Introduction to Traumatic Brain Injury (TBI) for Educators

Funded by an IDEA Discretionary Grant #2007-9911-22

Wisconsin Department of Public Instruction

(http://www.dpi.wi.gov)

Outline______________________________________________________

• Brain injury definition

• Brain Function

• Common Problems

• Steps to evaluation and programming success

• Resources

WHAT IS A BRAIN INJURY?

What is a brain injury?______________________________________________________

• An injury to the brain caused by a blow to the head; penetration of the skull caused by an accident.

• The injury may disrupt functioning in a single area of the brain (focal damage) or impact multiple areas of brain functioning (diffuse damage).

• Adverse effects could be short term or life-long.

Types of Brain Injury

______________________________________________________

Brain Injury

Congenital and Perinatal(no period of normal development)

Acquired(following a period of normal development)

Perinatal (e.g., birth stroke)

Congenital(e.g., PKU)

Non-traumatic(internal occurrence

e.g., tumor)

Traumatic (external physical force)

Open(e.g., gunshot)

Closed(e.g., fall)

Wisconsin TBI Definition ______________________________________________________

• Traumatic brain injury

– an acquired injury to the brain – caused by an external physical force – resulting in total or partial functional disability

or psychosocial impairment, or both– adversely affects a child’s educational

performance

Prevalence______________________________________________________

• Every 23 seconds 1 person in the U.S. sustains an acquired brain injury

• 1 in 500 students sustain an acquired BI each year in the U.S.

• 1 in 25 students will sustain an acquired BI before high school graduation

• Overall twice as many boys as girls

• Highest risk: 0-4 year olds and 15-19 year olds

Primary Causes of BI by Age______________________________________________________

• InfantsAbuse; neglect

• ToddlersAbuse; falls

• Early ElementaryFalls; pedestrian-motor vehicle accidents

• Late elementary/Middle schoolPedestrian-bicycle accidentsPedestrian-motor vehicle accidentsSports

• High schoolMotor vehicle accidents

(Savage & Wolcott, 1994)

What Happens When the Brain is Injured?______________________________________________________

• Brain injuries are either:1. Closed head – Skull not penetrated (car

accident, falls)

2. Open Head – Skull and meninges are penetrated (gunshot, nail)

• Both of these result in: A disruption of communication within the

brain due to torn or stretched neurons Lack of oxygen to the brain resulting in cell

death.

Primary Effects of Brain Injury______________________________________________________

• Injury to brain tissue at the initial site of impact and at the second injury site (Coup & Contracoup)

• Shearing and tearing of neurons throughout the brain disrupts communication

Mechanism of injury: Coup/Contracoup

______________________________________________________

Reprinted with permission from the North Carolina Department of Public Instruction

Shearing & Tearing of Neurons

• When an injury occurs the neurons stretch, twist or tear.

Secondary Effects of Brain Injury_______________________________________________________

• Bleeding (contributes to increased intracranial pressure)

• Swelling (contributes to increased intracranial pressure)

• Lack of oxygen to the brain (results in cell death)

Mild, Moderate, Severe______________________________________________________

• Injuries can range from “mild” (a brief change in mental functioning) to “severe” (extended period of unconsciousness)

• Significant long-term disability.

• Full effects of brain injury may not be apparent until later when the child is expected to perform more advanced skills and to self-regulate behavior.

Severity of Brain Injury: Mild______________________________________________________

• Brief or no loss of consciousness

• Signs of concussion– Nausea and vomiting– Headache– Fatigue– Dizziness– Poor recent memory

• Unable to form new memories following the injury (less than 1 hour)

Severity of Brain Injury: Moderate______________________________________________________

• Coma less than 24 hours

• Unable to form new memories following the injury (less than 24 hours)

Severity of Brain Injury: Severe_______________________________________________________

• Coma more than 24 hours

• Unable to form new memories following the injury (longer than 24 hours)

Proportion of Mild, Moderate, and Severe Brain Injuries

_______________________________________________________

0%10%20%30%40%50%60%70%80%90%

Mild Severe

MildMod.Severe

• The vast majority of students with brain injuries returning to school have mild injuries.

Brain Function ______________________________________________________

• The adult brain weighs about 3 pounds.

• The brain is a complex organ made up of billions of neurons that all relate to each other.

• Each area of the brain has primary responsibilities that contribute to our ability to function.

