Parent(s)

Plan and agree with the contents.Date

Teacher ____I_____1_____J____I

School Liaison LJ Teacher

School Nurse Other ____I_J________J_J

LEA Representative Other _____I_I____.____L___/

Physician: order for medication/specialized procedure (if pertinent)

Administrative Comments

Effective Beginning Date Date Health Cue Checklist Completed

1EP if Appropriate Date

Next Review Date

IVORY-1992

164

Appendix D

Modifying the elementary classroom. (1991). In Oregon Department ofEducation and Portland Public Schools. Traumatic Brain Injury: Aneducator's manual (p. 29). Salem: Oregon Department of Education.



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Oth

erM

odif

y th

e Sc

hool

Set

ting:

Post

cla

ss r

ules

Giv

e pr

efer

entia

l sea

ting

Cha

nge

to a

noth

er c

lass

Cha

nge

sche

dule

(mor

e di

ffic

ult c

lass

es in

the

mor

ning

)Po

st d

aily

sch

edul

eE

limin

ate

dist

ract

ions

Mod

ify

leng

th o

f sc

hool

day

Prov

ide

time

for

freq

uent

bre

aks

5Pr

ovid

e pl

ace

for

quie

t tim

ecl

)M

aint

ain

cons

iste

nt s

ched

ule

Oth

er

1 r;

t3

Ada

pt I

nstr

uctio

nal M

ater

ials

:R

educ

e le

ngth

of

assi

gnm

ents

Use

eas

ier

mat

eria

lsU

se a

ids

(cal

cula

tor,

wor

d pr

oces

sor)

Und

erlin

e or

hig

hlig

ht w

ords

Cha

nge

skill

/task

Use

man

ipul

ativ

e m

ater

ials

Use

col

or-c

oded

text

Use

boo

ks-o

n-ta

peU

se g

raph

ic o

rgan

izer

s(v

isua

l/spa

tial d

ispl

ays)

Mod

ify

test

ing

mod

e/se

tting

Oth

erE

nhan

ce H

ome/

Scho

ol R

elat

ions

:Pa

rent

con

fere

nces

eve

ryD

aily

/wee

kly

repo

rts

hom

ePa

rent

con

trac

tH

ome

visi

ts o

nO

ther

.M

odif

y St

uden

t's B

ehav

ior:

Ret

each

exp

ecte

d be

havi

orIn

crea

se s

tude

nt s

ucce

ss r

ate

Lea

rn to

rec

ogni

ze s

igns

of

stre

ssG

ive

nonv

erba

l cue

s to

dis

cont

inue

beha

vior

Rei

nfor

ce p

ositi

ve b

ehav

ior

(4:1

)U

se m

ild, c

onsi

sten

t con

sequ

ence

sSe

t goa

ls w

ith s

tude

ntU

se s

choo

lwid

e re

info

rcem

ent

with

targ

et s

tude

ntU

se g

roup

or

indi

vidu

al c

ouns

elin

gT

each

stu

dent

to a

ttend

to a

dvan

ceor

gani

zers

at b

egin

ning

of

less

onPr

ovid

e op

port

uniti

es to

rol

e pl

ayO

ther

.

29

Mar

shal

Res

ourc

es F

rom

:O

ccup

atio

nal t

hera

pist

Phys

ical

ther

apis

tSp

eech

and

lang

uage

spe

cial

ist

Oth

er (

incl

udin

g pa

st)

teac

hers

Res

ourc

e te

ache

rsR

esou

rce

spec

ialis

tSc

hool

psy

chol

ogis

tSt

uden

t stu

dy te

amC

hild

Dev

elop

men

t Spe

cial

ist

Prin

cipa

l/ass

ista

nt p

rinc

ipal

Reh

ab f

acili

tyO

ther

Prov

ide

Nee

ded

Supp

ort (

budd

y sy

stem

):E

xpla

in d

isab

ilitie

s to

oth

er s

tude

nts

Tea

ch p

eers

how

to b

e he

lpfu

lPo

sitio

n ap

prop

riat

ely

Poin

t out

sim

ilari

ties

to p

revi

ous

wor

kT

each

seq

uenc

ing

skill

sT

each

stu

dy s

kills

Tea

ch v

isua

l im

ager

yW

rite

ass

ignm

ents

in d

aily

log

Enc

oura

ge r

eque

sts

for

clar

ific

atio

n,re

petit

ion,

etc

.T

each

mem

ory

stra

tegi

esE

licit

resp

onse

s w

hen

you

know

stud

ent k

now

s th

e an

swer

Allo

w e

xtra

tim

eO

ther

Rec

ord

of a

ll m

odifi

catio

ns a

ttem

pted

.R

eed/

Ote

gon

Dep

artm

ent o

f Edu

catio

n, 1

991

Modifying the secondary classroom. (1991). In Oregon Department ofEducation and Portland Public Schools. Traumatic Brain Injury: Aneducator's manual (p. 30). Salem: Oregon Department of Education.


1 Go

Traumatic Brain injury 171

MO

DIF

YIN

G T

HE

SE

CO

ND

AR

Y C

LA

SSR

OO

MFo

r a

Stud

ent w

ith T

raum

atic

Bra

in I

njur

ySt

uden

t:T

each

erB

irth

Dat

e:T

oday

's D

ate:

Pres

entin

g C

once

rn:

Cha

nge

the

Tea

chin

g M

ode:

Rep

eat d

irec

tions

Incr

ease

act

ive

part

icip

atio

nT

each

er c

ircu

late

aro

und

room

Prov

ide

visu

al p

rom

pts

(boa

rd/d

esk)

Prov

ide

imm

edia

te f

eedb

ack

(stu

dent

cor

rect

s ow

n w

ork)

Tea

ch s

eman

tic m

appi

ngU

se f

requ

ent r

evie

w o

f ke

y co

ncep

tsT

each

to c

urre

nt le

vel o

f ab

ility

Spea

k m

ore

slow

ly o

r lo

udly

Ret

each

Use

pee

r tu

tor

Use

sm

all g

roup

inst

ruct

ion

Use

sim

ple

sent

ence

sU

se in

divi

dual

ized

inst

ruct

ion

Paus

e fr

eque

ntly

Dis

cuss

err

ors

and

how

mad

eU

se c

oope

rativ

e le

arni

ngU

tiliz

e in

stru

ctio

nal a

ssis

tant

Oth

erM

odif

Y th

e Sc

hool

Set

ting:

Post

cla

ss r

ules

Giv

e pr

efer

entia

l sea

ting

Cha

nge

to a

noth

er c

lass

Cha

nge

sche

dule

(mor

e di

ffic

ult c

lass

es in

the

mor

ning

)Po

st d

aily

sch

edul

eE

limin

ate

dist

ract

ions

Mod

ify

leng

th o

f sc

hool

day

Prov

ide

time

for

freq

uent

bre

aks

Prov

ide

plac

e fo

r qu

iet t

ime

Mai

ntai

n co

nsis

tent

sch

edul

eM

ove

dass

site

to a

void

phy

sica

l bar

rier

s(s

tair

s, lo

ng h

alls

, cha

nge

of b

uild

ing)

Oth

er.

1 r.

Ada

pt I

nstr

uctio

nal M

ater

ials

:R

educ

e le

ngth

of

assi

gnm

ents

Use

eas

ier

mat

eria

lsU

se a

ids

(cal

cula

tor,

wor

d pr

oces

sor)

Und

erlin

e or

hig

hlig

ht w

ords

Cha

nge

skill

/task

Use

man

ipul

ativ

e m

ater

ials

Use

col

or-c

oded

text

Use

boo

ks-o

n-ta

peU

se g

raph

ic o

rgan

izer

s(v

isua

l/spa

tial d

ispl

ays)

Mod

ify

test

ing

mod

e/se

tting

Oth

er.

Enh

ance

Hom

iSch

ool R

elat

ions

:Pa

rent

con

fere

nces

ever

yD

aily

/wee

kly

repo

rts

Pare

nt c

ontr

act

Hom

e vi

sits

on

Oth

erM

odif

y St

uden

t's B

ehav

ior

Ret

each

exp

ecte

d be

havi

orIn

crea

se s

tude

nt s

ucce

ss r

ate

Lea

rn to

rec

ogni

ze s

igns

of

stre

ssG

ive

nonv

erba

l cut

s to

dis

cont

inue

bth

avio

rR

einf

orce

pos

itive

beh

avio

r (4

:1)

Use

mild

, con

sist

ent c

onse

quen

ces

Set g

oals

with

stu

dent

Use

key

stu

dent

s fo

r re

info

rcem

ent o

fta

rget

stu

dent

Use

gro

up o

r in

divi

dual

cou

nsel

ing

Tea

ch s

tude

nt to

atte

nd to

adv

ance

orga

nize

rs a

t beg

inni

ng o

f le

sson

Prov

ide

oppo

rtun

ities

to r

ole

play

Tea

ch s

tude

nt th

e gr

adin

gsy

stem

Oth

er

30

Mar

shal

Res

ourc

es F

rom

:O

ccup

atio

nal t

hera

pist

Phys

ical

ther

apis

tSp

eech

and

lang

uage

spe

cial

ist

Oth

er (

incl

udin

g pa

st)

teac

hers

Res

ourc

e te

ache

rsR

esou

rce

spec

ialis

tSc

hool

psy

chol

ogis

tSt

uden

t stu

dy te

amC

ouns

elor

Prin

cipa

l/ass

ista

nt p

rinc

ipal

Reh

ab f

acili

tyO

ther

:Pr

ovid

e N

eede

d Su

ppor

tU

se p

eer-

part

ner

(Bud

dy s

yste

m)

Exp

lain

dis

abili

ties

to o

ther

stu

dent

sT

each

pee

rs h

ow to

be

help

fid

Posi

tion

appr

opri

atel

yPo

int o

ut s

imila

ritie

s to

pre

viou

s w

ork

Tea

ch s

eque

ncin

g sl

rills

Tea

ch s

tudy

ski

llsT

each

vis

ual i

mag

ery

Wri

te a

ssig

nmen

ts in

dai

ly lo

gE

ncou

rage

req

uest

s fo

r cl

arif

icat

ion,

repe

titio

n. e

tc.

