School Planning & Educational Strategies Following Traumatic Brain Injury

– And particularly with a
focus on how parent centers can assist and support
parents who have children who may have a, or have
a suspected brain injury and are not seeing any symptoms or challenges related to it until after the actual injury may have occurred. So, let’s start with a
little webinar etiquette. Right now, everyone’s line is muted, and that’s just to minimize the amount of noise that sometimes
interrupts our presenters. However, if you do have
a question or if you need assistance, feel
free to use the chat box, because we do have a couple
of folks in the SIPR team who are monitoring the
chat box and can help you if you need assistance,
or if you have a question can bring the question to our group. And who didn’t mute their line? Sounds like Debra. Finally, there’s a way for
you to raise your hand, and there’s a little icon at the top just under your toolbar,
where there’s a person with a hand, and you can
use that to raise your hand and let people know you
have a question, or let us know if you’re having
a hard time hearing us, we’re talking too fast, talking too slow, please feel free to use that. Before we get started,
we’re going to have a, just a couple of comments
from Carmen Sanchez, who is the OFET project officer for the Center for Parent
Information and Resources as well as a number of parent
centers across the country. Carmen, are you ready to join us? – [Carmen] Yes, can you hear me, Debra? – You are coming across loud and clear. – [Carmen] Great, thanks. I’m Carmen Sanchez, I’m
the project officer for many of the parent centers
throughout the country, and as Debra said, the center for parent information and resources, and two of the regional parent technical
assistance centers. We had a series of
webinars that were sort of disability-specific several years ago, and we covered a lot of topics, but one of the topics that we didn’t cover was brain injury, and it
was brought to our attention through leadership here at
OSCE that perhaps we needed to have a webinar around brain injury since that’s often one of the most misunderstood of the disabilities, and that
that would build the parent center’s staff capacity
around brain injury. And the brain injury
association of America was particularly interested
in reaching out to parent centers to start a
new kinds of collaboration and partnerships around
brain injury, and bringing their information to parent centers. They actually did a kind of… a dry run, so to speak, or a pilot webinar for the PTI in central Florida, and they got to learn a lot about what the parent centers in
Florida, that parent center with their staff knew about brain injury and can figure out how to
tailor-make this webinar to meet the needs of
the parent center staff who are oftentimes
very, very knowledgeable about a whole range of disabilities. So, that’s really the
intent of this webinar, and it is a way, again, to know more about the resources that are available, and ways of forming partnerships across a lot of groups that work in disabilities, and that can be helpful to our families as we refer people to
resources in the community. So, with that, I’ll turn it
back to Debra, thank you. – Thank you, Carmen, and I want to let everyone
know that we are now joined by Brenda Eagan Brown, and she’s going to share her screen with
a presentation for us, and so while she’s doing
that, let me introduce her. Brenda is the state-wide
program coordinator for Pennsylvania’s brain
injury school re-entry consulting program, which
is called BrainSTEPS. STEPS is strategies teaching educators, parents, and students. This initiative is funded
by Pennsylvania’s department of health and education,
and that’s through the bureau of special education and education. And it is implemented by the Brain Injury Association of Pennsylvania. Brenda received her masters
from George Washington University in transitional
special education with a focus on traumatic brain injury. She’s a certified brain injury specialist, and she serves on a number of state, national, and
international advisory boards, including the brain injury task force, the national collaborative regarding children with brain injury, and the international board of directors for the Sarah Jane brain foundation. She is well-published and
she regularly presents at conferences, and she’s
received a number of awards. I think it should be noted that Mrs. Eagan Brown was invited by the Centers for Disease Control
to serve on an expert panel regarding concussion
in schools in Atlanta, and also, she was chosen to
present for President Obama in the appointed institute
of medicine’s national research council’s
committee, which is compiling a comprehensive, federal report regarding youth concussions that we hope will guide federal and state agencies
and their policies. She’s spearheaded work with Pennsylvania department of education
to create state-wide concussion materials
for educators, including a return to school and academics protocol. And Mrs. Eagan Brown also
recently developed and implemented the return to
school concussion management team model project, which
has established and trained over 670 school-based concussion teams in Pennsylvania over the past year. Brenda, thank you for joining us. – Thank you so much. I am just going to get my PowerPoint up. Okay, Debra, can you see my PowerPoint? – [Debra] Yes, it’s coming
across very nicely, it’s perfect. Thanks. – Okay, great. Now I cannot see any questions
or anything coming through when I’m sharing my desktop,
so we’re going to save questions ’til the end,
and I’m gonna get started. So I’m really happy to be here today, as Debra said, traumatic brain
injury is so important in the lives of the students who
have traumatic brain injury. And it’s vital that people
who are working with these students have a really firm
understanding of not just how these students function
in the classroom, but other things also, such as how traumatic
brain injury is different in students, compared
to other disabilities. So, as Debra said, I am the
program coordinator for the BrainSTEPS program in the
state of Pennsylvania. If anyone has any questions
after this that we don’t get to, or if you think in a few
days of some more questions, you can always go to
our website right here, BrainSTEPS dot net, and get ahold of me. Also, the BrainSTEPS
program in Pennsylvania was started in 2007 by the Pennsylvania Department of Health,
it’s jointly funded by the Pennsylvania Department of Health and the Pennsylvania
Department of Education bureau of special education,
and it’s been implemented for the past, we’re
starting our eighth year, by the Brain Injury
Association of Pennsylvania. So all three entities
work together to implement the brainSTEPS program,
which is a brain injury school re-entry program
for students who have brain injuries in the
state of Pennsylvania. So today we’re going to
