Transcript Traumatic Brain Injury 101

Students with TBI:
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Who and Where are They?
What are the Effects of TBI?
What Do They Need?
The Brain
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About 3.5 pounds
Consistency of 3 day-old Jello
Bony, bumpy case surrounded by less than ¼ cup
of spinal fluid
10 billion neurons
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Each neuron connects with others
 average of 10,000 synapses
Brain Injury
Congenital Brain Injury
Acquired Brain Injury
Pre-birth or during birth
After birth process
Traumatic Brain Injury
(TBI)
Closed Head Injury
•Concussion
•Swelling results in further
(secondary) injury
•No loss of consciousness
•Damage great or greater than
open brain injury
Open Head Injury
•Skull is fractured
•Blood & swelling have a
place to go
Types of
Damage
in a
Closed
Head
Injury
Compression
fracture
Subdural veins
torn as brain
rotates forward
Swelling of
brain stem
Damage to
temporal lobes
from rough
bones at skull base
Shearing strains
throughout the
brain
Coup
Contra-coup
Skull Protrusions
Brain
Shearing Plane
Protrusion
Adapted From: Pang, 1985
Skull
Overly Simplified Brain Behavior
Relationships
Frontal Lobe
• Initiation
• Problem solving
• Judgment
• Inhibition of behavior
• Planning/anticipation
• Self-monitoring
• Motor planning
• Personality/emotions
• Awareness of
abilities/limitations
• Organization
• Attention/concentration
• Mental flexibility
• Speaking
(expressive language)
Parietal Lobe
Parietal
Lobe
Frontal
Lobe
Occipital
Lobe
• Memory
• Hearing
• Understanding language
(receptive language)
• Organization and sequencing
Occipital Lobe
• Vision
Temporal
Lobe
Temporal Lobe
• Sense of touch
• Differentiation:
size, shape, color
• Spatial perception
• Visual perception
Cerebellum
Brain
Stem
Cerebellum
• Balance
• Coordination
• Skilled motor activity
Brain Stem
• Breathing
• Heart rate
• Arousal/consciousness
• Sleep/wake functions
• Attention/concentration
What’s Different about TBI?
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No two brain injuries are exactly the same.
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Brain injury is complex and varies greatly from person to
person.
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Cause, location and severity of injury determine the effects.
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Long-term effects are not always apparent and may present
as cognitive and environmental demands increase.
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Attainment of developmental milestones may be effected by
a past injury.
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Commonly results in functional deficits that may be
identified in another disability category(ies)
Causes of TBI in Children
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Motor Vehicle Crashes
High Risk Sports
ATVs, rodeo, skiing, snow boarding
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Motorcycle incidents
Pedestrian vehicle incidents
Violence
Falls
Abuse
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Shaking
TBI in Children
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1.4 million children injured annually
Highest risk groups ages 0-4 and 15-19
More likely to survive than adults
Less likely to lose consciousness
1/50 kids have had a concussion
Scope of the Problem:
Oregon
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Approximately 1000 children hospitalized
annually in Oregon
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More than 1/3 experience persisting functional
limitations
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Expected yield = approx 3,000-4,000 identified
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Just over 300 identified for SPED under TBI in
Oregon
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Just 50 in NWRESD service area
Why Don’t We Find Them?
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Lack of medical training and referral
Lack of educational training and awareness
Lack of parental recognition
Many “look good” physically
Developmental bias that they will be OK
Under–Identification Cycle
Apparent Low
Incidence
Lack of
Services for
those
Identified
Eligible Under
Different
Category
Lack of
Training
Lack of
Awareness
Lack of
Research
Money
Special Educational
Definition of TBI
…an acquired injury to the brain caused by an external
physical force, resulting in total or partial functional
disability or psychosocial impairment, or both, that
adversely affects a child’s educational performance.
The term applies to open or closed head injuries
resulting in impairments in one or more areas, such as
cognition; language; memory; attention; reasoning;
abstract thinking; judgment; problem-solving; sensory,
perceptual, and motor abilities; psychosocial behavior;
physical functions; information processing; and speech.
