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School Reentry Issues for Adolescents with TBI

School Reentry Issues for Adolescents with TBI. Presented at National Association of School Psychologists INASP) 2011 Annual Convention San Francisco, CA Thursday, February 24, 2011 Ethan Schilling, M.S. Yvette Q. Getch, Ph.D., CRC The University of Georgia. Chronic Illness and School.

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School Reentry Issues for Adolescents with TBI

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  1. School Reentry Issues for Adolescents with TBI Presented at National Association of School Psychologists INASP) 2011 Annual Convention San Francisco, CA Thursday, February 24, 2011 Ethan Schilling, M.S. Yvette Q. Getch, Ph.D., CRC The University of Georgia

  2. Chronic Illness and School Demographic Facts • 20% of all school-age children have a chronic illness • 6.5% (4.4 million): Condition severe enough to interfere with normal activities; Including School • 1 million are limited in their ability to attend school Kaffenberger, 2006

  3. What is “School Reentry” • Refers to the sick or injured child’s return to school and reintegration into the school setting after diagnosis or prolonged hospitalizations • Can be very stressful for the child due to: • Changes in Appearance • Anxiety about being able to keep up with work • Feeling isolated from peers Worchel-Prevatt et al., 1998; Sexson & Madan-Swain, 1993

  4. What is 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; psycho-social 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.” [34 Code of Federal Regulations §300.7(c)(12)

  5. Primary Causes of TBI • http://www.cdc.gov/ncipc/tbi/Causes.htm

  6. General Outcomes (Langlois, Rutland-Brown, & Thomas, 2004) • Of approximately 1.4 million TBI Cases • 50,000 die • 235,000 are hospitalized • 1.1 million are treated and released from an emergency department • 80-90,000 experience disabilities as a result of TBI (National Center for Injury Prevention and Control, 2003)

  7. Adolescents and TBI (http://www.cdc.gov/ncipc/tbi/Causes.htm) • Most TBIs are due to motor vehicle accidents (MVA) for those aged 15-19 • Most hospitalizations are due to MVA (Langlois, Rutland-Brown, & Thomas, 2004) • 1.6 – 3.8 million sports/recreation-related TBIs occur in the United States each year • Most of these are considered mild and do not require hospitalization • (Langlois, Rutland-Brown, & Wald, 2006)

  8. Of Particular Concern for Adolescents • Repeated mild TBIs occurring over time (i.e., months, years) can cause cumulative deficits. • Repeated mild TBIs that happen over short periods of time (i.e., hours, days, or weeks) can be debilitating or fatal.

  9. Categorizations/Definitions • Glasgow Coma Scale (GCS) • Individual rated on scale of 3 to 15 • Eye Opening Response • Best Verbal Response • Best Motor Response • Injury classified as Mild, Moderate or Severe Teasdale and Jennett, 1974

  10. GCS Categories • 13 or greater = Mild • E.g., 13 = spontaneous eye opening response, able to localize pain, well oriented verbal response following injury • 9 – 12 = Moderate • E.g., 9 = eye opening in response to sound, able to bend limbs appropriately, incomprehensible speech • 3 – 8 = Severe • E.g., 3 = no eye opening, no motor or verbal response

  11. Levels of TBI ****(http://www.traumaticbraininjury.com) • Mild Brain Injury is the result of the forceful motion of the head or impact causing a brief change in mental status (confusion, disorientation or loss of memory) or loss of consciousness for less than 30 minutes. • Post injury symptoms are often referred to as post concussive syndrome. • Most common form of brain injury • 15% of those with Mild TBI have symptoms for over a year • Often called a concussion • Moderate brain injury is defined as a brain injury resulting in a loss of consciousness from 20 minutes to 6 hours and a Glasgow Coma Scale of 9 to 12 • Severe brain injury is defined as a brain injury resulting in a loss of consciousness of greater than 6 hours and a Glasgow Coma Scale of 3 to 8

  12. School Reentry: Assessment Issues • Traditional Assessment alone is not sufficient, especially for Mild TBI (Lewandowski & Rieger, 2009) • In addition, should include: • Clear assessment of attention, memory, processing speed, mental effort and fluency (Lewandowski & Rieger, 2009) • Information gathering from parents, doctors, therapists (Bowen, 2005) • Consideration of pre-morbid functioning (D’Amato & Rothlisberg, 1996) • Functional Behavior Analysis (FBA) and Antecedent-Behavior-Consequence (ABC) assessment (Bowen, 2005) • Dynamic Assessment/think-alouds (Farmer et al., 1996)