cover how TBI is different than other disabilities,
we’re gonna talk about educational safeguards, and
also strategies to facilitate student learning after sustaining
a traumatic brain injury. I have heard many, many,
many quotes from teachers, so I compiled some of them
for you that are very, very commonly heard when teachers
don’t have a firm understanding of what traumatic brain
injury actually is, and how it can manifest in students. So, I put some of the quotes here for you, and I wanna go through them now. One quote was, ‘his brain injury
happened when he was two.’ ‘He’s 12 now, his behaviors are due’ ‘to bad parenting, not a TBI’. And we’re going to debunk
that myth in a few minutes. ‘He’s using his brain injury as an excuse’ ‘to get out of doing school work.’ ‘She doesn’t look brain injured’. Well, that would be because
it’s called the silent epidemic, and a lot of students after
brain injury, the great majority don’t look like they have a brain injury. It’s silent. ‘She’s acting out just to spite me.’ The big one we always hear is, the brain injury should be healed by now. We’re also gonna debunk
this myth, and talk about why, when a student seems
like they have recovered completely, maybe in
some cases, other issues could show up on down the road. ‘He was disruptive
before his brain injury.’ ‘Nothing has changed, the
TBI didn’t cause this.’ Now nationwide, students who
sustain TBIs of all severities are often under-identified
and sim-identified in schools for many, many reasons. It is so crucial when
you’re working with parents, you want them to understand
so that the school hopefully will then understand
that if that student needs something like special
education, and they’ve had a prior traumatic brain
injury that’s resulting now in issues that student may be having that is requiring them to
have special education, they need to be labeled correctly on their special education plan, which is an IEP. There are I think 13 different categories, different labels; some students may be labeled as having an emotional disability, others as a learning
disability, and we’re gonna talk about how TBI is its own category. And what happens is,
nationwide, many times schools don’t know about students
who’ve had a prior brain injury, so when they start to
have issues in school, it can look like maybe
a learning disability. So if they qualify for
special education services, they might list that student
as having a learning disability instead of a traumatic brain injury. Or needing emotional support
instead of a student having behavior issues secondary
to a traumatic brain injury. And it’s very, very important
because we work with students who have traumatic
brain injuries differently than we might work with students of
other disability categories. Now, it would be easy to identify
all students who come back to school after a traumatic
brain injury if they had bandages on their head, but we
don’t see students like this very often, so there are
many, many other clues, and you’re gonna learn about them today, that hopefully you will
incorporate and share with parents so that parents can be sure
that they know the red flags to look for to notify schools about when their child’s had
a prior brain injury. So first I wanna tell you about some traumatic brain injury statistics. According to the Centers
for Disease Control, brain injury is a leading
cause of death and disability in children and young adults. But, nationwide again, traumatic
brain injury educationally is considered a low-incidence disability. So you can see where
the big discrepancy is. Brain injury is a leading
cause of disability in children, according to
the statistics we have. But yet, educationally, it’s
considered low-incidence. The discrepancy there is students. Schools don’t know about
the students that have prior brain injuries, or they may
not be identifying students correctly when they do need
special education services. About a half a million children
every year, according to the Centers for Disease Control,
are actually hospitalized or have an emergency department
visit for a traumatic brain injury, and this includes
children ages zero to 14. The majority of these children
will return to school, and they probably will
have at least one impact. Now, students who have
concussions, which are also, can be considered maybe mild
traumatic brain injury, these students, when they
come back to school, sometimes they might have some cognitive
issues, they might have some emotional issues or
behavioral issues, and then even the more moderate
to severe brain injuries. Sometimes the impacts, when the
student goes back to school, are minimal, other times they could last for a very, very, very long time. But there are three medical
severities of traumatic brain injury, and I didn’t wanna go
into all the different types of traumatic brain injuries
today, but I did want to be sure that we talked about mild, moderate, and severe traumatic brain injury. Regardless of what the
medical diagnosis is, just because you hear a student has a mild traumatic brain injury or a concussion, that does not mean that
functionally, when that student comes back to school,
they’re going to be okay. The majority, yes, they probably will be. But not always. We have had students in our program who were diagnosed with concussions, never experienced any
loss of consciousness, and they were faring much worse in school than a student that had been
in a coma for one to to days. So you really, you have to
take each case individually. And the severe students
tend to get rehabilitation, students with severe
traumatic brain injuries, and so those students are
pretty easily identified because they’re coming
out of rehab facilities. With all of the concussion
clinics across the United States, mild traumatic brain injuries,
concussions, they are really starting to ramp up
how many are being identified, and I could spend two whole days with you just talking about concussion management. But I also wanna make
sure we focus today on the moderate traumatic brain injuries. These are the students that
are falling through the cracks, these are the students that
you’re probably going to be getting phone calls
about from parents, where the students are, maybe
they were hospitalized for a few days, and then
they were discharged home rather than going to rehab. And this injury may not really
manifest in these students, sometimes, until on down the road. So, we can never be too sure, that’s why it’s always important
to ask the questions. Schools should be asking,
has your child sustained a brain injury, has your child ever been seen in the emergency department with a traumatic brain injury, has your child ever
been in a car accident? Lots of different ways the questions can be asked to screen out students. Now, a child’s brain is
not like an adult’s brain. A child’s brain is not fully developed until around the early to mid-twenties. This is a graph I love to show, it’s by Dr. Sandra Champan
