1 Assessment, Intervention, and School Re-Entry for Children with Acquired Brain Injuries - PowerPoint Presentation

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Assessment, Intervention, and School Re-Entry for Children with Acquired Brain Injuries

Kerry Hankins, MA, CCC-SLP Vanderbilt Bill Wilkerson CenterEmail: Kerry.a.Hankins@vumc.org

Dana M. Bryant, M.Ed., CCC-SLPVanderbilt Bill Wilkerson CenterEmail: Dana.Bryant@vumc.org

Wendy Ellmo MS CCC-SLP, BCNCDS

Brain Links,

TN Disability Coalition

wendy_e@tndisability.orgSlide2

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Financial Disclosure

Financial: Salary through Vanderbilt Bill Wilkerson Center

TN Disability Coalition, ACL Grant Non-Financial: Talk with Me Tennessee board memberConsultant to Healing Heads Foundation Slide3

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1) Participants will be able to identify and interpret assessment tools for the pediatric acquired brain injury population2) Participants will be able to develop functional goals and treatment strategies for the acquired brain injury population3) Participants will learn to develop appropriate school re-entry plans including goals and accommodations in IEPs and 504 plans for the pediatric acquired brain injury population

Learning ObjectivesSlide4

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“The functional impact of TBI in children can be different than in adults—deficits may not be immediately apparent because the pediatric brain is still developing. TBI in children is a chronic disease process rather than a one-time event, because symptoms may change and unfold over time (DePompei & Tyler, in press; Masel & DeWitt, 2010).”

According to ASHA….Slide5

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Key Ideas

Cognitive after a TBI will vary greatly and no two students will present alike.Cognitive changes are unlikely to disappear fully over time.

Negative consequences may not be seen immediately, but may present themselves as developmental demands reveal deficits. An injured brain is less likely to meet the demands of the increasingly complex tasks that children encounter as they grow older

Drazinksi (2014)Slide6

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Formal AssessmentInformal AssessmentParent InterviewBehavioral Observation

Assessments Slide7

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The patient and family goalsVision

Hearing Behavior SchoolBaseline FunctioningMalingering Medical Status- Medications

Physician who is following them after rehab Psychosocial and Emotional impact on the patient and family Parent InterviewSlide8

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10 year old previously typically developing maleTraumatic brain injury due to sledding accident.

CT Scan: Left-sided acute skim subdural hematoma, scattered acute subarachnoid hemorrhage Hearing and Vision – WNL Continuum of Care: Acute care hospitalization, inpatient rehabilitation, day rehabilitation, then transitioned to outpatient services 6 months post injury. Followed by the PM&R clinic at Vanderbilt Parent Concerns: Reading, Personality Changes, Attention, Language.

Needs: Caregiver education, direct therapy, transition to the school system, development of the IEPCase Study ExampleSlide9

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Standardized Tests

PTBIChildren 6-16 years.

Assesses: orientation, receptive language, attention, word fluency, vocabulary, verbal expression, immediate and delayed recall, narrative comprehension and recall, visual memory, and organization.Comprehensive Test of Non-verbal Intelligence Children: 6 years-89 years and 11 months The CONTI-2 measures the ability to reason, problem solve, identify logical and abstract relationships, solve mental puzzles, and form meaningful associations. Associated with academic success Slide10

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Standardized Tests

Behavior Rating Inventory of Executive Function- 2nd Edition

Children 5 -18 years Parent, Teacher, and Self-Report forms Assesses executive function and self-regulation in children and teensBeneficial measure for functional goal formulation Slide11

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Standardized Tests

TOPSChildren 6-12 years Assesses: Inferencing, Sequencing, Pragmatics, Predicting, Problem Solving

TOPLChildren: 6-18 years Assesses: Self Regulation, Auditory Comprehension, Perspective Taking, Cognitive Flexibility SEEChildren: 6-12 years Assesses: Understanding Facial Expressions, Identifying Common Emotions, Recognizing Emotional Reactions, Understanding Social Gaffes, Understanding Tone of Voice