Tea

ch m

emor

y st

rate

gies

Elic

it re

spon

ses

whe

nyo

u kn

owst

uden

t kno

ws

the

answ

erA

llow

ext

ra ti

me

Dev

elop

obj

ectiv

e gr

adin

g sy

stem

usi

ngda

ily p

artic

ipat

ion

as a

per

cent

age

ofw

eekl

y an

d fi

nal g

rade

sSc

hedu

le r

egul

ar m

eetin

gs f

or a

ll st

aff

to r

evie

w p

rove

s ai

d m

airs

ain

cons

iste

ncy

Oth

er

Rec

ord

ci a

ll m

odif

icat

ions

ase

mpt

cd.

Ree

d/O

rtio

n D

epar

tmen

t ci E

duca

tion.

199

1

1 G

Serving the student with TBI. (1991). In Oregon Department of Education andPortland Public Schools. Traumatic Brain Injury: An educator'smanual (pp. 11 - 19). Salem: Oregon Department of Education.


1r3

Traumatic Brain injury 175

Cue

ing

syst

ems

may

incl

ude

assi

gnm

ent b

ook,

task

cue

s,re

peat

ed in

stru

ctio

ns, w

rit-

ten

inst

ruct

ions

, bud

dy s

ys-

tem

(fo

r ge

tting

from

cla

ss to

clas

s or

for

rem

embe

ring

as-

sign

men

ts),

map

s fo

r na

vi-

gatio

n w

ithin

the

scho

ol.

1 C

DE

FIC

IT

AC

AD

EM

IC S

KIL

LS

BE

HA

VIO

R

Dec

reas

ed a

bilit

y to

pla

n.

TE

AC

HIN

G S

TR

AT

EG

Y

Doe

s no

t rec

ogni

ze d

ue d

ates

.or

tim

e re

quir

ed to

com

plet

ecl

ass

proj

ects

.

Has

dif

ficu

lty g

ettin

g to

cla

sson

tim

e.

Forg

ets

to b

ring

mat

eria

ls f

orcl

ass

Forg

ets

to p

repa

re f

or f

ield

trip

.

Hel

p cr

eate

a s

yste

m f

or m

aint

aini

ng o

rgan

izat

ion.

Enc

oura

ge u

se o

f a

daily

log

of a

ctiv

ities

, sch

eduk

s, a

ssig

n-m

ent l

ists

, and

due

dat

es; m

onito

r fr

eque

ntly

.

Dev

elop

cog

nitiv

e pr

osth

eses

: wal

l cha

rts,

dai

ly s

ched

ules

,di

gita

l wat

ches

, wat

ch a

larm

s, ti

mer

s, c

alen

dars

, not

eboo

ks,

lists

, mar

kers

, tap

e re

cord

ers,

and

labe

ls

Use

con

sist

ent s

tnic

ture

for

less

ons

and

daily

act

iviti

es. P

ost

a sc

hedu

le o

f ac

tiviti

es.

Incl

ude

activ

ities

whi

ch in

volv

e pl

anni

ng. H

ave

the

stud

ent

orga

nize

an

activ

ity (

e.g.

, a p

arty

).

Prov

ide

orie

ntin

g da

ta s

ever

al ti

mes

a d

ay. R

emin

d a

stud

er:

of n

ames

, pla

ces,

sch

edul

es, a

nd g

oals

. Hav

e st

uden

tre

peat

dire

ctio

ns th

at w

ere

give

n fo

r an

ass

ignm

ent c

c fo

r fi

ndin

gan

othe

r cl

ass.

Dec

reas

ed a

bilit

y to

sto

rean

d re

trie

ve in

form

atio

nup

on d

eman

d.

Has

littl

e co

ncer

n fo

r de

tails

.

Una

ble

to r

ecal

l spe

cifi

cde

tails

or

sequ

ence

of

a le

sson

.

Use

vis

ual a

nd a

udito

ry c

ues

to d

raw

atte

ntio

n to

det

ails

:hi

ghlig

ht, u

nder

line,

use

ref

eren

ce p

ictu

res.

Tea

ch m

emor

y tr

icks

and

stu

dy s

kills

.

Hav

e th

e st

uden

t tak

e no

tes

or r

ecor

d in

form

atio

n on

tape

.

Und

erlin

e or

hig

hlig

ht k

ey w

ords

inpa

ssag

es.

Spea

k sl

owly

; be

clea

r, c

onci

se, c

oncr

ete.

Lim

it se

nten

ce le

ngth

and

com

plex

ity.

Pair

-ve

rbal

sta

tem

ents

or

com

man

ds w

ith p

ictu

res,

dem

on-

stra

tions

, or

gest

ures

.

Use

wri

tten

dire

ctio

ns.

RE

PEA

T, R

EPE

AT

, RE

PEA

T

Dec

reas

ed c

arry

over

for

Can

not r

ecal

l or

gene

raliz

ene

w le

arni

ng.

info

rmat

ion

pres

ente

d in

cla

ss.

12

Tea

ch m

emor

y st

rate

gies

: cat

egor

ize,

ass

ocia

te, r

ehea

rse,

chun

k in

form

atio

n.

Rhy

me

wor

ds to

hel

p re

mem

ber

them

. Mak

e a

wor

d us

ing

the

firs

t let

ter

of e

ach

wor

d in

a s

erie

s th

at n

eeds

rem

embe

r-in

g (e

.g.,

HO

ME

S=L

akes

Hur

on, O

ntar

io, M

ichi

gan,

Eri

e,an

d Su

peri

or).

1 C

;

DE

FIC

ITB

EH

AV

IOR

TE

AC

HIN

G S

TR

AT

EG

Y

Reh

ears

e ve

rbal

ly; p

ract

ice

visu

al im

ager

y.

Ass

ign

a st

uden

t bud

dy to

take

not

es o

r to

mon

itor

and

chec

k w

hat h

as b

een

wri

tten.

Req

uire

wri

tten

wor

k.

Tea

ch to

all

lear

ning

sty

les

and

mod

aliti

es.

Dec

reas

ed a

bilit

y to

gen

er-

aliz

e le

arne

d in

form

atio

n to

sew

or

diff

eren

t situ

atio

ns.

Is u

nabl

e or

ref

uses

to ta

kete

sts

whe

re n

ewly

lear

ned

info

rmat

ion

mus

t be

appl

ied

or g

ener

ated

.

Stre

ss s

imila

ritie

s. P

rovi

de a

var

iety

of

exam

ples

of

the

topi

c.

Prov

ide

stud

y qu

estio

ns.

Use

mul

tiple

cho

ice,

fill

-in-

the-

blan

k (i

nclu

de w

on:I

list

), o

rop

en b

ook

test

.

Lac

k of

initi

ativ

e.Fo

rget

s; d

oes

not c

ompl

ete

orH

elp

deve

lop

a da

ily w

ritte

n as

sign

men

t she

et. L

ist d

uedo

es n

ot tu

rn in

hom

ewor

k.da

tes

and

times

.

Dev

elop

a c

onsi

sten

t pla

ce a

nd r

outin

e fo

r tu

rnin

g in

wor

k.

Dec

reas

ed a

bilit

y to

sta

y on

Is u

nabl

e to

beg

in a

nd/o

rta

sk.

com

plet

e tim

ed te

sts.

Is u

nabl

e to

sit

still

in c

lass

.

Skip

s ar

ound

whi

le d

oing

assi

gnm

ents

; com

plet

es o

nly

part

s of

ass

ignm

ents

.

Sim

plif

y an

d or

gani

ze th

e en

viro

nmen

t Pro

vide

qui

etsp

ace.

Elim

inat

e di

suac

tions

and

con

fusi

on; v

erba

lly c

ue th

est

uden

t to

"beg

in"

a ta

sk; n

onve

rbal

ly r

egai

n an

d re

dire

ct=

anio

n to

the

requ

ired

task

.

Prov

ide

agen

da; d

irec

t atte

ntio

n to

wha

t has

bee

n co

m-

plet

ed a

nd w

hat n

eeds

to b

e co

mpl

eted

.

Lim

it in

form

atio

n; p

rese

nt s

hort

uni

ts.

Prov

ide

brea

ks a

nd/o

r re

st p

erio

ds.

Prov

ide

opdm

al p

hysi

cal p

ositi

onin

g. U

se b

ook

hold

ers,

penc

il gr

ips,

larg

e ;a

im b

ooks

.

Inab

ility

to p

erfo

rm w

ell i

nco

mpe

titiv

e an

d st

ress

ful

situ

atio

os.

1

Has

low

tole

ranc

e fo

r tim

edte

st s

ituat

ions

.

Can

not c

ompl

ete

wor

k in

the

allo

wed

tim

e.

Arg

ues

and

figh

ts w

ith p

eers

duri

ng a

ctiv

ities

.

Allo

w in

crea

sed

proc

essi

ng ti

me.

Do

not u

se ti

med

test

s.

Use

mat

eria

ls w

hich

do

not r

equi

re a

tim

e lim

it.

Cut

ass

ignm

ents

in h

alf;

do

ever

y ot

her

prob

lem

.

Use

coo

pera

tive

lear

ning

tech

niqu

es.