Brain Surface______________________________________________________

The Brainstem_______________________________________________________

• At the base of the brain above the spinal cord

• Comprised of the medulla, pons, and midbrain

• Responsible for basic life functions

• Severe injury causes death

The Cerebellum______________________________________________________

• Primarily helps modulate motor responses

• Regulates direction, rate, force, and steadiness

• Injury disrupts coordination and muscle tone

The Cerebral Cortex______________________________________________________

• Center of conscious brain activity

• Divided into two hemispheres connected by the corpus collosum

• The right side of the brain controls the left side of the body and vice versa

• Dominant hemisphere represents language (usually left hemisphere)

The Lobes of the Cerebral Cortex______________________________________________________

• Each hemisphere of the brain is divided into four lobes:

Frontal Temporal Parietal Occipital

Reprinted with permission from the North Carolina Department of Public Instruction

The Frontal Lobe Functions______________________________________________________

• Control executive functions• Area of motor cortex• Deficits may become

apparent over time

If Injured you may see impaired:-memory-motor planning and performance-behavior control-higher level thinking skills (summarizing, inferencing)-deficits may become more apparent as child is expected to perform higher level skills.

The Parietal Lobe Functions______________________________________________________

• Receives, analyzes, and integrates sensory and motor stimuli

If injured you may see impaired:-body awareness (poor judgment about space and distance)-sensations (hypo/hypersensitivity)-visual neglect (not attend to stimuli on affected side)

The Temporal Lobes______________________________________________________

• Receives, analyzes, and integrates auditory information

• Center for language

If Injured you may see impaired:-ability to listen, understand and generalize auditory input-expressive and receptive language-memory formation

The Occipital Lobes______________________________________________________

• Receives, analyzes. integrates visual information

If Injured you may see impaired:-ability to understand and integrate visual information-visual functions (restricted vision)-ability to track moving objects (ex: catching a ball)-ability to track stationary objects (ex: reading a line of print

Common Problems______________________________________________________

• Difficulties with memory, attention, concentration & fatigue are common.

• Anticipating & planning for these deficits increases the likelihood of student success.

• May have problems with motor, sensory/perceptual, cognitive/communication, social/emotional, behavioral functioning.

Common Problems______________________________________________________

• Certain types of difficulties are common in students with TBI

• Anticipating these difficulties can facilitate success in school

• Problems can be physical/medical, cognitive, sensory, motor, social, emotional, and behavioral

Common Motor Problems______________________________________________________

• Apraxia

• Ataxia

• Coordination problems

• Paresis or paralysis

• Orthopedic problems

• Spasticity

• Balance problems

• Impaired speed of movement

• Fatigue

Sensory/Perceptual Problems______________________________________________________

• Visual deficits– field cuts– tracking (moving and stationary objects)– spatial relationships– double vision (diplopia)

• Neglect

• Auditory deficits

• Tactile deficits

Cognitive/Communication Problems_______________________________________________________

• Executive functions

• Memory

• Attention

• Concentration

• Information processing

• Sequencing

• Problem solving

• Comprehension of abstract language

• Word retrieval

• Expressive language organization

• Pragmatics

Social/Emotional Problems_______________________________________________________

• Irritability

• Impulsivity

• Disinhibition

• Perseveration

• Emotional lability

• Insensitivity to social cues

• Low frustration tolerance

• Anxiety• Withdrawal• Egocentricity• Denial of deficit/

lack of insight• Depression• Peer conflict• Sexuality concerns• High risk behavior

Behavioral Problems______________________________________________________

• Deficits (all types) may lead to challenging behaviors– non-compliance– aggression– confrontational behavior– lack of initiative– withdrawal

Impact on Learning______________________________________________________

• Orientation and Attention to Activity

• Starting, Changing, and Maintaining Activities

• Taking in and Retaining Information

• Language Comprehension and Expression

• Visual-Perceptual Processing

• Visual-Motor Skills

• Sequential Processing• Problem-Solving,

Reasoning, and Generalization

• Organization and Planning Skills

• Impulse or Self-Control• Social Adjustment and

Awareness• Emotional Adjustment• Sensorimotor Skills

Identifying Educational Concerns______________________________________________________

• The educational team needs to consider the multifaceted implications of the brain injury.

• It is helpful to use checklists and other tools to assist in identifying child specific concerns.

• Traumatic Brain Injury checklist may be used as an evaluation tool to identify specific student concerns.