at the University of Texas. And she shows the normal
development trajectory of a child. It tends to go up over time. Now here in red, she has
superimposed the impact of a traumatic brain injury occurring. And as you can see, there is a dip down, and then it starts to go back up. But as you can see, that
student that’s identified by the red graph never completely
gets back to that developmental trajectory that the other
students may have been on. Now, this isn’t true for all
students after traumatic brain injury, but it is true for a
lot of them, and some of them when they first come back to
school, may seem like they’re really really starting to
keep up, and then over time, and this is over the next few
years, we could see something occur that she has coined
as neurocognitive stall. And if you look here at the
yellow circle, if students are supported, and families, when
the injury happens, by people who really understand brain
injury and can connect that family with resources, and
can make sure the school is aware that the student’s had a
brain injury, then over time, we can serve as a safety
net for these students. Because, the best
example I can give you of a neurocognitive stall,
or an issue manifesting years later after a prior brain injury, would be our frontal
lobe, which are in the front of our brain, are the
largest lobe of the brain, they are in charge of our
higher order thinking skills. And if you are six years
old, you aren’t using your higher order thinking
skills yet, because those skills really
don’t mature and develop until around middle school age. So if you’re six years
old in the first grade, and you hit your head
on a windshield during a car accident, injuring your frontal lobe. Maybe it’s summertime, the
student could maybe be in the hospital a few days and
then be discharged home. The student goes back to
school, the student very well could seem like nothing is
the matter, the school may have no idea, the parents may
not know to let the school be informed about this prior car accident, because their child seems fine. So during those first few years,
elementary school teachers developmentally, knowing
that executive functions are really not called upon until
the middle school years, they serve as a child’s
frontal lobe, the teachers. They tell them exactly
what to do, where to stand, what book to pull out,
what time to do this, what time to do that. So they’re functioning
as their frontal lobe. So if there was injury
to the frontal lobe, it may not manifest until that student is in middle school, and
the higher order thinking skills are now being called upon. Students are expected
to be more independent in middle school, they
have to be more organized in middle school, and
all of that is housed, the majority, in the frontal lobe. So this can be when we see
a prior injury manifest, and that is so crucial for
students who have brain injury. Just because they seem
like they’re doing okay one year, that doesn’t mean it’s gonna be consistent through graduation. So we always need to make
sure we’re checking in. Is the educational program
appropriate for this student? This is a little vignette, and this is a true story of a student. Riley, eight years old, was
on vacation with her parents. While traveling down the
highway in their RV one night, she woke up disoriented, walked
to what she thought was the bathroom, opened the door,
and fell out onto the highway. She was in the hospital for
one month and then transferred to rehab, where she
remained for six months. When Riley returned to school,
she seemed to be doing okay with appropriate supports in
place, but over the next two years, the teachers saw
her developmental momentum, in comparison with her
peers, begin to stall. Her knowledge base was
also extremely scattered. Some days, her teacher reported
she could do things like multiply 38 times 12 in her
head, but then the next minute she couldn’t remember
how to add 10 plus 12. And for those of you that
have been in the teaching profession, you can imagine
how frustrating that can be for a teacher who’s trying to
gauge a student’s learning, their new learning and
how much they’ve retained. And that’s one of the reasons why students with traumatic brain injury can be tricky. So how exactly are students who sustain traumatic brain injury
different from students who have other types of disabilities? Well first, students
who have traumatic brain injury were not born this way. A traumatic brain injury
is always a brain injury that has occurred after birth. So there is a sudden
onset of a disability. There are sudden, ongoing medical needs. Even if it’s a concussion,
if that concussion doesn’t resolve in the first few
weeks, that student will probably go to a physiatrist,
or a neurologist, or a concussion clinic, and
have some ongoing medical needs. There is a sudden disruption
of prior, normal brain development in many cases, and
the potential manifestation of new issues over the years. Sudden loss of peer relationships. This is such a big one after brain injury. These are students who usually,
if it’s been a car accident, and they’re in the
rehabilitation or in the hospital in acute care, the school rallies around. Kids are making cards, they
make signs when the student comes out of the hospital or
rehab, everyone’s rallying. And then over time, if
that student has some residual effects from their brain injury, sometimes, the peer
relationships start to fall away. And the hardest thing
about working, I believe, with students who have
traumatic brain injury is that their prior memories remain intact. Which is a good thing. It’s their future capability
for learning that’s impacted, but at the same time, even
though that’s a good thing, these are students,
after their brain injury, who remember who they used to be. They remember who their friends were. There’s also a potential
lack of self-awareness of new injury-imposed deficits. This is classic for many, many people who have traumatic brain injury. They have this lack of
self-awareness of their new deficit. And this is what I just
talked about, prior memory tends to remain intact, but
it’s the future learning of that student that’s impacted. This is why younger children,
you know, one year old, two year old, three year old, this is why they tend to fare worse
after a traumatic brain injury than someone who’s my age. Because I have already
gone through college, I’ve had all my life’s
experiences, so if I sustained a traumatic brain
injury at my age right now, I’d have all of that prior
knowledge to fall back on. So I might do a little better than a two year old who has a
severe traumatic brain injury, and hasn’t gone through
school, doesn’t have that prior learning to fall back on. So now that child will be doing
all of that future learning on a brain that has been
impacted because of injury. Also, traumatic brain injury,
like we just talked about in the little vignette of Riley,