Use

sm

all t

erou

p ac

tiviti

es; g

radu

ally

incl

ude

full

clas

s-M

OM

aC

tiviti

es. 13

Cla

ssro

om a

ids

may

incl

ude

calc

ulat

or, t

ape

reco

rder

,w

ritin

g ai

ds, p

ositi

onin

geq

uipm

ent,

augm

enta

tive

com

mun

icat

ion

devi

ces.

Flex

ibili

ty is

a k

ey in

gred

i-en

t for

suc

cess

fully

inte

grat

-in

g th

e st

uden

t with

TB

I.U

nlik

e ot

her

spec

ial e

duca

-tio

n st

uden

ts w

ho a

re n

eu-

rolo

gica

lly s

tabl

e, s

tude

nts

with

TB

I m

ay c

ontin

ue to

chan

ge n

euro

logi

cally

for

wee

ks, m

onth

s , o

r ev

en y

ears

follo

win

g re

turn

to s

choo

l.

Env

iron

men

tal c

onsi

der-

atio

ns m

ay in

clud

e no

ise

leve

l, ac

tivity

leve

l, sp

ecia

leq

uipm

ent,

task

arr

ange

-m

ent,

light

ing,

sch

edul

ing.

1 c'

,S

DE

FIC

IT

Low

tole

ranc

e fo

rfr

ustr

atio

n.

BE

HA

VIO

R

Has

out

burs

t of

tem

per

whe

not

hers

wou

ld tr

y a

diff

eren

tap

proa

ch o

r re

ques

t hel

p.

TE

AC

HIN

G S

TR

AT

EG

YD

o no

t atte

mpt

to c

hang

e th

e be

havi

orus

ing

trad

ition

albe

havi

or m

anag

emen

t app

roac

hes.

Lea

rn to

det

ect b

ehav

iors

lead

ing

up to

the

outb

urst

and

inte

rven

e pr

ior

to it

hap

peni

ng(w

atch

bod

y la

ngua

ge).

Prov

ide

area

that

is q

uiet

, tha

t is

away

fro

m a

ctiv

ity.

Allo

w ti

me

to b

e aw

ay f

rom

the

situ

atio

n an

d to

get

nee

ded

rest

cc

emot

iona

l rel

ease

.

Prov

ide

an u

nder

stan

ding

pers

on w

ho w

ill li

sten

to f

eelin

gsan

d fr

ustia

tions

.

Mod

e: a

ppro

pria

te b

ehav

iors

. Rol

epl

ay.

Inco

nsis

tent

per

for-

Man

Ce.

Doe

s si

mila

r w

ork

corr

ectly

one

day;

inco

rrec

tly th

e ne

xt.

Dem

onst

rate

s m

odel

beh

avio

r one

day

and

tota

lly in

appr

opri

ate

beha

vior

the

next

.

Dis

cuss

err

ors

and

how

they

mig

htha

ve b

een

mad

e.

Poin

t out

sim

ilari

ties

to p

revi

ous w

ork

whi

ch h

as b

een

com

plet

ed s

ucce

ssfu

lly.

Inab

ility

to c

ompl

yw

ith c

lass

room

rul

esan

d te

ache

r ex

pect

a-tio

ns.

Is w

ithdr

awn

and

not W

illin

gto

part

icip

ate

in g

roup

act

iviti

es.

Ref

uses

to r

ecite

in c

lass

.

Elic

it in

divi

dual

resp

onse

whe

n yo

u ar

c su

re th

at th

e st

uden

tkn

ows

the

answ

er, g

radu

ally

requ

est r

espo

nses

in s

mal

lgr

oups

; rep

eat u

ntil

the

stud

ent f

eels

com

fort

able

part

icip

at-

ing

in a

larg

e gr

oup.

Enc

oura

ge in

depe

nden

ce a

ndin

itiat

ion.

Ign

ore

fum

blin

g.W

rite

dow

n di

rect

ions

so s

tude

nt c

an w

ork

inde

pend

ently

.U

se s

tude

nt h

elp.

Pro

vide

time

for

crea

tive

wor

k in

art,

mus

ic, a

nd li

tera

ture

.

Giv

e fe

edba

ck o

n so

cial

beha

vior

s. T

alk

abou

t app

ropr

iate

and

inap

prop

riat

e be

havi

ors.

Vid

eo ta

pe s

essi

ons

and

stud

yth

em to

geth

er. I

ncre

ase

insi

ght

by d

iscu

ssin

g st

reng

ths a

ndw

eakn

esse

s.

Don

't ar

gue.

Pro

vide

clu

esfr

om th

e en

viro

nmen

t. E

ncou

r-ag

e sp

eech

, but

dis

cour

age

conf

abul

atio

n.W

hile

wor

king

,lim

it cl

iscu

ssio

n to

that

whi

chis

task

ori

ente

d.R

ude,

sill

y, im

mat

ure

for

age.

Mak

es in

appr

opri

ate

com

men

ts to

fello

w s

tude

nts

and

teac

hers

.

Lau

ghs

out l

oud

duri

ng s

erio

usdi

scus

sion

s or

qui

et s

eatw

ork.

14

Pres

ent "

wha

t if.

..."

situ

atio

nsan

d ch

oice

s

Prov

ide

oppo

rtun

ities

to r

ole

play

. Tal

k w

ith s

tude

ntab

out

appr

opri

ate

and

inap

prop

riat

ebe

havi

ors.

Vid

eo ta

pe s

essi

ons

and

stud

y th

em to

geth

er.

Incr

ease

insi

ght b

y di

scus

sing

stre

ngth

s an

d w

eakn

esse

s.

1 13

9

DE

FIC

IT

Ver

bally

agg

ress

ive.

BE

HA

VIO

R

Inte

rrup

ts c

onve

rsat

ions

.

TE

AC

HIN

G S

TR

AT

EG

Y

Tea

ch g

ood

liste

ning

tech

niqu

es.

Hav

e th

e st

uden

t con

cent

rate

on

the

com

men

ts o

f oth

ers.

Giv

e no

nver

bal c

ues

to d

isco

ntin

ue in

terr

uptiv

e be

havi

ors.

EX

PR

ES

SIV

E L

AN

GU

AG

E

Del

ayed

res

pons

esD

oes

not a

nsw

er im

med

iate

ly;

appe

ars

not t

o kn

ow th

ean

swer

.

Allo

w e

xtra

tim

e to

dis

cuss

and

exp

lain

.

Avo

id a

skin

g to

o m

any

ques

tions

.

Giv

e ad

vanc

e no

tice

of q

uest

ions

: allo

w ti

me

topr

epar

ean

swer

s.

Phr

ase

ques

tions

to a

llow

cho

ice

of a

nsw

er.

Wor

d re

trie

val e

rror

s.U

ses

"thi

s,"

"tha

t," "

thos

eth

ings

," "

wha

tcha

mac

allit

s."

Diff

icul

ty p

rovi

ding

ans

wer

son

test

s.

Has

dis

orga

nize

d sy

ntax

and

diffi

culty

thin

king

of w

ords

.

Tea

ch th

e as

soci

atio

n sk

ills.

Enc

oura

ge d

efin

ition

s or

desc

riptio

ns o

f wor

ds w

hich

can

not b

e re

calle

d.

Use

sem

antic

map

ping

or

web

bing

tech

niqu

es.

Tea

ch m

emor

y st

rate

gies

(e.

g., r

ehea

rsal

, ass

ocia

tion,

visu

aliz

atio

n, e

tc.)

.

Enc

oura

ge w

ord

retr

ieva

l. U

se p

hone

tic c

uein

gnd

desc

riptio

ns (

e.g.

. "C

an y

ou te

ll m

e an

othe

r w

ay?"

):

Pers

ever

atio

n on

wor

ds o

rph

rase

s.S

tart

s to

res

pond

and

get

s"s

tuck

" in

the

mid

dle

of a

sent

ence

. Rep

eats

wor

ds o

rph

rase

s (S

: "H

e w

ent,

he w

ent,

he w

ent"

).

Be

patie

nt. R

epea

t wha

t has

bee

n sa

id (

T: "

He

wen

t ...?

")`.

Inad

equa

te la

belli

ng o

rvo

cabu

lary

to c

onve

y cl

ear

mes

sage

.

Mis

labe

ls c

omm

on o

bjec

ts,

tool

s, m

ater

ials

, etc

.T

each

voc

abul

ary

asso

ciat

ed w

ith s

peci

ficsu

bjec

t are

as a

ndcl

assr

oom

act

iviti

es.

Tan

gent

ial c

omm

unic

atio

nR

ambl

es. D

oes

not a

ckno

wl-

edge

list

ener

's in

tere

st o

rat

tent

ion.

Tea

ch s

tude

nt to

rec

ogni

ze n

onve

rbal

beh

avio

rsin

dica

ting

lack

of i

nter

est o

r de

sire

to m

ake

a co

mm

ent.

(Wor

k w

ithth

is s

kill

durin

g pr

ivat

e co

nver

satio

ns w

ith th

est

uden

t.)

Tea

ch b

egin

ning

, mid

dle,

end

of s

torie

s.

Inte

rrup

t ram

blin

g sp

eech

; foc

us a

ttent

ion

on th

e ke

yis

sues

.

Com

mun

icat

ion

in in

form

alsi

tuat

ions

dif

fers

fro

mfo

rmal

situ

atio

ns s

uch

asth

e cl

assr

oom 1

ru9

Ans

wer

s qu

estio

ns a

t asu

rfac

e le

vel;

unab

le to

prov

ide

deta

iled

expl

anat

ion.

Enc

oura

ge c

onve

rsat

ions

to d

evel

op b

y gi

ving

inst

ruct

ions

such

as "

Tel

l me

mor

e"; "

How

man

y di

d yo

u se

e..."

