EDUCATIONAL INTERVENTIONS FOR CHILDREN WITH TRAUMATIC BRAIN INJURY (TBI):

A BEST PRACTICE APPROACH

P. Veleno University of Calgary

Overview
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3. 4. 5. 6.

Definition of TBI Developmental Considerations Symptoms of Localized Injury Factors Related to Recovery Educational Implications Best Practice

Assessment for Intervention Educational Planning Educational Interventions (SOS) Individualized Strategies Model Instruction

Overview (contd)
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9. 10. 11. 12. 13. 14.

Interventions for Cognitive Impairments Behavioural Interventions Interventions for Physical Impairments General Strategies in the Classroom Individual and Family Interventions Summary Questions/Comments References

TBI: Definition
From an educational perspective, TBI is defined as: 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 childs 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 behaviour; physical functions; information processing; and speech. (34 C.F.R. 300.7 (12)).

Developmental Considerations

Effects of ABI will vary depending upon developmental stage There are 5 peak maturation periods that occur during development: ages 1-6, 7-10, 11-13, 14-17, and 18-21 Skills acquired before the injury will often be maintained, however the ability to acquire new skills is often impacted Deficits may not emerge until particular skills are required, i.e., at a later stage of development

Symptoms of Localized Injury

Frontal Lobes Deficits in complex motor skills, including speech Difficulties planning, organizing, and sequencing events Emotional lability and behaviour/personality changes, decreased self-awareness, poor judgment and reduced social skills Attention and memory deficits Parietal Lobes Reading, writing, and language disorders Difficulty recognizing visual and tactile information Difficulty with dressing, drawing, and hand-eye coordination Distortions in body image and spatial abilities Temporal Lobes Specific memory impairments Difficulty understanding spoken language Impaired sense of smell Occipital Lobes Impairments in visual awareness and recognition

Factors Related to Recovery

1. Characteristics of the injury
Nature, severity, localization

2. Physical recovery of the brain

Plasticity and reorganization Age, personality traits, preexisting skills, etc.

3. Individual characteristics
4. The environment
Family, school and rehabilitation supports

Educational Implications of TBI

Complications can produce problems with respect to: Word retrieval, expressive language, physical strength and agility, and emotion regulation Can hamper the learning process and assessment of TBI Fatigue issues Balance and gait problems Frustration, anger, discouragement

Challenges to students include: cognitive, behaviour/emotional, and physical

Assessment for Intervention: Best Practice

Multidisciplinary

assessments

Help develop comprehensive evaluation of abilities Pre vs. post trauma comparison of function Direct vs. indirect measures of assessment Contextual assessment social, environmental, and motivational factors Neuropsychological assessment Level of function susceptible to rapid change, therefore requires multiple assessments over time (Havey, 1995) Curriculum-based assessment (CBA) important for program planning (Kranzler & Shaw, 1992; Cohen, 1996)

Educational Planning: Best Practice

Savage and Carter (1988) identified four crucial steps relevant to the transition to school:
Involvement of school-based special education team in the hospital/rehab setting 2. In-service training for relevant school-based staff 3. Short and long-term planning re: support services 4. Continued follow-up by rehab professionals post discharge Other factors to consider: Individualized approach based upon IEP Flexibility Coordinated services, case management
1.

Educational Interventions (SOS)

Structure

Create partnerships Plan for transition Consistency Environmental stimulation Consider stamina and fatigue Validate feelings

Organization

Consider instructional methods Organize assignments Adopt a life-skill curriculum Career education
Consider methods or processes Compensatory methods Remediation Role models Social skills
(DAmato & Rothlisberg, 1996)

Strategies

Individualized Strategies

No set strategies that will guarantee optimal learning for each child with TBI Developing strategies to meet individual needs takes time and patience Process involves: Identifying the problem and testing hypotheses Assisting the student to take ownership of the problem Restructuring the approach to a task Providing opportunities to rehearse and experience the strategy in a variety of environments Continually reinforcing the successful strategies Frequently evaluating the effectiveness of the strategy and modifying as necessary

Select least restrictive placement and services: school, classroom, and related services Prepare for transitions (new staff, school, academic and behavioural post secondary demands) Determine realistic academic and behavioural goals and demands

Agree on priorities for intervention

Select new modifications to promote students success in meeting goals and demands

ONGOING ASSESSMENT Static Curriculum-based Dynamic

Select modifications to promote students success in meeting goals and demands

Revise goals as childs performance changes

Able

Attempt gradually to fade modifications as competence increases

Unable Maintain modifications

Modifications as an integral part of educational programming for children with traumatic brain injury (Szekeres & Meserve, 1998)