these students, many times, have more extreme discrepancies
among their abilities, and uneven and unpredictable progress. Some people refer to its feel
as the Swiss cheese effect, where sometimes the
student knows an answer, and other times they
either can’t recall it, or it’s on the tip of their
tongue, so it’s really important we give students time,
give them time to answer. They may have slow processing
speeds, or memory issues. After traumatic brain
injury, many, many, many students return to school
and they don’t look like they’ve had a brain injury. There’s a reconciliation
of old self with new self, and this is hard, because the
older you are, when you have a brain injury, the more
sense of self you have. There was a student that we
had in our program, brainSTEPS, who was struck by lightning
when he was 12 years old. He was an all-star baseball
player, grades came very easily to him, he
would get all As and Bs. He was struck by
lightning, he sustained an acquired brain injury
because his heart stopped, and that cut off oxygen
to his brain, and he went back to school after going
through rehabilitation, and he was now in a special
education, self-contained class. He remembered who his friends used to be, he remembered how easily he used to learn. And so not only do we work with
these students to help them with their new ways of learning,
to come up with strategies, but we also have to be very,
very sensitive to the students and help them work through
the feelings of reconciling who they used to be with who they are now. So counseling is so effective, and not only that, but we have
to think about the parents. Because these are parents who
have actually gone through every parent’s worst
nightmare, many times. And they – when their child
was born, you have goals and dreams for your child,
and now, all of those goals and dreams may have to be re-thought. So that’s another thing, you just want to be really, really sensitive. Also, rabid gains tend to occur the first one to two years after brain injury. So, initial goals or objectives
that the school may set will probably quickly
become pretty obsolete, so someone should always
be frequently updating any goals for that
student, always monitoring to see if the educational
program is appropriate. Now we had students through
the brain injury program write down in an activity
through one of our teen support groups, what my
brain injury means to me. And I just wanted to share that with you. This student said, ‘I
remember getting good grades’ ‘and how easy it used to be for me.’ ‘My mom treats me like a baby.’ ‘It’s harder to complete my work.’ ‘I can’t wear flip-flops anymore.’ This was a big deal,
this was a teenage girl who could not wear flip
flops anymore to school, which, to us, as adults, that
may not seem like a big deal, but to a teenage girl, as
soon as that sun comes out and winter goes away, it’s very
important to wear flip-flops, but this student had hemiparesis,
so one side of her body was weaker than the other, and
she was unable to wear them anymore after her brain injury. ‘I can’t use the hand
I used to write with.’ ‘I don’t have any friends.’ ‘I remember how easy
school used to be for me.’ ‘I remember who my friends were.’ ‘I remember who I used to be.’ ‘I remember not needing
special education.’ I just wanted to say a
word about homebound. It’s so important, whether a
student has any severity of traumatic brain injury – the
best place for that student after they’re coming out
of the hospital, or home, or rehab, is to get back in school. Socially, emotionally,
academically – for instance, concussions, they’re now
saying about three to five days after concussion,
a student should be home on cognitive and physical rest. After that, the student really
needs to be back in school. But, the caveat to that is,
the school needs to be prepared for all of these students,
not all of these students, but all the different severities
of traumatic brain injury so that they can have
accommodations in place to keep facilitating
learning for that student, while the student is still recovering. Because as I said earlier,
the first one to two years, these students with more moderate
to severe brain injuries, they’re gonna have rapid
recoupment of who they used to be and how they used to be in
the classroom, many times. So they may seem like
they’re really, really doing really well for the first two years, at times, and they could have rapid gains. And then they may plateau a little bit. It’s very different for every student. Very different. But we definitely want the
students back in school as soon as possible, because now
students aren’t staying in rehabilitation facilities
for months and months like they used to 15, 20 years ago. Now they’re in for very
short periods of time, so the school, essentially,
is functioning as that rehabilitation for the student. So getting them back into their schedule, keeping them on-task,
keeping them on a schedule, that is helping them rehabilitate. And something is usually missing if a student isn’t back at school. Whether it’s a return to
school plan, whether it’s accommodations, maybe
the staff wasn’t trained in traumatic brain injury
to really understand it, and there has to be fluid,
consistent communication between home, school, medical, and rehab. All the parties involved
should really be fluidly communicating, not just
during transition periods. Like leaving hospital to
rehab, or rehab to school. It should be a fluid communication
the whole way around. So homebound, we really want to try to keep kids off of homebound, if we can. Now I wanted to touch
on some educational law for you, so that you can
help parents navigate this process after a student’s
had a traumatic brain injury. A student after a TBI may
not need any services. And the way I approach
it, is when students come back to school,
again, that first year or two, they’re gonna have rapid gains. So I really like to see the
school A, be completely trained and have a good understanding
of traumatic brain injury, have a good understanding of
that students needs, their strengths and their
weaknesses, now, and then, I like the school to front-load
these students with support. Front-load them with academic
accommodations, and then, over time, pull back, to
see how the student’s doing as they are making some gains. Because you never know how a student’s going to do over time. So front-load with support. Many students might need
a 504, a section 504 plan, which is not special education. And a smaller number may need an IEP, which is considered special education. Let’s talk about special education. Under the federal definition,
traumatic brain injury was added into the special
education law, the IDEA, back in the early 1990s
as a specific category requiring specialized understanding. And actually, a bit of
trivia, traumatic brain injury was added the same year
that autism was added to the special education
law as a classification for, a category for special education. The federal special ed law –