15

Mod

ific

atio

n in

mat

eria

ls!

test

s m

ay in

clud

e en

larg

edpr

int,

sim

plif

ied

wor

kshe

ets,

take

hom

e te

sts,

ext

ra ti

me.

17

1

Ong

oing

suc

cess

req

uire

sgo

od c

ase

man

agem

ent.

Goo

d in

itial

edu

catio

nal

prog

ram

s ca

n ea

sily

det

e-ri

orat

e, e

ither

bec

ause

the

serv

ices

fai

l to

keep

pac

ew

ith th

e st

udIn

t's r

ecov

ery

and

new

dev

elop

men

tal

mile

ston

es, o

r be

caus

e th

est

uden

t mov

es o

n to

teac

h-er

s w

ho h

ave

not b

een

ori-

ente

dto

the

stud

ent's

uni

que

stre

ngth

s an

d ne

eds.

1

DE

FIC

ITB

EH

AV

IOR

Con

vers

es w

ell i

n so

cial

situ

atio

ns; c

onve

rsat

ion

incl

assr

oom

lack

s de

pth.

TE

AC

HIN

G S

TR

AT

EG

YR

ole

play

for

mal

iznv

ersa

tions

in s

mal

l gro

ups.

Dir

ect r

espo

nses

with

ver

bal m

odel

s, c

ues,

and

lead

ing

ques

tions

.

Tea

ch m

emor

y st

rate

gies

(e.

g.. r

ehea

rsal

s, c

hunk

ing,

visu

aliz

atio

n, a

ssoc

iatio

n, e

tc.)

.In

abili

ty to

des

crib

eev

ents

in s

eque

nce.

Rel

ates

det

ails

out

of

orda

.

Can

't ex

plai

n di

rect

ions

for

play

ing

a ga

me

or d

oing

an

assi

gnm

ent.

Dif

ficu

lty w

ith a

bstr

act

lang

uage

; am

bigu

ity,

satir

e, in

fere

nces

,dr

awin

g co

nclu

sion

s.

Tea

ch s

eque

ncin

g sk

ills.

Rea

d sh

ort p

arag

raph

s an

d su

mm

ariz

e; p

lay

gam

es; d

opu

zzle

s, s

eque

ncin

g ac

tiviti

es, g

roup

ing,

sat

ing,

and

cate

gori

zing

.

Use

spe

cial

edu

catio

n m

ater

ials

to te

ach

spec

ific

ski

lls.

Says

thin

gs th

at c

lass

mat

esin

terp

ret a

s sa

tiric

al, f

unny

, ar

biza

rre,

alth

ough

they

wer

e no

tin

tend

ed to

be

that

way

.

Tea

ch th

e st

uden

t com

mon

phr

ases

use

d kr

sat

ire,

idio

ms,

puns

, etc

.

Red

uced

ver

bal r

easo

n-in

g ab

ility

.G

ives

a c

orre

ct a

nsw

er b

utun

able

to li

st th

e st

eps

fol-

low

ed to

sol

ve a

pro

blem

.

Tea

ch in

duct

ive

and

dedu

ctiv

e re

ason

ing

atap

prop

riat

e ag

ele

vels

.

Wor

k w

ith s

tude

nts

priv

atel

y to

dev

elop

rea

soni

ng a

ndex

plan

atio

ns.

Rzc

zrzy

nt L

AN

GU

AG

Z

Inab

ility

to d

eter

min

esa

lient

fea

ture

s of

"Wh.

." q

uest

ions

, ver

bal

info

rmat

ion,

or

assi

gn-

men

ts r

ead.

Com

plet

es th

e w

rong

ass

ign-

men

t (e.

g., i

nste

ad o

f pr

oble

ms

9-12

, stu

dent

doe

s 1-

9).

Wri

te a

ssig

nmen

ts in

dai

ly lo

g.

Inab

ility

to d

eter

min

eth

e sp

ecif

ic a

spec

ts o

fqu

estio

ns th

at n

eed

to b

eas

ked.

Get

s de

tails

con

fuse

d w

hen

answ

erin

g qu

estio

ns a

bout

deta

ils o

f a

less

on.

Res

pons

es m

ay b

e re

late

d to

spec

ific

que

stio

ns, b

ut n

otex

act.

Una

ble

to d

ecip

her

long

stor

ypr

oble

ms.

Failu

re to

org

aniz

eve

rbal

or

wri

tten

info

r-m

atio

n.

Ask

que

stio

ns w

hich

will

elic

it re

call

of im

port

ant f

acts

.T

each

stu

dent

to u

se h

ighl

ight

er to

mar

kre

spon

ses

firs

t.

Enc

oura

ge r

eque

sts

for

clar

ific

atio

n, r

epet

ition

, a s

low

ersp

eed.

Perf

orm

s st

eps

out o

fse

quen

ceT

each

seq

uenc

ing

to s

on a

nd o

rgan

ize.

Do

not a

llow

the

or f

ixat

es o

n on

e st

ep.

stud

ent t

o sk

ip s

teps

, eve

n if

he

says

he

know

s w

hat t

o do

.

1617

3

DE

FIC

ITB

EH

AV

IOR

TE

AC

HIN

G S

TR

AT

EG

YSe

quen

ce in

stru

ctio

ns. L

imit

the

num

ber

of s

teps

. Dis

cuss

one

step

at a

tim

e. C

heck

off

eac

h st

ep a

s co

mpl

eted

.

Tea

ch th

e st

ruct

ure

of th

e ta

sk. P

rovi

de s

ampl

e ite

ms

desc

ribi

ng h

ow to

pro

ceed

thro

ugh

a ta

sk. U

se y

este

rday

'sw

ork

as a

mod

el f

or to

day'

s.

Inab

ility

to a

naly

ze o

rin

tegr

ate

info

rmat

ion.

Dis

orga

nize

d or

inco

mpl

ete

wor

k.

Con

fuse

s ve

rbal

dir

ectio

ns;

goes

to th

e w

rong

roo

m.

Prov

ide

wri

tten

dire

ctio

ns.

Num

ber

dire

ctio

ns.

Hav

e st

uden

t cro

ss o

ff s

teps

whe

n co

mpl

eted

.

Eas

ily o

ver-

load

ed.

App

ears

to b

e da

ydre

amin

g or

nonr

espo

nsiv

e.Fo

cus

atte

ntio

n.

Paus

e fr

eque

ntly

.

Giv

e tim

e fo

r pr

oces

sing

info

rmat

ion.

Use

sho

rt, s

impl

e se

nter

ices

.

Inab

ility

to r

eact

non

verb

alcu

es.

Una

war

e th

at th

e te

ache

r or

othe

r cl

assm

ates

do

not w

ant

to b

e bo

ther

ed w

hile

wor

king

.

Inte

rrup

ts o

ther

s.

Incr

ease

soc

ial a

war

enes

s. U

se p

rees

tabl

ishe

d no

nver

bal

cues

to a

lert

the

stud

ent t

hat h

is b

ehav

ior

is n

ot a

ppro

pri-

ate.

Dis

cuss

.

Poor

com

preh

ensi

on o

fle

ngth

y or

rap

id s

peec

h.H

as p

oor

note

talc

ing

skill

s;=

bile

to s

elec

t sal

ient

fac

ts.

Use

sho

rt, s

impl

e se

nten

ces,

em

phas

izin

g ke

y po

ints

by

voic

e va

riat

ions

, int

onat

ions

, etc

.

Ale

rt th

e st

uden

t to

the

impo

rtan

t top

ics

bein

g di

scus

sed.

Dif

ficu

lty u

nder

stan

ding

ase

quen

ce o

f ev

ents

.G

ets

lost

in th

e da

ily r

outin

e(k

now

ing

orde

r, o

r lo

catio

n of

clas

ses)

.

Prov

ide

wri

tten

sche

dule

of

scho

ol r

outin

e an

d a

map

of

the

bui:4

ing

with

cla

ssro

oms

mar

ked

in o

rder

.

Prov

ide

pict

ures

of

sequ

ence

of

step

s.

Dif

ficu

lty w

ith a

ttent

ion

and

com

preh

ensi

on.

Loo

ses

plac

e w

hile

rea

ding

.Pr

ovid

e ad

ditio

nal t

ime.

Abi

lity

to c

once

ntra

tede

crea

sed.

'7

Una

ble

to r

elat

e in

form

atio

nre

cent

ly r

ead.

Eas

ily d

istr

acte

d du

ring

read

ing

assi

gnm

ents

.

Una

ble

to c

ompl

ete

sile

ntre

adin

g an

d se

atw

ork

assi

gn-

men

ts a

t the

sam

e ra

te a

scl

assm

ates

.

Red

uce

the

amou

nt o

f w

ork

to b

e do

ne.

17

Tea

cher

s sh

ould

n't e

mph

a-si

ze h

avin

g st

uden

ts c

atch

up o

n m

isse

d as

sign

men

ts.

The

y m

ay h

ave

to f

ocus

on

the

defi

cits

and

dev

elop

teac

hing

str

ateg

ies

to e

n-ha

nce

lear

ning

as

skill

s ar

ere

gain

ed o

r de

velo

p m

ore

perm

anen

t ass

ista

nce

whe

nit

appe

ars

that

reco

very

isno

t occ

urri

ng in

spe

cifi

car

eas.

lf te

achi

ng s

trat

egie

sre

med

iate

cog

nitiv

e an

dbe

havi

oral

impa

irm

ents

so

that

a s

tude

nt a

cts

mor

eap

prop

riat

ely,

pla

cem

ent

optio

ns c

an in

crea

se. F

orex

ampl

e, h

elpi

ng th

e st

u-de

nt g

ain

self

-con

trol

ove

rim

puls

ive

beha

vior

and

decr

easi

ng th

e am

ount

of

disr

uptiv

e or

soc

ially

inap

prop

riat

e be

havi

or w

illgo

a lo

ng w

ay to

war

dspl

acin

g th

e st

uden

t in

a le

ssre

stri

ctiv

e pr

ogra

m.