  13. TBI: Cognitive Effects • Inattention • Executive Dysfunction (especially disorganization) • Processing Speed deficits/Efficiency of information retrieval • Memory problems • Visual-Spatial difficulties • Motor skills deficits • General brain fatigue Lewandowski & Rieger, 2009; Jantz & Coulter, 2007; Clark, 1996

  14. Academic Effects • Poor memory • Difficulty with tasks requiring sustained mental effort / shifting attention easily following transitions • Physical limitations • Difficulty with planning/organization • Reading and math calculation difficulties • Aphasia (word finding difficulties) D’Amato & Rothlisberg, 1996; Clark, 1996

  15. Behavioral Difficulties • Increased irritability/frustration • Depression/anxiety • Confabulation • Mood Swings/Apathy • Poor impulse control Mayfield & Homack, 2005; Jantz & Coulter, 2007

  16. *Social/Emotional Effects* • Less is known/reported here • Socially inappropriate behavior (Jantz & Coulter, 2007) • Irritability, impatience, impulsivity (Mayfield & Homack, 2005) • Decreased awareness of self and other/poor social competence (Farmer et al., 1996) • Also, time away from school/more absences, changes to appearance/behavioral style, etc. • Emotional difficulties: Just dealing with the injury and the changes that go along with it • Some interesting findings: • Adolescents with TBI have greater difficulties with social cognition, emotion recognition and theory of mind tasks (Turkstra et al., 2008) • Greater difficulties interpreting facial expressions (Knox & Douglas, 2008)

  17. School Psychologists/Counselors role • Understand development • Can work with small groups • Can facilitate meetings and understandings • Recognize the impact on making friends and fitting in • Can be a resource for parents and teachers • Can advocate for and empower students • Can facilitate students’ learning of their disabilities and needed accommodations

  18. Issues for Reentry • When to come back to school? • How much (academics, etc) is enough? • What kind of “socialization” issues might arise? • What accommodations may be needed? • What emotional, physical, and cognitive supports and accommodations are needed? • What communication strategies are in place?

  19. Family Issues • Trauma • Family separation during hospitalization and rehabilitation • The “unknown” • Long recovery process • Living with a different person • Grief • Anger • Exhaustion

  20. Adolescents: Special Considerations • Driving • Substance abuse • Emotional/physical development • Aggression • Sexual inhibitions • Filtering problems • Normal/abnormal behavior • Individual and Family adjustment and coping

  21. So what can we do? • Educate those involved in school reentry process: Even School Psychologists are misinformed (Hooper, 2006) • Plan early/use a team approach (Clark, 1996; Doelling & Bryde, 1996) • Use behaviorally-based interventions: positive reinforcement of appropriate behavior, clear rules, regular verbal feedback (Arroyos-Jurado et al., 2006) • Provide flexibility in scheduling as well as consistent routines (Bowen, 2005; Lewandowski & Rieger, 2009) • Direct Instruction including self-management skills (Bullock et al., 2005) • Set up social support networks; Social skills training (D’Amato & Rothlisberg, 1996) • Cognitive Remediation Therapy is promising (Salazar et al., 2001)

  22. Accommodations • Rest times • Extra time for assignments and tests • Assistive Technologies • Breaking down assignments • Limited academic load • Alternative assignments • Testing accommodations • Cueing/prompting/redirecting

  23. Scenario • A friend asked Alex a question and Alex was trying to help his friend out. They both went to lunch. After a while, Alex realized he was at first lunch, not second lunch. Alex was tardy for class. The teacher gave him a note to go to detention. • What may be going on here? • What should the teacher have done? • What can be done in the future?

  24. Scenario • Sancho yelled at his friend for something minor that he wouldn’t have reacted to in that way before his brain injury. He yelled at a teacher for correcting him in class. • He told the school psychologist that • he felt all his teachers thought he wasn’t smart anymore & they disliked him. • his emotions seemed out of control which made him frustrated, embarrassed, and ashamed

  25. Discuss the case • What might be going on? • What should the school psychologist do? • What accommodations might be needed?

  26. Scenario • The parents of Mason are frustrated. Things are so overwhelming at home. Their child is no longer the same child. Yes, he looks the same, but his personality, his emotional explosions, and his low frustration tolerance, make things very taxing at home. They often don’t know how Mason will respond or act. They feel they are “walking on eggshells” around their own child.