TAPS

Children: 6-12 years

Assesses: Auditory Attention, Auditory Memory, Listening Comprehension, Language Processing, Narrative Comprehension, Cognitive Flexibility, Working Memory, Slide12

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Environment: Quiet vs. NoisyDistractions FatigueBehavior Motivation Self-

Correction Impulse Control Length of time needed to administer assessments Standardized Test ConsiderationsSlide13

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Cognitive Stall: As young children with TBI develop, behavioral and cognitive problems might continue to emergeSpecifically in the preschool population

(5 years and younger) may not demonstrate academic or behavioral difficulties until several years following their brain injury.Do not just use 85-115 score range to assess eligibility for servicesAssessment Considerations Slide14

Referrals for Further Testing

School Psychologist or Learning SpecialistAcademic Testing IQ TestingMay add other testsNeuropsychological Testing: Gold Standard for TBI Testing

Brain-Behavior RelationshipsAcademic TestingIQ TestingSpecific Domains of Cognitive FunctionAttentionMemoryExecutive FunctioningVisual-spatial FunctionInformation ProcessingSlide15
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Case Study- AssessmentSlide17

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Casey’s Assessment

Language: Oral and Written Language Scales Second Edition:Listening ComprehensionStandard Score: 80Percentile Rank: 9 Oral Expression

Standard Score: 77Percentile Rank: 6 Oral Language CompositeStandard Score: 77Percentile Rank: 6Interpretation: ModerateObservations:Incorrect responses were marked incorrect- however, to assess therapeutic strategies, many of the testing items were presented again with visual supports, re-wording of stimuli, and extended wait time. When given these modifications, Casey was successful on many items that were initially incorrect. Slide18

Articulation:Arizona Articulation and Phonology Scale 4th Edition-

Mild dysarthria. 100% intelligible in conversational speech. Noted difficulty with rate of speech and intonation.

Casey’s Assessment Slide19

Cognition: Pediatric Test of Brain Injury (PTBI).  

  Ability Score Performance Category Orientation 26 Very Low Following Commands 11 Low Naming 12.5 High Word Fluency 15 Low What Goes Together 73 ModerateDigit Span 6.5 Low Story Retelling- (Immediate) 36.5 Low Yes/No/Maybe N/a ______ Picture Recall 32 High Story Retelling- (Delayed) 13 Very Low

Observations: Strengths: Spatial Orientation, Visual Memory

Weaknesses: Auditory Memory (immediate and delayed), Temporal Orientation, Word fluency, Word Retrieval.  

Casey’s Assessment Slide20

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TreatmentSlide21

6 Approaches to Cognitive Rehabilitation

Personalized Education

Cognitive Strategy TrainingTraining Use of Assistive TechnologyDirect Training of Cognitive ProcessesTraining Specific SkillsEnvironmental ManagementBeyond Workbooks: Functional Cognitive Rehab for TBI, McClennan &

Sohlberg, ASHA Webinar 2017Slide22

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Goals shouldBe functional- incorporate assistive technology and use of strategiesBe motivating for pt and family

Build on pt strengthsTarget areas of notable weakness Examples of cognitive rehabilitation areasAttentionRecall

SequencingProblem Solving (inferencing, deductive reasoning, etc)Figurative LanguageGoal FormulationSlide23

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Alertness and Arousal

Sustained Attention- Maintain attention over a period of time to complete a task. Play with one toy for 2 minutesAttend to a book Selective Attention- Attend to stimuli that is important and be able to disregard stimuli that is not.

Attend to a book with the therapy door openAttend to a structured activity when the cabinet door is openAttend to homework activity when a sibling is talking

Attention TreatmentSlide24

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Alternating Attention- Ability to switch between activities. Joint attention during play

Take notes off of a white board in class Divided Attention- MultitaskingStudying for a test while listening to musicEating a snack and watching television.

Hemi-NeglectModality Specific

Attention TreatmentSlide25

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Visual SupportsI need a breakEyes in the Group

Brain in the GroupWhole Body ListeningMichelle Garcia WinnerHave family talk to their MD about possible medical interventions to pair with therapy.