1 P'

"

DE

FIC

IT

Red

uced

abi

lity

toun

ders

tand

abs

trac

tla

ngua

ge.

BE

HA

VIO

R

Mis

unde

rsta

nds

inst

ruct

ions

and

com

men

ts m

ade.

Doe

s no

t und

erst

and

hum

or.

TE

AC

HIN

G S

TR

AT

EG

Y

Use

cor

rect

lang

uage

whe

n pr

esen

ting

impo

rtan

tin

form

atio

n or

cor

rect

ing

beha

vior

.

Tea

ch th

e m

eani

ng o

f id

iom

s, f

igur

ativ

e la

ngua

ge,

ambi

guou

s ph

rase

s, e

tc.

WR

ITT

EN

LA

NG

UA

GE

Stru

ctur

e an

d co

nten

tof

the

wri

ting

may

not

be o

f th

e sa

me

skill

leve

l as

prei

njur

y.

Has

num

erou

s gr

amm

atic

aler

rors

in e

ssay

s.G

ive

the

stud

ent t

ime

to g

o ov

er w

ritte

n w

ork

with

apa

rtne

r or

teac

her

aide

to f

ind

and

corr

ect e

rror

s.

Tea

ch v

ocab

ular

y, g

ram

mar

, and

pro

ofre

adin

g sk

ills.

Sent

ence

str

uctu

re is

sim

plis

tic a

nd s

ynta

xdi

sorg

aniz

ed.

Use

s in

corr

ect a

nd u

norg

a-ni

zed

sent

ence

str

uctu

re.

Wri

tes

belo

w a

ge a

nd g

rade

leve

l; th

emes

may

be

sim

plis

tic, s

hort

and

dry

.

Doe

s no

t use

fig

urat

ive

lang

uage

; wri

ting

cont

ains

irre

leva

nt o

r un

subs

tant

ial

info

rmat

ion.

Allo

w th

e st

uden

t to

verb

ally

sta

te id

eas,

tape

rec

ord,

or w

rite

fro

m d

icta

tion.

Use

"qu

estio

n ca

rds"

to in

dica

te th

e sp

ecif

ic is

sues

tobe

add

ress

ed in

wri

tten

assi

gnm

ents

.

Tea

ch to

cur

rent

leve

l of

abili

ty.

Dec

reas

ed s

peed

and

accu

racy

.

Poor

han

dwri

ting.

Doe

s po

orly

on

timed

test

s.In

crea

se ti

me

and

decr

ease

req

uire

men

ts.

GE

NE

RA

L B

EH

AV

IOR

SSO

CIA

L S

IUL

IS

Dec

reas

ed ju

dgem

ent.

Is e

asily

per

suad

ed b

yot

hers

.

Is im

puls

ive.

Spea

ks o

ut o

f tu

rn in

cla

ss,

gets

up

and

mov

es a

bout

or

leav

es c

lass

room

.

18

Post

cla

ss r

ules

Dis

cuss

app

ropr

iate

soc

ial c

ondu

ct

Use

sig

nals

to c

ue s

tude

nt to

ale

rt b

ehav

ior.

Sche

dule

tim

e fo

r fr

eque

nt b

reak

s.

Est

ablis

h sp

ecif

ic r

ules

for

beh

avio

r.1

",1

Pi

DE

FIC

IT

Inab

ility

to p

lan

for

the

futu

re.

BE

HA

VIO

R

Is c

arel

ess

abou

t saf

ety.

Doe

s no

t loo

k be

fore

cros

sing

str

eets

; poo

rde

cisi

ons

abou

t pla

ying

on

the

play

grou

nd o

r ac

tiviti

esin

PE

cla

ss.

Res

ents

sup

ervi

sion

.

TE

AC

HIN

G S

TR

AT

EG

YU

se c

ontr

olle

d se

tting

bef

ore

allo

win

g st

uden

t to

bein

depe

nden

t.

PRA

CT

ICE

, PR

AC

TIC

E, P

RA

CT

ICE

Doe

s no

t rec

ogni

ze p

hysi

-ca

l or

cogn

itive

lim

itatio

ns.

Stre

ss n

eed

for

safe

ty.

Adj

ust c

ompl

exity

leve

l of

activ

ities

to th

e st

uden

t'slim

itatio

ns.

Bui

ld o

n su

cces

s ra

ther

than

fai

lure

.

Prov

i, e

appr

opri

ate

voca

tiona

l tra

inin

g.

Self

insi

ght l

acki

ng.

Doe

sn't

unde

rsta

nd o

ther

pers

on's

rea

ctio

n to

his

beha

vior

.

Res

pond

s de

fens

ivel

y to

com

men

ts m

ade

or q

ues-

tions

ask

ed b

y te

ache

rs o

rfe

llow

stu

dent

s.

Poin

t out

inap

prop

riat

e be

havi

or. D

escr

ibe

appr

opri

-at

e be

havi

or. M

odel

beh

avio

r. R

ole

play

.

Do

not r

eact

or

resp

ond

as if

you

nee

d to

pro

ve a

poin

t; av

oid

conf

ront

atio

n; a

void

"bu

ying

into

" th

ear

gum

ent.

Poor

pro

blem

sol

ving

skill

s,no

t car

eful

ly th

ough

t out

.So

lutio

ns to

situ

atio

ns a

re

1

Ask

que

stio

ns d

esig

ned

to h

elp

the

stud

ent i

dent

ify

the

prob

lem

, pla

y ou

t sol

utio

n, a

nd o

rgan

ize

impl

e-m

enta

tion

of p

lan.

Prov

ide

supp

ort t

he s

tu-

dent

nee

ds b

y al

low

ing

mul

tiple

opp

ortu

nitie

s to

prac

tice,

app

ropr

iate

rol

em

odel

s, a

nd c

aref

ully

stru

ctur

ed o

ppor

tuni

ties

tole

arn.

1 P9

9

Observable behaviors and strategies. (1992). In Virginia Department ofEducation and the Rehabilitation Research and Training Center onSevere Traumatic Brain Injury (pp. 66 - 84). Guidelines for EducationalServices for Students with Traumatic Brain Injury. Richmond:Author.


1 s 0

Traumatic Brain Injury 186-

Observable Behaviors and Strategies111.111111111111111111111111111

A. III al. _et 41_ I IL

Observable Behavior:

Confused with time (day, date), place (classroom, bathroom), and personal information(birth date, address, phone, schedule)

Seems "in a fog" or confused

Stares blankly

Appears deepy or to fatigue easily

Fails to finish things started

Can't concentrate or pay attention

Daydreams or gets lost in thoughts

Inattentive, easily distracted

Strategies:

Provide an uncluttered, quiet environment.

Provide printed or pictorial charts, schedules, or classroom maps that describe routinesand rules of expected behaviors. Review these before each session and as neededthroughout the day. These may be kept in a notebook that travels with the student.

Maintain consistent staff, room arrangement, and materials.

Label significant objects and areas; provide name tags for staff.

Redirect undesirable behavior by focusing student's attention on tasks that are suffi-

ciently interesting to break the pattern of disruptive or perseverative responses. (Note:Do not use this technique if the student's behavior is attention seeking. Consultationwith a behavior psychologist may be indicated.)

Teach student to look for permanent landmarks and name the landmarks when they

come to them.

187

Si

Have student verbalize how to go to a specific place before starting or while moving.

Use a buddy system.

Remove unnecessary distraaions, such as pencils and books. Limit background noisefirst and gradually increase it to more normal levels.

Provide visual cues to attend (e.g., have a sign on student's desk with the work orpictured symbol for behaviors, such as LOOK or LISTEN. Point to the sign when stu-dent is off task).

Limit the amount of information on a page.

Adjust assignments to the length of students' attention span so that they can completet:-.Llss successfully.

Focus student's attention on specific information: "I'm going to read a story and askV1-10 is in the story."

Demonstrate a new task, repeat instructions and ask the student to repeat instructions.If this is unsuccessful, vary the activities so that less similar activities follow each other.

Distractibility,' resulting from the noise and confusion of large numbers of studentschanging classes may not allow the student to find the class until the halls are clear.Allow the student to leave a few minutes early from each class to beat the rush.

Redirect the student's attention as soon as his/her attention drifts away from the assign-ment. Gradually lengthen time of on-task behavior by strengthening U. e intervals oftime that a student could receive reinforcement (either social praise or tangibles).

',:se clearly defined objectives that are meaningful for the student.

Use short and concise instructions and assignments.

Reward on-task behavior; avoid punishing behavior that results from extreme distract-ibility.

Use novel, unusual, relevant, or stimulating activities.

Provide well-placed rest periods or breaks to minimize the effeas of mental fatigue orstamina problems.

Closely monitor time of day, medications and fatigue factors; confer with physicians todetermine the feasibility of adjusting medication times so as not to conflict with instruc-

tional time.

188

Be alert for attentional drifts and redirect the student to task ,.vhen necessary.

Explore a variety of cuing systems, e.g., verbal cues, gestural cues or signs at the study

site that remind the student to stay on task.

Use verbal medication strategies, such as inserting questions within a lesson, directing

attention to the task and topic.

Use tasks specifically designed to help the student focus his;her attention; e.g., simple

maze learning tasks or letter/number cancellation tasks, emphasizing speed, accuracy,

and the self-insu-uctions that might promote heightened attention to task; help the

student to transfer this improved, self-directed attending skill into the classroom envi-

ronment.