now I know we have people here from all the different states. Each state has their own –
whether they follow the federal definition, which is what
Pennsylvania follows, and I’m gonna talk about the
federal definition today. But you really wanna check with
your department of education to see, because there are some
states, like Colorado, and I can’t think of the rest off
the top of my head who have – I’m not even sure if
Colorado has, I’m sorry. I’m not sure what states but,
they have actually added, they’ve done away with TBI as
a label and they call it ABI. So acquired brain injury. Well, we’re gonna talk about
today the federal definition. And the definition is,
TBI is 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. That is the federal definition. The term applies to open
or closed head injuries. An open head injury is when
the skull has been fractured. Or when a bullet penetrates,
or any kind of skull fracture. A closed head injury is very
common with falls, it’s when the brain, you know it sits
inside of a bony skull, and if my fist is a brain,
and I hit a windshield, my brain is going to go back
and forth inside of my skull, and (mumbles) neurons,
that’s a closed head injury. So the skull isn’t opened,
instead the brain injury occurs like a concussion,
bouncing inside the skull. And it results in an
impairment in one or more of these areas that are bulleted. So, it’s key. If a student is thought
to need special education, the school will look at these
different types of areas to see, okay, the student
has a medical diagnosis of a traumatic brain injury,
or parent reporting of a prior traumatic brain injury,
and then do they have a difference in how they were
functioning before the injury. So what was that student’s
baseline maybe in seventh grade? Let’s look at their educational
records compared to now, in eighth grade, after they
had a traumatic brain injury. And they really can go back
and look at the records and can compare them, and then
there’s also many different tests that school psychologists
or neuropsychologists, that maybe the school
hires or the parents hire for an independent evaluation. A neuropsychologist tests
students cognitive processes. So they’re like experts
in brain-based learning. But school psychologists also
have really good grips now on different tests to use to
help identify students’ areas of weakness, and strength,
after a brain injury. Now this is important, the
TBI definition does not apply for special education purposes
to brain injuries that are congenital, degenerative,
or induced by birth trauma. Also, the federal definition
for special ed under TBI does not include brain injuries
caused by other internal conditions such as stroke,
brain infection, tumor, anoxia, or exposure to toxic substances. That does not mean that a
student won’t qualify for special education if they need it,
this just means if a student qualifies for special education
and they have a traumatic brain injury under the
definition, they can then be classified as having a
primary exceptionality, being traumatic brain injury. But other students can still
have special education services if they qualify under a different
special ed classification. Gets a little confusing, but
you all have these slides, and you can go back and refer to them. So, I put this little chart here, traumatic brain injury
is an open head injury, a closed head injury, or a near drowning. A near-drowning is in the regulations as being a brain injury that is caused by the external physical force of the water. But yet, other health-impaired is also a special education classification, OHI. So students that have any type
of brain injury that is not traumatic, that is non-traumatic,
like stroke, brain tumors, brain infection, lightning
strike – these students fall under other health
impaired, rather than TBI. But the near-drowning,
that’s a little caveat. So we talked about that, and that is also what I just talked
about, the near drowning. What happens in a near-drowning is there is lack of oxygen to
the brain, the heart stops. Lack of oxygen to the brain,
if you don’t have oxygen going to the brain – your
neurons survive with oxygen. So they will start dying
if you’re without oxygen for a period of so many minutes. That is that. I also wanted to touch on IEPs. So if you’re a student that
needs special education, then you would have an
individualized, an IEP. A plan for your programming,
your educational programming. After brain injury, I know
a lot of times, you know, students’ IEPs will be
reviewed once a year, but after brain injury,
remember, that first one to two years, students are making
rapid gains, so it would not make sense to only review
that IEP every May. Instead, for the first one to
two years, you really wanna review or have someone take
a look at that IEP and those goals to see, every three months, are they still appropriate for this student? That’s crucial. Also, the first one to
two years back we really, highly encourage the
school to offer extended school year services to the student. And that is because,
when they’re making those rapid gains, we don’t want them off for two and a half months for summer break. The scheduling consistency is key to helping these students with their cognitive processing. And then also, I was trying to
think, what would really help states understand what they can do better for students who have brain injuries. So we got the idea years
ago from Oregon, who has, also, a school re-entry TBI program. And that’s who Pennsylvania’s
brainSTEPS program is based off of, Oregon’s program. But their program coordinator created a guided IEP for Oregon. So, in Pennsylvania,
we created a guided IEP for students with traumatic brain injury. I’ve shared this with you
in the resources section, so any time you have a
parent that may be going to an IEP meeting, and they
contact you and they say, you know, I need help, how
do I know what’s appropriate? This can walk through that parent or that IEP team, with key questions to ask. I know this is a Pennsylvania IEP form – they’re all based on
basically the same ideas. You have goals, you have
present levels of performance, so please check that out
in the resources section. And this is one of the examples. So, when we’re talking about, is the student blind or visually impaired? Well, we put a little
yellow box here that says, many students after TBI may
have vision difficulties, and we list out some different
things that the IEP team should really take into consideration. Some students should be seen
by a pediatric ophthalmologist, because there are many, many,
many, many different types of vision impacts, even after concussions. The whole way up through
more severe injuries. One eye could be off a few
degrees, there could be convergence issues, so lots of different things to think about. But, as you can see, I won’t
spend any more time on that, but I hope you share it with parents. Now section 504 plans. As I said, 504 plans are