The term does not apply to brain injuries that are
congenital or degenerative, or to brain injuries induced
by birth trauma.
Sequence of Skill Recovery
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Motor
 Gross motor functioning (1 to 2 months)
Sensory
 Improves relatively rapidly in children (1 to 2 months)
Speech Communication skills
 Expressive speech may resolve within a few months,
 Subtle language problems may persist indefinitely
Measured IQ
 May be small changes
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Not as rapid as motor, sensory and speech functions
Memory, Attention, Processing speed
 May lag for many months or be forever reduced
 Higher Level Cognition
 Information processing
 Learning under new, complex or difficult situations
 Ability to adapt to new problems or situations.
 Children negatively affected by stress more easily than before.
 May be impacted for years or permanently
2 Years After Injury….
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Memory problems (74%)
Fatigue (72%)
Word-Finding difficulties (67%)
Irritability (67%)
Impaired Speed of Thinking (64%)
Impaired Concentration (62%)
(Ponsford, 1995)
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Depressed Mood
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40-50% of people with TBI
(Glenn, 2001)
Pet Scans – New Learning
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Everything lights up
with new learning
Pathways rewire
Pathways are created
through repetition
Eventually, learning
results in more
efficiency
Tend to encode
Irrelevant Information
Residual Cognitive Deficits
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Disorders of Attention – easily fatigued, impaired shifting,
impaired maintenance, impaired selection
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Disorders of Memory – poor rote, short term difficulties,
storage and retrieval difficulties, prospective memory
problems (remembering to remember)
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Disorders of Planning – slowed initiation, disinhibition,
poor at abstraction, poor sequencing, doesn’t learn from
mistakes, doesn’t ask for help, can’t get started
Residual Cognitive Deficits
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Disorders of Judgment – misinterprets actions of others,
can’t handle multiple bits of information at once, socially
unacceptable physical and verbal behaviors, little self
awareness of strengths and weaknesses
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Disorders of Information Processing Speed – extreme
slowness in reaction time, slowed psychomotor activities
– writing, talking, etc.
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Disorders of Communication – anomia, inefficient word
retrieval, hyperverbal, peculiar use of words and
phrases, uninhibited word choice
Roberta DePompei, 2009
Observed Behaviors
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Daydreams, pesters
peers, fiddles with
materials
Blurts out, interrupts,
tangential speech
Poor test-taker,
inconsistent memory of
information
Needs multiple repetitions
of directions, acts rude,
doodles, bolts
Misunderstands humor,
puns, double meanings
Underlying Problems
 Impaired attention,
perception, memory
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Inflexibility, impulsivity,
disorganized thinking
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Inefficient storage and/or
retrieval of information
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Inefficient processing of
info: rate, amount,
complexity
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Difficulty processing
abstract information
Observed Behaviors
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Can’t learn new games,
decision rules, changes in
targeted task
Temper tantrums, sticks
with one solution, won’t
change mind
Poor social interactions,
foul language, hot temper
Lack of awareness, poor
task completion, trouble
with change
Underlying Problems
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Inflexibility, poor working
and short term memory,
poor “shifting” (multitask)
Ineffective problem
solving and judgment,
Limbic dysregulation
Poor judgment, lack of
self-awareness, language
deficits
Impaired “executive”skills
0-21
INTERVENTIONS – What do they
need?