  27. Scenario • Rod was called to the office with a group of other kids who hadn’t showed up for mandatory remediation for failing a standardized test. Rod was angry and confused. He didn’t know he was supposed to go to remediation during lunch. He got flustered and forgot about an upcoming quiz until he walked into class. He was so upset he couldn’t concentrate and failed the quiz. To make things even worse, he forgot to stay for a make-up quiz after school that had been scheduled.

  28. Discussion • What are the issues? • What steps could be taken, if any. • What should the teacher do? • What should the school psychologist do?

  29. References Arroyos-Jurado & Savage, T.A. (2008). Intervention strategies for serving students with traumatic brain injury. Intervention in School and Clinic, 43, 252-254. Bowen, J.M. (2005). Classroom interventions for students with traumatic brain injuries. Preventing School Failure, 49, 34-41. Bullock, L.M., Gable, R.A. & Mohr, J.D. (2005). Traumatic brain injury: A challenge for educators. Preventing School Failure, 49, 6-10. Centers for Disease Control and Prevention (1997). Sports-related recurrent brain injuries—United States. Morbidity and Mortality Weekly Reports, 46(10), 224–7. Clark, E. (1996). Children and adolescents with traumatic brain injury: Reintegration challenges in educational settings. Journal of Learning Disabilities, 29, 549-560. D’Amato, R.C. & Rothlisberg, B.A. (1996). How education should respond to students with traumatic brain injury. Journal of Learning Disabilities, 29, 670-683. Doelling, J.E. & Bryde, S. (1995). School reentry and educational planning for the individual with traumatic brain injury. Intervention in School and Clinic, 31, 101-107. Farmer, J.E., Clippard, D.S., Luehr-Wiemann, Y., Wright, E. & Owings, S. (1996). Assessing children with traumatic brain injury during rehabilitation: Promoting school and community reentry. Journal of Learning Disabilities, 29, 532-548. Hooper, S.R. (2006). Myths and misconceptions about traumatic brain injury: Endorsements by school psychologists. Exceptionality, 14, 171-182.   http://www.ldonline http://www.ncld.org/ld-basics Jantz, P.B. & Coulter, G.A. (2007). Child and adolescent brain injury: Academic, behavioural, and social consequences in the classroom. Support for Learning, 22, 84-89. Kaffenberger, C. J. (2006). School reentry for students with a chronic illness: A role for professional school counselors. Professional School Counseling, 9(3), 223-230. Knox L,& Douglas J. Long-term ability to interpret facial expression after traumatic brain injury and its relation to social integration. Brain and Cognition, 69, 442-449. Langlois, JA., Rutland-Brown, W., Thomas, K.E. (2004).Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, Nation Center for Injury Prevention and Control. Lewandowski, L.J. & Rieger, B. (2009). The role of a school psychologist in concussion. Journal of Applied School Psychology, 25, 95-110. Mayfield, J. & Homack, S. (2005). Behavioral considerations associated with traumatic brain injury. Preventing School Failure, 49, 17-22. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. (2003, October 8). Traumatic brain injury . http://www.cdc.gov/ncipc/factsheets/tbi.htm National Institute of Neurological Disorders and Stroke. Traumatic brain injury: hope through research. (2002 Feb.). Bethesda, MD: National Institutes of Health. NIH Publication No.: 02-158. Sexson, S. & Madan-Swain, A. (1995). The chronically ill child in the school. School Psychology Quarterly, 10(4), 359-368. Teasdale & Jennett (1974). Assessment of coma and impaired consciousness: A practical scale. Lancet, 2, 81-84. Turkstra, L.S., Williams, W.H., Tonks, J., Frampton, I. (2008). Measuring Social Cognition in Adolescents: Implications for Students with TBI Returning to School. NeuroRehabilitation, 23, 501-509. U.S. Department of Education. (2002). To assure the free and appropriate public education of all children with disabilities: Twenty-fourth annual report to Congress on the implementation of the Individuals with Disabilities Education Act . Worchel-Prevatt, F. F., Heffer, R. W., Prevatt, B. C., Miner, J., Young-Saleme, T., Horgan, D., Lopez, M. A., Rae, W. A., & Frankel, L. (1998). A school reentry program for chronically ill children. Journal of School Psychology, 36(3), 261-279.

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