not special education. But they are educational
safeguards that are available under the law for students who qualify. A 504 plan is a person with a disability who has a physical or mental impairment that substantially limits – and that’s key here, the word substantially, has to limit one or more
major life activities, have a record of such impairment, or is regarded as having such an impairment. So if you have a student with
a traumatic brain injury, a student with a
concussion, either of those, if it substantially limits one
or more of these activities. So seeing, hearing, walking
– and I starred some that denote common concussion impact. Learning, breathing, reading, thinking, concentrating, sleeping,
eating, bowel functions, bladder functions, digestive functions. So there are 13 different
major life activities, and it’s up to the school
team to make a decision based on how that is impacting, that disability’s impacting one of these. If it’s substantial enough,
then they will create an accommodation plan for that student. Again, it’s not special
education, it’s accommodations to make the learning – to make it even with students who don’t have
these types of impairments. It levels the playing field, that’s the word I was looking for. This is a recent journal article
I wanted to share with you, I can put it into
resources, I will send it, I didn’t send it yet, but it’s K-12 students with concussions,
a legal perspective. And it talks all about
the importance of using either IHPs, which are
health plans, individual health plans with students,
after concussion, or any type of brain injury, and
also 504 plans and IEPs. Now there are some effective
instructional practices, but brain injury, even
though it’s so prevalent, there has not been a lot
of research in the field of what are effective educational practices? There has been some. So a lot of it is trial
and error, a lot of it is we figure out, if the student’s
having attention issues, what works for other
disability populations, what types of instructional practices work with students that have ADHD, maybe, and we try to employ them here. But we’re gonna talk about some that are known to be effective. So first, when you have a
student coming back to the classroom, relay to the
teacher that classroom rules are clearly displayed for the student. These are just good teacher practices. So, most teachers nowadays
will post classroom rules. But for a student with a
traumatic brain injury, repetition is key. So those rules should not
just be posted and reviewed on the board, they should
also be on the student’s desk, maybe in the student’s
binder, and they have to be reviewed, reviewed,
reviewed, because we want the student to become consistent. Another effective
instructional practice are agendas, routines, and schedules. They should be clearly defined, and again, posted in the classroom. Now for the student with a TBI, just like we just said
with the classroom rules, it should be posted on their
desk, it could be posted in a planner, it could
be on an index card – these serve as cuing
mechanisms for the student. And it’s so important that
we not just give students instructional practices
or accommodations to use, but we actually instruct the
student on how to use them. This is a good visual schedule for a student that had a brain injury. So as you can see, this student
needed a pretty detailed morning and afternoon schedule. Arrive on bus at 8:50,
go to the cafeteria. And then English, room two, because a lot of students have memory issues. So this tells what room
to go to, what time, when you get there, you
have your English book, you turn in your homework, you write your homework in your planner. These serve as effective cuing mechanisms after brain injury. The more that we can
set the environment up for these students to succeed, by using things like
visual schedules for them, the more that they are going to succeed. Also, you wanna think
about schedules at home. We hear a lot of times
parents will say that their child comes home, they
held it together all day in school, they come home,
they’re cognitively fatigued. Because their brain is overloaded. And when they get home, they have behavioral outbursts, or they explode. So, try to be consistent. What they’re doing at school,
if they’re using schedules, create a schedule at home. Be consistent with that schedule. And this is an at-home
schedule that we used for a student, and it
really, really helped. Also, classroom organization and structure allows for smooth
transitions between groups and activities, and all-day learning. And for the student with a traumatic brain injury let’s think about this. What is the best type of
classroom environment? Many times after a brain
injury when the student’s re-entering back in the
school and we’re having a meeting with the school district, the parents say, we want Mr. Collinberg, who is the best teacher at that school. Well typically, think about the best teachers in first grade. They’re the ones that all the parents see as being the one with all
the different room sections where games are going on,
there’s some light music playing in the background,
there is complete environmental words
everywhere, everything is labeled, very colorful, very busy. Sometimes, these are not the
best classroom environments for students after brain injury. Because many, many, many times
when they come back to school after more moderate to severe
traumatic brain injuries, they could be very easily over-stimulated by too much environmental stimulation. So a lot of times – and again,
it depends on the student, but for these students, we
like to have them in classrooms that have minimal
environmental stimulation. We like to have them with
teachers that are consistent, every day, the schedule’s
posted, that teacher doesn’t sway from her schedule,
that teacher doesn’t have a substitute in very much, that
teacher is routine-based. That is so important. And then effective instructional
strategies are also where, before we teach something to a student, we make sure that we pre-teach. So the prerequisite skills are
mastered before continuing, whether it’s teaching them
vocabulary, connecting the information to prior learning,
so the students can say, oh yeah, yeah, I remember
learning that before. That’s gonna help solidify this in their minds to build upon. And what we know is that
for the student with a traumatic brain injury,
direct instruction is a technique for teaching
that is very beneficial. It’s an instructional
strategy, and some of you may be familiar with it,
there is a curriculum – there’s several different
curriculums that are based on direct instruction,
but a very common one that schools use is the
SRA reading or SRA math. Those are direct instruction
and tend to be very helpful after brain injury, because
they’re very predictable. Also time, teachers that
are good teachers for all students, they tend