Physical Challenges
EXECUTIVE FUNCTIONS
• Inhibition
• Rigidity/Inflexibility
• Sustained Energy
• Poor monitoring and awareness
of behavior
• Frequent distractions
• Difficulty with multi-Step tasks
• Engaging in independent tasks
• Organizational difficulties
Self
Regulation
Planning
Strategic
Learning
Memory
• Metacognition
• Goal-Directed activity
• Problem solving for attainment of
future goal
• Inability to form Mental
representations & interpretations
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Difficulty holding
instructions/Information
• New learning is most difficult
• Difficulty with multiple cognitive
demands (writing)
Memory Interventions
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Repeat often and summarize
Have child paraphrase, doodle, condense for encoding
Carry assignment sheet for each class
Closed-ended tasks (fill-in vs. essay)
Categorize or “chunk” information
Use visualization
Link new information to prior knowledge
Give examples with instruction
Discrete task objectives (Vocabulary)
Rehearsal (often doesn’t work real well)
Visual interventions such “Inspiration” Software
Auditory interventions such as tape recorder, books on
tape
Self Regulation
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Reduce distractions in work area
Make tasks shorter
Behavior contract
Divide work into smaller segments
Use cues (words, sounds, tactile) to alert person to pay
attention
Build in choice
Increase joyfulness, high interest and relationship
Ignore dis-inhibited response
Incentive Systems
Keep tools and materials available
Keep it structured
Allow for frequent breaks
Slow processing speed
Processing Speed Strategies
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The Wright Family Story!
Give more time to complete requested tasks
Slow pace of Instruction
Note taker
Condense tasks
Music
Use Scaffolding and Modeling
Strategic Learning Strategies
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Prompts and reminders
Provide scoring rubric
Have child provide a written plan
Break down tasks and timelines (note cards)
Coaching
Structured teaching
Re-teach affect and social clues
Flexible performance options
Visual and written instructions
High degree of tactile reinforcers
Teach Note Methods
SQ3R (Survey, question, read, write, review)
Concrete Thinking
Difficulty with abstraction, synthesis,
inference etc.
Planning Interventions
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Draw maps, use lists, timelines, visual schedules
Goal Setting
Color-code materials, information (definition vs.
main idea
Electronic organizers
Preview completed assignment
Answer – “How will I know when I am done?”
Establish Routines
Use paraphrasing, re-teaching, reciprocal
coaching
Meet at beginning and end of day
Post-activity reflection
Self-Regulation and Behavior
Goal
Review
Obstacle
Do
Plan
Predict
Template Prompts
Plan-Do-Review
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Goal “What do you need to do?” “What are we here for?” “What will it look like
when it’s finished?”
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Obstacle “What stands or might stand in the way of accomplishing the goal?”
Plan “What will you do first, second, third, etc?”
Student makes prediction about success of plan “Will it
be hard or easy?” Is it scary or not scary?”“Will it take an hour or take 6 hours?” “Is it a
choice or not a choice?”
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Do “Let me know if you need any help.”
Review “How did that work out?” “What would you do differently?” “Do you think
you met your goal?”
Behavioral Interventions
(Very Common)
Conduct a FBA
Give very clear written and verbal guidelines
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Big 5
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When to start
What to do
How much to do
What finished looks like
What to do next
Coach to assist with misperceptions
Implement Positive Behavior Supports
Self
Regulation
Executive
Functioning
Communication Skills
We must teach and support the underlying processes to get to
self-regulation
R. DePompei 2009
What Can You Do?
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Remember that TBI is vastly under identified
When you see unexplained behaviors or
learning characteristics….suspect!
Ask! “Has your child ever had a blow to the
head or a concussion?”
Add the question to medical cards
Visit some of the great websites available
NWRESD TBI Educational
Consulting Team
Laura Bekken [email protected] 503-614-1683
Cindy Hodges [email protected] 503-614-1670
Kristy Young [email protected] 503-614-1672
Oregon Brain Injury Resources
http://www.tr.wou.edu/tbi
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Resource librarian (Laura Beck) is available to
find specific information for your particular request
regarding TBI
http://www.tbied.org
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TBI Educator website from Teaching Research
Institute is very dense with information, resources,
forms, training opportunities
Websites of Interest
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http://www.bianys.org/learnet/ - LearnNet – excellent
resource for educators and parents
http://www.schoolbehavior.com/conditions_edfovervi
ew.htm
http://www.braininjurypartners.com/login/?next=/
especially for parents-Username=wear your
Password=helmet
www.cde.state.co.us/cdesped -Enter “TBI manual”
in search for excellent educator’s manual on TBI
QUESTIONS/COMMENTS