Attention TreatmentSlide26

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Classroom Management/AccommodationsNoise Canceling Headphones during tests

Preferential SeatingAssistive TechnologyApps - use with cautionAssignment notebooksGraphic Organizers

Voice Recorders Timers Visual reminders - sticky notesFrequent Brain BreaksMovement Breaks

Attention TreatmentSlide27

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MetaCognitive Strategies If the patient has awareness of their attention deficits, work together to determine situations where their attention is the worst (classroom, study time, etc.)

Identify strategies together that work to improve attentionExample: Attention Monsters and Attention Superheroes

Attention TreatmentSlide28

Casey’s Goals: Attention

Example goal: Casey will independently identify distractions and implement attention strategies to complete functional and academic tasks in ¾ opportunities. Slide29

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Short Term: Ability to story information in your mind for a short duration

Working Memory: incorporates dynamic aspects of holding onto information and manipulating itLong Term: Unlimited Memory with no decayEpisodic: Memory of eventsSemantic: Storage of factsProcedural: Acquisition of perceptual motor skills and sequences

Anterograde: Difficulty remembering events occurring after brain injury. New learningRetrograde: Inability to retrieve information stored prior to brain damage

Memory TreatmentSlide30

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Memory Treatment

“In an effort to restore lost memory, some clinicians subject clients to direct training via memory calisthenics such as digit span, list learning, paper and pencil tasks, and computer software programs. Clients are exposed to novel information, asked to perform manipulations on it, and then recall it on demand. This follows the physical rehabilitation model of exercise, with repetition through drill work to boost strength. Despite the apparent popularity of such tasks, many investigations have proven that this approach is ineffective. Improvements in circumscribed tasks can be achieved, but generalization to unscripted or unstructured activities rarely occurs Avery & Kennedy, 2002). Slide31

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Contextualized: A common rehabilitation approach is to attempt to use an intact system to support a deficient one

Build your patient’s “meta” skills by building awareness of memory deficits. Allow your student to identify situations where their memory is impacting their school/life performance

Memory TreatmentSlide32

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Errorless learning — minimizing or eliminating errors during the acquisition phase of learning (e.g., Baddeley & Wilson, 1994)

Clearly define the instructional target(s) (e.g., information, multi-step skills, cognitive strategies).Ensure the target is relevant and personally meaningful to the client.

Minimize errors during the acquisition phase (i.e., errorless learning), particularly for those with more severe impairments.Provide high rates of correct practice.Provide opportunities to practice over increasingly longer periods of time (i.e., spaced retrieval).Use multiple training examples.

https://www.brainline.org/article/effective-instruction-optimizing-outcomes-following-abiSlide33

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Internal Memory Strategies: Verbal Rehearsal

VisualizationSing a SongRhyming Associations Make a Connection Acronyms

Mnemonics Chunking Gestures

Memory TreatmentSlide34

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External Memory Strategies Post it notes

CalendarsRemindersApps Checklists Daily Planners

Class Schedule and school map“Cheat Sheet” for testsMemory log

Memory Treatment

https://www.brainline.org/article/life-changing-apps-people-brain-injurySlide35

Casey’s Goals:Memory

Example Goal: Casey will independently use an effective memory strategy to remember information in classes with 80% accuracy as measured on quizzes and tests.Slide36

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Definition: set of processes required to manage one’s self or resources (attention, memory, problem solving, sequencing, inferencing, deductive reasoning, etc)

Executive function is considered the highest form of human cognition (Helm-Estabrooks, 2000

Examples of daily living tasks that require executive fx skills:Cooking, cleaning, dressing, driving, school and work assignments, etc. Treatment can be:Restorative Compensatory

Both: “compensatory strategies can have restorative outcomes

Executive FunctionsSlide37

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OrganizationEmotional Regulation

Impulse Control Goal SettingPlanningSelf Correction PredictionsInferencing

Problem Solving Safety AwarenessReasoning Time Management

Executive FunctionsSlide38

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Activities:Functional - must have a meaningful impact