B. Starting. Changing. and Maintaining Activities


Confused or requires prompts about where, how, or when to begin assignment

Doesn't know how to initiate or maintain (walks away, etc.) conversation

Confused or agitated when moving from one activity, place, or group to another

Stops midtask (math problem, worksheets, story, or conversation)

Unable to stop (perseverates on) inappropriate strategies, topics, or behaviors

Gives up quickly on challenging tasks

Strategies:

Begin the day by reviewing the schedule and highlighting any changes in the activities.

Help prepare the student for transitions throughout the day by reminding him or her of

the next activity several minutes in advance.

"Walk through" transitiuns with the students: return the reading text to the desk, take

out the math book, and move to the appropriate area for the math lesson.

Encourage the student to refer to printed or pictorial schedules with changes of activi-

ties, materials, or lesson locations.

Teach the student to model peer behavior to know what to do next.

189

Explain the purpose of the lesson; relate following directions to functional, everyday situa-tions, such as assembling a model car or reading a recipe.

Review printed or pictorial description of how to do a task to relieve tensions that.resultfrom the student's not knowing what is expected.

Talk though several examples to help individuals get started.

Review pictorial or printed rules of behavior before each lesson: "Look, listen, raise yourhand."

Praise students once they have begun a task and remind them that they are capable ofcompleting the activity.

Role-play or tell students what to say when they are initiating social contacts with peers.

Emphasize closure of activities by giving srudents jobs such as collecting papers, cleaningup materials, or writing in their log books.

Encourage srudents to observe the behavior of others as tasks end.

List steps to the task and check them off when completed; emphasize where they are inrelation to the final step.

List end-of-session behaviors: "Put papers in blue box, return to desk."

C. Taking in and Retaining Information


Forgets things that happened, even the same day

Problems learning new concepts, facts, or information

Can't remember simple insu-uctions or rules

Forgets classroom materials, assignments, and deadlines

190

Forgas information learned from day to day (does well on quizzes, but fails tests covering

sel eral weeks of learning)

514

Strategies:

Provide time at the end of a session for students to tell personal stories or jokes.

include pictures or visual cues with oral information, since this multisensory input strength-

ens the infornution and provides various ways to recall it.

Try to make the material to be learned significant and relevant to the student.

Give meaning to rote data to enhance comprehension and learning.

Regularly summarize information as it is being taught.

Have the srudent overlearn material.

Couple the new information with previously learned information.

Teach the student to use one or more of the following techniques: visual imagery,

"chunking" techniques (organizing infomation into easily retrieved segments), associationtechniques, mnemonic devices, such as acronyms, repetition and rehearsal techniques.

Use verbal rehearsal. After the visual or auditory information is presented, have the student"practice" it (repeat it) and listen to themselves as they act on it.

Limit the amount of information presented so that student can retain and retrieve it.

Provide a matrix for the student to refer to if he or she has difficulty recalling information.

Have the student take notes or record information on tape.

Underline key words in a passage for emphasis.

Provide a log book to record assignments or daily events.

Provide a printed or pictured schedule of daily activities, locations, and materials needed.

Role-play or pantomime stories to be remembered, such as who, what, when.

Have student gesture or role-play. He or she may be able to act out a situ.ltion that has

occurred but not have adequate verbal language to describe it.

Provide visual or auditory cues: Is it or or give the beginning sound of a word.

.M111111.1

191

Include written multiple choice cues or pictures in worksheets.

Teach students to compensate for work-finding problems by describing the function, size,or other attributes of times to be recalled.

NOTE: Many of the strategies listed under memory and attending can be used also toimprove language comprehension.

D. Language Comprehensioiiand Expression


Confused with idioms ("climbing the walls") or slang

Unable to recall word meaning or altered meaning (homonym or homographs)

Unable to comprehend or breakdown instructions and requests

Difficulty understanding "Wh" questions: who, what, where, when, and why

Difficulty understanding complex or lengthy discussion

Processes information at a slow pace

Difficulty finding specific words (may describe but not label)

Difficulty with clear articulation (slurs words)

Difficulty fluently expressing ideas (speech disjointed, stops midsentence)

Strategies:

Limit amount of information presented - perhaps one or two sentences.

Use more concrete language.

192

Teach the student to ask for clarification or repetitions or for information to be given at aslower rate.

Use pictures or written words to cue students: use a picture of a chair and the written wordsit if you want the students to exhibit that behavior.

Pair manual signs, gestures, or pictures with verbal information.

96

Act out directions: if the student is to collect papers and put them in a designated spot,demonstrate how this should be done.

Use cognitive mapping (Gold, 1984): diagram ideas in order of importance or sequence toclarify content graphically. This also helps students to see part-whole relationships.

Many of the strategies listed under memory and attending can also be used to improvelanguage comprehension.

Limit the amount of information presented; give the student instnictions or other verbalinformation in appropriately small units.

Present verbal information at a relatively slow pace, with appropriate pauses for processing

time and with repetition if necessary.

Limit the amount of extraneous or background noise when listening and understanding is

State information in concrete terms; use pictures or visual symbols if necessary.

Have the student sit dose to the teacher, with an unobstructed view.

Teach the student to ask questions about the insuuctions or materials presented, to ensurecomprehension.

Teacn the srudent to request slower or repeated presentations if the material is presented

too rapidly.

E. Visual-Perceptual Processing


Cannot track when reading, skips problems, or neglects a portion of a page of writtenmaterial

Orients body or materials in unusual positions when reading or writing

Gets lost in halls and cannot follow maps or graphs

Shows left-right confusion

11111111111111111

193

3

Strategies:

Describe the visual instructional material in concrete terms.

Provide longer viewing times or repeat viewings when using visual instructional materials.

Facilitate a systematic approach to reading by covering parts of the page.

Place arrows or cue words, left to right, on the page to orient the student to space; teachthe student to use the cues systematically to scan left to right.

Provide large print books or use books on tape.

Move the student closer to visual materials or have the materials enlarged.

Place materials within the student's best visual field; consult with an ophthalmologist oroccupational therapist about possible visual-perceptual problems.

F. Visual-Motor Skills


Difficulty copying information from the board

Difficulty with note taking

Difficulty with letter formation or spacing

Slow, inefficient motor output

Poor motor dexterity (cutting, drawing)

Strateg'es:

Use large paper.

Use raised line paper.

Use paper with black lines on white, rather than dittoed or newsprint paper.

Provide visual clues for beginning and end of lines. Place a green dot in the left marginand a red dot in the right margin.

194 38

If not able to do handwriting worksheets with peers, the disabled child can practice letter

or shape formation using materials appropriate for their muscle endurance. For example,

writing with fingers can be done with finger paint, crazy foam, shaving cream; or sand

trays. Nlore resistance is offered by writing with a pencil in a clay tray.

Cursive handwriting may be inappropriate for students with limited endurance and stability

(cursive requires a sustained, fluid motion, while manuscript allows for frequent breaks and

repositioning). Such children should be taught to read cursive but be allowed to continue

to wnte ifl manuscnpt.

Sometimes all that is needed is to provide the student with extra time to compleze written

tests and assignments.

Be certain that the activity you have assigned must be in written form before denying the

child the opportunLy to participate in other class activities or assigning completion for

homework.

Alter length of written responses. Permit students to write shorter compositions than

classmates.

Let student underline answers on worksheets rather than copying them onto a blank space.

Let student answer questions in one or two words rather than a complete sentence.

Because positioning may be influenced by head movements, far-point copying may not be

appropriate for some students. Provide a near-point model at the student's desk.

A vertical paper holder may be useful to hold the model in front of the student.

Some students are not able to copy the same amount as peers. If copying can be limited,

do so. If not, allow the student to copy what he/she can and have another student copy an

extra set of notes for him with carbon paper.

Older students often are responsible for note taking as a means of extending textbook

information. This may present more difficulty to the student with a disability than mere

copying. As mentioned earlier, a near-point model can be supplied, often a xerox copy of

the teacher's notes.

When handwriting modifications st ch as those listed above have not been successful,

alternative means of written communication may need to be considered. Among these are

typewriters, computers, and calculators. Familiarity with these keyboards should be en-

couraged at an early age. Commercial typing programs are available for this purpose.

BEST COPY AVAILABLE

I F39

195

Depending on the severity of the disabling condition, adaptive equipment may be neededto facilitate use of the keyboard. Such equipment may include keyguards, which fit overthe keyboard and prevent the student from striking more than one key at a time; dowels,which the child grasps to use instead of fingers to hit keys; and head sticks, which arepointing sticks strapped to the head for students who are unable to use their hands.

Electric typewriters offer features that provide students with the most independence ofoperation and require less adaptation, such as automatic pper feeding, automatic linereturn, and self-correcting features. Easy access off and on switches also are important.Non-portable typewriters are preferable due to their weight, which prevents movement onthe desk.

Computers with printers are available in all schools and can be utilized by students withdisabilities fv written assignments, as well as communication. If a student cannot use thetraditional computer keyboard with typewriter adaptations, expanded keyboards and visualscanners are available.

Remember that while these alternatives to writing will improve legibility and accuracy, theywill not necessarily increase speed. It may still be necessary to provide the student withmore time to complete written assignments.

Allow student to write or highlight in textbooks.

Provide student with extra set of textbooks to keep at home rather than having to carrybooks back and forth to school.

G. Sequential Processins


Difficulty with sequential steps of task (getting out materials, turning to page, starting andassignment)

Confuses the sequence of events or other time-related concepts

Strategies:

Limit the number of steps in a task.

Present part of a sequence and have students finish it.

Show or discuss one step of the sequence (lesson) at a time.

Give general cues with each step: "What should you do first? What should you do sec-ond?"