to give time provided for corrective feedback
and error correction. And for the student with
a traumatic brain injury, one technique that tends to work is called errorless learning. And I’m sure that that’s a
new idea for many people, a lot of people haven’t
heard of errorless learning, but please jot down the
note to Google that. Because errorless learning, essentially, doesn’t let the student have a chance, while they’re learning
content, to make a mistake. Because there’s something
about making mistakes after a traumatic brain injury, where the mistakes stick
in the kid’s brain. So, errorless learning
can be really, really helpful, it’s a good strategy to try. Also, cue cards. These students are gonna
have cognitive fatigue. Their brain is still trying
to recover as much as it can, and so anything we can do
to alleviate their mind, or their brain, which should
just be spending all of its effort recovering, we
want to try to help do. So cue cards, multiple choice, word banks, those are much less cognitively
demanding for students. Because I always tell
teacher this, and parents. After a brain injury, I am
not as interested in the process that a student
uses to get to an answer, I wanna know if they
know the right answer. Therefore, I’m not gonna
give a student a unit test after a traumatic brain injury
and say, find these answers. I would probably give maybe a
word bank or multiple choice, there’s lots of different
ways that you can put the answers in front of a student to have them identify the correct answer. So there’s lots of –
and again, that would be another whole day of
training to talk about that. But there’s lots of cue cards
that you can help students guide them, so this
student was having trouble doing independent seat
work after a lesson. So we came up with a cue card. And this student, every time
they became a little off task, whenever they were supposed
to be doing independent seat work, the teacher would tap
the student on the shoulder, and the student would look
down, that was the cue to read their cue card, and
this one said, you know, read the directions, try
the first one on your own. And it took the student, step
by step, through the process of independent seat work, and over time, students internalize these. Same with math. You can use cue cards for everything. Now this is a script, scripts
are very, very powerful. Kelly sustained a severe TBI
when she was in a car accident. After months at rehab,
she returned to school. Our brainSTEPS program
worked with her teachers and found that task
analysis and social scripts were very beneficial for her new learning. But the following summer,
her father passed away. He was her only living parent. She was extremely anxious
about going back to school in the fall for fear of questions
that she would be asked. So she had a lot of anxiety. So her brainSTEPS team
worked with her on a script, and this really helped
alleviate her anxiety. So they worked on this. She had this index card, she
carried with her to remind her, in case she started to
forget, but they reviewed this with her until she
internalized what to say. So they would role play. Hi Kelly, I heard something
happened to your dad, or maybe a student might
say, Kelly, did your dad die? And Kelly was prepared, and
it alleviated her anxiety because she knew what to say. My dad was in a car
accident, he passed away, I’m still really sad, thanks for asking. Scripts need to be distributed practice, repeated, repeated, repeated, embedded in meaningful activity, and used across everyday partners. This is from Mark
Ylvisaker and Tim Feeney, they are also awesome
experts in this field, if you wanna Google them, you can find more information about them. But after brain injury, we
want students to self-regulate. Self-regulate is internalized self-talk. And these are some of my favorites I wanted to share with you. For a lot of students who
have trouble getting started on a project, we do
goal, plan, do, review. And we teach students
over and over to say this, goal, plan, do, review,
goal, plan, do, review. So first they set a goal, then they work out a plan, then they do it, and then we come back together and we review it. This can be used for long-term
projects, it can be used for short-term homework,
it can be used for lots of different things, but
it really is helpful. That’s one script. And these are also other
favorite scripts that I like. And these are good for
things that, not just with traumatic brain injury,
but with all disabilities. Every student can benefit
from self-regulation scripts. So what these are, are a
hard/easy, big deal/little deal, ready/not ready, scary/not scary, and I’m gonna show you how we use these. Hard to do, easy to do. Ready, not ready. Big deal, little deal. So for this student, everything to this student was a big deal. Everything was a big deal. So we sat down with the
student and we said okay, let’s talk about what
is a really big deal? What really, really upsets you? And this student said
someone punching, hitting, or kicking him, someone
swearing at him, someone touching him, someone
touching papers on his desk. So then we said, okay,
now what’s a little deal? Something that doesn’t
upset you that much? What would a little deal be? And the student said well, my
pencil falling on the floor, not liking the girl sitting
next to him, wanting to eat a snack, and the pencil lead breaking. Those were little deals. So now, moving forward,
every time the student started to get upset about
something, the teacher would say, is this a big
deal or a little deal? Big deal or little deal? And the student then, over time
– and it’s not always fast. But over time, the student,
before getting upset, started to think to himself, is this
a big deal or a little deal? And he could kind of rate it
based on what he now knows a big deal is and what a little deal is. If it’s a little deal, you don’t worry about it and you try to move on. Another one we use is the scary/not scary. This student after brain
injury, when they came back to the classroom, everything
frightened this student. So we talked about, what’s scary to you? And this student said
mean dogs, the principal, the spiders, getting
yelled at, talking in front of the class, and substitute teachers. So then we said okay, what’s not scary? Well, talking to friends,
nice dogs, caterpillars, when the teacher’s smiling,
my house, my mom and dad. So from this point forward, we
said, okay, scary/not scary? Any time the student started
to get really worked up and upset about something,
we would regroup by saying, okay, Joey, is this scary or not scary? And then he would start to
internalize this self-talk. Now, I know we’re running out
of time, so to wrap things up, it’s important, after brain injury – yes? – [Debra] These people are gonna
have questions, and we have about three minutes left in
the presentation so, we will have all of the slides available
for everyone, and there’s some great resources included,