Patient CenteredUse assistive technologies or external aids whenever possible Have student develop goals and monitor their own progress Make sure your activities can generalize into home/school environments

Executive FunctionsSlide39

Task Initiation

Sequencing Multi-steps Problem SolvingEmotional Regulation

InhibitionImpulsivity Casey’s Goals:Executive Functions

Example Goal: Casey will plan, prep, organize, and complete functional and/or academic tasks with minimal prompting and the use of external aides as needed in 4/5 opportunities. Slide40

Awareness

Very often impacted by TBIDifferent from DenialmTBI often Hyper-aware

TypesIntellectualEmergentAnticipatorySlide41

Casey’s Goals:Awareness and Self-Advocacy

Often becomes frustrated or discouraged when unable to complete a taskExample Goal: Casey will identify cognitive breakdowns in functional/academic situations and will initiate the use of a visual support/strategy to advocate for his needs when he misses information (more info, slow down and repeat, etc.)Example Goal:

Casey will accurately identify tasks as easy/hard for him in 8/10 opportunities.Slide42

Pediatric TBI in the Schools Slide43

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Concussion

Functional vs. structural injury

-Chemical CascadeSlide44

Common Symptoms following Concussion

Emotional/BehavioralIrritability

Quick to angerDecreased motivationCries easily

PhysicalHeadaches

Changes in vision

Sleep disturbance

Fatigue

Balance/Dizziness

Sensitivity to light/sounds

Cognitive/Communication

Feeling dazed or in fog

Word finding problems

Slowed information processing

Project BRAIN 2017Slide45

Signs and SymptomsSlide46

For Young Children..Slide47

Rates of Development for the Four Regions of the Brain

% of maturation increments

age increments

1 3 5 7 9 11 13 15 17 19 21

5 Distinct Periods of Maturation

P-O

parietal/ occipital

C

central (limbic & brainstem)

T

temporal

F-T

frontal/ temporal

0

2

4

6

P-O

C

T

F-T

P-O

C

F-T

P-O

T C

F-TSlide48

Tennessee TBI Eligibility Guidelines

Definition: Traumatic Brain Injury means 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 (1) 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. Slide49

Returning to School

Begin with fewer hours spent at school

Rest periods during the day (quiet place for lunch, study hall in library, etc.)

Clear expectationsAccommodations for standardized testing (504)

https://cbirt.org/back-school/return-school-plan

Project BRAIN 2017Slide50

Academic & behavior changes may not

immediately

be linked to the injury

Many students with brain injury

are not appropriately identified

for accommodations

Challenges that result from a TBI can be similar to those of students with other disabilities

Challenges in the School Setting

Project BRAIN 2017Slide51

Casey’s Classroom Modifications and Accommodations:

Extended timeSmall group or individual test setting to minimize distractionsFrequent breaks during testingRead information aloud (maybe more than once)

Present material slowly, reinforce, repeatIf possible, eliminate timed testsAllow longer time to complete work without penaltyModify or shorten workload if neededAssess Casey’s knowledge over shorter rather than longer time periodsChoose testing formats that will best assess his knowledgeIncorporate technology

Short, simple instructionsCheck for understanding; repeat and clarify as neededUse a limited number of choices to assess knowledgePair verbal with visual information (for comprehension)Give semantic or phonemic cues to aid retrievalSlide52

Psychosocial

1. Impaired ability to perceive, evaluate, or use social cues

or context appropriately that affect peer or adult relationships; 2. Impaired ability to cope with over-stimulation environments and low frustration tolerance; 3. Mood swings or emotional liability; 4. Impaired ability to establish or maintain self-esteem; 5. Lack of awareness of deficits affecting performance;

6. Difficulties with emotional adjustment to injury (anxiety, depression, anger, withdrawal, egocentricity, or dependence); 7. Impaired ability to demonstrate age-appropriate behavior; 8. Difficulty in relating to others; 9. Impaired self-control (verbal or physical aggression, impulsivity); 10. Inappropriate sexual behavior or disinhibition;

11. Restlessness,

limited motivation and initiation

; and

12.