196

1 0

iimmorminNHave students repeat multistep directions and listen to themselves before attempting a task.

Provide pictures or a written sequence of steps to remember: Tape a cue card to the deskwith words or pictures of materials needed for a lesson, then expand original written.directions. For example, if the direction was "Underline the words in each sentence inwhich ou or ow stands for the vowel sound; change this to (1) "read the sentence;" (2)"underline ou and ow words;" (3) "read the underlined words;" (4) "find the two words thathave the same vowel sounds;" (5) "write these two words on the lines below the sentence."

Tell students how many steps are in a task: "I'm going to tell you three things to do."(Hold up three fingers)

Act out a sequence of events to clarify information.

Provide sample items describing how to proceed through parts of a workshop.

Number the steps in written directions and have the students cross off each step as it iscompleted.

Teach students to refer to directions if they are unsure of the task.

H. Problem-Solving, Reasoning, and Generalization


Fails to consider alternatives when first attempt fails

Does not use compensatory strategies (outlining or underlining)

Problems understanding abstract concepts (color, emotions, math, and sdence)

Confusion with cause-effect relationships

Unable to categorize (size, species)

Problems making inferences or drawing

Can state facts, but cannot integrate or synthesize information

Difficulty applying what they know in different or new simations

197

91

Strategies:

198

Teach the structure or format of a task (e.g., how to complete a worksheet or mathematicsproblem.

Maintain a known format and change the content of a task to help students see a relation-ship: Two pictures are presented and students must say if they are in the same category, orhave the same initial sound; a worksheet format requires filling in blanks with words ornu mbers.

Change the format of the task: Have students solve mathematics facts of a worksheet aswell as on flash cards.

Have completed sample worksheets in a notebook serve as models indicating how toproceed.

Demonstrate how skills can be used throughout the day: Discuss how students rely on theclock or a schedule to get up in the morning, begin school, or catch a bus.

Role-play in situations that simulate those which students may encounter, emphasizing thegeneralization of specific skills taught: completing school assignments and going to thestore may imolve the same strategies (making a list or asking for help).

Develop a problem-solving guide to help students through the stages of problem solving(e.g , identify the problem; acquire relevant information for solving the problem; generateseveral possible solutions; list pros and cons for each solution; identify the best solution;create a plan of action; evaluate the effectiveness of the plan).

Raise questions about alternatives and consequences.

Allow the student to bring up relevant real-life problems that are appropriate for groupdiscussion; promote brain-storming about alternative solutions and their usefulness.

Introduce roadblocks and comPlications to enhance "detouring" skills and to encourageflexibility.

Provide ongoing, non-judgmental feedback.

Provide concrete dialogue.

Be certain expectations are clear and understood.

Ask the student to explain his/her understanding of what he/she has just heard or under-stands regarding a situation.

Rephrase oral communication if student does not understand.

1 92

I. Qgan1zatJon


Difficulty breaking down complex tasks (term papers, projects)

Problems organizing materials

Problems distinguishing between important and unimportant information

Difficulty making plans and setting goals

Difficulty following through with and monitoring plans

Sets unrealistic goals

Strategies:

Attempt to limit impulsive responses by encouraging the students to take "thinking time-before they answer.

Have students organize information by using categories, such as who, what, when, where.This strategy can be used in an expanded fonn to write a story.

Teach students a sequence of steps to aid in verbal organizazion: have the students use cuecards with written pictured steps when formulating an answer.

Focus on one type of information at a time.

Decrease rambling by having students express a thought "in one sentence."

Limit the number of steps in a task.

Provide part of a sequence and have the student finish it.

Give cues, such as "Good, now what would you do?"

Structure thinking processes graphically, e.g., with time lines, outlines, flow charts, graphs.

Use categories to focus on one topic at a time.

Identify the main idea and supporting details; categorize the details (e.g., using who, what,when, where, and why questions); teach the student to do the same when reading or

listening to lecture material.

199

93

J. Impulse or Self Control


Blurts out in class

Makes unrelated statements or responses

Acts without thinking (leaves class, throws things, sets off alarms)

Displays dangerous behavior (runs into street, plays with fire, drives unsafely)

Disturbs other pupils

Makes inappropriate or offensive remarks

Shows compulsive habits (nailbiting, tapping)

Hyperactive, out.of-seat behavior

Strategies:

Place unnecessary materials out of sight or out of reach.

Discuss rules and their importance at the beginning of the lesson.

Explain how student' impulsive acts (e.g., calling out) disturb others.

Role-play appropriate responses (e.g., raising hand). Place a sign on the student's deskwith a picture of a hand and point to this when the student interrupts.

Employ "stop-action" technique: Immediately stop individuals from disrupting an activity,encourage them to verbalize an alternative behavior, and have them follow through appro-priately.

Provide time at the end of a session for students to tell personal stories or jokes.

Assure the student that he or she has sufficient time to complete tasks and need not "hurrythrough" them. If needed, break a large task down into smaller tasks.

Recognize that the student will have difficulty "taking turns and sharing.' Try to alleviatethose situations when possible. If that is not possible, attempt to reduce the stress with aremark such as, "We have plenty of time before we have to get started, so take your timesharpening your pencils."

200

K. Social Adjustment and Awareness


Acts immature for age

Too dependent on adults

Too bossy or subrrzssive with peers

Peculiar manners and mannerisms (stands too dose, interrupts, unusual):! loud, poorhygiene).

Fails to understand social humor

Fails to correctly interpret nonverbal social cues

Difficulty understanding the feelings and perspective of others

Doesn't understand strengths, weaknesses, and self presentation

Doesn't know when help is required or how to get assistance

Denies any problems or changes resulting from injury

Strategies:

Make students aware of what they can and cannot do: Expand tasks that are done success-

fully by adding one step that will be "harder.'

Make asking for help a student goal and reinforce this heavily.

Attach cue cards to desk: "Raise your hand for help."

Decrease daydreaming that results from an inability to proceed by asking direct questions

or by providing cue cards: "Are you stuck?" "Is that dear?"

Model desired behavior; role-play situations.

Review directions or sample items.

Provide a written sequence to follow and thus circumvent memory problems and anxiety.

Assure them that they can complete the task.

201

Select only a portion of the task or short assignments to be completed independently.

Point to a sign "Return to work" when students stop working.

Use a timer intermittently, and reward students who are working when it rings.

Provide additional time for students who work slowly to complete tasks.

L. Emotional Aditign_xm


Easily frustrated by tasks or if demands not immediately met

Becomes argumentative, aggressive, or destructive with little provocation

Cries or laughs too easily

Feels worthless or inferior

Withdrawn, doesn't get involved with others

Becomes angry or defensive when confronted with changes resulting from injury

Apathetic and disinterested in friends or activities

Makes constant inappropriate sexual comments and gestures

Unhappy or depressed affect

Nervous, self-conscious, or anxious behavior

Strategies:

a

Emphasize what the individuals can do and point out progress that they have made: Com-pare recent past and present work.

Chart achievement of goals to build self-confidence.

Limit perseverative behavior by using verbal directions ("Erase only once") or by focusingattention on less threatening or more sodally appropriate tasks.

2021 96

M. Sensorimotor Skills


Identified problems with smell, taste, touch, hearing, or vision

Problems with visual acuity, blurring, or tracking

Problems with tactile sensitivity (e.g., can't type or play an instrument without watchinghands)

Identified problems with oromotor (e.g., swallowing), fine motor, or gross motor skills

Poor sense of body in space (loses balance, negotiating obstacles)

Motor paralysis or weakness of one or both sides

Motor rigidity (limited range of motion), spasticity (contractions), and ataxia (erratic move-

ments)

Difficulty with skilled motor activities (dressing, eating)

Strategies:

Building site should include ramps or level spaces to allow the student in a wheelchair easy

access to entering/exiting the building. A f:reemergency exit plan should be establishedwith necessary modifications.

Ramps should have a slope of one foot length per inch of rise. A level space of at leastthree feet must be available for resting at teach 30 foot interval of ramp.

Walkways should allow safe mobility in a wheelchair from bus to building.

Students should open doors independently if possible. A physical therapist can provideconsultation or teach the child this skill if possible.

Restrooms should be aLcessible - this may require the use of toilet rails, wider stalls, raised

toilet seats, and more space for maneuverability.

A student in a wheelchair should be able to reach the paper towel dispenser, trash can,soap dispenser, and sink. Pipes under the sink should be insulated if a student in a wheel-chair is using the sink.

A water fountain or sink with cup should be accessible in the area of the student's class.

203

A public telephone should be accessible if it is available for other students.

Lockers should be accessible to students in wheelchairs. Height of the locker depends onthe student's size, balance, and flexibility. It is helpful to have a locker so they are as muchas possible in the same are of the building. Locks with keys may be better than combina-tion locks for some students.

Consult the building principal and physical therapist if assistance is needed to make modifi-cations

A Lift bus should be used for students in wheelchairs or those who cannot climb steps andwho sit in a chair on the lift only.

Seat belts, car seats, harnesses should be provided on a special education bus.

Bus driver may discharge/pick up student at a location which provides maximum indepen-dence for the student. A curb or stationary step may be used to assist students who havedifficulty climbing steps.

Independence getting off/on the bus along with safety should be stressed.

If the student needs a seat belt or harness and can otherwise ride a regular bus, the trans-portation department can equip the bus to be used with a seat belt or harness.

If the student needs a lift bus, encourage the other students to ride with him. If all thestudents cannot fit on the lift bus but could fit in a regular bus, the special education de-partment can be contacted by the Director of Elementary or Secondary Education andasked to cover the cost of the lift bus. Other students should ride the bus with the studentwith a disability.