Traumatic Brain Injury ChecklistPlease rate the student’s behavior (in comparison to same-age classmates) using the following rating 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 gets lost in thought

Inattentive, easily distracted

B. Starting, Changing, and Maintaining Activities

Confused or requires prompts about where, how or when to begin assignment

Does not know how to initiate or maintain conversation (walks away, etc)

Confused or agitated when moving form one activity, place, or group to another

Stops midtask (math problem, worksheets, story, or conversation)

No

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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 instructions or rules

Forgets information, learned from day to day (does well on quizzes, 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 (homonym or homographs)

Unable to comprehend or breakdown instructions with request

Difficulty understanding complex or lengthy discussion

Processes information at a slow pace

Difficulty finding specific words (may describe but not label)

Stammers or slures words

Difficulty fluently expressing ideas (speech disjointed, stops midsentence)

No

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E. Visual-Perceptual processing

Cannot track when reading, skips problems, or neglects a portion of a page of written material

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

F. Visual-Motor Skills

Difficulty copying information from board

Difficulty with notetaking

Difficulty with letter formation or spacing

Slow, inefficient motor output

Poor motor dixterity (cutting, drawing)

G. Visual-Perceptual 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 relationshops

No

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Unable to categorize (size, species)

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 Skills

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

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 (masturbation, nail biting, tapping)

Hyperactive, out-of-seat behavior

No

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K. Social Adjustment and Awareness

Acts immature for age

Too dependent on adults

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, weaknesses and self presentation

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 little provocation

Cries or laughs too easily

Feels worthless or inferior

Withdrawn, does not get involved with others

Becomes angry or defensive when confronted with changes resulting from injury

Makes constant inappropriate sexual comments and gestures

Unhappy or depressed affect

Nervous, self-conscious, or anxious behavior

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M. Sensorimoter Skills

Identified problems with smell, taste, touch, hearing or vision

Problems discriminating sound or hearing against background noise

Problems with visual acuity, blurring or tracking

Problems with tactile sensitivity (e.g., cannot type or play an instrument without watching hands)

Identified problems with oromoter (e.g., swallowing), fine motor or gross moter 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 movements) circle one

Impaired dexterity (cutting, writing) or hand tremors

Difficulty with skilled motor activities (dressing, eating)

Reprinted from Guidelines for Educational Services for Students with Traumatic Brain Injury (Virginia Department of Education, 1992)

Waaland and Bohannon (1992)

WHAT ARE THE NEXT STEPS TO SUCCESSFUL EVALUATION AND

PROGRAM PLANNING?

What are the next steps? ______________________________________________________

• Once a student suspected of having a disability is referred for a special education evaluation, the next step is to gather information.

• You will need two types of information

1. Brain Injury information(type of injury, location of injury, length

of coma, etc.)

2. Information on current functioning(physical/medical, social/emotional, academic, cognition and memory, speech/language and communication, sensory/perceptual

What’s Next? (continued)______________________________________________________

How will you gather the information? Review medical reports Observe student Interview the student and knowledgeable

others (therapists, medical personnel, parents, etc.)

Use curriculum based measures and work samples

What’s Next? (continued)______________________________________________________

• Identify appropriate team members

(If student has fine and gross motor difficulties, should an OT, PT or APE person be part of the IEP Team?)

• Conduct a thorough educational evaluation of the student to:1. Determine eligibility and need for special education and related services

2. Identify disability-related educational needs

What’s Next? (continued)______________________________________________________

If the student has a disability, identify major issues to address in the IEP such as:

Student health and safety issues (wheelchair transportation, medication management, etc.)

Schedule (need for a shortened day, more frequent breaks during the day, etc.)

Classroom instruction (enlarged print, preferential seating, other modifications)

Staff training (TBI, medical procedures)

What can be done if the IEP Team determines that the student does not

have a disability?

* To support the student in regular education, the team could recommend short term accommodations such as: adjust schedule delay high stakes tests prioritize homework educate parents, teachers, peers assign case manager to monitor progress refer to a building team

Resources______________________________________________________

• Dept. of Public Instruction (DPI): http://dpi.wi.gov/sped/tbi.html

• Level I TBI Training: http://dpi.wi.gov/sped/tbi-trg-pres.html

• CESA-based TBI consultants: http://dpi.wi.gov/sped/pdf/tbi-contacts.pdf

• TBI Kit (available at each CESA)– Teacher tools, charts, and checklists– Level I trainings– Memory training and resources– Links and resources

• Additional TBI materials (on DPI website)– Mild brain injury informational brochure– Parent Information packet– Teacher Information packet– Administrator’s information packet– Informational brochure for hospitals and clinics