Intensification of pre-existing maladaptive behaviors or disabilities

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Casey’s Psychosocial Suggestions for School

Look for ways to include him socially. Buddy up. Where can he participate? Clubs, manager, etc. Watch mood over time. Social skills group? Educate kids about how to help him. Educate each next set of teachers.Slide54

Physical/Motor Considerations

Fall Precautions Mobility issues

Fine Motor ImpairmentsSeizures Precautions Dietary Monitoring by physician with knowledge of brain injury

Medical clearance for returning to sports/activities Slide55

Casey’s Physical/Motor Recommendations

Closely monitored when walking and/or participating in physical activitiesDecrease demands for writing (decreased speed & coordination)Extra time for paper and pencil tasksUse word processing programs Provide alternatives to handwriting Slide56

General Classroom Management Strategies

Structure the classroom environment as much as possibleBreak tasks into component parts

Allow extra time to process information & to respondAdditional classroom adjustments:Direction instruction techniquesRepetition and practiceCueing/scaffoldingModeling Decreased use of time limitsProvide immediate and direct feedbackSlide57

Additional Classroom StrategiesIntegrate assistive technology: computers/

ipads, alarms, recorders, calculators, appsAgree on prompts, cues, cue cards, gesturesPace the workClassroom buddyAdjust work based on physical ability – headaches, handwriting, speed of processingDevelop organizational systemsReward on-task behavior & avoid punishing off-taskSlide58

Behavioral Issues

Help identify triggers-Always look at communication and cognitive demands Practice alternative behaviors/responses

Quickly intervene (may need to do in the moment)Prevent loss of friendsPrevent labeling

Prevent punishment Brain Links 2018Slide59

Brain Links – Brain Injury Specialists

Wendy Ellmo

Middle TN908-458-7532

Wendy_e@tndisability.org

Brain Links is a non-profit program of the TN Disability Coalition.

No cost resources

Enriching the lives of Tennesseans with brain injury by training and empowering the people serving them.Slide60

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Resources

Brain LinksThe Arc of Davidson County Tucker’s House (wheelchair ramps, house adaptations, etc.)Technology Access CenterSocial Workers CBIRT.org

brainline.orgSlide61

Additional Resources

Brainline.orghttp://www.brainline.org/content/2011/06/reap-the-benefits-of-good-concussion-management_pageall.html

TN Department of Health

http://www.tn.gov/health/article/tbi-concussionESPN E60 –Preston

Plevretes

https://www.youtube.com/watch?v=F4foY1EtmKo

The Center on Brain Injury Research & Training

http://cbirt.org

Centers For Disease Control and Prevention

https://www.cdc.gov/traumaticbraininjury/

CDC Heads Up TBI and Concussion

https://www.cdc.gov/headsup/index.html

CDC Heads Up for Schools: Know Your Concussion ABCs

https://www.cdc.gov/headsup/schools/index.html

Oregon Center for Applied Science

http://brain101.orcasinc.com/1000Slide62

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References

(2011) “Accommodations Guide for Students with Brain Injury” Jeffrey Kreutzer, PhD and Nancy Hsu, PhD, Department of Physical Medicine and Rehabilitation Virginia Commonwealth University https://www.brainline.org/article/accommodations-guide-students-brain-injury

Intervention for memory disorders after a TBI. Avery & Kennedy (2002). Neurophysiology and Neurogenic Speech and Language Disorders . Project BRAIN: Working Together to Improve Educational Outcomes for Students with TBI. Denslow et al 2012. SIG 2 Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders. Vol 22/ 106-118. “Got (Treatment) Game?” Dudley, Nikki (2016) The ASHA Leader. Volume 21, 42-43. Cognitive Rehabilitation Interventions for Executive Function: Moving from Bench to Bedside in Patients with Traumatic Brain Injury. Cicerone & Malec, 2006. Journal of Cogntive Neuroscience. 18.17. 1212-1222.