The student may need an adult as an aide on the field trip. This may be the parent, 1volunteer, or an aide from the school. The special education department may be contactedif these individuals are not available.

The site being visited on a field trip should be studied prior to the trip to determine anypossible problems (e.g., accessibility of bathrooms, walking terrain, distance).

lf a student will be unable to walk the entire distance included on a trip and he/she doesnot have a wheelchair or other mode of mobility, the physical therapist can assist in secur-ing a wheelchair for the day.

Classroom should be set up v.) the student can easily move to his/her desk, teacher's desk,and work stations.

Secondary classes should be scheduled with as little distance between classes as possible.

204

111111111111111i

The student may need to leave class early to get to hislier next class and avoid crowedhalls.

A basket may be added to the side of a student's wheelchair or to his/her walker to carryhis/her books. A back pack is helpful for some ambulatory students or a bUddy may needto carry his/her books.

A student who may need to take his/her computer or typewriter from class to class may beable to do so independently if it is on a rolling table.

Use a table of the correct height, where forearms comfortably rest flat on the table whensitting erect.

Use only the necessary amount of side and back support.

Use a belt around the pelvis which doesn't impair breathing, if a belt is necessary.

Support the child's feet so that the hips and knees are at 90 degree angles.

Prevent incorrect positioning, such as knees crossed.

The trunk and head should be as straight as possible.

If a child has an unusual pencil grasp, do not immediately try to change his/her grip. Thi.,grip may be a reflection of unstable positioning. Children will often use a tight pencil gripas a means of gaining postural stability.

Pencil Grips may be useful with some swdents to provide pencil stability. CtImmercialgrips can be purchased. They can also be made from clay, plaster of paris, masking tape,or rubber bands.

The writing utensil affects the quality of written work equally as much as the skill in execut-ing the various handwriting strokes. When selecting a writing instrument, keep in keepthat a pencil or crayon requires the most physical strength because they provide the mostresistance. If you see that a student is having difficulty using these instruments, try havinghim write a flair or ball-point pen, which provides less resistance.

Tape or secure paper to desk.

1 9205

Compensatory Strategies. (1994). New York State Education Department (pp.40 - 43).Traumatic Brain Injury: A Guidebook for Educators . NewYork: Author.



COMPENSATORY STRATEGIES

Orientation:The Student

111 uses a map or written schedule to show bum her where to go.describes bow to get to a locat:oti before going.leaves class earh 1(1 avoid conlUsion hall traffic.

11 uses an alarm watch or //MO* set jOr retudar nuenals.uses assignnwnt books.

Attention/Concentration:The Student

uses color Cu tuf.; (». underli)ing to.lOelts attention.11 requests thou teachers repeat instructions slowly.

recognizes and communicates when she is presentedwith too much ilybrniation at one ttme.

Visual/Perceptual Process:The Student

uses a marker to limit the amount of written informationon a page.uses an index card to assist scanning and maintaininghis/her place.

Organization:The Student

uses a notebook to organize scheeules. maps, homework, strategies.uses graphic organizers such as charts, graphs, flow charts, timelines,arrows.highlights and makes notations in long passages.uses task organization checklists with sequenced steps.

Memory:The Student

uses notes, lists, schedules.uses a tape recorder.npeats information over and oyer silently to place it in memon..

Problem Solving:The Student

uses a checklist to identify alternatives, weigh consequences. and selectcourse of action.

Self-Monitoring:The Student

uses "self-talk" (e.g., Is the task complete? Was I successful? What do Ineed for this task?).

209201

210

Following are examples of instructional modifications to address cognitiveproblems. This list is not exhaustive and not all examples are relevant for allstudents.

iNSTRUCTIONAL MODIFICATIONS

Orientation:Provide cues to help with transitions -In fil.e minutes, we be goingto lunch.-Cue the student to obsertv peers.

Attention/Concentration:Provide cues to the student to look or listen for certain iqormation.1.Se short and concise instructions.Provide verbal. z.isual. or physical redirection.Present verbal information at a relatively slow pace, with appropriatepauses for processing time and with repetition if necessary.

Visual/Perceptual Process:

Provide longer viewing times and repeat viewing.Provlie arrows or cue words on a page to orient the student.Use color or underlining to focus attention.Use t.'rbal cues.

Organization:I Condense lengthy directions into steps.

Provide a list of key words and concepts for lessons being taught.Organize thoughts by teaching from the concrete to the abstract.

Memory:

Summarize information as it is being tqught.Couple new information with previously learned information.Reinforce information presented with pictures or other visual images.Emphasize information to be remembered.

Problem Solving:

Teach the student steps involved in problem solving.Use events that occur in the class to help him/her practiceproblem solving.Use modeling. rehearsing. and role playing

Initiation:Provide cues to the student to begin tasks.

2n2

InstructionalModifications

Three types of instructional modifications effective for students with THIinclude promoting academic success while addressing cognitive problems, cur-riculum modifications, and teacher modifications.

Focus oo Cognitive Problems While Teaching Academic ContentIt is important academically, and to the student's self-esteem, that the stu-dent continue to progress educationally with his her peers to the greatestextent possibli . Teachers should approach instruction in subject areas withtwo goals in mind - teaching the content and addressing a student's cognitivedeficit areas. The integration of these two goals is necessary to ensure that thestudent learn how to learn and apply learning strategies to actual school-relat-ed. real-life situations ifor example. arithmetic instruction is an ideal opportu-nity to promote general improvements in problem identification and problemsolving. Reading and writing assignments that go beyond one or two para-graphs are an opportunity to focus on general organizational skills or strate-gies. Instructional interactions ohen present opportunities to improve the stu-dent's executive functions by asking questions related to planning and evaluat-ing his her performance (e.g.. -Is this easy or difficult for you? Why or whynot? How well do you think you will do? Why? How do you plan to achievethat goal? How are you doing? Did you do as well as you thought you would?What could you do to improven (Ylvisaker, 1993).

Curricular ModificationsStudents with TBI oftenhave profiles of abilitiescharacterized by preservedislands of skills and gaps in basal areas (Cohen et. al.. 1988). Students may haveintact higher level skills but have difficulty performing lower level tasks. Forexample, a student may be able to complete division problems bu t. not simpleaddition problems. Testing for students with TBI should include inveigation ofskills below basal and above ceiling levels. Most curriculum is sequence.] -edon skill hierarchies, and achievement at a given skill level implies that a studenthas all the antecedent skills intact. For students with TBI, assumptions cannot bemade that antecedent skills are intact or that a student who cannot perform aspecific skill has not retained higher level skills (Cohen et. al.. 1988). Instructionshould be provided to take advantage of preserved higher level skills whilepractice in lower level skills must be creatively added.

Teaching Modificationsjust as students learn compensatory strategies to address their cognitiveproblems, teachers need to consider modifications in their teaching approach-es to promote successful learning situations. For example, for students withorganizational problems, teachers may need to consolidate lengthy directionsinto steps, provide the student with a list of key words and concepts forlessons being taught, and help the student to organize his/her thoughts byteaching from the concrete to the abstract and use techniques to help the stu-dent categorize and associate (link) the material with known material.

203BEST COPY AVAILABLE

211

EnvironmentalModifications

212

Students with TBI can be assisted in their learning through modifications h.the environmer% materials, and teaching approaches. The goal for all studentsshould be to gradually decrease the amount of environmental compensationneeded at a rate to ensure a student's successful functioning.

Types of environmental compensations include:

adaptations to the physical environment (such as preferential seatingarrangements. removal of visual distractions, optimal location of class-rooms, and decreased noise levels):

=.1 attention to routines (such as consistent schedules. formats):

assignment of personnel to promote consistency: and

material adaptation (such as use of assistive technohgy. large print, etc.).

Examples of environmental modifications are listed below. This list is notexhaustive and not all examples are relevant forall students.

ENVIRONMENTAL MODIFICATIONS

Orientation:Provide for consistent room arrangement, materials, androutines.Assign a peer to assist student in locating classes, following schedules,etc.

Attention/Concentration:Build in rest periods to address fatigue and stamina problems.Minimize visual and auditory distractions in the room (use of a studycarrel, limit the number of items on a desk).Place the student's desk near the teacher.

Visual/Perceptual Process:use large print books, visual guides, books on tape.Arrange preferential seating.Use adaptive materials such as a lap board to modify the angle of thestudent's desk.

Organization:Structure a studentS thinking process graphically through timelines,flow charts, and graphs.Provide two sets of books one for home and one for school.Set up a nowbook for the student to use for all subjects.

Memory:Display written rules and assignments.Provide a written set of questions before reading the material.

I Tape record lessons.

204

Waaland, P. (1991). Developing an Educational Program. In Academicreentry of children and youth following Traumatic Brain Injury (pp. 6 -7). Special Topic Report #4. Richmond, VA: Rehabilitative Research& Training Center on Severe Traumatic Brain Injury.


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ecor

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a,. I

t doe

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t add

ress

the

need

to s

impl

ify

mum

mer

,hi

ch h

as m

any

appl

icat

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, is

a bo

on to

pers

ons

with

traw

natic

bra

in in

jury

. It m

ay p

rovi

de th

eonl

y m

eans

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mum

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and

enh

ance

atte

ntio

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r th

e st

uden

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mod

erat

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pair

men

ts; a

nd a

ts a

y to

suc

cess

fully

neg

otia

te c

ours

ewor

ko.

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sing

cap

abili

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allo

w th

e st

uden

t (an

d a

tuto

r) to

eas

ily m

odif

y, r

eorg

am/e

, and

sys

tem

atic

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re in

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atio

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e st

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t may

hav

e in

gra

mm

ar, s

pelli

ng, a

nd w

ord

find

ing.

BE

ST C

OPY

AV

AIL

AB

LE

2119