Instruction: Best Practice

Clearly defined academic and social goals and related activities toward accomplishment of established goals (Blosser and DePompei, 1994; New York State Education Department, 1995) Well-organized textbooks, lectures and learning activities (Scott, 1994) Ongoing assessment (Llambie, 1980; Palincsar et al., 1994) Scaffolding instruction (Stillman and Wilkinson, 1994) Use of multiple modalities in instruction (Lazear, 1991) Motivating and interesting contexts for learning (Bear et al., 1996) Appropriate and clearly defined rules and expectations (Creaghead, 1992; Lambie, 1980) Teacher acceptance and cooperation (Burke, 1993) Effective use of behaviour management techniques

Interventions for Cognitive Impairments

can include: problems with acquisition of new knowledge, memory, organization, attention and concentration, perception, reasoning, problem-solving, and initiation Strategies can include:

Chunking Use of memory aids checklists, organizers, etc. Visual cues Structure, predictability and consistency Mnemonic strategies Repetition Task analysis Journaling Environmental modifications to reduce distractions Peer support Cuing and much more

Behavioural Interventions

Functional analysis approach Antecedent-based interventions, i.e., alter the environment to produce desired behaviours Setting events Behavioural momentum Provision of choices and control Positive roles, routines, and scripts Building skills replacement behaviours Direct instruction, social skills training Self-monitoring Crisis management Long-term, flexible and adjustable supports Meaningful engagement in chosen life activities

Interventions for Physical Impairments

Physical problems can include: headaches, tinnitus, visual neglect, cognitive/physical fatigue, seizures, self-care, mobility and fine motor issues Strategies can include: frequent breaks modified days/demands close monitoring staffing supports adaptive equipment contingency planning, etc.

General Strategies for in the Classroom

Be sensitive to partnering students with peers for collaborative work Provide face-saving strategies such as prepping the student ahead of time for reading assignments, modifying work, using nonverbal strategies, etc. Keep lines of communication open both with the student and with the family Monitor mood and behaviour changes Determine triggers (antecedents) to problem behaviour Encourage a strength-based approach Discuss with the student and the family the possibility of orienting the students in the class to what implications a TBI might have for their friends and their relationship with their family (to be reviewed on a case-by-case basis) (Educating Educators about ABI, 2003)

Individual and Family Interventions

Individual counselling vs. family counselling Psychoeducation, including behaviour management Encourage family participation in planning Seeking familial input encourages successful outcomes Support groups

Summary
Effects of TBI vary dramatically across individual and are dependent upon a host of factors Multidisciplinary assessment is necessary to inform Best Practice, and should involve the school team, and a coordinated team of rehabilitation professionals Ongoing assessment and flexibility is required to facilitate a successful individualized approach Comprehensive supports should include: Cognitive and behavioural strategies Individual treatment and familial involvement Coordinated rehabilitation Educational adaptations Social skills training

Questions/Comments

References

Bohmann, J. (2007). Traumatic brain injury and teens: Information for school administrators. Retrieved May 23, 2009, from www.nasponline.org/resources/principals/Traumatic%20Brain%20InjuryNASSP%20Dec%2007.pdf DAmato, R., & Rothlisberg, B.A. (1996). How education should respond to students with traumatic brain injury. Journal of Learning Disabilities, 29, 6, 270-283. DAmato, R.C., Rothlisberg, B.A., & Leu Work, P.H. (1999). Neuropsychological assessment for intervention. In Reynolds, C.R. & Gutkin, T.B. (Eds.), The handbook of school psychology (3rd ed., pp. 452-475). New York, NY: John Wiley & Sons, Inc. Ewing-Cobbs, L., & Fletcher, J.M. (1987). Neuropsychological assessment of head injury in children. Journal of Learning Disabilities, 20, 9, 526-535. Harvey, J. M. (1995). Best practices in working with students with traumatic brain injury. In A. Thomas & J. Grimes (eds.), Best practices in school psychology, 3rd edition. Washington, DC: National Association of School Psychologists. Middleton, J.A (2001). Brain injury in children and adolescents. Advances in Psychiatric Treatment, 7, 257-265. Rapp, D.L. (1999). Interventions for integrating children with traumatic brain injuries into their schools. In Reynolds, C.R. & Gutkin, T.B. (Eds.), The handbook of school psychology (3rd ed., pp. 863-884). New York, NY: John Wiley & Sons, Inc. The Ontario Brain Injury Association. (2009). Educating educators about ABI. Retrieved 21 May 2009, from http://www.abieducation.com/binder/English/toc.html Ylvisaker, M. (Ed). (1998). Traumatic brain injury rehabilitation: children and adolescents. Boston: Butterworth-Heinemann.