but I think it would be good if we could take a few questions
now, is that okay, Brenda? – [Brenda] Oh, sure, that’s fine, yeah. – [Debra] So if you have a
question, you can unmute your line, hit star six,
and that’ll help you to be able to ask your question orally, or you can type it into the chat box. And I actually have a question of the parent centers
that are on the call. If you have any suggestions
that you wanna share with your colleagues
about ways that you’ve worked with families
with children who have suffered a traumatic
brain injury, I think it would be great to hear
from you, if you have anything that you’d like
to share from your work. Cathy is typing. Does someone have a question? This is a quiet group. (muffled talking) There’s a question from Cathy Harstead. Do you have information and
resources that are helpful to high school teachers in
working with these populations? Brenda? – Yeah, we actually, because we work with students kindergarten through 12th grade, so we have lots of different resources. If you send me an email, I
can send you lots of different links, also, there are links
at the end of my PowerPoint presentation online, and they
are great sites like project LEARNet out of New York, and
CBIRT which is in Oregon, C-B-I-R-T, on one of my last
slides, and there are a lot of great information on
there for high schools. – [Female] Debra – – [Debra] Kelly Henderson has a question, have you had a specific
experience, or know of data related to the impact of TBI on children
who have experienced abuse? Any differences in
approaches for this group? That’s a great question, Kelly. – It is, and we do work
with students that have things such as shaken baby
syndrome, whenever they were younger, or even
children that are in crisis shelters from being
beaten, and they sustain traumatic brain injuries of any severity. When we work with students
with concussion or any severity of brain injury, it’s – a
brain injury is a brain injury, but they all manifest differently. So we always make sure – you know, some of these students have dual-diagnoses coming in of PTSD and
traumatic brain injury. So we’re really sensitive
to helping connect them with counselors who can help,
and just keeping that PTSD, knowing that that’s there, also, working with the schools around that. – [Female] Debra? Can you hear me, Debra? – [Debra] Yes, we have
a question from Leah. Any resources to help families
whose children have autism, and who head bang? And she put in quotes, significant. – You know, we have gotten
that question before, and I am not familiar with
any materials on that. I’m sorry I can’t be more
helpful with that, but it does occur, and they
can cause brain injuries, obviously, if they’re banging their head. So just forming some sort
of team around this child to try to alleviate them
banging their head, although I know that that’s really
difficult to do, 24 hours a day. (muffled talking) – [Carmen] Debra this is
Carmen, I saw a question from Jill Cline that I’m not sure
you’ve asked yet, which is, is there a time of day
that is more difficult for kids to learn and absorb who
have traumatic brain injury? – That’s a good question,
so is there a time of day. No, there’s no set time of day. We always look at how does
the student’s sleep function? A lot of times after a more
severe traumatic brain injury, many students become almost
nocturnal, where they are, they wanna sleep all day,
and they’re up all night. So for those students, we
would always recommend that whenever they start back at
school, their core classes, if they can go half-day in the afternoon, put their core classes in the afternoon. Other students, mornings
tend to work better because you want to alleviate
their cognitive fatigue. So, you don’t wanna have the
hard classes for some students in the afternoon, because
they’ll be too tired, so you wanna front-load
those in the morning. Very individualized to the student. (muffled talking) – [Debra] Also there’s a question, do you have any data or resources about being nocturnal after
traumatic brain injury? – Carol I don’t have any… If you send me an email, I do
have some things on fatigue, not specifically to
nocturnal, but a lot on the fatigue that persists
after brain injury, very common and it’s very common that it might last the rest of their life. Because their brain has to actually, a lot of times, work harder, to learn the same information
that we may be able to learn without a brain injury, easier. I see a question, do you have
any peer to peer approaches? Well, what we’ve done in
Pennsylvania is nothing formalized for the peer-to-peer, but
we have 30 brainSTEPS teams across the state that work,
when students are having peer issues, after traumatic brain
injury, we kind of try to form a peer circle of
support, where we’ll pull in key student leaders that
are willing to help out and facilitate friendships
with the student, but we were just talking
about this yesterday – it may work during the
school day, but it’s so hard to keep facilitating those friendships outside of the classroom environment. And so just building up
students and peers, their understanding of brain
injury, so that they’re more empathetic to their
friends, rather than just not being aware of the
differences in students who have brain injuries, and what
it means for their friends. But definitely, we do a
lot of peer education, with parent permission, of course. – Cathy also shared a
website, worry wise dot com, w-o-r-r-y, worry, wise, w-i-s-e, dot com. Do I see any other questions? We’re at just over five minutes
after the hour and we know that we promised that this
will be a one-hour webinar. If you do have other questions,
feel free to keep chatting away in the chat box, and
we’ll keep answering them, but in the meantime, do take a minute to complete our evaluation
survey, the link is in the chat box, it’s also on the screen, and we look forward to your
joining us on September the 4th, where we will have a discussion on the alternate assessments for
college and career ready standards and common core standards, and so we’re hoping that
you’ll be able to join us for that webinar, as well. Again, thank you to
everyone for joining us, and do continue to post your questions. – [Lisa] Debra? Can you hear me? – [Debra] Yes. – I just wanted to – this is Lisa. I just wanted to say,
Brenda, thank you so much for the great work you do in this area. – [Brenda] Oh, sure. – [Lisa] And thank you for sharing your knowledge with us today. It’s been very, very informative. – Oh, that’s great, I’m glad to hear that. – [Debra] Yes, thank you, Brenda, and thank you, Nolan and Elaine for doing a great job with our
technology for us today, and we will see everyone next month. It looks like, I don’t
see anymore questions, Angela’s (sound cuts
out) thank you very much, thank you, bye. – [Brenda] Thank you. – [Debra] (laughs) Buh-bye.

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